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Fan P, Lyu P, Gao F, Li J, Wei C, Du G. A Novel Endoscopic Approach for Treating Breast Cancer: Haigui-1 Hole. Surg Innov 2024; 31:349-354. [PMID: 38867678 DOI: 10.1177/15533506241262563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2024]
Abstract
OBJECTIVE Endoscopic surgery is an effective technique for preserving the nipple and areola, as well as for sentinel lymph node biopsy and breast implant reconstruction. However, the technical challenges associated with endoscopic surgery have limited its widespread adoption. METHODS In the normal single-port endoscopic surgery, the ultrasonic knife was accessed through the retractor. In our modified procedure, a tiny 5 mm incision was made at the lateral margin underneath the breast, serving as the second entry port for the ultrasonic scalpel, which was referred to as the "Haigui-1 hole". Preoperative and postoperative indicators such as blood loss, operative time, and postoperative drainage volume were collected. Differences between parameters were compared using Student's t test. RESULTS Endoscopic surgery with the assistance of the "Haigui-1 hole" led to preserved breast aesthetics with minimal scarring. Moreover, "Haigui-1 hole" surgery significantly reduced the operation time, intraoperative bleeding, and postoperative drainage volume compared to normal single-port endoscopic surgery. CONCLUSION The "Haigui-1 hole" procedure, which involves the addition of a second entrance to improve the maneuverability of the ultrasonic knife, is worthy of further promotion.
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Affiliation(s)
- Pingming Fan
- Department of Breast Surgery, The First Affiliated Hospital of Hainan Medical University, Haikou, China
- Department of Breast Surgery, Guangxi Medical University Cancer Hospital, Nanning, China
| | - Pengfei Lyu
- Department of Breast Surgery, The First Affiliated Hospital of Hainan Medical University, Haikou, China
| | - Fangfang Gao
- Department of Breast Surgery, The First Affiliated Hospital of Hainan Medical University, Haikou, China
| | - Jingtai Li
- Department of Breast Surgery, The First Affiliated Hospital of Hainan Medical University, Haikou, China
| | - Changyuan Wei
- Department of Breast Surgery, Guangxi Medical University Cancer Hospital, Nanning, China
| | - Guankui Du
- Key Laboratory of Tropical Translational Medicine of Ministry of Education, School of Basic Medicine and Life Sciences, Hainan Medical University, Haikou, China
- Department of Biochemistry and Molecular Biology, Hainan Medical University, Haikou, China
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Xu X, Gao X, Pan C, Hou J, Zhang L, Lin S. Postoperative outcomes of minimally invasive versus conventional nipple-sparing mastectomy with prosthesis breast reconstruction in breast cancer: a meta-analysis. J Robot Surg 2024; 18:274. [PMID: 38951387 DOI: 10.1007/s11701-024-02030-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2024] [Accepted: 06/19/2024] [Indexed: 07/03/2024]
Abstract
Breast cancer is the most common malignant tumor worldwide, and mastectomy remains the primary strategy for treating early stage breast cancer. However, the complication rates, surgical variables, and oncologic safety of minimally invasive nipple-sparing mastectomy (MINSM) have not been fully addressed. We systematically searched PubMed, Web of Science, Embase, and the Cochrane Library for randomized-controlled trials (RCTs) and non-RCTs that compared MINSM with conventional nipple-sparing mastectomy (CNSM), both followed by Prosthesis Breast Reconstruction (PBR). The main outcomes observed included overall complications, (Grade III) complications, skin and nipple necrosis, wound dehiscence, infection, seroma, hematoma, implant loss, and oncologic safety (positive margins and recurrence). Secondary outcomes included operation time, blood loss, hospital stay, cost-effectiveness, and patient satisfaction. Binary and continuous variables were compared using odds ratios (OR) and mean differences (MD) with 95% confidence intervals (CI). A total of 10 studies involving 2,166 patients were included. There were no statistically significant differences between MINSM and CNSM in terms of skin necrosis, wound dehiscence, infection, seroma, hematoma, implant loss, or oncologic safety. However, MINSM significantly reduced overall complications (OR = 0. 74, 95% CI [0. 58, 0. 94], p = 0. 01) and (Grade III) complications (OR = 0. 47, 95% CI [0. 31, 0. 71], p = 0. 0003). Nipple necrosis events were also significantly reduced in the MINSM group (OR = 0. 49, 95% CI [0. 30, 0. 80], p = 0. 005). Patient satisfaction improved notably in the MINSM group. Additionally, compared with the CNSM group, the MINSM group had longer operating times (MD = 46. 88, 95% CI [19. 55, 74. 21], p = 0. 0008) and hospital stays (MD = 1. 39, 95% CI [0. 65, 2. 12], p < 0. 001), while intraoperative blood loss was significantly reduced (MD = -29. 05, 95% CI [-36. 20, -21. 90], p < 0. 001). Compared with CNSM, MINSM offers advantages in reducing complications and intraoperative blood loss, as well as improving aesthetic outcomes and patient satisfaction. Therefore, MINSM may become a viable option for breast surgery. Nevertheless, a long-term evaluation of the oncologic safety of this approach is necessary to ensure its efficacy and safety for patients.
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Affiliation(s)
- Xia Xu
- Department of Breast Surgery, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Xiang Gao
- Department of Breast Surgery, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - ChaoYing Pan
- Department of Breast Surgery, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Jing Hou
- Department of Breast Surgery, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - LinXing Zhang
- Department of Breast Surgery, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Shuai Lin
- Department of Breast Surgery, Affiliated Hospital of North Sichuan Medical College, Nanchong, China.
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Awad L, Reed B, Bollen E, Langridge BJ, Jasionowska S, Butler PEM, Ponniah A. The emerging role of robotics in plastic and reconstructive surgery: a systematic review and meta-analysis. J Robot Surg 2024; 18:254. [PMID: 38878229 PMCID: PMC11180031 DOI: 10.1007/s11701-024-01987-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Accepted: 05/19/2024] [Indexed: 06/19/2024]
Abstract
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.
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Affiliation(s)
- Laura Awad
- Charles Wolfson Centre of Reconstructive Surgery, University College London, Royal Free Hospital, London, UK.
- Department of Plastic Surgery, Royal Free Hospital, London, UK.
- Department of Surgery and Interventional Sciences, University College London, Royal Free Hospital, London, UK.
| | - Benedict Reed
- Charles Wolfson Centre of Reconstructive Surgery, University College London, Royal Free Hospital, London, UK
- Department of Plastic Surgery, Royal Free Hospital, London, UK
| | - Edward Bollen
- Charles Wolfson Centre of Reconstructive Surgery, University College London, Royal Free Hospital, London, UK
| | - Benjamin J Langridge
- Charles Wolfson Centre of Reconstructive Surgery, University College London, Royal Free Hospital, London, UK
- Department of Plastic Surgery, Royal Free Hospital, London, UK
- Department of Surgery and Interventional Sciences, University College London, Royal Free Hospital, London, UK
| | - Sara Jasionowska
- Charles Wolfson Centre of Reconstructive Surgery, University College London, Royal Free Hospital, London, UK
- Department of Plastic Surgery, Royal Free Hospital, London, UK
| | - Peter E M Butler
- Charles Wolfson Centre of Reconstructive Surgery, University College London, Royal Free Hospital, London, UK
- Department of Plastic Surgery, Royal Free Hospital, London, UK
- Department of Surgery and Interventional Sciences, University College London, Royal Free Hospital, London, UK
| | - Allan Ponniah
- Charles Wolfson Centre of Reconstructive Surgery, University College London, Royal Free Hospital, London, UK
- Department of Plastic Surgery, Royal Free Hospital, London, UK
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Narui K, Satake T, Ishikawa T, Muto M, Tsunoda Y, Yamada A, Kawashima K, Uenaka N, Fujiwara Y, Oshi M, Adachi S, Suzuki C, Wada T, Yamamoto S, Tanabe M, Maegawa J, Endo I. Endoscopic mastectomy followed by immediate breast reconstruction with fat grafting for breast cancer. Breast Cancer 2024; 31:476-484. [PMID: 38512534 DOI: 10.1007/s12282-024-01561-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 02/24/2024] [Indexed: 03/23/2024]
Abstract
BACKGROUND Although endoscopic mastectomy has been associated with good tolerance and enhanced patient satisfaction, limitations such as the implant or flap size for reconstruction with small incisions remain unresolved. Fat grafting (FG) can expand tissue volume with pinhole skin incisions. Herein, we evaluated the safety and efficacy of endoscopic mastectomy followed by immediate FG. METHODS Patients who underwent endoscopic mastectomy with immediate FG reconstruction from 2015 to 2021 were retrospectively evaluated to establish surgical outcomes and prognosis. RESULTS Twenty-three patients with clinical stage 0 or I breast cancer underwent unilateral endoscopic mastectomy with immediate FG. The median age was 45 years (41-55), and the median body mass index was 19.3 kg/m2 (15.8-26.6). Endoscopically performed procedures included skin-sparing mastectomies in 18 patients (78%) and nipple-sparing mastectomies in five patients (22%). The median procedure duration was 295 min (242-346). The median specimen weight was 133 g (71-334), and the median grafted fat volume was 200 mL (136-320). No patient required reoperation or additional procedures for complications. One patient experienced recurrence at a median follow-up of 56.1 months and underwent resection; the patient was alive without recurrence 54 months post-resection. CONCLUSION To the best of our knowledge, this is the first report of endoscopic mastectomy with immediate FG for reconstruction. When compared with other immediate autologous reconstructions, our strategy could minimize the skin incision and procedure duration, as well as limit complications. Further prospective investigations are needed to evaluate oncological safety, surgical outcomes, and patient satisfaction.
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Affiliation(s)
- Kazutaka Narui
- Department of Breast and Thyroid Surgery, Yokohama City University Medical Center, 4-57 Urafune-Cho, Minami-Ku, Yokohama, Kanagawa, 232-0024, Japan.
| | - Toshihiko Satake
- Department of Plastic, Reconstructive and Aesthetic Surgery, Toyama University Hospital, Toyama, Toyama, Japan
| | - Takashi Ishikawa
- Department of Breast Surgery and Oncology, Tokyo Medical University, Tokyo, Tokyo, Japan
| | - Mayu Muto
- Department of Plastic Surgery, Yokohama City University Medical Center, Yokohama, Japan
| | - Yui Tsunoda
- Department of Plastic Surgery, Yokohama City University Medical Center, Yokohama, Japan
| | - Akimitsu Yamada
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama, Kanagawa, Japan
| | - Kei Kawashima
- Department of Breast and Thyroid Surgery, Yokohama City University Medical Center, 4-57 Urafune-Cho, Minami-Ku, Yokohama, Kanagawa, 232-0024, Japan
| | - Natsuki Uenaka
- Department of Breast Surgery and Oncology, Tokyo Medical University, Tokyo, Tokyo, Japan
| | - Yoshie Fujiwara
- Department of Breast and Thyroid Surgery, Yokohama City University Medical Center, 4-57 Urafune-Cho, Minami-Ku, Yokohama, Kanagawa, 232-0024, Japan
| | - Masanori Oshi
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama, Kanagawa, Japan
| | - Shoko Adachi
- Department of Breast and Thyroid Surgery, Yokohama City University Medical Center, 4-57 Urafune-Cho, Minami-Ku, Yokohama, Kanagawa, 232-0024, Japan
| | - Chiho Suzuki
- Department of Breast and Thyroid Surgery, Yokohama City University Medical Center, 4-57 Urafune-Cho, Minami-Ku, Yokohama, Kanagawa, 232-0024, Japan
| | - Tomoko Wada
- Department of Breast and Thyroid Surgery, Yokohama City University Medical Center, 4-57 Urafune-Cho, Minami-Ku, Yokohama, Kanagawa, 232-0024, Japan
| | - Shinya Yamamoto
- Department of Breast and Thyroid Surgery, Yokohama City University Medical Center, 4-57 Urafune-Cho, Minami-Ku, Yokohama, Kanagawa, 232-0024, Japan
| | - Mikiko Tanabe
- Department of Pathology, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
| | - Jiro Maegawa
- Department of Plastic and Reconstructive Surgery, Yokohama City University Hospital, Yokohama, Kanagawa, Japan
| | - Itaru Endo
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama, Kanagawa, Japan
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Chang YL, Sae-Lim C, Lin SL, Lai HW, Huang HI, Lai YC, Chen ST, Chen DR. Scarless totally implantable venous access port (TIVAP) implantation: Surgical technique, preliminary results, learning curve, and patients-reported outcome in 125 breast cancer patients. Surg Oncol 2024; 53:102048. [PMID: 38412756 DOI: 10.1016/j.suronc.2024.102048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 01/11/2024] [Accepted: 02/12/2024] [Indexed: 02/29/2024]
Abstract
BACKGROUND Minimal-access (endoscopic or robotic-assisted) breast surgery has been increasingly performed and shown better cosmetic results. However, location of totally implantable venous access port (TIVAP) for systemic treatment at anterior chest may compromise its aesthetic benefits. Therefore, we proposed a new scarless technique for TIVAP implantation, and reported the preliminary results, learning curve, and patients-surveyed outcome. METHODS Surgical technique of the new "scarless" TIVAP implantation was proposed. Patients receiving this procedure in a single institution were included. The preliminary results of the scarless TIVAP implantation, learning curve, and patient-reported outcome were analyzed and reported. RESULTS A total of 125 breast cancer patients received scarless TIVAP procedures were enrolled. The primary success rate of the scarless TIVAP implantation was 100%. Mean operative time was 46 ± 14 min. Mean amount of blood loss was 8.5 ± 3.2 ml. The cumulative sum plot showed operation time significantly decreased after 24th cases. In the initial learning phase, the mean operative time was 55 ± 17 min, and decreased to 43 ± 12 min in the later mature phase (P = 0.003). There were 5 (4%) complications detected, which included 1 (0.8%) seroma formation, 2 (1.6%) revisions, and 2 (1.6%) unplanned explantations. From patients-evaluated questionnaires, more than 90% of responders were satisfied with aesthetic results, experience during surgery, and application of scarless TIVAP for systemic therapy. CONCLUSIONS The scarless TIVAP implantation is a safe & reliable procedure with high patients-reported aesthetic satisfaction, and could be an alternative TIVAP procedure for patients requiring chemotherapy and desiring a less noticeable scar.
