Microdochectomy / major duct excision (Hadfield)

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

• loss of breastfeeding from the operated breast (certain after total duct excision, possible after microdochectomy)
• numbness of the nipple and areola
• nipple inversion or flattening
• necrosis of nipple or areolar skin
• haematoma and wound infection
• discharge for a few weeks after surgery
• recurrence of discharge or abscess, or mammary fistula
• cancer may be found on histology

Pre-operative details for this operation

1. Side and discharge detailsbreast, single or multiple ducts, o'clock position of the duct opening, spontaneous or on pressure, colour (bloody, clear, other)
2. Imagingmammogram and ultrasound findings, dilated duct, intraductal nodule, other lesions, ductogram or ductoscopy if done
3. Cytology / core biopsyresult if done
4. Operation plannedMicrodochectomy (single duct)Total (major) duct excisionDuct excision with excision of mammary fistulareason for the choice: wish to breastfeed in future, age, single or multiple ducts
5. Localisation of a non-palpable lesionNot neededWireRadioactive seed
6. Patient toldno breastfeeding from that breast after total excision, possible malignancy on HPE, discharge may continue for a few weeks
7. Antiplatelets / anticoagulants stoppeddrug and date

Anaesthesia and position

1. AnaesthesiaGeneralGeneral with local infiltrationLocal (field block)local agent not injected into the duct area itself
2. PositionSupine, ipsilateral arm on arm board
3. Areolar border marked before prepYes

Operative findings

1. Discharge expressed in OTo'clock position and colour
2. Duct cannulatedYes, lacrimal probe passed (depth)Could not be cannulated
3. Duct appearancedilated, discoloured contents, nodule felt within the duct, size
4. Other nodulesin the nipple dermis or the wound after excision
5. Pus or fistula tractNonePresent (describe)

Procedure (steps)

1. Nipple squeezed and discharging duct cannulatedfine lacrimal duct probe, no force
2. IncisionCircumareolar at inferior areolar borderCircumareolar at the o'clock position of the ductRadial ellipse including fistula or old scarlength as fraction of areolar circumference (not more than half)
3. Areolar flap raisedplane under the areolar smooth muscle, some fat left on the flap
4. Duct(s) identified around the probedissection kept narrow towards the nipple
5. Duct(s) divided under the nippleSingle duct ligated and dividedWhole duct bundle encircled and dividedfine absorbable ligature at the nipple end, cautery on low cutting setting
6. Wedge of tissue excised with the duct(s)depth excised (e.g. 3 to 5 cm), distal duct end ligated
7. Specimen orientedmarker stitch and what it marks
8. Cavity and nipple palpated for residual nodules
9. Haemostasis

Closure, drains and dressing

1. Deep tissue under the nippledefect closed to prevent nipple retraction, suture used
2. Purse-string at nipple baseNot neededPlaced (suture)
3. Skintwo layers: buried deep dermal absorbable sutures, then intradermal suture, areolar edge level with or slightly above breast skin
4. DrainNoneSmall Penrose drain (pus found)
5. Dressingno pressure on the nipple, donut-shaped dressing if pressure is needed

Specimens and implants

1. Duct(s) sent for HPEoriented, with marker stitch, side and o'clock position on the form
2. Pus for cultureSentNot applicable
3. Localisation wire or seed retrievedNot usedRetrieved with specimen

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. Woundkeep clean and dry, shower allowed
2. Nippleno tight clothing on the nipple, donut foam dressing if needed
3. Watch for haematomaswelling under the areola
4. Analgesiadrug, dose, frequency
5. Discharge after surgerysome discharge in the first few weeks is expected
6. Stitchesremove nipple skin sutures at 1 week if non-absorbable
7. Smokingadvise stopping (for duct ectasia and periductal mastitis)
8. Follow-upOPD with HPE report, plan depends on histology

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