What is a radical mastectomy? Elective and preventive mastectomy: what is it, indications and result of treatment, reconstructive plastic after surgery Do they give disability after mastectomy.

Diseases that you can't get rid of. They require intense attention, examination and treatment. Among oncological diseases in women, breast cancer ranks first, among other diseases - the second. Consequences are not always predictable.

Prevention and timely treatment are important. In some cases, an operation is inevitable - radical.

What is a radical mastectomy

Radical, i.e., removing entirely, completely, with a root. The concept of mastectomy is of Greek origin - mastòs "breast" and ek tome "I remove". The term is over 100 years old.

Several types of mastectomy are practiced. Each of them is effective, they differ in the degree of trauma. Radical mastectomy is a complex operation, but sometimes only it can solve an existing problem.

There are three main types of mastectomy:

• by Madden,
• by patey,
• according to Halsted.

Madden's radical mastectomy is considered the most sparing.

Carefully! Video showing radical mastectomy (click to open)

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Kinds

By Madden

The method involves the preservation of both pectoral muscles, which makes it as gentle as possible. The mammary gland is removed as a block with lymph nodes and a subcutaneous fat layer.

After the extraction of the mammary gland, all nerve endings and vascular links can be traced, which helps to avoid blood loss. This type of operation is endowed with a significant advantage: the preservation of radicality, relatively low trauma, and a low percentage of complications.

According to Halstead

The Halsted-Meyer mastectomy is a classic operation. A single complex removes the mammary gland, skin, subcutaneous tissue, pectoral muscles, subcutaneous fatty tissue (subclavian, axillary and subscapularis), lymph nodes.

The method often causes complications, the main of which is the restriction of mobility of the shoulder joint. It is used extremely rarely when other methods will not help to cope with the problem, for example, extensive ones that affect the pectoral muscle, lymph nodes, etc.

By Pati

Patey's mastectomy is a modification of the previous type and has the full name - modified radical mastectomy. Its founder, Dr. Patey, proposed a wide excision of the skin and preservation of the pectoralis major. During the operation, only a small muscle is removed, which makes the method more gentle and avoids serious complications.

According to Pirogov

The mammary gland and fiber of the axillary region are removed.

Simple mastectomy

The mammary gland and fascia of the pectoralis major muscle are removed.

Tram-flap technique

A method of breast restoration, which is carried out simultaneously with a mastectomy or six months after the operation. In this case, the patient's own tissue is moved, which is called the TRAM flap, which is a tissue with preserved blood flow. This may be an iliac-femoral flap or a greater omental flap. Sometimes a flap of the rectus abdominis muscle on the leg (together with the skin) is used.

Subcutaneous surgery technique

A technique that allows you to save the radicalness of the surgical intervention and achieve the highest possible aesthetic results. This is a method of extended subcutaneous mastectomy, when the mammary gland with muscular fascia (sheath) and lymph nodes are removed, while maintaining muscle and fatty tissue. P

When using this technique, it is also possible to perform a breast reconstruction operation at the same time. This can be an operation using one's own tissues or using an implant for which a "pocket" is previously formed.

Carefully! The photo shows the breast after a radical type mastectomy (click to open)

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Indications for holding

• varying degrees,
• Purulent mastopathy (in rare cases),
• Correction of previous treatment,
• Individual indications (prevention, etc.).

Contraindications

General contraindications:

• Violation of cerebral circulation.

Contraindications for tumor localization:

• Breast edema extends to the chest wall,
• Multiple with edema of the upper limb,
• Germination of a tumor of the chest.

Carefully! Video showing a radical mastectomy (click to open)

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Operation

Preparation

Preparation for the operation consists of several stages:

• Medical checkup, which is fundamental. The doctor examines the history and prescribes an examination,
• survey, including a series of tests and tests: (a photograph of breast tissue), and a blood test for clotting ().
• The doctor prescribes sparing (light) diet, warns of limiting the intake (or complete cessation) of drugs that thin the blood (aspirin, etc.). They are excluded a week before the operation. On the day of the operation, it is unacceptable to drink and eat.

Operation progress

The operation is performed under general anesthesia. Its duration is from 1 to 3 hours.