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Affiliation(s)
- Yi-Lin Chang
- Division of General Surgery, Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan; Division of Breast Surgery, Yuanlin Christian Hospital, Yuanlin, Taiwan.
| | - Chayanee Sae-Lim
- Department of Surgery, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
| | - Shih-Lung Lin
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan.
| | - Hung-Wen Lai
- Division of General Surgery, Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan; Division of Breast Surgery, Yuanlin Christian Hospital, Yuanlin, Taiwan; Endoscopic & Oncoplastic Breast Surgery Center, Changhua Christian Hospital, Changhua, Taiwan; Comprehensive Breast Cancer Center, Changhua Christian Hospital, Changhua, Taiwan; Minimal Invasive Surgery Research Center, Changhua Christian Hospital, Changhua, Taiwan; Kaohsiung Medical University, Kaohsiung, Taiwan; School of Medicine, Chung Shan Medical University, Taichung, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
| | - Hsin-I Huang
- Department of Information Management, National Sun-Yat-Sen University, Kaohsiung, Taiwan.
| | - Yuan-Chieh Lai
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan.
| | - Shou-Tung Chen
- Division of General Surgery, Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan; Comprehensive Breast Cancer Center, Changhua Christian Hospital, Changhua, Taiwan.
| | - Dar-Ren Chen
- Division of General Surgery, Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan; Comprehensive Breast Cancer Center, Changhua Christian Hospital, Changhua, Taiwan.
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Wong AWJ, Kuo WL, Cheong DCF, Tsai HP, Kao SW, Chen CF, Huang JJ. Six steps for a successful aesthetic free flap reconstruction after minimally invasive mastectomy: a retrospective case-control study. Int J Surg 2024; 110:645-653. [PMID: 38000051 PMCID: PMC10871604 DOI: 10.1097/js9.0000000000000871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 10/22/2023] [Indexed: 11/26/2023]
Abstract
OBJECTIVE Breast cancer treatment has evolved to the modern skin-sparing mastectomy and nipple-sparing mastectomy. To better perform these surgeries, minimally invasive techniques using the endoscope, or Da Vinci Robotic Surgery platform have been developed. The deep inferior epigastric perforator (DIEP) flap is the gold standard in breast reconstruction, but it is still not commonly performed after minimally invasive mastectomy due technical difficulty. Here the authors introduced six key steps to a successful aesthetic autologous free flap reconstruction in in minimally invasive mastectomies. METHODS There are six main steps to our technique: placement of mastectomy incision, precise flap design after angiography studies, trial of shaping, transcutaneous medial suture, footprint recreation and postoperative shaping with bra. Between November 2018 and July 2022, a total of 67 immediate breast reconstructions using free perforator flaps were performed in 63 patients after minimally invasive nipple-sparing mastectomy. RESULTS The results from the minimally invasive mastectomy group were compared with a group of conventional mastectomy patients ( n= 41) performed during the same period. There were no significant differences in flap exploration rates. One hundred percent of the flaps survived. In the minimally invasive group, the final scar was placed in the lateral region, where it would be hidden from the anterior view. Only 70.7% of the conventional mastectomy group could achieve a hidden lateral scar ( P <0.001). The aesthetic revision rates were similar between two groups. CONCLUSION With attention to the six steps above, autologous free flap reconstruction can be offered reliably in the setting of minimally invasive mastectomy.
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Affiliation(s)
- Allen Wei-Jiat Wong
- Departments of Plastic and Reconstructive Surgery
- Plastic, Reconstructive & Aesthetic Surgery Service, Sengkang General Hospital, Singapore
| | - Wen-Ling Kuo
- General Surgery
- Center for Tissue Engineering
- College of Medicine, Chang Gung University, Taoyuan
- School of Medicine, National Tsing Hua University, Hsinchu, Taiwan
| | - David Chon-Fok Cheong
- Departments of Plastic and Reconstructive Surgery
- College of Medicine, Chang Gung University, Taoyuan
| | - Hsiu-Pei Tsai
- General Surgery
- College of Medicine, Chang Gung University, Taoyuan
| | - Shu-Wei Kao
- Departments of Plastic and Reconstructive Surgery
| | - Chia-Fang Chen
- Departments of Plastic and Reconstructive Surgery
- College of Medicine, Chang Gung University, Taoyuan
| | - Jung-Ju Huang
- Departments of Plastic and Reconstructive Surgery
- College of Medicine, Chang Gung University, Taoyuan
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Nessa A, Shaikh S, Fuller M, Masannat YA, Kastora SL. Postoperative complications and surgical outcomes of robotic versus conventional nipple-sparing mastectomy in breast cancer: meta-analysis. Br J Surg 2024; 111:znad336. [PMID: 37890072 PMCID: PMC10769157 DOI: 10.1093/bjs/znad336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 07/04/2023] [Accepted: 09/27/2023] [Indexed: 10/29/2023]
Abstract
BACKGROUND Breast cancer is the most common cancer worldwide, with remarkable advances in early diagnosis, systemic treatments, and surgical techniques. Robotic nipple-sparing mastectomy has been trialled; however, the complication rates, surgical outcomes, and oncological safety of this approach remain obscure. METHODS A systematic search of the literature was conducted from conception until September 2022. Studies examining complications and operative variables where robotic nipple-sparing mastectomy was compared with conventional nipple-sparing mastectomy were included. Primary study outcomes were complications (Clavien-Dindo grade III complications, skin or nipple necrosis, seroma, haematoma, infection, implant loss, and wound dehiscence) and oncological safety (recurrence and positive margins). The secondary outcomes included operative variables, length of stay, cost-effectiveness, learning curve, and aesthetic outcome. RESULTS A total of seven studies of overall fair quality, involving 1674 patients, were included in the systematic review and meta-analysis. Grade 3 complications were reduced in robotic nipple-sparing mastectomy without statistical significance (OR 0.60 (95 per cent c.i. 0.35 to 1.05)). Nipple necrosis was significantly reduced in robotic nipple-sparing mastectomy (OR 0.54 (95 per cent c.i. 0.30 to 0.96); P = 0.03; I2 = 15 per cent). Operating time (mean difference +58.81 min (95 per cent c.i. +28.19 to +89.44 min); P = 0.0002) and length of stay (mean difference +1.23 days (95 per cent c.i. +0.64 to +1.81 days); P < 0.0001) were significantly increased in robotic nipple-sparing mastectomy, whereas the opposite was true for blood loss (mean difference -53.18 ml (95 per cent c.i. -71.78 to -34.58 ml); P < 0.0001). CONCLUSION Whilst still in its infancy, robotic breast surgery may become a viable option in breast surgery. Nonetheless, the oncological safety of this approach requires robust assessment.
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Affiliation(s)
- Ashrafun Nessa
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
- General Surgery, Aberdeen Royal Infirmary, Aberdeen, UK
- Breast Surgery, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Shafaque Shaikh
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
- General Surgery, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Mairi Fuller
- Breast Surgery, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Yazan A Masannat
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
- Breast Surgery, Aberdeen Royal Infirmary, Aberdeen, UK
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Chen K, Zhang J, Beeraka NM, Song D, Sinelnikov MY, Lu P. Robot-assisted nipple-sparing mastectomy and immediate breast reconstruction with gel implant and latissimus dorsi muscle flap: Our initial experience. Int J Med Robot 2023; 19:e2528. [PMID: 37194617 DOI: 10.1002/rcs.2528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 05/04/2023] [Accepted: 05/08/2023] [Indexed: 05/18/2023]
Abstract
BACKGROUND This study reports the preliminary results of da Vinci robot XI robot-assisted nipple-sparing mastectomy immediate breast reconstruction (R-NSMIBR) with gel implant and latissimus dorsi muscle flap. METHODS A total of 15 patients who underwent R-NSMIBR with gel implant and latissimus dorsi muscle flap surgery for breast cancer between September 2022 and November 2022 were evaluated. RESULTS Mean total operative time for R-NSMIBR was 361.9 ± 77.0 min. As the learning curve increased, the robot arm docking time decreased rapidly from the initial 25-10 min. Average total blood loss was 27.8 ± 10.7 mL and posterior surgical margin positivity rate was 0%. Perioperative complications and local recurrences or deaths were not observed at a mean follow-up of 3 ± 1 month 15 patients were satisfied with postoperative aesthetic results. CONCLUSIONS R-NSMIBR with a gel implant and latissimus dorsi muscle flap could be a new therapeutic option for breast reconstruction.
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Affiliation(s)
- Kuo Chen
- Department of Breast Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jin Zhang
- Department of Pharmacology and Toxicology, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Narasimha M Beeraka
- Raghavendra Institute of Pharmaceutical Education and Research (RIPER), Anantapur, India
- Department of Human Anatomy, I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russian Federation
| | - Dajiang Song
- Department of Oncology Plastic Surgery, Hunan Province Cancer Hospital and the Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, Hunan, China
| | - Mikhail Y Sinelnikov
- Department of Human Anatomy, I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russian Federation
- Sinelab Biomedical Research Centre, Minnesota, New York, USA
- Research Institute of Human Morphology, Russian Scientific Center of Surgery, Moscow, Russia
| | - Pengwei Lu
- Department of Breast Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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Wu WP, Lai HW, Liao CY, Lin J, Huang HI, Chen ST, Chou CT, Chen DR. Use of Magnetic Resonance Imaging for Evaluating Residual Breast Tissue After Robotic-Assisted Nipple-Sparing Mastectomy in Women With Early Breast Cancer. Korean J Radiol 2023; 24:640-646. [PMID: 37404106 DOI: 10.3348/kjr.2022.0708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 04/03/2023] [Accepted: 05/17/2023] [Indexed: 07/06/2023] Open
Abstract
OBJECTIVE Prospective studies on postoperative residual breast tissue (RBT) after robotic-assisted nipple-sparing mastectomy (R-NSM) for breast cancer are limited. RBT presents an unknown risk of local recurrence or the development of new cancer after curative or risk-reducing mastectomies. This study investigated the technical feasibility of using magnetic resonance imaging (MRI) to evaluate RBT after R-NSM in women with breast cancer. MATERIALS AND METHODS In this prospective pilot study, 105 patients, who underwent R-NSM for breast cancer at Changhua Christian Hospital between March 2017 and May 2022, were subjected to postoperative breast MRI to evaluate the presence and location of RBT. The postoperative MRI scans of 43 patients (age, 47.8 ± 8.5 years), with existing preoperative MRI scans, were evaluated for the presence and location of RBT. In total, 54 R-NSM procedures were performed. In parallel, we reviewed the literature on RBT after nipple-sparing mastectomy, considering its prevalence. RESULTS RBT was detected in 7 (13.0%) of the 54 mastectomies (6 of the 48 therapeutic mastectomies and 1 of the 6 prophylactic mastectomies). The most common location for RBT was behind the nipple-areolar complex (5 of 7 [71.4%]). Another RBT was found in the upper inner quadrant (2 of 7 [28.6%]). Among the six patients who underwent RBT after therapeutic mastectomies, one patient developed a local recurrence of the skin flap. The other five patients with RBT after therapeutic mastectomies remained disease-free. CONCLUSION R-NSM, a surgical innovation, does not seem to increase the prevalence of RBT, and breast MRI showed feasibility as a noninvasive imaging tool for evaluating the presence and location of RBT.
