Endoscopic breast-conserving surgery

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 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 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 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 SLNB 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.

Tunnelling and development of skin flap

After completion of the axillary staging procedure, a semi-circular peri-areolar skin incision or a single axillary incision was made (depending on surgeon's preference) as previously described. A physiological saline solution containing lidocaine 0.05% and epinephrine 1:1,000,000 was injected subcutaneously into the whole breast to minimize bleeding. An approximately 3–5-mm-thick skin flap was created via tunnelling method using an optical bladeless trocar Xcel (Johnson & Johnson, Tokyo, Japan) under endoscopic guidance. Subsequently, the septa between the skin flap and parenchyma was dissected and taken off under endoscopic guidance using endoscissors, bipolar scissors, or a harmonic scalpel.

Performing wide excision and repair of resection cavity

After development of adequate skin flap (either via a single axillary or combination of axillary and peri-areolar incision, wide excision was performed using bipolar or monopolar diathermy). To guide resection with adequate margins, the authors recommended the use of intra-operative ultrasound and marking of resection margin with blue dye injection. Specimen was retrieved thereafter and haemostasis secured. Level I oncoplastic techniques were used to approximate breast parenchyma and drain was placed on a case-to-case basis.

Patient/demographics

This is a case of a 40-year-old lady with a 1.3-cm tumor in the left upper outer quadrant. Core biopsy pre-operatively revealed an invasive ductal carcinoma, ER/PR positive, CerbB2 positive. Metastatic workup was negative. The patient opted for breast conservation, and she was not keen for any form of reconstruction.

Surgery and pathology report

The patient underwent an endoscopic-assisted breast-conserving surgery with sentinel lymph node biopsy via a single axillary incision. The frozen section for the sentinel lymph node biopsy was negative, and final routine histopathology revealed a T1cN0 (0/4 LN)M0 tumor with clear margins.