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R E S E A R C H Open Access
Skin sparing mastectomy and robotic
latissimus dorsi-flap reconstruction through
a single incision
Gilles Houvenaeghel
1*
, Marie Bannier
2
, Sandrine Rua
2
, Julien Barrou
2
, Mellie Heinemann
1
, Eric Lambaudie
1
and
Monique Cohen
2
Abstract
Background: Robotic latissimus dorsi-flap reconstruction (RLDFR) after skin-sparing mastectomy (SSM) for breast
cancer (BC) has been performed through a single nipple incision. We report results of SSM with RLDFR, mainly with
analysis of feasibility, morbidity, indications, and technique standardization.
Methods: We determined characteristics of patients, previous treatment of BC, and type of reconstruction. Surgical
technique, duration of surgery, and complication rate were reported according to three successive periods: P1–3.
Results: Forty RLDFR, with breast implant for 16 patients, with previous breast radiotherapy in 30% had been
performed. In logistic regression, factors significantly associated with duration of surgery ≥300 min were P2 (OR
0.024, p= 0.004) and P3 (OR 0.012, p= 0.004) versus P1. The median mastectomy weight was 330 g and 460 g for
BMI < and ≥23.5 (p= 0.025). Length of hospitalization was 4 days. Total complication rate was 20% (8/40): seven
breast complications (four re-operations) and one RLDF complication with re-operation. Periods were significantly
predictive of complications (p= 0.045).
Conclusion: SSM with RLDFR is feasible, safe, and reproducible. We reported a decrease of duration of surgery,
length of post-operative hospitalization, and complication rate.
Keywords: Breast reconstruction, Latissimus dorsi-flap, Robotic surgery
Introduction
Development of robotic surgery since several years was
very important for prostatic cancer, gynecologic cancer,
colo-rectal cancer, and thoracic and thyroid surgery [1–
3]. Endoscopic non-robotic latissimus dorsi-flap breast
reconstruction (LDFR) has been reported in several
studies [4–9].
Very few experiences were reported in the field of
breast surgery, with a small number of series including
very few patients on robotic mastectomy or LDFR [10–
14]. Nipple-sparing mastectomy (NSM) with immediate
robotic latissimus dorsi-flap (RLDF) reconstruction has
been reported in seven patients in Selber et al.’s study
[10] and in four cases in Chung et al.’s study [12]. Skin-
sparing mastectomy (SSM) with LDF reconstruction was
reported in 17 patients for delayed-immediate breast re-
construction after SSM and placement of a tissue ex-
pander [13] and in one patient for immediate breast
reconstruction with 3D endoscopy using another inci-
sion than areolar incision [15]. In a recent French pro-
spective cohort study, Immediate breast reconstruction
(IBR) was performed with LDFR in 46.9% of cases
(24.3% combined with an implant), with implant in
46.5%, and rectus abdominis musculo-cutaneous flap in
6.6% [16]. The aim of this study was to report results of
SSM with robotic LDFR performed during 29 months,
through the analysis of feasibility, morbidity, indications,
and standardization of patient positioning and operative
technique.
© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
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* Correspondence: houvenaeghelg@ipc.unicancer.fr
1
Department of Surgical Oncology, Paoli Calmettes Institute and CRCM,
CNRS, INSERM, Aix Marseille Université, 232 Bd de Sainte Marguerite, 13009
Marseille, France
Full list of author information is available at the end of the article
Houvenaeghel et al. World Journal of Surgical Oncology (2019) 17:176
https://doi.org/10.1186/s12957-019-1711-8
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Material methods
A prospective cohort of patients undergoing SSM and
robotic latissimus dorsi-flap reconstruction (RLDFR)
over a period of 29 months (March 2016 to July 2018)
was analyzed. All patients agreed to surgery with robotic
assistance and received information on the procedure.
The study protocol was approved by our institutional
ethical committee.
