DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Recurrent left breast cancer, invasive ductal cell, with lobular features.
POSTOPERATIVE DIAGNOSIS: Recurrent left breast cancer, invasive ductal cell, with lobular features.
OPERATION PERFORMED: Bilateral skin-sparing mastectomy.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General endotracheal anesthesia.
ESTIMATED BLOOD LOSS: 50 mL.
COMPLICATIONS: None.
SPECIMENS:
1. Left breast with pectoralis fascia and 2 cm pectoralis major muscle island deep to previous resection site sent for permanent pathology.
2. Right breast with pectoralis fascia sent for permanent pathology.
DESCRIPTION OF OPERATION: The patient was taken to the OR and transferred to the OR table in the supine position. Following adequate induction of anesthesia, the area was secured with an endotracheal tube. At this time, a brief time-out was taken to identify the patient and planned procedure. The chest and abdomen were then prepped and draped in the usual sterile fashion. The left breast, which was the site of recurrent disease, was approached first.
A periareolar incision was then made, including the previous lumpectomy site. This was made sharply and then Bovie electrocautery was used to carry this incision down into the subcutaneous fat. Once this layer was identified, careful dissection using electrocautery was then carried out to raise skin flaps circumferentially around the breast tissue. The skin flaps were taken immediately to approximately 1.5 cm lateral to the sternum, superiorly to encompass the entirety of breast tissue and inferiorly to the inframammary fold.
Laterally, the dissection was carried out to the level of the lateral border of the pectoralis major muscle. Additionally, the axillary tail was also identified and separated from the overlying subcutaneous fat. Once the breast tissue was circumferentially dissected free, dissection was then carried down to the level of the pectoralis fascia. The pectoralis fascia was incised circumferentially.
Next, the breast was carefully dissected free from the underlying pectoralis major muscle paying careful attention to take the entirety of the pectoralis fascia. Massive dissection was carried out laterally. The previous surgical clip was noted, and in this area, we proceeded to resect a portion of the pectoralis major muscle measuring approximately 2 cm in total dimension. This was performed to ensure that both fascia and muscle were resected at the level of the recurrent disease. Again, this dissection was carried out laterally to remove the axillary tail and then inferiorly to take the breast tissue off the serratus anterior and the lateral margin of the pectoralis major muscle.
Next, the specimen was removed through the periareolar incision and labeled with a short stitch superiorly and a long stitch laterally. The specimen was then handed off the field and sent for permanent pathology. Of note, there was no palpable disease within the breast; however, there was some fibrosis associated with the previous lumpectomy site. The field was then again inspected and made hemostatic with electrocautery. The wound was then copiously irrigated and a moist gauze was placed in this wound.
Next, attention was paid to the right breast where again a periareolar incision was made sharply. Electrocautery was again used to dissect down to the level of the subcutaneous fat and then skin flaps were raised circumferentially off the breast tissue. Again, these flaps were elevated inferiorly to the level of the inframammary fold, medially to approximately 1.5 cm lateral to the midline of the sternum, superiorly to the extent of the breast tissue and then laterally to the level of the axillary tail and lateral margin of the pectoralis major muscle extending onto the serratus anterior muscle.
Once skin flaps had been adequately raised, dissection was carried down to the level of the pectoralis fascia. The fascia was incised circumferentially and then dissection was initiated medial to lateral, taking the breast tissue off the underlying pectoralis major muscle. The specimen was taken with the pectoralis fascia.
Our dissection was carried out laterally until the lateral border of the pectoralis major was identified and then it was divided free of the underlying serratus anterior muscle and pectoralis major muscle. Careful dissection was performed in the axillary tail region to avoid any critical vascular or nervous structures.
During this dissection, a small branch of nerve, which appeared to be consistent with an intercostal brachial branch, was noted. A single clip was placed proximally and then this was divided with scissors. Once the specimen was freed from the underlying chest wall, it was withdrawn from the wound and marked with a short stitch superiorly and a long stitch laterally. This specimen was passed off the field and sent for permanent pathology also.
The wound was then inspected and made hemostatic with electrocautery. The wound was also copiously irrigated and a moist gauze was placed in the wound. The remainder of the procedure was performed by the plastic surgery service. There were no complications encountered during this portion of the procedure.
