Introduction

Modified radical mastectomy was traditionally the preferred method for treating operable breast cancer. With advances in surgical techniques over the past few decades, breast-conserving surgery (BCS) and sentinel lymph node biopsy are now acceptable treatments for early breast cancer. Over the last two decades, endoscopic techniques had initially been adapted to facilitate cosmetic breast augmentation surgery but are now increasingly adopted in the surgical management of breast cancer [1,2,3]. It is often done to optimize the cosmetic outcome by performing surgery through small wounds hidden in the axilla or periareolar areas. If endoscopic mastectomy is performed, it is often followed by immediate reconstruction.

Indications [1, 3, 4]

  • Early stage breast cancer (ductal carcinoma in situ (DCIS), stage I or II).

  • A tumor size less than 3 cm for endoscopic breast conserving surgery (EBCS) or no larger than 5 cm for endoscopic-assisted total mastectomy (EATM).

  • No evidence of multiple lymph node metastasis.

  • No evidence of skin or chest wall invasion.

Contraindications [1, 3, 4]

  • Multifocal/multicentric lesions (for EBCS).

  • Inflammatory breast cancer.

  • Paget’s disease of the nipple/nipple discharge.

  • Breast cancer with nipple, pectoralis major/chest wall, or skin invasion.

  • Locally advanced breast cancer.

  • Breast cancer with extensive axillary lymph node metastasis (stage IIIB or later).

  • Patients with severe comorbid conditions, such as heart disease, renal failure, liver dysfunction, and poor performance status as assessed by the primary physicians.

Pre-op Assessment

  • Thorough history and physical examination.

  • Histopathologic confirmation of breast cancer.

  • Routine investigations as to hospital protocol for fitness to undergo general anesthesia.

  • Breast imaging—Mammogram/Ultrasound/MRI (for EBCS) to delineate the extent of disease.

Preoperative Preparation

  • Preoperative marking of inframammary fold, extension of breast tissue at the lateral and superior aspects performed with the patient in an upright position.

  • For nonpalpable lesions undergoing EBCS—hookwire placement.

  • EBCS—preoperative marking of resection margins under ultrasound guidance with either methylene blue or indocyanine green dye with at least a 1 cm margin.

  • Preoperative radiocolloid (99mTc) is injected to aid in identification of the sentinel lymph node.

OT Setup

Instruments Required

  • Lighted retractor (Vein harvest, Ultra Retractor, Vein Retractor).

  • 30 straight rigid 5 mm endoscope.

  • Bipolar scissors/electrocautery or Energy device (e.g., Harmonic scalpel).

  • Wound protector.

  • OptiView port.

  • Endocatch retrieval bag.

Patient Position

  • The patient is in supine position.

  • Both arms are abducted to 90°.

  • Endoscopic video monitors are positioned on the opposite side of the patient.

  • 5 ml of diluted 0.5% Patent blue dye is injected into the upper outer quadrant of the periareolar after induction of anesthesia for sentinel lymph node biopsy.

Surgical Technique [1, 4,5,6,7,8]

Incisions

  • 2 cm axillary incision (A).

  • Semicircular Periareolar incision (less than half of circumference of areolar) (B).

  • If required, additional 5 mm incisions are placed at the lateral breast and/or at inframammary fold for trocars to assist in dissection (C/D) (Fig. 1).

Fig. 1
A semi-circle labeled B represents a right side breast with a nipple. Below the armpit, there are three circles labeled A, C, and D. M.Crespi's text is identified below.

Skin incisions

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Sentinel Lymph Node Biopsy (SLNB)

  • 2 cm transverse axillary incision is made close to the site of the hottest nodes that are detected using a hand-held gamma probe.

  • The axillary tissue is dissected to identify any blue ducts, which is traced to identify the sentinel lymph node.

  • SLNB is then confirmed with the hand-held gamma probe and sent for intraoperative frozen section.

  • If the frozen section results show malignancy in the sentinel lymph node, axillary dissection is performed through the same incision after completion of the breast surgery.

Posterior Dissection

  • After completing the SLNB, the dissection is carried out to the lateral border of the pectoralis major muscle.

  • Dissection in the retromammary space, between the pectoralis muscle fascia and posterior breast parenchyma is carried out using a retractor with an optical system (endoscopic vein harvest, Ultra retractor, Vein Retractor) with blunt dissection (Fig. 2).

  • The surrounding tissue is pulled up using the endoscopic retractor and a suction tube to create sufficient working space and to evacuate mist and smoke.

