OT notes · General Surgery

Modified radical mastectomy

Usual anaesthesia
General
Position
Supine, ipsilateral arm abducted (less than 90 degrees) on an arm board, sandbag under the shoulder
Setting
elective

Operative note template for a modified radical mastectomy, with a filled example for a left MRM with level I and II axillary clearance (Auchincloss) for carcinoma breast under general anaesthesia.

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Blank template

Follow this order in the case sheet. Tick the options that apply and fill the blanks.

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

  • seroma needing repeated aspiration
  • bleeding and haematoma
  • skin flap necrosis and wound infection
  • numbness of the inner upper arm (intercostobrachial nerve)
  • arm swelling (lymphoedema)
  • shoulder stiffness and pain
  • winged scapula (long thoracic nerve injury)
  • weak shoulder adduction (thoracodorsal nerve injury)
  • axillary vein injury
  • flat chest wall; later reconstruction and prosthesis options

Pre-operative details for this operation

  1. SideRightLeftmarked with the patient awake
  2. Tumourquadrant, clock position, size in cm, skin or chest wall involvement
  3. Tissue diagnosiscore biopsy result and date; ER, PR, HER2
  4. Axillaclinical nodes; FNAC / core of node if done
  5. Clinical stage (TNM) and metastatic work-upinvestigations and results
  6. Neoadjuvant therapyNoneChemotherapyEndocrineregimen, cycles, response, date of last cycle
  7. Tumour board / MDT decisiondate and plan
  8. Reconstruction discussedDeclinedDelayed reconstruction plannedImmediate reconstruction (separate note)
  9. Blood reservedgroup and units

Anaesthesia and position

  1. AnaesthesiaGeneralrequest no further muscle relaxant after intubation so nerves can be seen to twitch
  2. PositionSupine, arm abducted on arm boardSupine, arm draped freeabduction under 90 degrees; sandbag under the shoulder
  3. Parts preparedchest wall to beyond midline, axilla, shoulder, arm

Operative findings

  1. Tumoursize, site, fixity to pectoral fascia or muscle
  2. Axillary nodesnumber palpable, largest size, matted or fixed, levels involved
  3. Pectoral muscle / chest wallFreeFascia involved: disc of muscle excised
  4. Skin flapsthickness, colour and bleeding at the end
  5. Nerveslong thoracic, thoracodorsal, medial and lateral pectoral, intercostobrachial: preserved or sacrificed and why

Procedure (steps)

  1. Skin preparation and drapingantiseptic; arm covered in a stockinette if draped free
  2. IncisionStewart (transverse / oblique elliptical)Oblique, high laterally, low mediallySkin-sparinginclude the nipple-areola, skin over the tumour and any biopsy scar
  3. Upper and lower flaps raisedplane between subcutaneous fat and breast; limits: clavicle, sternum / midline, rectus sheath, anterior border of latissimus dorsi; knife or cautery
  4. Breast removed off pectoralis major with pectoral fasciamedial to lateral; internal mammary perforators ligated or cauterised
  5. Axilla enteredfascia at lateral border of pectoralis major incised; interpectoral (Rotter) nodes cleared
  6. Pectoralis minorPreserved (Auchincloss, level I and II)Divided from coracoid / excised (Patey, level I to III)Incised (Scanlon)
  7. Axillary vein exposedfat divided along the anterior surface; tributaries ligated; no dissection above the vein
  8. Thoracodorsal bundle and long thoracic nerve identified and preservedhow confirmed (seen / stimulated)
  9. Medial and lateral pectoral nervesPreservedSacrificed (reason)
  10. Intercostobrachial nervePreservedSacrificed
  11. Specimen removed en bloc and orientedsutures or clips: e.g. short = superior, long = lateral / axillary apex
  12. Haemostasis and washsaline; flaps checked

Closure, drains and dressing

  1. Drainsnumber, type, size; one in the axilla along latissimus dorsi, one over pectoralis major; brought out through separate stabs and anchored (material)
  2. Dog earsNoneCorrected: method and length of limbs
  3. Subcutaneous / deep dermal layerinterrupted absorbable, material and size
  4. SkinSubcuticularInterruptedStaplesmaterial and size
  5. DressingLight dressingCompression dressing

