Technology-Assisted Mastectomy: Robotic-and Endoscopic-Assisted Mastectomy

Breast cancer is the most common malignancy in women around the world, with a lifetime risk of one in eight. Its surgical approach has become less and less mutilating in the last decades thanks to screening programs and early diagnosis. However, the overall number of mastectomies and breast reconstructions has significantly increased. Mastectomy is in fact one essential pillar of the treatment for approximately one-third of affected women. In order to enhance long-term quality of life, psychological well-being, and patient satisfaction, breast reconstruction is the second pillar of coordinated treatment. Today oncological safety of skin-envelope preservation seems to be demonstrated by many studies in which skin-sparing mastectomy and nipple-sparing mastectomy are reported to have a local recurrence rate similar to that of modified radical mastectomy (5-6%), even in invasive cancer. The latest new option for NSM and breast reconstruction is represented by the advent of technology-assisted surgery that is used not only to perform mastectomies but also to harvest flaps in breast reconstruction. In the second decade of twenty-first century, the single small hidden axillary scar Robotic Nipple-Sparing Mastectomy (RNSM) and Immediate Robotic Breast Reconstruction (IRBR) surgical techniques have been published, as an evolution of endoscopic-assisted breast surgery. Some of the premises that make technology-assisted breast surgery a feasible future option for minimally invasive prophylactic and reconstructive breast surgery are: reduction of breast skin necrosis risk after mastectomy, reduced invasiveness, improved bleeding control by better visualization, higher precision in movements allowed by motion scaling and tremor abolition with high technology instruments allowing 7 degrees of freedom. It also brings the possibility to place scars in hidden areas far from the implant pocket, and it allows to perform immediate direct-to-implant reconstruction with subcutaneous implant placement with or without requirements of acellular dermal matrices (ADM) nor meshes, as skin flaps can be gently handled with no need for retractors. Some of the downsides of technology-assisted breast surgery are certainly the high costs, the long and steep learning curve, and the increased operative time. Reduction of certain complications such as bleeding, scarring or infections, and reinterventions need to be considered when adopting these technologies. Not only does it yields a positive impact on post-operative patient comfort and satisfaction, but also the reduction in complications can have a positive impact on the costs which may contribute to bring the overall costs of the technology-assisted surgery closer to those of traditional surgery. It may hypothetically help to make technology-assisted surgery a “gold standard” procedure for the future generations of breast surgeons.