Below is a write-up by Dr. Joyce Epili, a surgical resident from Manila Medical Center, who assisted me in my modified radical mastectomy recently.
I asked for this write-up as my additional teaching tool for Joyce. With this write-up, I feel she will reinforce what she learned in the operating room while assisting me, observing what I did, and listening to my explanations and pointers.
I will not correct this first write-up now (overall, I am satisfied though on its comprehensiveness) but will ask Joyce to refine it further as she assists me in more modified radical mastectomies in the future (at least 3 more).
I will also ask for the same activities for other surgical residents as they assist me and as I impart my tips.
HOW DR. JOSON USUALLY DOES HIS MASTECTOMY
By Dr. Joyce Epili (MCM Surgical Resident)
March 10, 2015
- After anesthetic induction, he position the patient with arms adducted on the side of operation. He then place his markers. He starts to mark the borders of the breast mass with 2cm margin. He then draws an elliptical shape that includes the mass and edge of the areola. After marking the incision site, the arm will abducted and extended. Now proceeds with aseptic and antiseptic technique.
- Mastectomy proper. Using a blade 10 knife, Dr. Joson will start the incision superiorly up to subdermal layer to create the superior flap. He then uses cautery up to subcutaneous layer. His cautery is controlled with foot pedal to liberately control the cautery pen. Tractions are done using manual (hand) technique rather than using retractors such as breast clamps or allis.with the use of hands, the depth of the flaps would be more assessed. Too close to the skin could affect the vascularities that would lead to skin necrosis and too thick could include breast tissue. Inferior flaps is the created. After creating the flaps, the breast tissue is being separated from the chest wall using cauterization and manual traction-counter traction. Mastectomy is done.
- Axillary dissection. Clavipectoralis fascia is opened. Dissection is done using blunt and sharp technique. He uses metzembaum scissors to separate the lymph nodes and identify the structure. Small bleeders are then cauterized while medium sized vessels are being ligated using cotton 3-0. As he visualize the axillary vein, he would start to pull down the structures and remove the specimen (breast and axillary fat pad).
- Washing and hemostasis. Breast flaps are raised by richardson retractors. He does not use asepto syringe. Sterile water is poured and is being observed for active bleeders. Chest wall should not be touched so as to avoid the burned and clotted bleeders. Afterwards, fluids are being suctioned out.
- JP drain is placed lower outer area of the operative site and being anchored using cotton 3-0.
- Prior closure proper, flaps are apposed initially with interval sutures using cotton 3-0. He checks for possible tension and avoids dog ear formation. He uses single layer technique with absorbable suture.
- Light dressing is applied to cover the post op site and jp drain.
- End of procedure.
Everytime Dr. Joson has a procedure, he would always put patient’s welfare first before anything else that why he always think of BRCA*
* BRCA- Benefit / Risk / Cost / Availability