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clinmed/2000050005v1 (May 15, 2000)
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Mastectomy by electrodissection: a report of technique and short term complications.

Kirsten Cleemann Rasmussen, Mussa Krasniqi, Knud Søndergaard and Steen Watt-Boolsen.

Department of Surgery, Regional Hospital of Nykøbing Falster , DK 4800 Nykøbing Falster, Denmark.

Correspondence:
Kirsten Cleemann Rasmussen, MD, Dunhammervej 7, DK-4000 Roskilde, Denmark.
E-mail: dockcr@yahoo.com

Abstract

Objective: Description of treatment of primary breast cancer with radical mastectomy by electrodissection technique improving short term complications.

Design: A prospective controlled study of one hundred consecutive females with operable primary breast cancer who underwent modified radical mastectomy by electrodissection employing spray-coagulation. The technique and the electrical current used is described in detail.

Results: The intraoperative bleeding ranged from 25 ml to 600 ml, median 150 ml. The short term specific and general complication rates were very low, not exceeding the rates observed using cold scalpel. The frequency of seroma was 74% partly due to early, very active shoulder training. The occurrence of seroma, the total seroma volume and the total suction tube discharge was not correlated to the area of dissection or the depth of electrical tissue injury.

Conclusion: In spite of the relatively high frequency of seroma, we advocate the use of spray-coagulation for mastectomy as bleeding is minimised, the visibility during dissection is highly increased and the rate of short term complications is very low.

Key-words: Breast cancer, mastectomy technique, electrodissection, bleeding, complications, seroma.

Introduction

Mastectomy by electrodissection reduces intraoperative bleeding (8,5,4,6), but can be associated with a higher rate of wound complications compared to mastectomy by conventional cold scalpel and scissors (5,4,6,2). Thus surgeons have generally disfavoured electrodissection and accepted bleeding, eventually necessitating blood transfusion.

With the evidence of the possible negative effect on survival of perioperative blood transfusion to breast cancer patients (10) increasing efforts to reduce bleeding during mastectomy should be employed. We thus reconsidered electrodissection.

Our experience with the first 100 modified radical mastectomies using electrodissection is presented here with special emphasis on the technique, the intraoperative blood loss and the short term complications.

Material and method

The series comprises 100 females aged 32-91 years , median 58 years, with operable primary breast cancer who consecutively had modified radical mastectomy including removal of level I- and II-lymphnodes. The mastectomies were performed by one surgeon (SWB) and the pathological examination including calculation of wound areas and the extent electrical tissue injury by one pathologist (KS).

Wound areas were calculated by considering the breast specimen as a cylinder with an elliptical basis and the axillary fat as a rectangular box with parallel sides. Thus the largest and smallest diameter, the height and the circumference of the breast specimen was measured. Furthermore the length, the breadth and the height of the axillary fat was measured.

The extent of tissue injury was estimated for each breast specimen by measuring the mean value in millimetres of basofil discolouration of the resection margin in six randomly taken tissue blocks from the deep resection margin using an ocular micrometer.

The intraoperative blood loss was estimated by the weight of swabs. Furthermore, the difference between pre- and postoperative haemoglobin was determined. Seroma was explicitly looked for and verified by needle aspiration. Wound infection was defined as accumulation of pus needing debridement. Haematoma was defined as accumulation of blood in the operative field needing surgical evacuation. Mortality was defined as death within the first 30 postoperative days. General complications were clinically diagnosed.

The surgical diathermy unit.

The Bard 5000 surgical diathermy solid-state table-top unit was employed for unipolar tissue coagulation with the power ranging from 25 to 35 Watt (9). Spray-coagulation was used for dissection of tissue planes and to a smaller extent for deeper coagulation of bleeders. In spray-coagulation mode, the diathermy unit generated a pulse modulated 500 kHz damped sinusoid current of 1.8 seconds pulse duration at a 32 second period. Pin-point coagulation was mainly used in the axilla for well-defined bleeders. Great care was taken to minimise tissue carbonisation.

