Breast cancer robotic nipple sparing mastectomy: evaluation of several surgical procedures and learning curve

Abstract

BackgroundFew studies of robotic nipple sparing mastectomy (NSM) were reported. We report feasibility of robotic NSM and determine standard surgical procedure and learning curve threefold.MethodsA cohort of patients with robotic NSM for breast cancer was analyzed. Complications and post-operative hospitalization stay were reported. The same technic was used for all patients except for skin and nipple areolar complex (NAC) dissection. Differences between three surgical procedures of NAC dissection were analyzed: group 1, dissection with robotic scissors using coagulation; group 2, dissection with robotic scissors without coagulation; and group 3, dissection with non-robotic scissors and then robotic dissection. We explored possible effect of learning curve among patients from group 1 with the same surgical procedure.ResultsTwenty-seven NSM with immediate breast reconstruction for breast cancers, 22 invasive and 5 in situ, were performed, with robotic latissimus dorsi-flap (RLDF) only in 17 cases, RLDF and breast implant in 6 cases, and implant alone in 4 cases. Repartition according to 3 surgical procedure groups was 16, 5, and 6 patients. Mean time of surgery and anesthesia decrease according to groups 1 to 3. Among 16 patients from group 1, time of surgery and anesthesia decreased with learning curve. Post-operative hospitalization decreased from group 1 to 3. We reported a total of 11 complications, with significant difference between groups (10 for group 1). Skin complications were higher for group 1 in comparison with groups 2–3 (p = 0.02).ConclusionRobotic NSM can be performed with a brief learning. Standardized technique is proposed with non-robotic scissors superficial dissection and then dissection with robot.

The modern approach to the nipple‐sparing mastectomy

“…Mayo reported their results with NSM over the last decade, showing a decrease in complication rate even with the broadening of indications for the procedure to higher‐risk patients; this confirms a team learning curve for the procedure 60 . Interestingly, the robotic approach to NSM, which was only first reported within the last 3 years, already has several published manuscripts regarding the learning curve 44,61‐63 …”

Residual breast tissue after robot-assisted nipple sparing mastectomy

“…Subsequently, few additional publications have described the use of RNSM ( Table 3 ) [ [8] , [9] , [10] , [11] , [12] , [13] , [14] , [15] , [16] , [17] , [18] , [19] , [20] ]. Reported complications include nipple areolar complex necrosis, mastectomy flap necrosis, temporary skin blistering, hematoma, seroma, infection, loss of implant from infection, delayed axillary wound healing, transient brachial plexus neurapraxia (due to arm positioning), transient common peronal nerve neurapraxia (due to patient positioning during surgery).…”

“…Furthermore, future studies assessing the mastectomy skin flap viability may demonstrate low rates of flap complication and thus improved success of immediate breast reconstruction. Although current published number of cases are small, there is a trend for low skin flap necrosis [ 8 , 12 , 16 , 17 , 31 ]. While the same anatomic planes are adhered to during RNSM compared to open, the skin retraction with CO 2 insufflation rather than physical retraction may be less traumatic through the duration of the surgery.…”

“…Total mammary glandular excision in NSM can be technically challenging, due to small size of the incision and poor visualization of the dissection plane. To help overcome the challenges in open NSM, use of the robot (da Vinci Surgical System, Intuitive Surgical, Sunnyvale, CA) for robot-assisted nipple sparing mastectomy (RNSM) is an emerging operation [ [8] , [9] , [10] , [11] , [12] , [13] , [14] , [15] , [16] , [17] , [18] , [19] , [20] ].…”

Axillary lymph node dissection using a robotic surgical system: Initial experience

“…16 A previous study suggested that the cost of RNSM could be decreased with about 300 procedures, with one robotic surgical system and minimal use of robotic instruments. 17 With those results and the development of cost-effective robotic surgical systems and instruments in this industry, we predict reductions in the cost of RNSM.…”