Documents: Breast

OPERATIVE REPORT

DATE:

_____

FACILITY:

{name of facility}

SERVICE:

Plastic Surgery

PREOPERATIVE DIAGNOSIS:

1. Stage IIIa right breast IDC (T3, N2, M0, G1, ER+, PR+, Her2+, bx: {date}).

2. BRCA2+ mutation.

3. H/o neoadjuvant CTX (AC-T); clinical CR/radiographic CR.

4. Acquired absence of B breasts s/p B SSM and R axillary SNB; IBR with prepectoral DTI ({date}).

- Path: _____

- R breast mass: ___ gm. L breast mass: ___ gm. BD = ___ cm.

- Mentor MemoryGel smooth round moderate plus profile Xtra implant, 440 cc, 13.1 x 4.5 cm.

5. H/o R breast adjuvant XRT, 50 Gy in 25 fx ({start - end dates}).

6. Ongoing endocrine therapy: tamoxifen.

7. Wound healing risk factor(s): class I obesity (BMI 30.7), neoadjuvant CTX/steroids, adjuvant XRT.

8. Caprini risk score: 5 (major OR, BMI, CA); 7d chemoprophylaxis.

POSTOPERATIVE DIAGNOSIS:

Same

PRIMARY PROCEDURE:

Bilateral delayed-immediate breast reconstruction using abdominal free flaps (B ms-2 TRAM or DIEP) including microvascular anastomoses to the B internal mammary arteries and veins.

CPT 19364-50.

SECONDARY PROCEDURE:

Bilateral breasts total capsulectomy, with removal of intact breast implants.

CPT 19371-50.

TERTIARY PROCEDURE:

Left internal mammary open excisional lymph node biopsy.

CPT 38530.

QUATERNARY PROCEDURE:

Injections x 2 of fluorescent indocyanine green (ICG) dye with intraoperative SPY-PHI laser angiography to evaluate perfusion of the breast free flaps.

CPT 15860 x 2.

FIFTH PROCEDURE:

_____

SIXTH PROCEDURE:

_____

ATTENDING SURGEON:

_____, MD

RESIDENT SURGEON(S):

_____, MD

_____, MD

ANESTHESIA:

1. General anesthesia.

COMPLICATIONS:

None.

ESTIMATED BLOOD LOSS:

150 mL.

SPECIMENS:

1. R breast capsule (permanent pathology).

2. L breast capsule (permanent pathology).

3. L breast internal mammary LN (permanent pathology).

EXPLANTS:

1. Bilateral breast implants, intact.

IMPLANTS:

1. 15 Fr round Blake drains x 4 (abdomen x 2, R breast x 1, L breast x 1).

DISPOSITION:

PACU in stable condition.

OPERATIVE INDICATIONS:

H/o B SSM with IBR using DTI technique, then adjuvant XRT. The patient presents today for implant removal and replacement with B abdominal free flaps.

FINDINGS:

1. B breast base diameter = 13 cm.

2. 40 x 14 cm abdominal flap designed.

3. B breast exposure via pre-existing transverse scars.

4. Identical R and L ms-2 TRAM FF dissected including both the medial and lateral row perforators, sparing the lateral 1/3 of the muscle and medial 1/3 of the muscle.

5. R abdominal flap to L chest. LIMA x 1 and LIMV x 1 present at the level of the third rib space. Venous anastomoses x 2, each end-to-end, using 2.5 mm coupler to antegrade and retrograde LIMV. Arterial anastomosis x 1, end-to-end, hand sewn to antegrade LIMA.

6. L abdominal flap to R chest. RIMA x 1 and RIMV x 1 present at the level of the third rib. Venous anastomoses x 2, end-to-end, using 2.5 mm coupler to antegrade RIMV and 3.0 mm coupler to retrograde RIMV. Arterial anastomosis x 1, end-to-end, hand sewn to antegrade RIMA.

OPERATIVE DETAILS:

The patient was seen and examined in the preoperative area. The planned procedure and anticipated postoperative course were reviewed. All questions were answered. The patient was marked in the upright and supine and positions. Planned incision/scar locations were demonstrated. Thereafter the patient was evaluated by the entire OR team including members from the anesthesia service and nursing providers; a pre-operative huddle was performed.