During the dissection of tissue planes heavy traction to near the point of tissue bursting was applied at right angles to the desired plane of cleavage. The active electrode was flat with a bluntly shaped tip and placed inside a suction tube, which was fixed parallel to the of handle.

The surgical procedure

The skin was incised transverse-ovally with a scalpel. The subcutaneous tissue was divided with spray-coagulation and traction down to the superficial layer of Scarpas fascia followed by development of the skin flaps. Spray-coagulation was also employed for stripping the fascia from the pectoral muscles and for macroradical resection of muscle in case of invasion, for dissection of the interpectoral tissue and the lowest part of the axilla and division of the cranial part of the axillary fascia.

The axillary lymphnodes in levels I and II were removed with scissors and scalpel, using pin-point coagulation for smaller bleeders and ligation of larger vessels. The intercostobrachial nerves were usually sacrificed in contrast to the long thoracic and thoracodorsal nerves, which were always preserved.

Lateral skin adjustment was performed with either hockey-stick excision or V-Y-plastic, using scalpel for skin incision and spray-coagulation for dividing the subcutaneous tissue. A suction tube was placed in the axilla and exteriorized through the lower flap. The tube was usually removed when the discharge was serous and less than 40 ml at 24 hours, however not later than the seventh postoperative day. The subcutaneous tissue was approximated with resorbable sutures and the skin with metal clips. Occlusion of the space beneath the skin flaps was not attempted. The metal clips were removed on the tenth to twelfth postoperative day. Active physical training of shoulder-arm movement was instituted on the very first postoperative day. Prophylactic antibiotics were not administered.

Results

Patient-characteristics including histopathological data are given in Tables 1 and 2. 44 patients (44%) had lymphnode metastasis.

General complications, mortality and wound dehiscence were zero. Eighty-three patients had a completely uneventful postoperative course. In another ten patients a remarkable hyperaemia of the skin flaps lasting for 3 to 4 days was observed. In only one of these a positive culture (staffylococcus aureus) from the drain fluid was obtained. The patient was successfully treated with antibiotics. Wound infection needing surgical debridement was observed in one patient. Moreover, haematoma was seen in one patient, minute flap margin necrosis or epidermiolysis in another 4 and sugillation in one patient.

A total of 74 patients developed seroma. The patients developing seroma were aspirated 1 to 9 times, median 3 times. The total aspirated volume was median 350 ml, ranging from 10 to 2940 ml.

In Table 3 the volume of intraoperative bleeding and the difference between pre- and postoperative haemoglobin as well as the calculated wound area and the estimated depth of electrical tissue injury are given. Neither the calculated wound area nor the estimated depth of electrical tissue injury was related to intraoperative bleeding, volume of suction tube discharge, the occurence of seroma, the number of seroma aspirations or seroma volume.

The duration of mastectomy, i.e. "the knifetime", ranged from 55 to 190 minutes, median 113 minutes. Increasing experience with electrodissection shortened the duration of the entire procedure considerably.

Discussion

This study confirmed that intraoperative bleeding during modified radical mastectomy using electrodissection is very small. The study also showed that the short term complication rate is quite comparable to traditional mastectomy and even lower (6,2,10). Using electrodissection we found a low incidence of wound complications, which is in agreement with Porter et al. (6), but inconsistent with other studies on mastectomy using electrodissection (5,4,2,3,1). The inconsistency may be due to the type of current used in the present study, i.e. spray-coagulation and the relatively small amount of electrical energy. However, the exact type of current and the amount of electrical energy employed in electrodissection was usually not precisely stated in these reports.

Another cause of the low complication rate using electrodissection could be the increased precision of dissecting the skinflaps due to the better visibility caused by lessened bleeding. In our experience, the inherent much slower progression of tissue division using electrodissection supports the necessary precision to stay within the correct plane of cleavage, especially when developing the skin flaps. Furthermore, great care to minimise tissue carbonisation by applying heavy traction at right angles to the desired plane of cleavage was taken. Although tissue division progresses much slower using electrodissection than cold scalpel and scissors, the duration of the entire procedure is not prolonged. The time used for haemostasis is reduced to a minimum.

