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Choe J, Aiello C, Yom J, Minasian RA, Sugiyama G, Smith ML, Selber JC, Tanna N. Embracing Robotics in Microsurgery: Robotic-Assisted Deep Inferior Epigastric Perforator Flap Breast Reconstruction. J Reconstr Microsurg 2024. [PMID: 39191414 DOI: 10.1055/a-2404-2445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2024]
Abstract
The integration of robotic-assisted surgery (RAS) has transformed various surgical disciplines, including more recently plastic surgery. While RAS has gained acceptance in multiple specialties, its integration in plastic surgery has been gradual, challenging traditional open methods. Robotic-assisted deep inferior epigastric perforator (DIEP) flap breast reconstruction is a technique aimed at overcoming drawbacks associated with the traditional open DIEP flap approach. These limitations include a relatively large fascial incision length, potentially increasing rates of postoperative pain, abdominal bulge, hernia rates, and core weakening. The robotic-assisted DIEP flap technique emerges as an innovative and advantageous approach in fascial-sparing abdominal autologous breast reconstruction. While acknowledging certain challenges such as increased operative time, ongoing refinements are expected to further improve the overall surgical experience, optimize results, and solidify the role of robotics in advancing reconstructive microsurgical procedures in plastic surgery. Herein, the authors provide an overview of robotic surgery in the context of plastic surgery and its role in the DIEP flap harvest for breast reconstruction.
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Affiliation(s)
- Joshua Choe
- Department of Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Christopher Aiello
- Department of Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Jina Yom
- Department of Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Raquel A Minasian
- Department of Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Gainosuke Sugiyama
- Department of Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Mark L Smith
- Department of Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Jesse C Selber
- Department of Surgery, Corewell Health, Grand Rapids, Michigan
| | - Neil Tanna
- Department of Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
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Cheong DCF, Wong AWJ, Kao SW, Chang SY, Huang JJ. DIEP Donor Site Satisfaction between Patients with and without History of Pregnancy. J Reconstr Microsurg 2024; 40:504-510. [PMID: 38176429 DOI: 10.1055/a-2238-8399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2024]
Abstract
BACKGROUND With the success of free autologous breast reconstruction, the abdominal donor site is now an important consideration, especially in patients of childbearing age. In our institution, there are increasing patients who have successfully undergone the deep inferior epigastric artery perforator (DIEP) flap despite previous pregnancy. This study aims to answer questions on the effect of the donor site on pregnancy and vice versa. METHODS A retrospective cohort study was conducted to identify breast cancer patients who received a free DIEP flap for breast reconstruction from January 2018 to August 2020. Patients were allocated to two groups according to whether they had prior pregnancies with successful deliveries. Demographics, flap-related parameters, surgical outcomes on breast and abdomen, and patient-reported outcome (Breast-Q questionnaire) were analyzed. Patients were excluded if follow-up time was less than 1 year, or if there was incomplete medical records or Breast-Q replies. RESULTS Ninety-nine of 116 patients had had successful pregnancies with delivery, 17 of them remained nulliparous. No statistically significant differences existed between groups regarding demographic data, flap-related parameters, surgical outcomes on breast and abdomen. Nulliparous patients exhibited significantly lower score in physical well-being in the abdomen domain compared with delivery-experienced patients (62.1 vs. 73.4, p = 0.025). Significantly, nulliparous patients felt more tightness and pulling of the abdominal wall than the delivery-experienced patients (2.9 vs. 3.7; p = 0.05 and 3.5 vs. 4.0; p = 0.04). CONCLUSION Free DIEP flap can be transferred safely in nulliparous patients despite a slight increase in abdominal tightness and abdominal pulling. Precise flap design and surgical approaches may help to minimize the abdominal discomfort especially on young, normal body mass index, and nonchildbearing patients.
