Modified radical mastectomy (MRM)

Introductions:
a. Definition
Modified Radical Mastectomy is a surgical oncologist action on breast malignancy is to remove the entire breast tissue consisting of stroma and parenkhim entire breast, areola and nipple and the skin over the tumor with axillary lymph node dissection ipsilateral level I, II / III en bloc WITHOUT lifting m.pektoralis major and minor.
b. Scope
The breast is the breast stroma and parenkhim located in the anterior wall of the piston between the ICS II and VI and parasternal up to the line axilaris medius. Breast primary vascularization of the branch gets a. the internal mammary, a. Torakoakromialis and branch a. Intercostal 3,4,5.
Regional lymph nodes in the breast is axillary lymph nodes, supra-and infraclavicular and internal mammary. Axillary nodes are divided into three zones namely Level I, II and III. Level I is the KGB is located lateral to the pectoralis minor muscular, level II is located behind the KGB m.pektoralis minor and Level III is located medially of the KGB m.pektoralis minor. Besides, there is also a KGB interpektoral or called Rotter.
Tumors of the breast is divided into
· Benign tumors: fibroadenomas, cysts,
· Malignant tumors: invasive ductal, invasive lobular and other variants (mucoid, papillary, medullary, kribriform etc.)
· Situ malignancy: lobular in situ, in situ ductal and mikroinvasif
Until now the exact cause of breast cancer, is unknown because it is multifactorial
Breast cancer risk factors:
Age of> 35 years
· Menarche <12 years
· Menopause> 55 years
· Nullipara
· Family history (parents, siblings) with breast cancer
Breast cancer diagnosis is made by:
· Diagnosis confirmation of malignancy: clinical examination, FNA & imaging (mammography and / or breast ultrasound. (Tripple diagnostic)
· Diagnosis stage breast cancer: clinical examination, laboratory and imaging (ultrasound images toraks/paru- liver/abdomen- k / p bone scanning).
In circumstances where one component of the triple diagnostic discrepancy experienced biopsy interpretation is done by examination of frozen pieces (if there are facilities) or biopsy only had to know what type of histopatologinya. Subsequent therapy depends on the outcome histopatologinya
c. Indications of surgery
· Cancer early-stage breast (I, II)
· Cancer locally advanced breast with specific requirements
· Soft tissue malignancies of the breast.
d. Contra indications operation
· Tumor attached to the chest wall
· Edema of the arm
· Extensive satellite nodules
· Mastitis inflamatoar
e. Differential diagnosis
· Other malignancies of the breast (sarcoma, lymphoma, etc.).
· Phylodes tumors (malignant and benign).
· Mastitis spacious (especially tuberculous mastitis)
f. Investigations
· Mandatory
- Mammography and / or breast ultrasound
- CXR
- FNAB of breast tumors
- Ultrasound liver / abdomen
- Complete blood chemistry examination in preparation for surgery
· Oprional
- Bone scanning
- Chemical examination of blood / tumor markers: CEA, Ca 15-3, CA 125
Engineering operations
In brief, the operating technique of modified radical mastectomy can be explained as follows:
1. Patients in general anesthesia, the arm ipsilateral to the operated positioned abduction 900, ipsilateral to the operated shoulder propped a thin pillow.
2. Disinfection of the operating field, the upper and mid-neck, the bottom up to the umbilicus, medial to the mid mammma contralateral, lateral to the lateral edge of the scapula. Disinfected circular upper arm until the elbow is then wrapped with sterile doek followed by narrowing the operating field with sterile doek
3. When you get ulcers on the breast tumor, the ulcer should be covered with sterile gauze thick (Buick Gaas) and circular stitches.
4. Do incision (various incision is Stewart, Orr, Willy Meyer, Halsted, incision S) where the line of incision is at least within 2 cm from the edge of the tumor, then created a flap.
5. Flap top to below the clavicle, medially to parasternal ipsilateral flap, flap down to the inframammary fold, the flap lateral to the anterior edge of the m. Latissimus dorsi and identify vasa and. N. Thoracalis dorsalis
6. Mastectomy started from the medial to lateral while caring for bleeding, especially branches of the intercostal blood vessels in the parasternal area. At the time until the lateral edge of the mayor with the help of Haak m.pektoralis maamma tissue removed from the m. Pectoralis minor and serratus anterior (simple mastectomy). In a radical mastectomy pectoralis muscle has begun to
7. Axillary dissection begins with finding the existence of Level I axillary lymph nodes enlargement (lateral pectoralis minor), level II (behind the pectoralis minor) and level III (medial pectoralis minor). Dissection is not higher in vasa axillary region, because it can lead to arm edema. Veins leading to the network mamma ligated. Further identify vasa and n. Thoracalis longus, and thoracalis dorsal, interkostobrachialis. Internerural KGB and eventually further didiseksi mamma tissue and axillary lymph nodes as a single unit detached (en bloc)
8. Field operations sublimat and washed with a solution of 0.9% Nacl.
9. All the tools used during surgery was replaced with a new set, as well as handschoen operators, assistants and instruments as well as doek sterility.
10. Re-evaluation of the source of bleeding
11. 2 pieces mounted drain, a large drain (Redon no. 14) is placed under the vasa axillary, being a smaller drain (12) is directed medially.
12. Surgical wound was closed lapais by layer
Complications of surgery
Early: - bleeding,
- Lesions n. Thoracalis longus à wing scapula
- Lesions n. Thoracalis dorsalis.
Slow: - infection
- Necrosis of flap
- Wound dehiscence
- Seroma
- Edema of the arm
- Stiffness of the shoulder joint contractures à
Mortality
almost no
Post-surgical care
Post-surgical patients admitted to the room by observing the drain production, post-surgical check Hb. Rehabilitation as soon as possible by exercising the shoulder joint movement. Drain removed when the production of each drain <20 cc/24 hours. Generally medial removable drain early, because fewer production. Stitches are generally removed the day ke10 s / d 14.
Follow-up
Year 1 and 2 à controls every 2 months
Year 3 s / d 5 à controls every 3 months
After year 5 à controls every 6 months
Physical examination: each time the control
Thorax picture: every 6 months
Lab. Marker: every 2-3 months
Contralateral mammography: every year or there are indications
Abdominal ultrasound: every 6 months or no indication
Bone scanning: every 2 years or no indication