Endoscopic Bilateral Nipple-sparing Mastectomy via a Single Axillary Incision with Immediate Pre-pectoral Implant-based Breast Reconstruction

In view of the shortcomings of conventional endoscopic nipple-sparing mastectomy, here, we introduce new techniques, concepts, and the detailed surgical procedures of endoscopic bilateral nipple-sparing mastectomy via a single axillary incision with immediate prepectoral implant-based breast reconstruction. A 33-year-old female exhibited bilateral breast lumps on ultrasound categorized as BI-RADS 4 with relatively large-sized lumps. Histopathological confirmation through Mammotome-assisted minimally invasive resection identified bilateral ductal carcinoma in situ.

Endoscopic bilateral nipple-sparing mastectomy via a single axillary incision with immediate prepectoral implant-based breast reconstruction was performed. Ultrasound showed nodules in the left breast at six o'clock and multiple calcifications in the right breast at 10 o'clock. Preoperative pathological results indicated bilateral breast ductal carcinoma in situ.

Mark the inferior fold of axilla, edge of breast, and inframammory fold of bilateral breasts. Induce general anesthesia and perform tracheal intubation. Place the patient in the supine position with bilateral arms abducted at 90 degree.

Sterilize the surgical area with povidone-iodine skin disinfectant. Wrap the bilateral limbs with sterile drapes, and fix them abducted at 90 degree. Use a one-milliliter syringe to extract carbon nanoparticle suspension injection and saline mixed in a one-one ratio to achieve a total volume of one milliliter for the formulation of the sentinel lymph node tracer.

Inject the tracer into the parenchyma of the outer upper quadrant of the breast at any three points. Massage for five minutes, and wait for five minutes. Make an approximately four-centimeters curved axillary incision along the line marked before to complete SLNB under direct vision.

The sentinel lymph node biopsy is exam to be negative by intraoperative frozen section biopsy. Bend the arm of the patient on the operation side, and secure it to the head rack. Seek the lateral edge of the pectoralis major muscle from the axillary incision.

Dissect the retromammary space for two centimeters and the subcutaneous fat for three centimeters under direct vision. Insert the wound protector into the incision. Then connect with the four-trocar single port.

Connect the 12-millimeter trocar with a constant pressure pneumoperitoneal device to construct a walking space. The air cavity is maintained by the application of carbon dioxide insufflation at 8 millimeter of mercury pressure, 40 liters per minute air flow. An oblique-ended rigid endoscope measuring five millimeters in diameter with a viewing angle of 30 degree is inserted through the 10-millimeter trocar.

An electric hook and laparoscopic grasping forceps are inserted through two 5-millimeter trocars, respectively. Use the circum-mammary ligaments as the boundary of the breast, paying attention to exposing and identifying ligamentous structures. Integrity of the ligament can be ensured by staining, finger-press, and resistant feeling from endoscopic instruments.

Dissect the retromammary space under endoscopic vision using the electric hook. Extend this dissection superiorly to the subclavian ligament, medially to the parasternal ligament, inferiorly to the inframammary fold, and laterally to the lateral border of the mammary gland. This case is ductal carcinoma in situ confirmed preoperatively.

Therefore, complete preservation of the pectoralis major fascia is administered intraoperatively, both to reduce trauma and pain and to allow fixation of the meshes to the pectoralis major fascia, preventing prosthesis displacement. Pull the wound protector to reach the subcutaneous layer. Follow the zoning dissection sequence.

The dissection is performed with the electric hook in the following sequence, basically, outer upper quadrant, inner upper quadrant, outer lower quadrant, retro-nipple area. Apply the endoscopic scissors to cut off the root of nipple, preventing nipple-areolar complex necrosis. A tissue biopsy specimen from the posterior margin of the nipple is taken for intraoperative frozen sectioning.

And in the lower quadrant. Utilize the electric hook to carefully dissociate the inner lower quadrant of the mammary gland. Remove the intact breast specimens through the axillary incision.

The contralateral breast is operated in the same way. Irrigate the implant cavity with 2, 000 milliliters warm, sterile distilled water. Soak the implant cavity with 0.45%to 0.55%povidone-iodine solution for 10 minutes.

Disinfect the surgical region, and change gloves. Cover the prothesis fully with two meshes. Suture the meshes with 3-0 absorbable sutures and simple interrupted sutures for fixation.

Insert the prosthesis into the implant cavity. Place one drainage tube on each of the inframammary fold and axilla in the subcutaneous layer. Maintain under low negative pressure suction.

Close the axillary incision wound with 4-0 absorbable sutures. Between June 2021 and October 2022, a cohort of 10 patients diagnosed with bilateral breast cancer or necessitating contralateral prophylactic mastectomy underwent endoscopic bilateral nipple-sparing mastectomy via a single axillary incision with immediate prepectoral implant-based breast reconstruction. The average age of the patients was 42 years with an average body mass index of 22.12 kilogram/m square.

The mean duration of the surgical procedure was 4.25 hours, and the average volume of intraoperative blood loss measured 33 milliliters. The postoperative recovery of each patient was characterized by an uneventful course devoid of significant complications, and the typical duration of postoperative hospitalization averaged 11 days. Subsequently, all patients received regular follow-up care with appointments scheduled every three months throughout the initial two years following surgery.

Notably, the Harris scores of three patients were rated as excellent, while seven patients received a rating of good. They universally expressed satisfaction with the postoperative cosmetic outcomes. Breast implant displacement exercise is necessary for smooth implants.

We draw the conclusion that this procedure, which is a safe, feasible method, is a select choice for patients who are young, have bilateral breast cancer, or require contralateral prophylactic mastectomy and have a strong demand for cosmesis and physical function.