Partial Mastectomy (Lumpectomy) Utilizing Savi Scout for a Nonpalpable Papilloma

CHAPTER 1

Hello all. My name is Thais Fortes. I am a breast surgeon working at University of Michigan Health-Sparrow in Lansing, Michigan. And today we're going to do a breast lumpectomy on a 46-year-old patient that presented to me with a nipple discharge. We did the workup with mammogram, ultrasound, and biopsy, and the results were consistent with papilloma. Patient elected to have it removed because of the discomfort associated with her constant discharge. The procedure that we're gonna perform is called a lumpectomy. Because the lump in her breast is not palpable, we had a radio frequency device called the Savi Scout placed on the center of the lump, and that's what's gonna guide the procedure. It's a quick surgery, about 40 minutes. It can be done under sedation and local anesthetic, and that's what we are doing today. And what we plan to do is we incise the breast, we create some flaps, we localize the lesion with the Savi Scout probe, and we make a circumferential dissection around the lesion, and we try to remove it completely. We do have an x-ray inside the operating room, and that's what we use to confirm that the specimen was removed appropriately, that we removed all the targets in the breast.

CHAPTER 2

It's always good form to do a quick exam and make sure you can find your lesion before the surgery. Now you move around until you find the closest. Right there you got nine millimeters. Just sometimes, it's just twitching a little bit your... That should do it. Okay, so mark an X just so we have an idea of the location. Okay, now we can prep and drape. And then - just here. All right, so you already kinda know where it is, the general location. What... I was gonna go more like around the... What you gonna do, you're gonna do periareola, right? Do you see the areola? Sometimes if you take the light a little bit away from- from the area, you can see it better. So you can mark. I usually do a bunch of small dots around it. Yeah, all the way around the areola. So I promise you can have a better idea of the location. And then this is still the same spot, right? So how big are you gonna make your incision? Now you can mark the beginning and the end of it. Like a semi-circle, or like a quarter of it. Like right about here. Yeah, I would go just a little bigger here, and then, yeah, it should be, stop here. Here should be plenty. Now put the lights back. Take a look and see if she's still has the nipple discharge that she was having before. So the papilloma is here. Usually you get the discharge with expression. See right there? It's kind of very, very subtle, but it's coming right here. And that was her concern before the procedure. Inject the local in the dermal plane. Try to raise the wheal. Yep. You can come closer. She's moving. We're injecting local. Okay, thanks. If we can get a little bit deeper. Yeah, sure will. Thank you. Okay.

CHAPTER 3

And you know where you're gonna stop? Right there. Okay. Make it curved, the incision, not a straight line. Skin incision. Okay. 43. Okay. Actually I think that's fine. Okay. You might need a little bit more room there. You might need to use your knife again. Not deeper just yet, just wider. Yes. Yep. Good. Now go through dermis. Use your pickup. More away? Yeah. Go on cut. Not coag. Okay. Thank you. Okay. We will take skin hooks. So one thing that, before the hooks, I just wanted to make sure you use the entire incision. Even more so here. Yeah, do you see there? Yep. Nope, you don't. All right, we take the hooks, please.

