How long does radical mastectomy take?

1. Position: supine position, with the affected upper limb abduction at 90 degrees, fixed on the limb frame of the operating table. Be careful not to overstretch and prevent brachial plexus palsy. Use a soft pillow to cushion your chest for about 5cm.

2. The incision is separated from the flap: generally, the coracoid process is used as a longitudinal spindle incision in the umbilical direction, with the upper end at the midpoint between clavicles at the outer edge of pectoralis major and the lower end at the 2 ~ transverse finger below the rib arch to expose the anterior sheath of rectus abdominis. The incision should be changed according to the location of the tumor The margin is 3 fingers away from the tumor. Pay attention to draw a spindle-shaped incision line from top to bottom with gentian violet liquid before disinfection.

First cut at the outer edge, then cut at the inner edge. After cutting to subcutaneous tissue, use hemostatic forceps to clip a little subcutaneous tissue every 3cm. Lift hemostatic forceps with your left hand, and lift the skin from the outside with your fingers to make it horizontal and tight. The right hand cuts the subcutaneous adipose tissue with a broad-edged knife, and makes an invisible incision around the skin to stop bleeding while cutting. The medial flap is separated to the sternum midline, and the lateral flap is separated to the front of latissimus dorsi, up to the clavicle and down to the anterior sheath of rectus abdominis. After one side flap is separated, use hot saline gauze pad to stop bleeding. If the bleeding point is large, it should be ligated or electrocautery. You can also use low-voltage electrotome to cut subcutaneous adipose tissue to form a flap, which can stop bleeding while cutting, greatly reducing the amount of blood loss during operation.

After the flap is separated, it is necessary to identify the rectus sheath, serratus anterior, latissimus dorsi, deltoid and cephalic vein, and then protect the incision with a sterile towel.

3. Cut off pectoralis major: The surface of pectoralis major is covered with axillary fascia and adipose tissue. After separation, the cephalic vein was found in the intermuscular sulcus of pectoralis major and deltoid muscle, which should be properly protected to avoid injury. Incise the axillary fascia at the outer edge of pectoralis major, and then use the left index finger to separate it from the outer edge of pectoralis major to the inner side until it reaches the clavicle of pectoralis major near the cephalic vein. Keep a little muscle fiber to protect the cephalic vein. Then the pectoralis major tendon was separated to the crest of the greater tubercle of the humerus, and it was slowly cut with an electric knife, and electrocautery or suture was performed at the bleeding point to stop bleeding [Figure 3- 1]. Continue to separate the connecting part of pectoralis major with clavicle and sternum with index finger, and cut and suture with electrotome to stop bleeding. And cut off the arteries, veins and nerve branches of the thoracoacromion from the deep into the muscle.

4. Cut off the pectoralis minor: First, turn the pectoralis major downward to expose the pectoralis minor surrounded by the clavicular pectoralis fascia of the beak. At the lower edge of the pectoralis minor, use hemostatic forceps to open this fascia, reach behind the pectoralis minor with your left hand, then close to the back of the pectoralis minor, and separate to the point of the coracoid process of the scapula, with your fingers behind to protect the great blood vessels under your armpit. Clamp, cut off, suture, and stop bleeding near the dead center. Then the pectoralis minor muscle is turned down, and the lateral thoracic blood vessels and nerves supplying the muscle are cut off and ligated.

5. Anatomy of axillary vein and excision of axillary lymph nodes and adipose tissue: The severed pectoralis major and pectoralis minor muscles are pulled together to expose the coracoid clavicular pectoralis fascia (which is thick and clear) and the adipose tissue in the armpit. At this time, the finger touches the pulse of axillary artery. The brachial plexus is above the artery and the axillary vein is below the artery. Anatomy begins with axillary blood vessels. This step is the key to the whole operation, and the operation should be especially careful. Axillary vein begins at the lower edge of teres major and ends at the lower edge of clavicle, and is connected with subclavian vein. Axillary artery, axillary vein and brachial plexus are surrounded by axillary sheath.

