Description
General anesthesia is used. Subtotal thyroidectomy is the removal of greater than
90 % of the thyroid gland, leaving the posterior aspects of the gland, and is used
for patients with hyperthyroidism due to diffuse hyperfunction, or rarely for multinodular
goiter. The nature of the pathology has almost always been determined
prior to surgery.
Saturday, June 28, 2014
Partial Thyroidectomy (Hemithyroidectomy, Thyroid Lobectomy)
Description
General anesthesia is used. Partial thyroidectomy is the removal of an entire thyroid
lobe and isthmus or a portion of a lobe. The nature of the lesion has almost always
been determined prior to the operation. Nodules are confi ned to a single thyroid
lobe or the isthmus. Most often a certain or suspected diagnosis of malignancy is
the indication for surgery; less often the nodule(s) is either hyperfunctional or is
enlarged and causing obstructive symptoms. The patient is supine with a roll placed
transversely under the scapulae to allow optimal neck extension.
General anesthesia is used. Partial thyroidectomy is the removal of an entire thyroid
lobe and isthmus or a portion of a lobe. The nature of the lesion has almost always
been determined prior to the operation. Nodules are confi ned to a single thyroid
lobe or the isthmus. Most often a certain or suspected diagnosis of malignancy is
the indication for surgery; less often the nodule(s) is either hyperfunctional or is
enlarged and causing obstructive symptoms. The patient is supine with a roll placed
transversely under the scapulae to allow optimal neck extension.
Thyroid Surgery
Useful Risk Reduction and Management Strategies
Acute respiratory distress following thyroidectomy can be of several types:
• Postoperative hemorrhage and hematoma – usually within 24 h, often 6–8 h after
thyroidectomy, causing laryngeal edema, which if uncorrected may prove fatal
• Excessive wound edema – causing pressure on the larynx and surrounding tissues
• Post-traumatic from endotracheal intubation
• Idiopathic – no apparent cause
Management
• Treat major bleeding with urgent surgical drainage.
• Ice packs on the neck after thyroidectomy – routine use may reduce wound
edema.
• Humidifi ed respiratory environment can relieve all local forms of laryngeal
edema.
• Check for inspissated subglottic mucus sputum retention (plug) – endotracheal
suction.
• Tracheostomy is rarely required.
Acute respiratory distress following thyroidectomy can be of several types:
• Postoperative hemorrhage and hematoma – usually within 24 h, often 6–8 h after
thyroidectomy, causing laryngeal edema, which if uncorrected may prove fatal
• Excessive wound edema – causing pressure on the larynx and surrounding tissues
• Post-traumatic from endotracheal intubation
• Idiopathic – no apparent cause
Management
• Treat major bleeding with urgent surgical drainage.
• Ice packs on the neck after thyroidectomy – routine use may reduce wound
edema.
• Humidifi ed respiratory environment can relieve all local forms of laryngeal
edema.
• Check for inspissated subglottic mucus sputum retention (plug) – endotracheal
suction.
• Tracheostomy is rarely required.
Free Transverse Rectus Abdominis Myocutaneous
(TRAM) Flap Reconstruction
Description
The operation is performed under general anesthesia, sometimes supplemented by a
paravertebral or epidural block. Adequate preoperative planning and preparation is key
to the success of TRAM fl ap breast reconstruction. Good lighting, careful positioning,
and high-quality equipment simplify the procedure. Appropriate intravenous antibiotics
are given for 24 h or more. An island of skin and underlying rectus abdominis muscle is
raised from the lower abdomen attached to its inferior vascular pedicle (inferior epigastric
vessels) and divided. Immediate free-TRAM fl ap breast reconstruction (ITRAM)
is carried out at the same time as mastectomy (Figs. 2.6 , 2.7 and 2.8 ).
Description
The operation is performed under general anesthesia, sometimes supplemented by a
paravertebral or epidural block. Adequate preoperative planning and preparation is key
to the success of TRAM fl ap breast reconstruction. Good lighting, careful positioning,
and high-quality equipment simplify the procedure. Appropriate intravenous antibiotics
are given for 24 h or more. An island of skin and underlying rectus abdominis muscle is
raised from the lower abdomen attached to its inferior vascular pedicle (inferior epigastric
vessels) and divided. Immediate free-TRAM fl ap breast reconstruction (ITRAM)
is carried out at the same time as mastectomy (Figs. 2.6 , 2.7 and 2.8 ).
Pedicled Transverse Rectus Abdominis Myocutaneous (TRAM)
Flap Reconstruction
Description
The operation is performed under general anesthetic, sometimes supplemented by
a paravertebral or epidural block. Adequate preoperative planning and preparation
is key to the success of TRAM fl ap breast reconstruction. Good lighting, careful
positioning, and high-quality equipment simplify the procedure.
Description
The operation is performed under general anesthetic, sometimes supplemented by
a paravertebral or epidural block. Adequate preoperative planning and preparation
is key to the success of TRAM fl ap breast reconstruction. Good lighting, careful
positioning, and high-quality equipment simplify the procedure.