We analyzed patient characteristics (age, body mass
index (BMI), tobacco use, diabetes, ASA score, breast
volume), previous treatment for breast cancer (BC) (sen-
tinel lymph node biopsy (SLNB), axillary lymph node
dissection (ALND), neo-adjuvant chemotherapy (NAC),
previous breast radiotherapy), primary breast cancer
(BC) or local recurrence, and type of reconstruction
(LDFR with or without breast implant).
Surgical technique using da Vinci Si®Surgical System
SI or XI (Intuitive Surgical, Sunnyvale, CA), number of
trocars, skin incision, and duration of anesthesia and
surgery were recorded according to period of treatment
and associated surgical procedures (breast implant,
LDFR, ALND, and contra-lateral breast surgery). Dur-
ation of anesthesia was defined as time from anesthesia
induction to tracheal extubation and duration of surgery
as time from skin incision to the end of skin suture in-
cluding all associated procedures and changes in patient
positioning. Three periods were established: P1 (year
2016), P2 (year 2017), and P3 (year 2018).
Complication rate was determined using Clavien-Dindo
grading [17]. Re-operation rate, type of complication, and
number of post-operative hospitalization days were
reported.
Statistics
Main characteristics were reported using median, mean,
and 95% confidence interval (CI95) for quantitative cri-
teria. Comparisons were performed using χ
2
for categor-
ical variables, ttest or Anova for continuous variables,
and logistic binary regression with odds ratios, CI95 and,
pvalue with SPSS® software version 16.0. We considered
pvalue ≤0.05 as significant result.
Results
During the study period of 29 months, 119 patients were
operated for breast surgery and/or RLDFR, 117 with da
Vinci robot, and 2 with 3D endoscopy. Among these pa-
tients, we analyzed 40 patients with the same surgical
procedure, SSM and RLDFR, performed by the same
surgeon. Breast reconstruction was performed in 25 pa-
tients with autologous LDF associated with breast im-
plant in 7 patients and in 15 patients with non-
autologous LDF (without fat around LDF) associated
with breast implant in 9 patients. The number of pa-
tients was 11, 18, and 11, respectively, for periods P1–
P3. Chest sizes were 85, 90, 95, 100, and > 100, respect-
ively, in 4, 10, 17, 6, and 3 patients. Patients’characteris-
tics are reported in Tables 1and 2.
Indications and type of reconstruction
Twelve patients had previous breast radiotherapy (30%,
12/40) including seven patients with SSM after NAC
and radiotherapy (17.5%, 7/40). SSM was performed for
five local BC recurrences with previous radiotherapy and
35 primary BC: 11 ductal carcinomas in situ (DCIS) and
29 invasive BC.
RLDFR with breast implant was performed in 40% of
patients (16/40) (Table 3), in 58.3% (7/12) after previous
radiotherapy. Mastectomy weight, breast cup size, and
BMI according to the type of reconstruction are re-
ported in Table 2.
Robotic breast surgery was indicated in selected cases
during the study period: 92 RLDF for IBR (40 SSM and
52 nipple sparing mastectomy) among 437 IBR (21%)
and among 1193 patients who required a total mastec-
tomy (7.7%). A selection of patients for RLDF was made
according to patient’s wishes to avoid dorsal scar and to
offer IBR without implant for patients who do not want
implant breast reconstruction.
Surgery: (Fig. 1)
All patients were either first positioned in dorsal decubi-
tus for SSM followed by a side decubitus for RLDFR.
The anterior border of the LD muscle and the inferior
mammary fold were designed and marked before inci-
sion. Incision around the nipple areolar complex was
performed for SSM, and LDF dissection was performed
in 33 patients through this incision and in 7 patients
through a short axillar incision more often during P1
and P2 (Table 1).
The beginning of the dissection for sub-cutaneous
plan of LD muscle and a limited dissection under the
incision along the anterior axillary line in order to in-
troduced one robotic trocar about 6–7 cm under axil-
lar basin (at the inferior mammary fold level) was
performed.
Then, a Gelpoint®path single site device (Applied
Medical) was inserted through the incision with two ro-
botic trocars and one trocar for an Airseal®device insuf-
flation (Applied Medical) also used by the assistant
surgeon when necessary. We operated under low pres-
sure (7 mmHg). Depending of the breast side, we
inserted monopolar scissors and bipolar forceps into up
and down robotic trocars with 0° camera in the middle
robotic trocar.
