Table 3.
Technique for R-NSM with IBR (Implant Based)
| Study | Sample Size | Robot System | Incision | Port | Technique | Implant Pocket | Operation Length | Complications |
|---|---|---|---|---|---|---|---|---|
| Toesca et al22–25 | 24 patients; 29 R-NSMs and IBR | da Vinci Xi (except for 5 procedures with da Vinci Si) | 1 cm × 3 cm incision along midaxillary line in axillary fossa | Single port with 4 mm × 5–12 mm access. Insufflator set to 8 mm Hg pressure. Camera: rigid 0-degree 12 mm diameter |
Dissection performed with 5-mm monopolar cautery with cautery spatula tip. Traction performed with 8-mm Cadiere Bipolar Forceps. R-NSM—superficial dissection of gland moving from axilla toward NAC and continued to breast fold along lateral, inferior, and internal margins. Followed by deep layer dissection posterior to gland, from lateral to medial along major pectoral fascia. Specimen removed en bloc through axillary incision. Implant inserted manually. Drains—submuscular and subcutaneous planes |
Submuscular pocket | R-NSM: 90 min. Implant placement: 60 min. Total: approximately 180 min (included extra time for docking) |
2 cases (6.9%) converted to open. 1 to reduce procedure time and 1 for NAC positivity |
| Sarfati et al29–33 | 33 patients; 63 R-NSMs and IBR | da Vinci Xi | 2 × incisions; a high vertical 3–5 cm incision within the footprint of bra and a subcentimeter vertical incision 8 cm below (both lateral thoracic wall 6 cm posterior from lateral mammary fold | 3 mm × 8 mm diameter ports via the lower incision. Insufflator set to 8 mm Hg pressure. Camera: 30-degree camera |
Dissection performed with monopolar curved scissors. Traction performed with bipolar grasping forceps. R-NSM—began with infiltration of adrenaline containing saline solution to reduce bleeding. Subcutaneous dissection with manual scissors as far as possible, linking the 2 incisions. 3 ports were inserted and fixed with stitches to the skin (2 in upper incision and 1 in lower incision). Subcutaneous dissection of gland from lateral to medial, followed by separation from pectoralis major muscle from lateral to medial. Robot undocked and ports removed, with gland removed en bloc through larger upper incision and implant insertion. Drain inserted through inferior incision. Implant pocket closed with stitches between skin and thoracic wall |
Prepectoral pocket | Nonrobotic section: approximately 45 min. Robotic section: approximately 40 min Total: approximately 85 min per breast. (plus docking approximately 10 min) |
No major complications. 3 infections (4.8%) and 1 conversion to open (1.6%) due to bleeding perforator |
| Lai et al26–28,35 | 35 patients; 39 R-NSM and IBR | da Vinci Si | 1 cm × 2.5–5 cm oblique axillary incision in the extra-mammary region | Single port. Insufflator set to 8 mm Hg pressure with CO2. Camera: 30-degree 12 mm diameter |
Dissection performed with 8-mm monopolar scissors. Traction performed with 8-mm prograsp forceps. R-NSM—began with subcutaneous infiltration with lidocaine and epinephrine saline solution to reduce bleeding. Dissection began with superficial skin flaps in all quadrants with tunneling technique with subnipple biopsy to exclude NAC involvement. Followed by peripheral and posterior detachment of gland from pectoralis major muscle. Gland removed en bloc through axillary incision |
Subpectoral pocket. | Docking time: 10 min. R-NSM time: 100 min. R-NSM + IBR time: 240 min. Total operation time: 250 min |
Overall complication rate 30.8% |
BC, breast cancer; DIEV, deep interior epigastric vessels.