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Ähnlich wie Preventing Surgical Complications of Modified Radical Mastectomy - ROJoson - 14sept5
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Preventing Surgical Complications of Modified Radical Mastectomy - ROJoson - 14sept5
- 1. Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes How I Usually Do it Reynaldo O. Joson, MD, MHA, MHPEd, MSc Surg September 5, 2014
- 2. Preventing Surgical Complications of Modified Radical Mastectomy – Improving 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
- 3. Preventing Surgical Complications of Modified Radical Mastectomy – Improving 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 extirpation NO surgical complications and unwanted side-effects (or lowest acceptable rate)
- 4. Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes How I Usually Do it Good-Excellent Postoperative Outcomes NO local recurrence NO surgical complications (dehiscence, flap necrosis, hematoma, infection, major axillary vascular and nerve injury) NO unwanted side-effects (seroma, dog-ear, ugly scar)
- 5. Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes How I Usually Do it Good-Excellent Postoperative Outcomes NO local recurrence NO surgical complications (dehiscence, flap necrosis, hematoma, infection, How do we prevent major axillary vascular and nerve injuries) these? NO unwanted side-effects (seroma, dog-ear, ugly scar)
- 6. Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes How I Usually Do it For every intraoperative move made, there is a risk for surgical complications and unwanted side effects! Intraoperative Risk Management
- 7. Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes How I Usually Do it Good-Excellent Postoperative Intraoperative Outcomes Risk NO local recurrence Management NO surgical complications (dehiscence, flap necrosis, • hematoma, Good Planning infection, major axillary vascular and • nerve Good injuries) Execution NO unwanted side-effects • Good Contingency (seroma, dog-ear, ugly scar) Adjustment during Execution
- 8. Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes How I Usually Do it Procedure MRM Outcomes Evaluation Planning Execution with contingency adjustment Asepsis Incision Flap Creation Total Mastectomy Axillary Dissection Drain Incision Repair Risks Local recurrence Surgical complications Unwanted side-effects
- 9. Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes How I Usually Do it Procedure MRM Outcomes Evaluation Planning Execution with contingency adjustment Asepsis Incision Flap Creation Total Mastectomy Axillary Dissection Drain Incision Repair Local Recurrence Dehiscence Flap Necrosis Hematoma Infection Major Axillary Vascular / Nerve Injury Seroma Avoidance of Others Dog-ear Deformity Ugly Scar
- 10. Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes How I Usually Do it Surgical Complications and Unwanted Side-effects Key Strategies on Prevention Flap necrosis Provide an adequate layer of subcutaneous tissue in the flap Dehiscence Plan incision properly to avoid tension; close and repair wound securely Seroma Provide adequate drainage Bleeding and hematoma Ensure effective and adequate hemostasis
- 11. Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes How I Usually Do it Surgical Complications and Unwanted Side-effects Key Strategies on Prevention Infection Maintain sterility of the operative field Iatrogenic injuries Dissect carefully and precisely Dog ear Plan and close incision properly (with trimming if needed to avoid dog ear) Ugly scar Plan and close incision properly to promote a cosmetically acceptable scar Local recurrence Provide adequate surgical margins around the breast cancer mass
- 12. Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes How I Usually Do it Procedure MRM Outcomes Evaluation Planning Execution with contingency adjustment Asepsis Infection Key Strategies on Prevention • Asepsis • Maintain sterility of the operative field
- 13. Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes How I Usually Do it Procedure MRM Outcomes Evaluation Planning Execution with contingency adjustment Asepsis Infection Procedures to eliminate / reduce microorganisms in operative field Suture drapes along the posterior axillary line to avoid contamination of the lateral field (close to operating table) and during axillary dissection
- 14. Suturing of the Drape along the Posterior Axillary Line to Prevent Contamination in the Lateral Field
- 15. Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes How I Usually Do it Procedure MRM Outcomes Evaluation Planning Execution with contingency adjustment Incision Local Recurrence Tension-Dehiscence Dog-ear Deformity Key Strategies on Prevention • Proper and accurate planning of incision before and during operation
- 16. Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes How I Usually Do it Key Strategies on • Proper and accurate Procedure MRM Outcomes Evaluation Prevention planning of incision before and during operation Planning Execution with contingency adjustment Incision Local Recurrence Adequate margin At least 2 cm around palpable tumor on the surface
- 17. Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes How I Usually Do it Key Strategies on • Proper and accurate Procedure MRM Outcomes Evaluation Prevention planning of incision before and during operation Planning Execution with contingency adjustment Incision Tension-Dehiscence Determine the axis/ direction of the elliptical incision that will best promote primary closure without tension.