CHAPTER 4

Okay, start your flaps. You kind of already marked the general area of where- she'll take DeBakeys. You already marked the general area where the papilloma is. So if you just create flaps all around to make room for the case, and then we go chase it. Usually start with the DeBakey, and then when you have room... Careful with skin so you don't - go through the skin. You're getting too close to skin. That's not necessary for this case. Go a little bit deeper like right here. Yeah. Nope, when you're correcting yourself it's not a lot. Just pull this, and you go... Can I have another DeBakey please? Just go right on the filmy area right there. Yep. Longer strokes, much better. Okay. Now you might have room for your finger, and it'll give a better retraction. And again, get yourself space with both flaps. I think you might have it here. One second. Hold this and this for me. Hold this one. I usually tell you to get your flaps straight, but see what I'm seeing right here? Some changes. Okay, so no, that's not what I thought. Alright, hold this there. Okay. More traction so you can dissect the tissue. Put your head there so you can... I'm just trying to connect now with what you did. Are you just trying to like get around the whole thing? Yeah. And here's where the needle came, so you can kind of see a little bit of like old changes that were not done by us right there. Okay, now take a few here of how far I went with my dissection, and I want you to do the same laterally and all the way around, okay? I'm pretty much there laterally but not so much that way. Okay. Don't need to be super close to skin. Yeah. Okay we're good. Now we go this way. One second. Get the DeBakey again. Yes. Kind of connect lateral with superior. Like right there. Yeah. Traction with your left hand. Okay. Good, very good. Alright, I think it's good. And now medially, can you guys hold this for us please? Medially, the only thing, you really don't need to go all the way behind the nipple. Just dissect a little bit of a flap here. A little bit like there. And then stop right here. Yeah. Okay, take this. You see where my finger is? Just dissect right there. Not there. No, right here, yeah. And stop. Okay. Nice. Now let me just put my finger here. Okay, do just a little bit more dissection going deep and not towards the, yeah. Like right there and down. Correct. Okay. Okay. You can let this one go. Now we should have enough room to get this specimen out. Go ahead and feel and see where the papilloma is with the Scout. Right there. That's the best one you've got. Can I have two small Riches please?

CHAPTER 5

Okay, we're gonna be dealing with a seven-millimeter papilloma that has been biopsied. I doubt you're gonna be able to feel it. Want me to hold this one, doctor. No, not yet, but thank you. I just need to, but I'll need you in a minute. So hold on. Nope, do it again. You were 11 millimeters even though in the- now, yeah, right there. So take it out. Take your finger out. This is the closest you are. You're seven millimeters away of the lesion. You should not go any closer to it. See if you can feel anything abnormal or different first. Not really, no. Okay, so we're gonna use, then we're gonna go all by... The Scout? Via the Scout. Get the DeBakey and show me how big you're gonna do your... Can we have a Ray-Tec please? So... You have to be... That's nerve. Yeah, you probably, now that I moved it around, you have to try it again. Sorry. Okay. And. Okay so that's nine millimeters you were just a second ago. Nope. Nope. Yeah, right there. So now show me - go around and tell me what you do in terms of lumpectomy. So I'm basically going in like a cube just to kind of... Or a circle, yeah. Yeah. And starting this way. Okay. This is where my Scout is. Yep. I'm gonna make my incision there. So this is gonna be your medial margin. Traction with your non-dominant hand. Nice. Can I move you? Yes, please. Okay. Go inferiorly as well, yep. Okay, good. So... I'm connecting this way. You're doing everything the right way, you just released one. Try the Scout again. Make sure you didn't... Yep, you have it. Perfect. Now you're gonna connect whatever the medial is with the superior margin. Right here to like right... Yeah, but you need traction. You're probably gonna need the Ray-Tec to pull the tissue in. Beautiful. See your non-dominant hand makes most of the retraction. That's perfect, Olivia. All right, so again, now you have medial and superior margins. We are gonna go for lateral, and you're gonna do the same thing. Make sure your Scout is just centered on the center of the specimen. And yeah, same thing. Just gonna connect these. Yeah. And whenever you see any like tissue changes like you're seeing here, you have to make sure you're not going through the lesion that we're looking for. Do you wanna take this with us? One second. Continue retracting. Can I have DeBakey? So this here looks like, this area looks like post-biopsy changes. You just need to make sure this is not what you are going for, and it looks like it's close to it. So you're gonna have to re... Re-go. Yes, readdress. Re... I'm gonna go like right above it. Yeah. To incorporate that to your... Okay. That kind of sparkled. This all kind of looks like it's all post-biopsy changes up here too. Okay, so put it in. Alright, let it go. You're doing great, but because I have a better angle, I would do the inferior margin. Okay. Always, always make sure you are double checking with the Scout when you are testing the probe. Okay. Because sometimes the sound has nothing to do... Hold on. Let's incorporate this. The sound can have nothing to do with the distance. She's moving. We'll stop in one second. I'm just gonna stop. Yep, can you give her a little bit more? I just stopped, so just stopping the bleeding. You want more local? Probably, yeah. We inject a little bit more local there too. We're putting local here too. Sorry, I think it'll be fine. Hoping that most of the dissection has been done already. Okay. Let me connect to... Okay. Let's see if you have it. Oh, you wanted to put the cadence? Yes. I think you actually do. Get another DeBakey. Can I steal a DeBakey? Lift it all up. So it's the, a little bit more stuck on this side. Yep, let's see where the Scout is. How far is it? Six millimeters. So you are close but not there yet. She is snoozing. I know. Yeah, very close. So a little bit deeper. Yes, go a little... Can you hold this retractor for her now? Okay. Thank you. Okay. I'm gonna go like right about there. Sorry. I'm trying to grab it right... Okay, go around here. Test the Scout again. Thank you. Can you give us a Babcock? See if it's within specimen here now. Thank you. Just grab those two here together on top of where I am. Now test your Scout. Okay. I think right there. Okay. Start taking the... Yeah, you need to go deeper. I'm just holding this for you, but you need to go deeper with your - yeah. Like right down there? Yeah. Okay. Careful, don't touch the suction to this specimen, please. Just because we don't wanna suck up the biopsy clip. Okay. Still deeper here, or do you want to go across. Deeper, a little bit deeper. You wanna kind of take this with us? Sure. Okay. Now test the Scout again and see if you can amputate this specimen. Yep, I think you're ready. I think we might have to go just a bit deeper over here. On this side, yep. Go for it. Can you see? Mm-hm. Right there, release this. Sorry. No, no, no. We are tangling. Get more local. Okay, good. Make sure you can see what you are cutting. Okay. Just move this a little bit here. This, I mean you should have it. Yep, right there. Bring this across. Yep. Do you wanna try this Scout one more time to be on the safe side? Okay, you have it. A little bit lower. Right here? Mm-hm. Okay, I usually, what I like doing, take this out, and I get to this is putting my own... This is your... Fingers here so we can feel for anything that could be... Okay. Go around this area here. Just through here? Yes. Now just make sure you're not gonna... Okay. Okay. Should have this out now. Just the tip of the Bovie. Yep. One second. Have him retract the skin for you here. Sure. Don't pull too hard. It's just taking the skin. Yep. I want to tilt it that way a little bit. Okay. Looks like her skin's pretty close right here, so I'm just gonna... Okay. You should have it out. Yeah. Specimen is out. Right breast papilloma. Do hemostasis. Put some local while I do the picture. You guys can... Right breast what? Papilloma. Papilloma? Yep.

