Extended radical mastectomy for breast cancer

Extended radical mastectomy for breast cancer refers to the removal of the chest wall of the medial part of the breast at the same time as the radical mastectomy, ie, the 2nd, 3rd, and 4th costal cartilage, including the thoracic internal and external venous and parasternal lymph nodes (ie, intramammary movement) , the veins and the surrounding fat and lymphoid tissue are removed. In particular, the 5-year survival rate (about 10%) of patients with central and medial breast cancer is more effective. Treatment of diseases: breast cancer sarcoma breast cancer Indication 1. Large or multiple benign tumors in the breast. 2. Intraductal papilloma or proliferative chronic cystic breast disease with a wide range of lesions, older age and malignant transformation. 3. Severe breast tuberculosis is associated with multiple sinus and long-term unhealed. 4. Breast sarcoma. 5. Advanced breast cancer with local ulcers, should not be used for radical mastectomy (preoperative and post-operative with chemical drugs and radiation therapy). Contraindications One of the following conditions is not suitable for surgery: 1. There is extensive edema in the breast and its surrounding skin, and its range is more than half of the breast area. 2. The mass is fixed with the chest wall. 3. The axillary lymph nodes are significantly enlarged and have been closely adhered to the deep tissues, or the upper limbs have edema or shoulder pain. 4. There are satellite nodules in the breast and its surrounding skin. 5. Metastasis of the supraclavicular lymph nodes. 6, inflammatory breast cancer. 7, there has been a distant transfer. Preoperative preparation The scope of surgical field preparation is the ipsilateral chest and supraclavicular region and armpit. Shave the mane. For tuberculous lesions, anti-tuberculosis treatment should be performed before surgery. Surgical procedure 1. Position: supine position, the upper limb of the affected side is abducted 90° and fixed on the limb rest of the operating table. Be careful not to over-extension, prevent brachial plexus paralysis, and use the soft pillow to raise the chest by about 5cm. 2. Incision and separation flap: Generally, a longitudinal fusiform incision is made from the condyle to the umbilicus, the upper end is at the midpoint between the clavicle of the outer edge of the pectoralis major muscle, and the lower end is 2 to horizontal under the rib arch to reveal the straight line. Muscle front sheath. The incision should be changed according to the position of the tumor. The margin of the tumor was 3 horizontal fingers. Note that before the disinfection, use a gentian violet liquid to draw a fusiform incision line from top to bottom. First make the outer edge incision, then the inner edge, cut into the subcutaneous tissue, hold a small amount of subcutaneous tissue with a hemostatic forceps, clamp the clamp every 3cm, lift the hemostat with the left hand, and lift the skin from the outside with your fingers. Tightly tightened, the right hand-held wide-faced knife cuts the subcutaneous fat tissue, and sneak cuts around the skin to cut around the side to stop bleeding. The medial flap was separated to the midline of the sternum, and the lateral side was separated to the anterior latissimus dorsi, up to the clavicle, down to the anterior sheath of the rectus abdominis. After the one side flap was divided, the hot saline gauze pad was used to stop the hemostasis. Should be ligated or electrocautery. The low-voltage electric knife can also be used to cut the subcutaneous fat tissue to form a flap, so that hemostasis can be greatly reduced while cutting blood. After separating the flaps, the tissues of the rectus sheath, the anterior serratus, the latissimus dorsi, the deltoid muscle, the cephalic vein, etc. should be identified, and then the incision should be protected with a disinfecting towel. 3. Cut off the pectoralis major muscle: the superficial pectoralis muscle is covered with fascia and adipose tissue. After separation, the cephalic vein is found in the intermuscular groove of the pectoralis major and deltoid muscle and should be properly protected from injury. The fascia fascia was cut at the outer edge of the pectoralis major muscle, and then separated from the blunt to the medial side of the pectoralis major muscle by the left hand finger, until the clavicle of the pectoralis major muscle near the cephalic vein. Keep a few muscle fibers to protect the cephalic vein. Then the pectoralis major tendon is separated into the humeral nodule, and the muscle tendon is slowly cut with an electric knife, and the blood is burned or sutured at the bleeding point to stop bleeding. Use the finger to cling to the lower edge of the clavicle to continue to separate the pectoralis major muscle from the clavicle and sternum, and cut and suture with an electric knife to stop bleeding. And cut off the chest and shoulders, veins and nerve branches that are sewn from the deep into the muscles. 