Mastectomy

Definition

• Removal of the breast, with or without surrounding structures.

Discussion

Mastectomies can be performed in four distinct methods, depending on the diagnosis and the extent of the pathologic findings.

1. Partial Mastectomy: Excision of breast tumor, leaving appropriate tumor-free margins.
2. Subcutaneous Mastectomy: Removal of all breast tissue. Overlying the skin and nipple are left intact.
3. Simple Mastectomy
4. 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.

Position

• Supine, with arms extended on armboards; folded sheets or sandbag under the affected shoulder.

Incision Site

• Dependent on the proposed technique

Packs/ Drapes

• Major Lap pack
• Impervious stockinette
• Extra drape sheets
• Extra Mayo tray cover
• The affected arm, once draped with stockinette, is brought through the fenestration.

Instrumentation

• Major Lap tray
• Curved Crile hemostasis
• Hemoclip
• Rake retractors
• Lahey clamps
• Intraductal probes
• Minor tray

Supplies/ Equipment

• Basin set
• Blades
• Needle counter
• Drainage system
• Pressure dressing
• Suture
• Solutions – saline water
• Medications

Procedure Overview

Partial Mastectomy

1. The incision is usually made over the lesion. The skin is elevated and the breast mass is excised.
2. Hemostasis is controlled, and the wound is irrigated with warm saline or water.
3. The wound is closed in a routine fashion, and if a drain is used, it is secured.

Simple Mastectomy

1. The skin is incised using an elliptical incision around the breast.
2. The incision is deepened with the cautery pencil or second knife, and the skin flaps are elevated.
3. Kocher or Allis clamps are placed along the skin edge and retracted upward as dissection continuous.
4. Once the skin flaps have been raised, the breast is freed from the chest wall at the level of the fascia.
5. If the incision extends at the axilla, sharp dissection is performed.
6. If a lymph node is needed for a frozen section examination, the tissue is gasped with an Allis clamp and dissected free.
7. Once the breast is completely mobilized, it is removed en bloc, and placed in a basin for fixed specimen evaluation.
8. The wound is irrigated with warm saline and the drainage system established.
9. 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.
10. The skin is then closed, and the drains are secured with the surgeon’s choice of suture and skin closure material.

Modified Radical

1. A transverse or longitudinal skin incision is performed.
2. The dissection is performed and the incision is extended well into the axilla.
3. The axillary contents are dissected free from the vascular and nerve structures, and are carefully removed.
4. Care must be taken to avoid injury to the nerve supply to various muscles.
5. After the hemostasis is achieved, the skin flaps are approximated over the drains.
6. The wound is irrigated with a warm saline and closed as described for a simple mastectomy.

Perioperative Nursing Considerations

1. 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.
2. Additional personnel may be needed to hold the arm during a circumferential extremity skin prep.
3. Several knife maybe needed because of the fibrous nature or the tissue incised.
4. Irrigation solution may be water in place of saline in order to lessen the survival of the tumor cells.
5. Estrogen and progesterone may be requested.