Robotic Technologies in the Treatment of Breast Cancer

Abstract

In recent years, there has been a tendency to reduce the volume of surgical intervention in breast cancer in full compliance with the requirements of oncologic radicalism. The abandonment of aggressive surgical treatment, used for many years, is explained, first of all, by the significant success of early diagnosis of breast cancer and the natural increase in the number of patients with early stages of the disease. Robot-assisted radical subcutaneous mastectomy with single-stage endoprosthesis proved to be a feasible and safe method. In all known studies, the surgery has a low conversion rate, a reasonable learning curve and a low complication rate. This technique allows to obtain excellent esthetic results.

1. Introduction

Over recent years, there has been a tendency to reduce the volume of surgical intervention in breast cancer in full compliance with the requirements of oncological radicalism. The rejection of aggressive surgical treatment, which has been used for many years, is primarily due to the significant success of early diagnosis of breast cancer and a natural increase in the number of patients with early stages of the disease [1, 2]. At the same time, breast-conserving surgery (BCS) at the initial stages of the disease is recognized as the preferred type of surgical treatment in the vast majority of cases [3, 4]. An important stage in the treatment of early stages of breast cancer should be the unification of the principles of BCS with elements of plastic surgery and precision endovideosurgical techniques. By virtue of the use of modern technologies and improved visualization of the surgical area, the accuracy of surgical manipulations increases and the volume of damaged tissues decreases, thereby minimizing the risk of hematogenic and lymphogenic dissemination [1, 2, 3, 4]. In recent decades, the use of robotic technologies in various fields of modern surgery has had a significant impact on surgical technique and patient treatment outcomes. Presently robot-assisted surgery is considered one of the most relevant options for performing prostatectomy, cystectomy, hysterectomy, and is also successfully used in colorectal surgery [5, 6]. Despite the absence of a natural cavity necessary for endoscopic control, robotic interventions have also been used in the surgical treatment of diseases of superficially located organs (thyroid gland), as well as in plastic and reconstructive surgical interventions (oropharyngeal zone and breast) [7].

A patient with histologically verified stages I-IIa breast cancer, who was being treated in the oncosurgical department of the breast of the Loginov Moscow Clinical Scientific Center MHD, underwent a robot-assisted radical subcutaneous mastectomy with single-step endoprosthesis (Table 1).

Indications for performing RARSM	Contraindications to performing RARSM
Age from 35 to 60 years old	Presence of clinically significant comorbidities
Absence of distant and regional metastases	Body mass index less than 24 kg/m^2
The largest tumor size is less than 3 cm	Data on alcohol, drug, and tobacco abuse
Absence of clinical and morphological data on multicentric growth of breast cancer	Breast ptosis of degree 2 (or more)
Absence of clinical and morphological evidence of widespread intraductal invasion	Breast volume is less than 150 and more than 350 cm^3
No clinical or morphological evidence of tumor or inflammatory infiltration and erosion of the skin or nipple	Radiation therapy on the anterior chest wall area on the surgical side
Location of the tumor at least 1.5 cm from the areola
Breast volume from 150 to 350 cm^3

Table 1.

Indications and contraindications for performing RARSM.

On the eve of the operation, a preoperative cutaneous marking of the area of the alleged tissue dissection with a skin marker is performed (Figure 1).

Figure 1.

Preoperative marking (the skin marker indicates the areas of the alleged dissection of the tissues of the right breast, the projection of the tumor on the skin, the median line and the spot of the left breast are indicated).

The basic kit for accomplishment robot-assisted subcutaneous mastectomy includes a monitor, a video camera, a light source and a light guide, a 0-degree 10-mm endoscope, a radiofrequency scalpel, three 12-mm trocars, a monopolar endoscopic clamp, an irrigation-aspiration system, a CO₂ insufflator, a “SI Da Vinci Robotic” platform, a bipolar endoscopic clamp, endoscopic monopolar curved scissors (Figure 2).

Figure 2.

The layout of the patient on the surgical table, the operating team and the “Da Vinci” complex.

One of the most important issues of the robot-assisted subcutaneous mastectomy is the optimal positioning of the patient’s trunk, upper limb and the robot platform in the operating room. At the same time, it is necessary to achieve the most effective interaction of the operating team and avoid the separation of the operating zone by the sleeves and diaphragm of the robotic complex. To achieve all the above-stated goals, the patient should be under general anesthesia with orotracheal intubation in a supine position, the patient’s arm on the side of the operation is bent at the elbow joint and put behind the head—this position is ideal both for avoiding conflicts with the robot diagram and for preventing damage because of distortion the brachial plexus. In addition, the introduction of 3 trocars provides effective triangulation of operational equipment in each area of the operative field, which, in return, allows optimizing the location of the elements of the robotic complex. The surgical table is given a slight tilt towards the affected breast. 3 trocars are inserted along the lateral edge of the breast (along the anterior axillary line) at the level of 3–6 ribs (Figure 3).

Figure 3.

