Bridging Technology: Endoscopic Nipple-Sparing Mastectomy Using SOLOASSIST II® Robotic Arm

Abstract

Introduction:

The surgical management of malignant breast tumors has undergone significant evolution. There is an increasing need to adopt less traumatic and aggressive procedures, favoring minimally invasive techniques that provide oncologically safe outcomes, superior cosmetic results, and fewer complications—particularly through endoscopic and robotic approaches.

Case Presentation:

We present the case of a 48-year-old female with no relevant medical history, in whom multiple suspicious lesions were detected in the left breast during routine screening. Histopathological evaluation confirmed an infiltrating lobular carcinoma, luminal B subtype. Following a favorable response to neoadjuvant chemotherapy, a skin- and nipple-sparing endoscopic mastectomy was performed, assisted by a robotic arm that holds the camera, with immediate reconstruction.

Discussion:

Skin- and nipple-sparing surgery aims to provide optimal local disease control, improve cosmetic outcomes, and reduce complication rates. Minimally invasive techniques, whether endoscopic or robotic, can be combined safely and effectively to achieve these goals, as demonstrated in this case, which resulted in excellent cosmetic outcomes and no postoperative complications.

INTRODUCTION

The surgical treatment of malignant breast tumors has undergone a long and significant evolution: from mutilating procedures with psychological consequences to the current era of minimally invasive surgeries. Consequently, there is a growing need to adopt less aggressive and traumatic approaches, focusing primarily on minimally invasive techniques that ensure oncologically safe, functional, and aesthetically favorable outcomes. These approaches have been shown to provide superior patient satisfaction^1,2 through endoscopic, laparoscopic, and robotic systems.^3,4

Endoscopic surgery enables complete resection of the mammary gland while preserving the skin and nipple–areolar complex (NAC). However, this approach presents technical limitations: it demands extensive laparoscopic training due to its complexity, and the instruments currently available are not specifically designed for breast surgery, which complicates handling, extends operative time, and increases surgeon fatigue.^3,4

Robotic-assisted surgery offers advantages over purely endoscopic techniques due to the sophisticated movement of robotic arms, which allow for greater precision in narrow surgical fields. These systems help reduce intraoperative complications such as bleeding and infection, postoperative pain, and length of hospital stay, thereby facilitating faster recovery.^5,6

In the context of breast surgery, robotics facilitate dissection through minimal incisions, providing better visualization and greater control in anatomically complex planes.¹ Both endoscopic and robotic techniques have demonstrated reductions in postoperative morbidity, improved breast symmetry, and preserved nipple sensitivity.³

In 2017, Toesca et al reported the first robotic-assisted nipple- and skin-sparing mastectomy using a small, hidden axillary incision. Since then, the approach has gained popularity, and multiple studies have confirmed its feasibility and safety.⁷

However, access to surgical robots such as the Da Vinci Surgical System (Intuitive Surgical) remains limited in many parts of the world. Considering the ergonomic challenges of single-port endoscopic surgery, the SOLOASSIST II® articulated robotic arm (AKTORmed GmbH, Neutraubling, Germany) has emerged as a potential bridge between endoscopic and fully robotic techniques.⁸ To our knowledge, this is the first reported case in the literature of an endoscopic nipple-sparing mastectomy assisted by the SOLOASSIST II® robotic arm.

CASE PRESENTATION

A 48-year-old female patient with no relevant medical history presented with multiple suspicious lesions in the left breast identified during routine screening.

Magnetic resonance imaging revealed three irregular nodules with noncircumscribed, spiculated margins, isointense and hypointense on T1–T2, heterogeneously STIR, with restricted diffusion: 10 × 16 mm, 15 × 12 mm, and 14 × 11 mm respectively, located at 5 cm (R1h), 4 cm (R2), and 2 cm (R5) from the nipple (Figure 1). Histopathological analysis confirmed an infiltrating lobular carcinoma, luminal B-like subtype (ER 90%, PR 100%, HER2 negative, Ki-67 20%).

Figure 1.

Magnetic resonance imaging revealed three irregular nodules with noncircumscribed, spiculated margins, isointense and hypointense on T1–T2.

After discussion in a multidisciplinary tumor board, the patient underwent six cycles of neoadjuvant taxane-based chemotherapy, achieving a favorable clinical and radiological response. However, the ratio between breast volume and residual lesion distribution remained unfavorable for breast-conserving surgery.

Informed consent was obtained for the surgical procedure and approved by the multidisciplinary committee.

A 3-cm axillary incision was made to insert a single-port system. Subcutaneous flaps were raised, and tumescent solution containing lidocaine and epinephrine was infiltrated. CO₂ insufflation was maintained at 7 mmHg. The robotic arm was positioned on the ipsilateral side of the affected breast and helped to hold and manipulate the camera during the procedure (Figure 2). Dissection was performed using monopolar cautery and 5-mm scissors, with a Maryland forceps used for traction. Dissection began in the superficial flap through the outer quadrants and progressed toward the nipple.

Figure 2.

Surgeon position and robot arm docking.

Tissue samples from the posterior portion of the nipple were obtained and sent for intraoperative cytopathological analysis. Anterior dissection was completed to create adequate space for posterior dissection over the pectoralis major. The entire gland was then removed through the initial incision.

