Pfannenstiel incision This suprapubic transverse incision allows access to the pelvic cavit y predominantly for gynecological purposes. The incision is 8 \200\22312cm long superior to the pubis. It divides skin, fat, external oblique, internal oblique, and transversalis fas cia from one inferior epigastric artery to the other. The rectus abdominis muscles are spli t vertically in the midline for several centimeters to expose the peritoneum, which is then opened between artery forceps. If greater access is required, the rectus may also be divid ed transversely and retracted cranially. ABDOMINAL INCISIONS1 141 Fig. 4.53 Abdominal incisions CHAPTER 4 Surgical instruments, materials, and skills 142 Upper gastrointestinal endoscopy Check list 1 Ensure that the patient is fully prepared, ha s received an adequate explanation, and has given consent. 2 Ensure that the endoscope is working properly. 3 Ensure that the endoscope has been clean ed. Insertion technique Wear gloves during the procedure. Insert a butterfly needle or small ve nflon into a vein on the dorsum of the hand. Spray the fauces with anesthetic. Ask the pati ent to lie in the left lateral position. Insert a mouth guard and administer oxygen with pu lse oximetry with nursing supervision. If requested give the patient sedation with reversal agents readily available. This varies according to preference but midazolam in 1 \200\2232 mg increments usually up to 5 \200\22310mg is appropriate. Hold the instru- ment controls i n the left hand. Insert the tip of the endoscope with the right hand into the mouth. Gently advance the endoscope passing it over the tongue with the tip flexed. When the laryngx and vocal cords are visualized anteriorly the endoscope is directed posteriorly, and ask the p atient to swallow. Do not force the instrument. Inspection of upper GI tract Esophagus Look for webs or carcinoma in the upper third. Gentl y inflate after clearing mucus by suction. The gullet usually distends so that a clear view can be obtained. Look for landmarks like the cardiac impulse. In the lower esophagus check the mucosal folds for inflammation due to oesophagitis and note the distance from the inci sor teeth. Check also for hiatus hernia. Deep inspiration by the patient is helps to identi fy the position of the diaphragm. If there is an obvious lesion pass the biopsy forceps dow n the biopsy channel and take a specimen for histology (preferably brushings for cytology, which is safer). Stomach Follow the lumen at all times. Inflate as required. On entry note obvious abnormalities like abnormal folds, tumors, blood, bile, retained fluids or foods. A spirate excessive fluid to prevent inhalation. Now in- spect the whole lumen, the greater a nd lesser curves, the incisura and roof of the pyloric antrum. The fundus can be visualized at this point by flexing the tip of the instrument by 180(cid:13) (J maneuver). Alternativ ely this can be done after examination of the duodenum if access was convenient earlier. Ca rry out biopsy or CLO test if indicated. Now advance the endoscope to inspect the pylorus. Note its mobility and the presence of deformity or inflammation. Duodenum Enter the duodenu m by keeping the pylorus in the center of your view. The \200\230up-and-down \200\231 cont rol with the left hand assists ad- vancement. Once inside the duodenal cap carry out a full inspection, withdrawing the tip and depressing it to achieve this. To examine the remainde r of the duodenum the endoscope usually has to be rotated 90 to the right using the up-an d-down control to see the lumen. UPPER GASTROINTESTINAL ENDOSCOPY1 143 Withdrawal Re-inspect the lumina of the duodenum, stomach and oe- sophagus on withdrawal by rotating the tip. Aspirate excessive air from each area once you are satisfied with the ex amination. Ensure the patient has appropriate instructions and prescriptions after the proc edure. CHAPTER 4 Surgical instruments, materials, and skills 144 Examination of the anus and rectum Tell the patient what you intend to do. Ask them to lie on their left side with their knees drawn up towards their abdomen and their buttocks at th e edge of the bed. Stand with your left side next to the patient \200\231s back. Action Separate the buttocks and inspect the anus. Note whether there are changes of excori ation, erythema, moistness, or soiling of the perianal skin and underwear. Identify anal ta gs, prolapsed hemorrhoids or peri- anal warts. Digital examination Wear rubber gloves and apply lubricating jelly to the tip of the right index finger. Place the pad of your index finger on the anal orifice poste- riorly and appl y enough pressure to permit entry. At this stage the pa- tient may complain of pain and dis comfort and you may note spasm of the sphincter. This suggests an anal fissure. Do not pers ist with the digital rectal examination. Note if there is a sentinel at the lower end of th e fissure, usually