Technique for single axillary incision robotic assisted quadrantectomy and immediate partial breast reconstruction with robotic latissimus dorsi flap harvest for breast cancer: A case report

Abstract

Rationale: The clinical application of robotic surgery in breast conserving surgery or volume replacement with robotic latissimus dorsi flap harvest (RLDFH) has been rarely reported. In this study, we report the preliminary experience and clinical outcome of robotic assisted quadrantectomy (RAQ) and immediate partial breast reconstruction (IPBR) with RLDFH.

Patient concern: Decreasing and avoid back scar length after latissimus dorsi flap harvest.

Diagnoses: One 28 years old female with left breast cancer underwent RAQ and IPBR with RLDFH. Initially, she was diagnosed with left breast infiltrating carcinoma that was clinical stage T3N1M0 and triple negative.

Interventions: Neoadjuvant chemotherapy consisting of 4 cycles of epirubicin and cyclophosphamide followed by 4 cycles of docetaxel was performed. Breast magnetic resonance imaging showed residual breast cancer about 4.5 cm over the left upper outer quadrant of the breast. Sentinel lymph node biopsy showed no lymph node metastasis. RAQ, which took 82 minutes, was performed first, and the resected breast specimen's weight was 203 gm. She received IPBR with RLDFH, which took 97 minutes.

Outcomes: The overall blood loss was 40 mL. The final pathology result was ypT2 (4.2 cm)N0 (sn0/3)M0 and stage IIA. The resection margin was free of tumors. The post-operative recovery was smooth except for seroma formation over the back, which was relieved after repeated aspiration at an outpatient clinic. The patient was satisfied with the post-operative scar and aesthetic outcome. No local recurrence, distant metastasis or case mortality was found during 5 months of follow-up.

Lessons: RAQ and IPBR with RLDFH is a safe alternative for small-to-medium-breast-size women with breast cancer who desire breast conservation and are indicated for volume replacement with autologous latissimus dorsi flap.

Conflict of interest statement

The authors declare no conflicts of interest. This study was partially funded by the Ministry of Science and Technology of Taiwan, and the number of this funding is 104-2314-B-371-006-MY3. This study was also sponsored by research funding provided by the Changhua Christian Hospital: 104-CCH-ICO-006 and 106-CCH-IRP-011.

None of the authors have conflicts of interest or financial ties to disclose.

Figures

Figure 1

Magnetic resonance imaging (MRI) of current reported case. A, Pre-neoadjuvant chemotherapy MRI (transverse view) showed left breast cancer occupying large area of breast, size about 8.5 × 6 cm2. B, Pre-neoadjuvant chemotherapy MRI (sagittal view) showed left breast cancer occupying left upper half of breast. C, Post neoadjuvant chemotherapy (sagittal view) showed left breast cancer size had decreased to 4.5 cm. D, Post neoadjuvant chemotherapy (transverse view) showed left breast cancer size decreased and confined to upper outer quadrant. MRI = magnetic resonance imaging.

Figure 2

Demonstration of technique tips for RAQ. A, Pre-operative and intra-operative sonography was used to mark the location of the tumor and resection margin. Axillary incision and two additional trocar sites for RAQ and robotic latissimus dorsi flap harvest were marked with red dotted lines and arrows. B, After creation of the working space, a single port (Glove Port, Nelis, Gyeonggi-do, Korea) was inserted over the operating axilla. It was then inflated with carbon dioxide with air pressure kept at 8 mm Hg to create space for partial mastectomy. C, Picture shows the setting of RAQ, which was performed with a da Vinci Si (Intuitive Surgical, Sunnyvale, CA) robotic platform with the operating surgeon controlling at the console. D, Anterior skin flap dissecting was performed by dissection between skin flaps and breast glandular tissue with monopolar scissors. The parenchyma resection was performed with monopolar scissors along the inked resection margin, which was created by methylene blue containing jelly. E, After peripheral dissection and parenchyma resection, the left upper outer quadrantectomy was completed. F, The entire resected quadrantectomy breast specimen, which was intact and marked with silk threads for pathologic orientation, was removed through the axillary wound. G, Immediately post RAQ, the wound was small and hidden in the axilla region. However, a defect over the left upper outer quadrant was obvious due to a large portion of breast being removed. RAQ = robotic assisted quadrantectomy.

Figure 3

Demonstration of technique tips of IPBR with RLDFH. A, From the axillary wound, the thoracodorsal pedicle was identified and marked with a vessel loop. Then the wound was packed, and the patient was shifted to decubitus position. B, Two 12 mm balloon trocars (Kii Balloon blunt tip system, Applied Medical, Rancho Santa Margarita, CA) were used as port site for monopolar scissor and prograsp forceps. After all the 3 ports were set, the video camera was shifted to the middle port, and the monopolar scissors were shifted to the inferior port. The prograsp forceps were shifted to the inferior opening of the axillary accessory port. C, Dissection was suggested to begin along the undersurface of the muscle. After the undersurface of the muscle is dissected to the borders, the prograsp forceps is used to direct the anterior edge of the muscle toward the chest wall, and dissection proceeds over the superficial surface of the muscle. D, Once dissection is complete along both the deep and superficial surfaces, monopolar scissors are used to disinsert the muscle from the inferoposterior border. As the muscle is released, it is gathered toward the axilla to maintain tension and visualization along the posterior border. E, The pedicled latissimus dorsi flap, which was harvested by robotic means, was ready for transfer to post mastectomy subcutaneous space. The wound was small over the axilla, and 2 1 cm trocar wounds could be used as drain exit sites. F, Front view of immediate post-breast reconstruction outcome. The flap was fixed internally in the resected defect to ensure full coverage of the post partial mastectomy defect. IPBR = immediate partial breast reconstruction, RLDFH = robotic latissimus dorsi flap harvest.

Figure 4

Pre- and post-operative pictures for patient who received RAQ and IPBR with RLDFH. A, Pre-operative front view of the 28 years old female with large left breast cancer post neoadjuvant chemotherapy indicated for left upper outer quadrantectomy. B, The location and presumed resection margin of left breast cancer was marked pre-operatively under the guidance of sonography. C, The borders of the LD muscle are marked: the anterior border was marked during LD muscle contraction, the superior border is marked over the tip of the scapula, and the posterior border is defined about 3 to 4 cm lateral to the spine. D, Left lateral-front view, which was taken 3 weeks post operation, showed that after IPBR with RLDFH, the left breast was in good shape and in symmetry with the right breast. E, Post-operative lateral view showed that the wound was small and well hidden in the inconspicuous axilla region. Two other 1 cm trocar wounds, which were used as drain exit sites, were also small and inconspicuous. F, Post-operative posterior view showed no incision scar was left over the back. IPBR = immediate partial breast reconstruction, LD = latissimus dorsi, RAQ = robotic assisted quadrantectomy, RLDFH = robotic latissimus dorsi flap harvest.