Discussion
1.The use of laparoscopic technology in the treatment of breast cancer has a long history, and single-port endoscopic subcutaneous gland excision via the axillary approach has ultimately become the most suitable approach.
Originally, laparoscopic technology was mainly used to obtain skin flaps for reconstruction. Since Fine[6]et al. used laparoscopy to obtain latissimus dorsi flaps in 1994, more and more people have been involved in the innovation of this technology. This technology can achieve better hemostasis, improve visualization, promote wound healing, and reduce postoperative pain. Initially, people used suspension systems or traction wires to obtain a larger operating space[7]. With the development and improvement of endoscopic technology, Pomel[8]et al. introduced CO2 gas injection technology in 2003. During the separation process, CO2 gas pressure can not only obtain a good operating space, but also provide a clear plane for separation, thus simplifying the operation. In addition, in the development of laparoscopic breast reconstruction technology, some scholars have adopted the three-stab technique[9](one 12mm camera stab and two 8mm operation stabs). Since breast reconstruction surgery requires the removal of gland tissue and placement of implants, the three-stab technique requires an additional incision in the armpit for such operations, which increases the number of incisions and operation steps, and has gradually been replaced by the axillary single-incision technique. In 2018, Serra-Mestre[10]et al. introduced the use of a single incision in the armpit for breast resection and reconstruction. The use of the axillary single-incision technique can not only perform some suturing and separation operations directly under visualization, but also is very suitable for the removal of breast tissue and placement of implants, and has been increasingly recognized by scholars. This incision can be hidden when the arm is lowered or covered with a bra.
Compared with traditional surgery, laparoscopic surgery has the following advantages: (1) Axillary approach for radical breast cancer resection results in a small incision and the removal of axillary lymph nodes first, which is more in line with the principle of tumor-free surgery compared to traditional surgery. (2) Compared with traditional surgery, laparoscopic surgery can enlarge the tissue by 4 times, which can display the intraoperative anatomical structures more clearly, avoid the occurrence of collateral damage, and provide more accurate protection for nerves and blood vessels, thereby minimizing postoperative discomfort for patients[11]. (3) Traditional surgery incisions are often located on the surface of the breast. After reconstruction, the skin tension is large, and local tissue swelling occurs. The skin incision destroys the subcutaneous vascular network, leading to an increasedrisk of skin necrosis and infection[12]. In addition, incision necrosis and infection can increase the risk of implant exposure and infection, leading to the risk of implant failure. Laparoscopic surgery via the axillary approach can perfectly avoid similar complications [13]. In our study, a total of 8 patients had postoperative complications, with a complication rate of 15.38%. In Sakamoto’s study [14], the total incidence of complications in 89 patients who underwent laparoscopic nipple-sparing mastectomy was 22% (20 cases), including 1 case of infection (1.1%), 3 cases of skin flap necrosis (3.4%) and 16 cases of nipple necrosis (18%). Among them, 7 cases were partial necrosis (7.9%), and 9 cases were complete necrosis (10%). Liu et al. [15] collected clinical data from 23 patients who underwent axillary approach laparoscopic stage I breast reconstruction with implants, and 4 cases (17.39%) had postoperative complications, including 2 cases of partial ischemic necrosis of the nipple-areola complex. Balasubramanian et al. [16] found that the incidence of incision complications between traditional autologous immediate implant breast reconstruction was 24.3%. Based on the above data on incision infection and skin necrosis, the incidence of incision complications in axillary approach laparoscopic immediate implant reconstruction surgery is lower than that in traditional immediate implant reconstruction. Moreover, due to its more concealable incision, the axillary single-incision technique will eventually become the most suitable approach.
2.Can laparoscopic surgery achieve the goal of radical treatment?
Firstly, laparoscopic surgery is only a change in the surgical approach and does not change the scope of gland removal and lymph node dissection. According to literature reports, the local recurrence rate is equivalent between subcutaneous gland resection with nipple-areola complex preservation under laparoscopy and traditional modified radical surgery [11][13][17]. Lai HW [18] and others have shown that there is no significant difference in local recurrence (p=0.89), distant metastasis (p=0.08), and overall survival (p=0.14) between laparoscopic breast surgery and traditional breast surgery. Laparoscopic surgery is feasible and safe for breast cancer patients. In our study, all 52 patients obtained negative margins. Among the 26 patients who underwent axillary lymph node dissection, the average number of lymph nodes obtained was 18.77±5.32, and among the 25 patients who underwent sentinel lymph node biopsy, the average number of lymph nodes obtained was 4.48±1.59. There were 18 patients with lymph node metastasis, and no tumor recurrence or metastasis was found in these patients during the 3-month follow-up after surgery. Our data indicate that laparoscopic surgery can meet the requirements of open surgery in obtaining negative margins and lymph node removal. As for disease-free survival and overall survival, due to the short follow-up time, this study did not conduct in-depth analysis.
