Endoscopic breast-conserving surgery with immediate local advancement/perforator flap reconstruction

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 raised above the ahead and secured 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. Pre-operative marking and design of the flap were performed, taking into consideration the location of intercostal artery perforator vessels using Doppler ultrasound. The lateral intercostal artery perforator (LiCAP) flap was used in the case discussion later.

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.