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the number of incisions and operation steps, and has gradually been
replaced by the axillary single-incision technique.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.