Radical mastectomy

Preparation and surgical approaches

The surgery is performed under endotracheal anesthesia. The patient lies supine, with the arm on the surgical side abducted at a right angle — this is necessary for adequate access to the axillary fossa.

The surgeon makes two semi-oval incisions encircling the gland, keeping a 6–8 cm margin from the tumor edges.

• Medial incision: begins at the outer third of the clavicle, runs toward the middle of the sternum, descends along the parasternal line, and ends at the costal margin.
• Lateral incision: connects the beginning and end of the medial incision, passing along the anterior border of the axillary fossa.

Skin flaps are widely undermined using an electrosurgical knife. Only a thin layer of subcutaneous adipose tissue is left on the skin. The boundaries of undermining are well-defined: superiorly — to the clavicle, medially — to the mid-sternum, laterally — to the anterior border of the latissimus dorsi muscle (m. latissimus dorsi), inferiorly — to the costal margin.

Muscle management and lymph node dissection

Radical mastectomy involves the en-bloc removal of tissues. After incising the subcutaneous tissue and fascia, the surgeon proceeds with the muscular apparatus:

1. Pectoralis major muscle (m. pectoralis major): the surgeon isolates the tendinous part near the humerus (often over the index finger of the left hand) and transects it. Then, the muscle is detached from the clavicle and sternum, while preserving its clavicular portion.
2. Pectoralis minor muscle (m. pectoralis minor): the tendon is detached from the coracoid process of the scapula with scissors, and the muscle itself is retracted inferiorly.

Next, the lymph node dissection stage begins. The subclavian adipose tissue is exposed, and the vessels (vasa axillaris) are prepared. The axillary fossa and subclavian region must be cleared of adipose tissue and lymph nodes so thoroughly that they visually resemble an "anatomical specimen." During dissection, it is critically important to protect the long thoracic nerve (n. thoracicus longus) and subscapular vessels (vasa subscapularia).

Note: There is also a conservative variant of radical mastectomy in which the pectoralis major muscle is preserved.

Hemostasis, drainage, and wound closure

After removing the organ complex, an extensive wound surface remains. Simple and transfixing ligatures, as well as electrocoagulation, are used for hemostasis.

A drain is mandatory to remove accumulating blood and lymph. A drainage tube with multiple side holes is placed along the base of the lateral skin flap and brought out through a small separate incision along the anterior border of the latissimus dorsi muscle.

The skin edges are carefully mobilized and sutured with interrupted stitches. With good mobilization, the edges can be approximated without excessive tension. If the tension is high, plastic surgery is used: additional local tissue transposition flaps are formed to close the defect. In other, less extensive breast surgeries, incisions are modified: near the areola, the incision is made along the pigmentation border (for cosmetics), and in the lower quadrants, in an arcuate fashion along the skin fold.

Associated procedures: pleural puncture

During surgical interventions on the chest wall and in the development of complications (e.g., fluid accumulation), a puncture may be required. The procedure is performed under local anesthesia with a 0.5% novocaine solution.

Execution Technique:

• The patient sits up, torso leaned forward, and the arm on the puncture side is abducted upward and forward (which widens the intercostal spaces).
• Injection site: strictly along the upper edge of the rib (to avoid damaging the intercostal vessels and nerve running along the lower edge).
• The needle is inserted perpendicularly to the skin to a depth of 3–5 cm until a "yielding" sensation is felt (puncture of the parietal pleura).

Prevention of complications: Connecting the needle directly to the syringe is unacceptable due to the risk of air suction and the development of pneumothorax. A rubber tube or stopcock adapter is used, which is clamped when changing the syringe. Large volumes of fluid are removed slowly to avoid rapid mediastinal shift. Errors in needle insertion can lead to puncture of the lung tissue, entry into the costodiaphragmatic recess adhesion, or even penetration into the abdominal cavity with injury to the liver, spleen, or stomach.

Briefly: answers to topical questions

Class and exam questions

What else to study on this topic

• Topographic anatomy of the axillary fossa and its walls.
• Lymph drainage pathways from the mammary gland and regional metastasis zones.
• Options for plastic closure of extensive skin defects after mastectomy.
• Technique of sector resection of the breast for benign tumors (e.g., fibroadenoma).
• Complications following radical mastectomy: shoulder joint stiffness and upper extremity lymphedema.

Other topics in the section "Operations on the Chest Wall and Thoracic Organs"

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