Breast wide local excision

Principles

If palpable, can use palpation guidance
If non-palpable, need hookwire (also radioactive seed localisation)
>3cm nonpalpable lesions, especially DCIS or other tumours with in situ component, would benefit from 2 localising devices. One at medial and lateral extents, +/- superior/inferior extents
Send excision specimens down to radiology intra-op x-ray
Imaging on display in OT
Suture or ink specimen immediately

Hookwire localisation morning of procedure, may need lymphoscintigraphy too
Review biopsy results and imaging, have available in theatre, also have lymphoscintigraphy detection device

TT, GA, prep and drape taking care of hookwire, IV Abx, TEDs, incision marked on breast, blue dye
Supine, ipsilateral arm out, myself standing medial on ipsilateral side
WLE
- Curved incision overlying the tumour location, not at hookwire entry site
  - Always safe to plan the incision directly over the tumour
  - Incisions above nipple require curved incision; those below nipple seem to do well with radial incisions
  - Raise a skin flap in every direction over the tumour to prevent dimpling - thickness will vary depending on depth of tumour. Assistant with cat's paws.

Deliver hookwire into wound (likely coming from lateral side) and apply artery clip to it
Excise a cone of breast tissue down to fascia, follow hookwire down and avoiding exposing tip of hookwire. Assistant with Langenbeck's at 90 degrees to one other. With my left hand on tumour, ensuring I have a 1cm margin on each side as the cone is developed on each side.
Elevate the cone out of the wound - if unable, need a bigger incision
Mark in situ (S, M, L)
Peel off fascia. Remove and prepare for imaging - placed on a piece of foam, marked and in appropriate orientation
Can consider doing USS intra-op on specimen if facility available
Send for imaging