Robotic surgery started with a superficial dissection of
LD muscle from the middle of the muscle to the inferior
part (5–6 cm under the inferior mammary fold) and to
the superior part with a total section of the tendinous
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Table 1 Characteristics of all patients and according to periods of treatment
P1-2016 P2-2017 P3-2018 χ
2
Population n%n%n%n%p
Number patients 40 11 27.5 18 45.0 11 27.5
Primary BC 35 87.5 7 63.6 17 94.4 11 100 0.017
Local recurrence 5 12.5 4 36.4 1 5.6 0 0
Tobacco 9 22.5 5 45.5 3 16.7 1 9.1 0.090
Diabete 3 7.5 2 18.2 1 5.6 0 0 0.247
ASA 1 18 45.0 5 45.5 6 33.3 7 63.6 0.252
2 21 52.5 5 45.5 12 66.7 4 36.4
3 1 2.5 1 9.1 0 0 0 0
Breast size A–B 15 37.5 2 18.2 8 44.4 5 45.4 0.20
C 18 45.0 5 45.5 9 50.0 4 36.4
D–F 7 17.5 4 36.3 1 5.6 2 18.2
Prosthesis size < 300 5 29.4 4 40.0 1 16.7 0 0 0.50
≥300 12 70.6 6 60.0 5 83.3 1 100
Previous radiotherapy Yes 12 30.0 6 54.5 4 22.2 2 18.2 0.10
No 28 70.0 5 45.5 14 77.8 9 81.8
Neo adjuvant chemotherapy 7 17.5 2 18.2 3 16.7 2 18.2 0.992
Reconstruction Autologous LDF 18 45.0 2 18.2 12 66.7 4 36.4 < 0.0001
Non-autologous LDF 6 15.0 0 0 0 0 6 54.5
LDF + implant 9 22.5 4 36.4 5 27.8 0 0
Autologous LDF + implant 7 17.5 5 45.5 1 5.6 1 9.1
Incision for RLDFR Axillar 7 17.5 3 27.3 3 16.7 1 9.1 0.490
Areolar 33 82.5 8 72.7 15 83.3 10 90.9
BC Invasive 29 72.5 8 72.7 14 77.8 7 63.6 0.710
DCIS 11 27.5 3 27.3 4 22.2 4 36.4
Number of surgical procedures 2 21 52.5 2 18.2 12 66.7 7 63.6 0.070
3 16 40.0 7 63.6 6 33.3 3 27.3
4 3 7.5 2 18.2 0 0 1 9.1
da Vinci system SI 17 42.5 11 100 6 33.3 0 0 < 0.0001
XI 23 57.5 0 0 12 66.7 11 100
Number of arms 2 29 72.5 3 27.3 15 83.3 11 100 < 0.0001
3 11 27.5 8 72.7 3 16.7 0 0
Hospitalization days < 4 days 13 32.5 0 0 8 44.4 5 45.5 0.026
≥4 days 27 67.5 11 100 10 55.6 6 54.5
Time of surgery < 300 mn 26 65.0 1 9.1 15 83.3 10 90.9 < 0.0001
≥300 mn 14 35.0 10 90.9 3 16.7 1 9.1
Time of anesthesia < 382 mn 26 65.0 2 18.2 14 77.8 10 90.9 0.001
≥382 mn 14 35.0 9 81.8 4 22.2 1 9.1
BMI < 23.5 17 42.5 5 45.5 7 38.9 5 45.5 0.916
≥23.5 23 57.5 6 54.5 11 61.1 6 54.5
Previous contra lateral BC No 36 90.0 8 72.7 18 100 10 92.9 0.059
Yes 4 10.0 3 27.3 0 0 1 9.1
Previous homolateral BCT No 21 52.5 5 45.5 10 55.6 6 54.5 0.859
Yes 19 47.5 6 54.5 8 44.4 5 45.5
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insertion. Then, we performed dissection underneath the
LD muscle from the middle to the inferior part and to
the level of vascular pedicle. The section of LD muscle
was performed with monopolar scissors for posterior
dorsal insertions, then at the inferior part of dissection,
with progressive mobilization of muscle. Two drains
were placed through the inferior infra-centimetric scar
for the dorsal area and one for mastectomy.
