DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Ductal carcinoma in situ of the right breast with possible microinvasion.
POSTOPERATIVE DIAGNOSIS: Ductal carcinoma in situ of the right breast with possible microinvasion.
PROCEDURE PERFORMED: Sentinel lymph node biopsy of the right axilla of one sentinel node in addition to needle localized right breast lumpectomy.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General with endotracheal intubation plus an additional 7 mL of local anesthetic to the incision (0.5% lidocaine with 0.25% Marcaine at final concentration).
ESTIMATED BLOOD LOSS: Less than 20 mL.
COMPLICATIONS: None.
INTRAOPERATIVE FINDINGS: A single sentinel node was identified, which had an ex vivo count of 2184 counts over 10 seconds. The specimen, as excised, was oriented with a short suture placed superiorly and a long suture placed laterally. Intraoperative specimen mammogram demonstrated the presence of the abnormality within the lumpectomy specimen.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed in a supine position. After smooth induction, she was carefully endotracheally intubated and administered a general anesthetic. Prior to surgery, the patient had been brought for needle localization at the breast imaging center and then for injection for her sentinel node biopsy in Nuclear Medicine. She had been injected in a periareolar fashion with 1 mCi of technetium sulfur colloid. Preoperative lymphoscintigraphy had demonstrated the presence of what appeared to be a single sentinel node in the axilla.
After the patient was placed in the supine position, the right extremity was placed on an arm board at a right angle to her body. The right breast with an inserted needle, the right lateral thorax, the upper arm, and shoulder were then carefully prepped and draped in the usual aseptic fashion following administration of general anesthetic.
A time-out was called and the patient’s identity as well as the procedures planned, site, and side were confirmed before we proceeded. The patient also underwent an additional injection of 5 mL of sterile isosulfan blue dye about the lumpectomy site, which was then carefully massaged over a 10 minute period of time in the context of the sentinel node biopsy preparation.
Once the patient was prepped and draped, a small degree of torque was placed on the needle and inserted into the right breast from a medial approach. This demonstrated the presence of the tip near the inferior areolar border but more centrally located and deep. An inferior periareolar incision was planned and drawn on the skin with a sterile skin marker. A sterile covered gamma probe was also used to identify the hot spot within the right axilla. This was marked on the skin with a sterile skin marker.
An incision was planned that would be part of the anterior aspect of a full axillary node dissection incision should one be necessary in the future. A small incision was drawn under the hair-bearing area just behind the axillary fold in a pre-existing skin fold for a length of approximately 3.5 cm. Local anesthetic was first used to infiltrate along the planned incisions. We then turned our attention to perform the sentinel node biopsy.
The incision was made with a #15 blade scalpel and then extended to the remainder of the dermis using electrocautery, maintaining hemostasis as we progressed, that extended through the tissues down to the clavipectoral fascia using a combination of blunt dissection and electrocautery. Once the fascia was carefully incised, the gamma probe was again inserted in order to directionally guide us to the sentinel node.
Once this was performed, the single hot spot was identified and its directionality in level 1 identified. Further blunt dissection led us to the slightly palpable node under the skin. This node was dissected free from the adjacent tissues leaving a small rim of fat. Care was taken to preserve any adjacent nerves or vasculature. The node was passed off the field as sentinel node #1 after a 10 second count was taken. The 10 second ex vivo count was 2184 counts.
The gamma probe was inserted again within the axilla and no further hot spots could be identified. The blue dye had not reached the axilla, and therefore, no nodes or lymphatics could be identified. Upon palpation, there were no enlarged nodes. Consequently, the axillary wounds were inspected for adequacy of hemostasis. Small points of bleeding were easily controlled with electrocautery. The wound was then irrigated with sterile saline and inspected again. Having obtained excellent hemostasis, the incision was then closed in two layers. The deep dermis was approximated using running simple sutures of 3-0 Vicryl and the skin closed with running subcuticular suture of 4-0 Monocryl. This was then cleansed and dried, covered with a dry towel, and our attention turned to the lumpectomy.
The needle, as inserted into the breast, came from a medial approach. The skin incision was not in continuity with the insertion of the needle. Consequently, the incision was made with a #15 blade scalpel and extended through the remainder of upper dermis with electrocautery, maintaining hemostasis as we progressed. Skin flaps were raised laterally as well as under the areola. The skin flaps were raised medially as well, and in extending this medially, the insertion site of the needle under the skin was encountered. An Allis clamp was placed around the needle, as it inserted into the breast tissue and the wire and needle cut. The internal aspect of this wire and needle were then discarded.
The dissection of the tissues around the needle was then extended with electrocautery using a radius of approximately 2 cm about the hub of the needle and beyond the needle tip. Once excised, the tissue was oriented with a short suture placed superiorly and a long suture placed laterally. This was passed off the field for intraoperative specimen mammogram. The operative field was inspected for adequacy of hemostasis. Small points of bleeding were easily controlled with electrocautery. The wound was then irrigated and inspected again. Excellent hemostasis had been obtained. A small pursestring 3-0 Vicryl suture was placed at the base of the nipple in order to prevent any open ducts from communicating with the underlying seroma cavity. Hemoclips were placed about the lumpectomy cavity for purposes of postoperative radiotherapy planning.
We received word at this point in time that the intraoperative specimen mammogram indeed contained the abnormality within and was centralized within the specimen. There appeared to be at least mammographically normal tissue along the entire rim. Consequently, we then proceeded to close the skin of the lumpectomy site in two layers. The deep dermis was approximated using interrupted inverted simple sutures of 3-0 Vicryl and the skin closed with subcuticular suture of 4-0 Monocryl. The incisions were then cleansed, dried, and dressed with Steri-Strips before placement of gauze and Tegaderm dressings.
The patient tolerated the procedures well. Sponge, needle, and instrument counts were all correct at the end of the procedures. The patient was brought back to the PACU at the end of the procedures, extubated, awake, and in good condition. Estimated blood loss was less than 20 mL. There were no complications.