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Affiliation(s)
- David Chon-Fok Cheong
- 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
| | - Allen Wei-Jiat Wong
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
- Plastic Reconstructive and Aesthetic Service, Sengkang General Hospital, Singapore
| | - Shu-Wei Kao
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
| | - Shu-Ying Chang
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Division of General Plastic Surgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
| | - 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
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Murariu D, Chen B, Bailey E, Nelson W, Fortunato R, Nosik S, Moreira A. Transabdominal Robotic Harvest of Bilateral DIEP Pedicles in Breast Reconstruction: Technique and Interdisciplinary Approach. J Reconstr Microsurg 2024. [PMID: 39191380 DOI: 10.1055/s-0044-1788930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2024]
Abstract
BACKGROUND The deep inferior epigastric artery perforator (DIEP) flap is the gold standard for autologous breast reconstruction. However, the conventional procedure's anterior sheath division, from perforating vessels to the pedicle origin, risks weakening the abdominal wall's primary strength layer. Employing the da Vinci Xi Surgical System with indocyanine green dye and near-infrared fluorescence imaging, we refined a robotic technique for bilateral DIEP flap harvest. This approach enhances safety during vessel dissection, utilizing smaller fascial incisions. This study will present this technique in detail to microsurgeons interested in robotic DIEP flaps. METHODS In a retrospective cohort study spanning July 2021 to September 2022, female patients undergoing robotic bilateral DIEP flap reconstruction were analyzed. Following suprafascial flap dissection, the surgical robot was docked to target the pelvis, identifying and exposing deep inferior epigastric vessels intracorporeally. Mobilization and division occurred at their bases, with retrieval through a minimal anterior fascial incision, minimizing disruption to the abdominal wall and its motor innervation. RESULTS The study comprised 23 patients (46 flaps), with a mean fascial length of 4.1 cm and mean pedicle length of 12.82 cm. Mesh usage was absent. Robotic time averaged 139 minutes, overall case length was 739 minutes, and the average length of stay was 3.9 days. Notably, no pedicle or intra-abdominal injuries were reported. CONCLUSION This technique ensures safe and efficient pedicle dissection in robotic DIEP flap harvests. Given the limited number of plastic surgeons adept in minimally invasive abdominal surgeries, we recommend collaborative efforts, with general surgeons initially assisting microsurgeons in adopting the robotic approach. This strategy facilitates a smooth transition until plastic surgeons attain confidence and competence in independent robotic dissection.
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Affiliation(s)
- Daniel Murariu
- Department of Surgery, Allegheny Health Network, Pittsburgh, Pennsylvania
- Department of Plastic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Brian Chen
- Department of Surgery, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Elizabeth Bailey
- Department of Plastic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - William Nelson
- Department of Surgery, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Richard Fortunato
- Department of Surgery, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Stanislav Nosik
- Department of Surgery, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Andrea Moreira
- Department of Surgery, Allegheny Health Network, Pittsburgh, Pennsylvania
- Department of Plastic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Moreira A, Bailey EA, Chen B, Nelson W, Li J, Fortunato R, Nosik S, Murariu D. A New Era in Perforator Flap Surgery for Breast Reconstruction: A Comparative Study of Robotic versus Standard Harvest of Bilateral Deep Inferior Epigastric Artery Perforator Flaps. J Reconstr Microsurg 2024. [PMID: 39102843 DOI: 10.1055/s-0044-1788642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/07/2024]
Abstract
BACKGROUND Traditional deep inferior epigastric artery perforator (DIEP) flap harvest splits the anterior sheath, weakening the abdominal wall and predisposing patients to bulge or hernia. Abdominal wall morbidity may be decreased using minimally invasive techniques. We refined a transabdominal approach to the robotic harvest of bilateral DIEP flaps. METHODS A retrospective medical record study involving all patients who underwent bilateral or bipedicled robotic DIEP (rDIEP) or standard DIEP (sDIEP) flap harvest between July 2021 and September 2022. Outcomes included abdominal wall morbidity, total operative time, length of stay (LOS), and complications. RESULTS Forty-seven patients were included (48 sDIEP flaps, 46 rDIEP flaps) with no significant difference in patient characteristics. Fascial incision length in the rDIEP group was shorter (4.1 vs. 11.7 cm, p < 0.001). Mesh reinforcement of the abdominal wall was used in 13/24 sDIEP and none in rDIEP patients (p < 0.001). Operative time was longer in the rDIEP cohort (739 vs. 630 minutes, p = 0.013), although subanalysis showed no difference in the second half of the cohort. The average robotic dissection time was 135 minutes, which decreased significantly with the surgeon's experience. There were no intraoperative complications from using the robot. LOS was shorter with rDIEP but not statistically significant (3.9 vs. 4.3 days, p = 0.157). CONCLUSION This study represents the most extensive cohort analysis of bilateral rDIEP flap harvest, offering a comprehensive comparison to traditional sDIEP. The initial results underscore the viability of robotic techniques for flap harvesting, highlighting potential advantages including reduced fascial incision length and decreased abdominal disruption. Furthermore, using robotics may obviate the necessity for fascial reinforcement with mesh.