Seventeen rights and 23 left SSM were realized. Ro-
botic procedures were performed using SI daVinci sys-
tem in 17 patients and XI system in 23 patients. We
used 3 arms for 11 patients and 2 arms for 29 patients
(72.5%): 3 arms 8/11 (72.37%) during 2016, 3/18 (16.7%)
during 2017, and 0/11 during 2018 (p< 0.0001).
Concomitant with other surgical procedures, in 19
cases (47.5%), a previous partial ipsilateral breast resec-
tion had been performed. Axillary surgery was per-
formed concomitantly in 23 cases (16 SLNB, 5 ALND,
and 2 SLNB with ALND) (5 previous ALND for 5 local
recurrences). A contra-lateral breast surgery was per-
formed during the same operation in 2 (5%) patients.
Duration of procedure
Median anesthesia duration was 353 min and median
surgery duration was 290 min (Table 2). The duration of
the surgery for the successive patients is reported in
Fig. 2. The number of surgical procedures performed
(LDFR, breast implant, ALND, contra-lateral breast sur-
gery) was ≥3 for 19 patients (47.5%) including 3 patients
with 4 procedures. BMI was ≥23.5 in 57.5% of patients
(23/40).
In univariate analysis, duration of surgery were sig-
nificantly different according to robot system used
(p= 0.002), period P1 versus P2–3(p< 0.0001 and
non-significant between P2 and P3), number of ro-
botic arms used (> for 3 arms: p< 0.0001), number of
surgical procedures > 2 (p= 0.015) (non-significant for
BMI < or ≥23.5: p= 0.790). In binary logistic regression in-
cluding the 3 study periods and number of surgical proce-
dures (> or ≤2), significant factors of duration of surgery
≥300mn were: P2 with a reduction in duration of surgery
(OR 0.024, CI 0.002–0.298, p= 0.004) and P3 (OR: 0.012,
CI 0.001–0.234, p = 0.004) versus P1 (number of surgical
procedures: non-significant: p=0.634). A strong correl-
ation was observed between periods and robot system
used and number of robotic arms.
In univariate analysis, the duration of anesthesia were
significantly different according to the robot system used
(p< 0.0001), number of robotic arms (> 3 arms, p<
0.0001), number of surgical procedures > 2 (p= 0.012),
and period P1 versus P2–3(p< 0.0001 and significance
between P2 and P3, p= 0.043). In binary logistic regres-
sion including the three periods and the number of sur-
gical procedures (> or ≤2), duration of anesthesia < or ≥
382 mn differed significantly for the following periods:
P2 (OR 0.062, CI 0.008–0.506, p= 0.009) and P3 (OR
0.022, CI 0.001–0.325, p= 0.006) versus P1 (number of
surgical procedures—non-significant, p= 0.955).
Decrease rate of mean duration of surgery was 31.9%
and decrease rate of mean duration of anesthesia was
28.5% from P1 to P3.
Pathologic results
The median mastectomy weight was 401 g: 330 g (CI
251–377, mean 314, range 100–527) for BMI < 23.5 and
460 g (CI 378–696, mean 537, range 72–1600) for BMI ≥
23.5, respectively (p= 0.025). Median breast implant vol-
ume was 340 cc (range 225–395).
The median size of invasive BC was 25 mm (mean
42.3, CI 28.6–56.1, range 0.7–130) with 15 multifocal
BC (20 ductal, 10 lobular, 1 other type, and 9 DCIS).
Median DCIS size was 50.0 mm (mean 54.2, CI 22.2–
86.2, range 1–120).
Post-operative treatment
Six patients (21.4%) underwent post-mastectomy radio-
therapy among 28 patients without previous radiother-
apy, 8 patients received adjuvant chemotherapy, 28
patients endocrine therapy, and 3 patients received
trastuzumab.
