ROBOT MASTECTOMY
Mastectomy is one of the surgical treatments for women with breast cancer or a risk-reducing procedure for women with high risk for breast cancer. Even though breast-conserving surgery was developed to increase cosmesis and the quality of life (QoL) of patients, approximately 30-50% of patients with breast cancer are still undergoing mastectomy rather than breast-conserving surgery.
Figure 1. Postoperative scars of breast-conserving surgery (left) and mastectomy (right)
Mastectomy causes body deformity because this procedure removes not only the breast tissue but also the overlying skin and nipple. To improve cosmetic outcomes, procedures preserving the overlying skin and nipple were developed: skin-sparing or nipple-sparing mastectomy. However, these procedures have several limitations such as long scars on the overlying skin (Figure 2A), skin or nipple necrosis, and difficult technique to achieve proper surgical outcomes. To overcome these disadvantages of mastectomy, endoscopic or robotic procedures were developed.
Robot and endoscopic mastectomy have several advantages compared to conventional mastectomy. A main advantage of these procedures is a hidden small scar (Figure 2B). The procedure through a small axillary incision results in better cosmesis causing increased QoL compared to conventional mastectomy. Without precise endoscopic devices like robotic surgical systems, the small axillary incision, sized 2.5-6cm, is nearly impossible to perform. Surgeons call this procedure minimally invasive or minimal-access breast surgery.
Various types of incisions in conventional nipple-sparing mastectomy and robot-assisted nipple-sparing mastectomy. (A) Types of incision in conventional nipple-sparing mastectomy: 1) Lower-periareolar incision with/without extension, 2) Radial incision, 3) Curvilinear incision, 4) Upper-periareolar incision with/without extension, 5) Elliptical incision, 6) Inframammary fold incision; (B) Type of incision in robot-assisted nipple-sparing mastectomy: 7) Lateral incision.
Figure 2. Postoperative scars between conventional NSM (A) and Robot mastectomy (B)¹
Main differences between robot and endoscopic mastectomy are their technical difficulty and feasibility. Rigid endoscopic devices need specialized techniques to handle them, and furthermore a procedure using these devices is quite labor-intensive for surgeons. Meanwhile, robotic surgical systems enable surgeons to perform mastectomy more easily than endoscopic devices do. The high-resolution 3D camera and highly flexible robotic arms allow a full range of motion mimicking surgeon’s motion on the surgical field.
Figure 3. Robotic surgical systems²
The US FDA announced that the use of robotic surgical systems in mastectomy is not cleared because of the lack of clinical evidence. Therefore, the US FDA recommends that the benefits, risks, and alternatives of all available treatment options should be discussed between patients with health care providers. The surgeon’s experience and surgical outcomes should be discussed before choosing robotic mastectomy.
The Severance Robot Mastectomy Program
In 2013, the inaugural robotic mastectomy program began in Severance Hospital. The first attempt for robotic mastectomy in Severance was not a procedure on a living subject but on a cadaveric model. At that moment, robotic surgery in various fields including thyroid, stomach, colorectal, thoracic, pediatric, and urologic surgery was far advanced in Severance Hospital, however, robotic mastectomy was still in uncharted water even in this world-leading hospital in robotic surgery.
The first motivation for a robotic mastectomy was the article by Selber et al. from MDACC. The first LD reconstruction using a robotic system quite fascinated Prof. Park and his colleagues in plastic surgery to apply the new method. After discussion, they decided to begin not only a robotic reconstruction but also a robotic mastectomy for the first time in the world. The first cadaveric studies in 2013 were quite successful and suggested valuable implications for robot mastectomy.
From this beginning, he first performed robot mastectomy for a patient in 2016 at Severance Hospital, Seoul, Korea. This was the first case in Asia. So far, Prof. Park and his team have performed over 300 cases of robot mastectomy since 2016. His team makes efforts to establish new methods of innovative surgery in the treatment and preventive management for women with breast cancer or high-risk factors.
Reference
1. Lee J, Park HS, Lee H, et al. Post-Operative Complications and Nipple Necrosis Rates Between Conventional and Robotic Nipple-Sparing Mastectomy. Front Oncol. 2020;10:594388.
2. Intuitive. Intuitive, da Vinci, Robotic Surgical System2019 Available at: https://www.intuitive.com/en-us/products-and-services/da-vinci Accessed December 10, 2019.