- 18. Planning an Incision to Determine Direction of Elliptical Incision 1° Objective: Primary closure without tension
- 19. Planning an Incision to Determine Direction of Elliptical Incision 1° Objective: Primary closure without tension
- 20. Planning an Incision to Determine Direction of Elliptical Incision 1° Objective: Primary closure without tension 4 5
- 21. Planning the Incision Avoid a scar that can be seen when patient wears a bra!
- 22. Planning an Incision Avoid placement of the scar at the upper and mid-sternal areas (areas known to be keloid prone). Place at the lower part.
- 23. Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes How I Usually Do it Key Strategies on • Proper and accurate Procedure MRM Outcomes Evaluation Prevention planning of incision before and during operation Planning Execution with contingency adjustment Incision Dog-ear Deformity Plan out incision to avoid dog-ear deformities! Frequent, particularly in patients with large body habitus and large breast Unsightly and source of long-term discomfort!
- 24. Planning an Incision to Avoid Lateral Dog-ear Deformity 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.
- 25. 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.
- 26. Techniques to Avoid Lateral Dog-ear Deformity Tear-drop / Waisted Teardrop Y-incision / Fish-tail Sliding-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!
- 27. Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes How I Usually Do it Procedure MRM Outcomes Evaluation Planning Execution with contingency adjustment Incision Dog-ear Deformity Plan out incision to avoid dog-ear deformities!
- 28. Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes How I Usually Do it Procedure MRM Outcomes Evaluation Planning Execution with contingency adjustment Flap Creation Flap Necrosis Not TOO thick to include breast tissue Not TOO thin to cause flap necrosis Local Recurrence Key Strategies on Prevention
- 29. Flap Creation – How I Usually Do It 1-cm of subcutaneous tissue (subcutaneous tissues only – pink-whitish tissues stay away)
- 30. Flap Creation – How I Usually Do It Control thickness / thinness of flap
- 31. Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes How I Usually Do it Procedure MRM Outcomes Evaluation Planning Execution with contingency adjustment Total Mastectomy Local Recurrence Hematoma Ensure TOTAL mastectomy! Ensure adequate and secure hemostasis!
- 32. Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes How I Usually Do it Procedure MRM Outcomes Evaluation Planning Execution with contingency adjustment Total Mastectomy Local Recurrence 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
- 33. Removing part of pectoralis major muscle in MRM
- 34. Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes How I Usually Do it Procedure MRM Outcomes Evaluation Planning Execution with contingency adjustment Total Mastectomy Hematoma 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
- 35. Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes How I Usually Do it Procedure MRM Outcomes Evaluation Planning Execution with contingency adjustment Total Mastectomy Hematoma Promote a taut flap over the chest wall Ensure ever-functional tube drain
- 36. Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes How I Usually Do it Procedure MRM Outcomes Evaluation Planning Execution with contingency adjustment Local Recurrence Hematoma Axillary Dissection Major Axillary Vascular / Nerve Injury
- 37. Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes How I Usually Do it Procedure MRM Outcomes Evaluation Planning Execution with contingency adjustment Axillary Dissection Local Recurrence Remove ALL grossly palpable masses / nodes guided by the usual boundaries of the axilla
- 38. Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes How I Usually Do it Procedure MRM Outcomes Evaluation Planning Execution with contingency adjustment Axillary Dissection Major Axillary Avoid injury Careful dissection when near the areas Vascular / Nerve Injury
- 39. Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes How I Usually Do it Procedure MRM Outcomes Evaluation Planning Execution with contingency adjustment Axillary Dissection Hematoma Adequate and secure hemostasis.