There are many ways to drain the lymph of the breast, which are collected in the lymph nodes around the axillary vein, then to the subclavian and supraclavicular lymph nodes, and then to the thoracic duct.

Carefully lift the axillary vein sheath, cut it open, carefully dissect the axillary vein, and gently separate the surrounding lymph nodes and adipose tissue from the chest wall. Then the branches of axillary artery and axillary vein below axillary vein are separated, clipped one by one, and then ligated with thin thread. These vascular branches include short thoracic vein, lateral thoracic artery, long thoracic vein, subscapular vein, lateral thoracic vein and subscapular artery [Figure 5- 1]. When axillary lymph nodes, subclavian lymph nodes and adipose tissue are resected, the dorsal thoracic nerve and long thoracic nerve accompanied by lateral thoracic vein can be seen [Figure 5-2], and injuries should be avoided. Continuing the anatomical separation in the posterolateral direction, we can see the subscapular muscle, teres major and latissimus dorsi. Pay attention to the lymph nodes arranged close to the axillary vein in the armpit. If the adhesion is tight, the vein is most likely to be damaged when it is separated. If there are obviously enlarged lymphatic vessels, they should be ligated to prevent postoperative lymphatic fistula. Fat block should not be pulled hard, iron will damage the dorsal thoracic nerve and the long thoracic nerve on the lateral side of the chest wall, and avoid the atrophy of serratus anterior and latissimus dorsi after operation.

6. Mastectomy: After axillary lymph nodes and adipose tissue are removed, they are filled with hot saline gauze pad. Then the pectoralis major muscle and pectoralis minor muscle are pulled outward and downward, and the operator cuts off the attachment points of these two muscles on the sternum and costal surface with a sharp knife or electrotome, and ligatures them to stop bleeding while sending hair; Axillary fat and lymph nodes were removed from the chest wall together with part of the anterior sheath of rectus abdominis.

After mastectomy, pad the wound with warm saline gauze, carefully stop bleeding, and use electrocoagulation to stop bleeding if necessary. Then prepare suture with warm physiological salt containing 10 ~ 20 mg of tetipai without washing.

7. Drainage suture: poke a small hole under the armpit, put a soft rubber tube under the armpit for drainage, then add a few stitches to reduce tension and suture, and then sew intermittently or continuously from the upper and lower corners to the middle with thin thread. The drainage tube fixes 1 needle on the skin [Figure 7]. If it is difficult to sew, skin grafting is needed. Skin graft can be done in the medial thigh of the same side for medium-thick skin graft [Figure 8]. The armpit and the upper end of rectus abdominis were stuffed with soft gauze, and the dressing was added to compress and bind.

Matters needing attention in operation

1. The incision should be suitable, depending on the size of the tumor. Don't cut too little, otherwise the tumor will recur locally after operation. At the same time, it must be noted that the upper end of the incision cannot extend to the top of the armpit, otherwise vertical scar tissue will be formed in the armpit, which will affect the functional activities of the upper arm.

2. The axillary anatomy should be careful, and the fat, connective tissue and lymph nodes below the vein should be removed as much as possible, but it is not necessary to dissect the axillary artery and brachial plexus upwards, because this will cause postoperative brachial plexus neuralgia.

Anatomy of axillary vein must be careful and patient to prevent damage to great vessels. Once the axillary vein is torn, it should be repaired with thin thread as far as possible, and it should not be ligated to avoid aggravating the edema of the upper arm. If the axillary artery is ruptured, two arterial clamps should be used to clamp the distal end and the proximal end of the ruptured artery respectively to control the blood loss, and then suture and repair it with thin lines.

Thoracodorsal nerve runs outward and downward along axillary vein, often accompanied by subscapular blood vessels, so injury should be avoided to avoid affecting abduction and internal rotation of upper arm. The long thoracic nerve descends from the axillary apex along the superficial surface of the serratus anterior muscle, and wing-like shoulders are easy to occur when it is cut by mistake.