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Affiliation(s)
- Andrea Moreira
- Department of Surgery, Allegheny Health Network, Pittsburgh, Pennsylvania
- Department of Plastic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Elizabeth A Bailey
- Department of Plastic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Brian Chen
- Department of Surgery, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - William Nelson
- Department of Surgery, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Jenna Li
- Department of Surgery, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Richard Fortunato
- Department of Surgery, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Stanislav Nosik
- Department of Surgery, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Daniel Murariu
- Department of Surgery, Allegheny Health Network, Pittsburgh, Pennsylvania
- Department of Plastic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Elameen AM, Dahy AA. Surgical outcomes of robotic versus conventional autologous breast reconstruction: a systematic review and meta-analysis. J Robot Surg 2024; 18:189. [PMID: 38693427 PMCID: PMC11063005 DOI: 10.1007/s11701-024-01913-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: 02/08/2024] [Accepted: 03/17/2024] [Indexed: 05/03/2024]
Abstract
Breast reconstruction is an integral part of breast cancer management. Conventional techniques of flap harvesting for autologous breast reconstruction are associated with considerable complications. Robotic surgery has enabled a new spectrum of minimally invasive breast surgeries. The current systematic review and meta-analysis study was designed to retrieve the surgical and clinical outcomes of robotic versus conventional techniques for autologous breast reconstruction. An extensive systematic literature review was performed from inception to 25 April 2023. All clinical studies comparing the outcomes of robotic and conventional autologous breast reconstruction were included for meta-analysis. The present meta-analysis included seven articles consisting of 783 patients. Of them, 263 patients received robotic breast reconstruction, while 520 patients received conventional technique. Of note, 477 patients received latissimus dorsi flap (LDF) and 306 were subjected to deep inferior epigastric artery perforator (DIEP) flap. There was a significantly prolonged duration of surgery (MD 58.36;95% CI 32.05,84.67;P < 0.001) and duration of anaesthesia (MD 47;95% CI 16.23,77.77;P = 0.003) among patients who underwent robotic surgery. There was a similar risk of complications between robotic and conventional surgeries. The mean level of pain intensity was significantly lower among patients who received robotic breast surgery (MD- 0.28;95% CI - 0.73,0.17; P = 0.22). There was prolonged length of hospitalization among patients with conventional DIEP flap surgery (MD- 0.59;95% CI - 1.13,- 0.05;P = 0.03). The present meta-analysis highlighted the feasibility, safety, and effectiveness of robotic autologous breast reconstruction. This included the successful harvesting of LDF and DIEP flap with acceptable surgical and functional outcomes.
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Affiliation(s)
- Ali Mohamed Elameen
- Department of Plastic and Reconstructive Surgery, El-Sahel Teaching Hospital, Cairo, Egypt
| | - Asmaa Ali Dahy
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine For Girls, Al-Azhar University, Gameat Al Azhar, Nasr City, Cairo, Egypt.
