Types of Breast Surgery

Types of Breast Surgery

Various types of breast surgery

Partial Mastectomy and Sentinel Lymph Node Biopsy

Partial mastectomy is when just the portion containing the breast abnormality is removed. Depending on the patient, this may be done with or without needle localization. In cases of ductal carcinoma in situ (noninvasive cancer), this is done as a stand-alone procedure. In cases of invasive breast cancer, it is paired with an axillary lymph node biopsy which is done at the same time but through a second incision. As invasive cancer has the potential to spread, a lymph node from underneath the axilla is removed during the surgery to screen it for cancer. This is called a sentinel lymph node biopsy. The lymph node is identified by the surgeon injecting blue dye around the nipple of the breast after the patient has gone under general anesthesia. The body’s lymphatic vessels pick up the dye and carry it through the breast into the axilla where the dye will stain the first lymph node that it encounters. This is a way to map how a cancer cell might similarly be carried. If the first lymph node does not have cancer, the chance for subsequent further lymph nodes to be affected is small. This prevents lymph nodes from unnecessarily being removed. If the first lymph node does have cancer, it is then necessary to remove the entire packet of lymph nodes from the axilla to properly stage the cancer. As the dye will just stain the first lymph node, the rest of the lymph nodes are removed as a mass together. The major blood vessels and nerves in the axilla will stay will all remaining fatty tissue and lymph nodes removed. If a single lymph node is removed, it is often no necessary for a drain tube to be used to promote healing. However, if all the lymph nodes are removed, a drain will be used to help the area underneath the axilla heal. The drain will also alert to any leaking lymphatic fluid as the color of the fluid will look more like milk rather than blood tinged. The amount of time that the drain is necessary depends on the output. As there are many sensory nerves in the axilla, it can be very normal to have numbness underneath the arm from the shoulder to the elbow. It can be normal for a patient to favor that arm after surgery in the axilla, but range of motion exercises are vital to protect against scar tissue formation.

Mediport Insertion

A mediport is recommended to patients who expect to have intravenous chemotherapy following surgery. The medications can be quite irritating to the veins and repeated IV sticks can be bothersome to the patient. This especially true for patients who have had axillary lymph nodes removed in which case the recommendation is not to ever have an IV stick on that arm to prevent further damage to the lymphatic vessels. A mediport is essentially an implanted IV through which blood can be drawn or medication infused. Placement requires general anesthesia. After asleep, a small incision is made on the upper chest and a pocket underneath the skin is created. A needle is then placed in a large blood vessel (either the internal jugular in the neck or subclavian underneath the clavicle). Once inside the vessel, a wire is placed through the needle to serve as a guide into the superior vena cava, which is the large vein leading to the heart. Imagine taking the side roads to lead to the interstate. Once the wire is in place, a small hollow rubber tube is placed over the wire and then the wire is removed. The part of the tubing that is outside of the patient is then tunneled under the skin to attach to a special reservoir that will be placed into the created skin pocket. The reservoir has a special center that will allow needles to go into and out of it without leaking. A form of real time x-ray called fluoroscopy will be used to trace the pathway of the tubing from the reservoir on the chest wall as it leads to the vena cava to ensure there are no kinks or twists. The port pocket is then sealed with dissolving stitches and can be used immediately. A bump will be visible and palpable on the chest wall so that the nurses will know where the port is and be able to access it. A chest x-ray is performed following the procedure. Sometimes an inadvertent puncture of the lung can happen as the needle is finding the correct blood vessel. This can cause the lung to deflate and because the air is trapped within the chest, the lung cannot reinflate. A special tube is needed to remove the trapped air and allow the lung to reinflate. This is very rare but important to rule out for all patients who have had this procedure. Fortunately, removal of the port is very easy as there are no needles to insert and no tubing to guide. The removal of the port can be done in the office.

Insertion of a SAVI device

In cases where radiation is deemed necessary, sometimes a SAVI might be indicated. The SAVI is an inplanted device that is placed following partial mastectomy to deliver radiation directly into the cavity where the cancer used to be. It is beneficial in that it drastically reduces the number of days of radiation therapy and minimize the potential for radiation damage to other structures near the breast (lungs and heart). It is most useful in early-stage small breast cancers. If a patient is a candidate, the procedure is done in the office under local anesthesia. After a cancer is removed from the breast, there is a small cavity that remains that fills with fluid. Under usual circumstances, the fluid is reabsorbed by the body and the space heals. For insertion of the device, this fluid filled area can be seen with ultrasound. A small incision is made near the cavity and a specialized needle is introduced into the cavity. The fluid is removed, and the area is stretched with a balloon. The SAVI looks a little like an umbrella. The SAVI is slid into the cavity and then the spokes of the umbrella are opened. The idea is to have each spoke of the device touch each wall of the cavity. When completely opened, the device is taped into place and the part that is external to the patient is tucked into the bra. The radiation is then able to be attached to that outside part. When done, the radiation team can close the umbrella and slide the device out. Usually, a patient might have 1-2 stiches or just steri strips to close the incision.