Endoscopic breast conserving surgery with immediate partial breast reconstruction using robot-assisted harvest of pedicled omental flap

Pre-operative marking and positioning

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. Endoscopic video monitors (Olympus Optical Co., Tokyo, Japan) were set up on both sides of the patient's head to allow both the surgeon and the assistant to view the monitor. An oblique-ended rigid endoscope measuring 5 mm in diameter with a viewing angle of 30 degrees was used in all procedures.

Axillary staging 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-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.

Dissection of breast parenchyma off pectoralis major fascia

After completion of axillary staging procedure, dissection was carried out to the lateral border of the pectoralis major muscle. The margin between pectoralis muscle and breast parenchyma was clearly identified. An endoscopic Ultra Retractor (Johnson & Johnson KK or Karl Storz) vein harvester was used for the dissection pectoral muscle fascia off posterior portion of breast parenchyma. The penetrating vessels were coagulated and cut with bipolar scissors (PowerStar, Johnson & Johnson KK) or a harmonic scalpel to ensure adequate haemostasis and therefore better visual clarity. Counter traction was applied by retracting surrounding tissue with the Ultra Retractor under endoscopic guidance to create a sufficient working space, and a suction tube can be used to evacuate mist and smoke.