Development of Robotic Mastectomy Using a Single-Port Surgical Robot System

Safety and Feasibility of Robotic Nipple-Sparing Mastectomy With Immediate Direct-to-Implant Reconstruction - Insights From the One of the Largest Centers in Asia

BACKGROUND

The use of robotic-assisted nipple-sparing mastectomy (R-NSM) with immediate direct-to-implant (DTI) reconstruction in treatment of breast cancer has been a controversial topic. The adoption of robotic surgery in breast cancer treatment has gained traction globally due to its minimally invasive nature, potential for improved cosmetic outcomes and better intraoperative visualization. This study provides insights on safety and feasibility robotic mastectomy at one of the largest centers in Asia.

METHODS

This retrospective study included patients who underwent robotic nipple-sparing mastectomy (R-NSM) with immediate direct-to-implant (DTI) reconstruction from April 2018 to September 2024. Our endpoints were mainly focused on perioperative outcomes, patient satisfaction, and oncologic outcomes.

RESULTS

A total of 266 procedures were included in our series, with 233 patients undergoing unilateral R-NSM with either DTI reconstruction or a tissue expander, and 33 patients underwent surgery on both breasts. Postoperative complications were recorded in 11 patients (4.14 %). The median follow-up of this study is 37.2 ± 23.3 months. Locoregional recurrence (LRR) was observed in 6 patients (2.5 %), with isolated skin recurrence being the most common. Distant metastasis was observed in 9 patients (3.86 %). The 3-year overall survival rate was 98.3 %.

CONCLUSION

Robotic NSM is a safe and feasible novel minimal invasive surgical approach for breast cancer surgery, providing both excellent cosmetic results and oncological outcomes that are noninferior to conventional or endoscopic approaches.

Use of the Da Vinci SP surgical system in robot-assisted nipple-sparing mastectomy: a single-center, retrospective study

We investigated the safety and performance of the Da Vinci SP single-port robot (SP robot) in nipple-sparing mastectomy (NSM) with immediate reconstruction. Medical records of 60 women aged ≥ 19 years who had undergone SP robot-assisted unilateral or bilateral NSM with immediate reconstruction between October 2020 and August 2021 were retrospectively analyzed. Stage I (31, 47.1%) was the most common pathological tumor-node-metastasis stage, followed by stages II (22, 33.3%), 0 (7, 10.6%), and III (4, 6.0%). The median total duration of NSM performed by a breast surgeon and reconstruction performed by a plastic surgeon was 154.0 min (interquartile range [IQR], 130.5-206.0 min) and 133.0 min (IQR, 80.0-255.0 min), respectively. The median length of hospitalization was 5.5 days (IQR, 3.0-9.0 days). Conversion to robotic multiport or open surgery was not required in any case. The median duration to drain removal was 5.0 days (IQR, 4.0-6.0 days). Recurrence of cancer within 6 months was not observed in any patient. SP robot-assisted NSM with immediate reconstruction was performed successfully in all patients without conversion to open surgery or the incidence of significant perioperative complications, indicating its precision and ability to minimize the size of the surgical incision.

Conventional versus Robot-Assisted Immediate Breast Reconstruction: Reconstructive Outcome and Patient-Reported Outcome Measures

BACKGROUND

In this study, the authors compared conventional and robot-assisted mastectomy and breast reconstruction. To the authors' knowledge, this study is the first to report the results of robot-assisted mastectomy and breast reconstruction and provide a comparison of patient-reported outcomes.

METHOD

This retrospective study included 473 breasts of 423 patients who underwent conventional mastectomy and breast reconstruction and 164 breasts of 153 patients who underwent robot-assisted mastectomy and breast reconstruction from July of 2019 to October of 2021. Demographic and oncologic data, reconstructive outcomes, and patient-reported outcomes (BREAST-Q) were evaluated. The results of implant-based and autologous breast reconstruction were evaluated separately.