situated posteriorly. Lubrication of the finger with ligno- caine gel ma y permit digital examination. However if there is spasm and pain it is better to examine th e patient under anesthetic. Once the finger is in the anus, change its direction so that the tip \200\230points \200 \231 into the rectum. With the pad of the finger feel the posterior and lateral walls. Are there any abnormalities \200\224mass, ulcer, polyp? Now bend your knees and rotate the finger so that you can feel the anterior rectal wall. Is there a mucosal abnormality? Can you feel the prostate anteriorly in a male patient? Note its consistency. In female patients you can feel the cervix through the anterior wall as a knob-like projection. Note whether movement of the cervix leads to pain or dis- comfort. Proctoscopy The proctoscope is a short instrument consisting of an obturator en- closed in a viewing barrel with a handle and a light source. Action Apply lubricating jelly to the tip of the obturator and press it on to the anal orif ice until it has penetrated. Once the instrument has been com- pletely inserted, remove the obturator, attach the light source and gently but slowly withdraw the instrument. Note the state of the rectal mucosa. Is it pink (normal)? Does it bleed easily? Does it completely fill the barrel (prolapse)? As you withdraw the instrument note whether there are hemorrhoi ds. They can appear as purple projections at the 3, 7, and 11 positions or circumferentiall y. Band or inject them if indicated. Note also whether there are polyps or an anal fissure anteriorly or posteriorly (proctoscopy is usually painful in the presence of a fissure but it may be made possible by applying lubricating jelly containing a local anesthetic.) EXAMINATION OF THE ANUS AND RECTUM1 145 Sigmoidoscopy The sigmoidoscope is a rigid steel or plastic hollow tube about 25 \200\22330 cm in length and up to 2cm in diameter. It comprises an outer hollow tube, an obturator, wh ich is withdrawn after the instrument has been inserted, and a light source, which is fiber -optic in modern instruments. There is an attachment on the lens piece for the insufflation of air to open up the lumen ahead of the instrument. Preparation of patient The patient should have the procedure explained fully and give conse nt. Preparation of the bowel is often unnecessary. A disposable enema may help in cases of difficulty, but sometimes may have the reverse effect. Position The patient lies in the left lateral position with the hips flexed and the buttock s raised. Procedure (cid:142)(cid:3) Carry out a digital examination of the rectum. If it is loaded, defer sigmoidoscopy until the bowel has been prepared with a disposable enema. (cid:142)(cid:3) Lubricate the sigmoidoscope. Disposable plastic sigmoidoscopes are lubricated under running warm tap water. With the obturator in place, introduce the sigmoid oscope gently through the sphincter to about 5cm by pointing it towards the umbilicus. (cid:142)(cid:3) Remove the obturator and advance under direct vision after attaching the e yepiece, insufflator and light source. Keep the lumen in view at all times as you pass the instrument upwards to its full length. Negotiation of the rectosigmoid junction requires co nsiderable experience and skill. If the patient suffers discomfort, do not persist. (cid:142)(cid:3) Note the appearance of the mucosa and the presence of contact bleeding, ulceration or neoplasm. Take biopsies of suspected abnor- malities for histologic al examination using the specialized biopsy forceps provided. Polyps can be removed by snar ing and diathermy. It requires considerable experience to interpret what you see. NB If a biopsy has been taken the patient should not have any type of enema for at least a week because of the risk of perforation of the bowel or air embolus. Carry out proctoscopy last; this is best for banding and injection procedures. Flexible sigmoidoscopy This fiber-optic instrument is now in routine use. It is longer than the rigid sigmoidoscope allowing views as far as the proximal descending colon. Bowel prep aration is required. As with OGD, considerable train- ing is required to become skillful. Colonoscopy The colonoscope is longer than the flexible sigmoidoscope. The entire colon to the caecum and terminal ileum can be inspected. It has diagnos- tic and therapeutic uses. CHAPTER 4 Surgical instruments, materials, and skills 146 Indications (cid:142)(cid:3) Assessment of the colon in patients with suspected malignant d isease (can be passed to the caecum). (cid:142)(cid:3) Follow-up assessment of patients with resected malignancy. (cid:142)(cid:3 ) Assessment and biopsy of inflammatory bowel disease. (cid:142)(cid:3) Screening of patien ts with adenomas (and their removal). (cid:142)(cid:3) Assessment and biopsy of diverticula r disease (which may mimic carcinoma on occasions). (cid:142)(cid:3) Removal of