The patient was transported to the operating room and placed in supine position. Monitoring equipment as well as bilateral sequential compression devices were placed. General anesthesia was successfully induced. All pressure points were padded and the patient was safely secured to the table. Antimicrobial prophylaxis was administered before the start of surgery and at appropriate intervals throughout the case. The patient was prepped and draped in the standard sterile fashion. Markings were redrawn and important landmarks including the midline were stapled. A final surgical timeout occurred and the proper patient, procedure, and site of the procedure were among the items verified.

The entire case was performed with 4.5x loupe magnification, except the portion performed with the operative microscope.

The internal mammary (IM) vessels on each side were then prepared. The R chest was prepared first. The pre-existing transverse breast scar was sharply re-opened. The intact breast implant was removed and discarded. The capsule was very dense and constricted. A total capsulectomy was performed. The anterior half of the capsule easily delaminated and the posterior capsule was carefully dissected from the underlaying chest wall using a combination of blunt dissection and monopolar electrocautery. The capsule was labeled and sent for pathology. Thereafter the IM vessels were carefully dissected.

The third intercostal space was identified. The pectoralis major was split over the 3rd rib to the costochondral junction. The chondral part of the rib was dissected away from the intercostal musculature. The superficial perichondrium was incised and elevators were used to circumferentially free the perichondrium from the cartilage. A chondrotomy was created at the junction of the bony and cartilaginous parts of the rib and then the cartilaginous rib was excised working lateral to medial with a rongeur. The deep perichondrium was then carefully dissected to reveal the internal mammary vessels. No pleural rents were created. One IMA and one IMV were present. Each appeared to be approximately 2.5-3.0 mm in size.

An identical process was then repeated on the left side. At the level of the third rib, one IMA and one IMV were present. The LIMA appeared to be approximately 3.0 mm in size and the LIMV was 2.5-3.0 mm in diameter.

A closed suction 15 Fr round Blake drain x 1 was inserted on each side, which were secured internally with 3-0 Vicryl and externally with 3-0 Nylon.

The abdominal free flaps were then dissected. The superior flap incision was created and the dissection proceeded down to the level of the abdominal fascia. The upper abdominal soft tissues were elevated in that plane superiorly to the level of the xiphoid with very limited and discontinuous lateral elevation. Upon dissection of the superior flap border, it was transposed inferiorly to verify the lower incision closure. With no table flexion, the abdominal tissue laxity was sufficient for primary abdominal wound closure with minimal tension. The inferior incision was then created. The bilateral superficial inferior epigastric veins (SIEV) were explored. A very small SIEV was present on the R abdomen. On the L, a moderate sized, approximately 2 mm, SIEV was identified, dissected, and clip-ligated in order to preserve the vessels for potential microsurgical anastomosis. The flap was split in the midline and then the umbilicus was circumferentially incised and dissected with a cuff of preserved tissue to ensure viability. It was marked and oriented with a long 3-0 Vicryl suture for later transposition.

The R abdominal flap perforators were then identified by raising the flaps along the anterior abdominal fascial plane in a lateral to medial approach towards the semilunar line. The perforators were then identified and isolated. A ms-2 flap was planned. The myotomy was created and dissected immediately lateral to the lateral row perforators, preserving the lateral 1/3 of the muscle. The pedicle was identified and dissected to its origin. A medial myotomy was then created immediately medial to the medial row perforators, and then the myotomy was fully completed moving superior to inferior along the length of the flap. With the dissection performed, the flap was re-interrogated. Doppler signals along the medial row and lateral row were preserved. The muscle was then divided proximal and distal, completing the flap dissection. The circular central portion of the skin paddle was preserved; the peripheral skin was sharply de-epithelized.

The L abdominal flap dissection was then performed in an identical manner.

