DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Right breast cancer.
POSTOPERATIVE DIAGNOSIS: Right breast cancer with axillary metastasis.
OPERATION PERFORMED:
1. Right axillary sentinel node biopsy.
2. Lumpectomy, right breast.
3. Completion axillary node dissection.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal.
DESCRIPTION OF OPERATION: The patient underwent radionucleotide injection in nuclear medicine and lymphoscintigraphy showed sentinel nodes visible by lymphoscintigram in the right axilla. There was faint uptake in a couple of internal mammary nodes as well, but very intense uptake in the axilla. The patient was placed in the supine position, and after satisfactory induction of general anesthesia, 500 mg of Levaquin was given intravenously. Isosulfan blue dye 4 mL was then injected into the breast in the subareolar fashion. The breast was then massaged briefly. The right breast, axilla, upper chest, neck and arm were prepped with Betadine and draped in the sterile fashion. A 5-minute massage of the right breast was then conducted on the clock to allow the blue dye to enter the lymphatics.
At the conclusion of that, a transverse incision was made in the lower end of the axilla after anesthetizing the skin with 0.5% Marcaine with epinephrine. The incision was carried deeper into the axillary tissue and a blue-stained lymphatic was identified and traced distally to a very firm and large node, which was partially blue stained and highly radioactive. This was dissected free from its surrounding tissue. It grossly was positive for metastatic disease. It was hard and lobulated. There was a second blue-stained node just posterior to that, which also was radioactive. Both of these were completely dissected free and labeled sentinel node #1 and sentinel node #2 respectively. Both were sent to pathology for immediate evaluation. Both were found to have metastatic carcinoma by touch imprint cytology.
A completion axillary dissection was then performed, dividing axillary contents away from the breast tissue using cautery. It was then dissected away from the lateral chest wall and extended up towards the apex of the axilla. The axillary vein was visualized, but not stripped, and the axillary contents were dissected laterally away from the chest wall. There were additional firm nodes palpable within these axillary contents. Specimen was then dissected away from the anterior border of the latissimus muscle. It should be noted that an intercostobrachial nerve branch was identified and preserved during the dissection. The axillary contents were then sent to pathology for routine examination. There were no palpable suspicious nodes remaining after completion of the dissection. The wound was irrigated with sterile water and hemostasis was secured with cautery. A large Blake drain was inserted into the axilla and brought out through a separate stab incision inferiorly and secured to the skin with 2-0 silk stitch. The subcutaneous tissue was then closed with interrupted 3-0 Vicryl. The skin was closed with running subcuticular suture of 4-0 Vicryl. Drain was connected to a bulb suction.
At that point, attention was then turned to the right breast, and the skin was marked for an elliptical incision overlying the palpable mass. The palpable mass was in the lower inner quadrant at the edge of the breast tissue. Marcaine 0.5% with epinephrine was injected in the proposed skin incision. An incision was then made with a #15 scalpel blade and carried through the skin and subcutaneous fat and straight down to the chest wall. The specimen was completely dissected from the chest wall taking pectoralis fascia. The specimen was oriented for the pathologist with sutures and sent for routine examination.
The wound was irrigated with sterile water. Hemostasis was secured with cautery. Breast parenchyma was mobilized and then closed with interrupted 3-0 Vicryl. The subcutaneous tissue was closed with interrupted 4-0 Vicryl. The skin was closed with running subcuticular suture of 5-0 Vicryl. Benzoin and Steri-Strips were applied followed by 4 x 4 and Tegaderm dressing. Benzoin, Steri-Strips, 4 x 4 and Tegaderm were applied to the axillary incision as well. Gauze was placed around the drain and taped in place. Estimated blood loss was 25 mL. Counts were correct. The patient tolerated the procedure well and was taken to the recovery room in good condition.
