Operаtive Repоrt Preоperаtive Diаgnоsis: Carcinoma of the left breast. Postoperative Diagnosis: Carcinoma of the left breast. Procedure: Left mastectomy. Excision of needle localized left axillary lymph node. Left sentinel lymph node biopsy x3. Completion left axillary dissection. Details of Procedure: The patient was brought to the operating room, where general anesthesia was induced. The patient had an erector spinae block done for postop analgesia. 5 mL of isosulfan blue was injected into the periareolar dermis of the left breast after prepping it with Betadine. The left breast was then massaged for 5 minutes. The left breast, chest, and axilla were then prepped and draped in the usual sterile fashion. We did the node procedure first. The left axilla was examined transcutaneously with the NeoProbe, which was used as our Gamma counter. There was a radioactive site and it appeared to be where the previously positive node was located. a transaxillary incision was made centered on the entrance site of the localizing wire. We dissected down the wire to the underlying node, which was approximately 6 cm deep to the skin insertion site. The node was stained blue, it had an in situ count of 55. This node was excised along with the needle localizing wire and the count over the node after excision was 60. A specimen radiograph of the node was then done in the operating room, which demonstrated the clip, which had been placed at the time of her original biopsy to be present in the specimen and the entirety of the wire. This was then sent for permanent sections. While the first node was being examined, we used the NeoProbe and identified 3 other specimens. Each of these had an in-situ count between 60 and 70, the first sentinel node did not have blue staining. This was excised and the count over the node after excision was similar to its in-situ count. The other 2 nodes were excised, and their counts were similar as well as their in-situ counts. These were sent to the Pathologists, and we were initially going to ask them to do touch prep and frozen section. However, these nodes grossly were positive and the report from the first node was that it was still filled with tumor on frozen section. Therefore, we did not have them do the frozen section on the other 3 nodes and she will need an axillary dissection. While awaiting the node report, we marked an elliptical incision on the left breast, which encompassed the initial needle core biopsy skin entrance site as well as the skin overlying the tumor. The report then returned from the Pathologist that the needle localized node was still positive and we then began the mastectomy. The skin incision was made as had been marked. A standard flap was then done. Superiorly, the flap was taken to the clavicle. She has a Port-A-Cath in the left infraclavicular area, and we dissected around the port, which is in the subcutaneous tissue without disturbing it. Laterally, the flap was taken to the latissimus dorsi muscle, medially to the sternum and inferiorly to well below the inframammary fold. We then dissected the breast and pectoralis major fascia off the chest, moving medial to lateral. A transition was made to the axillary dissection. The axillary vein was identified, and this was the superior aspect of the dissection. A level 1 and 2 node dissection were done in continuity with the breast. The long thoracic nerve of Bell and the thoracodorsal nerve were both identified and protected during the procedure. After removal of the specimen, the breast skin was marked with a suture to orient the pathologist and then the specimen sent for permanent sections. During the mastectomy, and the initial node removal procedure, vessels were clamped as encountered, divided and ligated with 2-0 ties. Several areas were also suture ligated as needed. The wound was then irrigated with saline. Two #19 Blake drains were then passed through separate stab wound incisions through the lower flap and each drain sewn to the skin at the exit site. One of the drains was directed anteriorly, the other toward the axilla. After ensuring hemostasis, the axillary incision was closed with a running subcuticular 3-0 Vicryl. The mastectomy incision was closed with interrupted inverted 2-0 Vicryl dermal sutures, followed by running subcuticular3-0 Vicryl. A Dermabond dressing was placed over the mastectomy incision and over the axillary incisions. Biopatches were placed around each drain exit site and then they were covered with a Tegaderm dressing. The procedure was then terminated, and the patient transported to the recovery room in stable condition, having undergone the procedure without complication.
Investigаtоrs whо аre interested in studying аttitudes and want tо gain a lot of information very quickly are likely to use
It is а recоmmended thаt а patient with a STEMI (ST-Elevated MI) undergо cardiac catheterizatiоn within ____ minutes of presentation to the Emergency Department.