Mastectomy in bitch - any advice welcome!

Re: Mastectomy in bitch - any advice welcome!

Bob Russell — Wed, 17 Nov 2010 17:03:08 GMT

I admit I am not good with naming blood vessels. I work on 'if it bleeds stop it' however I do know from experience where the big vessels are most likely to be!!

Not perhaps ideal but for most routine surgery it works. Having reviewed the anatomy of the area in one of my textbooks, surprisingly I could name most of the blood vessels in the diagrams. Perhaps from now on I will bore the nurses by trying to name them rather than use expletives and 'thank goodness I didn't cut that one'!!! (only joking smiley)

Re: Mastectomy in bitch - any advice welcome!

Martin Atkinson — Wed, 17 Nov 2010 10:42:01 GMT

[quote user="Peter Ding"]

i would suggest you revise the anatomy and location of Lymph nodes and blood vessels on a similar fresh bitch cadaver prior to doing the surgery.

It will give you more confidence.

[/quote]

A good suggestion but how often in general practice do you get that opportunity? Anyway where's the adventure in surgery these days - knocked out of us by the litigious society?

Re: Mastectomy in bitch - any advice welcome!

Peter Ding — Mon, 15 Nov 2010 18:06:35 GMT

i would suggest you revise the anatomy and location of Lymph nodes and blood vessels on a similar fresh bitch cadaver prior to doing the surgery.

It will give you more confidence.

Re: Mastectomy in bitch - any advice welcome!

Mark Holmes — Sun, 14 Nov 2010 17:55:23 GMT

[quote user="Amanda Magrath"]

Thank you everyone for your replies to this post, very much appreciated. I decided that it was just a bit much to take on with no assistance for the first time - I could well have been fine but just didn't want to get into a situation where things weren't going well and didn't have someone to holler at for help! I've rearranged the op for tomorrow and have an experienced colleague coming to help me...phew!

Thank you again :-)

[/quote] Great now you can relax and enjoy it. Have fun. ;)

Re: Mastectomy in bitch - any advice welcome!

Aurelijus vet — Sun, 14 Nov 2010 13:44:02 GMT

General Considerations

•surgical excision of mammary tumors is recommended

•contraindications: metastatic disease or inflammatory carcinoma

•inflammatory carcinoma often advanced at diagnosis and recurrence common

•excisional techniques include: excisional biopsy, local mastectomy, regional mastectomy, unilateral mastectomy, and simultaneous or staged bilateral mastectomy

•no difference in recurrence rate or survival time of simple mastectomy and radical mastectomy

•radical surgery may reduce risk of de novo tumor development and malignant transformation of benign lesions, however, radical mastectomy is associated with greater morbidity and over-treatment for both benign and malignant mammary tumors

•aim: removal of all neoplastic tissue with simplest procedure

•± ovariohysterectomy

Local Mastectomy

•indications: centrally located lesions, lesions > 1.0 cm, and masses with any degree of fixation

•local mastectomy is the removal of a single mammary gland

•2 elliptical incisions performed around the mammary gland

•soft tissue dissection to the abdominal wall with muscular fascia included in the resected tissue

•enlarged lymph node is removed or normal lymph node is biopsied for metastatic disease

•2 layer closure

Regional Mastectomy

•regional mastectomy is the removal of ≥ 2 mammary glands and associated lymph nodes

•regional mastectomy was originally proposed based on the venous and lymphatic drainage of mammary glands

•mammary glands 1, 2, 3 ± 4 drain into axillary and cranial sternal lymph node

•mammary glands 3, 4, 5 ± 2 drain into superficial inguinal lymph node

From: Slatter DH (ed): Textbook of Small Animal Surgery (3rd ed).

