Core procedures 1 Flashcards
Advantages of breast conserving surgery
- Same survival advantage as mastectomy
- If received course of radiotherapy afterwards then recurrence rate is same as mastectomy
- Improved psychological wellbeing
- More widely used then mastectomy
Risks of breast conserving surgery
- 15% risk of malignant cells on margin of excision meaning further surgery
- Radiotherapy is required- less likely in mastectomy.
- If radiotherapy is contraindicated i.e. previous radiotherapy to same place, then mastectomy has to be performed
Types of breast conserving surgery: wide local excision
- most commonly used. excision of a block of breast tissue containing the malignant lesion along with a ‘margin’ of normal breast tissue surrounding the disease. Negative margins means no cancer cells at the edge
- If breast tissue is <20% of total volume then surrounding breast tissue can be sutured together to close the cavity.
- If >20% will need volume displacement or replacement techniques
Types of breast conservation surgery: Therapeutic Mammoplasty
- Breast reduction procedure containing the wide local excision of the breast lesion. Volume displacement procedure: remaining tissue is reshaped to form smaller breast mounds
- Lots of methods chosen based on: breast size and shape, tumour location, patients risk factors for reduced peripheral tissue and surgeons preference
- Normally performed on contralateral breast for symmetry
- Breast skin is removed to provide uplift
- Allows exclusion of larger tumours from large breasts minimum D cup
Types of breast conservation surgery: volume replacement procedure
- In patients with smaller breasts but large lesions: wide local excision then filling the cavity with a flap of tissue adjacent to the breast
- These are pedicled flaps: tissues original blood supply is kept intact
- Tend to be names after the flaps blood supply i.e. LTAP (lateral thoracic artery perforator)
Locating impalpable tumours
In breast conserving surgery need to be able to locate the tumour intraoperatively. Normally insert wire which goes from the surface of the breast to the tumour centre. Surgeon follows the wire down. Some have replaced with radioactive seeding where radiofrequency tags from small mental pellets are inserted into the tumour and a probe detects them
Pre-operatively breast conserving surgery
- Can drink water up to 2 hours before and eat up to 6 hours before
- May administer endotracheal tube or supraglottic airway device like laryngeal mask
- Regional nerve block to numb the operative site: reduces intra-operative and post-operative pain.
Breast conserving surgery: what to warn people of
- Bleeding
- Wound infection
- Chest infection
- Scars and scar complications
- Seroma (occurs in the majority of patients but not often requiring intervention): pocket of serous fluid
- Haematoma
- Further surgery (approx. 15%)
- Lymphoedema: rarely from breast surgery alone but with axillary lymph node procedure
- Sensation changes/loss (temporary or permanent)
- Skin/breast fat/nipple/flap necrosis (if blood supply is lost to any of these)
- General anaesthetic risks
- DVT / PE risk
Breast conserving surgery: procedure
- Incision: either at lateral border, inframammary fold or circumareolar- provide better cosmesis
- Dissection: margin of macroscopically normal tissue on all 4 borders. Breast tissue is excised from underside of skin/subcutaneous fact to pectoralis major muscle
- Excised specimen is placed on portable x-ray to see if tumour margins are clear, if not shave off further tissue
Breast conserving surgery: recovery
- Minor surgery performed as day case especially in units which have regional nerve block
- Require simple analgesics and codeine/oramorph for breakthrough pain
- Given breast care nurse number if questions
- By two weeks: breast specimen will be analysed and discussed by MDT to see if adjuvant treatment is needed: chemotherapy, radiotherapy, endocrine therapy
- Patient reviewed in clinic 2 weeks op: normally well though avoid heavy lifting till 4 weeks. Most patients don’t return to work till all cancer treatment is finished
Indications for mastectomy
- Breast cancer
- Risk reduction surgery
- Symmetrising surgery (in patients with contralateral mastectomy)
- Other reasons: recurrent infections or necrotising fascitis
Decision to do a mastectomy
- Tumour size (in relation to the individual’s breast volume)
- Multifocal tumour
- Contraindication to chest wall radiotherapy: previous radiotherapy to the same area, p53 gene mutation (Li-Fraumeni Syndrome).
- Patient choice
Bilateral risk reduction mastectomy
- High risk of breast cancer: lifetime risk >30% i.e. with gene mutation BRCA-1, BRCA-2 or P53
- Reduces risk by 95%
- Need psychological assessment before
Mastectomy: symmetrising surgery and breast reconstruction
Symmetrising surgery: after a mastectomy with no reconstruction. provides symmetry and reduces need t wear prosthesis. Other option is reconstruction wear an external prosthesis is fitted to match the opposite breast.
Simultaneous breast reconstruction: breast reconstructions are performed in the same operation as the mastectomy. The native breast skin + nipple can be preserved and only the volume needs replacing. Can have delayed reconstruction later on.
The two types of breast reconstruction
- Implant based: less invasive and shorter surgery (day case), better cosmetic outcome in the short term. Over time scar tissue forms causing capsular contracture which looks less natural and causes discomfort. Often needs revisional surgery
- Analogue tissue based: takes skin, fat and sometimes muscle and makes it into a breast shape. More major surgery requires more recovery. Appears more natural in the long term. Donor site complication risk
Factors you should consider when referring a patient for cataract surgery
- How the cataract affects their vision and quality of life.
- Whether one or both eyes are affected.
- What surgery involves, including the risks and benefits
- How their quality of life may be affected if they choose not to have surgery.
- Whether they want to have surgery.
- Do not restrict access to cataract surgery on the basis of visual acuity.
Benefits of cataract surgery
Improving vision, correcting patients pre-existing refractive error (through choice of replacement lens), increases quality of life, reduces falls and improves mental health.
Risks of cataract surgery 1
- Posterior capsule rupture: can cause vitreous entering the anterior chamber or the lens falling through the posterior chamber. May need second surgery
- Cystoid macular oedema: inflammatory response causing oedema formation at the fovea, presents after a few weeks with a drop in vision. Treated with topical NSAID’s and steroids
Risks of cataract surgery 2
- Retinal detachment: early on or several years after surgery, more common if myopic prior to surgery. More likely to occur if vitreous loss during surgery
- Endophthalmitis- red flag take to theatre immediately, infection of whole eye, can cause total loss of vision in the eye. Any patient with increasing redness, pain and loss of vision following cataract surgery must be seen immediately
Factors which increase risk of cataract surgery
- Any ocular infection: conjunctivitis, blepharitis, blocked tear duct. Treat prior to surgery
- Previous trauma to the eye: uveitis, corneal opacification, shallow anterior chamber secondary to hypermetropia
- High myopia
- Previous laser refractive surgery
- Hypertension: BP should be below 200/100
- Diabetes: BM should be below 20
