mastectomy

The main purpose of radical mastectomy is to remove the primary tumor, extensively remove the affected skin and lymph nodes in the area, and to minimize the impact of the shape and function of the operation. Breast cancer is characterized by multi-centeredness. Clinically discovered tumors are only the most prominent part of cancer. The larger the lesion in breast cancer, the higher the incidence of polycentricity. The later the stage of breast cancer, the higher the rate of axillary lymph node metastasis. Traditional radical mastectomy is the simultaneous removal of lymph nodes. Studies have shown that regional lymph nodes have immune function, so whether you need to do axillary lymph node dissection, the opinions are still inconsistent. Some authors believe that the presence or absence of metastasis of axillary lymph nodes is only meaningful for clinical staging. Determining the presence or absence of axillary lymph node metastasis is only a basis for adjuvant therapy. Therefore, the significance of axillary lymph node biopsy seems to be more practical than the removal of cancerous foci. Another author attaches great importance to the removal of axillary lymph nodes, strives for residual tumors in the breast area, improves the cure rate of early cancer and reduces the recurrence rate of cancer in the chest and ankle areas after breast cancer surgery. Clinical studies have shown that the lymph node metastasis rate of the primary breast cancer lesions <1cm is much lower than that of the larger cancer lymph node metastasis. The higher the proportion of axillary lymph node metastasis, the worse the prognosis, and the lymph node metastasis is more than the primary cancer. Size is more meaningful for predictive treatment. Breast cancer is a systemic disease, and surgical treatment is only an important aspect of comprehensive treatment. Radiation and chemical therapy, female hormone therapy and neuroendocrine regulation are not negligible treatments Treating diseases: breast cancer Indication Radical mastectomy is suitable for breast cancer in stage I and II (according to TNM international stage). There is no distant metastasis of heart, lung, liver, bone and brain. The general condition is still good, younger, no serious heart and lung function. Abnormal. Contraindications There are dyscrasia, breast skin with extensive orange peel and multiple satellite nodules, cancer and skin adhesions, accompanied by cancerous ulcers. Breast cancer and the chest wall adhesion fixation, the parasternal and supraclavicular lymph nodes have metastasis. The metastasis of cancer cells is metastasized, the lymph node adhesions are aggregated into blocks, the sacral vein is invaded, and the upper limb edema is affected. Preoperative preparation The nature of the tumor should be as clear as possible before radical surgery. Fine needle aspiration can now be used for cytology. Experienced doctors draw tissue from larger lesions with diagnostic accuracy of over 90%. However, for small lesions, such as cytology, can not judge its nature, you should first open the suspicious tissue during the operation to perform a rapid biopsy or completely remove the smaller mass and immediately perform pathological examination. The cut site should be within the scope of the radical resection. When performing a radical surgery for a cancer, the instruments used for biopsy should not be used repeatedly in radical surgery. The surgical field should be re-sterilized and surgical gowns and gloves replaced. There should also be a correct estimate of the extent of local lesions and whether there is distant metastasis in the lungs, bones or viscera before surgery. If the primary tumor is large and the regional lymph nodes are metastasized, cancer cells are hidden in the above-mentioned areas, and there will be obvious clinical manifestations in the short term after surgery. Therefore, every patient with breast cancer should undergo a very detailed and comprehensive examination. Blind expansion of the surgical indications can not improve the quality of treatment. On the contrary, serious surgical trauma may damage the body's immune mechanism and adversely affect the patient. Surgical procedure 1. The incision has been designed in a variety of ways, as shown. At present, a fusiform incision is often used. The size of the breast determines the orientation of the incision based on the location of the tumor. Marked 5 cm from the edge of the tumor, and then a longitudinal fusiform incision centered on the tumor. The margin should be kept as far as possible from the tumor to avoid tumor infiltration. The axis of the longitudinal fusiform incision can be directed to the umbilicus, and a transverse fusiform incision can be made according to the same principle. Due to the different shape of the breast and the location of the lumps, the flaps on both sides of the incision are not equal, especially those with obesity and loose skin. After suturing, a "dog ear" deformity is often formed on the outside of the incision. Nowacki MP introduces the fish-shaped incision, adding