3. Arteries should be ligated firmly. When removing pectoralis major and pectoralis minor, the branch of internal thoracic artery passing through intercostal space must be cut off, and hemostatic forceps parallel to the chest wall should be clamped to stop bleeding. If it slips and the blood vessels contract to the intercostal muscle, it is necessary to suture the intercostal muscle separately to stop bleeding. If the bleeding cannot be controlled, the internal thoracic arteries at the upper and lower ends must be sutured. Don't damage the pleura during the operation.

4. Suture the incision to avoid tension. Before suture, check the blood supply at the edge of the flap. If it is too thin or the blood supply is poor, a part should be removed, and then bilateral flaps should be sutured. The purpose of pressure dressing is to prevent dead cavity, blood leakage and fluid leakage, and increase the chance of incision infection.

Polizel's therapy

1. General treatment: ① Take supine position after operation. Place a small sandbag on the wound and armpit for 24 hours. ② Lift or fix the affected upper limb to the chest wall for 5-7 days to prevent movement, and tear off the skin flap (wrist and elbow joints are allowed to move); ③ According to the situation of axillary hydrops, the drainage tube was removed 3 ~ 4 days after operation. If there is too much effusion, puncture can be used to draw fluid. After the drainage tube is pulled out, it still needs to be bandaged by pressure to eliminate the dead space.

2. Radiotherapy and chemotherapy are beneficial to eliminate residual cancer cells. The chemical medicine can be intravenous thiotepa, 65438±00mg per day, and the total amount of a course of treatment is 200mg；; For example, intravenous injection of fluorouracil, 500mg per day, every other day 1 time, 10g is a course of treatment. It can also be treated with cyclophosphamide, zilmycin, colchicine and other drugs.

Management of common complications

1. Pneumothorax: Most cases were caused by hemostatic forceps's tip accidentally puncturing the pleura when dealing with intercostal perforating artery. Pneumothorax is often unilateral. If there is more lung atrophy after diagnosis, thoracic puncture and aspiration can be used, and a small amount of pneumothorax can be absorbed by itself.

2. Infection: Once infected after radical mastectomy, it is often very serious. This is because the operation time is long, the skin flap is thin, the blood supply is poor, and axillary lymph nodes are removed. Therefore, antibiotics should be routinely used for prevention after operation. If the skin flap is found to be necrotic, it should be removed as soon as possible, and skin grafting is necessary.

3. Axillary contracture: Infection, split incision and unreasonable incision can all lead to axillary skin contracture. When contracture is mild, Z-shaped flap can be used to repair it. In severe cases, the scar can be removed and repaired with medium-thick skin graft.

4. Limited upper arm activity: After removing pectoralis major and pectoralis minor, the upper arm activity will be affected, but if you start exercising on the fifth day after operation, you can prevent the upper arm activity from being limited. The methods are as follows: ① Move the upper arm back and forth and slightly lift it to the head. ② Gradually increase the upward radian of temples. If you insist on such activities, you can basically comb your hair and move your arms up and down freely before leaving the hospital.

5. Treatment of upper limb edema: Edema of the affected upper limb is a common complication, especially for obese women.

Type (1): temporary edema, often caused by surgical destruction of large soft tissues. Elastic bandages can be used to wrap or strengthen exercise activities. Persistent (secondary) edema, the incidence rate is 10%, which can last for months or years; It is more likely to occur if axillary lymph node metastasis is found during operation or radiotherapy is added after operation. One of the reasons is thrombophlebitis, which can be treated with preventive anticoagulation from 3 days after operation; One is that venous return is blocked and the pressure increases, 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 reaction, which is difficult to deal with.

(2) Prevention: Pay attention to carefully dissecting the armpit during the operation, protect the skin, prevent incision infection and avoid axillary hydrops; Prevention of dermatitis during radiotherapy; Blood transfusion and proper exercise of the affected upper limb are prohibited after operation. Among them, it is very important to prevent incision infection.

(3) Treatment: For mild patients, centripetal massage is feasible, 1 ~ 2 hours a day. In severe cases, a large amount of subcutaneous adipose tissue of upper limbs can be removed and then bandaged with elastic bandage; But this method is destructive. Obese patients can eat low-salt food and take diuretics appropriately. The effects of various physical therapies are not ideal.