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Affiliation(s)
- Wen-Pei Wu
- Department of Radiology, Changhua Christian Hospital, Changhua, Taiwan
- Department of Biomedical Imaging and Radiological Sciences, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hung-Wen Lai
- Kaohsiung Medical University, Kaohsiung, Taiwan
- Division of General Surgery, Changhua Christian Hospital, Changhua, Taiwan
- Comprehensive Breast Cancer Center, Changhua Christian Hospital, Changhua, Taiwan
- Endoscopic and Oncoplastic Breast Surgery Center, Changhua Christian Hospital, Changhua, Taiwan
- Minimally Invasive Surgery Research Center, Changhua Christian Hospital, Changhua, Taiwan
- Division of Breast Surgery, Yuanlin Christian Hospital, Yuanlin, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
| | - Chiung-Ying Liao
- Department of Radiology, Changhua Christian Hospital, Changhua, Taiwan
| | - Joseph Lin
- Division of General Surgery, Changhua Christian Hospital, Changhua, Taiwan
- Comprehensive Breast Cancer Center, Changhua Christian Hospital, Changhua, Taiwan
| | - Hsin-I Huang
- Department of Information Management, National Sun Yat-sen University, Kaohsiung, Taiwan
- We-Sing Breast Hospital, Kaohsiung, Taiwan
| | - Shou-Tung Chen
- Division of General Surgery, Changhua Christian Hospital, Changhua, Taiwan
- Comprehensive Breast Cancer Center, Changhua Christian Hospital, Changhua, Taiwan
| | - Chen-Te Chou
- Department of Radiology, Changhua Christian Hospital, Changhua, Taiwan
- Department of Biomedical Imaging and Radiological Sciences, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Dar-Ren Chen
- Division of General Surgery, Changhua Christian Hospital, Changhua, Taiwan
- Comprehensive Breast Cancer Center, Changhua Christian Hospital, Changhua, Taiwan
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10
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Park KU, Cha C, Pozzi G, Kang YJ, Gregorc V, Sapino A, Gazzetta G, Marrazzo E, Toesca A. Robot-assisted Nipple Sparing Mastectomy: Recent Advancements and Ongoing Controversies. CURRENT BREAST CANCER REPORTS 2023; 15:127-134. [PMID: 37293274 PMCID: PMC10133895 DOI: 10.1007/s12609-023-00487-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2023] [Indexed: 06/10/2023]
Abstract
Purpose of review The purpose of this review is to summarize the recent technical advancements in RNSM, describe the ongoing teaching programs, and discuss the ongoing controversies. Recent findings Robot-assisted nipple sparing mastectomy (RNSM) is the newest addition to the armamentarium of surgical techniques for patients who require a mastectomy. The potential benefits of using the da Vinci® Robotic Surgical System (Intuitive Surgical, Sunnyvale, CA) are the small 3D camera and lighting offering superior visualization, the Endowrist robotic instruments offering greater range of motion, and surgeon being at a seated position at the console rendering a more ergonomic operating position. Summary RNSM can potentially help overcome the technical difficulties of performing a conventional NSM. Further studies are needed to elucidate the oncologic safety and cost-effectiveness of RNSM.
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Affiliation(s)
- Ko Un Park
- Division of Breast Surgery, Department of Surgery, Brigham and Women’s Hospital, Breast Oncology Program, Dana-Farber Brigham Cancer Center, Dana-Farber Cancer Institute, Harvard Medical School, 450 Brookline Avenue, Boston, MA 02215 USA
- Division of Surgical Oncology, Department of Surgery, The Ohio State University James Comprehensive Cancer Center, Columbus, OH USA
| | - Chihwan Cha
- Department of Surgery, Hanyang University Seoul Hospital, Seoul, Republic of Korea
| | - Giada Pozzi
- Division of Breast Surgery, Candiolo Cancer Institute, FPO-IRCCS, Candiolo (To), Italy
| | - Young-Joon Kang
- Department of Surgery, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Incheon, Republic of Korea
| | - Vanesa Gregorc
- Department of Oncology, Candiolo Cancer Institute, FPO-IRCCS, Candiolo (To), Italy
| | - Anna Sapino
- Unit of Pathology, Candiolo Cancer Institute, FPO-IRCCS, Department of Medical Science, University of Turin, Turin, Italy
| | - Guglielmo Gazzetta
- Division of Breast Surgery, Candiolo Cancer Institute, FPO-IRCCS, Candiolo (To), Italy
| | - Emilia Marrazzo
- Breast Unit, Department of Surgery, Ospedale Maggiore Di Lodi, Lodi, Italy
| | - Antonio Toesca
- Division of Breast Surgery, Candiolo Cancer Institute, FPO-IRCCS, Candiolo (To), Italy
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11
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Fernandez-Pacheco M, Ortmann O, Ignatov A, Inwald EC. Does cavity margin shaving reduce residual tumor and re-excision rates? A systematic review. Arch Gynecol Obstet 2023; 307:1295-1309. [PMID: 35593951 PMCID: PMC10023760 DOI: 10.1007/s00404-022-06512-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 03/06/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE Cavity shaving (CS) is a surgical technique used in the treatment of breast cancer (BC). It may reduce margin positivity in histologic assessment and consequently reduces re- excision rates in breast conserving surgery (BCS). The evidence for this assumption is described in the present review. METHODS A systematic review of relevant literature in English from January 1999 to April 2019 was conducted. The analysis included studies on CS and its effects on re-excision rates and margin positivity. We searched PubMed databases for relevant publications. In total, 22 studies were included in the present review. RESULTS The benefit from CS on re-excision rates and histologic margin positivity was variable. Out of 22 studies, 17 reported a reduction in both re-excision rates and histologic margin positivity in margin shaved patients. Four studies could not find a significant reduction of second surgeries and residual tumor rates. One study suggested that CS after BCS was superior to single BCS only in subgroup analysis in IDC tumors. CONCLUSION CS is a surgical technique that was shown to reduce re-excision and margin positivity rates in most of the studies. Furthermore, it can be a useful tool to assess specimen margins and detect multifocality.
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Affiliation(s)
- M Fernandez-Pacheco
- Department of Gynaecology and Obstetrics, University Medical Center Regensburg, Landshuter Straße 65, 93053, Regensburg, Germany.
| | - O Ortmann
- Department of Gynaecology and Obstetrics, University Medical Center Regensburg, Landshuter Straße 65, 93053, Regensburg, Germany
| | - A Ignatov
- Department of Gynaecology and Obstetrics, University Medical Center Regensburg, Landshuter Straße 65, 93053, Regensburg, Germany
| | - E C Inwald
- Department of Gynaecology and Obstetrics, University Medical Center Regensburg, Landshuter Straße 65, 93053, Regensburg, Germany
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12
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Egan KG, Selber JC. Modern Innovations in Breast Surgery: Robotic Breast Surgery and Robotic Breast Reconstruction. Clin Plast Surg 2023; 50:357-366. [PMID: 36813413 DOI: 10.1016/j.cps.2022.11.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Robotic surgery has a history of applications in multiple surgical areas and has been applied in plastic surgery over the past decade. Robotic surgery allows for minimal access incisions and decreased donor site morbidity in breast extirpative surgery, breast reconstruction, and lymphedema surgery. Although a learning curve exists for the use of this technology, it can be safely applied with careful preoperative planning. Robotic nipple-sparing mastectomy may be combined with either robotic alloplastic or robotic autologous reconstruction in the appropriate patient.
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Affiliation(s)
- Katie G Egan
- The University of Texas M.D. Anderson Cancer Center, 1400 Pressler St., Unit 1488, Houston, TX 77030, USA
| | - Jesse C Selber
- The University of Texas M.D. Anderson Cancer Center, 1400 Pressler St., Unit 1488, Houston, TX 77030, USA.
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13
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Weinzierl A, Schmauss D, Brucato D, Harder Y. Implant-Based Breast Reconstruction after Mastectomy, from the Subpectoral to the Prepectoral Approach: An Evidence-Based Change of Mind? J Clin Med 2022; 11:jcm11113079. [PMID: 35683465 PMCID: PMC9181810 DOI: 10.3390/jcm11113079] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 05/16/2022] [Accepted: 05/27/2022] [Indexed: 01/15/2023] Open
Abstract
Over the last years, prepectoral implant-based breast reconstruction has undergone a renaissance due to several technical advancements regarding mastectomy techniques and surgical approaches for the placement and soft tissue coverage of silicone implants. Initially abandoned due to the high incidence of complications, such as capsular contraction, implant extrusion, and poor aesthetic outcome, the effective prevention of these types of complications led to the prepectoral technique coming back in style for the ease of implant placement and the conservation of the pectoralis muscle function. Additional advantages such as a decrease of postoperative pain, animation deformity, and operative time contribute to the steady gain in popularity. This review aims to summarize the factors influencing the trend towards prepectoral implant-based breast reconstruction and to discuss the challenges and prospects related to this operative approach.
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Affiliation(s)
- Andrea Weinzierl
- Institute for Clinical & Experimental Surgery, Saarland University, 66421 Homburg, Germany;
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Daniel Schmauss
- Department of Plastic, Reconstructive and Aesthetic Surgery, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale (EOC), 6900 Lugano, Switzerland; (D.S.); (D.B.)
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, 6900 Lugano, Switzerland
| | - Davide Brucato
- Department of Plastic, Reconstructive and Aesthetic Surgery, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale (EOC), 6900 Lugano, Switzerland; (D.S.); (D.B.)
| | - Yves Harder
- Department of Plastic, Reconstructive and Aesthetic Surgery, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale (EOC), 6900 Lugano, Switzerland; (D.S.); (D.B.)
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, 6900 Lugano, Switzerland
- Correspondence:
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14
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Go J, Ahn JH, Park JM, Choi SB, Lee J, Kim JY, Park HS. Analysis of robot-assisted nipple-sparing mastectomy using the da Vinci SP system. J Surg Oncol 2022; 126:417-424. [PMID: 35622078 DOI: 10.1002/jso.26915] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 04/24/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND As patients tend to be diagnosed with breast cancer at an early stage, the demand for better cosmetic outcomes has increased. Several studies revealed that robot-assisted nipple-sparing mastectomy (RNSM) shows favorable outcomes. The aim of the study was to reveal the feasibility of RNSM using the da Vinci single-port (SP) system with a minimal incision, hidden in the arm. METHODS From 2018 to 2021, 81 cases (70 patients) were retrospectively reviewed. Clinicopathologic characteristics, operative outcomes, and postoperative complications were evaluated. The operative outcomes were analyzed using the Mann-Whitney U test. RESULTS The median age was 42 years (range, 26-60 years). Bilateral RNSM was performed in 11 (27.2%) patients. The median size of the initial skin incision was 40 mm (range, 20-55 mm). Immediate reconstruction with direct-to-implant was performed in 54 (66.7%) patients and deep inferior epigastric perforator (DIEP) flaps in 15 (18.5%) patients. Postoperative complications of Clavien-Dindo Classification III occurred in six (7.5%) patients. Patients reconstructed with a DIEP flap had large breasts with more severe ptosis, yet grade III complications did not occur. CONCLUSIONS RNSM using the SP system can be applied for curative and risk-reducing mastectomy, regardless of breast size or ptosis grade.
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Affiliation(s)
- Jieon Go
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Jee Hyun Ahn
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Jung Min Park
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Soon Bo Choi
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Jeea Lee
- Department of Surgery, Uijeongbu Eulji Medical Center Eulji University, Gyeonggi-do, Korea
| | - Jee Ye Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Hyung Seok Park
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
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15
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Robot-Assisted Minimally Invasive Breast Surgery: Recent Evidence with Comparative Clinical Outcomes. J Clin Med 2022; 11:jcm11071827. [PMID: 35407434 PMCID: PMC8999956 DOI: 10.3390/jcm11071827] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 03/19/2022] [Accepted: 03/23/2022] [Indexed: 12/24/2022] Open
Abstract
In recent times, robot-assisted surgery has been prominently gaining pace to minimize overall postsurgical complications with minimal traumatization, due to technical advancements in telerobotics and ergonomics. The aim of this review is to explore the efficiency of robot-assisted systems for executing breast surgeries, including microsurgeries, direct-to-implant breast reconstruction, deep inferior epigastric perforators-based surgery, latissimus dorsi breast reconstruction, and nipple-sparing mastectomy. Robot-assisted surgery systems are efficient due to 3D-based visualization, dexterity, and range of motion while executing breast surgery. The review describes the comparative efficiency of robot-assisted surgery in relation to conventional or open surgery, in terms of clinical outcomes, morbidity rates, and overall postsurgical complication rates. Potential cost-effective barriers and technical skills were also delineated as the major limitations associated with these systems in the clinical sector. Furthermore, instrument articulation of robot-assisted surgical systems (for example, da Vinci systems) can enable high accuracy and precision surgery due to its promising ability to mitigate tremors at the time of surgery, and shortened learning curve, making it more beneficial than other open surgery procedures.