Post-operative outcome
The median length of post-operative hospitalization
was 4 days (Table 2): 13 patients < 4 days (32.5%) and
27 patients ≥4 days. Hospital stay ≥4 days was
significantly associated with periods P1 versus P2–3
(11/11 for P1 and 16/29 for P2–3, p= 0.006), robot
system used (p= 0.002), and type of reconstruction
(p= 0.022). Others criteria analyzed were not signifi-
cant: mastectomy weight, duration of anesthesia and
surgery, previous radiotherapy (≥4days 17/28 without
and 10/12 with radiotherapy, non-significant),
Table 1 Characteristics of all patients and according to periods of treatment (Continued)
P1-2016 P2-2017 P3-2018 χ
2
Population n%n%n%n%p
Contra lateral breast surgery No 38 95.0 11 100 17 94.4 10 90.9 0.613
Yes 2 5.0 0 0 1 5.6 1 9.1
BMI body mass index, SI da Vinci SI system, XI da Vinci XI system, LDF latissimus dorsi-flap, NSM nipple-sparing mastectomy, RLDFR robotic latissimus dorsi-flap
reconstruction, BC breast cancer, DCIS ductal carcinomas in situ, BCT breast-conserving therapy
Houvenaeghel et al. World Journal of Surgical Oncology (2019) 17:176 Page 4 of 9
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Table 2 Characteristics of patients and surgery
Population All patients Median Mean CI 95% Range
Age 64.0 61.2 40.8–81.6 39–83
Mastectomy weight 358 445 345–546 72–1600
BMI 24.5 25.4 23.9–26.9 18.3–38.0
Duration of surgery 290 298 276–321 195–495
Duration of anesthesia 353 364 341–387 249–540
Hospital stay duration 4 4.38 3.89–4.86 2.0–8.0
Duration of surgery P1 372 373 328–419 235–495
P2 271 280 257–302 215–410
P3 258 254 222–286 195–343
Duration of anesthesia P1 428 438 393–483 313–540
P2 355 351 328–373 276–457
P3 323 313 281–345 249–404
Duration of surgery SI 334 336 297–376 215–495
XI 266 270 248–292 195–410
Duration of anesthesia SI 403 410 376–444 313–540
XI 331 330 307–353 249–457
Duration of surgery 2 surgical procedures 258 273 245–301 195–410
3 surgical procedures 301 318 281–354 215–495
4 surgical procedures 420 372 167–577 277–420
Duration of surgery Autologous LDF 265 274 243–306 195–410
Non autologous LDF 262 268 225–312 219–343
LDF + implant 325 342 270–413 215–495
Autologous LDF + implant 334 330 293–366 270–372
Duration of anesthesia Autologous LDF 339 341 308–374 249–506
Non-autologous LDF 327 327 276–378 252–404
LDF + implant 409 412 351–474 294–540
Autologous LDF + implant 403 394 353–435 342–451
Hospital stay duration Autologous LDF 4 3.83 3.12–4.54 2.0–7.0
Non-autologous LDF 3 3.33 2.79–3.88 3.0–4.0
LDF + implant 5 4.89 3.99–5.79 3.0–7.0
Autologous LDF + implant 6 6.0 4.81–7.19 4.0–8.0
BMI Autologous LDF 25.3 26.6 23.8–29.4 18.3–38.0
Non-autologous LDF 21.7 22.3 20.2–24.4 19.7–25.3
LDF + implant 26.2 26.1 23.3–28.9 20.3–31.6
Autologous LDF + implant 23.1 24.2 21.3–27.2 20.8–28.6
Mastectomy weight Autologous LDF 340 503 298–708 100–1600
Non-autologous LDF 225 238 77–400 72–423
LDF + implant 370 409 281–536 201–696
Autologous LDF + implant 488 492 342–641 263–778
Hospital stay duration P1 6 5.64 5.02–6.26 4.0–7.0
P2 4 3.83 3.19–4.48 2.0–7.0
P3 4 4.0 2.88–5.12 2.0–8.0
BMI body mass index, SI da Vinci SI system, XI da Vinci XI system, P(1–3) period (1–3), LDF latissimus dorsi-flap
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mastectomy for primary BC or local recurrence, BMI,
age, and number of surgical procedures. In binary lo-
gistic regression, any factor was significant for post-
operative hospitalization ≥4 days.