Each flap was sequentially transferred to the recipient sites. The pedicle of the right abdominal flap was ligated with clips and sharply transected. The flap was transferred to the left chest. It was temporarily secured in place in an ice-cold lap pad. The operating microscope was brought into the field. The IM vessels were occluded with microvascular clamps and clips. The IMA and IMV were sharply transected to allow for creation of anastomoses. The flap was flushed with heparinized saline. The vessels were prepared, including resecting the site of the arterial crush injury from the flush. The first anastomosis was an end-to-end venous anastomosis performed with a 2.5 mm coupler between the DIEV and the antegrade IMV. A second venous anastomosis was created between the second DIEV and the retrograde IMV using a 2.5 mm coupler. The arterial anastomosis was then performed as an end-to-end, hand sewn anastomosis using 9-0 Nylon. Thereafter the microvascular clamps were removed and perfusion was restored. The flap re-perfused without incident. Total ischemia time was 1 hr:18 min. The pedicle demonstrated visible pulsations. Doppler integration confirmed arterial inflow and venous outflow through the anastomoses. Thereafter an intravenous injection of ICG dye x 3 mL was performed, followed by a 10 mL brisk flush of normal saline. The microscope’s laser-assisted imaging system and/or the SPY-PHI system were utilized to perform fluorescent angiography of the microanastomoses. This study confirmed the presence of expected and intact arterial flow into and venous flow out of the flap without leak or thrombosis. The pectoralis muscle flap was then repaired and the abdominal flap was then internally secured with 2-0 Vicryl suture to the chest wall. The flap fit well into the breast pocket under the skin flaps.

An identical process was then repeated on the opposite. The L abdominal flap was transferred to the R breast. The first anastomosis was an end-to-end venous anastomosis performed with a 2.5 mm coupler between the DIEV and the antegrade IMV. A second venous anastomosis was created between the second DIEV and the retrograde IMV using a 3.0 mm coupler. The arterial anastomosis was then performed as an end-to-end, hand sewn anastomosis using 9-0 Nylon. Thereafter the microvascular clamps were removed and perfusion was restored. The flap re-perfused without incident. Total ischemia time was 1 hr:35 min. The flap was assessed in an identical method with visible pulsations, Doppler examination, and fluorescent angiography using 3 mL of ICG. This study demonstrated complete perfusion of both abdominal flaps.

For the rest of the case, the free flaps were assessed at 10 minute intervals. The B breast flaps never demonstrated any vascular insufficiency.

The breast flaps were inset using 3-0 Vicryl and 5-0 Monocryl.

The abdomen was then repaired. Before closure, the abdomen was irrigated with normal saline and then Irrisept solution. Clean, fresh towels were placed around the abdomen. All surgeons changed into fresh gloves. The rectus muscle donor sites were then each repaired with an underlay of Prolene mesh, which was secured with 0-PDS. This allowed for a tension free primary fascia-to-fascia closure, also performed with 1-PDS suture. Meticulous hemostasis was obtained and then 15 Fr round Blake drains x2 were placed exiting the abdominal wound laterally on each side. Drains were secured with 3-0 Nylon suture. The patient was then placed into a minimal reflex position. The Scarpa’s fascia was then re-approximated with 2-0 Vicryl. Deep dermal closure was performed with 3-0 Vicryl and a running subdermal suture with 3-0 Monocryl was used. The umbilicus was brought through a U-shaped incision and inset with 4-0 Vicryl and then 5-0 Plain gut sutures. This marked the conclusion of the case.

Mepilex AG was then placed over all of the other incisions and used as drain dressings. The patient tolerated the procedure well. The patient tolerated the procedure well. There were no complications. At the end of the case the sponge, needle, and all instruments were counted and reported to be correct - times two. The patient uneventfully emerged from general anesthesia, was successfully extubated, and was transferred to the PACU in stable condition. The attending surgeon – Dr. _____ – was present, scrubbed, and participated in all key portions of the case and was immediately available and/or present at all other times.

Disclaimer: The information provided herein is for educational purposes only and is intended only as a general example. It does not constitute medical advice or represent best practices. Surgical techniques and approaches may vary among surgeons based on individual training, experience, and patient-specific factors. If this example is utilized as a template, the details of the surgery must be appropriately modified to accurately reflect the actual operative findings and procedure performed.