- Removal of the breast, with or without surrounding structures.
Mastectomies can be performed in four distinct methods, depending on the diagnosis and the extent of the pathologic findings.
- Partial Mastectomy: Excision of breast tumor, leaving appropriate tumor-free margins.
- Subcutaneous Mastectomy: Removal of all breast tissue. Overlying the skin and nipple are left intact.
- Simple Mastectomy
- Radical Mastectomy:
- Modified radical – removal of breast and axillary lymph nodes. Most frequently performed.
- Classic radical – includes removal of the entire breast, pectoralis muscles, axillary lymph nodes, fats, fascia, and adjunct tissue.
- Extended radical – bloc removal of breast, axillary contents, pectoralis muscles, and internal mammary lymph nodes.
- Supine, with arms extended on armboards; folded sheets or sandbag under the affected shoulder.
- Dependent on the proposed technique
- Major Lap pack
- Impervious stockinette
- Extra drape sheets
- Extra Mayo tray cover
- The affected arm, once draped with stockinette, is brought through the fenestration.
- Major Lap tray
- Curved Crile hemostasis
- Rake retractors
- Lahey clamps
- Intraductal probes
- Minor tray
- Basin set
- Needle counter
- Drainage system
- Pressure dressing
- Solutions – saline water
- The incision is usually made over the lesion. The skin is elevated and the breast mass is excised.
- Hemostasis is controlled, and the wound is irrigated with warm saline or water.
- The wound is closed in a routine fashion, and if a drain is used, it is secured.
- The skin is incised using an elliptical incision around the breast.
- The incision is deepened with the cautery pencil or second knife, and the skin flaps are elevated.
- Kocher or Allis clamps are placed along the skin edge and retracted upward as dissection continuous.
- Once the skin flaps have been raised, the breast is freed from the chest wall at the level of the fascia.
- If the incision extends at the axilla, sharp dissection is performed.
- If a lymph node is needed for a frozen section examination, the tissue is gasped with an Allis clamp and dissected free.
- Once the breast is completely mobilized, it is removed en bloc, and placed in a basin for fixed specimen evaluation.
- The wound is irrigated with warm saline and the drainage system established.
- If a Hemo Vac drain is used, the drainage tubes are brought out of the skin flap through two stab wounds created with the Hemo Vac trocar.
- The skin is then closed, and the drains are secured with the surgeon’s choice of suture and skin closure material.
- A transverse or longitudinal skin incision is performed.
- The dissection is performed and the incision is extended well into the axilla.
- The axillary contents are dissected free from the vascular and nerve structures, and are carefully removed.
- Care must be taken to avoid injury to the nerve supply to various muscles.
- After the hemostasis is achieved, the skin flaps are approximated over the drains.
- The wound is irrigated with a warm saline and closed as described for a simple mastectomy.
Perioperative Nursing Considerations
- If a mastectomy is to follow a biopsy, the drape should be reinforced with clean towels, the team should change gloves, and the biopsy instruments are removed.
- Additional personnel may be needed to hold the arm during a circumferential extremity skin prep.
- Several knife maybe needed because of the fibrous nature or the tissue incised.
- Irrigation solution may be water in place of saline in order to lessen the survival of the tumor cells.
- Estrogen and progesterone may be requested.