Types of radical mastectomy. Types of operations. Late complications after mastectomy

This type of surgery, as according to Madden, refers to radical therapy. During this operation, the mammary gland itself is removed along with the axillary tissue. At the same time, neither the pectoralis major nor the minor muscles are affected during surgery. Preservation of the pectoral muscles in itself greatly reduces the likelihood of complications such as impaired mobility of the shoulder joint, which is not uncommon when using other surgical techniques.

Progress of mastectomy operation according to Madden

The second surgical name for this type of surgery is functional-sparing radical mastectomy. From this definition it is clear that the main goal of the operation is rapid postoperative rehabilitation with a minimum of consequences and complications.

The surgery itself is performed exclusively under general anesthesia. After processing the surgical field, doctors make a transverse incision in the skin that borders the gland itself. In this case, the skin-subcutaneous flaps are separated in different directions. After this, in fact, the mammary gland is removed along with the fascia located underneath it. Subclavian-axillary-subscapular lymphadenectomy (removal of lymphatic structures located in this area) is performed almost simultaneously.

This type of mastectomy is preferable for the so-called nodal forms of the oncological process. However, preserving the pectoralis minor muscle creates a certain kind of technical difficulty in performing the operation, which requires the participation of qualified and experienced surgeons.

What are the features of the postoperative period for Madden mastectomy?

First of all, it must be said that a woman can get up after the operation within a day. In this case, getting out of bed should be done without any sudden movements.

As for the woman’s general well-being, chest pain may be noted for 4 days after the operation, which, if severe, can be relieved by the administration of analgesic medications.

Women who have undergone this type of surgery are strictly forbidden by doctors to raise their arms high. It is also necessary to completely avoid lifting heavy objects and carrying bags.

Despite the fact that the full rehabilitation period lasts about 3-4 weeks, as a rule, patients are discharged from the hospital already on the 3-4th day. hospital. In this case, the drainage system installed after the operation remains, and the woman receives recommendations for caring for it at home.

Mastectomy is an operation to remove a tumor in the mammary gland. In surgery, the name radical resection is also used. It is prescribed for breast cancer, Paget's nipple cancer or foliate fibroadenoma. It is less often carried out for preventive purposes if a woman has a predisposition to the occurrence of these diseases.

Kinds

Modern medicine allows mastectomy to be performed in several ways. At the moment, the Patey and Madden operation is the most popular, as they are characterized by the least trauma and disability.

The choice of method depends on the extent of the tumor, its stage and the presence of metastases.

Clinics in Moscow

• SM-Clinic – located at Tsetkin, 33/28. The cost here is 66,000 rubles;
• Family Clinic - located at Kashirskoye Shosse, 56. The operation will cost 70,000 rubles;
• K+31 is a medical center located on l. Lobachevskogo, 42, bldg. 4. The cost of a mastectomy is 60,000 rubles.

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Diseases that you can't ignore. They require intense attention, examination and treatment. Among oncological diseases in women, breast cancer ranks first, among other diseases it ranks second. The consequences cannot always be predicted.

Prevention and timely treatment are important. In some cases, radical surgery is inevitable.

What is radical mastectomy

Radical, i.e., removing entirely, completely, from the roots. The concept of mastectomy is of Greek origin - mastòs “breast” and ek tome “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 the existing problem.

There are three main types of mastectomy:

• according to Madden,
• by Patey,
• according to Halstead.

Radical mastectomy according to Madden is considered the most gentle.

Carefully! The video shows a radical mastectomy (click to open)

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Kinds

According to Madden

The method involves preserving both pectoral muscles, which makes it as gentle as possible. The mammary gland is removed en bloc with lymph nodes and subcutaneous fat layer.

After removing the mammary gland, all nerve endings and vascular links are traced, which helps to avoid blood loss. This type of operation has significant advantages: preservation of radicality, relatively low morbidity, low percentage of complications.

According to Halstead

Halstead-Meyer mastectomy is a classic operation. The mammary gland, skin, subcutaneous tissue, pectoral muscles, subcutaneous fatty tissue (subclavian, axillary and subscapular region), and lymph nodes are removed as a single complex.

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

By Patey

Patey's mastectomy is a modification of the previous type and has the full name - modified radical mastectomy. Its founder, Dr. Patey, proposed wide excision of the skin and preservation of the pectoralis major muscle. 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 tissue of the axillary region are removed.

Simple mastectomy

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

Technique using tram flap

A technique for breast restoration, which is performed simultaneously with a mastectomy or six months after surgery. In this case, the patient's own tissue is moved, which is called a TRAM flap, which is tissue with preserved blood flow. This may be an iliofemoral flap or a greater omentum flap. Sometimes a pedicled rectus abdominis muscle flap (along with skin) is used.