polyps. (cid:142)(cid:3) Decompression of sigmoid volvulus. (ci d:142)(cid:3) Investigation and decompression of pseudo-obstruction. Chapter 5 147 s5 Breast and endocrine surgery T. Lennard and S. Aspinall Breast: Fine needle aspiration cytology 148 Core biopsy 150 Brea st conservation surgery \200\224wide local excision 152 Mastectomy 154 Axillary surgery 156 Breast reconstruction 160 Incision and drainage of breast abscess (intermediate) 166 Excis ion biopsy of breast lump (intermediate) 168 Microdochectomy (intermediate) 170 Hadfield \200\223Adair operation (intermediate) 172 Endocrine: Fine needle aspiration cytology of th e thyroid gland 174 Thyroid lobectomy (major) 176 Parathyroidectomy (major) 180 Adrenalecto my (major) 182 Pancreas (complex major) 184 CHAPTER 5 Breast and endocrine surgery 148 Fine needle aspiration cytology FNAC is a quick, atraumatic and inexpensive diagnostic test for the inves- tigation of symptomatic or screen-detected breast lesions. Interpretation r equires an experienced cytopathologist and aspirates can be reported at a one-stop clinic, which allows inadequate aspirates to be repeated. Fine needle aspirates are graded as follows: (cid:142)(cid:3) AC1 inadequate (cid:142)(cid:3) AC2 benign (cid:142)(cid:3) AC3 indetermin ate (cid:142)(cid:3) AC4 suspicious of malignancy (cid:142)(cid:3) AC5 malignant. There is a false negative rate of approximately 5%. Failure to confirm the diagnosis by FNAC in brea st lesions with clinical or radiological signs of malignancy requires further investigation . Fine needle aspiration cytology of impalpable lesions may be performed under image guidan ce \200\224 ultrasound or mammography (stereotactic). Indications (cid:142)(cid:3) Triple assessment of breast lumps (cid:142)(cid:3) Screen-dete cted breast abnormalities (cid:142)(cid:3) Assessment of suspected recurrence or lymphadeno pathy. Consent Verbal consent only is required. Warn the patient that bruising might follow the pr ocedure. Pneumothorax is a complication. Technique Use a 21 \200\22323G needle, 20ml syringe, syringe holder, glass slides and slide holder. Local anesthetic is generally not required. (cid:142)(cid:3) Fix the breast lump b etween the thumb and index finger and clean the skin over the lump with an alcohol swab. (cid:142)(cid:3) Insert the needle into the center of the lump, apply suction with the syri nge with a freehand or with a syringe holder, pass through the lesion 4 \200\2235 times. It is not necessary to continue until aspirate appears in the hub of the needle. (cid:142)(cid:3) Release the suction with the tip of the needle in the lesion and withdraw the needle. Expel the contents of the needle onto a slide. Disconnect the syringe from the needle. Fill the syringe with air. Re- connecting the needle expel the contents on to a second slide (repeat). (cid:142)(cid:3) Spread the aspirate evenly over the slide with a clean slide held perpendicular. Dry the slides, label them, and place them in the slide holder. (cid:142)(cid:3) Ask the patient to apply pressure to the aspiration site to prevent haematoma formation. Complications (cid:142)(cid:3) 7Haematoma \200\224may make interpretation of the mammogram difficult. (cid:142)(cid:3) Pneumothorax \200\224rare, may be avoided by inserting the need le parallel to the chest wall. FINE NEEDLE ASPIRATION CYTOLOGY1 149 Left hand Thumb Index finger Hand-held syringe Lesion of breast steadied between thumb and index Right hand Fig. 5.1 Fine-needle aspiration of the breast. As an alternative to the hand-held syringe a Cameco gun can be used CHAPTER 5 Breast and endocrine surgery 150 Core biopsy Core biopsy removes a core of breast tissue for histopathological exami- nation . Confirmation of malignancy on core biopsy before definitive treatment avoids the need for excision biopsy of suspicious lesions. Core biopsy can be performed freehand for palpable lesions or under image- guidance \200\224mammographic (stereotactic) or ultrasound \200\224 for impalpable lesions. Indications (cid:142)(cid:3) Suspicious breast lesions (palpable or impalpable). (cid:142)( cid:3) Lesions indeterminate or suspicious of malignancy on fine needle aspiration cytology. (cid:142)(cid:3) Alternative to fine needle aspiration cytology, especially if cytopathological expertise is not available. (cid:142)(cid:3) Tumors being considered for neo-adjuvant or primary endocrine therapy. Position Supine with the head of the examination couch raised for freehand biopsy of palpab le lesions. Consent Only verbal consent is required. Explain the risks of haematoma and infection. Technique (cid:142)(cid:3) Clean the skin with an alcohol swab. Raise a wheal under the ski n with 2ml of 1% lignocaine and infiltrate in the subcutaneous tissue. (cid:142)(cid:3) Incise the skin sufficiently to introduce the tip of the biopsy needle. Core biopsy gun, such as the Bard MagnumTM, is a spring-loaded two- step firing device, whi ch