OPERATION: HERNIORRHAPHY (MCVAY REPAIR)

Operative Technique:

§ Patient supine under SAB

§ Asepsis- Antisepsis

§ Sterile drapes placed

§ Oblique/Transverse incision done on the skin between the anterior superior iliac spine and pubic tubercle and carried down to the subcutaneous tissue

§ Palpate for the location of the external inguinal ring

§ External Oblique aponeuroses identified, cut & opened up to the external inguinal ring

§ Place a clamp on both leaves of the external oblique aponeurosis and identify the ilioinguinal nerve

§ Intra op findings noted

§ Spermatic cord separated from the underside of the external oblique aponeurosis by sharp and blunt dissection

§ Pick up the cremasteric muscle and incised it longitudinally

§ Gently shell the cord from its surrounding cremasteric muscle

§ Identify the vas deferens

§ Hernial sac identified and isolated

§ Reduce any content of the hernial sac

§ Hernial sac ligated using purse string suture ligation using silk-0

§ Adequate relaxing incision in superomedial aspect of conjoint tendon

§ Break through inguinal floor beginning at the pubic tubercle

§ Identify Cooper’s ligament and skeletonize it

§ Identify sheath of femoral vein

§ Allis clamps on conjoint tendon and pull it down

§ Suture conjoint tendon to Cooper’s ligament with silk 0 interrupted sutures, beginning at the pubic tubercle and commencing laterally

§ Place a transition stitch midway between Cooper’s ligament and inguinal ligament

§ Place last suture between conjoint tendon and inguinal ligament at the level of the internal ring

§ Layer by Layer closure

§ Dry Sterile Dressing applied

§ Patient tolerated the procedure well

§ Post-op condition- stable

HERNIORRHAPHY (BASSINI REPAIR)

Operative Technique:

§ Patient supine under SAB

§ Asepsis- Antisepsis

§ Sterile drapes placed

§ Oblique/Transverse incision done on the skin between the anterior superior iliac spine and pubic tubercle and carried down to the subcutaneous tissue

§ Palpate for the location of the external inguinal ring

§ External Oblique aponeuroses identified, cut & opened up to the external inguinal ring

§ Place a clamp on both leaves of the external oblique aponeurosis and identify the ilioinguinal nerve

§ Intra op findings noted

§ Spermatic cord separated from the underside of the external oblique aponeurosis by sharp and blunt dissection

§ Pick up the cremasteric muscle and incised it longitudinally

§ Gently shell the cord from its surrounding cremasteric muscle

§ Identify the vas deferens

§ Hernial sac identified and isolated

§ Reduce any content of the hernial sac

§ Hernial sac ligated using purse string suture ligation using silk-0

§ Relaxing incision in superomedial aspect of conjoint tendon

§ Allis clamps on conjoint tendon

§ Suture conjoint tendon to inguinal ligament with silk 0 interrupted sutures

§ Tie the sutures snugly

§ Layer by layer closure done

§ Dry Sterile Dressing applied

§ Patient tolerated the procedure well

§ Post-op condition- stable

OPERATION: ADHESIOLYSIS

Operative Technique

§ Patient lying supine

§ Asepsis/antisepsis

§ Sterile drapes placed

§ Midline incision

§ Start new incision 3cm cephalad to upper margin of old incision

§ Carry skin incision through the middle of old scar and down to linea alba

§ Identify peritoneal cavity, then carefully incise the remainder of scar

§ After free abdominal cavity is entered and adherent segments of jejunum

were freed, remainder of incision carefully opened

§ Divide adhesions until entire anterior and lateral portion of abdominal wall and parietal peritoneum are free of underlying adhesions

§ Free the remainder of bowel of adhesions, from ligament of Treitz to ileocecal valve down to rectosigmoid junction by scissor dissection

§ Once the intestine has been freed, trace a normal-looking segment to the

nearest adhesion

§ Insert an index finger into the leaves of mesentery separating the two adherent limbs of the intestine