4. Cut off the pectoralis minor muscle: first turn the pectoralis major muscle down, reveal the pectoralis minor muscle surrounded by the shackle chest fascia, use the hemostatic forceps to pick up the fascia at the lower edge of the pectoralis minor muscle, and extend it with the left hand. Behind the pectoralis minor muscles, close to the chest muscles and separate to the scapula condyle stop point, and put your fingers behind to protect the axillary large blood vessels. Clamp, cut, and sew to stop bleeding near the stopping point. The pectoralis minor muscles are then turned down, severed, and ligated to the thoracic lateral vessels and nerves that supply the muscle. 5. Dissection of the iliac vein and removal of axillary lymph nodes and adipose tissue: Pulling the severed pectoralis major and pectoralis minor muscles together, the sternal fascia of the subclavian region can be revealed (the fascia is thicker) And clear) and adipose tissue in the armpits. At this point, the finger touches the pulsation of the radial artery. On the outer side of the artery is the brachial plexus, and the inner and lower parts are the iliac veins. Anatomy by the iliac vessels. This step is the key to the entire operation and the operation is particularly careful. The iliac vein begins at the lower edge of the great round muscle and ends at the lower clavicle bordering the subclavian vein. The tendon sheath surrounds the radial artery, the iliac vein, and the brachial plexus. The lymph fluid of the breast is drained by various means, and is collected into the lymph nodes around the axillary vein of the armpit, and then to the subclavian, supraclavicular lymph nodes, and then into the thoracic duct. Carefully lift the iliac vein sheath, cut it, carefully dissect the iliac vein, gently separate the surrounding lymph nodes and adipose tissue, and separate it from the chest wall. Then, the branches of the radial artery and the iliac vein below the iliac vein are separated, clamped, cut, and then ligated with a thin wire. These blood vessel branches include the thoracic short vein, the thoracic lateral artery, the thoracic long vein, the subscapular vein, the lateral thoracic vein, and the subscapular artery [Fig. 5-1]. When the axillary and subclavian lymph nodes and adipose tissue are removed, the thoracodorsal nerve associated with the subscapular vessels and the thoracic nerve associated with the lateral thoracic vessels can be seen. Damage should be avoided. Continue to anatomically separate from the posterior lateral direction, visible subscapularis, large round muscle, latissimus dorsi. Note that the lymph nodes arranged in the armpit close to the iliac vein, such as adhesion is very tight, the most likely to damage the vein when separated. In the case of a significantly enlarged lymphatic vessel, it should be ligated to prevent lymphatic spasm after surgery. The force block is not applied to the fat block, and the iron damages the thoracodorsal nerve and the thoracic nerve on the lateral side of the chest wall to avoid atrophy of the anterior serratus and latissimus dorsi. 6. Excision of the breast: After the axillary lymph nodes and adipose tissue are removed, fill the hot saline gauze pad. Then the chest and small muscles are pulled outwards and downwards. The surgeon cuts the attachment points of the two muscles on the sternum and ribs with a sharp knife or an electric knife, and ligates and stops the bleeding. The fat and lymph nodes of the armpits together with the part of the rectus abdominis. The sheath is removed from the chest wall. After removing the breast, apply the hot saline gauze pad to the wound, carefully stop the bleeding, and if necessary, use electrocoagulation to stop bleeding. Then, the warm physiological salt containing 10 to 20 mg of thiotepa is not washed, and the suture is prepared. 7. Drainage and suture: poke a small mouth under the armpit, use a soft rubber tube to drain into the armpit, then add a few needles to reduce the suture and then use the thin wire to make intermittent suture or continuous suture from the upper and lower corners to the middle. The drainage tube is fixed to the skin by 1 needle. If suturing is difficult, skin grafting is required. The medial thick skin of the ipsilateral femoral can be taken for skin grafting. Add a soft and soft gauze pad at the axillary and upper rectus abdominis, and apply a dressing to compress the dressing. 