Subcutaneous surgery technique

A technique that allows you to maintain the radicality of surgical intervention and achieve the best 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 preserving the muscles and fatty tissue. P

When using this technique, breast reconstruction surgery can be performed at the same time. This can be an operation using your own tissue or using an implant, for which a “pocket” is pre-formed.

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

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Indications for testing

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

Contraindications

General contraindications:

• Cerebrovascular accident.

Contraindications for tumor localization:

• Swelling of the mammary gland extends to the chest wall,
• Multiple with edema of the upper limb,
• Invasion by a tumor of the chest.

Carefully! The video shows a radical mastectomy (click to open)

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Carrying out the operation

Preparation

Preparation for surgery consists of several stages:

• Medical checkup, which is a fundamental point. The doctor examines the medical history and prescribes an examination,
• Survey, including a series of tests and tests: (photography of breast tissue), and a blood test for coagulation ().
• The doctor prescribes gentle (light) diet, warns about limiting the use (or completely stopping) of medications that thin the blood (aspirin, etc.). They are excluded a week before surgery. On the day of surgery, it is unacceptable to drink or eat.

Progress of the operation

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

Algorithm:

1. Markers are used to mark the upcoming cuts.
2. The skin is cut in the necessary places,
3. Subcutaneous tissue and mammary gland are separated from the skin,
4. Removal occurs as a single block, including lymph nodes,
5. Depending on the method, the pectoral muscle, fatty tissue, etc. are sequentially removed.
6. Nerve endings and vascular links are traced,
7. A drainage is installed through a special hole, which is removed on the 5th - 6th day.
8. Stitches are applied and removed on days 10-12.

Installing drainage is an important point. The doctor monitors the outflow of fluid.

Rehabilitation

After a mastectomy, rehabilitation measures are extremely important. These include gymnastics, physical therapy, and 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 at the back,
• Circular movements of the arms, rocking, etc.

Physiotherapy

If there are no complications, then physical therapy can be prescribed a week after the operation. What can be done about this:

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

Rehabilitation rules

• Using an elastic bandage
• Refusal to visit the bathhouse and solarium,
• You can't lift weights for a year,
• Stay 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,
• When flying by air, you must use a compression sleeve,
• An examination is required every six months,
• If you feel worse, consult a doctor immediately.

Lipofilling of the mammary glands after RM

This is a means of breast reconstruction after mastectomy, which uses the patient's tissue rather than implants. One session for the recovery procedure will not be enough; several will be required.

This is also a serious moment that requires thorough preparation.

• The surgeon determines the areas from which the necessary material can be taken,
• Prescribes an examination similar to that required for any plastic surgery,
• The operation is performed under general anesthesia,
• Before collecting adipose tissue, Klein's solution is injected into it,
• Selected fat cells are placed in a centrifuge, where they are separated into 3 parts,
• The middle part is used for direct reconstruction,
• The prepared fatty tissue is injected using 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 surgery is possible no earlier than after 4 months. For a lasting result, 2 to 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 remain high today (from 20 to 87%), despite equipment and new technologies. Complications can be early or late.

Early

• Leakage of lymph, which may necessitate further surgery,

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

Surgical treatment of breast cancer has gone through a difficult and long journey, from cauterization of the pathological focus to complete removal of the gland.

Just a few decades ago, the Halsted-Meyer radical mastectomy was the only surgical procedure that provided sick women with at least some hope. But new examination methods, early detection of malignant forms, radiation and chemotherapy allow the use of more gentle treatment methods.

Options for surgical intervention depend on the size of the node, growth into adjacent tissues, and the presence of metastatic foci. If the tumor is no more than 2.5 cm, and the cancer is stage 1-2, then surgeons try to preserve the organ tissue as much as possible. If the formation is large, then the operation is supplemented with simultaneous breast replacement. At stages 2B and 3, radical mastectomy is resorted to.

It's important to know that The surgeon's knife is still the only means of complete cure breast cancer.

Contraindications

• Infiltration of chest wall cancer;
• Advanced cancer;
• Metastatic damage to multiple lymph nodes with the development of lymphostasis in the arm on the affected side;
• Numerous ulcers in the area of ​​the gland;
• Erysipelas-like formation;
• Severe swelling of the affected organ with swelling spreading to the chest.

In addition to specific ones, there are also general contraindications that affect the entire body as a whole. The most significant: severe cardiovascular, renal, liver failure, stroke, in the stage of decompensation.

Surgical options

There are several main options for surgical treatment; we will consider each in detail.

Lumpectomy

This type of treatment involves excision of cancer without necessarily capturing healthy tissue. During lumpectomy, a cytological examination is performed directly during the operation to exclude the presence of tumor cells along the resection margin. The extent of intervention depends on previous diagnostic measures and histological findings.