Carrying out algorithm:

1. Marking is applied with a marker for upcoming incisions,
2. The skin is cut in the necessary places,
3. Subcutaneous tissue and mammary gland are separated from the skin,
4. Removal occurs in a single block, including lymph nodes,
5. Depending on the method, the pectoral muscle, fatty tissue, etc. are sequentially removed,
6. Tracing nerve endings and vascular links,
7. Drainage is installed through a special hole, which is removed on the 5th - 6th day,
8. Stitches are applied, which are removed on the 10th - 12th day.

Drainage installation is an important point. The doctor monitors the outflow of fluid.

Rehabilitation

After a mastectomy, rehabilitation measures are extremely important. These include gymnastics, physiotherapy, taking medications.

Gymnastics

Gymnastics, some examples of exercises:

• Squeezing a rubber ball
• hair combing,
• Putting your hands behind your back, as if you are trying to fasten a button from behind,
• Circular movements of the hands, swaying, etc.

Physiotherapy

If there are no complications, then physiotherapy can be prescribed as early as a week after the operation. What can be done from this side:

• Pool,
• Various simulators aimed at developing the shoulder joint,
• Massotherapy,
• Hydromassage,
• (apply),
• Bandage,
• Medical wrap.

Rehabilitation rules

• Using an elastic bandage
• Refusal to visit the bath and solarium,
• You can not lift weights during the year,
• Staying in an inclined position for a long time
• Try to avoid injuries, do not use traumatic objects (bracelets, etc.),
• Increase the amount of fluid you drink
• Compression sleeves must be worn during air travel.
• An examination is required every six months
• If you feel unwell, contact your doctor immediately.

Lipofilling of the mammary glands after RM

This is a means of breast reconstruction after a mastectomy, for which the patient's tissue is used, and not implants. One session for the recovery procedure will not be enough, they will definitely need several.

It is also a serious moment that requires thorough preparation.

• The surgeon determines the areas from which the necessary material can be taken,
• Assigns an examination similar to that required for any plastic surgery,
• Surgery is performed under general anesthesia
• Before taking adipose tissue, Klein's solution is injected into it,
• Selected fat cells are placed in a centrifuge, where they are stratified into 3 parts,
• The middle part is used for direct reconstruction,
• The prepared adipose tissue is injected with a syringe in small portions into the targeted areas.

The operation is performed under general anesthesia and lasts from 2 to 5 hours. After lipofilling, and are formed, which persist for 3-4 weeks. Repeated operation is possible not earlier than in 4 months. For a stable result, 2-5 procedures are required.

Lipofilling involves the use of a special system (BRAVA), which protects the transplanted cells from external influences. This system is put on and worn for 7 to 14 days.

Consequences and complications

The number of complications after mastectomy continues to be high today (from 20 to 87%), despite the equipment and new technologies. Complications may be early or late.

Early

• Lymph leakage, which may necessitate a second operation,

Prices vary a lot, which is not surprising. Each operation has its own characteristics, different methods are used. Pricing also plays a role. Approximately the minimum price threshold is 35 thousand rubles. It is possible to have a simple mastectomy at a lower cost, but this is unlikely. Average prices for an operation range from 60 to 120 thousand rubles.

In situations where the tumor is large, or the woman has aggressive breast cancer, a mastectomy is necessary, an operation in which the entire breast gland is removed. Complete removal of a breast with small tumors is an option for a woman who wants to avoid radiation therapy and minimize the chance of recurrence. Unlike partial resection (sectoral resection, lumpectomy, quadrantectomy), breast irradiation, as a rule, cannot be avoided.

Read in this article

Who is a mastectomy for?

• previous radiation therapy to the chest area;
• there are multiple tumors in the mammary gland located in different quadrants (1/4 of the breast);
• extensive damage to breast tissue DCIS (ductal carcinoma "in situ");
• a large tumor compared to the volume of the breast;
• there are clear criteria for familial breast cancer or certain genetic mutations in the BRCA1 and BRCA2 genes.