- 40. Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes How I Usually Do it Procedure MRM Outcomes Evaluation Planning Execution with contingency adjustment Axillary Dissection Hematoma 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
- 41. Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes How I Usually Do it Procedure MRM Outcomes Evaluation Planning Execution with contingency adjustment Axillary Dissection Hematoma Checking hemostasis prior to wound closure
- 42. Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes How I Usually Do it Procedure MRM Outcomes Evaluation Planning Execution with contingency adjustment Axillary Dissection Hematoma Promote a taut flap over the chest wall Ensure ever-functional tube drain
- 43. Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes How I Usually Do it Procedure MRM Outcomes Evaluation Planning Execution with contingency adjustment Drain Seroma Drain lateral Medial as indicated
- 44. Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes How I Usually Do it Procedure MRM Outcomes Evaluation Planning Execution with contingency adjustment Drain Seroma 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)
- 45. Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes How I Usually Do it Procedure MRM Outcomes Evaluation Planning Execution with contingency adjustment Incision Repair Dehiscence Ugly Scar Dog-ear Deformity
- 46. Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes How I Usually Do it Procedure MRM Outcomes Evaluation Planning Execution with contingency adjustment Incision Repair Dehiscence Avoid tension Secure knots
- 47. Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes How I Usually Do it Procedure MRM Outcomes Evaluation Planning Execution with contingency adjustment Incision Repair Ugly Scar Avoid excessive stitch marks Railroad tracks Avoid dog-ear deformity Dog-ear Deformity
- 49. How I usually repair mastectomy wound
- 51. Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes How I Usually Do it For every intraoperative move made, there is a risk for surgical complications and unwanted side effects! Intraoperative Risk Management
- 52. Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes How I Usually Do it Procedure MRM Outcomes Evaluation Planning Execution with contingency adjustment Asepsis Incision Flap Creation Total Mastectomy Axillary Dissection Drain Incision Repair Local Recurrence Dehiscence Flap Necrosis Hematoma Infection Major Axillary Vascular / Nerve Injury Seroma Avoidance of Others Dog-ear Deformity Ugly Scar
- 53. Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes How I Usually Do it Good-Excellent Postoperative Outcomes NO local recurrence NO surgical complications (dehiscence, flap necrosis, hematoma, infection, major axillary vascular and nerve injury) NO unwanted side-effects (seroma, dog-ear, ugly scar)
- 54. Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes How I Usually Do it Reynaldo O. Joson, MD, MHA, MHPEd, MSc Surg September 5, 2014 For further reading and copies of my slides: http://www.slideshare.net/rjoson/mastectomy-morbidities-pghrj08sept11 http://www.slideshare.net/rjoson/preventing-complications For feedback and queries: rjoson2001@yahoo.com 0918-804-03-04 (text me if you like my lecture now) Facebook / rjoson2001
Hinweis der Redaktion
- Modified radical mastectomy is a surgical procedure that removes the whole breast and the ipsilateral axillary lymph nodes that contain or may contain cancer.
- Good-excellent postoperative outcomes means complete or adequate removal of the whole breast and the ipsilateral axillary lymph nodes that contain or may contain cancer with NO surgical complications and unwanted side-effects as much as possible, if not, with the lowest acceptable frequency such as 1-2%.
- More specifically, we are talking of NO local recurrence; NO surgical complications; and NO unwanted side-effects. Examples of surgical complications to avoid are dehiscence; flap necrosis; hematoma; infection; major axillary vascular and nerve injury. Examples of unwanted side-effects are seroma, dog ear deformity, and ugly scar. There are others. For today, I will focus on the items listed.
- So how to prevent these complications?
- Let me start by saying that for every intraoperative move made by a surgeon, there is always a risk for surgical complications and unwanted side effects. Thus, every surgeon has to do an intraoperative risk management.
- It consists of good planning; good execution and good contingency adjustments during the execution.
- There must be good planning on asepsis; incision; flap creation; total mastectomy; axillary dissection; use of drain; and incision repair with good execution and contingency adjustments during execution to avoid the risks of local recurrence; surgical complications; and unwanted side-effects.
- As I said, we will focus on these nine risks today.
- Let’s start with asepsis. There must be good planning and execution of the plan with contingency adjustment to reduce the risk of postoperative wound infection.