•superficial inguinal lymph node has efferent drainage to medial iliac lymph node, lumbar trunk, and cisterna chyli

•indications: large mammary masses in adjacent glands

•dissection similar to local mastectomy

Unilateral Mastectomy

•unilateral mastectomy is the removal of 1 entire mammary chain

•indications: multiple mammary masses involving ≥ 2 ipsilateral mammary glands

•2 elliptical incisions performed ending cranial to gland 1 and caudal to gland 5 near the vulva

•soft tissue dissection to the abdominal wall with muscular fascia included in the resected tissue

•dissection begun at gland 5 as ligation of caudal superficial epigastric reduces hemorrhage

•Allis tissue forceps placed on gland 5 and sharp and blunt dissection used to elevate mammary chain

•caudal superficial epigastric artery and vein are ligated and divided

•plane of dissection is less defined at the paracostal arch

•superficial inguinal lymph node is located in the inguinal fat pad

•axillary lymph node is located immediately ventral to the latissimus dorsi muscle near the lateral thoracic artery

•2 layer closure ± penrose drain

•postoperative management: analgesia for 24 hours and non-adherent bandage and stockingette

Staged Bilateral Mastectomy

•staged procedure: unilateral mastectomy 6 weeks apart

•advantages: closure easier due to skin stretch and each procedure shorter than bilateral alone

•staged procedures preferred in breeds with less skin for closure (i.e., Greyhound and Dachshund)

•disadvantage: 2 general anesthetics and surgeries are required

Local Mastectomy

•indications: centrally located lesions, lesions > 1.0 cm, and masses with any degree of fixation

•local mastectomy is the removal of a single mammary gland

•2 elliptical incisions performed around the mammary gland

•soft tissue dissection to the abdominal wall with muscular fascia included in the resected tissue

•enlarged lymph node is removed or normal lymph node is biopsied for metastatic disease

•2 layer closure

PROGNOSIS

General Considerations

•poor prognostic factors include:

•tumor size > 3cm

•ulceration

•histologic grade and type

•degree of nuclear differentiation

•lymphoid cellular reactivity in tumor vicinity

•degree of invasion

•intravascular growth

•steroid hormone receptor activity (i.e., no estrogen receptors)

•DNA aneuploidy

•S-phase fraction as measure of cellular proliferation

•AgNOR counts

•metastatic disease to regional lymph nodes and distant sites

Tumor Size

•MST is significantly better for tumors < 5 cm (i.e., stage I and II disease) (MST 112 weeks v 40 weeks)

•MST is significantly better for tumors < 3 cm (i.e., stage I disease) (MST 22 months v 14 months)

•local tumor recurrence rates are significantly better for dogs with tumors < 3 cm at 1-year (30% v 70%) and 2-years (40% v 80%)

Re: Mastectomy in bitch - any advice welcome!

Amanda Magrath — Sun, 14 Nov 2010 12:15:35 GMT

Thank you again :-)

Re: Mastectomy in bitch - any advice welcome!

Rob Loxley — Sun, 14 Nov 2010 11:11:26 GMT

L+R chest xrays and scan abdo

If the mass is in gland 5 then often it is easier to remove 4&5 together than just 4.
Blunt dissect to find the cau sup epigastric vessels and ligate these early on, making life much easier.
Remove lymph node with the inguinal fat pad.

Whether to spay at the same time...?

Re: Mastectomy in bitch - any advice welcome!

Martin Atkinson — Fri, 12 Nov 2010 11:33:37 GMT

Much the same advice as everyone else. I would add to make your caudal skin incision futher back that you might think necessary - almost as far as the vulva, as it makes excising the most caudal bits easier and it is easier to identify and ligate the caudal blood supply. I would also usually also remove the 3rd gland with the 4th, it doesn't make it technically any harder, just a longer incision to suture and I think haemostasis is easier as you can ligate the blood vessel that supplies these glands from the deep inguinal region (sorry guys my anatomy is too poor to remember the names of blood vessels I just know where they are). It is easy to differentiate the mammary tissue from the fascia indeed if you make bold skin incisions, once you've started your dissection, you can often just grab hold of the skin strip and the associated m. gland tissue will tear out with it. I wouldn't bust a gut identifying the lymph nodes if they are not obvious as if it has spread that far it's probably already too late but remember at least 50% of histologically malignant mammary tumours in dogs don't act malignantly. We used to be advised that you should do a full mammary strip and spay if not already done but it is now frowned upon as it has little advantage prognostically and is stressful for both the surgeon and post-operatively for the patient. I aways put a drain in for a caudal gland mastectomy though as you cant close the dead-space and some of those little oozers you though had stopped seeping sometimes start up again post-surgically giving you a horrible big haematoma - not the end of the world but uncomfortable for the patient. Thermocautery/diathermy is a useful tool to blitz some of the oozers.