Mastectomy Options

In the last decade, there have been significant changes in approaches to the surgical treatment of breast cancer:

• The proportion of operations for the complete removal of the mammary gland has decreased significantly. With the advent of the so-called organ-preserving treatment, lumpectomy, sectoral resection, quadrantectomy, in which part of the mammary gland is excised, have become more frequently performed.
• The previously widely used radical mastectomy, which removed the entire mammary gland, as well as all nearby lymph nodes and chest muscles, was replaced with a modified, less traumatic operation (pectoral muscles are not removed).
• Many major oncology clinics have begun to perform mastectomies, which remove breast tissue while leaving large areas of her skin, nipple and areola intact, allowing for reconstructive surgery with a good cosmetic effect.

There are the following options for mastectomies (total removal of the breast), which are currently considered the gold standard for surgical treatment of breast cancer.

• A simple total mastectomy is the removal of the entire breast, nipple, and areola. Underarm lymph nodes are not removed, and breast reconstruction is usually done on time or two weeks later. The duration of hospitalization varies: for some women it is an outpatient procedure, for others it may be necessary to stay in a hospital bed for several days.
• Modified radical mastectomy. During this operation, the mammary gland, nipple and areola are removed, and axillary lymph node dissection (excision of the axillary lymph nodes) is also performed. Breast reconstruction (reconstructive surgery) is usually performed after three weeks.
• Subcutaneous mastectomy. When the breast, nipple and areola are removed, the skin of the breast is left intact. This variant of mastectomy allows to achieve a good cosmetic result and perform reconstruction of the gland during the operation. It also allows you to easily install a tissue expander during the operation if the reconstruction is delayed for any reason.
• Nipple-sparing mastectomy is a new breast removal technique used in women who have a small tumor located not near the areola, but deep in the breast tissue. During this operation, the surgeon performs an excision of the skin on the outside of the chest, as well as around the edge of the areola. It then separates the gland tissue from the inside of the areola, thereby preserving the nipple. This technique involves the simultaneous reconstruction of the breast, and also allows you to install a tissue expander as the first stage of reconstruction.
• Mastectomy preserving the nipple and areola. With this technique, the surgeon separates the breast tissue from her skin through an incision, usually made on the outside, thereby preserving the nipple and areola. This allows immediate breast reconstruction or, if that fails, insertion of a tissue expander (perform the first stage of breast reconstruction surgery).
• Scarless mastectomy is a fairly new surgical technique that has been developed and is being performed in major cancer centers. The main objective of this operation is, regardless of how the breast tissue is separated from the skin, to do it through small surgical incisions, thereby avoiding the formation of noticeable scars. It is not uncommon that tissue removal is performed through holes that are smaller than 2 inches.
• Preventive / prophylactic mastectomy - removal of one or both mammary glands. Its goal is to reduce the risk of developing breast cancer. Women who have mutations in genes such as BRCA1 and BRCA2 or have close relatives diagnosed with breast cancer (family history of cancer) are candidates for this operation. They are also sometimes advised to have their ovaries removed. Genetic counseling can confirm or rule out any suspicion that this cancer is hereditary.

Since there is no evidence that lymph node dissection (removal of axillary lymph nodes) is necessary for prophylactic mastectomies, it is not performed during such operations. To ensure that “everything is in order” at the site of the removed breast, after these interventions, it is necessary for the patient to undergo regular check-ups for 90 days.

All variants of mastectomy listed above, with the exception of the modified one, allow performing a simultaneous reconstructive operation (both operations, both removal of the mammary gland and its reconstruction, are performed simultaneously).

Possible complications of breast removal surgery

Like any surgical intervention, mastectomy has its own complications that are characteristic only for it. Here are some of them:

• Temporary tissue swelling.
• Pain in the area of ​​the postoperative wound.
• Hardening in the area of ​​the scar, which is formed at the site of the incision.
• Infection of the postoperative wound.
• Bleeding.
• Swelling of the arm on the side of the operation, if lymph node dissection was performed (removal of axillary lymph nodes). This may be preceded by earlier signs of this complication, such as a feeling of numbness in the arm, soreness of the skin to any touch, its redness.
• Symptoms of phantom pain, which are manifested by itching, tingling, pulsation in the area of ​​​​the removed breast. These sensations can be managed with medication, exercise, or massage. Phantom pain is not a sign of the presence of cancer cells in the area of ​​the removed breast and does not mean that the cancer can return.
• Seroma is a fairly common complication after mastectomy, the result of the accumulation of tissue fluid in the cavity formed after the operation (clear fluid in the wound trap). The surgeon treats large seromas (all kinds of manipulations that help remove fluid) on an outpatient basis.
• "Ugly" scar. Although it is impossible to avoid scarring, they are usually not very noticeable, provided that the mastectomy is performed by highly qualified specialists. Quite often, especially in the first year after surgery, many patients experience discomfort at the arm if a lymph node dissection has been performed.
• Depression and feelings of loss of gender identity.

