Position: Supine
Time: 1-2 hours (average)
Blood Loss: Moderate (50 – 200 ml)
Post-op Pain: Moderate (3-6)
Maintenance Paralytic: Ask surgeon

Approach – General with ETT tube is the most common. LMA can be utilized for short procedures.

Surgeon communication is key – Some surgeons are absolutely against paralytics because they interfere with general nerve testing and nerve reactions to the cautery, which tells the surgeon that he/she is close to major nerves. You’ll want to ask the surgeon their preferences! Low-dose rocuronium can provide good surgical conditions during the mastectomy and will typically be metabolized enough when the time comes for an axillary node dissection. Communicate twitches and reversal (if given) to the surgeon at the phase of axillary node dissection.

Intraoperative Stimulation – This is a very stimulating surgery, so be ready with your analgesics.

Repeat mastectomies – Many of these patients will be repeat mastectomies, so be sure to check the record and avoid any sides that have had axillary lymph node dissection. DO NOT put BP cuff or IV in the ipsilateral arm of the affected side if axillary lymph nodes have been or will be dissected.

Axillary lymph node dissection – If Axillary lymph node dissection is planned, avoid BP and IV application to the ipsilateral side. Because the surgeon will be testing nerve function on the ipsilateral side, be especially careful with long-term paralytics. Sometimes Succinylcholine is used for a quick induction, but longer-acting paralytics (e.g. rocuronium) should not be used, or should be used judiciously through the case and reversed at this phase.

Breast Implants – Always consider the possibilities of a breast implant procedure immediately after the mastectomy – which will add a substantial amount of time to the case.