Re: Mastectomy in bitch - any advice welcome!

Rob Reid — Fri, 12 Nov 2010 08:12:51 GMT

Mammary glands are a good place to start if you want to move onto bigger and more challenging ops. Removing them is essentially a lesson in dissection and sticking to your surgical principles.

As someone has already said - the main thing to watch for is to try and isolate caudal epigastric blood vessels at the cranial and caudal end of your incision but in this case particularly the caudal end. These really do bleed - I have hit the theatre light with one I failed to isolate in the past! You should see it at the fairly deep part of your dissection on the caudal aspect - go slow and use as much blunt dissefction as possible on this area until you have it isolated. It is good to get into the habit this as if you ever need to do an epigastric flap at some point in the future you want to be preserving this blood supply.

You should be able to remove the superficial inguinal lymph node through the same incision.

Good luck!

Re: Mastectomy in bitch - any advice welcome!

Mark Hedberg — Fri, 12 Nov 2010 07:07:32 GMT

[quote user="nikki"]

I'm a little concerned that a new grad is doing this op with no support? Perhaps I was just lucky with my first job but I'd never have been left to do anything like that without help on standby.

[/quote]

I got thrown in the deep end in my first job...absentee owner, no interest in day to day clinic running. I was there for 3 years and learned loads. Got ulcers, too, so I can't really say I'd recommend this path. Looking back it was a bit more stressful than I like. Oh, and no nurses at all, just a guy who had worked there for 12 years in the clinic. Not qualified nurse (this was not in the uk) but he had the finest animal sense i have ever seen.

Re: Mastectomy in bitch - any advice welcome!

nikki — Thu, 11 Nov 2010 23:30:40 GMT

not sure i'd have fancied doing my first one of these without at least a reassuring person on standby. the caudal most gland is the most difficult and bloody to remove due to the caudal epigastric blood vessel supplying this area which definitely needs ligating and ideally before you chop through it and blood goes everywhere. everything always seems to bleed a lot with mammary tumours, especially in that caudal gland. It's fairly straightforward to remove the lymph node through the same incision and you should be able to see it ok in the fat, but it will be down towards the inguinal canal so need to watch the scary important things that come out of there.

I'm a little concerned that a new grad is doing this op with no support? Perhaps I was just lucky with my first job but I'd never have been left to do anything like that without help on standby.

Re: Mastectomy in bitch - any advice welcome!

Mark Holmes — Thu, 11 Nov 2010 23:08:46 GMT

The two tissues are fairly obvious to me but then I've done loads. I suspect the first time I would have struggled. To be honest I cannot remember. I have a lot of operating experience and have been doing this for 10 years and still hate getting half way into an op and thinking WTF. Once you have some experience though you have some depth to fall back on and get through. Unfamiliar surgery as a new grad without supervision or somebody at least handy something I would not advise. If you have had a lot of operating time then you may well be ok but my worry is that if that was the case you wouldn't have felt the need to ask. My experience of new grads is that even a bit of haemorrhage can cause paralysis. This might not be you but be careful if there is nobody handy to help.

Re: Mastectomy in bitch - any advice welcome!

