Al-Azhar Assiut Medical Journal

ORIGINAL ARTICLE
Year
: 2017  |  Volume : 15  |  Issue : 4  |  Page : 168--171

Seroma formation after modified radical mastectomy


Mahmoud AboAmra 
 Department of Surgery, Faculty of Medicine, Al-Azhar University, Cairo, Egypt

Correspondence Address:
Mahmoud AboAmra
Department of Surgery, Faculty of Medicine, Al-Azhar University, Cairo
Egypt

Abstract

Background Modified radical mastectomy remains the most commonly performed surgery for breast cancer. Aim of the work The aim of this study was to evaluate the effect of different methods (conventional scalpel, electrocautery, and harmonic scalpel) of breast dissection during mastectomy on seroma formation. Patient and methods This study was conducted in Al-Azhar University Hospital in Assiut from April 2013 to April 2016, on 110 female patients aged from 25 to 70 years; all patients were having stage II breast cancer, according to the Manchester and International Union against Cancer (TNM). Modified radical mastectomy was done after complete preoperative assessment. Result One-hundred and ten female patients have stage II breast cancer aged from 25 to 70 years. During the modified radical mastectomy, in this study, the breast dissection was done by electrocautery in 42 patients, using conventional scalpel in another 42 patients and using harmonic scalpel in the remaining 26 patients. At the end of this study, there were 15 cases (out of 110 patients) of postmastectomy seroma detected postoperatively, only one case in the conventional scalpel group, 14 cases in the electrocautery group and no case in the harmonic scalpel group. The wound drains were removed in all cases on day 7postoperatively. In all patients of this study, a pressure garment was used postoperatively. Conclusion The use of harmonic scalpel in breast dissection is better than electrocautery use as regards postmastectomy seroma formation. If harmonic scalpel is not available, it is better to use the conventional scalpel.



How to cite this article:
AboAmra M. Seroma formation after modified radical mastectomy.Al-Azhar Assiut Med J 2017;15:168-171


How to cite this URL:
AboAmra M. Seroma formation after modified radical mastectomy. Al-Azhar Assiut Med J [serial online] 2017 [cited 2018 Nov 12 ];15:168-171
Available from: http://www.azmj.eg.net/text.asp?2017/15/4/168/237132


Full Text



 Introduction



Breast cancer is one of the most common cancers in our surgical practice and modified radical mastectomy remains the most commonly performed surgery for this type of cancer, so we must do more studies for seroma prevention or to decrease its incidence at least [1]. The reported incidence of seroma formation following mastectomy varies between 15 and 18% [2].

Postmastectomy seroma can be identified as a collection of serous fluid just under skin flaps or in the axillary space immediately following mastectomy with axillary dissection that can be detected clinically or sonographically [3].

Seroma is one of the most bothersome events that disturbs both the patient and the surgeon with multiple visits which delay starting the adjuvants therapy and cause patient’s discomfort with a possibility of increased surgical site infection [4].

The pathogenesis of seroma formation has not been fully elucidated. Seroma is formed by acute inflammatory exudates in response to surgical trauma and acute phase of wound healing [5].

Dissection of breast skin flaps during mastectomy using ordinary scalpel has low incidence of seroma formation than using electrocautery. Both has much more blood loss than that in the case of ordinary scalpel [6].

Kontos et al. [7] have reported low incidence of seroma accumulation in patients in which harmonic scalpel was used.

 Patients and methods



This study has been done in the Al-Azhar University Hospital in Assiut from April 2013 to April 2016. This study was conducted on 110 female patients aged from 25 to 70 years; all patients were having stage II cancer breast, according to the Manchester and International Union against Cancer (TNM).

The clinical picture for the studied case was a tumor of size 2–5, mobile axillary lymph node, no skin manifestation, no invasion for breast skin or chest wall, and no distant metastases. Modified radical mastectomy operation was done after complete preoperative assessment.

Clinical assessment

History

Personal history included age of the patients, history of the present illness onset, course and duration of the breast lump, and any associated symptom such as pain and nipple discharge.Past and family history of a similar condition and chronic systemic diseases.

Examination

General examination, pulse, blood pressure, temperature and for any sign of chronic disease, for example lower limb edema and ascites. Local examination: For breast lump to assess its size, shape, consistency, and its relation to the surrounding tissues.

Preoperative laboratory assessment included complete blood picture, random blood sugar, liver function tests, kidney function tests, and serum electrolytes were done. Preoperative radiological assessment included bilateral breast mammography and ultrasound in addition to chest plain radiograph. True-cut biopsy was done on all cases.