Specimens and implants

  1. Mastectomy with axillary contents for HPEside, orientation marks, formalin; request tumour size, grade, margins, number of nodes and positive nodes, ER / PR / HER2 if not done
  2. Separately labelled node levels (if sent separately)level I / II / III, apical node

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 flap checkpulse, BP, flap colour, swelling under the flaps (haematoma)
  2. Drainskeep on suction; chart daily output of each drain; remove when under 30 ml a day for 2 days
  3. Armposition of the operated arm; any restrictions advised by the unit
  4. Shoulder exerciseswhen to start and range allowed
  5. Analgesiadrug, dose, frequency
  6. Thromboprophylaxisearly mobilisation; pharmacological prophylaxis as per unit protocol
  7. Dietoral fluids when awake
  8. Seroma after drain removalaspiration in OPD
  9. Follow-upHPE report to tumour board; adjuvant therapy; external prosthesis advice

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

Worked example

Fictional case: Mrs. S.B., 52 years, postmenopausal, with a 4 x 3 cm lump in the upper outer quadrant of the left breast and a mobile 1.5 cm left axillary node. Core biopsy: invasive ductal carcinoma, ER and PR positive, HER2 negative. Node FNAC positive. Staging CT: no distant metastasis (cT2 N1 M0). Tumour board: MRM, then adjuvant therapy.

Case details

Date: 21/08/2026. Elective. OT 2.

In OT 09:00. GA induced 09:15. Skin incision 09:40. Skin closure completed 12:05.

Surgeon: Dr A. (3rd-year resident, General Surgery). Assistant: Dr B. (2nd-year resident). Consultant: Dr C., present and scrubbed for the axillary dissection.

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Indication: carcinoma left breast, upper outer quadrant, 2 o'clock, 4 x 3 cm, 3 cm from the nipple, skin free, not fixed to chest wall. Left axillary node 1.5 cm, mobile, FNAC positive. cT2 N1 M0.

Core biopsy (02/08/2026): invasive ductal carcinoma, grade 2, ER positive, PR positive, HER2 negative. CT chest and abdomen (08/08/2026): no metastasis. Tumour board 12/08/2026: MRM.

Breast conservation and reconstruction discussed. Patient chose mastectomy without reconstruction.

Hb 12.1 g/dl. Blood group B positive, 1 unit cross-matched.

Consent: general, procedure-specific (including seroma, lymphoedema, arm numbness, shoulder stiffness) and anaesthesia consent taken in Marathi from patient, husband as witness.

Left side marked with the patient awake. WHO checklist sign in and time out done. Inj cefazolin 2 g IV at 09:25, before skin incision.

Anaesthesia and position

General anaesthesia. Anaesthetist asked to avoid further muscle relaxant after intubation.

Supine, left arm abducted to 80 degrees on an arm board, sandbag under the left shoulder. Chest wall to beyond midline, left axilla, shoulder and arm painted with povidone-iodine and draped.

Procedure

Oblique elliptical Stewart incision from near the sternum towards the axilla, including the nipple-areola and skin 5 cm beyond the tumour margin.

Upper flap raised with cautery in the plane between subcutaneous fat and breast up to the clavicle, lower flap to the rectus sheath, medially to the sternal edge, laterally to the anterior border of latissimus dorsi.

Breast with pectoral fascia removed off pectoralis major from medial to lateral. Internal mammary perforators in the 2nd to 4th spaces ligated.

Findings: tumour 4 x 3 cm, free of pectoral fascia. Three palpable level I nodes, largest 1.5 cm, mobile, not matted. No palpable level II or III nodes. No interpectoral nodes.

Fascia at the lateral border of pectoralis major incised. Pectoralis minor preserved and retracted (Auchincloss). Axillary vein exposed along its anterior surface, small tributaries ligated. No dissection above the vein.

Medial and lateral pectoral nerves preserved. Long thoracic nerve identified on the chest wall and preserved, twitch seen on touch. Thoracodorsal nerve and vessels identified and preserved. Intercostobrachial nerve sacrificed as it ran through the node mass.

Level I and II nodes with axillary fat removed en bloc with the breast.

Specimen oriented: short silk suture at 12 o'clock (superior), long silk suture at the axillary apex.