uses a large-bore (14 gauge needle). (cid:142)(cid:3) Advance the tip of the needle to the edge of the lesion, keeping it parall el to the chest wall. Firing the gun advances a notched needle through the lesion followed by a cutting cannula. The specimen is collected in a notch on the side of the needle. (cid:142)(cid:3) Withdraw the needle, inspect the adequacy of the core and place it in formalin fixative (an adequate core often sinks). (cid:142)(cid:3) Repeat this procedure to obtain 4 \200\2235 cores of tissue. (cid:142)(cid:3) Apply pressure to the biopsy site. A small dressing only is required. The vacuum-assisted biopsy device (MammotomeTM) A vacuum-a ssisted biopsy system such as the MammotomeTM can be used as an alternative to the core bio psy gun. This device differs from the core biopsy gun in that it is inserted into the breas t only once. Multiple tissue samples are then obtained by means of a vacuum, which draws ti ssue into the sample notch. The indications for MammotomeTM may extend to excising small br east lesions. This page intentionally left blank CHAPTER 5 Breast and endocrine surgery 152 Breast conservation surgery \200\224wide local excision The aim is to excise a breast tumor with a margin of normal tissue. Breast conservation surgery for invasive breast cancer is usually per- formed with an axillary procedure. Radiotherapy is given to the remain- ing br east tissue following surgery. Overall survival following treatment for breast cancer is no t affected by the choice between breast conserva- tion and mastectomy, however, the inciden ce of local recurrence may be greater following breast conservation. Indications (cid:142)(cid:3) Breast cancer <4cm (pre-invasive or invasive). Contraindications (cid:142)(cid:3) Centrally placed tumors (cid:142)(cid:3) Breast cancer > 4cm (cid:142)(cid:3) Multi-focal tumors. Consent Present information to the patient so that a fully informed decision be- tween brea st conservation plus radiotherapy and mastectomy can be made. Warn the patient that further surgery may be required if excision margins are not clear. Preoperative preparation (cid:142)(cid:3) Mark the site of any palpable breast lumps preope ratively with the patient supine. (cid:142)(cid:3) There is no need to screen detected or impalpable lesions preoperatively. This is performed on the morning of the operation. A hood guidewire and she ath are inserted under image guidance into the breast lesion. Cranio-caudal and lateral mam mograms are taken to accompany the patient to theater. Position Supine with arm abducted on an arm board. Prepare and drape the breast and arm as for a mastectomy. Procedure Palpable breast lesions (cid:142)(cid:3) Incise over the breast lesion, bearing i n mind the direction of Langer \200\231s lines in the breast. Unless the tumor is superfici al, do not excise the skin over the tumor. (cid:142)(cid:3) Raise skin flaps on either side of the lesion. Use the index finger of the non-dominant hand on the lesion and excise the tumor with a margin of normal breast tissue down to pectoralis fascia. (cid:142)(cid:3) Continue dissection posteriorly in the plane between the breast and pector al fascia and excise a cylindrical specimen containing the breast tumor with a margin of no rmal breast tissue. BREAST CONSERVATION SURGERY \200\224WIDE LOCAL EXCISION1 153 (cid:142)(cid:3) Then orientate the specimen by placing a stitch marked with ligaclips in t he anterior, inferior and medial surfaces of the specimen, using the AIM technique (1 = ant erior, 2 = inferior, 3 = medial). Take tumor bed biopsies from the walls of the cavity. Impalpable breast lesions The patient comes to theater with the guidewire in situ protected by a dressing. (cid:142)(cid:3) Review the mammograms, palpate of the end of the guidewire sheath and make an incision over it. Proceed as outlined above, being careful not to dislo dge the guidewire. (cid:142)(cid:3) Placing a Babcock over the breast tissue containing the guidewire and carr y out local excision of the lesion. Orientate the specimen and take a radiograph of it with the wire still in situ, to confirm adequate excision of the target lesion. Tumor bed biops ies are performed as above. Closure (cid:142)(cid:3) Ensure haemostasis. Insert a Redivac drain in the cavity. Close th e subcutaneous tissue with 2/0 Vicryl and skin with 3/0 Monocryl. Complications (cid:142)(cid:3) Haematoma (cid:142)(cid:3) Infection (cid:142)(cid:3) Furthe r surgery. Anterior 1 cm 1 cm Tumor Posterior Fig. 5.2 Specimen excised at breast conservation surgery CHAPTER 5 Breast and endocrine surgery 154 Mastectomy Several types of mastectomy have been described for breast cancer. Hal- sted des cribed wide excision of the breast tumor with, in addition, the pectoralis minor and major. Patey modified the radical mastectomy excising pectoralis minor only, to facilitate axilla ry lymph node clearance. A simple mastectomy, usually