Latissimus Dorsi Flap Breast Reconstruction
Description
The operation is performed under general anesthetic, often supplemented by a
paravertebral block. Adequate preoperative planning and preparation is key to the
success of latissimus dorsi (LD) breast reconstruction. Good lighting, careful positioning,
and high-quality equipment simplify the procedure. Appropriate intravenous
antibiotics are given for 24 h. An island of skin and underlying latissimus
dorsi muscle is raised from the back attached to its thoracodorsal vascular pedicle
and tunneled anteriorly to reach the ipsilateral chest. Immediate LD breast reconstruction
(IBR) is carried out at the same time as mastectomy.
The operation is performed under general anesthetic, often supplemented by a
paravertebral block. Adequate preoperative planning and preparation is key to the
success of latissimus dorsi (LD) breast reconstruction. Good lighting, careful positioning,
and high-quality equipment simplify the procedure. Appropriate intravenous
antibiotics are given for 24 h. An island of skin and underlying latissimus
dorsi muscle is raised from the back attached to its thoracodorsal vascular pedicle
and tunneled anteriorly to reach the ipsilateral chest. Immediate LD breast reconstruction
(IBR) is carried out at the same time as mastectomy.
Reconstructive Breast Surgery
Breast Implants: Insertion of Saline- or Silicone-Filled
Prosthesis
Description
Implants are normally inserted under general anesthesia, as adequate local anesthesia
is diffi cult to achieve. Implants are artifi cial devices for providing additional
breast volume and are of various types, shapes, sizes, and contents (saline, silicone,
emulsion, or other). They are used in three main areas of surgical practice.
Firstly, for cosmetic bilateral breast augmentation, secondly to achieve symmetry
in patients with congenital conditions leading to asymmetry or where breast
reconstruction has failed to achieve symmetry, and thirdly as an integral part of
immediate or delayed subpectoral reconstruction or with latissimus dorsi breast
reconstruction.
Prosthesis
Description
Implants are normally inserted under general anesthesia, as adequate local anesthesia
is diffi cult to achieve. Implants are artifi cial devices for providing additional
breast volume and are of various types, shapes, sizes, and contents (saline, silicone,
emulsion, or other). They are used in three main areas of surgical practice.
Firstly, for cosmetic bilateral breast augmentation, secondly to achieve symmetry
in patients with congenital conditions leading to asymmetry or where breast
reconstruction has failed to achieve symmetry, and thirdly as an integral part of
immediate or delayed subpectoral reconstruction or with latissimus dorsi breast
reconstruction.
Gynecomastia
Description
General anesthesia is usually used, but local anesthesia and IV sedation may be
preferred. Gynecomastia is enlargement of the male breast. The causes of gynecomastia
include chromosome abnormalities such as Klinefelter’s syndrome, renal
or hepatic disease, endocrine dysfunction, exogenous or endogenous hormones,
and other drugs, particularly cimetidine and marijuana. Incidence increases with
increasing age.
General anesthesia is usually used, but local anesthesia and IV sedation may be
preferred. Gynecomastia is enlargement of the male breast. The causes of gynecomastia
include chromosome abnormalities such as Klinefelter’s syndrome, renal
or hepatic disease, endocrine dysfunction, exogenous or endogenous hormones,
and other drugs, particularly cimetidine and marijuana. Incidence increases with
increasing age.
Male Breast Surgery
Mastectomy (Modifi ed Radical Mastectomy)
Description
General anesthesia is usually used; occasionally local anesthesia and IV sedation
can be used. Male breast cancer accounts for <0.1 % of all cancers in males
and 1 % of all breast cancers. Risk factors include testicular disease, gynecomastia,
increasing age, Jewish ancestry, family history, Klinefelter’s syndrome, and
BRCA-2 genetic mutation. About 4–16 % of all men with breast cancer have the
BRCA-2 mutation.
Description
General anesthesia is usually used; occasionally local anesthesia and IV sedation
can be used. Male breast cancer accounts for <0.1 % of all cancers in males
and 1 % of all breast cancers. Risk factors include testicular disease, gynecomastia,
increasing age, Jewish ancestry, family history, Klinefelter’s syndrome, and
BRCA-2 genetic mutation. About 4–16 % of all men with breast cancer have the
BRCA-2 mutation.
Nipple Biopsy (Paget’s or Other Disease)
Description
Nipple biopsy is usually performed under local anesthesia, but sedation or general
anesthesia is occasionally used. The aim of the nipple biopsy is to exclude carcinoma.
Paget’s disease is in situ carcinoma of the nipple characterized by erythema,
scaling, or ulceration of the nipple, which is often associated with an underlying
breast carcinoma (95 %).
Breast Abscess Drainage
Description
General or local anesthetic +/− IV sedation is used. The aim is to drain the pus
from the breast abscess cavity. Most small abscesses can be managed with percutaneous
aspiration and antibiotics. If symptoms have been present for weeks, the
patient is systemically ill, the abscess is very large, or drainage is incomplete, the
General or local anesthetic +/− IV sedation is used. The aim is to drain the pus
from the breast abscess cavity. Most small abscesses can be managed with percutaneous
aspiration and antibiotics. If symptoms have been present for weeks, the
patient is systemically ill, the abscess is very large, or drainage is incomplete, the
Duct and Nipple Surgery (Microdochectomy and Central Duct Excision)
Description
General anesthesia is often used, but local anesthesia with IV sedation is sometimes
preferred. The aims are to diagnose or exclude malignancy or control discharge. Microdochectomy is used for a discharging duct that can be identifi
ed, cannulated, and excised. If available, ductoscopy can be used to visualize the
lumen of the duct.
