MODULE 11 Breast Surgery RPN2023.pdf

MODULE 11: Breast Surgery Suggested Readings Alexander’s Care of the Patient in Surgery (2022) Chapter 17 ORNAC Standards 2023 Sentinel Lymph Node Biopsy...

MODULE 11: Breast Surgery Suggested Readings Alexander’s Care of the Patient in Surgery (2022) Chapter 17 ORNAC Standards 2023 Sentinel Lymph Node Biopsy http://www.youtube.com/watch?v=Cdl2JhhTfYc http://www.youtube.com/watch?v=lkWm4EhQX4w Learning Outcomes Describe the normal anatomy of the breast. Understand instrument isolation for cases with carcinoma. Understand the importance of specimen handling in breast surgeries. Compare and contrast a sentinel node biopsy and an axillary node biopsy as it relates to treatment of breast cancer. Breast cancer affects primarily women, however less than 1% of men also develop breast cancer. The most common form of breast cancer is Infiltrating Ductal carcinoma. Survival rates are best when detected early. Breast Anatomy Blood supply: There are THREE arteries supplying each breast. The Internal Mammary (Thoracic) Artery will be discussed later- due to its use in cardiac surgery. In the text, it is written as "Mammary," but the picture in the test shows it as "Thoracic". These terms are used interchangeably Internal mammary artery Anterior aortic intercostal arteries Pectoral branch of the axillary arteries Lymphatics: Follow the course of the blood vessels. Axillary nodes and internal thoracic, c nodes are the main areas of drainage. Nerve Supply: Anterior cutaneous branches of upper intercostal nerves, 3rd and 4th branches of the cervical plexus, Lateral cutaneous branches of intercostal nerve. Module 11: Breast 2  Perioperative Nursing Considerations Nursing Assessment The diagnosis of breast cancer as with any type of cancer has a highly emotional impact on the patient and the entire family. Patient anxiety level may be considerable related to the fear of cancer diagnosis and fear of alteration of the body image. It is imperative that clinicians provide sensitive and supportive care using coping mechanisms and enabling family-centered care. Patient Positioning - The surgical procedure determines the patient’s intraoperative position. A patient who is undergoing breast surgery are placed in the supine position. Refer to the ORNAC Standards and the positioning performance checklist for appropriate practices. The patient position and the associated positioning devices may vary depending on the surgeon’s preferences and available institutional resources and policies. It is recommended that the perioperative nurse collaborates with the surgical team to ensure that the patient is positioned safely before, during, and after surgery. The perioperative nurse ensures that the patient return electrode pad is applied and the safety strap secured. Instrumentation and Counting A minor Instrument tray is required for all breast surgeries. All breast procedures require a minor count. Initial Count (minor) → Final Count (minor) Procedural Considerations Commonly used instruments are to be placed on mayo tray for use. All other remaining instruments are clean and not contaminated by any breast biopsy tissue that may have cancer cells present. Once the pathology report comes back you will either proceed to close the wound (no cancer cells present), or hand off all of the breast biopsy instruments and all sponges and sutures (cancer cells present). If cancer cells are found in the biopsy, the scrub nurse will then don a new surgical gown or change surgical gloves (hospital policy will guide this practice) and carry on with the lumpectomy or mastectomy if indicated. The specimen is sent to pathology for a frozen or quick section without delay, using a sterile specimen container without any medium. The surgical set up is kept sterile until a report comes back that the specimen biopsy is suitable and the margins for the diagnosis are confirmed. IF the patient has signed their consent appropriately, the procedure may proceed to include mastectomy or axillary node dissection. A separate set of sterile instruments is used so cancer 3 cells are not transferred to healthy tissue. The same instrument set may be used for the secondary procedure; however, the scrub nurse must keep the instruments from the breast biopsy (contaminated) separated from those needed for the following larger procedure (clean). Surgical Interventions Breast Biopsies and Breast Lumpectomy Fine needle aspiration biopsy done in Dr. Office and cells are sent to rule out a breast cyst or cancer cells. Core Needle Biopsy: Outpatient setting and local is used. Specimen is sent to lab. Biopsy of Breast Tissue: (open breast biopsy) for benign or malignant tumors. Open Breast Biopsy or excisional breast biopsy: These can be done under local anesthetic; however, many are done under a General anesthetic for comfort of the patient. Open Breast Biopsy with Wire Localization: The patient has a tiny wire placed by radiology into the breast lump before surgery. Then, when the lump is removed, and it is sent to Radiology with the wire (*not pathology). Sentinel Node Biopsy A sentinel node biopsy is a procedure that will predict the prognosis of patients with a breast lump. A sentinel node is the first node in the chain nearest the tumour. If the sentinel node biopsy is negative, this can mean that the patient has a greater likelihood of survival than one with positive lymph nodes. In a sentinel node the surgeon uses a Geiger-counter like device (sometimes called the navigator (Brand Name)) during the sterile procedure to locate the sentinel node. It emits a sound and shows a number when it is near the gamma rays that have embedded into the node. The surgeon removes the node and it is sent to pathology. Based on the result, the surgeon goes ahead with more surgery or may elect breast conservation. Negative Sentinel Node Biopsy – The patient does not require an axillary node dissection. Appropriate treatment will follow. Positive Sentinel Node Biopsy – The patient will require an axillary node dissection and adjunct therapy. Simple Mastectomy Removal of the entire breast. It can be done to remove extensive benign disease, male breast tissue for a malignancy that is confined to breast tissue. Always consider the anxiety level of patients undergoing mastectomy. 4  Modified Radical Mastectomy and Axillary Node Dissection Axillary Node Dissection – This procedure allows for staging of the disease, and is complete AFTER a sentinel node dissection with MALIGNANT results. Adjunct treatment can be planned when the correct pathology is determined. The lymph nodes between the pectoralis major and pectoralis minor muscles are removed. Care is taken to preserve the medial and lateral nerves of the pectoralis major muscle. Limited ESU used to prevent inadvertent injury to nerves. 5