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

The emerging role of robotics in plastic and reconstructive surgery: a systematic review and meta-analysis

The role of robotics has grown exponentially. There is an active interest amongst practitioners in the transferability of the potential benefits into plastic and reconstructive surgery; however, many plastic surgeons report lack of widespread implementation, training, or clinical exposure. We report the current evidence base, and surgical opportunities, alongside key barriers, and limitations to overcome, to develop the use of robotics within the field. This systematic review of PubMed, Medline, and Embase has been conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PROSPERO (ID: CRD42024524237). Preclinical, educational, and clinical articles were included, within the scope of plastic and reconstructive surgery. 2, 181, articles were screened; 176 articles met the inclusion criteria across lymph node dissection, flap and microsurgery, vaginoplasty, craniofacial reconstruction, abdominal wall reconstruction and transoral robotic surgery (TOR). A number of benefits have been reported including technical advantages such as better visualisation, improved precision and accuracy, and tremor reduction. Patient benefits include lower rate of complications and quicker recovery; however, there is a longer operative duration in some categories. Cost presents a significant barrier to implementation. Robotic surgery presents an exciting opportunity to improve patient outcomes and surgical ease of use, with feasibility for many subspecialities demonstrated in this review. However, further higher quality comparative research with careful case selection, which is adequately powered, as well as the inclusion of cost-analysis, is necessary to fully understand the true benefit for patient care, and justification for resource utilisation.

Early experience of robotic axillary lymph node dissection in patients with node-positive breast cancer

BACKGROUND

Robotic surgical systems enable surgeons to perform precise movement in the surgical field using high-resolution 3D vision and flexible robotic instruments. We aimed to evaluate the feasibility and safety of performing axillary lymph node dissection using a robotic surgical system in patients with node-positive breast cancer.

METHODS

Thirty-two women with breast cancer who underwent robot-assisted nipple-sparing mastectomy (RNSM) and level I/II axillary lymph node dissection were analyzed. Patients were divided into two groups: RNSM with conventional axillary lymph node dissection (CALND) vs. RNSM with robotic axillary lymph node dissection (RALND). Clinicopathological features and surgical outcomes were analyzed.

RESULTS

The median age of the patients was 44 (range 20-59) years. Eleven patients underwent RALND. None of the clinicopathologic features differed between the two groups. There were no statistically significant differences in surgical outcomes, except for the final incision size, between the two groups. The proportion of cases with an incision ≤ 40 mm was 63.6% in the RALND group and 36.4% in the CALND group (p = 0.020).

CONCLUSION

RALND can be safely performed in RNSM. RNSM with RALND is comparable to RNSM with CALND in terms of early surgical outcomes. The incision size can be reduced when using RALND.

Analgesic Efficacies of Intraoperative Pectoralis Nerve II Block under Direct Vision in Patients Undergoing Robotic Nipple-Sparing Mastectomy with Immediate Breast Reconstruction: A Prospective, Randomized Controlled Study

This prospective, randomized study aimed to evaluate the efficacy of an intraoperative pectoralis nerve II block (PECS II block) under direct vision in the reduction of fentanyl consumption during postoperative 24 h in patients undergoing robotic nipple-sparing mastectomy (RNSM) with immediate breast reconstruction (IBR) using direct-to-implant (DTI) or tissue expander (TE). Thirty patients scheduled for RNSM with IBR were randomly allocated to the PECS (n = 15) or control (n = 15) groups. The PECS II block was applied under direct vision after RNSM. The primary outcome was the cumulative dose of fentanyl consumption. The secondary outcomes were pain intensity using a numerical rating scale (NRS) at rest and acting during the postoperative 24 h. The cumulative dose of fentanyl at 24 h was significantly lower in the PECS group than in the control group (p = 0.011). Patients in the PECS group showed significantly lower NRS scores during the first postoperative 2 h compared to those in the control group in both resting and acting pain (p < 0.05). An intraoperative PECS II block under direct vision can reduce opioid consumption during the postoperative 24 h and provide effective analgesia in patients undergoing RNSM with IBR using DTI or TE.

Robotic harvest of a latissimus dorsi flap using a single-port surgical robotic system in breast reconstruction

Robot-assisted surgery is evolving to incorporate a higher number of minimally invasive techniques. There is a growing interest in robotic breast reconstruction that uses autologous tissue. Since a traditional latissimus dorsi (LD) flap leads to a long donor scar, which can be an unpleasant burden to patients, there have been many attempts to decrease the scar length using minimally invasive approaches. This study presents the case of a patient who underwent a robot-assisted nipple-sparing mastectomy followed by immediate breast reconstruction with an LD flap using a single-port robotic surgery system. With the assistance of a single-port robot, a simple docking process using a short and less visible incision is possible. Compared to multiport surgery systems, single-port robots can reduce the possibility of collision between robotic arms and provide a clear view of the medial border of the LD where the curvature of the back restricts the visual field. We recommend the use of single-port robots as a minimally invasive approach for harvesting LD flaps.

Postoperative pain assessment of robotic nipple-sparing mastectomy with immediate prepectoral prosthesis breast reconstruction: a comparison with conventional nipple-sparing mastectomy

Aims: Nipple-sparing mastectomy (NSM) is a surgical procedure for patients with breast cancer without nipple-areolar complex (NAC) involvement. Robotic NSM (RNSM) with immediate breast reconstruction has been recently introduced; however, reports regarding RNSM are still lacking. Therefore, this study aimed to evaluate the postoperative assessment with a focus on postoperative pain of RNSM with prepectoral immediate prosthesis breast reconstruction (IPBR) compared with conventional NSM (CNSM) in patients with breast cancer without NAC invasion. Methods: This retrospective study included 81 patients who underwent RNSM (n = 40) or CNSM (n = 41) with prepectoral IPBR using direct-to-implant or tissue expander between January 2018 and June 2020. The primary endpoint was to compare postoperative pain intensity based on a numerical rating scale (NRS). The secondary endpoint was to evaluate the postoperative recovery profile, including postoperative nausea/vomiting (PONV) and complications. Results: A statistical difference was observed in the resting NRS scores at 0-6 postoperative hours between the RNSM and CNSM groups (3.2 ± 1.5 versus 4.2 ± 1.6, respectively; Bonferroni corrected P = 0.005), however, no difference was shown at other time periods. Also, no between-group difference was found in the NRS scores for acting pain within 48 postoperative hours and the number of patients requiring additional analgesics. Conclusions: Despite a statistical difference in the resting NRS scores during the early postoperative phase, the absence of any significant difference in the requirement of additional analgesics between the groups suggested that RNSM does not significantly attenuate postoperative pain intensity.