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Hohenstein AA, Kraus D, Zeller J, Schneider LA, Liakos N, Gratzke C, Juhasz-Böss I, Eisenhardt S. [Robotic-Assisted DIEP Flap Harvest for Autologous Breast Reconstruction: Case Report, Technical Aspects and Identification of Suitable Patients]. HANDCHIR MIKROCHIR P 2024; 56:147-155. [PMID: 38417810 DOI: 10.1055/a-2239-6513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2024] Open
Abstract
BACKGROUND Robotic-assisted harvest of the deep inferior epigastric perforator (DIEP) flap is an innovative modification of the traditional open preparation for autologous breast reconstruction. It is assumed that donor-site morbidity (herniae, bulging) is reduced by minimising the fascial incision length in robotic-assisted DIEP flap harvest. MATERIAL & METHODS This is the first report of a robotic-assisted DIEP harvest in Germany, which was performed in April 2023 at the University Hospital of Freiburg in an interdisciplinary approach of the Departments of Plastic Surgery, Urology and Gynaecology. To determine the value of this novel technique, we assessed the demand by retrospectively performing an analysis of potential patients and conducted a cost analysis based on the breast reconstructions with DIEP flap harvest performed between April 2021 and May 2023 at the Department of Plastic Surgery at Freiburg University Hospital. To this end, we carried out a retrospective analysis of preoperative CT angiographies to determine the proportion of patients suitable for a robotic-assisted procedure in a post-hoc analysis. Furthermore, we describe the basic robotic-assisted techniques and discuss the TEP and TAPP laparoscopic approaches. RESULTS In line with the previously published literature, a short intramuscular course (≤25 mm) and a perforator diameter of≥1.5 mm and≥2.7 mm (subgroup) were defined as a crucial condition for the robotic-assisted procedure. We analysed 65 DIEP flaps harvested in 51 patients, of which 26 DIEP flaps in 22 patients met both criteria, i. e.≤25 mm intramuscular course and≥1.5 mm diameter of the perforator, while 10 DIEP flaps in 10 patients additionally met the criteria of the subgroup (≥2.7 mm diameter). Based on the intramuscular course of the perforators in the CT angiographies of those 26 DIEP flaps, a potential reduction of the fascial incision of 96.8±25.21 mm (mean±standard deviation) compared with the conventional surgical approach was calculated. The additional material costs in our case were EUR 986.01. However, ischaemia time was 33,5 minutes longer than the median of the comparative cohort. CONCLUSION The robotic-assisted procedure has already proven to be a feasible alternative in a suitable patient population. However, further studies are needed to confirm that robotic-assisted DIEP flap harvest actually reduces harvest site morbidity and thereby justifies the additional costs and complexity.
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Affiliation(s)
| | - Daniel Kraus
- Klinik für Plastische und Handchirurgie, Universitätsklinikum Freiburg, Freiburg, Germany
| | - Johannes Zeller
- Klinik für Plastische und Handchirurgie, Universitätsklinikum Freiburg, Freiburg, Germany
| | - Laura Anna Schneider
- Klinik für Plastische und Handchirurgie, Universitätsklinikum Freiburg, Freiburg, Germany
| | - Nikolaos Liakos
- Klinik für Urologie, Universitätsklinikum Freiburg, Freiburg, Germany
| | - Christian Gratzke
- Klinik für Urologie, Universitätsklinikum Freiburg, Freiburg, Germany
| | - Ingolf Juhasz-Böss
- Klinik für Frauenheilkunde, Universitätsklinikum Freiburg, Freiburg, Germany
| | - Steffen Eisenhardt
- Klinik für Plastische und Handchirurgie, Universitätsklinikum Freiburg, Freiburg, Germany
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Laurent R, Trifan A, Danino AD, Paek LS, Schoucair R, Pauchot J, Bernier C, Briand E, Danino MA. Autogenous breast reconstruction for total mastectomies: a narrative review. ANNALS OF TRANSLATIONAL MEDICINE 2024; 12:9. [PMID: 38304895 PMCID: PMC10777237 DOI: 10.21037/atm-23-1471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 11/22/2023] [Indexed: 02/03/2024]
Abstract