Location of trocars during left-sided robot–assisted subcutaneous mastectomy: a—schematic representation of trocars; b—marking the location of trocars on the surgical table.

Therefore, the surgeon is located in front of the main console, controlling the robotic complex and other operating equipment, and the assistant is at the surgical table, controlling the movements of the robotic manipulators. The first port is installed in the axillary region through a two-centimeter discission of the skin at the border of the breast and the axillary region.

A 12-mm trocar is inserted into this port, into which a Meriland clamp is installed. To create a sufficient working space, the required amount of carbon dioxide is dosed through the first port.

Carbon dioxide is insufflated at very low pressure (4–5 mm Hg) to prevent a subcutaneous emphysema. An 8 mm trocar for the endovideosystem is installed in the second port. A 12 mm trocar for Ligasure™ scissors is inserted into the third one (Figure 4).

Figure 4.

View of the operative field with installed trocars (a) and connected robotic complex (b).

While using ports, there is no need to form a deep and wide subcutaneous nook. In general, it was enough to separate the subcutaneous adipose tissue by no more than 1–2 cm along the entire contour of the skin discission. In addition, constant insufflation of carbon dioxide facilitates surface dissection, promotes stretching of Cooper’s ligaments and separation of glandular breast tissue. An additional advantage of this technique is that 3-port access avoids excessive uncontrolled stretching of the edges of the skin, which contributes to better wound healing in the postoperative period and provides an acceptable esthetic result. After insertion of monopolar curved scissors and bipolar clamp, the instruments are docked to the robotic complex. Using the “SI Da Vinci Robotic” system allows to arbitrarily change the position and length of the robotic arms, facilitating work in the very small operative field. In addition, during manipulations, the position of the channels can change independently of each other, which makes it possible to change the angles of robotic instruments in relation to the operative field. Finally, using such access allows to attach a system for CO₂ insufflation so as to provide the best dissection conditions.

The stages of skin flap formation and dissection of the nipple-areola complex during robot-assisted radical subcutaneous mastectomy basically have the same features as conventional video-assisted mastectomy. Dissection is performed with robotic monopolar scissors and bipolar forceps. During dissection with scissors, the activation time of thermal energy is minimized to prevent thermal damage of the skin flap. After the dissection is completed and the glandular breast tissue is completely separated, the robotic complex is disconnected. Then the trocars are removed. A linear discission connects the installation points of I and II trocars and then the breast gross specimen is removed. Lymphodissection of 1–2 levels is performed. Next, to perform the reconstructive stage of the operation, the greater pectoral muscle is separated from the V–VI ribs to the sternum. An anatomical silicone prosthesis is placed under the greater pectoral muscle. A drainage is installed in the muscle nook, which is removed through a skin discission along the inframammary fold, previously used to install the III robotic port. After completion of all manipulations, the surgical wound is sutured with an intradermal suture (Figure 5).

Figure 5.

The appearance of the operative field after the installation of the endoprosthesis (a) and the final appearance of the mammary glands after the operation (b).

2. Results

After performing robot-assisted radical subcutaneous mastectomy with single-step endoprosthesis, the severity of the endoprosthesis folds in the first weeks of the postoperative period is minimal, after 3–4 months, the endoprosthesis folds or pericapsular fluid are not determined by medical ultrasound. Early post-surgery complications did not occur. There was no case of significant pericapsular fibrosis or implant migration after robot-assisted radical subcutaneous mastectomy (Figure 6).

Figure 6.

Appearance of patient a, 35 years old, diagnosed with right breast cancer stage I cT1cN0M0 G2, luminal type a, after performing robot-assisted radical subcutaneous mastectomy with single-step endoprosthesis: a—1 month after surgery; b—1 year after surgery.

3. Discussion

The new Da Vinci SP robotic surgical platform offers many advantages, including better visualization using 3D optics, improved ergonomics of instruments equipped with a high degree of freedom of movement, and a better workspace due to the insufflation used. Discissions for the installation of ports are carried out along the anterior axillary line, which allows to obtain excellent esthetic results. The main disadvantages of this surgical technique include: the duration of the operation, high value, as well as low equipment with robotic installations in medical and preventive treatment centres in the Russian Federation. Robot-assisted radical subcutaneous mastectomy with with single-step endoprosthesis proved to be a feasible and safe method. In all known research studies, the operation has a low conversion rate, a reasonable learning curve and a low level of complications [8, 9]. The authors explain the low frequency of flap necrosis by the location of the discission and better visualization using 3D optics [10]. Oncological results were not reported, since the duration of observation in all research studies was less than 5 years. In all cases, excellent esthetic results were reported, and one study described the degree of patient satisfaction—most were satisfied with the results of the operation, especially in terms of the placement and length of the discission [11].

4. Conclusion

Robot-assisted radical subcutaneous mastectomy is a safe and radical intervention that can be effectively used in the surgical treatment of breast cancer in the early stages of the disease. This technique is associated with a low incidence of early and late complications, and allows to obtain excellent esthetic results.