Robotic-Assisted Nipple Sparing Mastectomy

Abstract

Minimally invasive approaches to breast surgery have evolved from endoscopic techniques to recent developments in robotic-assisted mastectomies. Initial studies on robotic-assisted nipple-sparing mastectomy (RNSM) have shown improved patient satisfaction and aesthetic outcomes with similar complication rates and oncological outcomes in selected patients. This chapter reviews techniques used and available data on complications and clinical outcomes for RNSM. Currently, RNSM is an investigational technique in the United States and should be performed in clinical trials with U.S. Food & Drug Administration approval to rigorously evaluate the safety and effectiveness of this approach.

Keywords: nipple-sparing mastectomy; robotic surgery; robotic-surgical platforms.

Fig. 1

Illustrations of different ipsilateral upper limb positions, incision placements, and techniques used in robotic nipple sparing mastectomy (R-NSM). ( A ) Photo showing ipsilateral upper limb position: downward with hand placed on the hip (change in position might be required in different stages of the operation). ( B ) Photo showing ipsilateral upper limb position: 90 degrees out on an arm board (change in position might be required in different stages of the operation). ( C ) Photo showing ipsilateral upper limb position-above the head (change in position might be required in different stages of the operation). ( D ) Photo showing intraoperative set-up and positioning of surgeon at the console and first assistant by the patient in R-NSM using da Vinci Si system. ( E ) Photo showing intraoperative view in R-NSM using da Vinci Xi system. ( F ) Intraoperative photo showing the tunneling technique: tunnels (indicated by red arrows) created by blunt dissection of Metzenbaum scissors after tumescent solution injection. ( G ) Intraoperative photo showing subnipple biopsy with the glandular tissue and lactiferous duct removed as cleanly as possible with only the nipple areolar complex (NAC) left behind. ( H ) Intraoperative view showing peripheral dissection of breast glandular tissue: the boundary of dissection was marked with methylene blue containing xylocaine jelly. ( I ) Intraoperative view showing subpectoral muscular dissection for preparation of muscular pocket using da Vinci surgical system. ( J ) Postoperative photo of patient A with left breast cancer who had R-NSM and immediate gel implant breast reconstruction (IGBR) showing a small and well-hidden scar in the axilla region. ( K ) Postoperative photo of patient B with left breast cancer who had R-NSM and IGBR showing a small and well-hidden scar along the anterior axillary line at the NAC level. (Reprinted with permission from Lai HW, et al. Consensus statement on robotic mastectomy—expert panel from international endoscopic and robotic breast surgery symposium (IERBS) 2019. Ann Surg 2020;271(6):1005–1012.)

Fig. 2

Intraoperative breast insufflation and robotic arm placement used in R-NSM. (Reprinted with permission from Sarfati B, et al. Robotic nipple-sparing mastectomy with immediate prosthetic breast reconstruction: Surgical technique. Plast Reconstr Surg 2018;142(3):624–627.)