Every precaution having been taken the operator should decide whether the operation is to be enucleation of the tumor or complete excision of the breast, with dissection of the axilla. An evidently innocent tumor of small size may be removed, either through a straight incision, which should be placed radially, or by raising a flap with an ovoid incision, by which more perfect dissection is permitted. Small nodules and superficial growths may be removed under cocaine anesthesia. The first essential is to leave behind nothing of the mass which it is desired to remove; the second is exact hemostasis, and the third is the closure of the wound. It is possible to remove portions of the gland itself, as well as to enucleate tumors from within its substance. V-shaped incisions may be coapted with sutures, by which the size of the gland is reduced, but its general proportions maintained. Tumors situated posteriorly may be removed by making an incision beneath the breast, around its border, raising it from the thorax, and returning it to place after the necessary excision. It is advisable to provide a small drain for these cases, as in the more or less loose tissues of the breast blood is likely to accumulate, and by distending the wound to interfere with its repair.
Operations for cancer of the breast are performed more radically than a few years ago. This is due to a more thorough knowledge of the pathology of the disease, and to the better appreciation of the value of thorough extirpation of all affected tissues, especially if this can be done early rather than late. Therefore the modern operation includes not only the removal of the breast and of the axillary nodes, but of the pectoral fascia and muscle, the fatty tissue in the neighborhood, and everything in which the disease may lurk.
The essential feature, then, of every case is the removal of all tissue which may be involved. It is therefore necessary to remove the skin covering the mamma, as well as the structures above mentioned. This is done by elliptical or ovoid incisions, the amount thus included being sufficient to take in every particle of skin which shows the slightest possibility of infection—i. e., every nodule or dimple which may be in any way connected with the primary disease. Inasmuch as only in cases seen early is it at all safe to be less radical than just mentioned the pectoral fascia and muscle should be removed. For these purposes large and long incisions are necessary, extending from the anterior border of the axilla down toward the costochondral junction, while the lower part of the opening is divided and the incision made elliptical, in order that the breast, with its coverings, may be completely removed. The upper end should follow the lower border of the pectoral tendon, or at least be placed near it, extending as far as the insertion of this tendon, since that portion belonging to the muscle excised should be divided at its insertion and removed with the rest of the mass. The incisions then are usually carried down first to the deep fascia, and then through this, in such a way that the underlying muscle may be lifted from the thorax and detached therefrom. The result is that there is dissected from the chest wall a total mass of gland, fat, fascia, and muscle, which is continuous upward and outward toward the axilla, from which the final dissection is made. Then, commencing on the outer side of the axilla, so much of the pectoral tendon is divided as may be necessary; close beneath it will be found the axillary vein, and this is next to be freed from its cellular and fatty surroundings. The dissection is now carried toward the deeper part of the axilla, vessels being secured before division, and the entire contents of the axilla being carefully removed in one continuous mass. This requires careful and sometimes tedious dissection, which is made much easier by exact hemostasis. If the greater part of the great pectoral muscle be removed, complete exposure of the axilla is easier. When this is not sufficient, because in the uppermost portion of the axillary cone may be felt enlarged lymph nodes, at the level of or beneath the clavicle, then the lesser pectoral should be divided at its middle, and its ends held apart, this affording a still better exposure of the axillary depths. By this measure the vessels and plexuses may be easily followed up to the level of the emergence of the former from the thorax, especially if the arm be held upward and forward, much depending upon the position in which the assistant thus holds it.
Everything which is actually involved should be sacrificed. This might even apply to the axillary vein, which may be doubly ligated and exsected. It will occasionally happen that it is cut or torn in some deep dissection. In this event, before resorting to final double ligation, an effort should be made to suture the opening with fine silk sutures passed with a round needle, which may be successfully done, or to secure a small tear within the jaws of a curved hemostat, may then be left within the dressings for forty-eight hours or longer; by this time a clot will have formed which will permit its detachment. While much work may thus be done upon the axillary vein the writer nevertheless has the feeling that when a case is advanced to such a degree as to demand this it is scarcely worth while, because recurrence is practically sure to follow. Nevertheless in the interest of general thoroughness, if the work has been begun, it is usually well to finish it as completely as possible.
Fig. 527
Diagram showing skin-incisions: triangular flap of skin, a b c, and triangular flap of fat. (Halsted.)
Fig. 528
Breast and pectoral muscle completely separated from thorax; axilla exposed. (Halsted.)