§ Decompress bowel and replace in the abdominal cavity

§ Irrigate abdominal cavity with saline solution

§ Close abdominal wall in usual fashion

§ Fascia à Vicryl 0, continuous interlocking

§ Skin & subcutaneous layer à silk 3-0, simple interrupted suture, reinforced by interrupted silk 0

§ Patient tolerated procedure well

OPERATION: CHOLECYSTECTOMY

Operative Technique

§ Patient supine under SAB

§ Asepsis- Antisepsis

§ Sterile drapes placed

§ Right Kocher incision done on the skin carried and down to the subcutaneous tissue

§ Rectus sheath cut and opened

§ Rectus abdominal muscle divided with electrocautery

§ Posterior rectus sheath picked up and cut

§ Peritoneum identified cut and entered

§ Pass a hand over the right lobe of the liver and pulled it down

§ Palpated gallbladder, confirming the presence of stones

§ Intra op findings noted

§ Gallbladder is grasp with forceps and retracted laterally

§ Put a finger into the foramen of Winslow and palpate the common bile duct for stones and the head of the pancreas for any mass

§ Sharp and blunt dissection on the peritoneum overlying the Calot’s triangle done

§ Cystic artery identified, clamped and suture ligated.

§ Cut the peritoneum overlying the fundus of the gallbladder and identify the blue submucosal space

§ Dissection of the gallbladder from the liver bed carried down to peritoneal reflection overlying the Calot’s triangle

§ Identify the common bile duct/cystic duct junction

§ Cystic duct identified, clamped, and suture ligated proximally and distally

§ Gallbladder removed

§ Hemostasis done

§ Peritoneal toilette done

§ Layer by layer closure

§ Dry Sterile Dressing applied

§ Patient tolerated the procedure well

§ Post-op condition- stable

OPERATION: CHOLECYSTECTOMY, IOC, CBDE, T-TUBE CHOLEDOCHOSTOSTOMY

Operative Techniques

§ Patient supine under SAB

§ Asepsis- Antisepsis

§ Sterile drapes placed

§ Right Kocher incision done on the skin carried and down to the subcutaneous tissue

§ Rectus sheath cut and opened

§ Rectus abdominal muscle divided with electrocautery

§ Posterior rectus sheath picked up and cut

§ Peritoneum identified cut and entered

§ Pass a hand over the right lobe of the liver and pulled it down

§ Palpated gallbladder, confirming the presence of stones

§ Intra op findings noted

§ Gallbladder is grasp with forceps and retracted laterally

§ Put a finger into the foramen of Winslow and palpate the common bile duct for stones and the head of the pancreas for any mass

§ Sharp and blunt dissection on the peritoneum overlying the Calot’s triangle done

§ Cystic artery identified, clamped and suture ligated.

§ Cut the peritoneum overlying the fundus of the gallbladder and identify the blue submucosal space

§ Dissection of the gallbladder from the liver bed carried down to peritoneal reflection overlying the Calot’s triangle

§ Identify the common bile duct/cystic duct junction

§ Two clamps placed with few mm apart from each other over the cystic duct and divide cystic duct in between the clamps

§ Gallbladder removed

§ A mosquito clamp applied on the anterior and posterior leaf of the cystic duct and release the previously placed clamp

§ Cystic duct opened a French 8 feeding tube inserted through the cystic duct opening

§ Another clamp placed snuggly over cystic duct and ligate the cystic duct with the feeding tube within its lumen

§ Intraoperative cholangiogram done.

§ Note for any filling defects

COMMON BILE DUCT EXPLORATION

§ Two fine silk 4-0 sutures are placed a few mm apart in its wall

§ The field entirely walled off with moist gauze packs

§ CBD opened using blade 12 about 1 cm, parallel to the long axis of the CBD

§ Exploration of the CBD done

§ Randall forceps inserted through the choledochostomy and retrieve any stones with in the CBD, as well as with in the intrahepatic ducts

§ Bakes dilator are passed through the papilla starting from the No. 3

§ A large catheter passed proximally and distally and flush the ducts with warm saline

§ Note for any debris or stones.