Haemostasis secured. Wound washed with saline. Flaps pink and bleeding at edges.

Closure

Two closed suction drains: one in the axilla along latissimus dorsi, one over pectoralis major. Both brought out through separate stab incisions below the wound and anchored with nylon 2-0.

Small lateral dog ear trimmed.

Subcutaneous layer closed with interrupted polyglycolic acid 3-0. Skin closed with continuous subcuticular poliglecaprone 25 (Monocryl) 3-0.

Light dressing.

Specimens and implants

Left MRM specimen (breast with level I and II axillary contents) sent in formalin for HPE with orientation marked on the form. Requested: tumour size, grade, margins, lymphovascular invasion, number of nodes and number positive. No implants.

End of procedure

Estimated blood loss 250 ml (suction 100 ml + mops). No transfusion.

Mop, needle and instrument count correct, confirmed by scrub nurse.

No intra-operative complications. Axillary vein intact.

Patient extubated and shifted to post-operative ward in stable condition. Pulse 86/min, BP 130/80 mmHg.

Post-op orders

Pulse, BP and flap check hourly for 6 hours, then 4-hourly.

Drains on suction. Chart output of each drain separately every 24 hours. Remove each when under 30 ml a day for 2 days.

Left arm supported on a pillow.

Oral fluids when awake, then normal diet.

Analgesia as per anaesthesia chart.

Early mobilisation. Pharmacological thromboprophylaxis as per unit protocol.

Gentle shoulder and hand exercises as taught by physiotherapist.

HPE report to tumour board for adjuvant therapy.

Signature

Dr A., JR-3, General Surgery. Reg. no. ________. 21/08/2026, 12:20.

Must document for this operation

  • Pre-operative diagnosis with biopsy, receptor status, stage and tumour board decision. A mastectomy must be backed by a tissue diagnosis, and the record shows the plan was agreed before surgery.
  • Type of MRM and levels of axilla cleared. Patey, Scanlon and Auchincloss differ in the nodes removed, and the oncologist plans axillary radiotherapy on this.
  • Each named nerve: preserved or sacrificed, with the reason. Winged scapula, weak adduction or arm numbness after surgery will be judged against this line.
  • Tumour fixity and whether pectoral fascia or muscle was taken. This affects the pathological T stage and the need for chest wall radiotherapy.
  • How the specimen was oriented. The pathologist can only report which margin is close if the orientation is marked and written.
  • Number, type and position of drains. Nurses chart each drain, and the ward team needs to know which one is axillary when seroma or bleeding occurs.
  • Dog-ear correction and the length of the limbs. It explains the scar shape and helps if revision or reconstruction is planned later.

Common mistakes in these notes

  • Writing 'MRM done' without the side, the type of MRM or the axillary levels.
  • Not mentioning the long thoracic and thoracodorsal nerves at all.
  • Sending the specimen without orientation marks.
  • No record of receptor status or tumour board decision in the pre-op section.
  • Drain output charted as a total instead of for each drain.

Sources

  • Scott-Conner CEH, Dawson DL. Operative Anatomy / Essential Operative Techniques. Wolters Kluwer; 2015, Ch 18, Mastectomy: Total (Simple), Modified, and Classic Radical, pp. 132-141.
  • Bhat SM. SRB's Surgical Operations: Text and Atlas. Jaypee; 2014, Ch 16, Surgeries for Breast Diseases: Modified radical mastectomy, pp. 482-491.
  • Farquharson's Textbook of Operative General Surgery. 11th ed. CRC Press, Ch 5, Surgery of the breast and axilla: mastectomy; level II and III axillary clearance, pp. 67-70.
  • Atlas of Breast Surgery (Springer), Ch 6.1, Modified radical mastectomy, pp. 61-62.
  • Bratzler DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283. Cefazolin 2 g (3 g if 120 kg or more) within 60 min before incision, redose at 4 h; cefazolin for breast procedures with risk factors. academic.oup.com/ajhp/article/70/3/195/5112717

Educational template for residents. Adapt it to your institution's case-sheet format and your consultant's instructions. Patient details in the example are fictional.

Videos of this operation

Teaching videos and pages for this operation, listed under the curriculum item that asks for it.

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