- Another recommended procedure is to suture drapes along the posterior axillary line to avoid contamination of the lateral field, which is close to the operating table, and during axillary dissection.
- Like so.
- For the incision, there must be good planning and execution of the plan with contingency adjustment to reduce the risk of local recurrence; tension during closure which may lead to dehiscence; and dog-ear deformity, particularly, on the axillary area.
- The first thing to do to lessen the risk of local recurrence is to have an adequate margin with at least 2 cm around the palpable tumor on the surface.
- The strategy that I usually use is to determine the long axis or direction of the elliptical incision that will best promote primary closure of the resultant mastectomy wound without tension.
- In this slide, the manuevers are being done to see whether a vertical elliptical incision can facilitate primary closure without tension. In this slide, the vertical direction of the elliptical incision cannot be done as the nipple-areola complex is far away.
- In this slide, the manuevers are being done again to see whether the decided elliptical incision can really facilitate primary closure without tension. With such maneuvers, one can be confident there will be no problem of primary closure and no tension and therefore, prevent or minimize risk of dehiscence related to tension.
- If there are several directions that can be used to promote primary closure, factor in cosmetic goal to make the final choice. The final elliptical incision does not have to be completely transverse, oblique, or vertical in a straight line. There may be curvings at both ends of the elliptical incision, as illustrated in No. 3 planned incision here. The lateral curving is done for cosmetic reasons, such as avoiding a scar that can be seen when patient wears a bra; to avoid risk of keloid in the sternal area; and to avoid lateral dog-ear deformity.
- such as avoiding a scar that can be seen when patient wears a bra (put the incision-line in the lower part of the sternum).
- to avoid risk of keloid in the sternal area (avoid placement of the scar at the upper and mid-sternal areas as these ae areas known to be keloid prone). Place at the lower part.
- The other consideration in the incision planning is to avoid lateral dog-ear deformity. This is frequently seen in obese patients and those with large breasts. This is not only unsightly but a source of long-term discomfort.
- There are several techniques that are being proposed to avoid a lateral dog-ear deformity. Shown here is the sliding-suturing technique in which the upper flap is divided into 2 parts and lower flap into 3 parts. The distal 1/3 of the lower flap is slided and sutured to to upper ½ of the upper flap.
- Another technique is the D-incision with triangular advancement meaning initially draw a D-incision as shown and then make a triangular extension of the incision and then suture the outer upper flap to the outlined triangular area.
- Thus, there are various techniques that one can choose from to avoid a lateral dog-ear deformity. I have tried all of them. At the moment, my stand is that there is no so-called one and only one-best technique. It will depend on the patient’s body stature, the location and size of the breast cancer; etc. What I can say is planning preoperatively (in standing, lying down, with arms on the side and extended) and before the incision at the operating table is the strategy to avoid a lateral dog-ear deformity. Choose from whichever technique that are being proposed with some adjustment if needed to avoid the dog-ear deformity as much as possible.
- Always have in mind this target - no or minimal lateral dog-ear deformity – like those seen in this slide.
- Let us now go to flap creation. There must be planning and execution with contingency adjustments on flap creation to prevent flap necrosis and local recurrence. The principle to follow is NOT too thick to include breast tissue to lessen the risk for local recurrence and NOT too thin to cause flap necrosis.
- What I usually do are the following: I make sure there is about 1-cm layer of subcutaneous tissue in the flap and I stay only at the layer of the yellow subcutaneous tissue – I stay away from pinkish and whitish tissues which I consider are breast tissues.
- I usually use my fingers, not clamps, when I establish the flaps, as I have better control of the thickness or thinness of the flap.
- Let us now go to total mastectomy. There must be planning and execution with contingency adjustments on total mastectomy to prevent local recurrence and hematoma. The strategies to follow are to ensure total removal of the breast to minimize the risk of local recurrence and adequate and secure hemostasis to minimize the risk of bleeding and hematoma.