T-TUBE CHOLEDOCHOSTOMY

§ A French 16 T-tube catheter, with shortened arm and wedge is excised opposite the main stem, is inserted through the CBD incision

§ Opening in the CBD about the catheter is closed securely by simple interrupted

§ Test for any leak by infusing warm saline through the T-tube

§ A stab wound about the size of the t-tube created at the abdominal wall just over the underlying choledochostomy

§ T-Tube pass through the stab wound and secured

§ Peritoneal toilette done

§ Hemostasis done

§ Drain placed

§ Layer by layer closure

§ Dry Sterile Dressing applied

§ Patient tolerated the procedure well

§ Post-op condition- stable

OPERATION: CBDE, CHOLEDOCHODUODENOSTOMY

Operative Techniques

§ Patient supine under GA

§ Asepsis- Antisepsis

§ Sterile drapes placed

§ Right Kocher incision done on the skin carried and down to the subcutaneous tissue

§ External Oblique aponeuroses ,Anterior Rectus sheath identified, cut & opened

§ Muscle transection done

§ Posterior Rectus sheath identified cut and opened,

§ Peritoneum identified cut and entered

§ Intra op findings noted

§ Kocher Maneuver done to mobilized 2^nd portion of the duodenum

§ Common bile duct exploration

§ Choledochoduodenostomy

§ Suction drain placed

§ Peritoneal toilette done

§ Layer by layer closure

§ Skin closed by subcuticular sutures using vicryl 5-0

§ Dry Sterile Dressing applied

§ Patient tolerated the procedure well

§ Post-op condition- stable

OPERATION: DISTAL PANCREATECTOMY

Operative Technique

Patient lying supine

Asepsis/antisepsis technique done

Sterile drapes placed

Midline incision done

Explore the abdomen for metastatic deposits

Liberate omentum from its attachments to the transverse colon

Incise peritoneum covering the pancreas along the inferior border of its tail

Palpate tail and body of pancreas

Palpate splenic artery along upper border of neck of pancreas

Splenic artery identified clamped, divided and doubly ligate with silk 2-0

Divide splenorenal ligament

Divide pancreatic attachments between diaphragm and transverse colon

Elevate spleen and tail of pancreas from renal capsule by blunt dissection

Liberate spleen from greater curvature of stomach by dividing left gastroepiploic and short gastric vessels between ligatures of silk 2-0

Identify inferior mesenteric vein on its way to join splenic vein; then clamp, divide and doubly ligate with silk 2-0

Skeletonize splenic vein; clamp, divide and doubly ligate with silk 2-0

Splenic artery identify, clamp, cut and doubly ligate with silk 1-0

Divide pancreas at its neck with scalpel

Occlude transected pancreas with interlocking interrupted mattress sutures of silk 2-0

If the pancreatic duct is identified, occlude the duct with interlocking interrupted mattress sutures of silk 3-0

Insert a Jackson-Pratt drain at the site of divided pancreas and bring out through a stab wound in the right upper quadrant

Complete hemostasis

Layer by layer closure of the abdomen

a. Peritoneum and fascia closed as single layer using PG 0 continuous interlocking suture with interrupted silk 0 suture over the fascia every five continuous interlocking sutures

b. Subcutaneous tissue approximated using chromic 3-0 inverted T sutures

c. Skin closed by silk 3-0 interrupted sutures

Betadine

DSD

Patient tolerated procedure well

OPERATION: HERNIOPLASTY

Operative Technique

§ Patient supine under SAB

§ Asepsis- Antisepsis

§ Sterile drapes placed

§ Oblique/Transverse incision done on the skin between the anterior superior iliac spine and pubic tubercle and carried down to the subcutaneous tissue