RESULTS

Skin necrosis requiring surgical débridement occurred significantly more frequently in the conventional group (8.0%) than in the robot-assisted group (2.0%) in implant-based reconstruction ( P = 0.035). At 6 to 12 months, patients who underwent robot-assisted breast reconstruction showed a higher Sexual Well-being score for implant-based reconstruction and a higher Physical Well-being score for autologous breast reconstruction than conventional breast reconstruction according to the BREAST-Q questionnaire.

CONCLUSIONS

Robot-assisted mastectomy and breast reconstruction was associated with less skin necrosis and better patient-reported outcomes (Sexual Well-being for implant-based reconstruction and Physical Well-being for autologous breast reconstruction) than the conventional option. Robotic surgery could be a good option for mastectomy and breast reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Learning curve for robot-assisted nipple-sparing mastectomy: A single institution experience

BACKGROUND

Robot-assisted nipple sparing mastectomy (RANSM) is emerging because it offers hidden incisions and ergonomic movements. In this study, we report the learning curve and feasibility of RANSM.

METHODS

A retrospective study was conducted among women who underwent RANSM with immediate breast reconstruction from July 2019 to June 2022. All RANSM procedures were performed by a single surgeon. We divided all the cases into two phases: the early phase (cases 1 to 21) and the late phase (cases 22 to 46). The total operation time, breast operation time, docking time, and console time were analyzed, and the cumulative sum (CUSUM) method was used to evaluate the effects of case experience accumulation on the time required for RANSM. Postoperative complications were analyzed according to their Clavien-Dindo grade.

RESULTS

Overall, 42 women underwent 46 RANSM procedures. In the early and late phases, the mean console times were 78.1 min and 60.1 min (p = 0.011), respectively. In learning curve analysis, 21 RANSM procedures were required to reduce the breast operation time. Two cases of Clavien-Dindo grade III postoperative complications occurred (4.3 %). One case was an implant removal caused by infection, and the other was partial nipple ischemia; both occurred in the early phase, with none in the late phase.

CONCLUSIONS

The breast operation time improved after the 21st RANSM procedure, and only two cases had Clavien-Dindo grade III or higher postoperative complications. RANSM is thus technically feasible and acceptable, with a short learning curve.

Da Vinci single-port robotic system current application and future perspective in general surgery: A scoping review

BACKGROUND

The da Vinci Single-Port Robot System (DVSP) allows three robotic instruments and an articulated scope to be inserted through a single small incision. It received FDA approval in 2014 and was first introduced in 2018. The aim of this new system was to overcome the limitations of single-incision laparoscopic and robotic surgery. Since then, it has been approved for use only for urologic and transoral surgeries in some countries. It has been used as part of experimental protocols in general surgery.

OBJECTIVE

By obtaining the CE mark at the end of January 2024, DVSP will soon enter the European market. This review aims to comprehensively describe the applications of DVSP in general surgery.

DESIGN

A search of PubMed, Embase, and Ebsco databases up to March 2024 was conducted, with registration in PROSPERO (CRD42024536430), following the preferred reporting items for Systematic reviews and Meta-analyses for scoping review (PRISMA-Scr) guidelines. All the studies about the use of DVSP in general surgery were included.

RESULTS

Fifty-six studies were included. The following surgical areas of use were identified: transabdominal and transanal colorectal, cholecystectomy, abdominal wall repair, upper gastroesophageal tract, liver, pancreas, breast, and thyroid surgery. The reported surgical and short-term outcomes are promising; a wide range of procedures have been performed safely. Some groups have found advantages, such as faster discharge, shorter operative time, and less postoperative pain compared to multiport robotic surgery.

CONCLUSION

Five years after its initial clinical applications, the use of the DVSP in general surgery procedures has demonstrated feasibility and safety. Hernia repair, cholecystectomy, and colorectal surgery emerge as the most frequently conducted interventions with this robotic system. Nevertheless, there is anticipation for further studies with larger sample sizes and extended follow-up periods to provide more comprehensive insights and data on the long-term outcomes, including the incidence of incisional hernia.