The choice of access depends on the location of the breast cancer. The incision can be made in three options: above the neoplasm, within the areola, or in an arcuate manner in the area of ​​the fold under the affected gland. The last two incisions are the most aesthetically pleasing in terms of cosmetics; after a couple of years, the woman will not even find a scar from the operation.

During the operation itself the tumor is completely excised, the doctor conducts a thorough inspection of the edges of the incision to be sure that there is no tumor tissue in the resection area.

This intervention is advisable to carry out in the presence of very small tumors that can only be detected using special research methods.

Sectoral resection

Already from the name it becomes clear that this technique involves resection of a specific sector in the affected gland with the neoplasm itself and the main milk ducts. Sometimes surgeons call this intervention radical resection.

If the cancer has affected the upper outer quadrant, then the lymph nodes and pathological focus are removed in one block. Such excision is possible by lengthening the incision in the area of ​​the pectoralis major muscle.

With sectoral resection, at least 2/3 of the gland is preserved so that reconstructive surgery can be performed. This technique in some cases makes it possible to perform an intervention while preserving the nipple-areolar complex, which will subsequently allow the young woman to breastfeed her baby.

To resort to such an organ-preserving operation, it is important to correctly assess the nature of the tumor process. Sectoral resection can be used in cases of slow progression of the disease and small sizes (up to 2.5 cm).

Nipple resection

The technique is used extremely rarely as a diagnostic measure for suspected Paget's cancer. A wedge-shaped excision is performed and cosmetic sutures are applied. If Paget's disease is confirmed, more radical interventions are performed.

Radical mastectomies

There are several mastectomy techniques, the choice will depend on the commitment of the surgeon and the school of oncologists.

According to Madden

Volumetric surgical intervention that allows you to preserve the pectoral muscles on the side of the affected organ. During this operation, the following structures are excised:

• underlying fascia;
• Subclavian, axillary and subscapular lymph nodes;
• Fiber between muscles.

The operation makes it possible to almost completely preserve the function of the hand, which is important for the patient. But this surgical treatment is suitable for the most part only for nodular forms of malignant tumors.

By Patey

This operation differs from the previous one by removing the pectoralis minor muscle. This mastectomy improves access to the lymph nodes under and above the pectoralis minor muscle.

Thanks to the preservation of the pectoralis major muscle the degree of disability of a woman decreases.

This technique is fraught with the appearance of scars near the subclavian vein.

According to Halstead

A very traumatic operation not only physically, but also psychologically for the patient. With this technique, the following is excised:

• Affected gland;
• Both pectoral muscles (major and minor);
• Subclavian, subscapular, axillary lymph nodes;
• Fiber in the area of ​​excised lymph nodes.

Surgery is used when cancer has spread to the pectoralis major muscle. Sometimes, it is not completely excised and a part is left in which there is no tumor process.

A wide variety of incisions are made, it all depends on the type of tumor and its size.

Extended axillary-sternal

A similar version of mastectomy is used when the tumor is located in the central or internal parts of the gland. During the operation, not only the affected organ with the pectoral muscles and subcutaneous fat, but also the periosternal lymph nodes with the pectoral vessels are removed en bloc. To perform this operation, 2 or 3 costal cartilages are removed.

If during the intervention the surgeon identified axillary lymph nodes, they are not removed, since this will no longer affect the course of the disease.

Expanded modified

Surgery is used for edematous forms of the tumor process, large ulcerative defects, and in the presence of an erysipelas-like neoplasm. Mastectomy is used in rare cases when recurrence of cancer is suspected.

During the operation, the affected gland and skin with fiber that is adjacent to the tumor are removed. The skin defect will begin 5 cm from the edge of the mammary gland. Its boundaries will be approximately as follows:

1. upper in the second intercostal space,
2. from the armpit along the posterior axillary line,
3. down the fold under the organ,
4. in the sternum area - on the opposite side of the affected gland.

Since the surgical wound is very large, closing the defect is quite difficult. For this purpose, a skin-subcutaneous flap from the abdomen is used, which is moved to the area of ​​the defect on the feeding vascular pedicle.

Simple mastectomy

This operation is used as palliative care when other methods would be unnecessarily traumatic and pointless. The surgeon excises the affected mammary gland, capturing the sheath of the pectoralis major muscle.

Simple mastectomy used in the last stages of the malignant process when tumor decay is observed. Also, palliative intervention is resorted to in severe chronic diseases and in elderly people, when other radical measures are more likely to harm than prolong the life of the sick person.

Reconstruction after mastectomy

Breast removal is extremely difficult for women, even if partial resection has been performed. Reconstructive interventions are essential so that a woman can socialize normally and return to her usual lifestyle.