  • The penetrating vessels are coagulated and cut with bipolar scissors, harmonic scalpel, or electrocautery to ensure a clear visual field and uncomplicated hemostasis.

  • Alternatively, the retromammary space could be dissected using a pre-peritoneal dissection balloon or carbon dioxide insufflation.

  • For mastectomy, the dissection is carried out throughout the whole retromammary space to the anatomic margins of the breast.

  • For EBCS, dissection is performed to cover an area further beyond the tumor margins (marked preoperatively) to facilitate tissue mobilization for closure of the defect [9].

Fig. 2
Image A depicts a breast with nipples and fat tissues. It is separated from the pectoralis muscle using a retractor. The breast has been detached from the pectoralis muscles in Image B. M. Crespi is written on both illustrations.

Retromammary space dissection

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Subcutaneous Skin Flap Development

  • A semicircular periareolar incision is made. An appropriately sized wound protector is placed into the incision to protect the periareolar wound and ensure adequate visualization.

  • The retroareolar tissue is dissected and the nipple base tissue is sampled and examined by intraoperative frozen section.

  • If the frozen section is positive for malignancy, the whole nipple areolar complex is removed.

  • A combination of normal saline, lignocaine 0.05%, and epinephrine 1:1000000 as a tumescent solution is infiltrated subcutaneously into the breast to facilitate dissection and minimize bleeding (Fig. 3).

  • A 5 mm thick skin flap is created using the optical bladeless trocar (Xcel port) using the “subcutaneous tunnelling method,” whereby the trocar is used to separate the breast parenchyma from the overlying skin and subcutaneous tissue under direct endoscopic visualization (Fig. 4).

  • The “septa” created between the tunnels are then dissected using bipolar scissors, electrocautery, and/or energy devices (e.g., harmonic scalpel).

  • For mastectomy, the dissection is carried out throughout the whole anterior surface of the breast to the anatomic margins of the breast (Fig. 5).

  • For EBCS, dissection is performed to cover an area further beyond the tumor margins (marked preoperatively) to facilitate tissue mobilization for closure of the defect [9] (Fig. 6).

Fig. 3
A right-side breast with a nipple is depicted. A tube with measurements sits atop a nipple. Seven arrows pointing outwards surround the nipples. M.Crespi's illustration reads the text.

Saline injection

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Fig. 4
An optical bladeless trocar is used to make an incision between the skin and the breast parenchyma, which is dissected from the pectoralis muscle. M.Crespi's illustration reads the text.

Subcutaneous tunneling method

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Fig. 5
A breast with a nipple illustration is surrounded by three arrows pointing clockwise above and three pointing counterclockwise below. A circle is drawn beneath the armpit. An arrow runs through it, pointing to the nipple. M.Crespi's text is illustrated.

Dissection along the anterior surface of the breast

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Fig. 6
An image displays two breasts. Three circles are highlighted beneath the right breast. These are labeled mammary gland resection ranges.

Dissection beyond tumor margins

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Specimen Excision and Reconstruction

  • For mastectomy, the anterior subcutaneous dissection will meet the posterior retromammary space dissection at the anatomic margins of the breast to complete the mastectomy.

  • For EBCS, the breast tissue is then divided according to the preoperative markings using bipolar scissors, energy devices, or electrocautery with the help of the endoscopic light retractor completing the lumpectomy [9].

  • The surgical specimen can then be removed through the axillary incision or periareolar incision (with or without an endocatch).

  • For mastectomy, immediate reconstruction can then be performed using implants or autologous tissue, and a drain may be placed in the surgical cavity [10].

  • For EBCS, surgical clips are placed in the cavity and the breast tissue is then mobilized to close the defect, with or without oncoplastic techniques [9].

Postoperative Care

  • Similar to open surgery, would depend on reconstructive technique (if any).

  • Standard analgesia as required.

  • Regular diet as tolerated.

  • Discharge the patients when comfortable and able to drink, eat, and walk.

Complications and Management [1, 8]

  • The complications reported with endoscopic breast surgery are generally similar to that of open surgery—e.g., Seroma, superficial or deep skin burns, ecchymoses, infection; and can be managed in a similar manner.

  • If insufflation is used to develop the surgical planes, the patient may have subcutaneous emphysema in the breast and surrounding tissues postoperatively. This is usually self-limiting and will resolve spontaneously.

  • For EBCS, the patient may develop fat necrosis if there are wide areas of tissue mobilization for resection and reconstruction.