Transaxillary endoscopic excision of benign breast lumps: a new technique

Trans-axillary single port insufflation technique-assisted endoscopic surgery for breast diseases: Clinic experience, cosmetic outcome and oncologic result

Purpose

With an increasing demand for postoperative cosmetic effects in breast diseases, the single port by trans-axillary incision and air-inflation system, which provided better space and spared the assistant the effort of retraction, is widely used in clinic surgical treatment for multiple breast diseases.

Methods

According to inclusion and exclusion criteria, patients who underwent trans-axillary single-incision surgery at Tianjin Medical University Cancer Hospital between December 2020 and July 2022 were included in the study. We collected and analyzed data on age, fertility history, ultrasound grade, clinical stage, pathological results, oncological prognosis, patient-centered cosmetic outcome, etc.

Results

A total of 115 cases were included, of which 33 patients with benign disease underwent mass resection, 68 patients with malignant tumors underwent mastectomy. 10 patients had a special type of breast lesion. A mastectomy was performed in 4 patients with male mammary gland development. Of the 115 cases, the maximum mass diameter was 3.00 ± 1.644 (0.6–8.5) cm. Blood loss during surgery was 85.77 ± 50.342 (10-200) ml. The surgery took 131.84 ± 59.332 (30-280) minutes to complete. The patient spent a total of 5.05 ± 2.305 (2-18) days in the hospital. And the length of surgical incision in all patients was 3.83 ± 0.884 (3-8) cm. All patients were very satisfied with the appearance of their breasts after dressing. 94.78% of patients were satisfied with the position of the incision.

Conclusion

Through this study, we believe that in benign breast diseases and malignant breast tumors, trans-axillary single port insufflation technique-assisted endoscopic surgery has oncological safety and an aesthetic effect for most people with breast diseases.

Aesthetic Scar-Less Mastectomy and Breast Reconstruction

Surgical approaches in breast cancer have been changing to ensure both oncologic safety and cosmetic results. Although the concept of "oncoplastic breast surgery" has been accepted for decades, breast and plastic surgeons have been striving to develop more advanced surgical skills that ensure non-inferior oncologic outcomes with better cosmetic outcomes. Endoscopic or robotic devices, which are currently available only for chest or abdominal surgeries, could be used for breast surgery to ensure better cosmetic outcomes. The authors refer to this surgical concept as "aesthetic scar-less breast surgery and reconstruction," a term that encompasses the consequential concepts rather than naming it with simple technical words such as endoscopy-assisted or robot-assisted surgery. The "scar-less" term simply means leaving less of a scar, and better results can be expected by designing incisions on invisible areas. Herein, we summarize our experiences with various techniques of "aesthetic scar-less" surgery and review the existing literature on this topic.

Pneumoendoscopic single port approach to breast cancer. How we do it?

Endoscopic procedures have not become the gold standard in breast surgery. In order to improve today's outcomes we have developed a pilot study in the Breast Pathology Unit of Hospital Germans Trias i Pujol. A surgical procedure was performed creating a pneumoendoscopic cavity by using a Single Incision Laparoscopic Surgery (Single port) approach with a follow up of four years. Four patients underwent pneumoendoscopic single-port breast surgery receiving skin-sparing quadrantectomy and axillary surgery requiring lymphadenectomy in all of them. All patients had immediate reconstruction with a Latisimus Dorsi flap. No perioperative complications appeared. Mean operative time was 290 min (range 240-315 min) and mean hospital stay was 3,2 days. Surgical margins of all cases were pathologically negative and all patients were disease free after four years of monitoring. All patients were satisfied with the cosmetic outcome in the immediate postoperative and during the follow up. Although all innovative techniques generate hesitation on their beginnings and are liable to improve, we believe that pneumoendoscopic single-port breast surgery can be suitable for breast cancer, offering better cosmetic outcomes with oncological safety.

Transaxillary endoscopic excision of benign breast tumors, early institution experience

BACKGROUND AND AIM

Benign breast diseases are one of the most common diseases in females. An important goal in its treatment should be cosmesis, so a new minimally invasive technique has advanced. One of these techniques is the transaxillary endoscopic resection. The aim of this study was to assess the feasibility, safety, operative time, postoperative pain, hospital stay, and cosmetic outcome of this transaxillary approach.

METHODS

This study was carried out on 40 female patients presented with benign breast tumors in the surgical oncology unit at the General Surgery Department, Tanta University Hospital during the period from January 2018 to January 2019. The patients included in the study aged ≥18 years, had solitary or multiple benign breast tumors, located at any breast quadrant. The patients subjected to transaxillary endoscopic excision of the tumors.

RESULTS

The age of the patients ranged from 20 to 49 years with a mean age of 32 years. 60% of the lesions located in the upper half of the breast. Fibroadenoma was the most common finding in 80% of the patients, 60% of the patients had solitary tumor. The operative time ranged from 42 to 105 minutes with a mean of 61.4 minutes. 88.8% of the patients considered the cosmetic outcome excellent.