Surgical technique

Preoperative guidelines

Cross-matched blood was available for transfusion during or after the operation if needed.Consent of mastectomy from the patient was taken.The site of carcinoma was marked.

Operative steps

Under general anesthesia the patient was placed in supine position. Skin ellipse was marked. Skin incision usually lies transversely and away from lesion and the nipple by ∼5 cm all around. Elevation of the skin flaps in the plane between subcutaneous fat and mammary fat was done either by electrocautery, conventional scalped, or by using harmonic scalpel (distributed randomly among the patients in this study). The assistant hold up the skin flaps with Allis forceps and every few cuts the flaps were checked as they must not be too thin or too thick with the breast tissue left behind the flaps. The upper flap was raised to the upper limit of the breast. This usually is 2–3 cm below the clavicle and the lower flap was raised to the lower limit of the breast and appearance of rectus sheath. Dissection was extended medially to the medial end of the breast and appearance of the sternum and extended laterally to see the anterior border of the latissmus dorsi muscle. Any bleeding vessels was caught with fine forceps and ligated. Dissection of the breast was done to remove it from medial to lateral in the plane between the breast and the pectoralis major muscle. The axillary tail of the breast was removed in continuity with axillary contents. The axillary tail of the breast and axillary contents were cleared from the lateral border of the pectoralis major muscle and from the anterior border of the latissmus dorsi. The pectoralis minor muscle was retracted to identify the axillary vessels. Dissection of axillary contents was done anterior and inferior to the axillary vessels with preservation of the thoracodorsal bundle (nerve and vessels) and of the nerve to the serratus anterior. The breast and axillary contents were sent as one specimen for histopathology. Good hemostasis before closure was done.

Closure

Insertion of vaccum drains was done and subcutaneous interrupted sutures were done. Suturing of the skin edges was performed with subcuticular sutures. After complete suturing of the wound, the vaccum drains were activated.

The breast dissection was done by three different tools either by electrocautery, conventional scalpel or by using harmonic scalpel which were chosen randomly. The pressure garment application in this study was achieved by multiple large-sized crepe bandages which surround the chest wall and the axilla over the wound dressing as early as possible after the operation. In this study all drains were removed on day seven postoperatively. Weekly follow-up to detect seroma formation was done for all patients up to 2 months.

 Results



In this study, in 110 female patients, who have stage II breast cancer aged from 25 to 70 years, modified radical mastectomy was done after preoperative assessment. During modified radical mastectomy operations in this study the breast dissection was done by electrocautery in 42 patients, by conventional scalpel in another 42 patients, and by harmonic scalpel in the remaining 26 patients. All of them were selected randomly.

Postmastectomy seroma was detected in 15 cases (out of 110 cases after drain removed) with 13.6% of all cases ([Table 1]).{Table 1}

Breast dissection was done by electrocautery in 42 cases and there were 14 cases of seroma formation out of those 42 patients ([Table 2]).{Table 2}

Breast dissection was done by conventional scalpel in 42 cases (out of 110 patients), and there was only one case of seroma formation out of those 42 patients ([Table 3]).{Table 3}

Harmonic scalpel was used in breast dissection in the remaining 26 cases out of 110 patients who were chosen randomly (i.e. 42 cases with electrocautery, another 42 cases with conventional scalpel, and the last 26 cases with harmonic scalpel), and there was no seroma cases within those 26 patients of harmonic scalpel usage ([Table 4]) while there were 15 cases of seroma in the other 84 cases.{Table 4}

So it has been concluded that the breast dissection by electrocautery is a highly significant factor in the development of postmastectomy seroma, but the use of conventional scalpel or harmonic scalpel in breast dissection is not a significant factor in the prevention of postmastectomy seroma. The wound drains were removed on day 7 postoperatively. Crepe bandages were covering the chest wall and the axilla over the wound dressing as early as possible after the operation.

 Discussion



Breast cancer has remained the second leading cause of death among women worldwide over the past three decades [8]. Modified radical mastectomy is a procedure in which the entire breast is removed including the skin, areola, nipple, and most axillary lymph node [9]. Seroma formation is the most frequent complication seen after mastectomy [10].

The meticulous attention applied to techniques of breast surgery to minimize the leakage from dissected blood vessels and lymphatic, and to obliterate the dead space may reduce the incidence of seroma formation [11].

The reported incidence of seroma formation following mastectomy varies between 15 and 18% [2].

In the present study the seroma formation was detected in 15 cases (out of 110 cases) with 13.6% of all cases.