3.How to reduce nipple and areola necrosis?
Preserving the nipple-areola complex (NAC) is a crucial step in ensuring the aesthetic appearance of breast reconstruction [20]. The traditional concept is that when preserving the nipple-areola complex, the tumor should generally be more than 2 cm away from the nipple-areola complex. However, more and more literature in recent years has shown that a distance of more than 1 cm can also preserve the nipple-areola complex [20][21], and the local recurrence rate does not increase under the premise of ensuring negative margins. This finding provides a basis for preserving the nipple-areola complex for more breast cancer patients. Ischemic complications involving the nipple-areola complex (NAC) are an important issue in nipple-sparing mastectomy (NSM) [22]. According to literature reports, the incidence of NAC necrosis after breast reconstruction surgery is between 2.5% and 8.8% [23]. The blood supply of the nipple-areola complex mainly includes small blood vessels from the surrounding skin and subcutaneous tissue, as well as intercostal perforating vessels from the glandular tissue. Glandular resection will damage the perforating vessels. If the subcutaneous fat around the nipple-areola complex is not preserved enough during the operation, it may affect the blood supply of the nipple-areola complex [24]. Some studies have shown that incisions on the breast surface, especially those related to the nipple-areola complex, can cause NAC ischemia [21]. To avoid NAC necrosis, we try to preserve the full-thickness skin flap in the area far away from the tumor during the surgery to protect the intradermal and subdermal vascular network. Laparoscopic surgery via the axillary approach does not involve any skin incision on the breast and preserves the integrity of the subcutaneous vascular network, which greatly reduces the incidence of NAC ischemia and necrosis. There has been a report that robot-assisted laparoscopic surgery can reduce the incidence of NAC ischemia and necrosis to 0% [25]. Therefore, laparoscopic surgery provides technical support for preserving the nipple-areola complex in breast cancer patients.
In this study, subcutaneous dissection was performed using tissue scissors and a cold knife. Yilmaz [26] et al. found that the use of a high-frequency electric knife can produce high local temperatures at the incision site, and the cytokine levels are higher than those in the scalpel and ultrasound groups, which can lead to more tissue damage and acute inflammatory reactions. Increased exudate can significantly increase the rate of skin flap necrosis. In this study, it was also found that patients with higher drainage volumes after surgery were more likely to develop wound infections (p=0.032). Similar results have been obtained by many scholars both at home and abroad [27][28][29][30][31]. The use of a cold knife to dissect the subcutaneous tissue can reduce thermal damage and has a good effect in preventing skin necrosis. In this study, it was found that applying pressure to the incision can increase the incidence of incision infections (p=0.035). In addition, in this study, there were two cases of skin flap necrosis, both of which were in the pressure dressing group (p=0.254). Due to the small number of cases, further testing is needed to determine whether there is a correlation between these two factors.
4.How to achieve better shaping results?
Patient satisfaction with the reconstructed breast’s shape and size is an important indicator that affects patient satisfaction. In 2020, Dong Won Lee et al. [32] compared breast reconstruction surgery using laparoscopic and open surgery. They evaluated patient satisfaction with scar repair, observer scar evaluation scores, breast shape and symmetry, and found that the laparoscopic group had higher satisfaction rates than the open surgery group. The aesthetic appearance of the incision is also an important factor that affects patient satisfaction. The incision through the axilla is concealed, and the incision is smaller than that of open surgery. The local tension around the axilla is small, and the resulting scar is not obvious. Therefore, the satisfaction of the laparoscopic group in this regard is better than that of the traditional surgery group. The magnifying effect of laparoscopic surgery can better preserve the wrinkles under the breast and avoid improper dissection of the cavity, which can cause implant displacement or bilateral hemispherical deformities [33]. In this study, we used the downward wrapping method to wrap the implant, which was pioneered in this study. Through technical improvements, we found that using this method to wrap the implant is more convenient, and the patch is smoother. No implant displacement was found during the follow-up after surgery. In this study, we conducted a Breast-Q questionnaire survey on patients 3 months after surgery, and the results showed that the breast satisfaction score was above 70 points. In the study by Qiu J et al. [34], the psychological and social health and sexual health scores of the laparoscopic reconstruction group were significantly higher than those of the open group (49.4 points and 40.8 points). Haiqian Xu et al. [35] also found that in an average follow-up of 10 months, patient satisfaction with the breast was higher than before surgery (satisfaction score of 64.9±5.6, 14.7±11.0). The results of this study did not investigate the patients’ preoperative Breast-Q questionnaire, and further verification is needed with longer follow-up time.
However, in clinical practice, laparoscopic surgery alone is not omnipotent. Due to the limited space in the retropectoral space, for patients with a breast volume of >500ml or significant breast ptosis, simple implant placement cannot meet the symmetry requirements [36]. For such patients, contralateral breast reduction and lifting surgery are often required to meet the requirements.