Robotic Nipple-sparing Mastectomy and Immediate Breast Reconstruction With Implant: First Report of Surgical Technique

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To the Editor:
Technical innovations have made it feasible to conduct endoscopic nipple-sparing mastectomy (NSM), which has been reportedly well tolerated and associated with greater patient satisfaction.1 However, the endoscopic technique (ET) has not had a wide diffusion and many centers have abandoned this technique because of technical challenges.2–4 In fact, the manual control of a 2-dimensional endoscopic in-line camera produces an inconsistent optical window around the curvature of the breast skin flap. Furthermore, the internal mobility results are limited and the dissection angles inadequate5,6 because rigid tips instruments are working through a single access.
The aim of the present study was to evaluate feasibility, safety, advantages and limitations of robotic surgery to perform NSM and immediate breast reconstruction (IBR) with implant. Our hypothesis is that robot technology could exceed the technical limits of ET. We describe the surgical technique of the first 3 operations carried out.
To exercise caution with regard to the oncological safety, we selected BRCA mutation carrier patients with a previous history of breast cancer surgery who had decided to receive a delayed contralateral risk-reducing NSM and IBR.
A 2.5-cm-long extra-mammary axillary incision was made so as to be hidden by the arm. The subcutaneous flap was dissected with electrocautery under direct vision in a 3 cm area. We then obtained a working space for the introduction of the single port (Access Transformer OCTO, Seoul, Korea) connected to an insufflator to keep the pressure at 8 mm Hg (Figure 1) and commence the mastectomy. All the operations were carried out by the same surgeon at the console using a DaVinci S (Intuitive Surgical, Sunnyvale, CA) robotic platform. The robotic arms’ elbows were opened as much as possible to avoid conflicts during dissection. The cavity was observed through a 30° 12-mm-diameter camera (Intuitive Surgical, Denzlingen, Germany). Dissection was carried out with a 5 mm monopolar cautery with spatula tip (Intuitive Surgical, Sunnyvale, CA) used on the right robotic arm. Traction and counter-traction, along with maintaining exposure and stretching out the tissue, was carried out with a 8 mm Maryland Bipolar Forceps (Intuitive Surgical, Sunnyvale, CA) fitted on the left robotic arm. The dissection started from the superficial flaps in all quadrants, then breast tissue was pulled up to create a sufficient posterior working space on the major pectoral fascia and completed dissection. The gland was then removed entirely en bloc through the 2.5 cm axillary skin incision using a “waving flag technique,” moving the slippery and greased gland freely and gently back and forth or up and down (greater size of the gland was 8.5 × 3.5 × 2 cm; areolar flap thickness ranged between 0.3 to 0.5 cm). In the reconstructive phase, as the gas pressure was not high enough to elevate the pectoralis major muscle, the monoport was removed and a long and narrow standard retractor was used to lift the muscle, although maintaining the same axillary access and the same robotic instruments. The submuscular pocket was prepared for adequate muscular distension. The drains and implant (Allergan Inc, Irvine, CA) were than inserted manually.
Surgical time was 7 hours for the first operation and 2 hours and 30 minutes for the last one. The first case was converted to an open technique near the end of the procedure to reduce the time of surgery (20% of the gland dissected using traditional scissors). No variation of pathologic review of the breasts were registered. In the first patient we observed a biceps brachii temporary strength reduction, which resolved spontaneously. The last patient had a mild ecchymosis in the lower quadrants and a small blistering from internal electrocautery. All patients were discharged on the second postoperative day.

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