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16
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Gui Y, Chen Q, Li S, Yang X, Liu J, Wu X, Zhu Y, Fan L, Jiang J, Chen L. Safety and Feasibility of Minimally Invasive (Laparoscopic/Robotic-Assisted) Nipple-Sparing Mastectomy Combined with Prosthesis Breast Reconstruction in Breast Cancer: A Single-Center Retrospective Study. Ann Surg Oncol 2022; 29:10.1245/s10434-022-11420-8. [PMID: 35171405 DOI: 10.1245/s10434-022-11420-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 12/26/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Minimally invasive (robotic or laparoscopic-assisted) nipple-sparing mastectomy combined with prosthesis breast reconstruction (NSM-PBR) is associated with smaller scars and greater patient satisfaction. However, the oncological safety of minimally invasive NSM-PBR remains controversial. PATIENTS AND METHODS This was a retrospective study of patients with breast cancer who underwent breast reconstruction between 1 January 2006 and 20 February 2021. Demographic and clinicopathological characteristics, operation information, postoperative complications, and survival outcomes were analyzed. RESULTS In all, 292 patients underwent minimally invasive NSM-PBR and 205 underwent open NSM-PBR for breast cancer. In the minimally invasive NSM-PBR group, 268 (91.8%) patients underwent laparoscopy and 24 (8.2%) patients underwent robot-assisted NSM-PBR. Mean operation time in the minimally invasive NSM-PBR group was significantly longer than that in the open NSM-PBR group (P = 0.023). Mean intraoperative blood loss was significantly less in the minimally invasive NSM-PBR group (P < 0.05). There was no significant between-group difference in total complications. Similarly, there were no significant between-group differences in overall survival, recurrence-free survival, and local recurrence rate (P = 0.450, P = 0.613, and P = 0.679, respectively). CONCLUSIONS The complication, recurrence, and mortality rates in minimally invasive NSM-PBR group were comparable to those in open NSM-PBR group. Our preliminary results are encouraging and suggest that minimally invasive NSM-PBR affords good cosmetic results and its oncological safety is comparable to that of open surgery.
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Affiliation(s)
- Yu Gui
- Breast Disease Center, Southwest Hospital, Army Medical University, Chongqing, China
| | - Qingqiu Chen
- Breast Disease Center, Southwest Hospital, Army Medical University, Chongqing, China
| | - Shichao Li
- Breast Disease Center, Southwest Hospital, Army Medical University, Chongqing, China
| | - Xi Yang
- Breast Disease Center, Southwest Hospital, Army Medical University, Chongqing, China
| | - Jing Liu
- Breast Disease Center, Southwest Hospital, Army Medical University, Chongqing, China
| | - Xin Wu
- Breast Disease Center, Southwest Hospital, Army Medical University, Chongqing, China
| | | | - Linjun Fan
- Breast Disease Center, Southwest Hospital, Army Medical University, Chongqing, China
| | - Jun Jiang
- Breast Disease Center, Southwest Hospital, Army Medical University, Chongqing, China
| | - Li Chen
- Breast Disease Center, Southwest Hospital, Army Medical University, Chongqing, China.
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17
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Lai HW, Chen ST, Lin YJ, Lin SL, Lin CM, Chen DR, Kuo SJ. 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. Front Oncol 2021; 11:739144. [PMID: 34868935 PMCID: PMC8640170 DOI: 10.3389/fonc.2021.739144] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 10/22/2021] [Indexed: 12/16/2022] Open
Abstract
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.
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Affiliation(s)
- Hung-Wen Lai
- Endoscopic and Oncoplastic Breast Surgery Center, Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan.,Division of General Surgery, Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan.,Comprehensive Breast Cancer Center, Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan.,Minimal Invasive Surgery Research Center, Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan.,Department of Surgery, Kaohsiung Medical University, Kaohsiung, Taiwan.,Division of Breast Surgery, Department of Surgery, Yuanlin Christian Hospital, Yuanlin, Taiwan.,Department of Surgery, School of Medicine, National Yang Ming University, Taipei, Taiwan.,Department of Surgery, School of Medicine, Chung Shan Medical University, Taichung, Taiwan.,Department of Surgery, Chang Gung University College of Medicine, Taoyuan City, Taiwan.,Division of General Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Shou-Tung Chen
- Endoscopic and Oncoplastic Breast Surgery Center, Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan.,Division of General Surgery, Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan.,Comprehensive Breast Cancer Center, Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan
| | - Ying-Jen Lin
- Tumor Center, Changhua Christian Hospital, Changhua, Taiwan
| | - Shih-Lung Lin
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan
| | - Ching-Min Lin
- Division of General Surgery, Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan.,Department of Surgery, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Dar-Ren Chen
- Endoscopic and Oncoplastic Breast Surgery Center, Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan.,Division of General Surgery, Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan.,Comprehensive Breast Cancer Center, Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan
| | - Shou-Jen Kuo
- Endoscopic and Oncoplastic Breast Surgery Center, Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan.,Division of General Surgery, Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan.,Comprehensive Breast Cancer Center, Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan
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18
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Park KU, Lee S, Sarna A, Chetta M, Schulz S, Agnese D, Grignol V, Carson W, Skoracki RJ. Prospective pilot study protocol evaluating the safety and feasibility of robot-assisted nipple-sparing mastectomy (RNSM). BMJ Open 2021; 11:e050173. [PMID: 34782341 PMCID: PMC8593753 DOI: 10.1136/bmjopen-2021-050173] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Nipple-sparing mastectomy (NSM) can be performed for the treatment of breast cancer and risk reduction, but total mammary glandular excision in NSM can be technically challenging. Minimally invasive robot-assisted NSM (RNSM) has the potential to improve the ergonomic challenges of open NSM. Recent studies in RNSM demonstrate the feasibility and safety of the procedure, but this technique is still novel in the USA. METHODS AND ANALYSIS This is a single-arm prospective pilot study to determine the safety, efficacy and potential risks of RNSM. Up to 12 RNSM will be performed to assess the safety and feasibility of the procedure. Routine follow-up visits and study assessments will occur at 14 days, 30 days, 6 weeks, 6 months and 12 months. The primary outcome is to assess the feasibility of removing the breast gland en bloc using the RNSM technique. To assess safety, postoperative complication information will be collected. Secondary outcomes include defining benefits and challenges of RNSM for both surgeons and patients using surveys, as well as defining the breast and nipple-areolar complex sensation recovery following RNSM. Mainly, descriptive analysis will be used to report the findings. ETHICS AND DISSEMINATION The RNSM protocol was reviewed and approved by the US Food and Drug Administration using the Investigational Device Exemption mechanism (reference number G200096). In addition, the protocol was registered with ClinicalTrials.gov (NCT04537312) and approved by The Ohio State University Institutional Review Board, reference number 2020C0094 (18 August 2020). The results of this study will be distributed through peer-reviewed journals and presented at surgical conferences. TRIAL REGISTRATION NUMBER NCT04537312.
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Affiliation(s)
- Ko Un Park
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Sandy Lee
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Angela Sarna
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Matthew Chetta
- Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Steven Schulz
- Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Doreen Agnese
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Valerie Grignol
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - William Carson
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Roman J Skoracki
- Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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19
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Huang JJ, Chuang EYH, Cheong DCF, Kim BS, Chang FCS, Kuo WL. Robotic-assisted nipple-sparing mastectomy followed by immediate microsurgical free flap reconstruction: Feasibility and aesthetic results - Case series. Int J Surg 2021; 95:106143. [PMID: 34666195 DOI: 10.1016/j.ijsu.2021.106143] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 10/05/2021] [Accepted: 10/07/2021] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Jung-Ju Huang
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan College of Medicine, Chang Gung University, Taoyuan, Taiwan Center for Tissue Engineering, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan Department of General Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan Division of Breast Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Switzerland Division of Craniofacial Surgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
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20
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Magnoni F, Alessandrini S, Alberti L, Polizzi A, Rotili A, Veronesi P, Corso G. Breast Cancer Surgery: New Issues. ACTA ACUST UNITED AC 2021; 28:4053-4066. [PMID: 34677262 PMCID: PMC8534635 DOI: 10.3390/curroncol28050344] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 10/06/2021] [Accepted: 10/07/2021] [Indexed: 12/24/2022]
Abstract
Since ancient times, breast cancer treatment has crucially relied on surgeons and clinicians making great efforts to find increasingly conservative approaches to cure the tumor. In the Halstedian era (mid-late 19th century), the predominant practice consisted of the radical and disfiguring removal of the breast, much to the detriment of women's psycho-physical well-being. Thanks to enlightened scientists such as Professor Umberto Veronesi, breast cancer surgery has since impressively progressed and adopted a much more conservative approach. Over the last three decades, a better understanding of tumor biology and of its significant biomarkers has made the assessment of genetic and molecular profiles increasingly important. At the same time, neo-adjuvant treatments have been introduced, and great improvements in genetics, imaging technologies and in both oncological and reconstructive surgical techniques have been made. The future of breast cancer management must now rest on an ever more precise and targeted type of surgery that, through an increasingly multidisciplinary and personalized approach, can ensure oncological radicality while offering the best possible quality of life.
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Affiliation(s)
- Francesca Magnoni
- Division of Breast Surgery, IEO European Institute of Oncology, IRCCS, 20141 Milan, Italy; (S.A.); (L.A.); (A.P.); (P.V.); (G.C.)
- Correspondence:
| | - Sofia Alessandrini
- Division of Breast Surgery, IEO European Institute of Oncology, IRCCS, 20141 Milan, Italy; (S.A.); (L.A.); (A.P.); (P.V.); (G.C.)
| | - Luca Alberti
- Division of Breast Surgery, IEO European Institute of Oncology, IRCCS, 20141 Milan, Italy; (S.A.); (L.A.); (A.P.); (P.V.); (G.C.)
| | - Andrea Polizzi
- Division of Breast Surgery, IEO European Institute of Oncology, IRCCS, 20141 Milan, Italy; (S.A.); (L.A.); (A.P.); (P.V.); (G.C.)
| | - Anna Rotili
- Division of Breast Radiology, IEO European Institute of Oncology, IRCCS, 20141 Milan, Italy;
| | - Paolo Veronesi
- Division of Breast Surgery, IEO European Institute of Oncology, IRCCS, 20141 Milan, Italy; (S.A.); (L.A.); (A.P.); (P.V.); (G.C.)
- Department of Oncology and Hemato-Oncology, University of Milan, 20122 Milan, Italy
| | - Giovanni Corso
- Division of Breast Surgery, IEO European Institute of Oncology, IRCCS, 20141 Milan, Italy; (S.A.); (L.A.); (A.P.); (P.V.); (G.C.)
- Department of Oncology and Hemato-Oncology, University of Milan, 20122 Milan, Italy
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21
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Lai HW, Chen ST, Liao CY, Mok CW, Lin YJ, Chen DR, Kuo SJ. Oncologic Outcome of Endoscopic Assisted Breast Surgery Compared with Conventional Approach in Breast Cancer: An Analysis of 3426 Primary Operable Breast Cancer Patients from Single Institute with and Without Propensity Score Matching. Ann Surg Oncol 2021; 28:7368-7380. [PMID: 33974198 DOI: 10.1245/s10434-021-09950-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 03/18/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Endoscopy-assisted breast surgery (EABS) performed through minimal axillary and/or peri-areolar incisions is a possible alternative to conventional breast surgery (CBS) for certain patients with breast cancer. In this study, we report the oncologic safety results of EABS compared with CBS. METHODS Patients underwent EABS for breast cancer during the period June 2010 to March 2020 were collected from the EABS database from single institute, and another cohort of patients, who received CBS, were identified to determine the effectiveness and oncologic safety of EABS. A case-control study was conducted using propensity score matching (PSM) to prevent bias from cases selection. RESULTS A total of 3426 patients were enrolled in the current study, including 405 patients receiving EABS and 3021 underwent CBS. Before PSM, patients selected for EABS tend to be smaller in tumor size, node negative, early stage, low histologic grade, and HER-2 negative. After PSM, 343 patients underwent EABS were compared with another 343 patients received CBS. The margin involved rate in EABS group is 2.6%, and 5.6% in CBS group (p = 0.054) after PSM. In breast conserving cases, the margin involved rates were 2% in EABS group, and 7.2% in CBS group (p = 0.04). In Kaplan-Meier survival curves analysis, there was no difference in local regional recurrence (p = 0.89), distant metastasis (p = 0.08), and overall survival (p = 0.14). CONCLUSION The preliminary oncologic safety analysis from current study showed EABS is a safe procedure and results in low margin involved rate, and no increase of locoregional recurrence, distant metastasis or mortality compared with CBS.