Emerging Role of Robotic Surgery in the Breast

In recent years, there has been increased adoption of robotic technology in oncologic breast surgery, particularly with the use of robotic nipple sparing mastectomy (r-NSM). Here we review the emergence of robotic-assisted surgery in breast procedures, and discuss the safety, limited oncologic outcomes, apparent advantages, and potential limitations of r-NSM compared to conventional open-NSM (c-NSM). Limited data suggests that robotic-assisted surgery offers smaller incisions and potential for improved cosmesis and ergonomic advantage when compared to c-NSM. Similar periprocedural complication rates are seen with r-NSM compared with c-NSM. Short-term oncologic follow-up is reassuring however, but remains early and continues to be investigated. The increased cost of r-NSM compared to open surgery and feasibility of widespread adoption of the procedure are important considerations that need to be evaluated. Randomized trials are currently ongoing to address the apparent advantages, oncologic outcomes, and cost/feasibility of robotic breast surgery.

Safety and Feasibility of Single-Port Robotic-Assisted Nipple-Sparing Mastectomy

Importance

Robotic-assisted nipple-sparing mastectomies with multiport robots have been described in the US since 2015; however, significant hurdles to multiport robotic surgery exist in breast surgery.

Objective

To demonstrate that the single-port da Vinci SP (Intuitive Surgical) robotic system is feasible in patients undergoing robotic nipple-sparing mastectomy (rNSM).

Design, Setting, and Participants

An initial case series of 20 patients at a large university hospital underwent bilateral single-port robotic nipple-sparing mastectomies (SPrNSM) with tissue expander reconstruction from February 1, 2020, through January 4, 2023. Participants included women who met surgical criteria for nipple-sparing mastectomies, per standard of care.

Intervention

Surgery using a single-port robot and the surgical technique of the authors.

Main Outcomes and Measures

Age, indication, body mass index, breast size, operative time, conversion to open surgery, systemic complications, postoperative skin necrosis, and reported skin and nipple areolar complex (NAC) sensation.

Results

Twenty women aged 29 to 63 years (median, 40 years) underwent bilateral SPrNSM. Eleven patients completed prophylactic surgery due to a high risk for breast cancer (more than 20% lifetime risk) and 9 patients had breast cancer. Breast size ranged from A through D cup with median B cup and a body mass index range of 19.7 through 27.8 (median 24.4). The total duration of the procedure from incision to skin closure for both sides ranged from 205 minutes to 351 minutes (median, 277). The median robotic time for bilateral SPrNSM was 116 minutes and varied by cup size (A cup, 95 minutes; B cup, 140 minutes; C cup, 118 minutes; D cup, 114 minutes) with no inflection point in learning curve. No cases were converted to open and no immediate complications, such as hematoma, positive margins, or recurrence, were seen. In the first 10 patients prior to routine sensation testing, 20 resected breasts had measurable NAC sensation at a range from 4 to 36 months post-index resection (65%). In the second 10 patients of the cohort, measurable NAC was preserved in 13 of 20 resected breasts 2 weeks following the index operation (65%).

Conclusion and Relevance

In this case series, SPrNSM with immediate reconstruction was feasible and performed safely by an experienced breast surgeon with limited previous robotic training. Further studies confirming the preliminary data demonstrating improved NAC and skin sensation following SPrNSM are warranted.

Trial Registration

ClinicalTrials.gov Identifier: NCT05245812.

