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Robotic nipple‐sparing mastectomy: The first experience from Indian subcontinent

Breast cancer is the second most common cancer in the world and it is the leading cancer affecting Indian women. With growing numbers and increasing cosmetic concerns, more and more women are opting for breast conservation surgeries (BCS). However, in patients in whom breast conservation is not possible, skin‐sparing (SSM) or nipple‐sparing mastectomy (NSM) with reconstruction is the option. Endoscopic approaches came into vogue to combat the cosmetic concerns associated with open NSM but they failed to gain popularity owing to technical difficulties associated. Robotics was introduced as an alternative to endoscopic approach to overcome these limitations. An initial study by Toesca et al showed the feasibility of this approach and this is our first experience of the innovative procedure. A 30‐year‐old lady with a lump in upper outer quadrant was evaluated and was found to have BIRADS IV lesion with diffuse microcalcification on imaging with no axillary lymphadenopathy. Fine‐needle aspiration from the lesion was suggestive of invasive ductal carcinoma, and rest of the routine work up was unremarkable. As the disease was not feasible for BCS and the patient was keen on breast reconstruction, patient was given the option of robotic NSM with reconstruction using an implant. The procedure was done as described by Antonio Toesca in his original series and our experience of witnessing his live surgery. About 3 cm long incision was taken in the midaxillary line (Figure 1). The incision was deepened, and planes were created using cautery for the insertion of octoport. The flaps were raised to a distance of about 3 cm, octoport was introduced, and insufflation started to a pressure of around 8 mm Hg (Figure 2). DaVinci Si robot was docked from the opposite side, and 12 mm (0 degree) camera was used. The dissection was carried out using a 5 mm spatula on the right arm and bipolar forceps on the left arm. Initial dissection was done in the superficial skin flap, and nipple shave was sent for frozen analysis which was reported negative. The assistant surgeon was at the operating table managing the skin flap thickness and providing necessary input to the surgeon at the console. After the dissection of superficial flap, breast tissue was dissected off the pectoralis major muscle and the specimen was delivered through the above‐said incision. The mono port was repositioned, and submuscular plane was created for implant placement. Axillary dissection was carried out through the same incision. After manually placing the implant, subcutaneous and submuscular drains were kept and the incision was closed. Duration of surgery was 5 hours and 30 min, and no skin necrosis was noted. However, there was minimum erythema of skin in lower inner quadrant which settled on its own. The patient was discharged on second postoperative day and had a routine recovery with no morbidity (Figure 3). With the established popularity of robotics in intra‐abdominal malignancies, there is a growing trend for usage of robotics in other areas such as oropharyngeal, thyroid malignancies, and the most recent being carcinoma breast. The oncological safety of NSM has been established and has both open, endoscopic approaches. The endoscopic mastectomy has various methods: NSM with liposuction, skin lift approach, multiple ports with a periareolar incision, and single incision transaxillary approach. Even though the single incision approach for NSM is cosmetically appealing, the technical difficulties associated with rigid arms of the instruments and limited