Michael Woodhouse — Thu, 11 Nov 2010 22:50:27 GMT

Mammary tumour removal isn't especially hard. I cut all the way through skin and then blunt dissect with a dry swab - you will get to a tissue plane over the abdominal musculature. Don't make too wide a skin incision caudally as you can have bother keeping tension off the wound. I usually go a strip 2.5cm centred over the nipples and dissect skin back.

Personally never needed a drain but do make a good job of closing dead space - an odd bite of abdominal musculature obliterates any space for fluid to pool. If you can feel any other mammary 'peas' then do a strip. Once you get going can be nice and simple once you have found your tissue plane. It's just a scary HUGE wound to put back together - the first time you do one you'll wonder what you started, but it's really not that bad.

Re: Mastectomy in bitch - any advice welcome!

Evelyn Barbour-Hill — Thu, 11 Nov 2010 22:35:10 GMT

After you have made your skin incisions it's an exercise in blunt dissection and haemostasis. Yes, you take the lymph node out through the same incision; quite often it makes itself pretty obvious unless there is a lot of fat.

If you cut some big blood vessel don't panic, put your thumb and a swab on it and reach for another pair of artery forceps. Have lots of decent artery forceps ready and heaps of swabs.

Closing the wound will probably be the most time-consuming bit, and may even present some difficulty. Be prepared to do more than one layer of buried sutures to draw it up. Don't try to be too clever with the final skin sutures; stick to what you know will work.

Allow lots and lots of time. Do not tolerate nurses tutting, sighing or yawning.

Re: Mastectomy in bitch - any advice welcome!

Amanda Magrath — Thu, 11 Nov 2010 22:30:32 GMT

Thank you all for your advice! I must say I'm a bit worried now - I thought it was relatively straightforward but am concerned if you think it's likely to be stressful - unfortunately I don't have any help which is why I'm now worrying! Is it easy to see the boundary between mammary tissue and abdominal fascia? And regarding the lymph node, can this be removed via the same incision if you extend it?

Re: Mastectomy in bitch - any advice welcome!

Gillian Mostyn — Thu, 11 Nov 2010 22:16:39 GMT

The biggest vssels feed into and out of the cranial and caudal aspects of the gland - find and ligate these and most of the bleeding will stop.

Re: Mastectomy in bitch - any advice welcome!

Mark Holmes — Thu, 11 Nov 2010 22:16:35 GMT

My best advice is get some help. It's an easy op but first time without help you will find it stressful. This medium is not good for talking you through such a proceedure. Identifying and stripping the mammary tissue really needs demonstration. I fear you risk taking on rather a big mouthful. As I said it is fairly straight forward but if you feel you need advice you need supervision. If you really have no option. Watch for femoral artery, keep it clean and place a drain.

Re: Mastectomy in bitch - any advice welcome!

Mark Hedberg — Thu, 11 Nov 2010 22:14:28 GMT

Sufficient margin is probably the number one thing I'd go for; at least 2cm. Don't be stingy; malignant breast neoplasia is NOT something you want to take liberties with.

A preoperative xray of the chest and abdomen would be something I strongly recommend to make sure that this is the PRIMARY tumor and not a secondary neoplasia.

Aside from that it's a fairly standard lumpectomy; have lots of hemostats around just in case you have some annoying skin vessels around. Dog won't bleed out from them; it's just a bit hard to see when the blood gets in the way.

Palpate the other teats carefully to make sure no other breast tissue is affected; if one is, you may want to consider a mammary strip. (Different, longer op, this.)

No need to panic. Just remember your basics. Sepsis, Hemostasis, your favorite suture pattern, postop pain relief and antibiotics.

Cheers,

Mark

Re: Mastectomy in bitch - any advice welcome!

Sara Ramsey — Thu, 11 Nov 2010 22:07:12 GMT

I'm not a particularly confident surgeon but my boss told me to try identify the margins of the mammary tissue properly. I use blunt disection (fingers) to separate mammary tissue from the abdominal muscle. My early ones bled more than they should because I went through mammary tissue on the lateral and midline aspect. Bit basic but it helped me.