Avoidance and management of complications of breast surgery

Documentation and audit

Clear and contemporaneous documentation of patient details, clinical findings, disease characteristics and discussions regarding options for management (both with the patient and with the multidisciplinary team) is crucial for safe patient management and for demonstrating this in the case of queries. Consent for procedures is not an event performed on the morning of surgery but an evolving process usually involving at least a couple of meetings with the patient involving the surgeon and breast care nursing team prior to the date of surgery. It is important to document the discussion of treatment risks and options (including no treatment) with the patient. Standard patient information sheets, diagrams, videos and consent forms listing potential complications are useful aids to the consent process.

All breast surgeons should routinely participate in audit of their practice. For common procedures this is often done against established standards. National audits of cancers detected by breast screening exist in the UK and of breast cancer management in Scotland. Particular care should be taken with new procedures or procedures performed using new techniques or materials. Ideally audit in these circumstances should be performed using common parameters on a national or international basis but, in the absence of these, local audit is crucial. Registries exist in some countries for implanted materials such as breast implants, and surgeons should submit relevant cases.

Audit results should be discussed regularly in an open forum with the emphasis on learning from any issues. National reporting mechanisms exist for issues with new materials and drugs and these should be used where appropriate. Where shortfalls have been noted in the care of patients in the diagnostic or treatment process, these should be discussed with the patient (duty of candour) with restorative action taken where necessary for the patient and to ensure any system issues contributing to the event have been addressed.

Postoperative complications

Breast surgery is generally extremely safe. Patients are usually mobile and do not suffer significant periods of fasting. The physiological impact of breast surgery is therefore less than surgery to some other areas of the body. This allows a high rate of day case surgery. However, the surgical and anaesthetic team can help further minimise the physiological impact of surgery. Clear information about the hospital environment and planned surgery should be given. Preemptive analgesia and paravertebral blocks should be considered. Intraoperative blood loss should be minimised and warming should be maintained. The risk of thromboembolism following breast surgery seems to be less than for surgery to many other systems. Debate continues on the necessity for routine thromboprophylaxis for patients undergoing breast surgery. Indeed the risk of postoperative bleeding probably exceeds the risk of thromboembolism for most patients. In our practice the use of compression stockings and intraoperative calf compression is routine for all patients. Medical thromboprophylaxis is not used in day case surgery unless the patient is at particular risk. Those where at least an overnight stay is expected, such as those having mastectomy, axillary node clearance and reconstructive surgery, are given prophylactic unfractionated or low-molecular-weight heparin. Consideration should be given to the use of tranexamic acid in reconstructive or revisional breast surgery where significant blood loss is anticipated. Patients should be provided with contact details on discharge to access advice and support if required.