Robot-assisted Mastectomy Followed by Immediate Autologous Microsurgical Free Flap Reconstruction: Techniques and Feasibility in Three Different Breast Cancer Surgical Scenarios

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.

Is minimal-accessed (endoscopic- or robotic-assisted) nipple-sparing mastectomy contraindicated for large breasts?

BACKGROUND

In the developmental stage of minimal-accessed nipple-sparing mastectomy (MA-NSM), selecting patients with small to medium-sized breasts was common for better cosmetic outcomes and oncological safety. However, the suitability of MA-NSM for large, ptotic breasts remained uncertain. This retrospective study aim to assess MA-NSM outcomes in patients with large breasts.

MATERIALS AND METHODS

This retrospective study included patients receiving conventional NSM (C-NSM) and MA-NSM from January 2011 to September 2022, at a single institution. We analyzed perioperative parameters and clinical outcomes based on breast specimen size, classified as small (≤300 g), medium (>300-450 g), large (>450-600 g), and very large (>600 g).

RESULTS

A total of 728 patients was enrolled. C-NSM was performed in 51% (371/728) of cases, while MA-NSM was done in 49% (357/728). The overall complication rate of MA-NSM was comparable to C-NSM (p = 0.573), but severe complications (Clavien-Dindo, CD III) was significantly reported more following C-NSM, regardless of breast size. During a median follow-up of 52 months, no significant difference in oncological outcomes was observed. Comparing MA-NSM and C-NSM outcomes in large-very large breasts (>450 g), MA-NSM demonstrated significantly less blood loss (p = 0.036) and lower incidence of severe complications (CD ≥ III) compared to C-NSM (p = 0.002).

CONCLUSION

MA-NSM is feasible for large breasts and offers benefits by reducing blood loss and decreasing the incidence of severe complications (CD ≥ III) in this patient group.

The learning curve of the MS-TRAM/DIEP breast reconstruction by dual-trained breast surgeons

BACKGROUND

Breast cancer surgeries involving MS-TRAM/DIEP breast reconstruction has traditionally been collaborative efforts between breast surgeons and plastic surgeons. However, in our institution, this procedure is performed by dual-trained breast surgeons who are proficient in both breast surgery and MS-TRAM/DIEP breast reconstruction. This study aims to provide insights into the learning curve associated with this surgical approach.

MATERIALS AND METHODS

We included eligible breast cancer patients who underwent MS-TRAM/DIEP breast reconstruction by dual-trained breast surgeons between 2015 and 2020 at our institution. We present the learning curve of this surgical approach, with a focus on determining factors affecting flap harvesting time, surgery time, and ischemic time. Additionally, we assessed the surgical complication rates.

RESULTS

A total of 147 eligible patients were enrolled in this study. Notably, after 30 cases, a statistically significant reduction of 1.7 h in surgery time and 21 min in ischemic time was achieved, signifying the attainment of a plateau in the learning curve. And the major and minor complications were comparable between the early and after 30 cases.

CONCLUSION

This study explores the learning curve and feasibility experienced by dual-trained breast surgeons in performing MS-TRAM/DIEP breast reconstruction.

TRIAL REGISTRATION

NCT05560633.

Robotic Microsurgery in Plastic and Reconstructive Surgery: A Literature Review

BACKGROUND

Surgical robots have innovated the microsurgical field by providing advantages that improve surgical performance. These robots have been adopted by certain specialties more than others. This study discusses the potential advantages of robotics in plastic and reconstructive surgery.

METHOD

This study is a literature review of articles investigating "robotic microsurgery in plastic and reconstructive surgery" using the PubMed database and the Cochrane Library.

RESULT

A total of nineteen relevant articles were found and 5 articles performed a direct comparison between the robotic and manual approaches. Longer operating times were reported in the robotic groups featuring higher learning curves. Reported advantages to robotic use included higher accuracy, precision and flexibility, elimination of tremor and improvement of ergonomic factors.

CONCLUSION

While the results provide an outlook into the outcome of robotic platforms in this field, current research is limited and further studies are required to provide a fundamental analysis.