There are other complications, the occurrence of which largely depends on the general health of the patient. Therefore, it is imperative to discuss with the surgeon before the operation all the possible risks of the procedure.

The condition of the woman after the operation

After the operation is completed, the patient is sent to the recovery room for observation. The type of mastectomy and the type of anesthesia largely determine how long the stay in this ward will last. After the patient's blood pressure, pulse, and respiration have stabilized and she has regained consciousness, she is transferred to a regular room.

After a mastectomy, patients usually stay in the hospital for 1 to 3 days, sometimes longer, depending on the type of operation, whether there was a breast reconstruction.

In most cases, the soreness can last for several days, although many patients do not experience pain after surgery. It is recommended that you take pain medication to relieve symptoms as recommended by your doctor. Aspirin and some other pain medications can cause bleeding. Therefore, before taking any remedy, you should consult your doctor.

Recovery at home

From the moment a woman is at home after being discharged from the hospital, she needs to ensure that the postoperative area is dry and clean. For this, the doctor will give certain instructions, and he can also give recommendations on how to change it yourself.

If the breast removal was performed with lymph node dissection, the surgeon may recommend doing exercises to help "work out" the arm from the side of the operation. Soreness after axillary lymph node dissection often forces a woman to hold her hand in a forced position, which leads to shoulder stiffness. That is why it is necessary to start exercises to prevent this pathology as early as possible. Like any physical activity, these exercises can lead to injury, so you should consult with your surgeon before doing them. They are useful to perform even if lymph node dissection has not been performed.

Women usually return to their usual rhythm of life within 4 weeks after a mastectomy. Recovery times may increase if breast reconstruction is performed at the same time, which can take several months.

Therefore, the recovery period largely depends on the individual case. The timing of your rehabilitation should be discussed with the surgeon in advance.

You should also tell your doctor if you experience any of the following symptoms:

• a sharp increase in body temperature, accompanied by chills;
• from the wound there is an outflow of fluid (blood, etc.), there is redness, swelling;
• increase in pain intensity;
• suddenly appearing numbness, tingling in the arm from the side of the operation.

Depending on the specific situation, the surgeon may give additional postoperative instructions.

Many patients have concerns about the appearance of their breasts after a mastectomy. Fortunately, recent options for this operation allow most women to perform breast reconstruction. An alternative solution to restore the shape of the breast after the intervention is to wear a prosthesis or a special bra.

The main therapeutic tactic for breast cancer is its surgical removal (mastectomy), both as an independent option and in combination with radiation, hormonal and chemotherapy. The surgical strategy of modern treatment is aimed at ensuring the solution of two main tasks - the reliability of a cure for a dangerous disease and the creation of conditions that allow for the restoration of the breast after mastectomy and improve the patient's quality of life.

Radical methods of surgical treatment

Among all oncological diseases in women, breast cancer (BC) ranks first and second after diseases of the heart and blood vessels - among the causes of death. The number of patients with breast cancer each year increases by an average of 1-2%. This testifies in favor of the need to prefer the most radical methods of treatment.

At the same time, in the initial stages, the proportion of which has increased in the last 10 years, it is possible to perform organ-preserving operations with reconstructive plastic elements or even without them, and advances in the field of endoprosthetics can significantly improve the quality of life of those who have undergone such operations even at later stages of the disease.

Mastectomy according to Halsted-Meyer

Classical radical operation. It is based on the principle of staged spread of cancer cells from the primary tumor to the regional lymph nodes through the vessels and collectors of the same name.

Therefore, the essence of the operation is to remove the mammary gland with skin and subcutaneous tissue as a single complex with pectoral muscles (small and large), as well as with lymph nodes and subcutaneous fatty tissue located in the subclavian, axillary and subscapular regions.