Single-Port Robotic Radical Prostatectomy Using Transvesical and Transperineal Access in Patients with a Hostile Abdomen

Introduction: Prostate cancer diagnosis and treatment is challenging in surgically complex patients. Radical prostatectomy can be performed without peritoneal entry using novel single-port (SP) transperineal (TP) and transvesical (TV) approaches. We sought to examine the outcomes of radical prostatectomy using novel TP and TV approaches in patients with extensive prior abdominal surgeries. Materials and Methods: From 2019 to 2023, 51 patients with extensive prior abdominal surgeries were identified who underwent TP (18) and SP TV (33) robotic radical prostatectomy. Indications included history of various surgeries with open laparotomy, including J-pouch reconstruction (22, 43%), active stoma (14, 27%), and open bowel resection (9, 18%). In all patients, 12/51 (24%) had a history of incisional hernia repair with mesh. A retrospective analysis was performed. Results: All cases were completed without open conversion, bowel injuries, or blood transfusions. Length of stay was 5.6 hours for TV and 22 hours for TP. No opioids were prescribed in 91% of TV vs 56% of TP. One intraoperative complication (ureteral injury) occurred in a patient undergoing the TP approach. Postoperative complications were noted in 14/51 (27%), including 10/18 (56%) TP vs 4/33 (12%) TV. High-grade complications (Clavien 3) occurred in three patients (6%, all TP). Pathologic staging showed pT3 in 26/51 (17 TV vs 9 TP), while the remainder were pT2. Biochemical recurrences were noted in four patients (8%, three TV and one TP). Immediate continence was noted in 30% of TV patients. Long-term continence after 12 months was 92% in TV and 67% in TP. Conclusions: In patients with extensive prior abdominal surgeries, radical prostatectomy is feasible using a TP or TV approach. No bowel injuries or open conversion were observed. The SP TV approach offers advantages of shorter hospital stay, shorter catheter duration, less opioid use, fewer complications, and improved continence recovery.

Clinical status and future prospects of single-incision robotic-assisted surgery: a review

Since the advent of conventional multiport laparoscopic surgery, the prosperity of minimally invasive surgery has been thriving on the advancement of endoscopic techniques. Cosmetic superiority, recovery benefits, and noninferior surgical outcomes weigh single-incision laparoscopic surgery as a promising modality. Although there are surgical challenges posed by steep learning curve and technological difficulties, such as instruments collision, triangulation loss and limited retraction, the establishment of robotic surgical platform as a solution to all is inspiring. Furthermore, with enhanced instrument maneuverability and stability, robotic ergonomic innovations adopt the advantages of single-incision laparoscopic surgery and surmount its recognized barriers by introducing a novel combination, single-incision robotic-assisted surgery. As was gradually diffused in general surgery and other specialties, single-incision robotic-assisted surgery manifests privileges in noninferior clinical outcomes an satisfactory cosmetic effect among strictly selected patients, and has the potential of a preferable surgical option for minimally invasive surgery.

Single-port versus multiport robotic total mesorectal excision for rectal cancer: initial experiences by case-matched analysis of short-term outcomes

Purpose

The da Vinci single-port (SP) system has been used in various surgical fields, including colorectal surgery. However, limited experience has been reported on its safety and feasibility. This study aims to evaluate the short-term outcomes of SP robotic surgery for the treatment of rectal cancer compared with multiport (MP) robotic surgery.

Methods

Rectal cancer patients who underwent curative resection in 2020 were reviewed. A total of 43 patients underwent robotic total mesorectal excision (TME), of which 26 (13 in each group, SPTME vs. MPTME) were included in the case-matched cohort for analysis. Intraoperative and postoperative outcomes and pathological results were compared between the 2 groups.

Results

Median tumor height was similar between the 2 groups (SPTME vs. MPTME: 5.9 cm [range, 2.2-9.6 cm] vs. 6.7 cm [range, 3.4-10.0 cm], P = 0.578). Preoperative chemoradiotherapy was equally performed (38.5%). The median estimated blood loss was less (20.0 mL [range, 5.0-20.0 mL] vs. 30.0 mL [range, 20.0-30.0 mL], P = 0.020) and the median hospital stay was shorter (7 days [range, 6-8 days] vs. 8 days [range, 7-9 days], P = 0.055) in the SPTME group. Postoperative complications did not differ (SPTME vs. MPTME: 7.7% vs. 23.1%, P = 0.587). One patient in the SPTME group and 3 in the MPTME group experienced anastomotic leakage.