§ Palpate for the location of the external inguinal ring

§ External Oblique aponeuroses identified, cut & opened up to the external inguinal ring

§ Place a clamp on both leaves of the external oblique aponeurosis and identify the ilioinguinal nerve

§ Intra op findings noted

§ Spermatic cord separated from the underside of the external oblique aponeurosis by sharp and blunt dissection

§ Pick up the cremasteric muscle and incised it longitudinally

§ Gently shell the cord from its surrounding cremasteric muscle

§ Identify the vas deferens

§ Hernial sac identified and isolated

§ Reduce any content of the hernial sac

§ Hernial sac ligated using purse string suture ligation using silk-0

§ Prolene mesh, placed under spermatic cord, 3-4 cm larger than the defect

§ Prolene mesh sutured with silk 2-0 with the used of interrupted mattress around the perimeter of the defect, penetrating the anterior rectus sheath, rectus muscle, and transversalis fascia along medial aspect. Along the lateral margin of the defect, it was sutured to the poupart’s ligament going from the pubic tubercle laterally to the region of femoral canal

§ Layer by Layer closure

§ Dry Sterile Dressing applied

§ Patient tolerated the procedure well

§ Post-op condition- stable

OPERATION: HERNIOTOMY

Operative Technique

§ Patient supine under SAB

§ Asepsis- Antisepsis

§ Sterile drapes placed

§ Oblique/Transverse incision done on the skin between the anterior superior iliac spine and pubic tubercle and carried down to the subcutaneous tissue

§ Palpate for the location of the external inguinal ring

§ External Oblique aponeuroses identified, cut & opened up to the external inguinal ring

§ Place a clamp on both leaves of the external oblique aponeurosis and identify the ilioinguinal nerve

§ Intra op findings noted

§ Spermatic cord separated from the underside of the external oblique aponeurosis by sharp and blunt dissection

§ Pick up the cremasteric muscle and incised it longitudinally

§ Gently shell the cord from its surrounding cremasteric muscle

§ Identify the vas deferens

§ Hernial sac identified and isolated

§ Reduce any content of the hernial sac

§ Hernial sac ligated using purse string suture ligation using silk-0

§ Layer by Layer closure

§ Dry Sterile Dressing applied

§ Patient tolerated the procedure well

OPERATION: HEPATECTOMY

Operative Techniques

Patient lying supine

Asepsis/antisepsis technique done

Sterile drapes placed

Bilateral subcostal incision

Perihepatic adhesions divided

Mobilize liver from hepatic flexure

Liver mobilized fully by division of its ligamentous attachments

Divide ligamentum teres hepatis and incise falciform ligament

Gastrohepatic omentum is divided

Foramen of Winslow is exposed

Cholecystectomy

Lobar hepatic artery is ligated initially

Pericholedochal lymph nodes excised, further exposing bile duct, portal vein, and hepatic artery

RIGHT LOBECTOMY

o Right lateral aspect of hepatoduodenal ligament incised longitudinally posterior to the bile duct

o Divide gastrohepatic omentum

o Right hepatic artery occluded temporarily while left hepatic artery palpated to ensure patency of arterial supply to liver remnant. Once appropriately confirmed, right hepatic artery doubly ligated with silk 1-0 and divided

o Lymphatic vessels around hepatic artery ligated

o Expose portal vein bifurcation

o Right portal vein exposed from right of the hepatoduodenal ligament

o Right lobar portal vein branch freed from surrounding lymphoareolar tissue and ligated with a running vascular suture after division between clamps

o Multiple small short hepatic veins between inferior vena cava and segments 1, 6, and 7 are ligated

o Expose the main right hepatic vein

§ Divide retrocaval ligament bridging segments 1 and 7

§ Main right hepatic vein is then dissected from the inferior vena cava and liver