The total complication rate was 20% (eight patients):
seven breast complications (three grade 1 and four grade
3: five hematomas, two infections) and one LDF compli-
cation (grade 3: dorsal bleeding). In univariate analysis,
periods (P1, 5/11; P2, 2/18; and P3, 1/11) and robot sys-
tem used (SI 5/17 and XI 3/23) were significantly associ-
ated with complications (respectively, 0.045 and 0.025),
and all others factors were non-significant, particularly
the type of reconstruction, BMI, and duration of surgery.
Five re-operations (12.5%) were required (five grade 3):
one for dorsal bleeding and four for breast complication
(two hematomas and two infections with implant re-
moval for one patient). Re-operations for dorsal bleeding
and hematomas were made during hospitalization stay.
For 14 patients, we observed dorsal seroma after drain
removal that required one or several punctures. Patients
were discharged before drain removal. Any conversion
to an open technique for LDF dissection was required.
Discussion
The purpose of this study was to assess feasibility of RLFR
through a single incision around NAC required for SSM.
The reproducibility of this procedure has been illustrated
by no conversion to open technique, and a short axillar in-
cision was used in 17.5% of patients particularly at the be-
ginning of the experience. The safety of RLDFR has been
also shown with only one complication for dorsal bleeding
which required re-operation performed through the same
incision (2.5%). We observed a significant decrease of the
duration of surgery throughout the learning curve after
Table 3 Results according to reconstruction type
RLDF without implant RLDF + implant χ
2
n%n%p
Age ≤50 years 8 33.3 3 18.8 0.261
> 50 years 16 66.7 13 81.2
Periods P1 2 8.3 9 56.2 0.002
P2 12 50.0 6 37.5
P3 10 41.7 1 6.2
Breast cup size A–B 12 50.0 3 18.8
C 9 37.5 9 56.2
≥D 3 12.5 4 25.0
BMI < 23.5 10 41.7 7 43.8 0.576
≥23.5 14 58.3 9 56.2
Primary BC 23 95.8 12 75.0 0.073
Local recurrence 1 4.2 4 25.0
Previous radiotherapy No 19 79.2 9 56.2
Yes 5 20.9 7 43.8
Hospitalization days < 4 days 12 50.0 1 6.2 0.004
≥4 days 12 50.0 15 93.8
Duration of surgery < 305 mn 20 83.3 6 37.5 0.004
≥305 mn 4 16.7 10 62.5
Duration of anesthesia < 382 mn 19 79.2 7 43.8 0.025
≥382 mn 5 20.8 9 56.2
Mastectomy weight ≥330 g 12 52.2 4 25.0 0.085
> 330 g 11 47.8 12 75.0
Median CI 95% Median CI 95%
Age 58 51–63 65 53–67
Mastectomy weight 329 280–611 439 357–532
BMI 24.0 23.5–28.0 25.6 23.4–27.1
Hospitalization days 4 3.18–4.30 5 4.68–6.07
BMI body mass index, BC breast cancer, RLDF robotic latissimus dorsi-flap
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Fig. 1 Surgical procedures
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the first period with 11 procedures. The mean duration of
the whole procedure for the third period was 254 min and
the robotic procedure currently lasts for approximately
45–60 min.
Very few experiences were reported for RLDF immedi-
ate breast reconstruction with no more than 17 proce-
dures [9–12]. The main differences in robotic surgical
technique that should be underlined included a single
incision realized around NAC for SSM and the use of a
single site trocar. In Selber et al.’s study [10], seven pa-
tients were reported with RLDF reconstruction per-
formed through an axillar incision for NSM without the
use of a single site trocar. Chung et al. [12] reported 12
RLDF procedures through a 5–6-cm axillar incision
without CO2 gas insufflation for three delayed breast re-
constructions, four IBRs with NSM, and five cases of
chest wall deformity. Clemens et al. [13] reported 17
RLDFRs in delayed-immediate breast reconstruction
after SSM and placement of a tissue expander through
anterior mastectomy incision without a single site trocar.
