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INDICATIONS

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Over the past 20 years, multiple international clinical studies have shown equivalent survival between patients treated with modified radical mastectomy and appropriately selected patients treated with breast-conserving surgery and adjuvant radiation, hormonal therapy, and/or chemotherapy. Accordingly, breast-conserving surgery has become the dominant mode of treatment, with modified radical mastectomy becoming the alternate choice in certain circumstances. A residual large cancer after neoadjuvant therapy (especially in a small breast), multicentric cancers, and patient preference or concerns about the complications of radiation therapy are the principal indications for the operation. Prior to surgery, the opposite breast should be evaluated by physical examination and mammography. The role of MRI to screen the contralateral breast is still an area of controversy. Appropriate blood tests and imaging scans and mammographic studies are made in a search for potential metastases to the lung, liver, or bone. The standard preadmission physical examination and laboratory evaluations are done in an ambulatory setting, as most patients are admitted to the hospital on the day of operation.

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PREOPERATIVE PREPARATION

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The skin over the involved area should be inspected for signs of infection. The skin is shaved and electrical hair clippers may be used over the axillae. Some surgeons give a single perioperative dose of parenteral antibiotics, particularly if a regional breast biopsy has recently been performed.

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ANESTHESIA

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General anesthesia is given via an endotracheal tube. Short-acting muscle depolarizing agents should be requested for the intubation, such that the motor nerves will be responsive during the axillary node dissection.

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POSITION

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The patient is placed nearest the edge of the operating table on the side of the surgeon. The arm is abducted and held by an assistant or placed upon a support at right angles to the patient to facilitate the preparation of the skin. Some prefer to wrap the arm, including the hand, in sterile drapes so that the arm can be moved upward as well as medially to facilitate the subsequent dissection of the axilla.

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OPERATIVE PREPARATION

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The skin is widely prepared with topical antiseptics. This includes not only the involved breast but also the area over the sternum; the supraclavicular region, shoulder, axilla, and collateral chest wall; as well as the upper abdomen on the involved side. A slight Fowler position with a tilt away from the surgeon improves the exposure. The surgical drape should be secured to the skin at appropriate points around the margin of the proposed field of operation. The arm should be free to be moved by an assistant as required for exposure in the axilla.

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INCISION AND EXPOSURE

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The diagnosis of malignancy is usually established by core needle biopsy under ultrasound guidance or stereotactic biopsy prior to mastectomy. If the diagnosis of malignancy has not been documented by previous biopsy, the ...

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