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Affiliation(s)
- Hung-Wen Lai
- Endoscopic and Oncoplastic Breast Surgery Center, Changhua Christian Hospital, 135 Nanxiao Street, Changhua, 500, Taiwan. .,Division of General Surgery, Changhua Christian Hospital, Changhua, Taiwan. .,Comprehensive Breast Cancer Center, Changhua Christian Hospital, Changhua, Taiwan. .,Minimal Invasive Surgery Research Center, Changhua Christian Hospital, Changhua, Taiwan. .,Kaohsiung Medical University, Kaohsiung, Taiwan. .,Division of Breast Surgery, Yuanlin Christian Hospital, Yuanlin, Taiwan. .,School of Medicine, National Yang Ming University, Taipei, Taiwan. .,School of Medicine, Chung Shan Medical University, Taichung, Taiwan. .,Chang Gung University College of Medicine, Taoyuan City, Taiwan. .,Division of General Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.
| | - Shou-Tung Chen
- Endoscopic and Oncoplastic Breast Surgery Center, Changhua Christian Hospital, 135 Nanxiao Street, Changhua, 500, Taiwan.,Division of General Surgery, Changhua Christian Hospital, Changhua, Taiwan.,Comprehensive Breast Cancer Center, Changhua Christian Hospital, Changhua, Taiwan
| | - Chiung-Ying Liao
- Department of Radiology, Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan
| | - Chi Wei Mok
- Division of Breast Surgery, Department of Surgery, Changi General Hospital, Singapore, Singapore
| | - Ying-Jen Lin
- Tumor Center, Changhua Christian Hospital, Changhua, Taiwan
| | - Dar-Ren Chen
- Endoscopic and Oncoplastic Breast Surgery Center, Changhua Christian Hospital, 135 Nanxiao Street, Changhua, 500, Taiwan.,Division of General Surgery, Changhua Christian Hospital, Changhua, Taiwan.,Comprehensive Breast Cancer Center, Changhua Christian Hospital, Changhua, Taiwan
| | - Shou-Jen Kuo
- Endoscopic and Oncoplastic Breast Surgery Center, Changhua Christian Hospital, 135 Nanxiao Street, Changhua, 500, Taiwan.,Division of General Surgery, Changhua Christian Hospital, Changhua, Taiwan.,Comprehensive Breast Cancer Center, Changhua Christian Hospital, Changhua, Taiwan
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22
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Lai HW, Chen ST, Mok CW, Chang YT, Lin SL, Lin YJ, Chen DR, Kuo SJ. Single-Port Three-Dimensional (3D) Videoscope-Assisted Endoscopic Nipple-Sparing Mastectomy in the Management of Breast Cancer: Technique, Clinical Outcomes, Medical Cost, Learning Curve, and Patient-Reported Aesthetic Results from 80 Preliminary Procedures. Ann Surg Oncol 2021; 28:7331-7344. [PMID: 33934239 DOI: 10.1245/s10434-021-09964-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 03/18/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND The preliminary results of an innovative surgical technique, which incorporated single-port three-dimensional (3D) videoscope and instruments for endoscopic nipple-sparing mastectomy (E-NSM), were reported. METHODS The medical records of patients who underwent single-port 3D E-NSM for breast cancer from August 2018 to September 2020 were analyzed, and the preliminary outcome of this procedure as well as the patient-reported aesthetic results are described in this article. RESULTS The study enrolled 70 patients who received 80 procedures of single-port 3D E-NSM. The mean operation time was 158 ± 36 min, and the mean blood loss was 41 ± 26 ml. Three procedures (3.8 %) associated with delayed axillary wound-healing, eight cases of transient nipple ischemia (10 %), three cases of partial nipple ischemia/necrosis (3.7 %), and one case of total nipple-areolar complex (NAC) necrosis (1.3 %) were observed. No patient had margin involvement. Satisfaction rates of approximately 90 % were observed in terms of postoperative scar appearance, location, and length. Most of the patients (87.8 %) reported that they would choose the same operation again if given the chance to do so. The overall cost of a single-port 3D E-NSM was 7522 ± 470 U.S. dollars. According to cumulative sum (CUSUM) plot analysis, about 14 cases were needed for surgeons to familiarize themselves with single-port 3D E-NSM and immediate gel implant reconstruction and to decrease their operation time significantly in the initial learning phase. CONCLUSION Single-port 3D E-NSM, a safe, efficient, lower-cost procedure, is associated with a good aesthetic result. It is a promising new technique for breast cancer patients indicated for mastectomy, but long-term oncologic safety follow-up evaluation still is needed.
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Affiliation(s)
- Hung-Wen Lai
- Endoscopy and Oncoplastic Breast Surgery Center, Changhua, Taiwan. .,Division of General Surgery, Changhua, Taiwan. .,Comprehensive Breast Cancer Center, Changhua, Taiwan. .,Kaohsiung Medical University, Kaohsiung, Taiwan. .,Division of Breast Surgery, Yuanlin Christian Hospital, Yuanlin, Taiwan. .,Minimal Invasive Surgery Research Center, Changhua, Taiwan. .,School of Medicine, Chung Shan Medical University, Taichung, Taiwan. .,School of Medicine, National Yang Ming University, Taipei, Taiwan. .,Chang Gung University College of Medicine, Taoyuan City, Taiwan. .,Division of General Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.
| | - Shou-Tung Chen
- Endoscopy and Oncoplastic Breast Surgery Center, Changhua, Taiwan.,Division of General Surgery, Changhua, Taiwan.,Comprehensive Breast Cancer Center, Changhua, Taiwan
| | - Chi Wei Mok
- Division of Breast Surgery, Department of Surgery, Changi General Hospital, Singapore, Singapore.,Singhealth Duke-NUS Breast Centre, Singapore, Singapore
| | - Yun-Ting Chang
- Endoscopy and Oncoplastic Breast Surgery Center, Changhua, Taiwan.,Minimal Invasive Surgery Research Center, Changhua, Taiwan
| | - Shih-Lung Lin
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Changhua, Taiwan
| | - Ying-Jen Lin
- Tumor Center, Changhua Christian Hospital, Changhua, Taiwan
| | - Dar-Ren Chen
- Endoscopy and Oncoplastic Breast Surgery Center, Changhua, Taiwan.,Division of General Surgery, Changhua, Taiwan.,Comprehensive Breast Cancer Center, Changhua, Taiwan
| | - Shou-Jen Kuo
- Division of General Surgery, Changhua, Taiwan.,Comprehensive Breast Cancer Center, Changhua, Taiwan
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23
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Jeon DN, Kim J, Ko BS, Lee SB, Kim EK, Eom JS, Han HH. Robot-assisted breast reconstruction using the prepectoral anterior tenting method. J Plast Reconstr Aesthet Surg 2021; 74:2906-2915. [PMID: 34023241 DOI: 10.1016/j.bjps.2021.03.120] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 03/12/2021] [Accepted: 03/25/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Prosthetic breast reconstruction in the prepectoral plane with acellular dermal matrix (ADM) support has been gaining popularity and the use of robotic assistance could enhance this procedure. This study introduces robot-assisted prosthetic breast reconstruction using the anterior tenting method. METHODS Sixteen patients (16 breasts) undergoing surgery from July 2019 to April 2020 were included in this study. The breast oncology team performed mastectomies with direct-to-implant (DTI) reconstruction using the da Vinci XiTM (Intuitive Surgical Corp., Sunnyvale, CA, USA) system. The prepectoral plane anterior tenting method using ADM was performed. RESULTS Of the 16 patients, 14 underwent a nipple-sparing mastectomy and two underwent a skin-sparing mastectomy. The average patient age was 44.9 years, body mass index (BMI) was 22.9 kg/m2, and mastectomy weight was 367.6 g. The breast oncology team had an average operating time of 194.7 minutes, and the plastic surgery team had an average operating time of 80.8 minutes. The average postoperative drainage was 943.6 mL, and minor complications occurred in two patients. CONCLUSION With the robot, only a small incision of approximately 4.5 cm is necessary and areas that are not readily visible, such as the side of the axilla, can be accessed during the surgery. Using a smaller ADM size, the implant pocket under the ADM can be easily created under a magnified view. Inframammary fold (IMF) restoration is also possible with robotic surgery and delayed bleeding from the pocket can be easily controlled.
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Affiliation(s)
- Dong Nyeok Jeon
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan, Seoul, South Korea
| | - Jisun Kim
- Division of Breast Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Beom Seok Ko
- Division of Breast Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sae Byul Lee
- Division of Breast Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Eun Key Kim
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan, Seoul, South Korea
| | - Jin Sup Eom
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan, Seoul, South Korea
| | - Hyun Ho Han
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan, Seoul, South Korea.
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24
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Morrow M. Robotic mastectomy: the next major advance in breast cancer surgery? Br J Surg 2021; 108:233-234. [PMID: 33723570 PMCID: PMC10576415 DOI: 10.1093/bjs/znab010] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 12/27/2020] [Indexed: 12/26/2022]
Affiliation(s)
- M Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, USA
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25
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Houvenaeghel G, Barrou J, Jauffret C, Rua S, Sabiani L, Van Troy A, Buttarelli M, Blache G, Lambaudie E, Cohen M, Bannier M. Robotic Versus Conventional Nipple-Sparing Mastectomy With Immediate Breast Reconstruction. Front Oncol 2021; 11:637049. [PMID: 33747960 PMCID: PMC7971115 DOI: 10.3389/fonc.2021.637049] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 01/25/2021] [Indexed: 11/13/2022] Open
Abstract
Background Several studies reported the feasibility and safety of robotic-NSM (R-NSM). The aim of our prospective study was to compare R-NSM and conventional-NSM (C-NSM). Methods We analyzed patients who were operated on with and without robotic assistance (R-NSM or C-NSM) and who received immediate breast reconstruction (IBR) with implant or latissimus dorsi-flap (LDF). The main objective was complication rate and secondary aims were post-operative length of hospitalization (POLH), duration of surgery, and cost. Results We analyzed 87 R-NSM and 142 C-NSM with implant-IBR in 50 and 135 patients, with LDF-IBR in 37 and 7 patients, respectively. Higher durations of surgery and costs were observed for R-NSM, without a difference in POLH and interval time to adjuvant therapy between R-NSM and C-NSM. In the multivariate analysis, R-NSM was not associated with a higher breast complication rate (OR=0.608) and significant factors were breast cup-size, LDF combined with implant-IBR, tobacco and inversed-T incision. Grade 2-3 breast complications rate were 13% for R-NSM and 17.3% for C-NSM, significantly higher for LDF combined with implant-IBR, areolar/radial incisions and BMI>=30. A predictive score was calculated (AUC=0.754). In logistic regression, patient's satisfaction between C-NSM and R-NSM were not significantly different, with unfavorable results for BMI >=25 (OR=2.139), NSM for recurrence (OR=5.371) and primary breast cancer with radiotherapy (OR=4.533). A predictive score was calculated. In conclusion, our study confirms the comparable clinical outcome between C- NSM and R-NSM, in the price of longer surgery and higher cost for R-NSM. Predictive scores of breast complications and satisfaction were significantly associated with factors known in the pre-operative period.