o Transect right hepatic vein with running silk 1-0 suture

o Parenchyma transected on the line of vascular demarcation along the principal plane

o Smaller bile ducts or vessels are doubly ligated on the resection side of liver and are ligated on the remnant side

o Middle hepatic vein is ligated during the parenchymal resection

o Lobar bile ducts to the lobe being resected are exposed

o Parenchyma of caudate process transected to expose the anterior surface of the inferior vena cava

o Remove right lobe of liver

o Hemostasis and bile stasis are obtained in the hepatic remnant

o Suction drain placed adjacent to transected liver surface and brought out through the abdominal wall

o Abdomen is closed

OPERATION: REPAIR OF UMBILICAL HERNIA

Operative Techniques

§ Patient supine under CLEA

§ Asepsis and Antisepsis done

§ Sterile drapes placed

§ Midline incision carried down from skin to sac

§ Dissection of skin away from the sac on each side until the area of hernial ring itself has been exposed in its entire circumference

§ Dissection was continued until the anterior muscle fascia of at least 2cm width was exposed around entire circumference of hernial defect

§ Incision was made along the apex of hernial sac, opening it and then separating adhesion between the sac and omentum and small bowel

§ Resection of hernial sac done

§ Reduction of hernial sac contents into the abdominal cavity done

§ Adhesion around the entire circumference of hernial ring was freed

§ Closure of the fascia done transversely using silk 0 using horizontal mattress

§ Hemostasis

§ Correct count

§ Drain applied

§ Closure of subcutaneous fat using chromic 2-0 simple interrupted

§ Closure of skin done using silk 3-0 simple interrupted

OPERATION: SPLENECTOMY

Operative Techniques

§ Patient lying supine

§ Asepsis/antisepsis

§ Sterile drapes placed

§ Midline incision from xiphoid to infraumbilical area

§ Divide gastrocolic omentum

§ Divide and ligate the left gastroepiploic vessels

§ Clamp and ligate splenic artery with 2‑0 silk

§ Mobilizing the Spleen

§ Dissect tail of the pancreas from the posterior wall of the splenic artery and vein

§ Identify previously ligated splenic artery and ligate it again near the hilus, leaving sufficient stump of splenic artery. Then divide the splenic artery.

§ Divide the splenic vein near its juncture with the superior mesenteric vein between ligatures of silk 2-0

§ Remove the spleen

§ Search area of pancreatic tail, kidney, gastrosplenic ligament, omentum, small and large bowel mesentery, and pelvis for accessory spleens

§ Complete and meticulous hemostasis

§ Irrigate upper abdomen with saline solution

§ Closure in layers

OPERATION: CHOLECYSTECTOMY, IOC, CBDE, T-TUBE CHOLEDOCHOSTOSTOMY

Operative Techniques

§ Patient supine under SAB

§ Asepsis- Antisepsis

§ Sterile drapes placed

§ Right Kocher incision done on the skin carried and down to the subcutaneous tissue

§ Rectus sheath cut and opened

§ Rectus abdominal muscle divided with electrocautery

§ Posterior rectus sheath picked up and cut

§ Peritoneum identified cut and entered

§ Pass a hand over the right lobe of the liver and pulled it down

§ Palpated gallbladder, confirming the presence of stones

§ Intra op findings noted

§ Gallbladder is grasp with forceps and retracted laterally

§ Put a finger into the foramen of Winslow and palpate the common bile duct for stones and the head of the pancreas for any mass

§ Do an extensive Kocher Maneuver, continued up to the third portion of the duodenum almost as far as the point where the superior mesenteric vein crosses the anterior wall of the duodenum

§ Intraoperative cholangiogram done.