Mastectomy with Reconstruction Including Robotic Endoscopic Surgery (MARRES): a prospective cohort study of the Korea Robot-Endoscopy Minimal Access Breast Surgery Study Group (KoREa-BSG) and Korean Breast Cancer Study Group (KBCSG)

BACKGROUND

Robotic nipple-sparing mastectomy (RNSM) has emerged as a new treatment option for breast cancer and risk-reducing mastectomy (RRM) for women who have a high risk of pathogenic variants. Even though several studies have reported that RNSM is a feasible procedure, some argue that it should only be performed by specialized surgeons, and data on oncologic outcomes and patient-reported outcomes (PROs) are limited. Recently, the United States Food and Drug Administration and several surgeons warned that robotic breast surgery should be performed only by specialized surgeons and recommended that the benefits, risks, and alternatives of all available treatment options be discussed with patients so they can make informed treatment decisions. The Korea Robot-Endoscopy Minimal Access Breast Surgery Study Group (KoREa-BSG) has been established to evaluate, standardize, and teach this state-of-the-art procedure. We have designed a multicenter prospective cohort study entitled Mastectomy with Reconstruction Including Robot Endoscopic Surgery (MARRES) to report surgical, PRO, and oncologic outcomes.

METHODS

MARRES is a multi-institution cohort study prospectively collecting data from patients undergoing mastectomy and reconstruction. The patient inclusion criteria are adult women older than 19 with breast cancer or a high risk of breast cancer (patients with BRCA1/2, TP53, PALB2 mutations, etc.), who have scheduled therapeutic or RRM and want immediate reconstruction. Surgical outcomes, including pre- and postoperative photos, oncologic outcomes, cost-effectiveness, and PRO, are collected. The primary endpoints are postoperative complication rates within 30 postoperative days and the Clavien-Dindo grade of postoperative complications within 180 postoperative days. The secondary endpoints are 5-year postoperative recurrence-free survival and cancer incidence rate (for those who underwent RRM), patient satisfaction with reconstruction expectations preoperative (baseline) and results within 6 to 12 postoperative months, surgeon satisfaction with postoperative results in 6 postoperative months, and cost-effectiveness of the definitive surgery. Patient recruitment will be completed in April 2025, and the target number of enrolled patients is 2000.

DISCUSSION

This study will provide evidence about the surgical outcomes, oncologic outcomes, and patient satisfaction with RNSM and endoscopic nipple-sparing mastectomy (NSM), compared with conventional NSM.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT04585074. Registered April 8, 2020.

A Preliminary Experience of Endoscopic Total Mastectomy With Immediate Free Abdominal-Based Perforator Flap Reconstruction Using Minimal Incisions, and Literature Review

PURPOSE

Endoscopic total mastectomy (ETM) is predominantly performed with reconstruction using prostheses, lipofilling, omental flaps, latissimus dorsi flaps, or a combination of these techniques. Common approaches include minimal incisions, e.g., periareolar, inframammary, axillary, or mid-axillary line, which limit the technical ability to perform autologous flap insets and microvascular anastomoses, as such the ETM with free abdominal-based perforator flap reconstruction has not been robustly explored.

METHODS

We studied female patients with breast cancer who underwent ETM and abdominal-based flap reconstruction. Clinical-radiological-pathological characteristics, surgery, complications, recurrence rates, and aesthetic outcomes were reviewed.

RESULTS

Twelve patients underwent ETM with abdominal-based flap reconstruction. The mean age was 53.4 years (range 36-65). Of the patients, 33.3% were surgically treated for stage I, 58.4% for stage II, and 8.3% for stage III cancer. Mean tumor size was 35.4 mm (range 1-67). Mean specimen weight was 458.75 g (range 242-800). Of the patients, 92.3% successfully received endoscopic nipple-sparing mastectomy and 7.7% underwent intraoperative conversion to skin-sparing mastectomy after carcinoma was reported on frozen section of the nipple base. Mean operative time for ETM was 139 minutes (92-198), and the average ischemic time was 37.3 minutes (range 22-50). Fifty percent of patients underwent deep inferior epigastric perforator, 33.4% underwent MS-2 transverse rectus abdominis musculocutaneous (TRAM), 8.3% underwent MS-1 TRAM, and 8.3% underwent pedicled TRAM flap reconstruction. No cases required re-exploration, no flap failure occurred, margins were clear, and no skin or nipple-areolar complex ischemia/necrosis developed. In the aesthetic outcome evaluation, 16.7% were excellent, 75% good, 8.3% fair, and none were unsatisfactory. No recurrences were observed.