combined with axillary lymph node cle arance for invasive breast cancer is described. More recently skin-sparing and subcuta- neo us mastectomies, which preserve the skin envelope and inframammary fold have been developed to facilitate breast reconstruction. Indications (cid:142)(cid:3) Breast cancer >4cm (cid:142)(cid:3) Patient preference for bre ast cancer <4cm (cid:142)(cid:3) Centrally placed tumors (cid:142)(cid:3) Multi-focal disea se. Preoperative preparation Mark the side of the mastectomy preoperatively. Position Supine with the arm abducted on an arm board. Prepare the skin from the sternal no tch to costal margin and from sternum to mid-humerus. Incision (cid:142)(cid:3) Mark an ellipse of skin orientated horizontally (or obliquely) to include the nipple areolar complex and skin over the tumor (if superficial). (cid:142)(cid :3) Hold the breast tissue to be excised and confirm that the skin flaps can be approximated at the end of the procedure. (cid:142)(cid:3) Incise skin and subcutaneous tissue along the marked ellipse. Procedure (cid:142)(cid:3) Use dissecting scissors or pencil diathermy, develop the plane b etween breast tissue and superficial fascia. Place Allis or Littlewood \200\231s forceps on the subcutaneous tissue of the skin flaps and ask your assistant to hold the skin flap ver tically. Countertraction on the breast may help identify the correct tissue plane. (cid:142)(cid:3) Continue the dissection down to the pectoralis fascia, taking care not to buttonhole the skin. In this manner the superior skin flap is elevated to the level of the second intercostals space and the inferior flap to the inframammary fold. (cid:142)(cid:3) Lift the breast laterally to develop the plane between the posterior surface of the breast and pectoralis fascia from the medial edge. Use a combination of blun t and sharp dissection, diathermising any internal mammary artery perforating branches, cro ssing this tissue plane. Continue the dissection lateral to the free border of pectoralis m ajor to include the axillary tail of the breast. (cid:142)(cid:3) Perform an axillary procedure with the mastectomy for invasive breast cancer (see Axillary surgery). MASTECTOMY1 155 Closure (cid:142)(cid:3) Place a Redivac suction drain under the skin flaps. (cid:142)(cid: 3) Close subcutaneous tissue with 2/0 Vicryl and skin with 3/0 Monocryl. Postoperative care Drains are left in situ until drainage is minimal. Complications (cid:142)(cid:3) Seroma (cid:142)(cid:3) Haematoma (cid:142)(cid:3) Infection (cid:142)(cid:3) (see also Complications of Axillary surgery) Skin sparing mastectomy This operative is performed in conjunction to an immediate reconstr uc- tive procedure for early stage breast cancer. The breast tissue, nipple areolar complex and skin overlying superficial tumors are excised. (cid:142)(cid:3) Make an incision throu gh skin and subcutaneous tissue around the areolar. Extend this laterally to improve the access for the mastectomy. (cid:142)(cid:3) M ake a separate incision in the axilla if an axillary procedure is to be performed (see Axillary surgery). (cid:142)(cid:3) Excise the breast as described for simple mastectomy proceeding in a centripetal direction to improve exposure. (cid:142)(cid:3) Remove the breast through the axillary incision enabling the specimen and axillary contents to be removed en bloc, once axillary node dissec- tion has been completed . The complications are similar to simple mastectomy and axillary surgery. Skin flap necros is is a complication particular to skin sparing mastectomy. (a) (b) Fig. 5.3 Incisions for simple and skin sparing mastectomy (a) Simple mastectomy (b) Skin sp aring mastectomy CHAPTER 5 Breast and endocrine surgery 156 Axillary surgery Removal of axillary lymph nodes in invasive breast cancer has two roles: 1 . Determination of the axillary lymph node status provides important prognostic information upon which decisions about adjuvant therapy are based. 2. Removal of metastatic lymph nodes treats axillary disease. Sentinel lymph node biopsy This is a minimally invasive technique to predict the nodal stat us of the axilla base on the histological examination of the first node to receive lymph fr om the breast cancer (sentinel node). An unnecessary axillary lymph node clear- ance can be avoided in patients with a node negative axilla. Procedure (cid:142)(cid:3) Inject blue dye and radio-labeled colloid into the breast parenc hyma surrounding the tumor or under the skin overlying the tumor. (cid:142)(cid:3) Use preoperative lymphoscintigraphy, intra-operative gamma detection probi ng or dissection along blue dye stained lymphatics to identify the sentinel node. Often a c ombination of these procedures is performed. (cid:142)(cid:3) Make a 2 \200\2233cm incision over the sentinel node, excise it and send it for histological examination. (cid:142)(cid:3) If metastasis is in the sentinel node this