COMMON BILE DUCT EXPLORATION

§ Two fine silk 4-0 sutures are placed a few mm apart in its wall

§ The field entirely walled off with moist gauze packs

§ CBD opened using blade 12 about 1 cm, parallel to the long axis of the CBD

§ Exploration of the CBD done

§ Milk down any possible stones from the common hepatic duct into the choledochotomy incision

§ Perform the same maneuver on the distal CBD

§ Pass a Randall stone forceps of the appropriate size up into the right and the left main hepatic ducts

§ Pass a Randall stone forceps down to the region of the ampulla

§ Irrigate both the hepatic ducts and the distal CBD with normal saline solution using a Fr.16 NGT

§ Pass a No. 3 Bakes dilator through the ampulla. Elicit a “steel” sign.

SPHINCTEROTOMY/SPINCTEROPLASTY

§ Pass a Fr.8 feeding tube or a No. 4 Bakes dilator into the choledochotomy incision and down to the distal CBD, making sure you do not pass it into the duodenum

§ Palpate tip of the tube or the Bakes dilator through the anterior wall of the duodenum

§ Make a 4-cm incision in the lateral wall of the duodenum opposite the ampulla

§ Make a 10-mm incision through the anterior wall of ampulla at 11o’clock position

§ Explore distal CBD through the sphincterotomy incision

§ Do a complete sphincteroplasty

§ Place two 4-0 silk sutures on each lateral side of partially incised ampulla

§ Identify orifice of the pancreatic duct, which enters the back wall of the ampulla and avoid injuring or traumatizing it

§ Continue incising the ampulla for about 3mm at a time followed by placement of 4-0 silk interrupted sutures, suturing the duodenal mucosa to the mucosa of the ampulla

§ Place a figure-of-eight silk 4-0 suture at the apex of the sphincterotomy

§ Close duodenotomy in 2 layers by inverting mucosa with a continuous Connell suture and the seromuscular layer by interrupted 4-0 silk Lembert sutures

§ Cover the duodenotomy with omentum

T-TUBE CHOLEDOCHOSTOMY

§ A French 16 T-tube catheter, with shortened arm and wedge is excised opposite the main stem, is inserted through the CBD incision

§ Opening in the CBD about the catheter is closed securely by simple interrupted

§ Test for any leak by infusing warm saline through the T-tube

§ Bring T-tube out through a stab wound near the epigastric area

§ Suture the T-tube to the skin, leaving enough slack between the CBD and the abdominal wall

§ Peritoneal toilette done

§ Do cholecystectomy

§ Hemostasis done

§ Drain placed

§ Layer by layer closure

§ Dry Sterile Dressing applied

§ Patient tolerated the procedure well

§ Post-op condition- stable

OPERATION: CHOLEC

Operative Techniques

§ Patient supine under SAB

§ Asepsis- Antisepsis

§ Sterile drapes placed

§ Right Kocher incision done on the skin carried and down to the subcutaneous tissue

§ Rectus sheath cut and opened

§ Rectus abdominal muscle divided with electrocautery

§ Posterior rectus sheath picked up and cut

§ Peritoneum identified cut and entered

§ Pass a hand over the right lobe of the liver and pulled it down

§ Palpated gallbladder, confirming the presence of stones

§ Intra op findings noted

§ Gallbladder is grasp with forceps and retracted laterally

§ The peritoneal reflection of the ampulla identified and incised

§ Common bile duct identified

§ Intra-op findings noted

§ Two fine silk 4-0 sutures are placed a few mm apart in its wall

§ The field entirely walled off with moist gauze packs

§ CBD opened using blade 12 about 1 cm, parallel to the long axis of the CBD

§ Exploration of the CBD done

§ Stone removal done

§ Patency of the duct and papilla identified

§ A catheter inserted and flush the ducts with warm saline, first towards the liver then downward towards the duodenum

§ A French 16 T-tube catheter, with shortened arm and wedge is excised opposite the main stem, is inserted through the CBD incision