The frequency of seroma after electrodissection may be increased compared to traditional mastectomy . This has also been shown in a randomized controlled trial by Porter et al. (6). Seroma is an exudate similar to the exudate produced in the early phase of acute inflammation and may thus reflect an increased duration of the exudative phase of wound repair (11). We do not know the cause of the relatively high frequency of seroma in our patients, since no correlation between the area of dissection or the depth of the tissue injury or wound complications was demonstrated. Schultz et al. (7) found that the incidence of seroma was reduced by 16 % when shoulder exercises were delayed for one week. Our patients started a very active training of shoulder-arm movement on the very first postoperative day. This might to a certain extent explain the relatively high incidence of seroma.

In spite of the relatively high frequency of seroma we advocate the use of spray-coagulation for mastectomy since the intraoperative bleeding is minimised, the visibility during dissection is highly increased and the frequency of wound complications is low .

References

1. Groot G, Chapell EW. Electrocautery used to create incisions does not increase wound infection rates. Am J Surg 1994 Jun;167:601-3.

2. Hoefer RA, DuBois JJ, Ostrow LB, Silver LF Wound complications following modified radical mastectomy: An analysis of perioperative factors. JAOA 1990 Jan;90(1):47-53.

3. Johnson CD, Serpell JW Wound infection after abdominal incision with scalpel or diathermy. Br J Surg 1990 Jun;77:626-27.

4. Kurtz SB, Frost DB. A comparison of two surgical techniques for performing mastectomy. Eur J Surg Oncol 1995;21:143-45.

5. Miller E, Morrissey K, Paull DE, Cortese A, Nowak E. Scalpel versus electrocautery in modified radical mastectomy. Am Surg 1988;54:284-87.

6. Porter KA, O`Connor S, Rimm E, Lopez M. Electrocautery as a factor in seroma formation following mastectomy. Am J Surg 1998 Jul;176(1):8-11.

7. Schultz I, Barholm M, Grøndal S. Delayed shoulder exercises in reducing seroma frequency after modified radical mastectomy: A prospective randomized study. Annals Surg Oncol 1997;4(4):293-7.

8. Sheen-Chen SM, Chou FF. A comparison between scalpel and electrocautery in modified radical mastectomy. Eur J Surg 1993 Sep; 159(9):457-59.

9. Spendley DG. Evaluation of surgical diathermy units. J Med Engineering & Technology 1988 Jul;12(4):172-8.

10. Tartter PI, Burrows L, Papatestas AE et al. Perioperative blood transfusion has prognostic significance for breast cancer. Surgery 1985;97(2):225-9.

11. Watt-Boolsen S, Jacobsen K, Blicher-Toft M. Total mastectomy with special reference to surgical technique, extent of axillary dissection and complications. Acta Oncol 1988; 27(6A):663-5.

 

Table 1. Characteristics of histopathological data in 100 patients.

 

Median

Range

Numbers of removed/microscopied lymphnodes per patient

18

8-33

Numbers of positive lymphnodes per patient

3

1-17

Table 2. Types and distribution of invasive neoplasms

Types

No.

Adenocystic

1

Ductal (incl. 2 cases of Paget's disease of the nipple)

84

Ductal and lobular

1

Lobular (incl. 1 sigillocellular case)

9

Medullary

4

Mucinous

1

Table 3. Perioperative data.

Criteria

Median

Range

Intraoperatiave bleeding (ml)

150

25-600

Difference between pre- and post-operative hemoglobine (mmol/l)

-0.8

+0.9 to -2.1

Suction tube discharge (ml)

640

20-2600

Wound area (cmsq)

663

264-3668

Depth of tissue injury (mm)

0.2

0.1-0.8





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Right arrow Oncology:
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Right arrow Surgery:
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