is an indication for axillary lymph node clearance. The absence of metastases in the sentinel lymph node indications a no de negative axilla. Current problems with this technique are a false-negative rate of 5% an d uncertainty of the signifi- cance of micrometastases. Axillary node clearance The extent of axillary node clearance performed in invasive breast cancer is dependent on the likelihood of finding involved lymph nodes. Three levels of axil lary node clearance are described: (cid:142)(cid:3) Level I \200\224up to lateral border of pectoralis minor (cid:142)(cid:3) Level II \200\224up to medial border of pectoralis minor (cid:142)(cid:3) Level III \200\224up to apex of the axilla. Level III axillary clearances is usually reserved for instances where there is a high probability of extensive axillary node involvement or there are palpable lymph nodes in the axilla. Indications (cid:142)(cid:3) Invasive breast cancer (cid:142)(cid:3) Positive sentinel lymp h node biopsy. Consent Warn the patient of the risk of frozen shoulder, lymphoedema, numbness of the skin under the arm and seroma. Position Supine with the arm abducted on an arm board. Prepare and drape the breast for mas tectomy or breast conserving surgery, including the axilla and arm down to the mid humerus. AXILLARY SURGERY1 157 Incision If axillary surgery is performed with mastectomy or breast conserving surgery for a tumor in the upper outer quadrant of the breast, a sepa- rate incision for the axilla may not be necessary. Otherwise, make a transverse incision from the lateral border of pectora lis major anteriorly to latissimus dorsi posteriorly. Procedure (cid:142)(cid:3) Identify the lateral border of pectoralis major. Continue up the lateral border identifying pectoralis minor beneath until the axillary vein is reached. Th is is the superior limit of the dissection. (cid:142)(cid:3) Retract pectoralis minor and major upwards and medially. Alterna- tively, for a level III clearance, detach the pectoralis minor from its at- tachments to th e ribs and coracoid process, then clean the anterior aspect of the axillary vein sweeping t he contents of the axilla down- wards from the inferior surface of the axillary vein with a pledget or dissecting scissors held open. (cid:142)(cid:3) Identify the thoraco-dorsal trunk laterally and the long thoracic nerve of Bell medially and preserve them. Identify the intercostobrachial nerve, which passes acros s the axilla from medial to lateral, it may be sacrificed. (cid:142)(cid:3) Place ligaclips on other small vessels and divide them. Then remove the axillary contents en bloc with the mastectomy specimen. Thoracodorsal nerve AV Thoracodorsal artery and vein TM PM SSM LD SA Long thoracic nerve of bell Fig. 5.4 Landmarks for axillary lymph node clearance. AV: axillary vein; LD: latissimus dor si; PM: pectoralis major; SA: serratus anterior CHAPTER 5 Breast and endocrine surgery 158 Closure (cid:142)(cid:3) Leave a Redivac drain in left axilla. (cid:142)(cid:3) Close the s ubcutaneous tissue with 2/0 Vicryl and skin with 3/0 Monocryl. Postoperative care (cid:142)(cid:3) Teach the patient to practice shoulder movements to pre vent frozen shoulder. (cid:142)(cid:3) Leave the axillary drain in place until there is minimal drainage over 24 hours. Complications (cid:142)(cid:3) Frozen shoulder (cid:142)(cid:3) Nerve damage: (cid:142)(cid:3) Intercostobrachial \200\224numbness and paraesthesia of the skin under the axilla (cid:142)(cid:3) Long thoracic nerve of Bell \200\224winging of the scapula (cid:142)(cid:3 ) Thoracodorsal nerve \200\224weakness of shoulder extension/adduction. (cid:142)(cid:3) Lymphodema (cid:142)(cid:3) Seroma. This page intentionally left blank CHAPTER 5 Breast and endocrine surgery 160 Breast reconstruction Tissue expansion and insertion of an implant The principle of this fo rm of breast reconstruction is expansion of the soft tissues of the chest wall to a larger than desirable size by a tempo- rary tissue expander, which is later replaced by a permanen t implant. This is the simplest form of breast reconstruction. Minimal extra scarring is in curred. However, the cosmetic results may not be as natural as an autologous tissue breast reconstruction and revisional surgery is fre- quently required. Indications (cid:142)(cid:3 ) Immediate or delayed breast reconstruction. Contraindications (cid:142)(cid:3) Radiothera py to chest wall (cid:142)(cid:3) Concurrent infection. Consent Discuss the advantages and limitations of each method of breast recon- struction with the patient, so that she can mak e an informed decision. Warn the patient of the short and long term complications of breast implants, i.e. infection, skin flap necrosis, extrusion and deflation of the implant and c apsular contraction. Preoperative preparation (cid:142)(cid:3) Determine the type, shape an d dimensions for the implant (cid:142)(cid:3) Mark the position