CHAPTER 6

So now we are just marking the edges of the specimen with different colors, and that's how we orient the specimens here. This will be important in case we end up finding any cancers to evaluate for margin status. Every side gets a different color. Can I use one of your containers so I can take an x-ray of this specimen please? All right, Jinx, are you ready? Let's do this again.

CHAPTER 7

Can you put the medial marker on this side? Just do inside the square, yeah. And then the, yes. Perfect. Okay. And close it. Tap here. Then tap one more time. Nope, once only, and press and hold. Okay. Nine seconds, and we'll have a picture of the specimen. All right, the specimen looks like it's in the center. Jinx can you come here then? Every time... Perfect, you can open. We are x-raying specimens. We try to do two views. If you can remove the medial and put the posterior there instead. So it's gonna be like an, I'm gonna turn, flip the specimen here in a 90-degree angle to make sure things look good. Close it very gently 'cause otherwise it will flip. Perfect. Same thing. Okay. Perfect. Both the biopsy clip and the Savi Scout are there and in appropriate position in relationship to the specimen. We're good. Jinx, if you can close patient. Actually can you get this one, tap on this picture here. Yeah, so they can record. Which one? The first one so they can see. This is the other view, just so you guys can have an idea of both views of the specimen. This is not palpable. Everything felt like normal breast tissue. The x-ray is helpful in confirming that we removed what we are looking for and we got margins. Perfect, close patient, and then you can take this specimen, and you can send to pathology. It's the only specimen for this case.

