Preventing Surgical Complications of Modified Radical Mastectomy

transcript

Back to BasicsPreventing Complications – Improving Outcomes

Preventing Complications of Breast Surgery

Reynaldo O. Joson, MD, MHA, MHPEd, MSc SurgSeptember 5, 2013

Back to BasicsPreventing Complications – Improving Outcomes

Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes

How I Usually Do it

Reynaldo O. Joson, MD, MHA, MHPEd, MSc SurgSeptember 5, 2013

How I Usually Do it

Preventing Surgical Complications toImprove Outcomes of MRM?

How I Usually Do it

MRM Procedure

To remove the whole breast and the ipsilateral axillary lymph nodes that contain or may contain

cancer

How I Usually Do it

MRM Procedure

cancer

GOOD-EXCELLENT POSTOPERATIVE OUTCOMES

How I Usually Do it

MRM Procedure

cancer

GOOD-EXCELLENT POSTOPERATIVE OUTCOMES?

How I Usually Do it

MRM Procedure

To remove the whole breast and the ipsilateral axillary lymph nodes that contain or may contain cancer

GOOD-EXCELLENT POSTOPERATIVE OUTCOMES?

Complete extirpationNO surgical complications and unwanted side-effects

(or lowest acceptable rate)

How I Usually Do it

Good-Excellent Postoperative Outcomes

NO local recurrenceNO surgical complications

(dehiscence, flap necrosis, hematoma, infection, major axillary vascular and nerve injury)

NO unwanted side-effects (seroma, dog-ear, ugly scar)

How I Usually Do it

Good-Excellent Postoperative OutcomesNO local recurrenceNO surgical complications (dehiscence, flap necrosis, hematoma, infection, major axillary vascular and nerve injuries)NO unwanted side-effects (seroma, dog-ear, ugly scar)

How do we prevent these?

How I Usually Do it

For every intraoperative move made, there is a risk for surgical complications and

unwanted side effects!

Intraoperative Risk Management

How I Usually Do it

How do we prevent these?

How I Usually Do it

Good PlanningGood Execution

Good Contingency Adjustment during

Execution

Preventing Surgical Complications of Modified Radical Mastectomy – Improving OutcomesHow I Usually Do it

Procedure MRM

OutcomesEvaluation

Planning Execution with contingency adjustment

AsepsisIncision

Flap CreationTotal MastectomyAxillary Dissection

DrainIncision Repair

Local recurrence

Surgical complications

Unwanted side-effects

Procedure MRM

OutcomesEvaluation

AsepsisIncision

Infection

DehiscenceLocal Recurrence

Flap NecrosisHematoma

SeromaMajor Axillary Vascular / Nerve Injury

Avoidance of

Others

Dog-ear Deformity

Ugly Scar

Procedure MRM

OutcomesEvaluation

Asepsis Infection

Procedure MRM

OutcomesEvaluation

Asepsis Infection

Procedures to eliminate / reduce microorganisms in operative field

Sterilize an operative field with a wide boundary

(at least 3 in)

Sterilize an operative field with a wide boundary (at least 3 in)

Supraclavicular area Subcostal

Upper arm

Contralateral mid-clavicular line

Posterior axillary line

Procedure MRM

OutcomesEvaluation

Asepsis Infection

Suture drapes along the posterior axillary line

to avoid contamination of the lateral field (close to operating table) and

during axillary dissection

Suturing of the Drape along the Posterior Axillary Line to Prevent Contamination in the Lateral Field

Procedure MRM

OutcomesEvaluation

Asepsis Infection

Maintain sterility of the operative field during the entire operation

Avoid contamination of operative fieldby unsterilized instruments, gloves, dirty specimen, etc.

Procedure MRM

OutcomesEvaluation

IncisionTension-Dehiscence

Local Recurrence

Dog-ear Deformity

Procedure MRM

OutcomesEvaluation

IncisionTension-Dehiscence

Local Recurrence

Planning and accurate planningBEFORE operation / incision! Dog-ear Deformity

Procedure MRM

OutcomesEvaluation

Incision Local Recurrence

Adequate marginAt least 2 cm around palpable tumor on the surface

Planning an Incision to Get an Adequate Margin

Outline the border of the mass

Allot at least 2-cm margin around the palpable border of the mass.

May be more if possible and if needed to have a taut (but no tension) mastectomy flap closure to avoid seroma and unsightly bulges.

Not too large to cause tension and dehiscence though.

Procedure MRM

OutcomesEvaluation

Incision

Determine the axis/ direction of the elliptical incision that will best promote primary closure without tension.

Tension-Dehiscence

Planning an Incision to Determine Direction of Elliptical Incision 1° Objective: Primary closure without tension

Avoid a scar that can be seen when patient wears a bra!

Planning the Incision

Planning an IncisionAvoid placement of the scar at the upper and mid-sternal

areas (areas known to be keloid prone).

Place at the lower part.

Procedure MRM

OutcomesEvaluation

Incision

Plan out incision to avoid dog-ear deformities!

Dog-ear Deformity

Frequent, particularly in patients with large body habitus and large breast

Unsightly and source of long-term discomfort!

Sliding-suturing

(Devalia Technique)

Devalia H, Chaudhry A, Rainsbury RM, Minakaran N, Banerjee D. An oncoplastic technique to reduce the formation of lateral 'dog-ears' after mastectomy. Int Semin

Surg Oncol. 2007 Dec 17; 4:29.

Planning an Incision to Avoid Lateral Dog-ear Deformity

D-incision with Triangular Advancement

IC Bennett and MA Biggar . A triangular advancement technique to avoid the dog-ear deformity following mastectomy in large breasted women

Ann R Coll Surg Engl. 2011 October; 93(7): 554–555.

