Streamlining Surgeon-Performed Intraoperative Localization: A Step-by-Step Guide for IOL

Introduction:

Intraoperative localization is a practice-changing, patient centric simple technique that can be readily incorporated into a breast surgeon’s practice.  Most breast lesions are ultrasound visible or can have an ultrasound visible biopsy marker placed at time of diagnosis. Most surgery centers are equipped with ultrasound machines that can be easily accessible for use at time of lumpectomy.  This article outlines a systematic approach for surgeon performed intraoperative ultrasound guided wire localization, IOL.

Steps:

  1. Patient Selection and Preoperative Planning
    1. Begin your practice by selecting patients with unifocal ultrasound visible tumors >1cm in size that have undergone ultrasound guided biopsy with clip placement.
  2. Comparison of Radiology Reports with Ultrasound Findings
    1. Confirm the placement and position of any clips.
    1. Verify that the lesion is ultrasound visible.
  3. Planning Incision and Approach (Flight Plan)
    1. Develop a plan for incision placement and direction of dissection. 
    1. Incorporate any oncoplastic plan into your design.
  4. Review Your Flight Plan
    1. On the day of surgery, review your plan and any related images and reports.
  5. Localization Set Up
    1. Ultrasound with linear probe (8-15MHz)
    1. Sterile Mayo Stand with the following:
      1. Wire
      1. Gauze
      1. Prep stick
      1. Gloves
      1. Wire cutter
  6. Lesion Identification:
    1. Prior to sterile set-up, identify the lesion with ultrasound and mark the tumor location in radial and anti-radial planes.
  7. Perform the procedure:

Once sterile, with gloves and probe

  • Place the wire into the needle transducer.
    • Identify the lesion with ultrasound and rest your hand with ultrasound on the breast to keep it in steady position.
    • Sterilize the skin lateral to the probe with chloroprep or other sterile solution.
    • Optional: Make a nick in the skin with an 11-blade at the planned entrance for your wire.
    • Insert the needle with wire, using the ultrasound for guidance, at the site of the lesion.
    • Set the probe down, remove the needle, holding the wire in place.
    • Optional: Use ultrasound to confirm wire localization.
    • Trim the wire to desired length.

Why use a wire?

  1. Reassurance of Target Lesion
    • The wire provides assurance that the lesion can be easily found, even if tissue is displaced with oncoplastic tunneling or other approaches.’
  2. Challenges with Intraoperative Ultrasound
    • Ultrasound use after incision can be challenging and tedious.  The tissue planes may be distorted, and ultrasound availability may be limited.
  3. Training and Efficiency
    • The use of wires allows for safe and efficient lumpectomies, especially in training institutions where residents are involved.

Conclusion:

The adoption of IOL stands to enhance surgical practices, elevate the patient experience, and optimize treatment timing.  Beyond assuring precise target localization, this approach effectively tackles challenges related to intraoperative ultrasound, making it a valuable and indispensable surgical tool.

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