Cosmetic reconstruction can be performed either directly during the operation itself or some time after surgery. Such operations are very complex and require high skill of a plastic surgeon, since after a mastectomy it is necessary to recreate the woman’s breasts.

During reconstructive interventions, the organ’s shape and size are restored, and the nipple-areolar complex is recreated. Despite the efforts of doctors, a pronounced postoperative scar often remains on the organ.

Most often fabric the defect can be restored using an autograft. To do this, a skin flap with a vessel feeding it is taken from the back or abdomen, this graft is gradually brought to the operated area and only then the defect is closed. Such a complex manipulation requires a long time, so the woman must tune in to the long-term recovery stage.

If the reconstruction was successful, then the woman recovers much faster and stabilizes psycho-emotionally.

Postoperative period

After the operation, the sutures are treated with iodine, and after 10 days, if there are no complications, they are removed.

It is extremely important that the arm on the operated side is not loaded; even a routine pressure measurement can pose a threat of infection. The woman is warned that it is better not to disturb the limb at all for some time and make do with her healthy hand.

The patient must be consulted by a psychologist, since some patients have a high risk of suicide. If necessary, the doctor prescribes the necessary medications.

Since the recovery process is difficult and lengthy, a woman should receive adequate nutrition with sufficient vitamins and minerals. The diet must include meat and fish products, vegetables, and fruits.

The patient is issued a certificate of incapacity for work, she also undergoes MSEC and, if necessary, she is issued a disability certificate.

After discharge, the woman should be observed by a gynecologist or mammologist and undergo routine examinations. In the first year she should visit him every 3 months, for 2-3 years every six months, and then annually.

Important! Every month, a woman should palpate her mammary glands on her own. Not only the operated mammary gland should be examined, but also the healthy one!

Every year the patient undergoes a mammography examination.

If the doctor suspects a relapse of the malignant process, the woman is referred for a consultation with an oncologist, who will select the necessary therapy.

A) Indications for mastectomy according to Peyti:
- Absolute readings: multicentric tumors, stage T4 tumors, tumors large in relation to the size of the breast. A combination with axillary lymphadenectomy is mandatory.
- Alternative operations: Quadrantectomy for smaller tumors or in patients in very poor general condition.

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

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

G) Anesthesia. General anesthesia (intubation).

d) Patient position. Lying on your back, arm abducted, armpit accessible.

e) Operative access for mammary gland removal according to Peyti. Horizontal elliptical excision of the mammary gland with transition to the axillary region.

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

- Expansion of the scope of the operation


- Closure of the wound

h) Anatomical features, serious risks, surgical techniques:
- The long thoracic nerve runs along the lateral chest wall (serratus anterior muscle), the thoracodorsal nerve lies dorsal to it (latissimus dorsi muscle).
- Avoid circumferential lymph node dissection around the axillary vein (the cranial edge of the axillary dissection is the intercostobrachial nerve).
- After surgery, apply an elastic bandage.
- The “unfixed” macroscopic specimen must be immediately sent to the pathology department to determine receptors for estrogen and progesterone, 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 active drainage after 2 days.
- Activation: movements of the hand as pain is overcome.
- Physiotherapy: to restore lymphatic drainage.
- Period of incapacity for work: 2 weeks, depending on the type of occupation and further medical measures.

l) Surgical technique of mastectomy according to Patey:
- Patient position
- Incision
- Caudal dissection
- Cranial dissection of the mammary gland
- Expansion of the scope of the operation
- Dissection of the axillary vein
- Resection of the pectoralis minor muscle
- Closure of the wound




1. Patient position. The patient is positioned on the operating table with his arm abducted and the armpit is shaved. The shoulder on the side of surgery can be slightly elevated using a flat pillow placed under the back.

2. Incision. The incision is made transversely and includes the scar from the previous biopsy. For interventions in the armpit, the incision can be extended laterally.




3. Caudal breast dissection. The incision deepens to the fascia of the pectoralis major muscle. The fascia is separated from the muscle and released in a cranial direction. Ventral arteries and intercostal vessels are coagulated or ligated with suturing. Dissection of the breast tissue along 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, ensuring separation of the fascia of the pectoralis major muscle to the axilla.




5. Expanding the scope of the operation. Dissection should continue along the fat pad of the axilla along the lymphatic collectors into the cavity itself. The most cranial point is the apex of the axilla. 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. To achieve this, wide intermuscular dissection should not be performed. After reaching the axilla, its contents are gradually separated from the serratus anterior muscle. During dissection, the long thoracic and thoracodorsal nerves are isolated and protected.

6. Dissection of the axillary vein. The axillary tissue, along with the breast tissue, is transected between the Overholt forceps at their most cranial point at the axillary vein. To avoid damage to the lymphatic vessels, dissection should not be continued more cranial to the vein.




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

8. Closing the wound. 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.