Background and Objective Mastectomies have a significant socio-psychological impact, motivating patients to undergo breast reconstruction. Initially, silicone implants were used to reconstruct the breast. However, breast implants have been the subject of successive crises throughout the years. Indeed, rupture, silicone bleeding, and capsular contracture remain topical. In 2019, the BIOCELL textured breast implants was banned and recalled due to the discovery of the breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). More recently, the breast implant illness has been depicted in the media. To cope with these issues and to respond to some patients' expectations for a natural reconstruction, plastic surgeons have developed autogenous solutions for breast reconstruction. Since Taylor's research on angiosomes, the development of the microsurgery and more recently fat grafting, autogenous breast reconstruction has known a tremendous expansion. Autologous breast reconstruction allows a more natural feeling and texture. This narrative review aims to provide to the readers a comprehensive and updated evidence-based overview of state of the art about autologous breast reconstruction after total mastectomy. Methods We conducted a narrative review of the literature searching for papers published between January 2010 and December 2022. The MeSH terms with different combinations were used to identify articles for inclusion. After screening article titles and abstracts independently by three authors, 66 papers were included in this review. Key Content and Findings In this review, the authors describe and discuss the different autogenous techniques in breast reconstruction. Conclusions Autologous reconstructions provide very satisfactory, durable, and reliable results with relatively low complication rates. Deep inferior epigastric perforator (DIEP) flaps, latissimus dorsi flaps and autologous fat grafting are the most common type of autogenous breast reconstructions.
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Affiliation(s)
- Romain Laurent
- Division of Plastic and Reconstructive Surgery, University of Montreal Hospital Center (CHUM), Montreal, Canada
| | | | | | - Laurence S. Paek
- Division of Plastic and Reconstructive Surgery, University of Montreal Hospital Center (CHUM), Montreal, Canada
| | - Ramy Schoucair
- Division of Plastic and Reconstructive Surgery, University of Montreal Hospital Center (CHUM), Montreal, Canada
| | - Julien Pauchot
- University Hospital Centre of Besançon, Besançon, France
| | - Christina Bernier
- Division of Plastic and Reconstructive Surgery, University of Montreal Hospital Center (CHUM), Montreal, Canada
| | - Etienne Briand
- University Hospital Centre of Martinique, Fort-de-France, France
| | - Michel A. Danino
- Division of Plastic and Reconstructive Surgery, University of Montreal Hospital Center (CHUM), Montreal, Canada
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Maes-Carballo M, García-García M, Rodríguez-Janeiro I, Cámara-Martínez C, Alberca-Remigio C, Khan KS. A systematic review of robotic breast surgery versus open surgery. J Robot Surg 2023; 17:2583-2596. [PMID: 37624486 DOI: 10.1007/s11701-023-01698-5] [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: 07/25/2023] [Accepted: 08/14/2023] [Indexed: 08/26/2023]
Abstract
Robotic-assisted breast surgery (RABS) is controversial. We systematically reviewed the evidence about RABS, comparing it to open conventional breast surgery (CBS). Following prospective registration (osf.io/97ewt), a search was performed in January 2023, without time or language restrictions, through bibliographic databases (PubMed, Web of Science, EMBASE, Scopus, Trip database and CDSR) and grey literature. Quality was assessed in duplicate using Qualsyst criteria (score range 0.0-1.0); reviewer agreement was 98%. The 16 selected studies (total patients: 334,804) had overall high quality (mean score 0.82; range 0.68-0.91). Nine of 16 (56.3%) were cohort studies, 2/16 (12.5%) RCTs, and 5/16 (31.3%) case-control studies. Taking p < 0.05 as the significance threshold, RABS versus CBS was better in aesthetic results and patient satisfaction (10/11 studies; 90%), was surgically costly (4/4 studies; 100%), time-consuming (9/13 studies; 69%), and less painful in the first 6-24 h (2/2 studies; 100%) and without statistically significant differences in complication rates (10/12 studies; 83%) or short-term oncological outcomes (10/10 studies; 100%). Surgical time could be dramatically reduced by training surgical teams, reaching no significant differences between approaches (p = 0.120). RABS was shown to be feasible and safe. The advantages of RABS and long-term outcomes need further research.