Tear-drop shaped incision

Mirza M, S. K., Fortes-Mayer K. and W. M. H. (2003). "Tear-drop incision for mastectomy to avoid dog-ear deformity." Ann R Coll Surg Engl. 85(2):131.

Waisted TeardropRebecca Thomas, Christine Mouat and Burton King. Mastectomy flap design: the ‘waisted teardrop’ and a method to reduce the lateral fold. ANZ J Surg 82 (2012) 329–333.

Initial drawing of elliptical incision

Retract laterally medial side and redraw to make a teardrop incision

Retract medially lateral side and redraw to make a teardrop incision(broader base)

Waisted Teardrop

Rebecca Thomas, Christine Mouat and Burton King. Mastectomy flap design: the ‘waisted teardrop’ and a method to reduce the lateral fold. ANZ J Surg 82 (2012) 329–333.

Resultant waisted” teardrop incision

Y-incision / Fish-tail Incision

Techniques to Avoid Lateral Dog-ear DeformityTear-drop / Waisted Teardrop

Y-incision / Fish-tailSliding-suturing

Planning preoperatively (standing, lying down, with arms on the side and extended) and before the incision is the strategy to avoid a dog-

ear deformity!

Procedure MRM

OutcomesEvaluation

Incision

Plan out incision to avoid dog-ear deformities!

Dog-ear Deformity

Procedure MRM

OutcomesEvaluation

Not TOO thick to include breast tissue

Not TOO thin to cause flap necrosis

Flap Creation Flap Necrosis

Local Recurrence

Flap Creation – How I Usually Do It

1-cm of subcutaneous tissue(subcutaneous tissues only –

pink-whitish tissues stay away)

Flap Creation – How I Usually Do It

Control thickness / thinness of flap

Procedure MRM

OutcomesEvaluation

Local RecurrenceTotal MastectomyHematoma

Ensure TOTAL mastectomy!Ensure adequate and secure hemostasis!

Procedure MRM

OutcomesEvaluation

Flap not TOO thick to include breast tissue

Be guided by the usual boundaries of the breast (clavicle, latissimus dorsi,

parasternal, rectus sheath)

Remove part of the pect major if too near

Local RecurrenceTotal Mastectomy

Removing part of pectoralis major muscle in MRM

Procedure MRM

OutcomesEvaluation

Ligate transected blood vessels ≥ 2 mm In diameter

Cauterize fully – transected vessels not to be ligated

Ligate and cauterize blood vessels right away

Check hemostasis prior to wound closure

Total Mastectomy Hematoma

Procedure MRM

OutcomesEvaluation

Promote a taut flap over the chest wall

Ensure ever-functional tube drain

Total Mastectomy Hematoma

Procedure MRM

OutcomesEvaluation

Local RecurrenceHematoma

Axillary Dissection

Major Axillary Vascular / Nerve

Injury

Procedure MRM

OutcomesEvaluation

Remove ALL grossly palpable masses / nodes

guided by the usual boundaries of the axilla

Local RecurrenceAxillary Dissection

Procedure MRM

OutcomesEvaluation

Avoid injuryCareful dissection when near the areas

Axillary Dissection Major Axillary Vascular / Nerve

Injury

Procedure MRM

OutcomesEvaluation

Adequate and secure hemostasis.

Axillary Dissection Hematoma

Procedure MRM

OutcomesEvaluation

Ligate transected blood vessels ≥ 2 mm In diameter

Cauterize fully – transected vessels not to be ligated

Ligate and cauterize blood vessels right away

Check hemostasis prior to wound closure

Procedure MRM

OutcomesEvaluation

Checking hemostasis prior to wound closure

Procedure MRM

OutcomesEvaluation

Promote a taut flap over the chest wall

Ensure ever-functional tube drain

Procedure MRM

OutcomesEvaluation

Drain lateralMedial as indicated

SeromaDrain

Procedure MRM

OutcomesEvaluation

Closed tube suction drain at axillary space

Medial drain indicated if there is a significant cavity

after laying down of flaps prior to wound repair

Drain removed if output is less than 50 cc

past 24 hours (assumption: tube functional)

SeromaDrain

Procedure MRM

OutcomesEvaluation

Incision RepairUgly Scar

Dog-ear Deformity

Dehiscence

Procedure MRM

OutcomesEvaluation

Incision Repair Dehiscence

Avoid tension Secure knots

Procedure MRM

OutcomesEvaluation

Avoid excessive stitch marksRailroad tracks

Avoid dog-ear deformity

Incision Repair Ugly Scar

Dog-ear Deformity

How I usually repair mastectomy wound

How I Usually Do it

For every intraoperative move made, there is a risk for surgical complications and

unwanted side effects!

Procedure MRM

OutcomesEvaluation

AsepsisIncision

Infection

DehiscenceLocal Recurrence

Flap NecrosisHematoma

SeromaMajor Axillary Vascular / Nerve Injury

Avoidance of

Others

Dog-ear Deformity

Ugly Scar

How I Usually Do it

Good-Excellent Postoperative Outcomes

NO local recurrenceNO surgical complications

(dehiscence, flap necrosis, hematoma, infection, major axillary vascular and nerve injury)

NO unwanted side-effects (seroma, dog-ear, ugly scar)

How I Usually Do itReynaldo O. Joson, MD, MHA, MHPEd, MSc Surg

September 5, 2013

For further reading and copies of my slides:http://www.slideshare.net/rjoson/mastectomy-morbidities-pghrj08sept11

http://www.slideshare.net/rjoson/preventing-mrm-complications-pghrj13sept5

For feedback and queries:

rjoson2001@yahoo.com0918-804-03-04 (text me if you like my lecture now)

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Preventing Surgical Complications of Modified Radical Mastectomy

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