Endoscopic non-robotic LDFR was reported in several
studies [4–8], and in 2007, Missana et al. reported a
study including 52 patients [4] and more recently by
others with smaller series [6–8]. Nakajima et al. [8] re-
ported a study with 168 LDF video-assisted reconstruc-
tions but only for reconstruction after partial
mastectomy. Finally, Dejode and Barranger [15] reported
one case of endoscopic 3D latissimus dorsi-flap harvest-
ing for SSM with immediate breast reconstruction.
The endoscopic approach decreases donor-site mor-
bidity [18] but the manual control of a two dimensional
in-line endoscopic camera with limited internal mobility
produces an inadequate optical window around the
curvature of the thorax and the rigid-tip instruments
also are inadequate to work along the curvature of the
thorax. The use of 3D endoscopic surgery offers a mag-
nified view but without the seven degrees of freedom of
motion at the tips of the robotic instruments.
For patients with previous radiotherapy for local re-
currence or after NAC and radiotherapy [19–21], the
latissimus dorsi-muscle nourishes and protects the
thin skin. In these cases, RLDFR can be associated
with implant according to breast size and according
to patient’s choice. One or several lipofillings were
next proposed in order to obtain a good cosmetic re-
sult and sufficient breast volume. SSM was proposed
for patients who want an IBR for whom NSM was
not indicated (NAC involvement or tumor-NAC dis-
tance < 2 cm). Latissimus dorsi-flap reconstruction
was offered in selected cases according to patient’s
choice and particularly for patients who do not want
reconstruction with breast implant (60% without im-
plant in our study). More and more centers offer
breast implant reconstruction with acellular dermal
matrix (ADM). However, covering the entire implant
with a thin, expensive ADM is not generally feasible,
and the use of ADMs also increases the risk of com-
plications such as infection and seroma [22].
Conclusion
SSM with RLDFR is feasible, safe, and reproducible with
a single incision for NAC resection. We reported with
progressive learning curve a decrease of the duration of
surgery, length of post-operative hospitalization, and
complication rate. The robotic procedure currently lasts
for approximately 45–60 min. Only one complication
was related with RLDFR with re-operation for bleeding.
After this technique standardization, we proposed to de-
velop this procedure with several surgeons of our de-
partment using the double robotic console.
Fig. 2 Duration of surgery for 40 successive patients in chronologic order
Houvenaeghel et al. World Journal of Surgical Oncology (2019) 17:176 Page 8 of 9
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Acknowledgements
Not applicable.
Authors’contributions
Data collection and analysis were performed by GH, MB, SR, JB, and MC.
Others authors contributed to the literature studies analysis for discussion
and participation to surgical procedures. All authors read and approved the
final manuscript in its present form.
Funding
This work did not receive any specific grant from funding agencies in the
public, commercial, or not-for-profit sectors.
Availability of data and materials
Administrative data and clinical data are compiled in a common database
and are available to editors and peer reviewers.
Ethics approval and consent to participate
This work was approved by our institutional review board (IPC—Comité
d’Orientation Stratégique).
All procedures performed in this study involving human participants were
done in accordance with the French ethical standards and with the 2008
Helsinki declaration.
All included patients provided written informed consent before surgery,
including the use of their data for research.
Consent for publication
Not applicable
Competing interests
The authors declare that they have no competing interests.
Author details
1
Department of Surgical Oncology, Paoli Calmettes Institute and CRCM,
CNRS, INSERM, Aix Marseille Université, 232 Bd de Sainte Marguerite, 13009
Marseille, France.
2
Department of Surgical Oncology, Paoli Calmettes
Institute, Marseille, France.
Received: 17 April 2019 Accepted: 12 September 2019
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