CONCLUSION

ETM through a minimal-access inferior mammary or mid-axillary line approach, followed by immediate pedicled TRAM or free abdominal-based perforator flap reconstruction, can be a safe means of achieving an "aesthetically scarless" mastectomy and reconstruction through minimal incisions.

Robotic-Assisted Microsurgery and Its Future in Plastic Surgery

Within the last 20 years, robotic-assisted surgeries have been implemented as routine procedures in many surgical fields, except in plastic surgery. Although several case series report promising results, technical and economic aspects have prevented its translation into clinical routine. This review is based on a PubMed and Google Scholar database search, including case reports, case series, clinical and preclinical trials, as well as patents. Past, recent approaches, ongoing patents, as well as eight specific systems for robotic-assisted microsurgery and their potential to be translated into a clinical routine, are described. They may lay the ground for a novel field within plastic surgery. This review provides an overview of the emerging technologies and clinical and preclinical studies and discusses the potential of robotic assistance in the field of plastic surgery.

Surgical and Oncologic Outcomes of Robotic and Conventional Nipple-Sparing Mastectomy with Immediate Reconstruction: International Multicenter Pooled Data Analysis

BACKGROUND

Robotic nipple-sparing mastectomy (RNSM) has been developed to reduce conspicuous scar and increase the quality of life in women. This study aimed to evaluate the surgical and oncologic outcomes of RNSM with immediate breast reconstruction (IBR) compared with conventional nipple-sparing mastectomy (CNSM).

PATIENTS AND METHODS

This international multicenter, pooled analysis of individual patient-level data enrolled a total of 755 procedures in 659 women (609 had breast cancer and 50 underwent risk-reducing mastectomy) who underwent nipple-sparing mastectomy with IBR. Surgical and oncologic outcomes, including 30-days postoperative (POD 30d) complication rate, nipple necrosis rate, grade of Clavien-Dindo classification, disease-free survival, and overall survival, were evaluated. Propensity score-matched analyses were performed to adjust for confounding factors.

RESULTS

The median age of both the RNSM and CNSM groups was 45 years. The RNSM group had lower body mass index (BMI) and a higher proportion of benign disease compared with the CNSM group. POD 30d complications and postoperative complication grade III rates were lower in the RNSM group than in the CNSM group (p < 0.05). The nipple necrosis rate was 2.2% and 7.8% for RNSM and CNSM, respectively (p = 0.002). After propensity score matching, significantly lower rates of POD 30d complications, nipple necrosis, and postoperative complication grade III occurred in the RNSM group than in the CNSM group (all p < 0.05). Oncologic outcomes were not significantly different between the two groups.

CONCLUSION

RNSM can provide better cosmetic results with favorable surgical and oncologic outcomes for women with early breast cancer or BRCA mutation.

Transcutaneous medial fixation sutures for free flap inset after robot-assisted nipple-sparing mastectomy

The application of minimal invasive mastectomy has allowed surgeons to perform nipplesparing mastectomy via a shorter, inconspicuous incision under clear vision and with more precise hemostasis. However, it poses new challenges in microsurgical breast reconstruction, such as vascular anastomosis and flap insetting, which are considerably more difficult to perform through the shorter incision on the lateral breast border. We propose an innovative technique of transcutaneous medial fixation sutures to help in flap insetting and creating and maintaining the medial breast border. The sutures are placed after mastectomy and before flap transfer. Three 4-0 nylon suture loops are placed transcutaneously and into the pocket at the markings of the preferred lower medial border of the reconstructed breast. After microvascular anastomosis and temporary shaping of the flap on top of the mastectomy skin, the three corresponding points for the sutures are identified. The three nylon loops are then sutured to the dermis of the corresponding medial point of the flap. The flap is placed into the pocket by a simultaneous gentle pull on the three sutures and a combined lateral push. The stitches are then tied and buried after completion of flap inset.