Conclusion

SP robotic TME showed perioperative outcomes similar to MP robotic TME. The SP robotic system can be considered a surgical option for the treatment of rectal cancer. Further prospective randomized trials with larger cohorts are required.

New Robotic Platforms in General Surgery: What's the Current Clinical Scenario?

Background and Objectives: Robotic surgery has been widely adopted in general surgery worldwide but access to this technology is still limited to a few hospitals. With the recent introduction of new robotic platforms, several studies reported the feasibility of different surgical procedures. The aim of this systematic review is to highlight the current clinical practice with the new robotic platforms in general surgery. Materials and Methods: A grey literature search was performed on the Internet to identify the available robotic systems. A PRISMA compliant systematic review was conducted for all English articles up to 10 February 2023 searching the following databases: MEDLINE, EMBASE, and Cochrane Library. Clinical outcomes, training process, operating surgeon background, cost-analysis, and specific registries were evaluated. Results: A total of 103 studies were included for qualitative synthesis after the full-text screening. Of the fifteen robotic platforms identified, only seven were adopted in a clinical environment. Out of 4053 patients, 2819 were operated on with a new robotic device. Hepatopancreatobiliary surgery specialty performed the majority of procedures, and the most performed procedure was cholecystectomy. Globally, 109 emergency surgeries were reported. Concerning the training process, only 45 papers reported the background of the operating surgeon, and only 28 papers described the training process on the surgical platform. Only one cost-analysis compared a new robot to the existing reference. Two manufacturers promoted a specific registry to collect clinical outcomes. Conclusions: This systematic review highlights the feasibility of most surgical procedures in general surgery using the new robotic platforms. Adoption of these new devices in general surgery is constantly growing with the extension of regulatory approvals. Standardization of the training process and the assessment of skills' transferability is still lacking. Further studies are required to better understand the real clinical and economical benefit.

Bibliometric analysis of robotic surgery research in breast cancer conducted between 2008 and 2022

BACKGROUND

To carry out a bibliometric analysis of robotic surgery research in the field of breast cancer conducted between 2008 and 2022 and to evaluate the status and trends in the field.

METHODS

A systematic search was undertaken in the Web of Science (WoS) for published articles related to surgical robots and breast cancer. R and VOSviewer software were used to carry out a quantitative analysis to explore the trend of annual publication volume and the cooperative relationship between countries, institutions, authors, and keywords.

RESULTS

A total of 177 publications were retrieved, 79.66% of which were published from 2016 to 2022, and most were conducted in the United States (US), China, and South Korea. Articles from the US had the most frequent international cooperation. A tally of institutional publications showed that Yonsei University (YONSEI UNIV; Korea) had produced the most publications. The author with the most published papers was Lee of YONSEI UNIV. The most accepted journal was the Asian Journal of Surgery. Keyword co-occurrence analysis showed that current research hotspots were mainly focused on nipple-conserving mastectomy and breast reconstruction, and breast-conserving and nipple-conserving mastectomy may be future research hotspots.

CONCLUSIONS

The annual incidence of robotic surgery and breast cancer is gradually increasing. The predominant countries conducting research in this field include the US, China, and South Korea, and the institutions are mainly distributed in universities and hospitals. Nipple-conserving mastectomy and breast reconstruction may be the current research hotspots, and breast-conserving mastectomy and minimally invasive surgery may represent hot research areas in the future. These findings may help scholars who are committed to the application of surgical robots to breast cancer to better understand the current research status and trends.

Robot-assisted Nipple Sparing Mastectomy: Recent Advancements and Ongoing Controversies

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.

