Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes

How I Usually Do it

Reynaldo O. Joson, MD, MHA, MHPEd, MSc SurgSeptember 5, 2014

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

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 extirpationNO surgical complications and unwanted side-effects

(or lowest acceptable rate)

Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes

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)

Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes

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?

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

Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes

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)

Intraoperative Risk Management

• Good Planning• Good 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

Asepsis

Incision

Flap Creation

Total Mastectomy

Axillary Dissection

Drain

Incision Repair

Risks

Local recurrence

Surgical complications

Unwanted side-effects

Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes

How I Usually Do it

Procedure MRM

OutcomesEvaluation

Planning Execution with contingency adjustment

Asepsis

Incision

Flap Creation

Total Mastectomy

Axillary Dissection

Drain

Incision Repair

Infection

Dehiscence

Local Recurrence

Flap Necrosis

Hematoma

Seroma

Major Axillary Vascular / Nerve Injury

Avoidance of

Others

Dog-ear Deformity

Ugly Scar

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

Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes

How I Usually Do itSurgical Complications and

Unwanted Side-effectsKey Strategies on Prevention

Infection Maintain sterility of the operative field

Iatrogenic injuries Dissect carefully and preciselyDog 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

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

Procedure MRM

OutcomesEvaluation

Planning Execution with contingency adjustment

Asepsis Infection

Key Strategies on Prevention

• Asepsis• Maintain sterility of

the operative field

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

Procedure MRM

OutcomesEvaluation

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

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

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

Procedure MRM

OutcomesEvaluation

Planning Execution with contingency adjustment

Incision

Tension-Dehiscence

Local Recurrence

Dog-ear Deformity

Key Strategies on Prevention

• Proper and accurate planning of incision before and during operation

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

Procedure MRM

OutcomesEvaluation

Planning Execution with contingency adjustment

Incision Local Recurrence

Adequate marginAt least 2 cm around palpable tumor on the surface

Key Strategies on Prevention

• Proper and accurate planning of incision before and during operation

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

Procedure MRM

OutcomesEvaluation

Planning Execution with contingency adjustment

Incision

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

Tension-Dehiscence

Key Strategies on Prevention

• Proper and accurate planning of incision before and during operation

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

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

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

45

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.

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

Procedure MRM

OutcomesEvaluation

Planning Execution with contingency adjustment

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!

Key Strategies on Prevention

• Proper and accurate planning of incision before and during operation

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.

Planning an Incision to Avoid Lateral Dog-ear Deformity

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!

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

Procedure MRM

OutcomesEvaluation

Planning Execution with contingency adjustment

Incision

Plan out incision to avoid dog-ear deformities!

Dog-ear Deformity

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

Procedure MRM

OutcomesEvaluation

Planning Execution with contingency adjustment

Not TOO thick to include breast tissue

Not TOO thin to cause flap necrosis

Flap Creation Flap Necrosis

Local RecurrenceKey Strategies on Prevention

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

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

Procedure MRM

OutcomesEvaluation

Planning Execution with contingency adjustment

Local RecurrenceTotal Mastectomy

HematomaEnsure TOTAL mastectomy!

Ensure adequate and secure hemostasis!

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

Procedure MRM

OutcomesEvaluation

Planning Execution with contingency adjustment

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

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

Procedure MRM

OutcomesEvaluation

Planning Execution with contingency adjustment

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

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

Procedure MRM

OutcomesEvaluation

Planning Execution with contingency adjustment

Promote a taut flap over the chest wall

Ensure ever-functional tube drain

Total Mastectomy Hematoma

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

Procedure MRM

OutcomesEvaluation

Planning Execution with contingency adjustment

Local Recurrence

Hematoma

Axillary Dissection

Major Axillary Vascular / Nerve Injury

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

Procedure MRM

OutcomesEvaluation

Planning Execution with contingency adjustment

Remove ALL grossly palpable masses / nodes

guided by the usual boundaries of the axilla

Local RecurrenceAxillary Dissection

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

Procedure MRM

OutcomesEvaluation

Planning Execution with contingency adjustment

Avoid injuryCareful dissection when near the areas

Axillary DissectionMajor Axillary Vascular

/ Nerve Injury

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

Procedure MRM

OutcomesEvaluation

Planning Execution with contingency adjustment

Adequate and secure hemostasis.

Axillary Dissection Hematoma

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

Procedure MRM

OutcomesEvaluation

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

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

Procedure MRM

OutcomesEvaluation

Planning Execution with contingency adjustment

Axillary Dissection Hematoma

Checking hemostasis prior to wound closure

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

Procedure MRM

OutcomesEvaluation

Planning Execution with contingency adjustment

Axillary Dissection Hematoma

Promote a taut flap over the chest wall

Ensure ever-functional tube drain

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

Procedure MRM

OutcomesEvaluation

Planning Execution with contingency adjustment

Drain lateralMedial as indicated

SeromaDrain

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

Procedure MRM

OutcomesEvaluation

Planning Execution with contingency adjustment

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

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

Procedure MRM

OutcomesEvaluation

Planning Execution with contingency adjustment

Incision Repair

Ugly Scar

Dog-ear Deformity

Dehiscence

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

Procedure MRM

OutcomesEvaluation

Planning Execution with contingency adjustment

Incision Repair Dehiscence

Avoid tension Secure knots

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

Procedure MRM

OutcomesEvaluation

Planning Execution with contingency adjustment

Avoid excessive stitch marksRailroad tracks

Avoid dog-ear deformity

Incision Repair Ugly Scar

Dog-ear Deformity

How I usually repair mastectomy wound

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

Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes

How I Usually Do it

Procedure MRM

OutcomesEvaluation

Planning Execution with contingency adjustment

Asepsis

Incision

Flap Creation

Total Mastectomy

Axillary Dissection

Drain

Incision Repair

Infection

Dehiscence

Local Recurrence

Flap Necrosis

Hematoma

Seroma

Major Axillary Vascular / Nerve Injury

Avoidance of

Others

Dog-ear Deformity

Ugly Scar

Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes

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)

Preventing Surgical Complications of Modified Radical Mastectomy – Improving Outcomes

How I Usually Do itReynaldo 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.com0918-804-03-04 (text me if you like my lecture now)

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