two triangular incisions to the outside of the fusiform transverse incision so that the incisions are equally long on both sides, cutting off excess loose skin. At the same time, the axilla can be fully exposed, and the incision is sutured to form a T or Y shape. The incision should not be cut to the middle of the armpit and the upper arm to prevent the scar from restricting the movement of the upper limb. The cutting edge of the skin should be no less than 5cm from the tumor, and according to the axillary fossa and the chest wound, the curvature of the cutting edge can be adjusted or an additional incision can be made to extend, such as the upper edge of the incision is longer than the lower edge. 2. After cutting the skin, use a sharp blade or electric knife, laser knife to separate the flap, and make a sharp anatomy in the skin and superficial fascia, from the plane of the clavicle, down to the rectus abdominis, inside and outside the flap. The boundary is the median line of the proximal sternum and the anterior latissimus dorsi, leaving the capillary layer supplying the flap. 3. At the sterno-lock joint, the pectoralis major muscle is bluntly separated, and the cephalic vein is exposed in the deltoid muscle of the pectoralis major muscle above the incision. 4. The pectoralis major muscle is exposed along the lower part of the clavicle. The pectoralis major muscle is cut 2 to 3 cm from the cephalic vein, and then the pectoralis major muscle is bluntly separated to the greater tibia. The proximal tendon is separated from the clavicle and sternum, and the pectoralis major muscle is transected. The thoracic and aortic nerves and the thoracic medial nerve were cut and ligated, and the pectoralis major muscle was cut from the attachment of the sternal border. 5. Separate the pectoralis minor muscles, cut and ligature the muscular vascular vessels at the inner edge. The pectoralis minor muscle tendon is disconnected at the attachment of the condyle, revealing the armpit. The thoracic fascia was separated from the superficial temporal muscle of the lower clavicle. The chest and shoulders, the radial artery, the iliac vein and the brachial plexus are revealed. 6. Clear the axillary lymphoid adipose tissue around important blood vessels and nerves, cut the iliac vascular sheath, cut off the thoracic and subscapular vessels and supply the blood vessels of the anterior serratus, and separate the axillary and subclavian lymph and adipose tissue from the chest wall. The excised tissues include the pectoralis major, the pectoralis minor, the adipose tissue of the armpit, the lymph and mammary glands, the cancerous tissue, and the skin of the breast. 7. Completely remove the lymphoid tissues of the breast, pectoralis major, pectoralis minor and axilla, and preserve the thoracic nerve and thoracodorsal nerve. 8. Check for no active bleeding in the wound, wash off the adipose tissue and residual blood clots. When suturing the incision, the flap should be aligned without tension, and the self-made mouth should be disposed at least into the vacuum suction tube, and the residual cavity should be eliminated. After checking the position of the upper limb, the tip of the drainage tube should not damage the blood vessel. The drainage tube is taken out from the incision hole and fixed on the skin. When the incision is interrupted intermittently, if the middle incision tension is too large, it is difficult to match, and the free surface of the flap can be enlarged, which is beneficial to the reduction. Otherwise, skin grafting should be performed to achieve wound healing in stage I. In order to reduce the massive plasma exudation of the wound after surgery, the wound can be sprayed and hemostasis, spray a thin layer of fibrin glue, and then suture the incision, the amount of plasma exudation of the wound can be significantly reduced. complication 1. Tissue ischemic necrosis occurs due to improper design of the flap. Use an electric knife to cut and stop bleeding. Excessive power can cause large eschars to hinder wound healing. 2. The first to second intercostal vessels, turbulence, and veins are similar to the trunk of the main vessel. It is not advisable to use electrocoagulation to stop bleeding. The ligature of the "0" line is about 1 mm away from the trunk. Otherwise, the main blood vessels can be damaged. 3. Extensive resection of lymphoid tissue at the axillary fossa can lead to lymphatic drainage disorder; during the anatomy of the axillary fossa, there is a rough mechanical stimulation of the iliac vein, resulting in damage to the intima or thrombosis; when the large amount of ligation or repair of the surrounding tissue of the vein is retracted Compression of the veins in the narrow area can lead to edema of the upper limbs. 4. When the vascular clamp is used to clamp the branch vessel at the thinner intercostal muscle, the vascular clamp can be inserted into the intercostal soft tissue vertically to cause pneumothorax. It should be repaired immediately after the discovery, and if necessary, the pneumothorax should be aspirated.