Analgesic Efficacies of Intraoperative Pectoralis Nerve II Block under Direct Vision in Patients Undergoing Robotic Nipple-Sparing Mastectomy with Immediate Breast Reconstruction: A Prospective, Randomized Controlled Study

This prospective, randomized study aimed to evaluate the efficacy of an intraoperative pectoralis nerve II block (PECS II block) under direct vision in the reduction of fentanyl consumption during postoperative 24 h in patients undergoing robotic nipple-sparing mastectomy (RNSM) with immediate breast reconstruction (IBR) using direct-to-implant (DTI) or tissue expander (TE). Thirty patients scheduled for RNSM with IBR were randomly allocated to the PECS (n = 15) or control (n = 15) groups. The PECS II block was applied under direct vision after RNSM. The primary outcome was the cumulative dose of fentanyl consumption. The secondary outcomes were pain intensity using a numerical rating scale (NRS) at rest and acting during the postoperative 24 h. The cumulative dose of fentanyl at 24 h was significantly lower in the PECS group than in the control group (p = 0.011). Patients in the PECS group showed significantly lower NRS scores during the first postoperative 2 h compared to those in the control group in both resting and acting pain (p < 0.05). An intraoperative PECS II block under direct vision can reduce opioid consumption during the postoperative 24 h and provide effective analgesia in patients undergoing RNSM with IBR using DTI or TE.

Analysis of robot-assisted nipple-sparing mastectomy using the da Vinci SP system

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.

Robot-assisted Nipple-sparing Mastectomy With Immediate Breast Reconstruction: An initial Experience of the Korea Robot-endoscopy Minimal Access Breast Surgery Study Group (KoREa-BSG)

OBJECTIVE

The aim of this study was to present the results of early experience of robot-assisted nipple sparing mastectomy (RANSM).

BACKGROUND

RANSM improves cosmetic outcomes over conventional nipple-sparing mastectomy. However, data on the feasibility and safety of the RANSM are limited.

METHODS

Patients who underwent RANSM with immediate breast reconstruction as part of the Korea Robot-endoscopy Minimal Access Breast Surgery Study Group (KoREa-BSG) from November 2016 to January 2020 were enrolled. clinicopathologic characteristics, perioperative complications, and operation time were collected.

RESULTS

Overall, 73 women underwent 82 RANSM procedures conducted by 11 breast surgeons at 8 institutions. The median patient age was 45.5 years old (20-66 years), and 52 (63.4%) patients were premenopausal. Invasive breast cancer was noted in 55 cases (40 cases were stage i, 11 cases were stage ii, and 4 cases were stage iii, respectively) and ductal carcinoma in-situ was recorded in 20 cases. Of those, 3 patients with BRCA1/2 mutation carriers underwent contralateral risk-reducing RANSM. The median length of hospitalization was 12.0 days (5.0-24.0 days). The incision location was the mid-axillary line and the median incision length was 50.0 mm (30.0-60.0 mm). Median total operation time, median total mastectomy time, and median reconstruction time was 307.0 minutes (163.0-796.0 minutes), 189.5 minutes (97.5-325.0 minutes), and 119.5 minutes (45.0-689.0 minutes). Only 2 cases (2.5%) required reoperation. Nipple ischemia was found in 9 cases (10.9%) but only 1 case (1.2%) required nipple excision given that 8 cases (9.7%) resolved spontaneously. Skin ischemia was observed in 5 cases (6.1%) and only 2 (2.4%) cases needed skin excision whereas 3 cases (3.6%) resolved spontaneously. There was no conversion to open surgery orcases of mortality. The mean time for mastectomy among surgeons who performed more than 10 cases was 182.3 minutes (± 53.7, minutes) and 195.4 minutes (± 50.4, minutes).

CONCLUSION

This was the first report of RANSM conducted in the KoREa-BSG. RANSM is technically feasible and acceptable with a short learning curve. Further prospective research to evaluate surgical and oncologic outcomes is needed.

