MASTECTOMY​

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A mastectomy is a surgical procedure to remove one or both breasts, either partially or completely. It is most commonly performed as a treatment for breast cancer or to prevent it in those at high risk. Here's an overview of the types of mastectomy and the reasons they may be performed:

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Types of Mastectomy:

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1. Total (or Simple) Mastectomy: This involves removing the entire breast, including the nipple, areola, and most of the overlying skin, but not the lymph nodes in the underarm area (axillary lymph nodes).

2. Modified Radical Mastectomy: The entire breast is removed, along with some of the axillary lymph nodes. The pectoral muscles remain intact.

3. Radical Mastectomy: This procedure removes the entire breast, axillary lymph nodes, and chest wall muscles under the breast. This surgery is rare and usually only done when the cancer has spread to the chest muscles.

4. Partial Mastectomy: Also known as a segmental mastectomy, this procedure removes the cancer and a portion of surrounding breast tissue, leaving the rest of the breast intact.

5. Lumpectomy: This is a breast-conserving surgery where only the tumor and a small margin of surrounding tissue are removed. Although this is not technically a mastectomy, it's a related procedure.

6. Double Mastectomy: This refers to the removal of both breasts and may be done as a preventive measure for those with very high risk of breast cancer, such as carriers of BRCA1 or BRCA2 gene mutations.

7. Skin-Sparing Mastectomy: Most of the skin over the breast is left intact, and only the breast tissue, nipple, and areola are removed. This can make reconstruction easier.

8. Nipple-Sparing Mastectomy: All the breast tissue is removed, but the nipple and areola are left intact. This may not be suitable for cancers close to the nipple.

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Reasons for Mastectomy:

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• Treatment for Breast Cancer: If a person has been diagnosed with breast cancer, a mastectomy may be recommended, especially if the tumor is large or if there are multiple tumors in different parts of the breast.

• Preventive Measure: For individuals at high risk of developing breast cancer, such as those with a strong family history or known genetic mutations like BRCA1 or BRCA2, a prophylactic or preventive mastectomy may be considered.

• Recurrent Breast Cancer: If breast cancer returns after treatment, a mastectomy may be recommended.

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Recovery:

 

Recovery from a mastectomy can take several weeks, and physical therapy may be needed to regain arm movement. The emotional impact can also be significant, and counseling or support groups may be beneficial.

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Reconstruction:

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Breast reconstruction surgery can be performed at the same time as a mastectomy or later on. It can help restore the appearance of the breast, though sensation and the natural look and feel of the breast may not be fully restored.

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Mastectomy is a major decision, and discussions with healthcare providers, including surgeons, oncologists, and genetic counselors, can help an individual make the choice that's best for them.

                                                                                                 

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                                                              Anesthetic Implications for Mastectomy

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Anesthesia type: General anesthesia

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Airway: ETT or LMA

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Preoperative:

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• PIV in non-operative arm

• Blood pressure cuff in non-operative arm

• Chemotherapy agents (ex. anthracyclines) can cause cardiomyopathy 

• Patients may have anemia or thrombocytopenia due to chemotherapy

• Consider EKG and echocardiogram 

• Consider the utilization of nerve blocks  and regional anesthesia

• When mastectomy and axillary dissection is scheduled, block T1-T6 is required

• Check with the surgeon regarding the use of paralytics because they interfere with nerve testing 

• Breast implant procedure after the mastectomy will add a considerable amount of time to the case

• The BRCA gene has a known relationship with breast cancer

• The surgery may involve axillary lymph node exploration called "sentinel lymph node biopsy (SLNB)" 

• The sentinel lymph node is the first axillary lymph node that would demonstrate metastatic disease

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Intraoperative:

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• Monitor the amount of local anesthetic used

• Position: supine, with the arm on the affected side extended

• Duration: 1-2 hours

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Postoperative:

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• Smooth emergence from anesthesia

• Multimodal pain management

• PONV prophylaxis

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Complications:

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• Lymphedema

• Seroma

• Pneumothorax

• PONV

• Infection

• Hematoma

• Injury to neurovascular axillary structures 

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Sources:

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Longnecker, D. E., Brown, D. L., Newman, M. F., & Zapol, W. M. (2012). Anesthesiology, 2nd ed.

 

Macksey, L. F. (2011). Surgical procedures and anesthetic implications: A handbook for nurse anesthesia practice. 

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Jaffe, R. A. (2020). Anesthesiologist's Manual of Surgical Procedures (6th ed.). 

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Singh-Radcliff, N. (2013). 5-Minute Anesthesia Consult.

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