The first thing that a surgeon does before performing the surgery is to take a physical test of his patient, which involves a mammogram or an x-ray of the breast’s soft tissues. Fine needle biopsy along with blood and urine test is also done. In case the tumor cannot be felt on touching, the doctor uses a wire-localization procedure. In this, a fine wire alongside an x-ray film or ultrasound is used to locate the tumor. A nurse or the surgeon himself may also use a felt-tip marker to mark the position of the tumor on the breast to make sure where the cut will be made.
The doctor then has a discussion with his patient, detailing her on the surgery, anesthesia, and the experience that she will be having during and after the surgery. The doctor will also ask for information regarding the medications and their dosages that the patient is taking, if at all she is taking any. The patient is advised not to eat or drink anything 8 to 12 hrs before the surgery.
As a preparation, the patient is either given local or general anesthesia. In local anesthesia, the breast and some of the surrounding tissues are made numb, while general anesthesia means complete unconsciousness. General anesthesia is used in case of extensive surgeries. In such cases, an intravenous infusion (IV) line is inserted into the patient’s arm or hand and then the anesthetic is given through this line. This kind of anesthesia also involves the usage of an oxygen tube inserted into the patient’s throat and intravenous lines to insert fluid required by the body.
During The Surgery
The duration of the surgery is roughly 1 to 3 hours depending on the size of the tumor and the area of metastasis.
First, the breast, chest and upper arm area is prepped and draped. Next, a cut is made at a point from where the tumor will be accessible. Usually, curved incisions are made which helps in the quick healing of the wound. A kind of electrical scalpel is usually used to make the incision as the heat produced cuts down the blood flow of the incision. The cut is made along the margins of the tumor along with some of the surrounding tissues. The extra tissues taken from the surrounding area are to check if the cancer has spread to other parts of the breast or not.
The surgeon may make a separate cut in the under arm area to remove axillary lymph nodes for more cancerous cells, just to confirm whether the cancer has spread to other parts of the patient’s body or not.
After the tumor is removed the wound is irrigated with a drain tube that was placed during the surgery. The wound is then finally closed and stitched.
Lymph Node Sampling
The following are the different techniques of sampling lymph nodes:
Sentinel node biopsy
In this process nearly five sentinel lymph nodes near the underarm area are collected. These are then tested for the presence of any cancerous cell. Normally, if these nodes are free of cancer, the axillary node will also remain unaffected as the sentinel node is more prone to cancer. This process is mostly used in comparison to axillary lymph node sampling or dissection, because in the latter process a bigger amount of nodes have to be taken, which may lead to other complications such as fluid buildup or decreased sensation. Moreover, sentinel biopsy causes less damage to the nodes.
Axillary lymph node dissection
This process involves the removal of nearly 6 to 20 nodes to test for cancer. Since so many nodes have to be removed, a drain tube is placed in the underarm to prevent the collection of lymph fluid. This drain is removed after 5 to 10 days. This kind of dissection has a lot of side effect including limitation in shoulder movement, a lingering pain, fluid buildup, numbness and an increased risk of infection. Hence, this procedure is used only if there is more than one lymph node containing cancer.
After the surgery, the patient is taken to the recovery room. Most patients are discharged home on the same day of surgery after giving certain instructions, while some patients are kept hospitalized for another day or two for observation. The size and location of the tumor removed, the general health of the patient and the preferences of the patient and her doctor are some of the post surgical factors that determine a patient’s recovery.
The immediate home care instruction that is given to the patient on discharge is to use an ice bag over the bandages in order to reduce pain and also to take special precaution to prevent any kind of infection. The other instructions given include the following:
Medications to relieve pain may be given in the recovery room itself. However, a prescription for other pain medications is also provided, which could be useful at home.
Care for the incision dressing
The doctor either instructs the patient on taking care of the dressing or bandage, or else asks the patient to wait for the first follow up visit, where the doctor himself removes the bandage and then instructs on how to handle the wound.
Care of the surgical drain
Usually, if a drain has been inserted into the patient’s armpit or breast area, it is removed before the patient is discharged. Sometimes, however, it might be left inserted and removed only at the first followup visit, 1 or 2 weeks later. In such a case, the drain has to be opened quite a few times throughout the day to empty the fluid. Instructions on caring for the surgical drains are usually given by the surgeon before discharge.
Stitches and staples
Nowadays, doctors mostly use dissolvable stitches, which leave the patient no tension of having them removed. At times, though, the head of the stitch may be noticed popping out of the cut like a whisker, this can be easily removed by the surgeon during the first post surgery visit. Another way of closing the wound is surgical staples, which are also removed by the surgeon during the post surgery visit.
The doctor also prescribes certain exercises, which must be performed to avoid shoulder and arm stiffness. These exercises usually start the next morning after the surgery, but some exercises are avoided till the drains are removed. The doctor may provide a written illustration of how to do the exercises.
A woman who has had a quarter of her breast removed should expect a slower rate of healing as compared to others. If any patient has undergone a lymph node biopsy or dissection along with lumpectomy, then she may take around 2 weeks to get back to her normal activities. During this time, if she experiences any complications, the possibility of which is very rare, or any kind of infection, she should immediately contact her doctor. Mostly, women after a lumpectomy can resume their activities of daily living within two to three days.
The patient is restricted from performing any strenuous physical labor and/or carrying anything heavier than 5 pounds for a few days following the surgery. The patient is also advised to wear a well-fitted bra that will provide good support to the breast, for about a week post surgery.
At a much later stage after lumpectomy, a patient may experience itchy feeling or pain as the nerves start re-growing. This irritation may vanish by itself or certain medications can be used to reduce it. Acetaminophen or NSAIDs such as ibuprofen or opioids are such medications, which help reduce this kind of pain. If this pain or irritation persists, contact your doctor.