From cadaveric and animal studies to the clinical reality of robotic mastectomy: a feasibility report of training program

Robotic nipple-sparing mastectomy (RNSM) provides better cosmetic outcomes and improves the quality of life of women with breast cancer. However, this has not been widely adapted due to the lack of well-structured training programs. The present study aimed to report the establishment of cadaveric and animal skill laboratory training programs for RNSM and the participants’ perception on the training programs. We performed 24 RNSMs using 11 cadavers and one porcine model. Then, the skill laboratory characteristics were reviewed. Five trainers and 10 trainees participated in the programs. The first four cadaveric RNSMs with latissimus dorsi flaps and implants were performed using the da Vinci Si® system. We performed 14 and six RNSMs using the Xi® and SP® systems, respectively. The scores for questionnaires on the satisfaction with the training consisted of the trainees’ perceived goals in attending the course, teaching/learning environment, and teaching staff performance. The scores were excellent. Cadaveric or porcine RNSM skill laboratory training may be essential programs that can provide safe and efficient training.

Robotic DIEP Flap Harvest through a Totally Extraperitoneal Approach Using a Single-Port Surgical Robotic System

SUMMARY

Deep inferior epigastric artery perforator (DIEP) flap surgery is one of the most common techniques for breast reconstruction using abdominal tissue. Although the DIEP flap reduces donor-site morbidity when compared with the conventional free transverse rectus abdominis musculocutaneous flap, violation of the anterior rectus sheath, rectus muscle, and motor nerves cannot be avoided. To further minimize tissue damage in the donor site, the use of a surgical robotic system for DIEP flap harvest with a totally extraperitoneal approach has been suggested. This totally extraperitoneal approach has a long learning curve because of the narrow preperitoneal space and the difficulty of converting a potential space to an actual space. Thus, the authors suggest a single-port robotic system optimized for narrow surgical spaces as a feasible option for DIEP flap harvest by a totally extraperitoneal approach, which has a shorter learning curve.

A Randomized Trial of Robotic Mastectomy versus Open Surgery in Women With Breast Cancer or BRCA Mutation

Objective

To compare robotic mastectomy with open classical technique outcomes in breast cancer patients.

Summary Background Data

As the use of robotic nipple sparing mastectomy continues to rise, improved understanding of the surgical, oncologic and quality of life outcomes is imperative for appropriate patient selection as well as to better understand indications, limits, advantages and dangers.

Methods

In a phase III, open label, single center, randomized controlled trial involving 80 women with breast cancer (69) or with BRCA mutation (11), we compared the outcome of robotic and open nipple sparing mastectomy. Primary outcomes were surgical complications and quality of life using specific validated questionnaires. Secondary objective included oncologic outcomes.

Results

Robotic procedure was 1 hour and 18 minutes longer than open (P < 0.001). No differences in the number or type of complications (P = 0.11) were observed. Breast-Q scores in satisfaction with breasts, psychosocial, physical and sexual well-being were significantly higher after robotic mastectomy vs open procedure. Respect to baseline, physical and sexual well-being domains remained stable after robotic mastectomy while they significantly decreased after open procedure (P<= 0.02). The overall Body Image Scale questionnaire score was 20.7 +/- 13.8 vs. 9.9 +/- 5.1 in the robotic vs open groups respectively, P < 0.0001. At median follow-up 28.6 months (range 3.7-43.3), no local events were observed.

Conclusions

Complications were similar among groups upholding the robotic technique to be safe. Quality of life was maintained after robotic mastectomy while significantly decrease after open surgery. Early follow up confirm no premature local failure. ClinicalTrials.gov NCT03440398.

An initial experience with a novel technique of single-port robotic resection for rectal cancer

BACKGROUND

The da Vinci single-port (SP) system is designed to facilitate single-incision robotic surgery in a narrow space. We developed a new procedure of rectal resection using this system. The aim of the present study was to evaluate the technical feasibility and safety of SP robotic rectal resection for rectal cancer patients based on our initial experience.

METHODS

A study was conducted on consecutive patients with mid or low rectal cancer who had SP robotic resection at our institution between July and September 2020. The demographic characteristics, perioperative data, and pathology results of the patients were retrospectively analyzed.