8. Excision of the 2nd to 4th costal cartilage: lift the medial flap and make a transverse incision in the center of the periosteum of the 2nd to 4th costal cartilage next to the affected side of the sternum, about 3cm long, about 0.5cm from the sternal border, and then in the periosteum. The ends of the incision are longitudinally cut, and the perichonal membrane is separated by a periosteal stripper. Care must be taken to prevent damage to the pleura. After the perichondrium was separated, the costal cartilage was revealed, and the length of each of the 2nd to 4th costal cartilage was about 3 cm. 9. Excision of blood vessels, fat and lymph nodes in the thoracic cavity: from the lower edge of the first rib to the upper edge of the fifth rib, longitudinally incision of the intercostal muscle and the medial cartilage of the costal cartilage. Take care to prevent cutting through the pleura. Cut a small mouth first, then gradually separate it with a hemostat, pick it up and cut it. After the incision, the thoracic fascia and perichondrium are removed, and then the thoracic internal organs and veins are exposed. The blood vessels are double-ligated, and the adipose tissue and lymph nodes are removed together, so be careful not to damage the pleura. 1-3]. Once the pleura is torn, apply a nearby soft tissue such as the intercostal space over the tear and suture. Then cover it with a wet gauze for a while. Rinse with thiotepa solution, completely stop bleeding, place drainage, suture the skin and pressure the wound. complication 1. Pneumothorax: Caused by the hemostasis of the hemostatic forceps when the intercostal artery is worn through the pleura. Pneumothorax is often unilateral. After diagnosis, if the lung atrophy is more, it can be used for thoracic puncture and pumping. A small amount of pneumothorax can absorb it by itself. 2. Infection: After radical mastectomy, once infected, it is often more serious. This is because the operation time is long, the flap is thin, the blood supply is poor, and the axillary lymph nodes are removed. Therefore, antibiotics should be routinely added after surgery. If the flap is found to be necrotic, it should be removed early and skin grafted if necessary. 3. Axillary contracture: infection, incision rupture and unreasonable incision can cause axillary skin contracture. When the contraction is light, the flap can be repaired by "Z" shape; when it is heavy, the scar can be removed and repaired as a medium-thickness skin patch. 4. Limited upper arm activity: Excision of the pectoralis major and pectoralis minor muscles will affect the upper arm activity, but if the exercise starts on the 5th postoperative day, it can prevent the upper arm from being restricted. The method is as follows: 1 The upper arm moves forward and backward, and is raised a little and reaches the head. 2 Gradually increase the upward arc of the temple. If you insist on activities like this, you can basically comb your hair and lift your arms up and down before you leave the hospital. 5. Upper extremity edema treatment: upper extremity edema on the disease side is a common complication, and obese women are more common. (1) Type: Temporary edema, often caused by surgery to destroy large pieces of soft tissue. Bandages can be worn or enhanced with elastic bandages. Persistent (secondary) edema, the incidence of 10%, can last for months or years, such as intraoperative findings of axillary lymph node metastasis or postoperative radiotherapy, it is more likely to occur. The reason is that thrombic phlebitis can be treated with prophylactic anticoagulant therapy on the 3rd postoperative day. One is that venous reflux is blocked, the pressure is increased, and raising the affected limb can alleviate the symptoms. One is that the obstruction of lymphatic reflux is related to surgical anatomy, infection, axillary effusion, and radiotherapy response, which is more difficult to handle. (2) Prevention: Carefully dissect the axillary fossa during surgery, protect the skin, prevent infection of the incision, avoid axillary effusion, prevent dermatitis during radiation therapy, and prohibit blood transfusion, infusion, and appropriate exercise after the upper limb. It is important to prevent infection of the incision. (3) Treatment: Light-weight patients, feasible centripetal massage, 1 to 2 hours a day. In severe patients, the subcutaneous fat tissue of the upper limbs can be removed in large amounts, and then elastic bandage is used to compress the bandage, but this method is more destructive. Obese patients can use low-salt foods and take appropriate diuretics. Various physiotherapy effects are not ideal.