§ Opening in the CBD about the catheter is closed securely by simple interrupted

§ Test for any leak by infusing warm saline through the T-tube

§ Drain placed

§ Hemostasis done

§ Peritoneal toilette done

§ Layer by layer closure

§ Dry Sterile Dressing applied

§ Patient tolerated the procedure well

§ Post-op condition- stable

MODIFIED RADICAL MASTECTOMY

Steps

A. Planning of Skin Incision

B. Creation of Skin Flaps ( Inferior and Superior)

C. Mastectomy Proper

D. Axillary Dissection

E. Skin Closure

A. Planning of Skin Incision

Execution

1. Localize and palpate the mass and mark its border with gentian violet using the tip of the cotton pledget.

2. Make a two cm margin circumferencially around mass and mark it accordingly.

3. Elliptical incision will be dependent on the following:

a. Should include the nipple-areolar complex

b. Should include the two cm margin of the mass

c. Should be cosmetically acceptable postoperatively

Execution:

· To determine if able to close primarily

1. Draw all the possible elliptical incision combinations by drawing a straight line crossing the central portion of the mass.

2. Connect the two ends of the line by drawing a ellipse equidistant to each other. Make sure that the two cm border and nipple areolar complex are within the ellipsoid.

3. Try to appose margins of superior and inferior lines of planned incision if able to meet at an imaginary midline.

· The ellipsoid could either be oriented transversely or obliquely towards the axilla.

· We recommend an oblique orientation for cosmetic purpose. This orientation has less tendency for keloid formation specifically over the medial part of the chest wall.

4. Once these concerns are executed, start of operation can be carried out.

5. Skin incision is done along previously outlined margins

6. Knife oriented perpendicularly to skin down to subcutaneous then beveling to superficial fascial layers of dermis.

7. Point electrocauterization of bleeding points along skin margins is done to minimize trauma and blood loss.

8. Subdermal skin incision ( less bloody) is done along the medial tip of the inferior ellipse towards its lateral end on the axilla. Thereafter cautery will be used to create the flaps.

9. The same technique is used on the superior elipse incision.

B. Creation of inferior and superior flaps

1. Inferior flap is created first using the cautery pen. Borders of dissection are lateral border of sternum medially, inframammary fold inferiorly, and lateral border of latissimus dorsi muscle.

2. Once a 1 cm thickness is achieved, beveling technique is executed to facilitate good skin closure.

3. We use the left hand to hold the flap because it provides gentle tissue handling and good flap control. Application of allis forceps subdermally will result to tissue ischemia and necrosis postoperatively. On the other hand, breast clamps are not readily available.

4. Creation of flaps is executed from medial to lateral. Identification of the medial border (sternal border), superior border (subclavius, not always the case because sometimes primary skin closure can be done without reaching the subclavius), inferior border (???), and lateral border (latissimus dorsi) should be done.

5. care should be taken during the dissection of the lateral border. This step should be limited to the medial border of the latissimus dorsi to avoid injury to the thoracodorsal and long thoracic nerves.

6. Bleeding vessels can be stopped using cautery. Application of curve mosquitos (pointing upward) to bleeding vessels is acceptable.

7. The same technique is used when creating the superior flap.

C. Mastectomy Proper

1. This is executed from the medial side of the specimen towards the axilla. this is the most easy way of starting this step. Medial border of dissection is the sternal border.

2. Pectoralis major fascia should be included in the specimen. If the mass invades the fascia or pectoral muscle, muscle can be trimmed or removed.

3. Medially, perforator vessels are encountered during this step. Vessels less than 2 mm can be controlled by cauterization. Ligation is not recommended. In the area towards the axilla, over the tail of the pectoralis major muscle, nerves(????) are encountered. We suggest these nerves be preserved.

4. An alternating removal of the breast tissue superiorly and inferiorly is done.

D. Axillary Dissection

1. once removal of the specimen reaches the axilla, the clavipectoral fascia is cut open.

2. intercostobrachial nerves should be preserved as much as possible. However, if it will hinder axillary node dissection, it can be sacrificed.

3. direct branches of the axillary vein must be ligated.