General anesthesia is often used, but local anesthesia with IV sedation is sometimes
preferred. The aims are to diagnose or exclude malignancy or control discharge. Microdochectomy is used for a discharging duct that can be identifi
ed, cannulated, and excised. If available, ductoscopy can be used to visualize the
lumen of the duct.
Wednesday, June 4, 2014
Modifi ed Radical Mastectomy (Usually Including Axillary Clearance)
Description
General anesthesia is required. The main indication is breast cancer that is not
amenable to breast conservation due to size, location, contraindication to radiation
therapy, local ulceration/extension, the presence of multiple cancers in different
quadrants of one breast, or patient preference. Some patients prefer mastectomy
with or without delayed reconstruction.
General anesthesia is required. The main indication is breast cancer that is not
amenable to breast conservation due to size, location, contraindication to radiation
therapy, local ulceration/extension, the presence of multiple cancers in different
quadrants of one breast, or patient preference. Some patients prefer mastectomy
with or without delayed reconstruction.
Partial Mastectomy (Segmental Breast Resection, Segmentectomy)
Description
General anesthesia is usually used, but local anesthesia may be used +/− IV sedation.
Partial mastectomy (PM) or lumpectomy is indicated for breast conservation for excision of invasive breast usually cancer or ductal carcinoma in situ (DCIS).
The aim is to remove the carcinoma with surrounding normal tissue to achieve
margins of 1–2 cm. Preoperative mammogram and ultrasound (and occasionally
MRI) are used to determine the nature and extent of the lesion and identify other
lesions in either breast.
General anesthesia is usually used, but local anesthesia may be used +/− IV sedation.
Partial mastectomy (PM) or lumpectomy is indicated for breast conservation for excision of invasive breast usually cancer or ductal carcinoma in situ (DCIS).
The aim is to remove the carcinoma with surrounding normal tissue to achieve
margins of 1–2 cm. Preoperative mammogram and ultrasound (and occasionally
MRI) are used to determine the nature and extent of the lesion and identify other
lesions in either breast.
Monday, June 2, 2014
Localization Biopsy of Mammographically Detected Lesions
Description
General
anesthesia is usually used, but local anesthesia and IV sedation may be
used.
A mammographic or ultrasound image-guided localization and excisional
breast
biopsy is indicated for a non-palpable mammographically detected lesions,
architectural
distortion, or suspicious microcalcifi cations.
Saturday, May 31, 2014
Female Breast Surgery
Excisional
Breast Biopsy (Lumpectomy)
Description
Excisional biopsy may be performed
with general anesthesia or under local anesthesia
with or without IV sedation.
Excisional breast biopsy is removal of an abnormality
in the breast typically for diagnosis.
The aim of the surgery is to determine
the nature of the mass and to rule out
carcinoma. The lump may be small or large;
however, the nature and breast size
are important factors in determining risk of
complications. A non-palpable mass will
usually require a form of localization (see
next case). Preoperative workup
includes mammogram (especially in women aged
>30–40 years as tumor may be
obscured by the density of younger breast tissue) and
ultrasound (for assessing solid,
cystic, or malignant characteristics). A diagnostic
fi ne- or core-needle biopsy is
usually performed prior to excisional biopsy, under
MMG or U/S guidance if required. Incisional biopsy for diagnosis may be
included
under this risk profi le; however,
excisional biopsy aims to remove the entire lesion,
often with a “cuff” of normal tissue. The incision chosen may be
peri-areolar,
horizontal, or even radial according
to the location and desired cosmesis. Dissection
usually aims to excise a margin of
normal tissue around the lesion, often including
pectoral fascia. Electrocautery, and
deep, absorbable suture closure, is used
for hemostasis, often avoiding wound
drains. Marking sutures are usually used to
orientate the specimen to defi ne
pathological margins.
Breast Surgery,General Perspective and Overview
General Perspective
and Overview
The relative risks and complications
increase proportionately according to the
type of surgery, site of a breast
lesion, extent of procedure performed, technique,
the complexity of the problem, and the
breast and lesion size. Extensive
or complex surgery usually carries
higher risks of bleeding and infection than
smaller procedures, in general terms.
Similarly, risk is relatively higher for
recurrent and complex breast problems,
for associated axillary lymph node
dissections and especially for those
closer to neural structures (e.g., brachial
plexus, axillary, long thoracic, or
thoracodorsal). Axillary lymph node dissection
procedures are typically associated
with a higher frequency and greater
range of complications compared to
procedures involving the breast alone.
This is principally related to the
surgical accessibility, risk of tissue/nerve
injury, seroma formation, and
interruption of lymphatic channels and outflow
from the upper limb and chest.
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