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Indications

Cytologically proven breast carcinoma

Preparation

GA
DVT prophylaxis
Supine position + arm on armboard

Procedure

1. Mark boundaries for skin incision
   • At least 3cm from tumour
   • Anatomical markers - medially: sternum / laterally: lat dorsi / superiorly: 2cm below clavicle / inferiorly: 1-2cm below infra-mammary fold
   • ?? Excision should include nipple/areolar complex
2. Dissect lump
   • Incise skin
   • Develop flaps (use clips/retractors) in plane corresponding to Scarpa's fascia between the subcutaneous fat and mammry fat - aim for thickness of 3-4mm medially increasing to 6-8mm laterally
   • Approaching clavicle superiorly, dissect more deeply to pectoral fascia
   • Raise inferior flap
3. Dissect axilla: - obtains regional control of disease, establishes prognostic information
   • peel breast laterally until border of lat dorsi
   • retract pec major to expose pec minor
   • divide pec minor (close to point of insertion onto coracoid process)
   • Identify Long thoracic nerve of Bell, thoracodorsal nerve (and intercostobrachial nerve)
   • Ligate all venous tributaries from axillary vein
4. Remove lump + axillary contents en-masse
   • Place stitch on most proximal node for pathological orientation
5. Place one suction drain on breast bed + one in axilla
6. Washout with antiseptic
7. Close

+ Can be combined with flap reconstruction

TRAM - transverse rectus abdominis

DIEP

Complications

• Bleeding / infected haematoma
• Buttonholing of skin flaps
• Nerve injury - LT nerve (serratus anterior - winged scapula); thoracodorsal nerve (lat dorsi)