Patey's operation for carcinoma of the breast, modified to remove pectoralis minor

The traditional radical mastectomy (Haagenson, Stiles, and others) removes both pectoralis major and minor. Removing pectoralis major is mutilating, and has not been shown to produce any more survivors than operations which leave it, such as Patey's. In its original form Patey's operation removes pectoralis minor also. This is is easier than preserving it, because it allows you to remove all the tissues containing the lymph nodes in the axilla ''en bloc', up to the axillary vessels and the brachial plexus.

Patey's operation is for the careful caring operator, who cannot refer his patient. Its aim is to try to remove her breast, and with it the triangular mass of fibrofatty tissue and lymph nodes in her axilla which is bounded by serratus anterior medially, latissimus dorsi posteriorly and laterally, by coracobrachialis above, and by the axillary apex superomedially. During the operation your assistant will have to retract pectoralis major forwards, so that you can see under it. The key to dissecting the axilla is to expose the anterior edge of latissimus dorsi, and to find the plane just medial to it, which contains the subscapular vessels and the nerve to this muscle. Having done this, you will have to remove all pectoralis minor, and the clavipectoral fascia in continuity with it.

The clavipectoral fascia is a sheet of tissue which extends from the apex of the axilla, where it is attached to the clavicle, to the base of the axilla, where it is continuous with the axillary fascia. It encloses pectoralis minor. Aim to remove it completely, together with the fat and lymph nodes that are associated with it.

Fig. 21-10 ANATOMY FOR A MODIFICATION OF PATEY'S OPERATION. A, the empty axilla to show its muscles, as if its contents were absent. B, pectoralis major is shown cut away to reveal the structures under it. In reality it is retained.

The key to structures in this and later figures is: 1, pectoralis major (retained in this operation). 2, pectoralis minor (removed in this operation). 3, serratus anterior. 4, subscapularis. 5, latissimus dorsi. 6, biceps. 7, triceps. 8, teres major. 9, coracobrachialis. 10, the axillary space. 11, the coracoid process. 12, the nerve to serratus anterior. 13, the nerve to latissimus dorsi. 14, the lateral pectoral nerve. 15, After Rob C and Smith R, ''Operative Surgery', Vol. 1 (2nd edn), (Butterworth), with the kind permission of Hugh Dudley.

PATEY'S OPERATION Refer the patient if you can; if not proceed as follows.

ANAESTHESIA. General anaesthesia. Have two units of blood cross-matched for her.

CAUTION ! For the methods of controlling bleeding, see the previous section.

EQUIPMENT. A general set (4.12). A large right-angled retractor. At least 24 Spencer Wells or similar haemostats. Find two competent assistants.

PREPARATION. Sit her up a little, prepare and paint her back and flank on the affected side, and then let her lie back on a plastic sheet covered with a sterile towel, as in A, and B, Fig. 21-11. If you don't do this, the back of her flank will not remain sterile during the operation. Drape her arm so that you can flex and extend it when necessary, without disturbing the drapes.

You may need to cover a bare area, so prepare her thigh for skin grafting (57.2). A sandbag behind her lower thigh will make cutting the graft easier (optional).

INCISION. Plan the incision so that the tumour is in the middle of an island of skin, and at least 4 cm away from any palpable edge of the tumour. Make an oblique incision from her coracoid process, which you will be able to feel 2.5 cm inferior to the junction between the middle and outer thirds of her clavicle, to a point about 5 cm superolateral to the xiphoid process of her sternum. Bring the lateral edge of the ellipse well medial to the outer border of her pectoralis major (the anterior axillary fold). Don't extend it down her arm or over the front of her shoulder.

Fig. 21-11 PATEY'S MASTECTOMY[md]ONE. A, and B, draping the patient. Unless you prepare and drape her like this, the back of her flank will not remain sterile during the operation. C, plan the incision, so that the tumour is in the middle of an island of skin, and at least 4 cm away from any palpable edge of the tumour. D, carry the inferior flap back to just beyond the anterior border of her latissimus dorsi. E, dissect the tissues superficial (not deep) to latissimus dorsi for 5 cm. For a key to numbered structures see caption to Fig. 21-10. After Rob C and Smith R, ''Operative Surgery', Vol. 1 (2nd edn), (Butterworth), with the kind permission of Hugh Dudley.

RAISE TWO FLAPS as you would if you were doing a simple mastectomy (21.5). Start with the inferolateral flap, and carry this back to 5 cm beyond the anterior border of her latissimus dorsi. Find the nerve to this muscle, which enters it with her subscapular vessels on its deep surface, near its anterior border. If you have placed your flap correctly, you will encounter latissimus dorsi as in E, Fig. 21-11.

CAUTION ! If you dissect the inferolateral flap too deep you will: (1) make it too thick, (2) leave pieces of breast or lymph nodes in it, (3) endanger the nerve to latissimus dorsi, and (4) find the accompanying subscapular vessels a nuisance.

Now dissect the superomedial flap to reach the edge of her breast. Dissect this from the underlying muscle, as described in Section 21.5 for for simple mastectomy.

TURN HER BREAST LATERALLY starting from the point where the flaps join inferomedially. Begin over her thoracic cage near the root of her xiphisternum. Dissect her breast away from her pectoralis major, clamping the vessels entering its deep surface as you progress. You will now have turned her whole breast over on itself to leave it lying laterally (F).