CONCLUSION

Endoscopic transaxillary excision of benign breast tumors is safe, feasible and has excellent cosmetic outcomes with high patient's satisfaction.

Endoscopic-assisted surgery in the management of breast cancer: 20 years review of trend, techniques and outcomes

To review current literature on the outcomes, techniques and trend of endoscopic-assisted breast surgery (EABS) in the management of breast cancer over a 20 years period Materials and Methods: Literature search was performed using PubMed/Medline database from 1st January 1998 to 31st December 2018 using the terms "endoscopy", "endoscopy-assisted", "breast cancer", "mastectomy" and "breast conserving surgery". Additional studies were also identified by reviewing references of relevant articles. Only case series and cohort studies were included in this review. Oncological and surgical outcome measures as well as detailed technical aspects were discussed. Results: EABS was comparable in terms of oncological, surgical as well as aesthetic outcomes if compared to conventional techniques. Patient selection and important adjuncts are essential to ensure successful and safe conduct of EABS. Conclusions: Standardization of techniques, practice guidelines and objective outcome assessments methods might pave the way for better conduct of EABS and place EABS as one of the standards of care for breast cancer care.

[Common benign breast tumors including fibroadenoma, phyllodes tumors, and papillary lesions: Guidelines]

OBJECTIVES

To provide guidelines for clinical practice from the French College of Obstetrics and Gynecology (CNGOF), based on the best evidence available, concerning common benign breast tumors: fibroadenoma (FA), phyllodes breast tumors (PBT), and papillary lesions (BPL).

METHODS

Bibliographical search in French and English languages by consultation of PubMed, Cochrane and international databases.

RESULTS

In case of percutaneous biopsy diagnosis of FA, clinico-radiologic and pathologic discordance or complex FA or proliferative lesions or atypia with FA, a family history of cancer, it seems legitimate to discuss management in a multidisciplinary meeting. When surgery is proposed for FA, periareolar compared to direct incision is associated with more insensitive nipple but better aesthetic results (LE4). When surgery is proposed for FA, indirect incision is preferable for better cosmetic results (Grade C). Techniques of percutaneous destruction or resection can be used (Grade C). The WHO classification distinguishes three categories of phyllodes tumors (PBT): benign (grade 1), borderline (grade 2) and malignant (grade 3). For grade 1 PBT, the risk of local recurrence after surgical excision increases when PBT lesion is in contact with surgical limits (not in sano). After in sano resection, there is no correlation between margin size and the risk of recurrence (LE4). For grade 2 PBT, local recurrence after surgical excision increases for margins under 10mm margins (LE4). For grade 1-2 PBT, in sano excision is recommended. For grade 2 PBT, 10-mm margins are recommended (Grade C). No lymph node evaluation or neither systematic mastectomy is recommended (Grade C). Breast papillary lesion (BPL) without atypia, complete resection of radiologic signal is recommended (Grade C). For BPL with atypia, complete excisional surgery is recommended (Grade C).

Biomolecular inflammatory response to surgical energy usage in laparoscopic surgery: results of a randomized study

OBJECTIVE

Use of surgical energy is integral to laparoscopic surgery (LS). Energized dissection (ED) has a potential to impact the biomolecular expression of inflammation due to ED-induced collateral inflammation. We did this triple-blind randomized controlled (RCT) study to assess this biomolecular footprint in an index LS, i.e., laparoscopic cholecystectomy (LC).

METHODS AND PROCEDURES

This RCT was conducted in collaboration with tertiary-level institutions, from January 2014 to December 2014 with institutional review board clearance. Consecutive, unselected, consenting candidates for LC were randomized (after anesthesia induction) into group I (ED) and group II (non-ED). They were managed with compliance to universal protocols for ethics, informed consent, anesthesia, drug usage and clinical pathway with blinded observers. Biomolecular inflammatory markers, i.e., interleukin 6 (IL-6), tumor necrosis factor-alpha (TNF-α) and highly sensitive CRP (HS-CRP), were measured with blood drawn juxta-preoperatively (H0), at 4 h (H4) and at 24 h (H24). The quantitative changes induced by ED on IL-6, TNF-α and HS-CRP at H0, H4 and H24 with their kinetic behavior were the study endpoint. Prospective data were analyzed statistically with a p value of <0.05 being significant.

RESULTS

Two cases from the ED group had biliary injury and hence were withdrawn from analysis. The ED (n = 49) and non-ED (n = 51) groups had similar demographic, clinical and H0 biomolecular variables. There was a significant increase in IL-6, TNF-α and HS-CRP from H0 to H4 in both the groups (p values <0.001). From H4 to H24, all three cytokines showed significant increase in ED group (p < 0.05), whereas in the non-ED group, IL-6 showed significant fall (p = 0.004) and TNF-α showed no significant change (p = 0.063). Both the groups showed H4-H24 elevation of HS-CRP (p = 0.000).

CONCLUSION

Energized dissection adds to the cytokine-mediated postoperative inflammation. The additional ED-induced inflammation can be measured objectively by IL-6 and TNF-α levels.