Initial report of extraperitoneal pedicle dissection in deep inferior epigastric perforator flap breast reconstruction using the da Vinci SP

The deep inferior epigastric perforator (DIEP) flap has been widely used for autologous breast reconstruction after mastectomy. In the conventional surgical method, a long incision is needed at the anterior fascia of the rectus abdominis muscle to obtain sufficient pedicle length; this may increase the risk of incisional hernia. To shorten the incision, several trials have investigated the use of endoscopic/robotic devices for pedicle harvest; however, making multiple additional incisions for port insertion and operating in the intraperitoneal field were inevitable. Here, we describe the first case, in which a DIEP free flap was successfully made using the da Vinci SP model. Our findings can help surgeons perform operations in smaller fields with a single port in the extraperitoneal space. Moreover, this method is expected to lead to fewer donor-related complications and faster healing.

Minimal Access (Endoscopic and Robotic) Breast Surgery in the Surgical Treatment of Early Breast Cancer-Trend and Clinical Outcome From a Single-Surgeon Experience Over 10 Years

Objective

Endoscopic assisted breast surgery (EABS) or robotic assisted breast surgery (RABS) performed through minimal axillary and/or peri-areolar incisions has become the representative of minimal access breast surgery (MABS). We report the trend and clinical outcome of MABS for treatment of breast cancer.

Methods

Information on patients who underwent breast cancer operation by the principal investigator during the period of 2011 to 2020 was collected from a single institute for analysis. The clinical outcome, trend, and cost of MABS were analyzed and compared with conventional breast surgery (CBS).

Results

A total of 824 breast cancer patients operated by a single surgeon were enrolled in this study: 254 received CBS and 570 received MABS, namely, 476 EABS and 94 RABS. From 2011 to 2020, the number of MABS performed annually has shown an increasing trend. Compared with CBS, MABS such as breast conserving surgery and nipple sparing mastectomy (NSM) have effectively reduced wound scar length. Since the sequential uprise from conventional NSM (C-NSM), dual-axillary-areolar-incision two dimensional (2D) endoscopic assisted NSM (E-NSM), single-axillary-incision E-NSM, robotic assisted NSM (R-NSM), and single-port 3D E-NSM, the development of minimal access mastectomies increasingly paralleled with NSM. The operation time of various MABS decreased significantly and showed no statistical difference compared with CBS. R-NSM was associated with highest cost, followed by 3D E-NSM, E-NSM, and C-NSM. The positive surgical margin rate and local recurrence rate of MABS and CBS were not statistically different.

Conclusion

MABS showed comparable clinical outcome and preliminary oncologic safety as CBS and has been increasingly performed as the surgical treatment of breast cancer, especially minimal access NSM.

Robotic-assisted nipple-sparing mastectomy followed by immediate microsurgical free flap reconstruction: Feasibility and aesthetic results - Case series

BACKGROUND

The application of robotic-assisted nipple-sparing mastectomy (R-NSM) has allowed mastectomy to be performed via a small incision. Breast reconstruction with free autologous tissue results in the most natural and long-lasting results, however, its application in R-NSM can be difficult via the small incision and haven't been explored in depth. The purpose of the study was to investigate the feasibility and aesthetic outcome of free perforator flap breast reconstruction via small lateral chest wall incision after R-NSM.

MATERIALS AND METHODS

A retrospective chart review was conducted to identify patients who received R-NSM and free perforator flap reconstruction as the study group and patients who received conventional nipple-sparing mastectomy (C-NSM) and free perforator flap reconstruction as the control group from January 2018 to August 2020 by single reconstructive surgeon. Patient demographic data, complications from both mastectomy and reconstruction, status of resection margin and oncological outcome were reviewed. Aesthetic outcome was evaluated by 9 plastic surgeons.

RESULTS

A total of 63 patients were included of which 22 (34.9%) received R-NSM and 41 (65.1%) received C-NSM. Their demographic data, reconstruction flaps, overall complication rate and follow up time were similar. Unlike C-NSM, majority of the R-NSM groups used the thoracodorsal or lateral thoracic vessels as the recipient vessels. Patients in the R-NSM group has smaller scar and better aesthetic outcome in the symmetry of breast inframammary fold, scar location and visibility, and overall aesthetic outcome.

CONCLUSION

Although with difficulty in microvascular anastomosis and flap inset and shaping, R-NSM with perforator flap reconstruction presented with equal surgical and oncological safety with C-NSM and even better aesthetic results.