Niranjan et al. [12], did a study on 46 patients undergoing modified radical mastectomy to compare between electrocautery and harmonic scalpel use and it revealed that the use of electrocautery was associated with a high incidence of seroma formation.

The present study proved that the use of electrocautery in the dissection of breast skin flaps during modified radical mastectomy leads to increased incidence of seroma formation postoperatively as there were 14 cases of seroma seen with electrocautery use from 15 cases of seroma that have appeared in the all patients of this study (110 cases) with 93.3% and the resulting P value was less than 0.001 which means it is significant.

Porter et al. [13] did study 80 patients with breast cancer to compare between electrocautery and conventional scalpel usage in breast dissection and shown that there were 16 cases of breast seroma with electrocautery usage from 21 cases of seroma with 76%; thus they proved that the use of conventional scalpel is associated with lower incidence of seroma formation than with electrocautery usage.

This study has shown that the use of conventional scalpel in breast dissection during modified radical mastectomy was associated with less incidence of seroma formation postoperatively than with electrocautery use as there was one case of seroma with conventional scalpel usage from 15 cases of seroma that have appeared in all patients of this study (110 cases) with 6.7% and the resulting P value was 0.007 which means it is significant.

The usage of harmonic scalpel during mastectomy is believed to reduce the rate of seroma formation when compared with that of electrocautery [14].

The present study has revealed that the use of harmonic scalpel in breast dissection during modified radical mastectomy was an important factor in the prevention of postoperative seroma formation as no cases of seroma appeared in 26 cases in which harmonic scalpel was used with a P value of 0.046 which means it is significant.

It has been concluded from this study that the use of conventional scalpel during mastectomy is better than electrocautery as regards seroma formation and also the use of harmonic scalpel is better than conventional scalpel.

 Conclusion



The use of harmonic scalpel in breast dissection is better than electrocautery use as regards postmastectomy seroma formation. If the harmonic scalpel is not available, it is better to use the conventional scalpel in breast dissection instead of electrocautery.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Wooworth PA, Mc Boyle MF, Helmer SD, Beamer RL. Seroma formation after breast cancer surgery incidence an predicting factors. Am surg 2000; 66:444–450.
2Akinci M, Cetin B, Aslans SS, Kulacoglu H. Factors affecting seroma formation after mastectomy with full axillary dissection. Acta Chir Belg 2009; 109:481–483.
3Sakkary MA. The value of mastectomy flap fixation in reducing fluid drainage and seroma formation in breast cancer patients. World J Surg Oncol 2012; 10:8.
4Ten Wolde B, Van den Wilenberg FJH, Keemers-Gels ME, Palat F, Strobbe LJA. Quilting prevents seroma formation following breast cancer surgery: closine the dead space by quilting prevents seroma following axillary lymph node dissection and mastectomy. Ann Surg Oncol 2014; 21:802–807.
5Pogson CJ, Adwani A, Ebbs SR. Seroma following breast cancer surgery. Eur J Surg Oncol 2003; 29:711–717.
6Lopez M, Rimm E. Electro cautery usage disadvantages during mastectomy. Eur Surg Res 1998; 30:148–151.
7Kontos M, Kothaari A, Hamed H. Effect of harmonic scalpel on seroma formation following surgery for breast cancer: a prospective randomized study. J BUON 2008; 13:223–230.
8Jemal A, Siegel R, Ward E, Hao Y, Xu J, Murray T et al. Cancer statistic 2008–. CA Cancer J Clin 2007; 58:96.
9Loukas M, Tubbs RS, Mirzayan N, Shirak M, Stein Berg A, Shoja MM. The history of mastectomy. Am Surg 2011; 77:566–571.
10Kuma S, Lal B, Misra MC. Postmastectomy seroma; a new look into the aetiology of an old problem. J R Coll Surg Edinb 1995; 40:292–294.
11Gong Y, Xu J, Shao J, Cheng H, Wu X, Zhao D, Xiong B. Prevention of seroma formation after mastectomy and axillary dissection by lymph vessels ligation and dead space closure; a randomized trial. Am J Surg 2010; 200:352–356.
12Niranjan B, Anthana S. Comparative study of modified radical mastectomy using harmonic scalpel and electro cautery. Singapore med J 2003; 47:250–252.
13Porter KA, O’Conner S, Rimm E. Electro cautery as a factor in seroma formation following mastectiomy. Am J Surg 1998; 176:8–11.
14Khan S, Chawla T, Murtaza G. Harmonic scalpel versus electro cautery dissection in modified radical mastectomy: a randomized controlled trial. Ann Surg Oncol 2014; 21:808–814.