of the submuscular pocket f or the temporary tissue expander on the chest wall preoperatively (cid:142)(cid:3) Give prophylactic antibiotics at the start of the procedure. Procedure (ci d:142)(cid:3) Make an incision through the previous mastectomy scar, continuing dissection to expose the underlying pectoralis major. Create access to the submuscular pock et by splitting pectoralis muscle along the line of fibers or by dissecting between pectora lis major and serratus anterior. Fill-up the submuscular pocket by blunt dissection. This s hould extend from the clavicle to the rectus sheath medially to the sternal attach- ment of the pectoralis major. (cid:142)(cid:3) Aspirate air from the tissue expander. Place it in the submuscular pocket and fill it with the largest possible volume of normal saline. (cid:142)(cid:3) Place the l ower border of the expander 2 \200\2233cm below the level of the contralateral inframammary fold. Site the reservoir valve subcutaneous in a lateral or inferior pocket. (cid:142)(cid:3) Close the incision in layers (subcutaneous tissue and skin). Normal saline is then injected at the out-patient department into the reservoir until the temporary expa nder is 150 \200\223250ml larger than the size of the permanent implant. This can be facili tated by measuring the volume of the specimen at mastectomy. Over-expansion is maintained f or about three months. The expander is then deflated to the desired volume. At a second procedure the temporary expander and reservoir are exchanged for the implant, w hich consists of an outer textured silicone envelope containing either saline or gel. It is placed in the submuscular BREAST RECONSTRUCTION1 161 Fig. 5.5 Temporary tissue expander, connecting tube and reservoir dome pocket and the incision is closed in layers. A Becker implant acts as both a tissue expande r and permanent implant. The reservoir port only needs to be removed with this implant. Complications (cid:142)(cid:3) Early \200\224haematoma, infection, skin necrosis (cid:142)( cid:3) Late \200\224pain, extrusion and deflation of the implant, capsular contraction (especially after radiotherapy). Latissimus dorsi flap Indications (cid:142)(cid:3) Immediate or delayed breast reconstructi on \200\224may be autologous or accompanied by a tissue expander/implant. (cid:142)(cid:3) Salvage procedures such as failed streetcar flap, locoregional recurrence and radionecrosis of the chest wall. Contraindications (cid:142)(cid:3) Smoking, obesity and diabetes mellitus (relative) (cid:1 42)(cid:3) Thoracotomy (cid:142)(cid:3) Transection of thoracodorsal pedicle. Consent Infor m the patient of possible partial or complete flap loss. Explain any complications specific ally related to an implant. Preoperative preparation (cid:142)(cid:3) Determine the size of the skin and tissue compone nts of the flap preoperatively (cid:142)(cid:3) Mark the skin ellipse and borders of latissimus dorsi on the patient \200 \231s back. The skin ellipse is usually placed under the brassiere strap as orientation to fill the mastectomy defect after rotation of the flap. Position Supine with the arm abducted for the mastectomy/excision of mastec- tomy scar and axillary surgery. Then place the patient in the lateral posi- tion to harvest the latissimu s dorsi, and finally reposition the patient supine to reconstruct the breast. Procedure (cid:142)(cid:3) Excise the mastectomy scar, raise skin flaps superiorly to the s econd intercostals space and inferiorly to the inframammary fold. CHAPTER 5 Breast and endocrine surgery 162 Skin elipse LD Posterior: extent of dissection Posterior: position of scar Position of implant Skin elipse LD Anterior: after transposing flap to chest wall Anterior: final result Fig. 5.6 Latissimus dorsi flap (cid:142)(cid:3) Dissect in the axilla to identify the thoracodorsal pedicle. Divide the branches of the thoracodorsal trunk to serratus anterior. (cid:142)(cid:3) Identify the anterior border of latissimus dorsi. Cover the mastectomy defect with a dressing. Turn the patient to the lateral position and incise the skin ellipse. Develop the plane bel ow Scarpa \200\231s fascia and identity the borders of latissimus dorsi. Divide the attachm ents of latissimus dorsi to the thora- columbar fascia and iliac crest and elevate the musc ulocutaneous flap. Tunnel the flap through the axilla to the mastectomy defect. Divide the latissimus dorsi tendon and the thoracodorsal nerve if required. (cid:142)(cid:3) Close the donor site over suction drains. Reconstruct the breast after returning the patient to the supine posi- tion. Attach the lat issimus dorsi to pectoralis major superiorly and insert the expander/implant into the submu scular pocket. Then complete the inset of the flap. Closure Close both wounds in layers over suction drains. Complications (cid:142)(cid:3) Functional impairment at the extremes of shoulder extension Partial or total flap