Robotic nipple-sparing mastectomy: The first experience from Indian subcontinent

Abstract

Breast cancer is the second most common cancer in the world and it is the leading cancer affecting Indian women. With growing numbers and increasing cosmetic concerns, more and more women are opting for breast conservation surgeries (BCS). However, in patients in whom breast conservation is not possible, skin-sparing (SSM) or nipple-sparing mastectomy (NSM) with reconstruction is the option.Endoscopic approaches came into vogue to combat the cosmetic concerns associated with open NSM but they failed to gain popularity owing to technical difficulties associated. Robotics was introduced as an alternative to endoscopic approach to overcome these limitations. An initial study by Toesca et al 1 showed the feasibility of this approach and this is our first experience of the innovative procedure.A 30-year-old lady with a lump in upper outer quadrant was evaluated and was found to have BIRADS IV lesion with diffuse microcalcification on imaging with no axillary lymphadenopathy.Fine-needle aspiration from the lesion was suggestive of invasive ductal carcinoma, and rest of the routine work up was unremarkable.As the disease was not feasible for BCS and the patient was keen on breast reconstruction, patient was given the option of robotic NSM with reconstruction using an implant. The procedure was done as described by Antonio Toesca in his original series and our experience of witnessing his live surgery. About 3 cm long incision was taken in the midaxillary line ( Figure 1). The incision was deepened, and planes were created using cautery for the insertion of octoport.The flaps were raised to a distance of about 3 cm, octoport was introduced, and insufflation started to a pressure of around 8 mm Hg (Figure 2). DaVinci Si robot was docked from the opposite side, and 12 mm (0 degree) camera was used. The dissection was carried out using a 5 mm spatula on the right arm and bipolar forceps on the left arm. Initial dissection was done in the superficial skin flap, and nipple shave was sent for frozen analysis which was reported negative. The assistant surgeon was at the operating table managing the skin flap thickness and providing necessary input to the surgeon at the console. After the dissection of superficial flap, breast tissue was dissected off the pectoralis major muscle and the specimen was delivered through the above-said incision. The mono port was repositioned, and submuscular plane was created for implant placement.Axillary dissection was carried out through the same incision. After manually placing the implant, subcutaneous and submuscular drains were kept and the incision was closed. Duration of surgery was 5 hours and 30 min, and no skin necrosis was noted. However, there was minimum erythema of skin in lower inner quadrant which settled on its own. The patient was discharged on second postoperative day and had a routine recovery with no morbidity (Figure 3).With the established popularity of robotics in intra-abdominal malignancies, there is a growing trend for usage of robotics in other areas such as oropharyng...

Robotic Versus Conventional Nipple-Sparing Mastectomy With Immediate Breast Reconstruction

“…Consequently, NSM is the procedure of choice when this technique is possible, mainly in relation to the tumor nipple-areolar-complex (NACx) distance on radiologic exams. Several studies reported a few cases of robotic-NSM (R-NSM) to evaluate feasibility, reproducibility, and safety (8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27). Recently, a technical robotic surgical consensual NSM procedure was reported (28).…”

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).…”

“…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] ].…”

Robotic-Assisted Nipple Sparing Mastectomy

“…Breast reconstruction is then performed as with open NSM with either a tissue expander, breast implant, and/or autologous tissue flap, which is detailed in a later chapter. 20 39 42 43 45 46 47 48…”

“…20,[42][43][44] R-NSM has been completed utilizing the da Vinci S, Si, and Xi systems (Intuitive Surgical, Sunnyvale, CA). 20,39,42,43,[45][46][47][48] The patient is placed in the supine position with the ipsilateral arm either resting below the plane of the operating table or abducted to 90 degrees on a surgical armrest attached to the operating table. Reported techniques describe the placement of 1 to 3 incisions (3-6 cm in length depending on breast size), with the main port site placed at the lateral aspect of the breast near the anterior axillary line.…”