The nature of the skin incision during surgery depends on the site of tumor localization. An oval transverse incision is mainly used, which allows, without much tension, to connect the edges of the wound with a skin suture at any localization. This method was used in all stages of breast cancer, but led to the development of serious late complications in most patients, especially in the form of limited mobility in the shoulder joint (in 60%). Currently, the Halsted-Meier technique is performed only in cases of:

1. Germination of the tumor in the pectoralis major muscle.
2. Involvement in the malignant process of the lymph nodes located on the back surface of this muscle.
3. The need for palliative surgery in a qualitative single solution.

Patty Dyson Mastectomy

It is the result of a search for more benign solutions for surgical intervention, which is a modification of the previous type. The author of the technique was based on the fact that lymphatic capillaries and vessels abundantly penetrate the skin and subcutaneous fat layer, but are almost absent in the fascia of the pectoral muscles. Therefore, D. Patey proposed to keep the pectoralis major muscle along with a wide excision of the skin and subcutaneous tissue around the cancer. In order to remove the subclavian and apical axillary lymph nodes, they were asked to confine themselves to removing only the pectoralis minor muscle. This technique made it possible to somewhat reduce the percentage and severity of late postoperative complications.

Mastectomy according to Madden

An even more gentle method in which both pectoral muscles are preserved. Removal of the mammary gland is carried out in a single block with the subcutaneous fat layer, subclavian, axillary and subscapular lymph nodes. The operation is characterized by no less radicalism, but is accompanied by significantly less trauma (compared to the previous ones), less blood loss and better and faster wound healing.

But most importantly, as a result of the application of the Madden modification, muscle preservation makes it possible to exclude or significantly reduce the number of patients with the development of limited functional mobility of the shoulder joint and obtain a more acceptable cosmetic effect. Due to this, operational modifications of this type are considered functionally sparing.

In recent years, there has been a trend towards a decrease in the volume of surgical intervention, while maintaining radicalism in oncological terms. The possibility of moving away from aggressive tactics that have persisted for decades is explained by:

• a significant increase (among all patients with breast cancer) of women with early stages of the disease;
• improvement of instrumental and diagnostic methods;
• development and application of effective combinations of surgical treatment with targeted, hormonal, chemotherapeutic and radiation types of exposure;
• revision of the biological and clinical concepts of the development of malignant processes - they take into account not only the stage of cancer, but also the degree of its activity, the rate of tumor growth, cell heterogeneity, the hormonal state of the body and its reactivity.

All this allows predicting the course of the disease, the likelihood of complications and choosing the tactics of treatment.

The listed types of radical mastectomy make it possible to quite successfully solve the problems of a therapeutic nature. However, after their implementation, the reconstructive possibilities associated with:

1. The need to restore the deficit of soft tissues in the absence of their reserve.
2. Creation of a transitional fold and a nipple-areolar complex.
3. Creation and correction of the shape and volume of the gland.
4. Restoring the symmetry of the mammary glands.

Subcutaneous mastectomy

This is a technique that allows you to optimally solve the main tasks of treatment:

1. Preservation of a sufficiently radical surgical intervention and oncological safety.
2. Significant facilitation of the primary reconstruction of the gland in order to achieve the best possible aesthetic results.

This technique consists in almost complete separation from the skin and removal of the glandular and adipose tissue of the mammary gland. At the same time, the nipple-areolar complex is also removed, which significantly worsens the expected aesthetic results of the operation. Therefore, many oncological surgeons strive to preserve it, for which various modifications are used.

Unfortunately, this is not always possible. Preservation of the nipple and areola depends on:

• the size of the primary node;
• localization of the tumor and its distance to the nipple-areolar apparatus;
• the severity of intraductal components;
• cell type of the tumor and the nature of its growth;
• the degree of involvement of the nipple-areolar apparatus in the cancer process (according to various sources, it ranges from 5.6 to 31%).
• status of regional lymph nodes.

In subcutaneous mastectomy, various incisions are used to provide wide visual access. Depending on the conditions, an extended subcutaneous mastectomy can be used, which involves an incision under the gland from the parasternal line to the middle axillary line. It allows you to remove the gland tissue along with the muscular fascia at the base, expose the excretory ducts of the nipple, and in the armpit - it is easy to isolate and remove the processes of the mammary gland along with the lymph nodes.