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Affiliation(s)
- Marta Maes-Carballo
- Department of General Surgery, Breast Cancer Unit, Complexo Hospitalario de Ourense, Calle Ramon Puga Noguerol, 54, 32005, Ourense, Spain.
- Hospital Público de Verín, Ourense, Spain.
- Department of Preventive Medicine and Public Health, University of Granada, Granada, Spain.
- Department of General Surgery, University of Santiago de Compostela, Santiago de Compostela, Spain.
| | - Manuel García-García
- Department of General Surgery, Breast Cancer Unit, Complexo Hospitalario de Ourense, Calle Ramon Puga Noguerol, 54, 32005, Ourense, Spain
- Department of General Surgery, University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Iago Rodríguez-Janeiro
- Department of General Surgery, University of Santiago de Compostela, Santiago de Compostela, Spain
| | | | - Claudia Alberca-Remigio
- Department of General Surgery, Breast Cancer Unit, Complexo Hospitalario de Ourense, Calle Ramon Puga Noguerol, 54, 32005, Ourense, Spain
| | - Khalid Saeed Khan
- Department of Preventive Medicine and Public Health, University of Granada, Granada, Spain
- CIBER of Epidemiology and Public Health (CIBERESP), Madrid, Spain
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Tanna N, Sugiyama G, Smith ML, Sanchez SB, Minasian RA, Robinson E, Silverman J, Shuck JW, Selber J. The Full Continuum of Robotic Breast Surgery: Robotic-assisted Mastectomy, Robotic DIEP Flap, and Robotic Supermicrosurgery. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5491. [PMID: 38130882 PMCID: PMC10735160 DOI: 10.1097/gox.0000000000005491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 10/24/2023] [Indexed: 12/23/2023]
Abstract
In recent years, robotic surgery has rapidly expanded to improve surgical outcomes in a variety of surgical subspecialties. Although plastic surgery has taken longer to integrate robotic surgery into practice, the advantages of robotic-assisted surgery, including improved visualization and resolution, minimally invasive approaches, and the ability to surpass human precision and scale, have driven its more recent adoption into plastic surgery. Currently, procedures performed with robotic assistance that are considered part of the continuum of surgical treatment of breast cancer include robotic-assisted nipple-sparing mastectomy, reconstruction with the robotic latissimus dorsi flap or the deep inferior epigastric artery perforator flap, and robotic microsurgery for the flap anastomosis and/or the surgical treatment of lymphedema. The authors provide an overview of robotic surgery and how it has been integrated into the field of plastic surgery, as well as a review of the most common procedures within the field where robotic assistance can be incorporated: nipple-sparing mastectomy, robotic latissimus flap, robotic deep inferior epigastric artery perforator flap breast reconstruction, and microvascular anastomoses.
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Affiliation(s)
- Neil Tanna
- From the Department of Surgery, The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, N.Y
- Department of Surgery, Northwell Health, Great Neck, N.Y
| | - Gainosuke Sugiyama
- From the Department of Surgery, The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, N.Y
- Department of Surgery, Northwell Health, Great Neck, N.Y
| | - Mark L. Smith
- From the Department of Surgery, The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, N.Y
- Department of Surgery, Northwell Health, Great Neck, N.Y
| | | | | | - Emma Robinson
- From the Department of Surgery, The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, N.Y
| | | | - John W. Shuck
- Department of Surgery, Corewell Health, Grand Rapids, Mich
| | - Jesse Selber
- Department of Surgery, Corewell Health, Grand Rapids, Mich
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10
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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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King BW, McCarter JH, Burns HR, Soleimani S, Maricevich MA, Yu JZ. Robotics in Implant-Based and Autologous Breast Reconstruction. Semin Plast Surg 2023; 37:168-175. [PMID: 38444960 PMCID: PMC10911900 DOI: 10.1055/s-0043-1771235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2024]
Abstract
Autologous and implant-based breast reconstruction continues to evolve as new technology and mastectomy techniques become available. Robotic-assisted breast reconstruction represents a growing field within plastic surgery, with the potential to improve aesthetic and functional outcomes, as well as patient satisfaction. This article provides a review of indications, techniques, and outcome data supporting the use of robotic assistance in both implant-based and autologous breast reconstruction from surgeons around the world.
