Modified Radical Mastectomy/Axillary dissection

ANATOMY
Nodes are at 3 levels based on the pec minor muscle

Axillary dissection has no influence on survivial

PROCEDURE
Position patient with arm wrapped in crepe and abducted 90 degrees
Make an incision on the breast incorporating an ellipse containing nipple, areola, a 3cm radius of skin over the point of the tumour and any scars from previous excision. Extend this ellipse towards the axilla where it can be a straight line.
Start with upper skin flap. Rake retractor on skin
Plane will be where fat lobules change: step back to see. Divide Coopers ligaments
Go down to pectoral fascia but leave fascia behind to enable better tolerance of XRT
Remove inner quadrant
Ligaclip 2nd and 3rd intercostal perforators from internal thoracic.
Move to upper outer quadrant.
Clip branches of lateral thoracic coming around pec major
Raise lower flap down to upper rectus muscle


(1)To find axillary vein, start at inferior aspect of arm and trace back into axilla. Ensures you don’t end up above vein.

There will be a fat pad anterior to vein, take down but don’t skeletonise vein posteriorly to decrease the chance of lymphoedema

Ligaclips for vein tributaries (except the thoracodorsal or its continuation the subscapular vein).

Dissect the medial wall of the axilla from medial to lateral. Identify the angular vein running into the subscapular (coming off axillary vein) and run a gauze swab along it. This should expose the long thoracic nerve. Identify the thoracodorsal nerve (from posterior cord) winding around the thoracodorsal pedicle (branch of subscapular trunk which comes off 3rd part of axillary artery). Nerve usually in front of vessel. Any intercostobrachial nerves identified should be attempted to be preserved.

Detach the specimen completely and insert a suture to mark the apex of the axilla.
Irrigate the wound and insert two suction drains (axillary and pectoral)
Close in two layers, infiltrate LA.

Need 10 nodes for adequate axillary examination

Troubleshooting
Subscapular vein avulsed off axillary vein

1.Pack, adjust light, tell anaesthetist, blood for x match, get help
2.Vascular tray and 5-0 prolene
3. Heparin 100u/kg then clamp vein
4. Bulldog clamp proximal and distal then
patch (can use subscapular) continual suture and evert vein, flush vein with heparin
excise damaged section and do end to end repair