Subcutaneous mastectomy makes it possible to simultaneously perform a reconstructive operation of the mammary gland by moving its own tissues or to form a pocket under the pectoralis major muscle for implant placement.

The choice of any of the listed methods largely depends on the stage of the prevalence of the tumor process.



Complications after mastectomy

Despite the constant improvement of surgical treatment methods, the number of complications remains quite high - from 20 to 87%. Complications in the immediate postoperative period contribute to the intensive development of connective tissue in the surgical area and the occurrence of late complications. Risk factors are:

1. Old age (after 60 years).
2. Obesity and even just overweight.
3. Significant volume of mammary glands (from the 4th size).
4. Concomitant diseases, especially diabetes mellitus, chronic diseases of the lungs and heart, arterial hypertension.
5. Additional preoperative radiation and/or hormonal therapy.

Major early complications

• lymphorrhea (lymph leakage) that occurs after radical mastectomy in all patients;
• marginal necrosis with subsequent divergence of tissue flaps at their junctions; this occurs mainly due to excessive tension of soft tissues with their deficiency;
• accession of infection and suppuration of the wound.

The causes of lymphorrhea, regardless of the volume of the operation, are the removal of lymph nodes and the inevitable intersection of the lymphatic vessels connecting them. Ligation of all vessels during the operation is impossible, since most of them remain invisible. The duration of abundant lymphorrhea can be 1 month or more, which creates conditions for infection and the development of marginal necrosis, delaying the timing of additional anticancer therapy, the formation of a seroma (lymphocele) in the axillary zone, which is a cavity surrounded by a capsule and filled with lymph. Its formation requires repeated surgical intervention.

Late complications after mastectomy

They occur in all patients and with any technique, but they are especially pronounced when using the Halstead-Meier method. The complex of the most typical complications, called post-mastectomy syndrome, includes:

1. Violation of the outflow of lymph from the tissues of the limb (lymphostasis).
2. Narrowing or complete closure of the lumen of the subclavian and / or axillary veins, as a result of which the outflow of venous blood is disturbed.
3. The development of rough postoperative scars involving the axillary nerves.

These complications are the cause of prolonged or even permanent pronounced edema of the limb, the development of adductor contracture of the shoulder (in 60%), which limits mobility in the shoulder joint and is accompanied by frequent pain, and permanent disability.

Gymnastics

A certain positive result has gymnastics after a mastectomy, recommended by the US Association for Breast Cancer and Mastectomy. Gymnastics includes exercises such as combing hair, squeezing a rubber ball with a brush, rotating and swinging arms, putting them behind your back with a towel and fastening a bra.




Breast reconstruction



Breast reconstruction after a mastectomy is carried out simultaneously with the main operation or, if this is not possible, approximately six months after it. Many different reconstructive techniques have been developed, which are conventionally divided into 3 groups:

1. Reconstruction by the tissues of the patient himself, which is the movement of a tissue flap with preserved blood flow - the iliofemoral flap, the greater omentum flap, the rectus abdominis muscle flap with skin (TRAM flap) on a leg or free, and others.
2. Use of expanders and silicone implants.
3. Combined methods - the use of methods of the first and second groups. For example, tissue deficiency is filled with a flap from the back of the back, and silicone implants are used for additional volume, shape and symmetry correction.

Reconstructive methods in terms of their capabilities and effectiveness are arranged in the following sequence:

1. The maximum use of organ-preserving techniques is possible, followed by volume replacement by moving local tissues. This option in most cases allows you to recreate the volume, shape and even symmetry of the mammary glands.
2. Reconstruction of the gland using endoprostheses after subcutaneous mastectomy with preservation of the nipple-areola complex. It is also possible to combine the same mastectomy method with a muscle (without skin) flap from the back and the addition (if necessary) of an endoprosthesis.
3. TRAM-patchwork method, which is used when it is impossible to apply the above options, since its technical implementation is much more complicated. In addition, it causes significant damage to the donor area.







Treatment of breast cancer is planned by an oncologist surgeon with the participation of other specialists - a morphologist, a chemotherapist and a radiologist, which allows for the optimal choice of the method of surgery, systemic treatment and postoperative rehabilitation.

