Surgical treatment is still one of the main treatments for breast cancer. There are many kinds of surgical operations, but there is still no consensus on their choice. The general development trend is to minimize surgical injuries and preserve the breast morphology of patients with early breast cancer as far as possible when the equipment conditions permit. No matter what kind of operation you choose, you should strictly master the principle of radical treatment, supplemented by preserving function and appearance.

(1) operation indication

Radical mastectomy initiated by halsted, because of its reasonable operation and clear curative effect, has become the standard way for people to treat breast cancer in recent hundred years. In the past half century, many exploratory modifications have been made to breast cancer surgery, and the general trend is nothing more than conservatism and expansion, which is still controversial. Local mastectomy and total mastectomy are typical conservative operations. Postoperative radiotherapy is needed, and the radiation dose varies, generally 30 ~ 70 Gy, which can obtain better curative effect for strictly selected localized early cancer. However, it is difficult to draw a conclusion whether it is the routine treatment of early breast cancer and how to accurately choose this early cancer.

(2) contraindication of operation

1. General contraindications: ① distant metastasis of tumor. (2) The elderly and infirm cannot tolerate surgery. (3) Generally poor, showing poor liquid. (4) Patients with major organ dysfunction who cannot tolerate surgery.

2. Contraindications to local lesions: One of the following conditions occurs in patients with stage III: ① Orange peel edema of breast skin exceeds half of breast area; ② Satellite nodules appeared in breast skin; ③ Breast cancer invaded the chest wall; ④ Clinical examination showed that parasternal lymph nodes were enlarged and metastasis was confirmed; ⑤ Edema of the affected upper limb; ⑥ Supraclavicular lymph nodes were pathologically confirmed as metastasis; ⑦ Inflammatory breast cancer. There are two of the following five situations: ① tumor rupture; (2) The celluloid edema of breast skin accounts for less than1/3 of the total breast area; ② Cancer and fixation of pectoralis major; ④ The maximum diameter of axillary lymph nodes is larger than 2.5cm；; ⑤ Axillary lymph nodes adhere to each other or to skin and deep tissues.

(3) Mode of operation

1. Radical mastectomy: In 1894, halsted and Meg respectively published the surgical principles of radical mastectomy:

① The primary focus and regional lymph nodes should be removed together;

② Excision of all mammary glands and large and small muscles;

③ Radical axillary lymph node surgery.

Haagensen improved radical mastectomy, emphasizing that the operation should be particularly thorough, mainly including:

① Carefully peel off the flap;

② After the flap was completely separated, pectoralis major and pectoralis minor were cut off from the chest wall and turned outwards;

③ The length and diameter of the chest should be preserved in the anatomy of the armpit. If there are no obvious swollen lymph nodes in the armpit, the thoracic dorsal nerve can also be preserved.

④ All chest wall defects should be grafted with skin.

The common complications in the operation are:

① Injury of axillary vein: It is mostly caused by unclear dissection of fat and lymphatic tissue around axillary vein, or because it is too close to the trunk of axillary vein when cutting off the branches of axillary vein. Therefore, it is very important to clearly expose and retain the broken heads of several branches.

② Pneumothorax: When the rib ends of pectoralis major and pectoralis minor are cut off, sometimes the small vessels in the chest wall are clamped through the branches, and the lower clamp is too deep, resulting in the rupture of intercostal muscles and pleura, resulting in tension pneumothorax. Postoperative complications include: ① subcutaneous effusion: most of them are caused by poor skin graft fixation or poor drainage. It can be prevented by repeated suture and fixation between subcutaneous and chest wall tissues and continuous negative pressure drainage. ② Necrosis of skin graft: Too tight skin suture and too thin skin graft can be the causes. When there are many skin defects, skin grafting should be used.

③ Edema of the affected upper limb. The limited elevation of the affected upper limb is mainly caused by decreased postoperative activity and subcutaneous scar traction. Therefore, it is required to carry out functional exercise as soon as possible after operation, which can basically reach the level of lifting within one month after operation.

2. Extended radical mastectomy: Extended radical mastectomy includes radical mastectomy, that is, radical mastectomy and internal mammary lymph node dissection, that is, excision of 1-4 intercostal lymph nodes, and the second, third and fourth costal cartilages need to be removed. There are intrapleural methods and extrapleural methods. The former has great trauma and many complications, and the latter is often used.

3. Pseudo-radical surgery (modified radical surgery): mainly used for non-invasive cancer or stage I invasive cancer. If there is no obvious axillary lymph node enlargement in the second stage, it can also be used.

(1) Type I: Preserve pectoralis major and pectoralis minor. The principle of skin incision and flap separation is the same as radical operation. First, total mastectomy (fascia resection of pectoralis major surgery) is performed, and the whole breast is dissected to the axillary side, and then axillary lymph nodes are removed. The scope of resection is basically the same as that of radical operation. The holy word on the chest should be preserved. Finally, the whole breast and axillary lymphatic tissue were removed in one piece.

(2) Type Ⅱ: Preserve pectoralis major and remove pectoralis minor. Skin incision and other steps are the same as before. After the breast is free to the outer edge of pectoralis major, the attachment points of the 4th, 5th and 6th ribs of pectoralis major are cut off and turned upward to expand the operation field, and the attachment points of pectoralis minor are cut off at the coracoid process of scapula. The following steps are the same as radical operation, but attention should be paid to preserving the thoracic nerve and accompanying blood vessels. Finally, the whole breast, pectoralis minor muscle and axillary lymph tissue were removed in one piece.

4. Simple mastectomy: As an ancient operation, it was once replaced by radical mastectomy. In recent years, with the development of breast cancer biology, total mastectomy has attracted people's attention again. Indications: 1. Early cases of non-invasive or axillary lymph node metastasis can be treated without radiotherapy after operation. Second, simple resection and radiotherapy were performed for locally advanced breast cancer. Judging from the increasing demand for cosmetic surgery, total mastectomy still needs complicated breast reconstruction. Is it not suitable for young and middle-aged women in the early stage of illness? Therefore, its main indications should be limited to the elderly or some advanced cases that can only be palliative resection.

5. Less surgery than total mastectomy: In recent years, due to the progress of radiotherapy equipment, lesions were found earlier than before, and patients' requirements for postoperative quality of life improved, so many conservative surgical methods less than total mastectomy were reported. Surgical methods range from local excision to L/4 mastectomy, and some operations are supplemented by radiotherapy.

Breast-conserving surgery is not suitable for all breast cancer cases, nor can it replace all radical surgery, but an improved way of breast cancer treatment, and attention should be paid to avoiding local recurrence. Indications are: ① the tumor is small, which is suitable for clinical T 1 and partial T2 (less than 4 cm) lesions; ② Peripheral tumors located under areola are often inappropriate; ③ Single lesion; ④ The tumor boundary is clear, and it is often inappropriate for the naked eye or microscope to see the tumor boundary clearly; ⑤ There is no definite metastasis in axillary lymph nodes. The therapeutic effect is related to the following factors: ① the tumor margin must have a normal boundary, and if there is enough normal tissue at the margin, the prognosis will be better; ② The size and histological grade of the primary tumor; (3) Postoperative radiotherapy. If postoperative radiotherapy is not performed, the local recurrence rate is high.