Breast-conserving surgery with sentinel lymph node biopsy

Patient and case

1. Name / Age / Sex
2. UHID / IP no. / Ward-Bed
3. Date of surgery / OT no.
4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

1. Operating surgeonname, designation
2. Assistant(s)
3. Supervising consultantpresent in OT / available / not applicable
4. Steps done by the residentwhole procedure / named steps, under whose supervision
5. Anaesthetist
6. Scrub nurse / circulating nurse

Diagnosis and procedure

1. Pre-operative diagnosis
2. Post-operative diagnosis
3. Procedure planned
4. Procedure performedif different from plan, state why
5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
2. Site / side markedYesNot applicable
3. WHO Surgical Safety ChecklistSign inTime outSign out
4. Antibiotic prophylaxisdrug, dose, route, time given before incision
5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

• positive or close margin needing re-excision
• conversion to mastectomy if clear margins cannot be obtained
• completion axillary dissection if the sentinel node is positive
• sentinel node not found (failed mapping)
• blue skin staining and blue-green urine after dye
• allergy or anaphylaxis to blue dye
• haematoma, seroma and wound infection
• numbness of the inner arm, arm swelling (lymphoedema)
• change in breast shape and asymmetry
• need for radiotherapy to the breast afterwards

Pre-operative details for this operation

1. Diagnosis and how it was madecore biopsy report (type, grade, ER/PR/HER2), imaging size of tumour, clinical T and N stage
2. Side and quadrant of tumourclock position and distance from nipple, marked on the skin before induction
3. Axilla status before surgeryClinically node negative, ultrasound normalNode positive, downstaged after neoadjuvant chemotherapy
4. Localisation of an impalpable lesionNot needed, palpableHookwire (mammography / ultrasound guided)Ultrasound in OTfor wire: time placed, check films reviewed
5. Mapping agent plannedBlue dye aloneRadiocolloid aloneDye plus radiocolloidradiocolloid: time of injection and lymphoscintigraphy result
6. Dye allergy and sulfa allergy askedNo allergyAllergy present
7. Consent for mastectomy / axillary dissection if neededTakenNot taken
8. Frozen section bookedYes, margins and nodeNode onlyNo

Anaesthesia and position

1. AnaesthesiaGeneralGeneral with local infiltration
2. PositionSupine, arm abducted on arm boardSupine, arm abducted, sandbag under shoulderabduction below 90 degrees
3. Anaesthetist told about blue dyedye can falsely lower the pulse oximeter reading

Operative findings

1. Tumoursize, site (quadrant, clock position), fixity to skin or pectoral fascia
2. Sentinel nodesnumber removed, blue / hot / palpable, counts of each node if probe used, site in axilla
3. Background count after removal (if probe)below 10% of the hottest node
4. Other palpable nodes in axillaNonePresent, removed
5. Frozen section resultsentinel node and any margin sent, with time of report
6. Specimen radiograph (if wire / calcification)lesion and wire tip within specimen

Procedure (steps)

1. Mapping agent injectedagent, volume, site (subareolar / intradermal / peritumoral), time, massage for 3 to 5 min
2. Painting and drapingbreast, axilla and arm prepared, arm lifted to include posterior axillary skin
3. Axillary incisionTransverse, below hair-bearing skinOblique along lateral edge of pectoralis majorThrough the breast incision (upper outer tumour)length; site chosen by probe count or blue lymphatic
4. Axillary fascia opened, sentinel node(s) foundfollowed blue lymphatics / probe; nodes blue, hot or palpable
5. Sentinel node(s) excisedhilar vessels and lymphatics clipped or tied; each node labelled separately
6. Breast incisionCurvilinear over tumourCircumareolarRadial with skin ellipselength; previous biopsy scar included or not
7. Wide local excisionabout 1 cm grossly normal tissue around tumour, down to pectoral fascia; fascia taken or not
8. Specimen orientedsutures / clips / ink for superior, medial, lateral, deep; which code used
9. Cavity shaves / re-excisionwhich margin, reason, labelled as new margin
10. Cavity clips placedYes, number and wallsNot placed
11. Haemostasis and cavity closurecautery used; cavity left open or breast tissue mobilised and approximated
12. Completion axillary dissection (only if node positive on frozen and planned)levels cleared, nerves preserved

Closure, drains and dressing

1. Axillary woundlayers and suture
2. Breast subcutaneous layerinterrupted fine absorbable
3. SkinSubcuticular absorbableInterrupted
4. DrainNoneSuction drain, axilla
5. DressingLight dressing with supportive brassierePressure dressing

Specimens and implants

1. Wide local excision specimen for HPEside, quadrant, orientation code written on the form
2. Separate margin shaveseach in its own labelled container
3. Sentinel node(s)number of containers, blue / hot, frozen section or paraffin
4. Hookwire and specimen radiographSentNot applicable
5. Cavity clipsnumber and type, for radiotherapy planning

End of procedure

1. Estimated blood lossml
2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
3. Swab, needle and instrument countCorrectIncorrect: action taken
4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

1. Vitals and wound checkpulse, BP, swelling in breast or axilla (haematoma)
2. Oral intakeliquids when fully awake, then normal diet
3. Analgesiadrug, dose, frequency
4. Drain (if placed)record daily output; removal plan
5. Arm and shoulder movementgentle movement of the arm allowed; physiotherapy advice if axillary dissection done
6. Supportive brassierewear day and night for comfort and to reduce haematoma
7. Tell the patient about blue dyeblue skin and blue-green urine are expected and fade
8. Dischargesame day or next day
9. Follow-upwound check and final HPE with margins and nodes; tumour board; radiotherapy referral

Signature

1. Name and designation of person writing note
2. Medical Council registration no.
3. Signature / date / time of writingwrite before the patient leaves recovery