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Affiliation(s)
- Gilles Houvenaeghel
- Department of Surgical Oncology, Paoli Calmettes Institute, Marseille, France.,CRCM, CNRS, INSERM, Aix Marseille Université, Marseille, France
| | - Julien Barrou
- Department of Surgical Oncology, Paoli Calmettes Institute, Marseille, France.,CRCM, CNRS, INSERM, Aix Marseille Université, Marseille, France
| | - Camille Jauffret
- Department of Surgical Oncology, Paoli Calmettes Institute, Marseille, France
| | - Sandrine Rua
- Department of Surgical Oncology, Paoli Calmettes Institute, Marseille, France
| | - Laura Sabiani
- Department of Surgical Oncology, Paoli Calmettes Institute, Marseille, France
| | - Aurore Van Troy
- Department of Surgical Oncology, Paoli Calmettes Institute, Marseille, France
| | - Max Buttarelli
- Department of Surgical Oncology, Paoli Calmettes Institute, Marseille, France
| | - Guillaume Blache
- Department of Surgical Oncology, Paoli Calmettes Institute, Marseille, France
| | - Eric Lambaudie
- Department of Surgical Oncology, Paoli Calmettes Institute, Marseille, France.,CRCM, CNRS, INSERM, Aix Marseille Université, Marseille, France
| | - Monique Cohen
- Department of Surgical Oncology, Paoli Calmettes Institute, Marseille, France
| | - Marie Bannier
- CRCM, CNRS, INSERM, Aix Marseille Université, Marseille, France
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26
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Lee H, Lee J, Lee K, Kim JY, Park HS. Comparison between Gasless and Gas-Inflated Robot-Assisted Nipple-Sparing Mastectomy. J Breast Cancer 2021; 24:183-195. [PMID: 33913274 PMCID: PMC8090802 DOI: 10.4048/jbc.2021.24.e20] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 02/15/2021] [Accepted: 03/16/2021] [Indexed: 12/14/2022] Open
Abstract
Purpose Nipple-sparing mastectomy (NSM) includes various techniques, including conventional or endoscopic mastectomies. Since the introduction of robot-assisted NSM (RANSM) in 2015, 2 main methods have been used: gasless and gas-inflated techniques. The aim of this study was to compare clinicopathologic characteristics, surgical outcomes, and postoperative complications between patients treated with gasless RANSM and those treated with gas-inflated RANSM. Methods We conducted a retrospective study of women who underwent gasless or gas-inflated RANSM with immediate breast reconstruction between November 2016 and May 2019. The indications for RANSM were early breast cancer, interstitial mastopathy, or BRCA1/2 mutation carriers. Clinicopathologic characteristics, surgical outcomes, and postoperative complications were analyzed. The severity of complications was graded using the Clavien-Dindo system. Results A total of 58 RANSM procedures were performed in 46 women: 15 cases of gasless RANSM and 43 cases of gas-inflated RANSM. The proportion of node-negative disease was higher in the gas-inflated group (97.1%) than in the gasless group (69.2%, p = 0.016). Adjuvant radiotherapy was administered in 30.6% of the cases in the gasless group and only 5% of the cases in the gas-inflated group. Other clinicopathological factors were not significantly different between the groups. Regarding surgical outcomes, the initial incision was 1 cm longer in the gasless group (5.17 ± 0.88 cm) than that in the gas-inflated group (4.20 ± 1.05 cm; p = 0.002). The final incision was also longer in the gasless group (5.17 ± 0.88 cm) than that in the gas-inflated group (4.57 ± 1.07 cm; p = 0.040). Operation time, complication rate, and complication grade were not significantly different between the 2 groups. Conclusion In this study, there were no significant differences in surgical outcomes or postoperative complications between gasless and gas-inflated RANSM, except for a longer incision with the gasless technique. Both techniques are reasonable options for RANSM followed by immediate reconstruction.
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Affiliation(s)
- Haemin Lee
- Division of Breast Surgery, Department of Surgery, Breast Cancer Center, Yonsei Cancer Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jeea Lee
- Division of Breast Surgery, Department of Surgery, Breast Cancer Center, Yonsei Cancer Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Kwanbum Lee
- Division of Breast Surgery, Department of Surgery, Breast Cancer Center, Yonsei Cancer Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jee Ye Kim
- Division of Breast Surgery, Department of Surgery, Breast Cancer Center, Yonsei Cancer Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hyung Seok Park
- Division of Breast Surgery, Department of Surgery, Breast Cancer Center, Yonsei Cancer Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
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27
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Quilichini O, Barrou J, Bannier M, Rua S, Van Troy A, Sabiani L, Lambaudie E, Cohen M, Houvenaeghel G. Mastectomy with immediate breast reconstruction: Results of a mono-centric 4-years cohort. Ann Med Surg (Lond) 2020; 61:172-179. [PMID: 33437474 PMCID: PMC7787913 DOI: 10.1016/j.amsu.2020.12.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 12/21/2020] [Indexed: 01/31/2023] Open
Abstract
Introduction Oncological safety, quality of life and cosmetic outcomes seems to be similar between breast conserving surgery (BCS) and mastectomy with immediate breast reconstruction (IBR). We report our experience of IBR for consecutive mastectomies realized in a recent period of four years in order to determined immediate surgical results according to type of mastectomy and type of reconstruction, as mains objectives. Methods All mastectomies with IBR during years 2016–2019 were included. A retrospective analysis with prospective data collection was performed. Results We analyzed 748 IBR: 353 nipple-sparing mastectomies (NSM), 391 skin-sparing mastectomies (SSM) and 4 standard mastectomies, 551 with definitive implant or expanders and 196 with latissimus dorsi-flap (LDF). More NSM were performed during the 2 last years and more LDF were performed for high BMI, high breast cup-size, neo-adjuvant chemotherapy and radiotherapy and local recurrence. We realized 111 robotic NSM and 125 robotic LDF. Longer duration of surgery was significantly associated with the robotic procedures. The overall complications crude rate was 31.4% with 9.9% of re-operations and 5.8% of implant loss. Grade 2–3 complications were significantly associated with smoking. Breast complications occurred in 32.9% of mastectomies with principally skin or nipple-areola-complex suffering or necrosis, hematomas and infections. A predictive score was determined to evaluate risk of complications before surgery. Conclusion Mastectomy with IBR seems to be a safe technique with an acceptable complication rate which is increased by tobacco use, high breast cup-size and IBR-type. Mastectomy with immediate breast to determined immediate surgical results. More Nipple Sparing Mastectomy performed during the 2 last years. More Latissimus dorsi-flap performed for high BMI, high breast cup-size, after radiotherapy.
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Affiliation(s)
- Olivia Quilichini
- Department of Surgery, Paoli Calmettes Institute, 232 Bd Ste Marguerite, Marseille, France
| | - Julien Barrou
- Department of Surgery, Paoli Calmettes Institute, 232 Bd Ste Marguerite, Marseille, France
| | - Marie Bannier
- Department of Surgery, Paoli Calmettes Institute, 232 Bd Ste Marguerite, Marseille, France
| | - Sandrine Rua
- Department of Surgery, Paoli Calmettes Institute, 232 Bd Ste Marguerite, Marseille, France
| | - Aurore Van Troy
- Department of Surgery, Paoli Calmettes Institute, 232 Bd Ste Marguerite, Marseille, France
| | - Laura Sabiani
- Department of Surgery, Paoli Calmettes Institute, 232 Bd Ste Marguerite, Marseille, France
| | - Eric Lambaudie
- Department of Surgery, Paoli Calmettes Institute & CRCM & Aix Marseille Univ, 232 Bd Ste Marguerite, Marseille, France
| | - Monique Cohen
- Department of Surgery, Paoli Calmettes Institute, 232 Bd Ste Marguerite, Marseille, France
| | - Gilles Houvenaeghel
- Department of Surgery, Paoli Calmettes Institute & CRCM & Aix Marseille Univ, 232 Bd Ste Marguerite, Marseille, France
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28
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Park KU, Tozbikian GH, Ferry D, Tsung A, Chetta M, Schulz S, Skoracki R. Residual breast tissue after robot-assisted nipple sparing mastectomy. Breast 2020; 55:25-29. [PMID: 33310481 PMCID: PMC7726449 DOI: 10.1016/j.breast.2020.11.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 11/24/2020] [Accepted: 11/27/2020] [Indexed: 11/25/2022] Open
Abstract
Introduction While the long-term oncologic safety of robot-assisted nipple sparing mastectomy (RNSM) remains to be elucidated, histologically detected residual breast tissue (RBT) can be a surrogate for oncologically sound mastectomy. The objective of this study is to determine the presence of RBT after RNSM. Methods Between August 2019–January 2020, we completed 5 cadaveric RNSMs. Full thickness biopsies from the mastectomy skin flap were obtained from predefined locations radially around the mastectomy skin envelop and nipple areolar complex to histologically evaluate for RBT. Results The first case was not technically feasible due to inability to obtain adequate insufflation. Five mastectomy flaps were analyzable. The average mastectomy flap thickness was 2.3 mm (range 2–3 mm) and the average specimen weight was 382.72 g (range 146.9–558.3 g). Of 70 total biopsies, RBT was detected in 11 (15.7%) biopsies. Most common location for RBT was in the nipple-areolar complex, with no RBT detected from the peripheral skin flaps. Conclusions In this cadaveric study, RNSM is feasible leaving minimal RBT on the mastectomy flap. The most common location for RBT is in the periareolar location consistent with previous published findings after open NSM. Clinical studies are underway to evaluate the safety of RNSM. Robot-assisted nipple sparing mastectomy (RNSM) is technically feasible. Residual breast tissue after RNSM is histologically detected only from the periareolar location. Further clinical trials are underway to determine oncologic safety of RNSM.
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Affiliation(s)
- Ko Un Park
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center James Cancer Hospital, Columbus, OH, USA.
| | - Gary H Tozbikian
- Department of Pathology, The Ohio State University Wexner Medical Center James Cancer Hospital, Columbus, OH, USA.
| | - David Ferry
- Robotic Surgery Program, The Ohio State University Wexner Medical Center James Cancer Hospital, Columbus, OH, USA.
| | - Allan Tsung
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center James Cancer Hospital, Columbus, OH, USA.
| | - Mathew Chetta
- Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center James Cancer Hospital, Columbus, OH, USA.
| | - Steven Schulz
- Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center James Cancer Hospital, Columbus, OH, USA.
| | - Roman Skoracki
- Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center James Cancer Hospital, Columbus, OH, USA.
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29
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Loh ZJ, Wu TY, Cheng FTF. Evaluation of the Learning Curve in Robotic Nipple-sparing Mastectomy for Breast Cancer. Clin Breast Cancer 2020; 21:e279-e284. [PMID: 33189563 DOI: 10.1016/j.clbc.2020.09.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 09/23/2020] [Accepted: 09/28/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND This study discusses the preliminary results of robotic nipple sparing mastectomy (R-NSM) in patients with breast cancer and analyzes the learning curve of the same surgeon in a single medical center. PATIENTS AND METHOD Patients with breast cancer from a single center who received R-NSM between 2018 to 2020 were recruited for clinical and pathologic tumor characteristics including family history, grade, type of tumor, treatment, and outcome. The learning curve for R-NSM was analyzed by using cumulative sum (CUSUM). RESULTS A total of 85 R-NSM procedures from 78 patients were evaluated. In the CUSUM plot analysis of the learning curve, a significant decrease in time for mastectomy, reconstruction, and total operation appeared in the 22nd, 23rd, and 26th procedures, respectively. Patients' body weight, gel implant size, and specimen weight had significant correlations with the time for mastectomy. Four (5.6%) patients had nipple partial ischemia, and 1 (1.4%) had total nipple necrosis. The mean follow-up was 11.4 ± 6.2 months; only 1 patient showed recurrence. CONCLUSION Robotic breast surgery is a feasible method with good cosmetic outcome under suitable patient selection. Oncologic safety is not a reason to stop its development.
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Affiliation(s)
- Zhu-Jun Loh
- Department of Surgery, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan
| | - Tzu-Yi Wu
- Department of Occupational Therapy, College of Medical and Health Science, Asia University, Taichung, Taiwan
| | - Fiona Tsui-Fen Cheng
- Division of General Surgery, Department of Surgery, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan.
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30
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Uras C, Enes Arıkan A, Kara H, Dülgeroğlu O, Avşar Y. Robotic nipple sparing mastectomy through a single incision: Advantages of starting with posterior dissection. Turk J Surg 2020; 36:303-309. [PMID: 33778387 DOI: 10.47717/turkjsurg.2020.4771] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 04/24/2020] [Indexed: 11/23/2022]
Abstract
Objectives Loss of breast, which is an important body marking of women, causes a huge decrease in quality of life (QoL) after treatment. In order to overcome this morbidity and increase QoL, nipple sparing mastectomy (NSM) has been developed. Even though the demand for better cosmetic results has yielded endoscopic nipple sparing mastectomy, limitations like unsuitable optical window and limited manual control of rigid-tip instruments, and struggling to keep dissection space have led robotic nipple sparing mastectomy (rNSM) to be developed. Material and Methods Records of three patients who underwent to rNSM for invasive breast carcinoma with DaVinci Xi (Intuitive Surgical, Sunnyvale, CA) in affiliated hospitals of xxxxx xxxxx xxx xxxx University, Research Institute of xxxxx in 2018 were investigated retrospectively. In all breasts (n=4), dissection was started from the posterior side of breast. Results In the unit, 738 breast cancer patients underwent surgery between 2018 and 2019 with an NSM ratio of 31.4% (n=232). Of these patients, three underwent rNSM with DaVinci Xi robotic system. The operation was performed on the left breast in one patient, right in one, and bilateral in one patient. Only in patient #2, who was a neoadjuvant chemotherapy recipient, seroma was observed six weeks after surgery (3 weeks after removal of drains) and spontaneously resolved in 4 weeks. No other complication was seen in all patients. In the follow-up period of median 21 months, no loco-regional recurrence or distant metastasis was seen. Conclusion A single incision robotic mastectomy can be performed easily and safely when the dissection starts from the pre-pectoral plane rather than the subcutaneous plane.