loss, infection and haematoma. BREAST RECONSTRUCTION1 163 Transverse rectus abdominis myocutaneous (streetcar) flap The transverse rectus abdominis m yocutaneous (streetcar) flap uses tissue from the lower abdominal wall, which is supplied b y perforators from the superior and deep inferior epigastric vessels, to reconstruct the br east. The pedicled streetcar flap uses the rectus muscle isolated on its superior epigas- t ric vascular pedicle, which is rotated up to fill the mastectomy defect. The free streetcar flap uses rectus muscle and sheath, harvested with the deep inferior epigastric vessels, w hich are detached from their origin and anasto- mosed to vessels in the axilla or the inter nal mammary artery. Indications Immediate or delayed breast reconstruction. Contraindications (cid:142)(cid:3) Previous surgical division of the inferior epigastric vascular pedicle (cid:142)(cid:3) Obe sity, diabetes mellitus, smoking (relative). Consent The patient should be aware of the spe cific complications of partial or complete flap loss and incisional hernia at the donor sit e. Though an excellent cosmetic result can be achieved with a streetcar flap, the proce- du re is lengthy, incurring additional scarring and a longer convalescence. Preoperative preparation (cid:142)(cid:3) Examine the abdomen for the presence of hernias, divarication of the recti, abdominal incisions, and weakness of the anterior abdominal wall. (cid:142)(cid:3) Mark the inframammary fold and upper margin of excision of the mastectomy scar. (cid:142)(cid:3) Mark the streetcar flap on the lower abdomen. This is an ellipse extend- i ng from the anterior superior iliac spines to the umbilicus superiorly and the suprapubic r egion inferiorly. Position Supine on the operating table with both arms abducted. Place a sandbag under the s capular region on the mastectomy side to facilitate exposure of the axillary vessels. Inser t a urethral catheter and place an intermittent venous compression device on the legs. Operative technique (cid:142)(cid:3) Excision of mastectomy scar (cid:142)(cid:3) Mark the inframammary fold and the upper margin of the mastectomy scar preoperatively. (cid:142)(cid:3) Excise the mastectomy scar. Elevate the upper skin flap extending the inci sion laterally to allow exposure of the axillary vessels. (cid:142)(cid:3) Raising the streetcar flap (cid:142)(cid:3) Excise skin and subcutaneous tissue down to fascia along the lines marked preoperatively. (cid:142)(cid:3) A lateral and medial row of myocutaneous perforators emerges through the rectus sheath. Raise the flap from lateral to medial in the plane above the dee p fascia. Preserve the medial row of perforators on the pedicled side to supply the subcuta neous tissue and skin of the flap. CHAPTER 5 Breast and endocrine surgery 164 (cid:142)(cid:3) Harvest the medial portion of rectus sheath and muscle below these perforators and extend this from the umbilicus to the arcuate line. Continue the rect us sheath incision inferiorly and laterally to- wards the origin of the deep inferior epiga stric vessels. Identify the deep inferior epigastric vascular pedicle, divided flush at its origin from the external iliac vessels to raise the flap. (cid:142)(cid:3) Closure of donor site (cid:142)(cid:3) Advance the free lateral edge of the rectus sheath to the midline and sutu re it to the linea alba with continuous non-absorbable sutures, reinforce the repair by dou ble-breasting the lower medial sheath to its lateral counterpart. (cid:142)(cid:3) Flap ins et and creation of breast mound The most commonly used recipient vessels are the thoracodor sal or circumflex scapular vessels. (cid:142)(cid:3) Secure the flap to the chest wall with temporary sutures while a microvasc ular anastomosis is performed. The creation of a breast mound involves replacement of the b reast volume, shape, skin defi- cit and re-establishment of the inframammary fold. (cid:142)(cid:3) Attach the flap to the chest wall under the upper skin flap. (cid:142)(cid :3) Inset the skin ellipse and suture it to the mastectomy defect. (cid:142)(cid:3) Leave d rains in the inframammary fold and axilla, but avoid suction in the region of the microvascular anastomosis. Postoperative care Nurse the patient in a warm room with analgesics and keep her well- hydr ated. Any compromise of flap perfusion may necessitate urgent surgical exploration. (cid:14 2)(cid:3) Remove the drains when drainage is minimal (cid:142)(cid:3) Remove the urethral c atheter once the patient is ambulatory. Complications (cid:142)(cid:3) Seroma (cid:142)(cid :3) Partial and total flap loss (cid:142)(cid:3) Fat necrosis (which may mimic recurrence o f breast cancer) (cid:142)(cid:3) Incisional hernia at the donor site. BREAST RECONSTRUCTION1 165 Mastectomy scar streetcar flap streetcar flap : Final result Incision for streetcar flap Fig. 5.7 streetcar flap CHAPTER 5 Breast and endocrine surgery 166