Modified Radical Mastectomy

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a. Definition Modified Radical Mastectomy is a surgical oncologists in breast malignancy that is by lifting the entire breast tissue consisting of stroma and parenkhim entire breast, nipple and areola and the skin above the tumor with axillary lymph node dissection ipsilateral level I, II / III en bloc WITHOUT lifting m.pektoralis major and minor. b. Scope Breast is the breast stroma and parenkhim piston located in the anterior wall between the ICS II and VI and parasternal until axilaris line medius. Breasts get a major vascularities of branch a. mammaria internal, a. Torakoakromialis and branch a. Intercostal 3,4,5. Regional KGB KGB in the breast is the axilla, supra and infraklavikula and internal mammaria. KGB axilla is divided into three zones namely Level I, II and III. Level I is the KGB muskulus located lateral to the pectoralis minor, level II is located behind the KGB m.pektoralis minor and Level III is located medially of the KGB m.pektoralis minor. In addition there is also a KGB interpektoral or called Rotter. Tumors in the breast is divided into · Benign tumors: fibroadenomas, cysts, · Malignant tumor: 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, not yet known because it is multifactorial Breast cancer risk factors: · Age> 35 years · Menarche <12 years · Menopause> 55 years · Nullipara · Family history (parents, siblings) with breast cancer Breast cancer diagnosis is established by: · Diagnostic confirmation of malignancy: clinical examination, Fna & imaging (mammography and / or breast ultrasound. (Tripple diagnostic) ·-Stage breast cancer diagnosis: clinical examination, laboratory and imaging (ultrasound images liver/abdomen- toraks/paru- k / p bone scanning). In circumstances where one component of the triple diagnostic interpretation of the corresponding instability experienced a biopsy done with frozen section examination (if any facility) or biopsy only had to know the type histopatologinya. Subsequent therapy depends on the outcome histopatologinya c. Operating indication · Early-stage breast cancer (I, II) · Locally advanced breast cancer with specific requirements · Soft tissue malignancies of the breast. d. Contra indications operation · Attached to the chest wall tumors · Arm edema · Extensive satellite nodules · Mastitis inflamatoar e. Diagnosis appeal · Other malignancies of the breast (sarcomas, lymphomas, etc.). · Phylodes tumors (malignant and benign). Mastitis · broad (especially mastitis, tuberculosis) f. Investigations · Mandatory - Mammography and / or breast ultrasound - Chest radiograph - FNAB of breast tumors - Ultrasound liver / abdomen - Complete blood chemistry examination in preparation for surgery · Oprional - Bone scan - Chemical examination of blood / tumor markers: CEA, Ca 15-3, CA 125 Operating Technique In brief, the operating technique of radical mastectomy modification can be described as follows: 1. Patients in general Anaesthesia, ipsilateral arm is positioned with the abduction of 900 surgery, shoulder surgery ipsilateral to the thin pillow. 2. Disinfection of the operating field, the upper to 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 was then wrapped with sterile doek followed by a narrow operating field with sterile doek 3. When the ulcer was found in breast tumors, the ulcer should be covered with sterile gauze thickness (Buick Gaash) and circular stitches. 4. Performed incision (incision variety is Stewart, Orr, Willy Meyer, Halsted, incision S) where the incision line is at least 2 cm from the edge of the tumor, then created flap. 5. Flap top to below the clavicle, medially to parasternal ipsilateral flap, flap down until the inframammary fold, the flap lateral to the anterior edge m. Latissimus dorsi and identify and Vasa. N. Thoracic dorsal 6. Mastectomy starting from the medial to lateral while caring for bleeding, especially branches of blood vessels in the parasternal intercostal. At the time until the lateral edge with the aid of major m.pektoralis haak maamma tissue removed from the m. Pectoralis minor and serratus anterior (simple mastectomy). In a radical mastectomy pectoralis muscle has begun 7. Axillary dissection begins by looking for the enlargement of the KGB Level I axilla (lateral to pectoralis minor), level II (behind the pectoralis minor) and level III (medial to pectoralis minor). Dissection should not higher in the axillary region Vasa, because it can cause arm edema. Veins ligated into the mamma network. Vasa and further identify n. Thoracic longus, and thoracic dorsal, interkostobrachialis. Next internerural didiseksi KGB and eventually mamma and KGB network as one entity irrespective of the axilla (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 new sets, as well as handschoen operators, assistants and instruments as well as doek sterilnya. 10. Re-evaluation of the bleeding source 11. Installed two pieces of drain, a large drain (Redon no. 14) placed under the axillary Vasa, was smaller drain (No.12) is directed to the medial. 12. Surgical wound was closed by layer lapais Complications of surgery Early: – bleeding, - Lesions n. À wing scapula thoracic longus - Lesions n. Thoracic dorsal. Slow: – infection - Necrosis of flap - Wound dehiscence - Seroma - Edema of the arm - Stiffness of the shoulder joint contractures à Mortality almost no Postoperative care Post-surgical patients hospitalized in the room by observing the production drain, check the postoperative Hb. Rehabilitation as soon as possible by training the shoulder joint movement. Drain off if the production each drain <20 cc/24 hours. Generally removable drain medial early, because fewer production. Removable stitches are generally day 10 s / d 14. Follow-up Year 1 and 2 à controls every two months Year 3 s / d 5 à controls every three months After five years of each six-month control à Physical examination: each time the control Thorax photo: every 6 months Lab. Marker: every 2-3 months Contralateral mammography: each year or there are indications (Source: http://bedahumum.wordpress.com) Bone scanning: every two years or there are indications Abdominal ultrasound: every six months or there are indications Please read this important information NURSING CARE PLAN DISTURBED SENSORY PERCEPTION Nursing Diagnosis: Chronic Pain Diarrhea and Diet for diarrhea Nursing Plan Malignant Mesothelioma,cause,treated malignan mesothelioma