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Affiliation(s)
- Cihan Uras
- Acibadem Mehmet Ali Aydinlar University, Research Institute Of Senology, Istanbul, Turkey
| | - Akif Enes Arıkan
- Acibadem Mehmet Ali Aydinlar University, School Of Medicine, Department Of General Surgery, Istanbul, Turkey
| | - Halil Kara
- Acibadem Mehmet Ali Aydinlar University, Vocational School Of Health Sciences, Istanbul, Turkey
| | - Onur Dülgeroğlu
- Acibadem Mehmet Ali Aydinlar University, Vocational School Of Health Sciences, Istanbul, Turkey
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Endoscopic assisted breast conserving surgery for breast cancer: Clinical outcome, learning curve, and patient reported aesthetic results from preliminary 100 procedures. Eur J Surg Oncol 2020; 46:1446-1455. [DOI: 10.1016/j.ejso.2020.02.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 02/09/2020] [Accepted: 02/17/2020] [Indexed: 01/16/2023] Open
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32
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Consensus Statement on Robotic Mastectomy-Expert Panel From International Endoscopic and Robotic Breast Surgery Symposium (IERBS) 2019. Ann Surg 2020; 271:1005-1012. [PMID: 31977514 DOI: 10.1097/sla.0000000000003789] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVES To achieve a consensus statement on robotic mastectomy. BACKGROUND Robotic-assisted surgery has gained much attention especially the results of few case series reporting on the technical feasibility, safety and early oncologic outcomes of robotic-assisted mastectomy in a few centers worldwide. The aim of this consensus statement was to develop and provide standardized guidelines on robotic mastectomy based on consensus statement by a panel of experts from indications to outcome measures and indicators, thereby providing a valuable guide for breast surgeons worldwide. METHODOLOGY An internationally representative expert panel of 10 surgeons was invited to participate in the generation of a consensus statement. 52 statements were created in 6 domains: indications, contraindications, technical considerations, patient counseling, outcome measures and indicators, training and learning curve assessment. Experts were asked to vote if they agree, disagree or of the opinion that the statement should be rephrased. Two electronic rounds via online survey of iterative rating and feedback were anonymously completed, followed by a final round of in-person meeting during the inaugural International Endoscopic and Robotic Breast Surgery Symposium 2019 from May 24 to 25, 2019. Consensus was reached when there was at least 80% agreement on each statement. RESULTS A total of 53 statements with at least 80% agreement were generated after 3 rounds of voting; 21 statements from first round of voting, 20 statements from second round of voting and 12 statements from the final round of in-person meeting. All experts agreed that the consensus statement served as expert recommendations but not mandatory for a successful and safe practice of robotic mastectomy. CONCLUSION Robotic mastectomy is a promising technique and could well be the future of minimally invasive breast surgery whereas proving to be safe and feasible. The first consensus statement on robotic mastectomy from an international panel of experts serves as an extremely important milestone and provides recommendations for breast surgeons keen to embark on this technique.
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Affiliation(s)
- Julie A Margenthaler
- Department of Surgery, Washington University School of Medicine, St Louis, Missouri
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34
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Analysis of the learning process for laparoscopic sleeve gastrectomy: CUSUM-curve of 110 consecutive patients with 1-year follow-up. J Visc Surg 2020; 158:198-203. [PMID: 32446913 DOI: 10.1016/j.jviscsurg.2020.05.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Laparoscopic sleeve gastrectomy (LSG) is the most popular bariatric procedure worldwide. A tremendous recent increase in the number of LSGs has not been driven by an accurate learning process, especially in low volume bariatric centers. The cumulative-sum (CUSUM) method is an effective analysis of the learning process, taking intraoperative and postoperative variables into account. This study was aimed at establishing a CUSUM learning curve for LSG in order to define the number of procedures needed to achieve sufficient surgical skill. METHODS All LSGs performed by a single general surgeon between September 2014 and November 2017 were considered. We hypothesized that the key t variables related to the LSG learning process (LP) are: operative time (OT), intraoperative complications or difficulties, need for expert assistance, length of hospital stay (LOS), and 3-month postoperative morbidity. All of these parameters are binary variables analyzed with the risk-adjusted CUSUM method. Two groups, learning group (LG) and experienced group (EG), were identified and compared by univariate analysis. Multivariate analysis was performed to identify the variables most closely associated with operative time and surgical success. One-year weight loss outcomes were likewise analyzed. RESULTS One hundred and ten (110) consecutive LSGs were considered. CUSUM-LSG showed that the mean number of consecutive interventions necessary to reach proficiency in LSG was 58. In multivariate analysis, surgical success was negatively correlated with longer operative time and need for expert assistance. Body mass index was not correlated with surgical success. CONCLUSION Fifty-eight LSG procedures were required to achieve surgical skill. Operative time and the need for expert assistance were variables most closely associated with surgical success. ACGME COMPETENCY Practice-based learning and improvement.
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Kopkash K, Sisco M, Poli E, Seth A, Pesce C. The modern approach to the nipple‐sparing mastectomy. J Surg Oncol 2020; 122:29-35. [DOI: 10.1002/jso.25909] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 03/13/2020] [Indexed: 01/04/2023]
Affiliation(s)
- Katherine Kopkash
- Department of SurgeryNorthShore University HealthSystem Evanston Illinois
| | - Mark Sisco
- Division of Plastic SurgeryNorthShore University HealthSystem Evanston Illinois
| | - Elizabeth Poli
- Department of SurgeryUniversity of Chicago Chicago Illinois
| | - Akhil Seth
- Division of Plastic SurgeryNorthShore University HealthSystem Evanston Illinois
| | - Catherine Pesce
- Department of SurgeryNorthShore University HealthSystem Evanston Illinois
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36
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Lai HW, Chen ST, Mok CW, Lin YJ, Wu HK, Lin SL, Chen DR, Kuo SJ. Robotic versus conventional nipple sparing mastectomy and immediate gel implant breast reconstruction in the management of breast cancer- A case control comparison study with analysis of clinical outcome, medical cost, and patient-reported cosmetic results. J Plast Reconstr Aesthet Surg 2020; 73:1514-1525. [PMID: 32238306 DOI: 10.1016/j.bjps.2020.02.021] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 01/01/2020] [Accepted: 02/09/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Robotic nipple sparing mastectomy (R-NSM), which uses the da Vinci surgical platform, could perform NSM and immediate breast reconstruction through a small and inconspicuous extra-mammary axillary or lateral chest incision. R-NSM was reported with extremely low nipple areolar complex (NAC) necrosis rate, good cosmetic results, and high patient satisfaction. However, there was little evidence available comparing the effectiveness and safety of R-NSM and conventional NSM (C-NSM) in the management of breast cancer. METHODS A case control comparison study was conducted for patients with breast cancer who underwent R-NSM or C-NSM with immediate gel implant breast reconstruction (IGBR) from July 2011 to September 2019 at a single institution to compare the clinical outcomes, patient-reported esthetic results, and medical cost. RESULTS According to the study design, 54 procedures of R-NSM were compared with 62 procedures of C-NSM in the surgical management of breast cancer combined with IGBR. Compared with C-NSM, R-NSM was associated with higher overall satisfaction (92% excellent and 8% good versus 75.6% excellent and 24.4% good, P = 0.046), and wound/scar related outcome in patient-reported esthetic results. The NAC ischemia/necrosis risk, overall complication rate, and blood loss were not significantly different between R-NSM and C-NSM groups. However, longer operation time and higher overall medical cost (10,877 ± 796 versus 5,702 ± 661 US Dollars, P<0.01) was observed in R-NSM group. CONCLUSION Compared with C-NSM, R-NSM showed comparable clinical outcomes and favorable patients' satisfaction with the esthetic results, but at the price of longer operation time and higher cost.
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Affiliation(s)
- Hung-Wen Lai
- Endoscopic & Oncoplastic Breast Surgery Center, Changhua Christian Hospital, 135 Nanxiao Street, Changhua 500, Taiwan; Division of General Surgery, Changhua Christian Hospital, Changhua, Taiwan; Comprehensive Breast Cancer Center, Changhua Christian Hospital, Changhua, Taiwan; Minimal invasive surgery research center, Changhua Christian Hospital, Changhua, Taiwan; Kaohsiung Medical University, Kaohsiung, Taiwan; Division of Breast Surgery, Yuanlin Christian Hospital, Yuanlin, Taiwan; School of Medicine, National Yang Ming University, Taipei, Taiwan; School of Medicine, Chung Shan Medical University, Taichung, Taiwan; Chang Gung University College of Medicine, Taoyuan City, Taiwan; Division of General Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.
| | - Shou-Tung Chen
- Endoscopic & Oncoplastic Breast Surgery Center, Changhua Christian Hospital, 135 Nanxiao Street, Changhua 500, Taiwan; Division of General Surgery, Changhua Christian Hospital, Changhua, Taiwan; Comprehensive Breast Cancer Center, Changhua Christian Hospital, Changhua, Taiwan.
| | - Chi Wei Mok
- Division of Breast Surgery, Department of Surgery, Changi General Hospital, Singapore; Singhealth Duke-NUS Breast Centre, Singapore.
| | - Ying-Jen Lin
- Tumor Center, Changhua Christian Hospital, Changhua, Taiwan.
| | - Hwa-Koon Wu
- Department of Radiology, Changhua Christian Hospital, Changhua, Taiwan.
| | - Shih-Lung Lin
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan.
| | - Dar-Ren Chen
- Endoscopic & Oncoplastic Breast Surgery Center, Changhua Christian Hospital, 135 Nanxiao Street, Changhua 500, Taiwan; Division of General Surgery, Changhua Christian Hospital, Changhua, Taiwan; Comprehensive Breast Cancer Center, Changhua Christian Hospital, Changhua, Taiwan.
| | - Shou-Jen Kuo
- Endoscopic & Oncoplastic Breast Surgery Center, Changhua Christian Hospital, 135 Nanxiao Street, Changhua 500, Taiwan; Division of General Surgery, Changhua Christian Hospital, Changhua, Taiwan; Comprehensive Breast Cancer Center, Changhua Christian Hospital, Changhua, Taiwan.
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Lai HW, Chen ST, Tai CM, Lin SL, Lin YJ, Huang RH, Mok CW, Chen DR, Kuo SJ. Robotic- Versus Endoscopic-Assisted Nipple-Sparing Mastectomy with Immediate Prosthesis Breast Reconstruction in the Management of Breast Cancer: A Case-Control Comparison Study with Analysis of Clinical Outcomes, Learning Curve, Patient-Reported Aesthetic Results, and Medical Cost. Ann Surg Oncol 2020; 27:2255-2268. [PMID: 32016631 DOI: 10.1245/s10434-020-08223-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND New surgical innovations of nipple-sparing mastectomy (NSM), such as endoscopic NSM (E-NSM) or robotic NSM (R-NSM), were emerging. However, there was a lack of evidence comparing the effectiveness and safety in the management of breast cancer. METHODS A case-control comparison study was conducted for patients with breast cancer underwent E-NSM or R-NSM with immediate prosthesis breast reconstruction (IPBR) from July 2010 to February 2019 at a single institution to compare the clinical outcomes, learning curve, patient-reported cosmetic results, and medical cost. RESULTS A total of 91 E-NSM and 40 R-NSM procedures were retrieved and analyzed. The surgical margin involvement rate in both R-NSM (2.5%) and E-NSM (4.4%) procedures were relatively low (P = 0.52). The R-NSM group was associated with higher satisfaction rates in terms of scar appearance, scar length, and surgical wound position compared with the E-NSM group. Compared with E-NSM, the R-NSM operation time took longer (241 ± 61 vs. 215 ± 70 min, P = 0.01), less blood loss (32 ± 29 vs. 79 ± 62 ml, P < 0.01), and higher medical cost (10,587 ± 554 vs. 6855 ± 936 U.S. dollars, P < 0.01). There was no statistically significant difference in nipple ischemia/necrosis or overall complication between R-NSM and E-NSM. In the learning curve analysis, it took the 27th procedure in E-NSM and 10th procedure in R-NSM to decrease operation time significantly. CONCLUSIONS R-NSM was associated with higher wound-related satisfaction, lesser blood loss, and shorter learning curve compared with E-NSM, however, at the price of longer operation time and higher medical cost.