Sentinel lymph node identification was performed using a dual-tracer technique with patent blue dye and technetium-99m (Tc-99m).

Operative notes included documentation of operative time (135 minutes), estimated blood loss (210 cc), and intraoperative assessment of surgical margins.

Immediate breast reconstruction was performed using a prepectoral pocket. Skin flaps were clinically evaluated (for thickness, tissue quality, and subdermal plexus preservation). After achieving adequate hemostasis, a 15 Fr closed-suction drain was placed, and an implant was inserted using a “no-touch” funnel-assisted technique. Closure was performed in two layers using Monocryl 3-0 sutures. The patient was discharged 24 hours after surgery without complications.

Final pathology revealed residual carcinoma of 9 × 5 mm in the R5 lesion.

At one and three months postoperatively, the patient completed the BRECON-31 questionnaire with a total score of 60 (Figure 3). On the “procedure satisfaction” subscale, she scored 14 out of 16, indicating high satisfaction. At 12 months follow-up, the patient remains disease-free.

Figure 3.

In the image, symmetry and aesthetics are observed two week after the surgery, with the scar hidden under the arm.

DISCUSSION

Currently, there are different types of mastectomy that vary in their extent and degree of aggressiveness, depending on the tumor characteristics and the needs of each patient. These range from radical mastectomy to minimally invasive, breast-conserving mastectomy performed either endoscopically or with robotic assistance.⁹ Preserving the NAC is key to ensuring psychological well-being and aesthetic satisfaction; therefore, minimally invasive approaches are performed more frequently.¹⁰

Breast-conserving surgery has two main objectives: to achieve local disease control with tumor-free margins and to obtain better aesthetic results, with the overall benefit of improving quality of life.^9,11,12 NAC-sparing surgery is considered acceptable, provided that the margin close to the nipple is free of tumor involvement.¹³

The main intraoperative complications in breast surgery are vascular and nerve injuries, and, less frequently, pneumothorax. The most common postoperative complications include hematoma, seroma, wound dehiscence, infection, and necrosis. Among the most frequent late complications are keloid scars, muscle atrophy, lymphedema, and mobility or sensory alterations due to nerve injury.⁹ In this case, none of these complications were observed. Compared to the open technique, this approach allows for more precise dissection, improving the preservation of neurovascular structures, minimizing sensory loss, and optimizing aesthetic results.¹⁴ Improved aesthetic satisfaction may be related to a smaller surgical wound, the strategic placement of the incision, and reduced scar visibility.¹⁰ Our case aligns with these findings, as demonstrated by the score obtained in the BRECON-31 test, which reflects high patient satisfaction.

Nipple-sparing mastectomy techniques have been reported with robotic assistance both with and without CO₂ insufflation. The use of CO₂ insufflation in the endoscopic technique creates positive pressure that improves visualization, facilitates the identification of anatomical structures, and allows for better surgical manipulation while reducing bleeding.¹⁰ However, Park et al described a gasless technique, stating that it avoids postoperative complications associated with gas insufflation, such as subcutaneous emphysema. Nevertheless, this requires the use of retractors, which may cause ischemic changes in the skin.³ In our case, the procedure was performed with CO₂ insufflation, with no complications reported related to its use.

Toesca et al reported a total procedure time of 180 minutes, with patients discharged on the second postoperative day; the breast volume in their patients ranged from 200–300 g.⁵ Park et al reported a median hospital stay of 11 days, a mean operative time of 351 minutes, and breast volumes ranging from 150–436 g.⁶ In our experience, the operative time was shorter than that reported in the literature, at 135 minutes, with a breast volume of 210 g. This difference may be partly explained by improved ergonomics and visualization provided by the SOLOASSIST II® system, in addition to surgical team experience. The shorter time may also reflect the influence of breast volume, although this cannot be concluded definitively from a single case.

To our knowledge, this is the first reported case in the literature of an endoscopic nipple-sparing mastectomy assisted by the SOLOASSIST II® articulated robotic arm.⁸ The system provided stable, hands-free camera control, reduced surgeon fatigue, and enhanced precision in narrow anatomical planes, without requiring access to a full robotic platform. This positions SOLOASSIST II® as a potential bridge between purely endoscopic and fully robotic techniques, particularly in regions where high-cost robotic systems are not available.

While the results are promising, the present report is limited by its single-case nature and short follow-up. Further multicenter, prospective studies are needed to compare SOLOASSIST-assisted E-NSM with both pure endoscopic and Da Vinci-assisted NSM, assessing not only oncological safety but also patient-reported outcomes, long-term aesthetic satisfaction, and cost-effectiveness.

CONCLUSION

Endoscopic mastectomy is an innovative technique that offers superior aesthetic outcomes and reduces the complications associated with conventional surgical approaches. By preserving the breast skin envelope and the NAC, it achieves excellent cosmetic results. In addition to its visual advantages, the technique has a very low incidence of adverse events and postoperative complications.

In this particular case, the use of the robotic arm stands out as a significant benefit, allowing greater freedom of movement for the surgeon and facilitating more precise dissection. Further studies and larger case series are needed to obtain objective data that can conclusively evaluate its advantages in terms of complications, operative times, and clinical outcomes.

We believe that this technique may serve as a bridge between purely endoscopic and fully robotic mastectomy surgeries.