CLINICAL TRIALS REGISTRY

Clinical Trials Registry, India (REF/2014/06/007153).

Videoendoscopic single-port nipple-sparing mastectomy and immediate reconstruction

PURPOSE

Single-incision videoendoscopic surgery has recently become popular as a result of the ongoing search for less invasive procedures. The aim of this study was to evaluate the safety and efficacy of endoscopic single-port nipple-sparing mastectomy, axillary lymphadenectomy, and immediate reconstruction in patients with breast cancer.

PATIENTS AND METHODS

From May 14, 2012 through January 23, 2013, 10 patients underwent videoendoscopic single-port nipple-sparing mastectomy and axillary dissection via a single, limited incision and immediate prosthetic reconstruction. Patient charts were reviewed, and demographic data, operative time, complications and pathology results were analyzed.

RESULTS

In all patients, videoendoscopic surgery was performed successfully. Of 10 patients, 7 were diagnosed as having invasive ductal carcinoma, 2 had a ductal carcinoma in situ, and 1 underwent bilateral prophylactic mastectomy. The weight of the resected gland was 300-650 g, with a mean of 420 g. There were no operative complications, and the mean operative time was 250 minutes (range, 160-330 minutes). One-stage reconstruction with implants was performed on 4 patients, whereas expanders were placed in the remaining 6. Surgical margins of all cases were pathologically negative, and there were no recurrences observed during the early follow-up period.

CONCLUSIONS

Videoendoscopic single-port nipple-sparing mastectomy is technically feasible even in larger breasts, enabling immediate reconstruction with good cosmetic outcomes. However, further studies with larger clinical series and long-term follow-up are required to compare the safety and efficacy of the technique with those of the standard nipple-sparing mastectomy.

Innovations in Endosurgery-Journey into the Past of the Future: To Ride the SILS Bandwagon or Not?

Progress in surgical practice has paralleled the civilizational evolution. Surgery has progressed from being the last resort in saving life to being form and function preserver. Post-renaissance Industrial age gave an impetus to this march of surgery. The currently on going digital technological revolution has further catalysed this march. Having achieved the stabilized and acceptable clinical outcomes, the surgeon has embarked on a journey of improving patient reported outcomes (PRO). Improvement in PROs with the advent of laparoscopic surgery with the attendant emphasis on minimising invasion has led to debates about invasion being just parietal or holistic in physiological sense. There is a concern that parietal invasiveness shouldn't be a trade-off for compromised clinical outcomes. Single Incision Laparoscopic Surgery (SILS) in its current avatar with current instrumentation seems to be an enthusiastic bandwagon rolling on with the cosmetic benefits acting as veil to hide the potential clinical concerns. History of surgical innovations is riddled with tales of vindictiveness and vicissitude. Lest the same fate befalls SILS we would do better to examine the SILS bandwagon in its current form till the emerging technologies address the current concerns.

Transaxillary approach with use of traction suture for excision of breast fibroadenoma: a new technique and its results

Avoiding a scar on the breast is an inherent feminine desire. We devised a new approach for breast fibroadenoma excision:Transaxillary approach with use of traction suture (TATS), in 50 patients with breast fibroadenoma. The swelling was present in the outer breast. The wound healed without noticeable scarring and the original shape of the breast was preserved. All the patients expressed their great satisfaction with the procedure.

Retromammary approach for endoscopic resection of benign breast lesions

BACKGROUND

One of the merits of endoscopic surgery is that it can be performed through small remote incisions made in inconspicuous areas. To improve cosmetic outcomes of surgical treatment of benign breast lesions, we performed endoscopic surgery through minimally sized axillary incisions with the goal of achieving scar-free breasts.

METHODS

From August 2007 to August 2008, 18 patients with 20 benign breast lesions underwent endoscopic breast excision in our institution. Endoscopic resection of benign breast lesions was performed via the retromammary route with video assistance. Cosmetic results were evaluated using the five-item, four-step ABNSW scoring system, assessing breast asymmetry, breast shape, nipple shape, skin condition, and wound scars.

RESULTS

The median age of the patients was 27 years (IQR 23.0, 29.0). Median resected lesion size was 3.3 cm (IQR 2.9, 3.9). Median operative time was 85.0 min (IQR 70.0, 100.0). A marginally significant difference in operative times was noted between fibroadenoma and/or juvenile fibroadenoma cases and mastopathy or benign phyllodes cases (80.0 vs. 100.0; p < 0.06). Median total ABNSW score was 14 points. Postoperatively, 5 patients had mild local subcutaneous emphysema, and one had transient brachial palsy. No breast ecchymosis or deformity was noted. No major complications developed in any patient, and 89% of patients had good or excellent results.

CONCLUSIONS

Video-assisted endoscopic breast surgery has changed routine breast surgery, manifesting cosmetic effects that cannot be achieved by previous routine surgical techniques. Patients with multiple or large benign tumors who desire excellent cosmetic results are good candidates for this approach.