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Affiliation(s)
- Brody W. King
- Michael E. DeBakey Department of Surgery, Division of Plastic Surgery, Baylor College of Medicine, Houston, Texas
- Division of Plastic Surgery, Texas Children's Hospital, Houston, Texas
| | - Jacob H. McCarter
- Michael E. DeBakey Department of Surgery, Division of Plastic Surgery, Baylor College of Medicine, Houston, Texas
- Division of Plastic Surgery, Texas Children's Hospital, Houston, Texas
| | - Heather R. Burns
- Michael E. DeBakey Department of Surgery, Division of Plastic Surgery, Baylor College of Medicine, Houston, Texas
- Division of Plastic Surgery, Texas Children's Hospital, Houston, Texas
| | | | - Marco A. Maricevich
- Michael E. DeBakey Department of Surgery, Division of Plastic Surgery, Baylor College of Medicine, Houston, Texas
- Division of Plastic Surgery, Texas Children's Hospital, Houston, Texas
| | - Jessie Z. Yu
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Yim NH, Burns HR, Davis MJ, Selber JC. Robotic Plastic Surgery Education: Developing a Robotic Surgery Training Program Specific to Plastic Surgery Trainees. Semin Plast Surg 2023; 37:157-167. [PMID: 38444955 PMCID: PMC10911909 DOI: 10.1055/s-0043-1771026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2024]
Abstract
Over the past two decades, the surgical community has increasingly embraced robotic-assisted surgery (RAS) due to its potential to enhance accuracy and decrease surgical morbidity. Plastic surgery as a field has been historically slow to incorporate RAS, with lack of adequate training posing as one of the most commonly cited barriers. To date, robot technology has been utilized for various reconstructive procedures including flap elevation and inset, pedicle dissection, and microvascular anastomosis. As RAS continues to integrate within plastic surgery procedures, the need for a structured RAS curriculum designed for plastic surgery trainees is rising. This article delineates the essential components of a plastic surgery-specific RAS curriculum and outlines current training models and assessment tools utilized across surgical subspecialties to date.
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Affiliation(s)
- Nicholas H. Yim
- Michael E. DeBakey Department of Surgery, Division of Plastic Surgery, Baylor College of Medicine, Houston, Texas
- Division of Plastic Surgery, Texas Children's Hospital, Houston, Texas
| | - Heather R. Burns
- Michael E. DeBakey Department of Surgery, Division of Plastic Surgery, Baylor College of Medicine, Houston, Texas
- Division of Plastic Surgery, Texas Children's Hospital, Houston, Texas
| | - Matthew J. Davis
- Michael E. DeBakey Department of Surgery, Division of Plastic Surgery, Baylor College of Medicine, Houston, Texas
- Division of Plastic Surgery, Texas Children's Hospital, Houston, Texas
| | - Jesse C. Selber
- Department of Plastic Surgery, Corewell Health, Grand Rapids, Michigan
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Burns HR, McLennan A, Xue EY, Yu JZ, Selber JC. Robotics in Microsurgery and Supermicrosurgery. Semin Plast Surg 2023; 37:206-216. [PMID: 38444959 PMCID: PMC10911899 DOI: 10.1055/s-0043-1771506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2024]
Abstract
Microsurgery has changed the ability to perform highly precise and technical surgeries through the utilization of high-powered microscopes and specialized instruments to manipulate and repair anatomical structures as small as a few millimeters. Since the first human trials of robotic-assisted microsurgery in 2006, the expansion of microsurgery to supermicrosurgery (luminal diameter less than 1 mm) has enabled successful repair of previously inaccessible structures. Surgical robotic systems can offer two distinct operative advantages: (1) minimal access surgery-by entering body cavities through ports, flap harvest can be redesigned to affect a minimally invasive approach for flaps such as the rectus abdominis muscle, the latissimus flap, and the deep inferior epigastric perforator flap; and (2) precision-by eliminating physiologic tremor, improving ergonomics, increasing accessibility to difficult spaces, and providing motion scaling, precision is significantly enhanced. Robotic-assisted microsurgery is a promising application of robotics for the plastic surgeon and has played an important role in flap harvest, head and neck reconstruction, nerve reconstruction, gender-affirming surgery, and lymphatic reconstruction-all the while minimizing surgical morbidity. This article aims to review the history, technology, and application of microsurgery and supermicrosurgery in plastic surgery.