- To minimize the risk of local recurrence during mastectomy, I am guided by these principles: 1) I ensure my flap is not too thick to include breast tissue (I am guided by the color of the tissue I am cutting when I am establishing the flap – I stay only the layer of the yellow subcutaneous tissue – I stay away from pinkish and whitish tissues which I consider are breast tissues); 2) I am guided by the usual boundaries of the breast (clavicle; latissimus dorsi; parasternal line; and rectus sheath); and 3) I remove part of the pectoralis muscle or other underlying tissue if the breast cancer mass is too near it.
- Like so.
- To minimize the risk of postoperative bleeding and hematoma, I am guided by these principles: 1) Ligate transected blood vessels ≥ 2mm in diameter; 2) Cauterize fully transected vessels which will not be ligated; 3) Ligate and cauterize transected blood vessels right away; 4) Checking of hemostasis prior to wound closure;
- Promoting a taut flap over the chest wall and ensuring ever-functional tube drain or drains.
- In the axillary dissection, there must be planning and execution with contingency adjustments to prevent local recurrence, hematoma, and injury to major axillary vascular and nerve.
- The strategy to minimize the risk of local recurrence is to remove all palpable masses or nodes in the axilla guided by the usual boundaries of the axilla.
- The strategy to minimize the risk of injury to the major axillary vessels and nerves is careful dissection when near the usual location of these structures.
- The strategy to minimize the risk of bleeding and hematoma is adequate and secure hemostasis.
- To minimize the risk of postoperative bleeding and hematoma, I am guided by these principles: 1) Ligate transected blood vessels ≥ 2mm in diameter; 2) Cauterize fully transected vessels which will not be ligated; 3) Ligate and cauterize transected blood vessels right away; 4) Checking of hemostasis prior to wound closure.
- Procedures that I usually use in checking hemostasis prior to wound closure consist of directly looking for bleeding in the whole operative field and using a maneuver of pouring sterile water into the axillary space to facilitate detection of bleeding, if present. There will be red staining of the water if there is bleeding.
- Promoting a taut flap over the chest wall and axilla; and also ensuring an ever-functional tube drain or drains.
- As to the use of drain, consider its use to prevent seroma formation. I usually use drain on the axilla. I use a drain in the parasternal area only there is a big dead space that I cannot obliterate.
- Thus, the principles that I follow are: 1) closed tube suction drain at the axillary space; 2) medial drain is indicated if there is a significant cavity after laying down the flaps prior to wound repair; and 3) drain/s are removed if the output is less than 50 cc during the past 24 hours.
- As to the repair of the mastectomy wound, there must be planning and execution with contingency adjustments to minimize risk of a dehiscence, an ugly scar and dog-ear deformity.
- Avoiding tension and providing well-secured knots are the two key strategies in avoiding dehiscence. Tension-avoidance is considered early on in the phase of incision planning.
- To prevent ugly scar, avoid excessive stitch marks which may resemble railroad tracks. Avoid dog-ear deformity.
- A close-up of an ugly scar with plenty of stitch marks and dog-ear deformity. Avoid this kind of an outcome.
- What I usually do, I usually use embedded absorbable sutures. I put attention in avoiding dog-ears like this.
- Always end with a wound repair that is appreciated as beautiful, not ugly, such as this, taut, no dog-ears, with minimal stitch mark.
- I am done with sharing with you what I usually do to prevent surgical complications of MRM thereby improving outcomes. In closing, if I may, my general take-home messages for you will be, one, for every intraoperative move made by a surgeon, by us, by you, always remember there is always a risk for surgical complications and unwanted side effects. Thus, all of us have to do an intraoperative risk management.
- I have shared with you how to do an intraoperative risk management using this slide. Essentially, the intraoperative risk management consists of planning and execution with contingency adjustments in consideration of the risks that may be involved with every surgical move.
- If you follow such an approach, I assure you (based on my experience), you will produce good-excellent postoperative outcomes in your modified radical mastectomy in terms NO or minimal local recurrence; NO or minimal surgical complications; and NO or minimal unwanted side-effects.
- On that note, I end my presentation. I hope I have shared things that you like. For further reading and copies of my slides, you may visit these sites which contain the lecture that I made in 2008 with focus on seroma, bleeding, and infection. For queries and feedback, you may email me; you can text me; or interact with me in Facebook. Thank you.