Modified Radical Mastectomy with Axillary Node Dissection (MRM)

Carly Winegar, Robert Saunders

Anatomy- Mammary Gland

Anatomy- Blood Supply, Nerves

● Blood Supply○ Internal thoracic

○ Lateral mammary

○ Intercostal

● Nerves○ Brachial Plexus

○ Thoracodorsal

nerve

○ Long Thoracic

Anatomy- Lymphatic System

● Closely interwoven with axillary plexus● Continuous network with the neck and abdomen● Lymph nodes located under and around pectoralis

minor● Level I,II,III nodes

○ Axillary

○ Pectoral

○ Superior apical

Physiology

● Mammary Gland○ Function of breast is for production of milk for

lactation○ Lobules where the milk is made that connects to

ducts that lead out to nipple● Lymph Nodes

○ Drain lymph from the lateral quadrants of breast○ Likely route of metastasizing cancer cells

Pathophysiology

● Stage I or II breast cancer● May be in conjunction with chemotherapy and radiation

treatments for Stage III and IV breast cancer● Can be cystic disease or malignant tumor

Diagnostic Exams

Mammography

Breast Biopsy

Surgical Intervention

● Removal of the breast, pectoralis major fascia, dissection of axillary, pectoral, and superior apical nodes, and sometimes the pectoralis minor muscle.

Special Considerations● May be done following a biopsy, so patient must be reprepped and

re-draped, and surgical team re-gowns and gloves for mastectomy● Can be cancerous ● Breast reconstruction may be done right after● Patients are particularly emotionally affected by this procedure so every

effort must be made by surgical team to be understanding and sensitive to the patient’s feelings

Special Considerations● Mammograms in the OR● Many 10 blades are used- when changing them out, tell the surgeon if the

blade is new● Make sure there is warm water for irrigation at end of procedure

General Anesthesia

PositioningSupine, with operative side near edge of table

● Arm of affected side resting on armrest

Skin Prep● Start at the lesion and go up into neck and

medial to sternum and all the way down to mid-abdomen (as far as possible laterally) including axilla and arm on affected side up to wrist

● A towel or sheet is placed on armboard while arm is being prepped

Draping

● Square off breast with four towels● Sterile ¾ drape placed on the armboard● Impervious stockinette placed on arm● Laparotomy sheet placed

Incision● Elliptical Transverse Incision that extends laterally into

the axilla● #10 knife blade

Supplies● At least 5 #10 blades (the fibrous tissue is very tough-

tell surgeon each time blade is switched)● Magnetic Instrument pad● Impervious Stockinette (over arm of patient on side

that is receiving mastectomy)● Marking pen● Active Wound Drain (Jackson-Pratt)● Bovie pen, tip, and scratch pad● Skin stapler● 3-0 or 4-0 silk for ligation of vessels and securing drain

tubes with cutting needle

Equipment

● Electrosurgical Unit● Suction ● Lights

Instruments● Major Instrument Set

○ Extra Crile Hemostats (kellys)○ Extra Allis-Adair clamps○ Extra rake retractors of various sizes

● Hemoclip Appliers with Ligating Clips

Procedural Steps● Mark contour of the breast to determine edges● Make incision (have ESU and lap sponges ready)● Use rake retractors to hold skin upward and dissect down to chest muscles and

laterally to pectoralis minor.

Procedural steps● Elevate breast off pectoralis fascia● Breast tissue and underlying pectoralis fascia resected

from muscle

Procedural steps● Locate axillary vein and other vessels and

ligate with 3-0 or 4-0 silk● Protect brachial plexus and axillary artery● Using scalpel or metzenbaum scissors, gently

evacuate the axillary contents of fat and lymph nodes, pushing them towards the breast

● Identify intercostal arteries and veins- double clamp and ligate

● Axillary vein and nerves that supply pectoralis major identified and preserved

Procedural Steps● Dissect fascia of lateral edge of pectoralis major and serratus anterior● Identify and preserve long thoracic and thoracodorsal nerves (vessel loops)● Complete dissection by resecting the breast and axillary fascia from latissimus

dorsi and suspensory ligaments ● Entire specimen is passed off sterile field to the circulator (large round basin)

Procedural Steps● Control bleeding (ESU, irrigate with warm water- NOT SALINE)● Two wound drains placed (Jackson-Pratt- one in inferior skin flap and other in

superior skin flap)● Excess skin is excised and wound is closed

Closing the wound● Drains brought out and secured to skin with 2-0 or

3-0 silk on a cutting needle● Surgeon may place some interrupted absorbable

sutures in subcutaneous layer to help approximate skin edges.

● Skin closed with skin staples, interrupted nonabsorbable sutures, or a running subcuticular stitch.

Counts

● Initial Count● Inter-op- when closing axillary region● Final Count

Dressing Materials

● Bulky dressing- usually Kerlix● Kerlix is opened and fluffed by surgical technologist● Held in place by Surgi-Bra, or elastic wrap

Specimen Care

● Place the dissected breast and axillary node tissue in a large round basin and pass it off to circulator

Prognosis● 6-8 week recovery with sponge baths,

arm exercises, and drains removed before patient leaves hospital or within 1-2 weeks post op.

● Related treatments like radiation or chemotherapy can alter lifestyle afterwards

● Increased chance of lymphedema through lifetime

Complications

Hemorrhage

SSI

Temporary or permanent numbness

of skin and anterior chest wall

Impaired arm and shoulder range of

motion called “frozen shoulder”

Hematoma formation

Skin flap necrosis

Seromas

Lymphedema

Phantom breast syndrome

Cellulitis

Death

Wound Class and Managment

● Class l: Clean● Sponge baths to keep wound clean

Bibliography

https://www.anatomylibrary.us/axillary-lymph-nodes-anatomy/axillary-lymph-

nodes-anatomy-the-role-of-ultrasound-and-lymphoscintigraphy-in-the-assess

ment-of/

http://www.breastcancer.org/treatment/surgery/lymph_node_removal/axillary

_dissection

http://www.surgeryencyclopedia.com/La-Pa/Modified-Radical-Mastectomy.ht

ml

http://www.breastcancer.org/treatment/surgery/mastectomy/expectations

Alexander’s Surgical Procedures, Jane C. Rothrock, Sherri M. Alexander, pg

325-327