ENTER HER AXILLA to mobilize the axillary tail of her breast, by dissecting along her chest wall posterior to pectoralis major. Ask your assistant to lift her pectoralis major to make this easier.

You should now see the edge of her pectoralis minor. Dissect towards it. Separate its origin from her chest wall[md]it arises from ribs 3, 4, and 5 and from the intervening intercostal spaces. Dissect her clavipectoral fascia from her thoracic wall, working superomedially to reach the apex of her axilla, where you will see the fascia carrying her axillary vessels, before they disappear under her clavicle. Your assistant will have to retract her pectoralis major well at this stage.

A cutaneous nerve, the intercostobrachial, crosses through her axillary fat from the chest wall medially (T2), to supply the skin of her axilla and upper arm. You can sacrifice this.

While you are dissecting away pectoralis minor, you will meet some of her lateral pectoral vesels. Clamp these and tie them with 2/0 multifilament, or coagulate them with diathermy.

Now start dissecting her axilla, where you have exposed the edge of her latissimus dorsi. Find the nerve to this muscle, if you have not done so already, and preserve it. Dissect the tissues off the superficial surface of latissimus dorsi for about 3 cm. This will help when you come to close the wound.

Now, start inferolaterally to dissect the contents of her axilla from latissimus dorsi laterally, and from serratus anterior covering her thoracic wall medially.

CAUTION ! Preserve: (1) The nerve to latissimus dorsi as it crosses the posterior wall of her axilla. (2) The nerve to serratus anterior, which lies on the surface of this muscle, on the medial wall of her axilla.

Work superiorly along the anterior edge of latissimus dorsi, towards her axillary vessels (the vein lies inferomedial to the artery) and her associated brachial plexus. You should see the vein first; it is delicate and has several small branches[md]so be careful!

Dissect the contents of her axilla away from her axillary vein along the line ''X' in G, Fig. 21-12.

As you dissect medially along the vessels and nerves, continuing to expose the inferior and medial aspect of the vein, you will meet from lateral to medial: (1) Her subscapular artery and its two veins. Leave these if you can. (2) Her lateral pectoral artery. (3) Her acromiothoracic artery with four branches, two of which enter the field medially. (4) Her superior pectoral vessels.

Use blunt dissection to separate the fascia anteriorly and posteriorly. While you dissect medially, ask your assistant to lift up her pectoralis major more. Ask another asistant to lift her arm, which has been lying on its arm board.

When you reach the apex of her axilla, you will be able to feel her first rib, and will meet the dissection you have done along her anterior chest wall. Now find the insertion of her pectoralis minor into her coracoid process. To reach it you will need sharp dissection with scissors along her axillary vessels. Divide its insertion near the bone (H). This will enable you to remove the contents of her axilla ''en bloc', including her pectoralis minor and her attached breast.

DRAINING AND CLOSING THE WOUND. If possible insert suction drains (a reusable ''Redivac' bottle and tube is ideal). A two-ended drain is best. Insert two perforated tube drains through separate stab incisions in the inferolateal flap. Corrugated drains can be used, but increase the risk of infection.

Starting at each end, use ''0' monofilament to close the wound with simple interrupted sutures, spaced about 1 cm apart and passing through the skin 0.5 cm or less from its edge. Or, use a continuous blanket suture. Avoid mattress sutures, which leave an ugly scar. You should be able to close the wound using skin sutures only, unless she is very fat.

If you cannot close the wound without tension, close its ends first. Then sew the edges of its middle part to pectoralis major, and apply a split skin graft (57.2) to the muscle bed. Place gauze over this graft, and hold it in place with 3 pairs of ''tie over sutures' (57-8) inserted through the skin edges.

Apply a pressure dressing for 3 or 4 days. Remove the drain when no fluid flows, usually at 4 to 7 days. Remove alternate stitches on the 9th day, and the others on the 10th day, or later if necessary. Start arm exercises on the 7th day, especially those for shoulder abduction, internal rotation (ask her to put her hand behind her lower back), and external rotation (ask her to put her hand on the back of her neck).

DIFFICULTIES [s7]WITH PATEY'S OPERATION If you DAMAGE HER AXILLARY VEIN, clamp it above and below with arterial clamps, or with Spencer Wells forceps with rubber tube over their jaws. Sew up the hole with 4/0 or 5/0 multifilament silk or monofilament, not catgut.

If you cannot repair the tear, tie her vein proximally and distally. This will usually only cause temporary ischaemia of her arm, because her cephalic vein is still intact.

If SHE IS UNABLE TO PULL HER SHOULDER DOWN, you have damaged the nerve to her latissimus dorsi. This is not a great disability.

If she has a WINGED SHOULDER, you have damaged the nerve to her serratus anterior. This looks unsightly.

Fig. 21-12 PATEY'S MASTECTOMY[md]TWO. F, clear the whole of the patient's pectoralis major to its lateral edge. G, the entire contents of her axilla, including her clavipectoral fascia, pectoralis minor, and her breast have been reflected laterally. The insertion of her pectoralis minor into her coracoid process is about to be divided (''X'). H, pectoralis minor has been divided and her clavipectoral fascia is about to be removed. For clarity, the nerve trunks of the brachial plexus are not shown. I, the wound has been closed, and long tubular drains are in place. For a key to numbered structures see caption to Fig.21- 10. THE THYROID