RESULTS

There were 5 patients (3 males, 2 females, median age 57 years (range 36-73 years). The median tumor height from the anal verge was 4 cm (range 3-5 cm). Two patients received preoperative chemoradiotherapy for advanced rectal cancer. A single docking was conducted, and the median docking time was 4 min 20 s (range 3 min 30 s to 5 min). The median total operation time was 195 min (range 155-240 min), and the median time of pelvic dissection was 45 min (range 36-62 min). All patients had circumferential and distal tumor-free resection margins. One patient experienced an anastomosis-related complication. The median duration of hospital stay was 7 days (range 7-8 days).

CONCLUSIONS

Our initial experience suggests that SP robotic rectal resection is safe and feasible. Further clinical trials comparing SP and multiport robotic rectal resection should be conducted to verify the superior aspects of this new system.

Postoperative pain assessment of robotic nipple-sparing mastectomy with immediate prepectoral prosthesis breast reconstruction: a comparison with conventional nipple-sparing mastectomy

Aims: Nipple-sparing mastectomy (NSM) is a surgical procedure for patients with breast cancer without nipple-areolar complex (NAC) involvement. Robotic NSM (RNSM) with immediate breast reconstruction has been recently introduced; however, reports regarding RNSM are still lacking. Therefore, this study aimed to evaluate the postoperative assessment with a focus on postoperative pain of RNSM with prepectoral immediate prosthesis breast reconstruction (IPBR) compared with conventional NSM (CNSM) in patients with breast cancer without NAC invasion. Methods: This retrospective study included 81 patients who underwent RNSM (n = 40) or CNSM (n = 41) with prepectoral IPBR using direct-to-implant or tissue expander between January 2018 and June 2020. The primary endpoint was to compare postoperative pain intensity based on a numerical rating scale (NRS). The secondary endpoint was to evaluate the postoperative recovery profile, including postoperative nausea/vomiting (PONV) and complications. Results: A statistical difference was observed in the resting NRS scores at 0-6 postoperative hours between the RNSM and CNSM groups (3.2 ± 1.5 versus 4.2 ± 1.6, respectively; Bonferroni corrected P = 0.005), however, no difference was shown at other time periods. Also, no between-group difference was found in the NRS scores for acting pain within 48 postoperative hours and the number of patients requiring additional analgesics. Conclusions: Despite a statistical difference in the resting NRS scores during the early postoperative phase, the absence of any significant difference in the requirement of additional analgesics between the groups suggested that RNSM does not significantly attenuate postoperative pain intensity.

Comparison of Single Incision Endoscopic Nipple-Sparing Mastectomy and Conventional Nipple-Sparing Mastectomy for Breast Cancer Based on Initial Experience

Purpose

Endoscopic breast surgery for patients with breast cancer was introduced for its superior cosmetic outcomes; it was initially studied in the field of breast-conserving surgery and, more recently, in robotic-assisted nipple-sparing mastectomy (NSM). The main purpose of this study was to investigate the feasibility and safety of endoscopic NSM (E-NSM) in patients with breast cancer by comparing E-NSM and conventional NSM (C-NSM).

Methods

Between May 2017 and October 2020, we retrieved the records of 45 patients who underwent NSM with permanent silicone implants and divided them into the E-NSM group (20 patients) and the C-NSM group (25 patients), depending on the use of the endoscopic device. We also analyzed demographic information, pathology, operative time, and complications.

Results

No significant differences were observed between the 2 groups based on demographic information, postoperative pathological data, mean length of hospital stay, and total number of complications. The mean preparation time for surgery was comparable between both groups. Compared to the C-NSM group, the E-NSM group had a significantly longer mean operative time and, subsequently, a significantly longer mean total operative time and number of complications.

Conclusion

The results showed that E-NSM was feasible and safe with a more inconspicuous incision in patients with breast cancer.