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Affiliation(s)
- Hung-Wen Lai
- Endoscopic and Oncoplastic Breast Surgery Center, Comprehensive Breast Cancer Center, Changhua Christian Hospital, 135 Nanxiao Street, Changhua, 500, Taiwan. .,Division of General Surgery, Changhua Christian Hospital, Changhua, Taiwan. .,Comprehensive Breast Cancer Center, Changhua Christian Hospital, Changhua, Taiwan. .,Kaohsiung Medical University, Kaohsiung, Taiwan. .,Division of Breast Surgery, Yuanlin Christian Hospital, Yuanlin, Taiwan. .,School of Medicine, National Yang Ming University, Taipei, Taiwan. .,School of Medicine, Chung Shan Medical University, Taichung, Taiwan. .,Minimal Invasive Surgery Research Center, Changhua Christian Hospital, Changhua, Taiwan. .,Chang Gung University College of Medicine, Taoyuan City, Taiwan. .,Division of General Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.
| | - Shou-Tung Chen
- Endoscopic and Oncoplastic Breast Surgery Center, Comprehensive Breast Cancer Center, Changhua Christian Hospital, 135 Nanxiao Street, Changhua, 500, Taiwan.,Division of General Surgery, Changhua Christian Hospital, Changhua, Taiwan.,Comprehensive Breast Cancer Center, Changhua Christian Hospital, Changhua, Taiwan
| | - Chin-Mei Tai
- Endoscopic and Oncoplastic Breast Surgery Center, Comprehensive Breast Cancer Center, Changhua Christian Hospital, 135 Nanxiao Street, Changhua, 500, Taiwan.,Comprehensive Breast Cancer Center, Changhua Christian Hospital, Changhua, Taiwan.,Minimal Invasive Surgery Research Center, Changhua Christian Hospital, Changhua, Taiwan
| | - Shih-Lung Lin
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan
| | - Ying-Jen Lin
- Tumor Center, Changhua Christian Hospital, Changhua, Taiwan
| | - Ren-Hung Huang
- Department of Pathology, Changhua Christian Hospital, Changhua, Taiwan
| | - Chi Wei Mok
- Division of Breast Surgery, Department of Surgery, Changi General Hospital, Singapore, Singapore.,Singhealth Duke-NUS Breast Center, Singapore, Singapore
| | - Dar-Ren Chen
- Division of General Surgery, Changhua Christian Hospital, Changhua, Taiwan.,Comprehensive Breast Cancer Center, Changhua Christian Hospital, Changhua, Taiwan
| | - Shou-Jen Kuo
- Division of General Surgery, Changhua Christian Hospital, Changhua, Taiwan.,Comprehensive Breast Cancer Center, Changhua Christian Hospital, Changhua, Taiwan
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Donnely E, Griffin MF, Butler PE. Robotic Surgery: A Novel Approach for Breast Surgery and Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2578. [PMID: 32095394 PMCID: PMC7015621 DOI: 10.1097/gox.0000000000002578] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 10/18/2019] [Indexed: 12/24/2022]
Abstract
Supplemental Digital Content is available in the text. Background: Breast cancer is the most prevalent cancer and second leading cause of cancer-related deaths in both the US and UK female population, a prominent cause of morbidity and cost to both health services. All surgically fit patients are offered breast reconstruction following the initial surgery, and this is traditionally an open approach: either implant-based or an autologous tissue flap. Both lead to scarring that is difficult to conceal. This paper aims to evaluate the novel minimally invasive technique of robotic-assisted surgery. Methods: A systematic review was conducted using Medline (OvidSP) and Embase (OvidSP) to evaluate the current application of robotic-assisted surgery in breast surgery and reconstruction. Results: Twenty-one articles were identified and discussed, composing of level 4 and 5 evidence comparing different surgeons' experiences, techniques, and outcomes. To date, the robotic system has been utilized to harvest the latissimus dorsi muscle for use as a tissue flap (total harvest time of 92 minutes), to perform nipple-sparing mastectomy with immediate breast reconstruction (total operation time 85 minutes) and lately to harvest a deep inferior epigastric perforator flap via an intraabdominal approach. Conclusions: Robotic-assisted surgery can successfully and reproducibly perform a nipple-sparing mastectomy with breast reconstruction. It can minimize the size of scarring and is superior to the laparoscopic technique, with improved 3-dimensional visualization, dexterity, and range of motion able to guide around the curvature of the breast. The main limiting factors are the lack of the US Food and Drug Administration approval, cost of the robot, and specialized skills required.
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Affiliation(s)
- Edward Donnely
- Division of Surgery and Interventional Science, University College London, Royal Free Hospital, London, UK
| | - Michelle F Griffin
- Division of Surgery and Interventional Science, University College London, Royal Free Hospital, London, UK
| | - Peter E Butler
- Division of Surgery and Interventional Science, University College London, Royal Free Hospital, London, UK
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39
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A Systematic Review of Learning Curves in Plastic and Reconstructive Surgery Procedures. Ann Plast Surg 2020; 85:324-331. [DOI: 10.1097/sap.0000000000002211] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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40
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Mok CW, Lai HW. Evolution of minimal access breast surgery. Gland Surg 2019; 8:784-793. [PMID: 32042687 PMCID: PMC6989909 DOI: 10.21037/gs.2019.11.16] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Accepted: 11/04/2019] [Indexed: 01/30/2023]
Abstract
Surgical management of breast cancer has been evolving rapidly over the past 20-30 years. Prior to this, conventional surgical options were limited to either a mastectomy or breast conserving surgery. The demand for better aesthetic outcomes had driven the development of oncoplastic breast conserving surgery where glandular rearrangement or replacement coupled with thoughtfully placed incisions became the standard approach to breast conserving surgery. As breast surgeons and patients demand for improved aesthetic outcomes, minimally invasive or minimal access breast surgery has gained much attention over the past two decades, from endoscopic assisted to robotic-assisted breast surgery more recently. However, there has been a lack of review articles discussing this relatively recent but under-reported subset of surgical techniques in the management of breast cancer. This article aims to discuss the concept and development of minimal access breast surgery along with a review of current literature on its indications, techniques and outcome measures as well as a discussion on the strengths, limitations as well as future directions. Continued improvement in techniques and advancement of technology will definitely increase the likelihood of minimal access techniques being placed as the standard of care in the management of breast cancer.
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Affiliation(s)
- Chi Wei Mok
- Division of Breast Surgery, Department of Surgery, Changi General Hospital, Singapore, Singapore
- Singhealth Duke-NUS Breast Centre, Singapore, Singapore
| | - Hung-Wen Lai
- Endoscopy & Oncoplastic Breast Surgery Center, National Yang Ming University, Taipei
- Division of General Surgery, National Yang Ming University, Taipei
- Comprehensive Breast Cancer Center, National Yang Ming University, Taipei
- School of Medicine, National Yang Ming University, Taipei
- Division of Breast Surgery, Yuanlin Christian Hospital, Yuanlin
- Minimal Invasive Surgery Research Center, Changhua Christian Hospital, Changhua
- Kaohsiung Medical University, Kaohsiung
- School of Medicine, Chung Shan Medical University, Taichung
- Chang Gung University College of Medicine, Taoyuan City
- Division of General Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung
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Toesca A, Invento A, Massari G, Girardi A, Peradze N, Lissidini G, Sangalli C, Maisonneuve P, Manconi A, Gottardi A, Baker JL, Bottiglieri L, Naninato P, Farante G, Magnoni F, De Scalzi A, Corso G, Colleoni M, De Lorenzi F, Sacchini V, Galimberti V, Intra M, Rietjens M, Veronesi P. Update on the Feasibility and Progress on Robotic Breast Surgery. Ann Surg Oncol 2019; 26:3046-3051. [PMID: 31342391 DOI: 10.1245/s10434-019-07590-7] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Robotic nipple-sparing mastectomy (RNSM) may allow for more precise anatomic dissection and improved cosmetic outcomes over conventional open nipple-sparing mastectomy; however, data regarding the feasibility and safety of the procedure are limited. OBJECTIVE The aim of this study was to present and discuss perioperative surgical outcomes and early oncologic follow-up data on consecutive patients undergoing RNSM from June 2014 to January 2019. METHODS Patients underwent RNSM and immediate robotic breast reconstruction through an axillary incision at a single institution. Perioperative data, complications at 3 months postoperatively, pathological data, and adjuvant therapies were recorded. Local recurrence-free, disease-free, and overall survival were analyzed. RESULTS Overall, 73 women underwent 94 RNSM procedures. Indications were invasive breast cancer in 39 patients, ductal carcinoma in situ in 17 patients, and BRCA mutation in 17 patients. Mean surgery time was 3 h and 32 min. One-step reconstruction with implant occurred in 89.4% of procedures. The rate of complications requiring reoperation was 4.3%, and the rate of flap or nipple necrosis was 1.1%. Median follow-up was 19 months (range 3.1-44.8). No local recurrences occurred. Overall survival at 12, 24, or 60 months was 98% (95% confidence interval 86-100%). CONCLUSION We observed a low complication rate in 94 consecutive RNSM procedures, demonstrating the procedure is technically feasible and safe. We found no early local failures at 19 months follow-up. Long-term follow-up is needed to confirm oncologic safety. Future clinical trials to study the advantages and disadvantages of RNSM are warranted.
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Affiliation(s)
- Antonio Toesca
- Division of Breast Surgery, European Institute of Oncology IRCCS, Milan, Italy.
| | - Alessandra Invento
- Division of Breast Surgery, European Institute of Oncology IRCCS, Milan, Italy
| | - Giulia Massari
- Division of Breast Surgery, European Institute of Oncology IRCCS, Milan, Italy
| | - Antonia Girardi
- Division of Breast Surgery, European Institute of Oncology IRCCS, Milan, Italy
| | - Nickolas Peradze
- Division of Breast Surgery, European Institute of Oncology IRCCS, Milan, Italy
| | - Germana Lissidini
- Division of Breast Surgery, European Institute of Oncology IRCCS, Milan, Italy
| | - Claudia Sangalli
- Data Management, European Institute of Oncology IRCCS, Milan, Italy
| | - Patrick Maisonneuve
- Division of Epidemiology and Biostatistics, European Institute of Oncology IRCCS, Milan, Italy
| | - Andrea Manconi
- Division of Plastic and Reconstructive Surgery, European Institute of Oncology IRCCS, Milan, Italy
| | - Alessandra Gottardi
- Division of Plastic and Reconstructive Surgery, European Institute of Oncology IRCCS, Milan, Italy
| | - Jennifer L Baker
- Breast Surgery Division, Department of Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Luca Bottiglieri
- Division of Pathology, European Institute of Oncology IRCC, Milan, Italy
| | - Paola Naninato
- Division of Breast Surgery, European Institute of Oncology IRCCS, Milan, Italy
| | - Gabriel Farante
- Division of Breast Surgery, European Institute of Oncology IRCCS, Milan, Italy
| | - Francesca Magnoni
- Division of Breast Surgery, European Institute of Oncology IRCCS, Milan, Italy
| | | | - Giovanni Corso
- Division of Breast Surgery, European Institute of Oncology IRCCS, Milan, Italy
| | - Marco Colleoni
- Division of Medical Senology, European Institute of Oncology IRCCS, Milan, Italy
| | - Francesca De Lorenzi
- Division of Plastic and Reconstructive Surgery, European Institute of Oncology IRCCS, Milan, Italy
| | - Virgilio Sacchini
- Division of Breast Surgery, European Institute of Oncology IRCCS, Milan, Italy.,Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,University of Milan School of Medicine, Milan, Italy
| | - Viviana Galimberti
- Division of Breast Surgery, European Institute of Oncology IRCCS, Milan, Italy
| | - Mattia Intra
- Division of Breast Surgery, European Institute of Oncology IRCCS, Milan, Italy
| | - Mario Rietjens
- Division of Plastic and Reconstructive Surgery, European Institute of Oncology IRCCS, Milan, Italy
| | - Paolo Veronesi
- Division of Breast Surgery, European Institute of Oncology IRCCS, Milan, Italy.,University of Milan School of Medicine, Milan, Italy
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Lai HW, Chen CY, Mok C, Liao CY, Chen CJ, Chen ST, Lin SL, Chen DR, Kuo SJ. Robotic nipple-sparing mastectomy: A preliminary report of a single institute and joint collective analysis of current reported series. FORMOSAN JOURNAL OF SURGERY 2019. [DOI: 10.4103/fjs.fjs_117_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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