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Pre-operative marking was done with the patient in standing and supine position. After induction of general anaesthesia, the patient was then placed in the supine position and ipsilateral arm abducted to 90 degrees to avoid affecting the operative procedure.
In patients for whom sentinel lymph node biopsy (SLNB) is indicated, a small amount (2–3 mCi) of radioisotope Tc99m was injected intradermally at the site of the tumour before operation (either on the day or 1 day prior).
After induction of general anaesthesia, 3 mL of 1% methylene blue (Merck, Darmstadt, Germany) was injected into the breast parenchyma in equally divided aliquots at five positions surrounding the hemisphere of the tumour facing the ipsilateral axilla. The breast tissue from the tumour to the axilla was then gently massaged for 5–10 minutes. Within 20–30 minutes after injection of the blue dye, a handheld gamma probe (Navigator; USSC, Norwalk, CT) was used to identify the hot spots and the location of the hottest nodes was then marked. An approximately 3–5 cm oblique axillary incision was then made close to the hottest nodes, and SLNB was then performed. Fresh frozen section was performed as indicated. If SLN was positive for metastases, a complete axillary lymph node dissection up to level II was performed.
To create working space for placement of the single port (Glove Port; Nelis Corporation, Gyeonggi-do, Korea), a 3–4 cm subcutaneous flap was dissected with electrocautery under direct vision. The tunnelling technique as described in endoscopic mastectomy was then used to facilitate skin flap dissection and create space between the skin flap and the breast parenchyma. Once adequate dissection was achieved, the single port was then inserted through the axilla incision, and carbon dioxide (CO 2 ) insufflation with air pressure kept at 8 mmHg was used to create space for mastectomy. The ipsilateral shoulder was elevated to 30 degrees to prevent conflict between the operating table and docking of the robotic surgery system. The robotic side cart (da Vinci; Intuitive Surgical, Sunnyvale, CA, USA) was then positioned from the contralateral side, with the two robotic arms endoscope extending over the patient near the ports before the ports were docked to the robotic arms. Subsequently, the operation was then shifted to the da Vinci Si or Xi (Intuitive Surgical, Sunnyvale, CA, USA) robotic platform controlled by the operating surgeon at the console. The authors used a 30 degree 12-mm diameter camera (Intuitive Surgical, Denzlingen, Germany) in the upper port to prevent collisions with other instruments. Dissection was carried out using an 8-mm monopolar scissors (Intuitive Surgical, Sunnyvale, CA, USA). Traction and counter-traction, along with maintaining exposure, were carried out using an 8-mm ProGrasp forceps (Intuitive Surgical, Sunnyvale, CA, USA). The location of the scissors and the ProGrasp forceps could be changed inter-variably during the operation. Dissection was initiated from the superficial skin flaps by dissecting the septa between the skin flap and parenchyma created by the tunnelling technique with monopolar scissors. A sub-areolar biopsy and fresh frozen section analysis can be performed in a nipple-sparing mastectomy (NSM). If cancer cell invasion was found in the sub-areolar area, the entire nipple-areola complex (NAC) was removed and conversion to a skin-sparing mastectomy was then performed. After completion of the superficial skin flap dissection, dissection of the peripheral portion of the breast parenchyma was carried out subsequently. Posterior dissection was then performed by detaching the breast tissue from the pectoralis major muscle fascia with the perforator vessels clearly identified and secured. After completion of dissection, the entire breast specimen was removed through the axillary wound.
Following removal of the specimen and adequate haemostasis, copious irrigation of the mastectomy pocket was performed. Subsequently, the lateral border of the pectoralis major muscle was elevated to allow for sub-muscular pocket dissection. The working space was developed under direct vision by electrocautery with assistance of a handle light retractor. The single port was then re-inserted with CO 2 insufflation for robotic sub-muscular pocket dissection using a da Vinci surgical platform. Dissection was performed medially towards the sternal border, taking care not to injure the perforator vessels. Inferiorly, the dissection was carried out beyond the inframammary fold over the lateral aspect, below which the muscle was released to continue the dissection to the subcutaneous plane thus allowing for a more natural placement of the implant. In the lateral border, the superficial fascia of the serratus anterior muscle was dissected posteriorly in a limited fashion so that it was just enough to accommodate the lateral border of the implant. After initial dissection of the sub-muscular space with the da Vinci surgical platform, the robotic instruments and single port were removed. The operating table was then moved into the sitting position. The adequacy of the sub-muscular pocket dissection was checked and completed with the assistance of a light source retractor. After creation of the sub-muscular pocket, an implant (Mentor Worldwide LLC, Santa Barbara, CA) was then placed followed by drains placement in both sub-muscular and subcutaneous planes. Care was taken when tagging the free muscle edges laterally.
This is a case of a 53-year-old lady who presented with a hard lump in her left breast. Core biopsy pre-operatively revealed an invasive ductal carcinoma, ER+, PR-, CerbB+
Her metastatic workup was negative.
The patient opted for mastectomy with immediate reconstruction, and she was offered a robotic nipple-sparing mastectomy with implant reconstruction.
The patient underwent a robotic nipple-sparing mastectomy, sentinel lymph node biopsy, and implant reconstruction. Intra-operative frozen section for sentinel lymph node and sub-nipple biopsies were both negative.
Her final histology reported a stage IIA disease (T2N0M0), and she subsequently received adjuvant chemotherapy and endocrine therapy for 5 years.
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