What are the intraoperative considerations in the surgical treatment of breast cancer?

Updated: Feb 13, 2019
  • Author: Mary Jo Wright, MD; Chief Editor: James Neal Long, MD, FACS  more...
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The keys to successful surgery of the breast include a thorough knowledge of anatomy, accurate assessment of the extent of disease, and recognition of the potential for future operations.

All biopsy incisions should be placed carefully with consideration for the placement of a future mastectomy incision. For instance, a radial incision in the upper inner quadrant does not incorporate into an elliptical mastectomy scar with the same ease as a horizontal or curvilinear incision. However, clearly, adequate surgical margins should never be compromised for the sake of cosmesis. Circumareolar incisions are cosmetically favorable and generally adequate for most central parenchymal lesions.

The axillary incision, if done separately, can be made in a curvilinear or S-shaped fashion based on surgeon preference. Dissection begins with incision of the clavipectoral fascia and identification of the lateral border of the pectoralis minor and the inferior border of the axillary vein. The vein then is traced laterally to the thoracodorsal complex. Once this has been identified with careful preservation of the nerve, attention is turned directly medially to the chest wall where the long thoracic nerve descends to the serratus.

Often, several branches of the intercostobrachial nerve can be identified superficially during axillary dissection. These can be divided if preservation means compromise of the extent of dissection. level I and II lymphatic tissue is resected with a combination of blunt and careful sharp dissection. Use of electrocautery should be avoided during deep dissection. Hemoclips or sutures are used to divide small vessels or lymphatics to reduce the risk of seroma and/or hematoma formation. Next, an axillary drain, if placed, is brought through a separate stab incision inferiorly.

For a mastectomy, the standard elliptical incision includes the nipple-areolar complex and extends from the lateral border of the sternum to the latissimus dorsi. An umbilical tape or suture may be helpful in measuring the upper and lower sides of the ellipse to ensure even lengths and avoid dog ears, particularly at the lateral corner. Cat's paw retractors or rakes are used to elevate the skin edges, and flaps are raised superiorly and inferiorly using electrocautery. Ideally, the thickness of the flaps should be approximately 1.0 cm.

This relatively avascular plane is readily identifiable with adequate flap traction perpendicular to the chest wall. The breast parenchyma is removed from medial to lateral either sharply or with electrocautery in continuity with the pectoral fascia. Care should be taken to ligate or cauterize any major perforating vessels. The axillary dissection then should proceed as described above through the same incision.

Some authors routinely place 2 drains through separate stab incisions inferior and lateral just above the inframammary fold. One is placed in the axilla and the other in the parenchymal defect. Fine subcuticular suture is used to close the skin.

In a randomized, double-blinded, parallel-group, placebo-controlled study of 66 women who had undergone ambulatory breast tumor resection, Abdallah et al found that multilevel, ultrasonographically guided paravertebral blocks and total intravenous anesthesia improved the quality of recovery and postoperative analgesia and expedited discharge in comparison with inhalational gas- and opioid-based general anesthesia. [14]

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