After injection of the dye, the anatomical borders of the breast could be identified within the working space without help from assistants during the second and third cadaveric studies. Thus, indigo carmine was injected into the borders of the breast parenchyma to identify the anatomical borders of the breast. During the first attempted cadaveric RANSM, the breast surgeons could not identify the anatomical borders of the breast. The detailed procedure of a gasless RANSM has been described in a previous case report 11. A Chung’s or modified Chung’s retractor for endoscopic and robotic surgeries was utilized during the gasless technique. The cadaveric study was performed by 2 breast surgeons and 2 plastic surgeons. Six breasts in 3 cadavers were used for the initial RANSM with IBR, and feasibility and safety of the procedure were evaluated. The sources of cadavers were body donation programs or unclaimed bodies provided by the Severance robot and MIS center 9, 10. Prior to evaluating the feasibility and safety of RANSM with IBR in humans, RANSM with a latissimus dorsi flap and/or implant insertion was performed on cadavers between December 2013 and November 2014 (Fig. We investigated the outcome of RANSM with IBR and analyzed the learning curve for this procedure.
Not many studies have analyzed the learning curve of RANSM. Only a few studies have evaluated the feasibility and safety of robot-assisted nipple-sparing mastectomy (RANSM) with immediate breast reconstruction (IBR) to treat breast cancer. first introduced robotic breast surgery in 2015 after which this technique was attempted globally 5, 8. Thus, robotic surgery scores over endoscopic surgery and is widely used for several intracorporeal procedures. The sophisticated and intuitive motion of robotic arms allows microscale manipulation, and surgeons can perform delicate tasks accurately even in a limited operative field. High-resolution, 10-fold image magnification, and 3-dimensional optics enable accurate visualization and differentiation of fine structures including intercostal perforators and lymphatics 7. Robotic surgery is widely used across various fields since its introduction in 1985 6 because of its several incomparable advantages. However, restricted maneuverability (because of inflexible endoscopic equipment) and inadequate operative field visualization (because of 2-dimensional cameras) are limitations of this technique 4, 5. Aesthetically, endoscopic breast surgery is expected to achieve complete cancer clearance with preservation of the patient’s body image 4. The risk of nipple necrosis associated with a periareolar incision is higher than that with a non-periareolar incision 3. An inframammary fold or lateral or periareolar incision ensures an inconspicuous scar however, removal of adequate quantities of breast tissue is technically challenging 2. However, a conspicuous scar on the breast dome and a change in the shape of the breast are unavoidable. Nipple-sparing mastectomy (NSM) is popular secondary to the excellent cosmetic effects achieved in appropriately selected patients 1. RANSM is an advanced surgical method with a short learning curve. We deemed that RANSM with IBR is safe and feasible for early breast cancer, benign disease of the breast, and BRCA 1/2 mutation carriers.
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One patient had self-resolved partial nipple ischemia, and two patients experienced partial skin ischemia. There was no open conversion or major postoperative complication. The learning curve presented as a cumulative sum graph showed that the console time decreased and then stabilized at the eighth case.
The median total operation time and console time were 351 min (267–480 min) and 51 min (18–143 min), respectively.
Postoperative outcomes including postoperative complications and final margin status of resected were analyzed. Age, breast weight, diagnosis, tumor size, hormone receptor status, and operation time were retrospectively collected. Patients with tumors measuring >5 cm in diameter, tumor invasion of the skin or nipple-areolar complex, proven metastatic lymph nodes, or planned radiotherapy were excluded. Ten patients underwent 12 RANSM with IBR between November 2016 and April 2018. Potentially addressing these limitations, we investigated the outcomes of gas and gasless robot-assisted nipple-sparing mastectomy (RANSM) with immediate breast reconstruction (IBR). Unfortunately, there are some limitations in the range of movement and visualization of the operation field. Seeking smaller and indistinct incisions, physicians have attempted endoscopic breast surgery in breast cancer patients.
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