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Affiliation(s)
- Heather R. Burns
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
- Division of Plastic Surgery, Texas Children's Hospital, Houston, Texas
| | - Alexandra McLennan
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
- Division of Plastic Surgery, Texas Children's Hospital, Houston, Texas
| | - Erica Y. Xue
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
- Division of Plastic Surgery, Texas Children's Hospital, Houston, Texas
| | - Jessie Z. Yu
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jesse C. Selber
- Department of Plastic Surgery, Corewell Health, Grand Rapids, Michigan
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Roy N, Alessandro CJ, Ibelli TJ, Akhavan AA, Sharaf JM, Rabinovitch D, Henderson PW, Yao A. The Expanding Utility of Robotic-Assisted Flap Harvest in Autologous Breast Reconstruction: A Systematic Review. J Clin Med 2023; 12:4951. [PMID: 37568353 PMCID: PMC10419897 DOI: 10.3390/jcm12154951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 06/22/2023] [Accepted: 06/27/2023] [Indexed: 08/13/2023] Open
Abstract
The expansion of robotic surgery has led to developments in robotic-assisted breast reconstruction techniques. Specifically, robotic flap harvest is being evaluated to help maximize operative reliability and reduce donor site morbidity without compromising flap success. Many publications are feasibility studies or technical descriptions; few cohort analyses exist. This systematic review aims to characterize trends in robotic autologous breast reconstruction and provide a summative analysis of their results. A systematic review was conducted using PubMed, Medline, Scopus, and Web of Science to evaluate robot use in breast reconstruction. Studies dated from 2006 to 2022 were identified and analyzed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Full-text, peer-reviewed, English-language, and human subject studies were included. Non-breast reconstruction articles, commentary, expert opinion, editor's letter, and duplicate studies were excluded. A total of 17 full-text articles were analyzed. The two robotic breast procedures identified were the deep inferior epigastric perforator (DIEP) and the latissimus dorsi (LD) flap. Results showed comparable complication rates and increased operative times compared to NSQIP data on their corresponding open techniques. Additional findings reported in studies included patient reported outcomes, incision lengths, and downward trends in operative time with consecutive procedures. The available data in the literature confirms that robotic surgery is a promising alternative to traditional open methods of breast reconstruction following mastectomy.
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Affiliation(s)
- Nikita Roy
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (N.R.); (T.J.I.); (A.A.A.); (J.M.S.); (P.W.H.)
| | | | - Taylor J. Ibelli
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (N.R.); (T.J.I.); (A.A.A.); (J.M.S.); (P.W.H.)
| | - Arya A. Akhavan
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (N.R.); (T.J.I.); (A.A.A.); (J.M.S.); (P.W.H.)
| | - Jake M. Sharaf
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (N.R.); (T.J.I.); (A.A.A.); (J.M.S.); (P.W.H.)
| | - David Rabinovitch
- The American Medical Program, Tel Aviv University, Tel Aviv 6997801, Israel;
| | - Peter W. Henderson
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (N.R.); (T.J.I.); (A.A.A.); (J.M.S.); (P.W.H.)
| | - Alice Yao
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (N.R.); (T.J.I.); (A.A.A.); (J.M.S.); (P.W.H.)
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