Robotic Surgery: A Novel Approach for Breast Surgery and Reconstruction

Abstract

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.

Fig. 1.

A flowchart to depict the database search and exclusion criteria identifying 21 articles.

Fig. 2.

LD muscle flap harvest. The LD flap harvested entirely through the axillary incision. Reprinted with permission from J Plast Reconstr Aesthet Surg 2015;68:966–972.

Fig. 3.

A 38-year-old patient with left-sided breast cancer. A, Before operation. B and C, At 1-year follow-up. The patient had undergone an NSM with IBR with a robotically harvested LD muscle flap and silicon implant. C, The largest incision can be well hidden in the axillary. Reprinted with permission from J Plast Reconstr Aesthet Surg 2015;68:966–972.

Fig. 4.

Intraoperative images of a robotic NSM and immediate reconstruction. A and B, The 3–5-cm incision with single port insertion. C, The positioning and docking of the robotic side cart posterior to the patient with the arms extending over the patient, aligned with the plane of the breast and nearly parallel to the floor. D, Superficial dissection separating the skin flap from the breast glandular tissue. E, Subpectoral pocket dissection for prosthesis insertion. F, Immediately post mastectomy and before reconstruction, followed by (G) immediate postbreast reconstruction with gel implant. Reprinted with permission from Ann Surg Oncol 2018;14:14. IPBR, immediate prosthetic breast reconstruction.

Fig. 5.

Operation time and learning curve of NSM. A, The docking time (minutes) and the chronologic case sequence demonstrated the robotic system could be fully setup in 10 minutes. B, The R-NSM time initially fluctuated and as cases accumulated, it could be performed in less than 100 minutes. C, The total time for R-NSM and IBR also initially fluctuated with the later cases completed within 250 minutes. Both (D) and (E) combine the docking time, R-NSM, and total R-NSM with IBR against the chronologic case sequence, along with considering the mastectomy tissue weight. The graphs illustrate that it took 13 procedures to refine and efficiently perform the procedure. Reprinted with permission from Eur J Surg Oncol 2018;17:17.

Fig. 6.

A patient at 3 months postoperatively after a bilateral NSM and IBR. A, arms fully abducted, and B, at rest. The incision scars are well hidden within the axillary. Reprinted with permission from Ann Surg Oncol 2018;25:2579–2586.