fgreen776
New
This patient had a mastectomy in 2012 and had a recurrence and we performed a completion mastectomy with reconstruction. Do we need to append any modifiers to indicate that this is a completion procedure?
Indication for Surgery
xxx is a pleasant 51 year old female with history of Stage II Left breast cancer in 2012 s/p L mastectomy, SLNbx for 1.7cm IDC, +ER, +PR, -Her2. Presented with L. axillary recurrence in the setting of axillary pain. CT scan of the chest/neck was obtained which demonstrated recurrent disease. She underwent chemotherapy with a mild tumor response but residual disease. She was thus consented for re-excision of her axillary tumor in addition to completion mastectomy. The risks, benefits, and alternatives were explained to the patient in detail and she agreed to a surgical approach.
Operation
L. breast completion mastectomy with axillary lymph node dissection
Technique
The patient was brought to the operating room and placed on the table in supine position. SCD's were placed on the bilateral lower extremities prior to the induction of monitored anesthesia care. A timeout was performed with all members of the team present. General anesthesia was initiated and the patient was intubated without complication. 20cc of 1/4% marcaine and 1% lidocaine with epi (mixed 1:1 ratio) was administered prior to prepping and draping. The patient was prepped and draped in usual sterile fashion. An additional 10cc of local anesthetic was given. An incision was made along Langer's line in the left axilla overlying the area of the axillary mass. Dissection was carried through the clavipectoral fascia and into level 1 of the axilla. The mass was encountered and there were was a notable adherence to structures of the axilla, namely the pectoralis minor and the surrounding soft tissues. Dissection initially proceeded with a combination of blunt dissection and electrocautery. The mass was circumferentially dissected in a meticulous fashion to avoid injury to neighboring structures. A significant amount of time was spent transecting adhesions to delineate the anatomy of the axilla. The axillary vein was identified, and the tumor was very adherent to the vessel and had started to grow into the vessel as well as extend superiorly toward the brachial plexus. Additionally, the intercostobrachial nerve was found to transverse through the mass. The nerve was clipped and sacrificed. Given the significant involvement of the axillary vein, an intra-operative consult for vascular surgery was called and Dr. Cameron Akbari scrubbed into the case. At this point, the axillary vein was dissected along its length, and unfortunately no plane could be identified between the vein and the tumor. Thus, the tumor was shaved sharply off of the vessel utilizing a 15-blade, however there was some residual microscopic disease left behind on the vein and thorcadoral vein. Once free from the axillary vein, attention was directed to the medial aspect of the mass. The thoracodorsal nerve was encountered and was also very adherent to the tumor. This too was sharply dissected with a 15-blade away from the tumor with a small amount of residual microscopic disease left behind. Once this was accomplished, the tumor was dissected free from the surrounding soft tissues and was passed off of the field as a surgical specimen. Hemostasis was obtained with a piece of gel foam thrombin. Attention was then directed to the completion left mastectomy. Utilizing the patient's old mastectomy incision, a transverse incision was made and flaps were raised circumferentially. There was a significant amount of lateral breast tissue as well has superiorly, medially and inferiorly that was removed (116g). The two surgical fields were irrigated copiously and hemostasis was obtained. Additoinal pieces of gel foam thrombin were placed in the axilla. At this point the plastics team scrubbed in to perform the reconstruction. The instrument count was correct at the end of the breast service's portion of the procedure. The patient tolerated it well, without complication. Dr. Tousimis, the attending surgeon, was present and scrubbed for all portions of the surgical procedure.
Indication for Surgery
xxx is a pleasant 51 year old female with history of Stage II Left breast cancer in 2012 s/p L mastectomy, SLNbx for 1.7cm IDC, +ER, +PR, -Her2. Presented with L. axillary recurrence in the setting of axillary pain. CT scan of the chest/neck was obtained which demonstrated recurrent disease. She underwent chemotherapy with a mild tumor response but residual disease. She was thus consented for re-excision of her axillary tumor in addition to completion mastectomy. The risks, benefits, and alternatives were explained to the patient in detail and she agreed to a surgical approach.
Operation
L. breast completion mastectomy with axillary lymph node dissection
Technique
The patient was brought to the operating room and placed on the table in supine position. SCD's were placed on the bilateral lower extremities prior to the induction of monitored anesthesia care. A timeout was performed with all members of the team present. General anesthesia was initiated and the patient was intubated without complication. 20cc of 1/4% marcaine and 1% lidocaine with epi (mixed 1:1 ratio) was administered prior to prepping and draping. The patient was prepped and draped in usual sterile fashion. An additional 10cc of local anesthetic was given. An incision was made along Langer's line in the left axilla overlying the area of the axillary mass. Dissection was carried through the clavipectoral fascia and into level 1 of the axilla. The mass was encountered and there were was a notable adherence to structures of the axilla, namely the pectoralis minor and the surrounding soft tissues. Dissection initially proceeded with a combination of blunt dissection and electrocautery. The mass was circumferentially dissected in a meticulous fashion to avoid injury to neighboring structures. A significant amount of time was spent transecting adhesions to delineate the anatomy of the axilla. The axillary vein was identified, and the tumor was very adherent to the vessel and had started to grow into the vessel as well as extend superiorly toward the brachial plexus. Additionally, the intercostobrachial nerve was found to transverse through the mass. The nerve was clipped and sacrificed. Given the significant involvement of the axillary vein, an intra-operative consult for vascular surgery was called and Dr. Cameron Akbari scrubbed into the case. At this point, the axillary vein was dissected along its length, and unfortunately no plane could be identified between the vein and the tumor. Thus, the tumor was shaved sharply off of the vessel utilizing a 15-blade, however there was some residual microscopic disease left behind on the vein and thorcadoral vein. Once free from the axillary vein, attention was directed to the medial aspect of the mass. The thoracodorsal nerve was encountered and was also very adherent to the tumor. This too was sharply dissected with a 15-blade away from the tumor with a small amount of residual microscopic disease left behind. Once this was accomplished, the tumor was dissected free from the surrounding soft tissues and was passed off of the field as a surgical specimen. Hemostasis was obtained with a piece of gel foam thrombin. Attention was then directed to the completion left mastectomy. Utilizing the patient's old mastectomy incision, a transverse incision was made and flaps were raised circumferentially. There was a significant amount of lateral breast tissue as well has superiorly, medially and inferiorly that was removed (116g). The two surgical fields were irrigated copiously and hemostasis was obtained. Additoinal pieces of gel foam thrombin were placed in the axilla. At this point the plastics team scrubbed in to perform the reconstruction. The instrument count was correct at the end of the breast service's portion of the procedure. The patient tolerated it well, without complication. Dr. Tousimis, the attending surgeon, was present and scrubbed for all portions of the surgical procedure.