CHAPTER 8

We're done with the Scout. Okay, you can let this go. I'll take the other Rich please. Then you already did hemostasis. Yep. Already put local. Yep. Perfect. Let go. Can we have another Ray-Tec, please? Just kind of make sure things are dry here. Did you wanna use any Surgicel? No. We'll take the 2-0 please. Okay. And can I do, oh, we have both of them. Because we formed this cavity inside the breast, we try to close it as much as possible to decrease the chances of seroma. Let go. Let go, yeah. So what are you gonna do? Go deep. Yep. Yep. I think like... Right there, yep. Nice. You want me to hold? No, I want you to get suture scissors, please. Oh, too much tissue. Less tissue, less tissue. Less suture? Less tissue. Oh, tissue. Yeah. Yep. Like I don't think I can... So if you get too close to behind the nipple, you deviate the nipple when it closes. For real, I've done it. All right, lemme take this out. See how it's gonna close. Nice. You think it's gonna dimple too much? Nope, don't put it too tight. Just make sure it's a loose closure. Okay. Cut it. Cut it, right by the knot. I have one needle working? Is it enough? Yep. Yep. Let's try more here. There is room for more, yeah. Yep. The specimen was very good over there. Thank you. It's not a big specimen, not small, just appropriate. The thing's in the middle of it. There is hope. Thanks, Dr. Fortes. Same thing, try again. You're gonna need a couple more stitches there. It's getting back nicely. Like one superficial. I would do one more, yeah. Like right, like from here to here. I would, no... This, DeBakey, oh, it's here. For sure, I would get this here that you got. See, get just this area, and then get this. Okay. Yeah. The white fibrous tissue is way better than just the fatty tissue when you're trying to, yep. Just nice and loose again. What? Just nice and loose again? Yes. Let's see. We might, just give us one second. I would go to... Okay, you can cover this here. That's it. Yeah, is it open already? If it's not I can make it work. I'll just pinch it and tie. Yep. Yeah. Get just this area here to close here, and you should be good. Yeah. To cover that. Like right through here. Yeah. It's kind of not... Oh, you... Locked myself. You locked yourself. If you're really trying to save sutures, this is a very good example of... I know. That's what I was thinking. If you cut the needle, you'll be able to... You know what, that's smart thinking though. Just don't put it too tight. Look at that. Almost all of it used. Thank you. Okay, start with the corners. She will take the skin pickups. Tie and pull it from under the skin. After I do the knot, I pull it to underneath the skin to make sure. Yeah. Okay, suture scissors. Cut it short. Yeah. So now do this corner here. I like tying away from the corner. Lemme do it from here. Tie away from the corners? Always. What you did here, I always do it from both sides. Oh, I see, like tug it like that way. Yeah. Got you. Just so the knot is not wanting to... Yeah. Okay. Yep, and I'll continue doing this. Like middle. When they're not closing perfectly, you can always use the skin marker and mark where you should go between one side and the other. Yep. You're gonna... That's perfect. Very excellent job. And you say you just like flip the knot that way? Yeah, I just like doing it. It's looking very good. Looks perfect. Jinx, procedure went as boarded, one specimen, right breast papilloma. You're supposed to cut shorter than that, please. If you slide it down to the knot, and then just turn it like 45 degrees, you'll be like right, right on it. So make it a little bit shorter, doctor? Correct. Also, the table is very low for you, Olivia. That's nothing new. That's baseline. Don't do that to your back. If we can get this to close with the... Steris? Steris, yep. It'll be fine. Yep, do one more just here. This hole though, you see? Yeah. One more, and we are done. A little bit lower. Do you see where the hole is? Lower? Here, yeah. Getting this thing here. Yeah. Beautiful. I'll take this. Steri-Strips, four by fours, and Tegaderms for the dressing, and a medium-sized binder for her. I can go large. Alright, you can do large.

CHAPTER 9

So our lumpectomy went as expected. No surprises. We did remove the area that was targeted by the Savi Scout. We couldn't feel any like abnormalities that could be seen at our gross inspection. However, we confirmed that the area that needed to be removed was removed when we performed the x-ray inside the OR. The patient did very well with surgery. Obviously everything that gets removed from the body needs to be sent to pathology. So our next steps are to confirm that we are really just dealing with a papilloma and nothing else. We should get results from her in about three or four days, and this will determine if any other interventions are necessary for her. This is an about 40-minute procedure, and it's outpatient. Patients will go home same day.