A) Indications for mastectomy by Pati:
- Absolute readings: multicentric tumors, stage T4 tumors, large tumor in relation to the size of the breast. Be sure to combine with axillary lymphadenectomy.
- Alternative operations: Quadrantectomy for smaller tumors or patients in very poor general condition.

b) Preoperative preparation. Preoperative examinations: mammography, chest x-ray, ultrasound (armpit, abdominal organs), bone scan.

V) Specific risks, informed consent of the patient. Lymphedema of the hand (in 10% of cases).

G) Anesthesia. General anesthesia (intubation).

e) Patient position. Lying on the back, the arm is abducted, the armpit is accessible.

e) Operational access when removing the mammary gland according to Pati. Horizontal elliptical excision of the mammary gland with the transition to the axillary region.

and) Stages of a mastectomy according to Pati:
- Patient position
- Incision
- Caudal dissection of the breast

- Expansion of the scope of the operation


- Wound closure

h) Anatomical features, serious risks, surgical techniques:
- The long thoracic nerve runs along the lateral chest wall (serratus anterior), the thoracic nerve lies dorsal to it (the latissimus dorsi muscle).
- Avoid circular lymph node dissection around the axillary vein (the cranial edge of the axillary dissection is the intercostal-brachial nerve).
- Apply an elastic bandage after the operation.
- "Unfixed" macropreparation must be immediately sent to the pathological department for the determination of estrogen and progesterone receptors, as well as for histological examination of the tumor.

And) Measures for specific complications. None.

To) Postoperative care after breast removal for cancer:
- Medical care: remove the active drain after 2 days.
- Activation: hand movements as the pain is overcome.
- Physiotherapy: to restore lymphatic drainage.
- Period of incapacity for work: 2 weeks, depending on the occupation and further medical measures.

l) Operative technique of mastectomy according to Pati:
- Patient position
- Incision
- Caudal dissection
- Cranial breast dissection
- Expansion of the scope of the operation
- Dissection in the axillary vein
- Resection of the pectoralis minor muscle
- Wound closure




1. Patient position. The patient is positioned on the operating table with the arm abducted, the armpit is shaved. The shoulder on the side of the operation can be slightly raised with a flat pillow placed under the back.

2. Incision. The incision is made transversely and includes a scar from a previous biopsy. For axillary intervention, the incision can be extended laterally.




3. Caudal dissection of the breast. The incision is deepened to the fascia of the pectoralis major muscle. The fascia is separated from the muscle and released in a cranial direction. The ventral arteries and intercostal vessels are coagulated or ligated with suture. The dissection of the breast tissue, together with the fascia of the pectoralis major muscle, continues into the axilla. Dissection is performed with a scalpel or diathermy.

4. Cranial breast dissection. Dissection from the cranial part of the incision is carried out in the same way, with a guaranteed separation of the fascia of the pectoralis major muscle to the axilla.




5. Expansion of the scope of the operation. The dissection should continue along the axillary fat pad along the lymphatic collectors into the axilla itself. The most cranial point is the apex of the armpit. When deepening into the axilla, the pectoralis major muscle is retracted medially to expose the pectoralis minor muscle. The fascia of the pectoralis minor muscle and the lymph nodes between the pectoral muscles are removed. Care must be taken not to disrupt the innervation of the pectoralis major muscle. For this, a wide intermuscular dissection should not be performed. After reaching the armpit, its contents are gradually separated from the anterior serratus muscle. During dissection, the long thoracic and thoracic nerves are exposed and protected.

6. Dissection in the axillary vein. The axillary tissues, together with the breast tissue, are transected between the Overholt forceps at their most cranial point at the axillary vein. To avoid damage to the lymphatics, the dissection should not continue cranial to the vein.




7. Resection of the pectoralis minor muscle. If the tumor is located near the pectoralis minor, the muscle can be cut at its insertion and removed. To do this, it is released from under the pectoralis major muscle and cut off using diathermy. We usually do not remove this muscle.

8. wound closure. The operation is completed by two active drainages, subcutaneous and skin sutures. In some situations, it is possible to perform a one-stage reconstructive operation.