Lobar Resection Under Ultrasound Guide

Abstract

In this chapter, we reported the experience of more than 40 years of use of interventional procedures guided by ultrasound which started in 1974 and stressed for surgical procedures considering the ultrasonic transducer as the third hand of the surgeon. The principle of breast surgical resection is based on the concept that the breast is not one gland but many, each with its own central milk-collecting duct in the nipple and several orders of branching tributary ducts draining the secretory glandular tissue. Each of the major ducts represents the anatomical element of every single breast lobe surgically identified as sector or segment; breast lobes are 15–20 as many as the ducts and that breast diseases are diseases of the epithelium of the ducts and finally a lobar disease (Townsend and Craig, Clin Symp 32(2): 1–30, 1980).

Consequently, understanding the need to strictly follow the lobar anatomy of the breast during the surgery and understanding the lobar nature of breast carcinoma, we started to systematically perform ultrasound examination in a radial and antiradial fashion before each operation in order to visualize the ductal system along the major axis and, using a special draft, indicating every lesion in clockwise fashion with all parameters achievable by ultrasound (Amy et al., J Med Ultrasonics 42:331–339, 2015; Amy, Breast cancer, a lobar disease. New York, NY: Springer, 2011; Jellins et al., Med J Aust 1:305, 1971; Jellins et al., Ultrasound Med Biol 1:393–404, 1975; Kikuchi et al., J Acoust Soc Am 29(7):824–833, 1957; Kobayashi, Japan J Clin Oncol 4(2): 145–158, 1974; Wild and Neal, Lancet 1:655–657, 1951; Wild and Reid, Am J Pathol 28:839–861, 1952).

The advances made in high-frequency ultrasound transducer technology have led to considerable improvements in two-dimensional and three-dimensional grayscale imaging of the breast allowing a well-defined anatomy and pathology and numerous parameters for an adequate staging and correct selection for more convenient surgical procedure oncologically radical, and anatomically correct. The experience of the author is based on 1582 cases from 1988 to 2010 with a follow-up from 6 to 28 years. Surgical planning with ultrasound involves drawing on the skin the extent of resection, according to the lobar anatomy, and deciding on the most advantageous incision using the Langer’s lines. Parameters used to plan surgery are the site of tumor, its dimensions, breast thickness, and the distances from the skin, fascia, and nipple. Ultrasound examination of the excised specimen allows the surgeon to assess the completeness of excision by measuring the distances between the lesion and antiradial margins. Experience suggests that surgeon-performed intraoperative ultrasound is a cost-effective and practical procedure.