Videoendoscopic single-port axillary dissection.

Videoendoscopy is newly used in breast and axillary surgery. Single-port surgery is one of the newest methods of minimally invasive surgery. This report describes the first case of videoendoscopic single-port axillary dissection. In histopathological evaluation, 24 lymph nodes were identified and one node was infiltrated by the cancer cells. Videoendoscopic single-port axillary dissection is a precise and improvable technique. Single-port videoendoscopic axillary dissection could be more feasible with individual tools that will be designed for minimally invasive breast surgery.

INTRODUCTION

Minimally invasive approaches are popular in many fields of general surgery. Videoendoscope is an indispensable tool of laparoscopic surgery. Laparoscopy evolves rapidly as a result of increased experience and contributes to the development of other branches of the videoendoscopic surgery. Videoendoscopy is also used during the surgical approaches of the retroperitoneum, the neck, or the axilla.[1-3] Single-port surgery is one of the newest methods of minimally invasive surgery. A 29-year-old woman had undergone neoadjuvant chemotherapy for locally advanced left breast adenocarcinoma. She received a breast-conserving surgery and videoendosopic single-port axillary dissection. This is the first description of videoendoscopic single-port axillary dissection.

PREOPERATIVE PREPERATION

The patient was fully consented for the operation entirely and also a detailed informed consent form was signed by the patient. The patient was aware of being our initial case for this specific procedure. We explained to the patient that as an initial procedure this technique would bring them no benefit, but for reducing the wound size relatively. Furthermore, they were fully aware that we would convert the operation to a conventional surgery in the event of intraoperative difficulty or complication.

Positioning of patient and ports

The patient was positioned supine on the operating table with the arm abducted maximally under general anesthesia with endotracheal intubation. A 2-cm long skin incision was made along wrinkles on the junction point of the midaxillary line and the fourth rib. The axillary space was created by blunt dissection after opening the clavipectoral fascia for providing the working space and access to the axilla. SILS Port™ (12 mm, Covidien AG, Norwalk, CT, USA) was inserted into the incision by using a Kelly clamp. Two 5-mm and one 10-mm trocars were inserted through the SILS Port™ [Figure 1].

Figure 1

Insertion of the SILS port™ and replacement of the trocars

OPERATIVE STEPS

The SILS Port™ connected to an insufflator (Karl Storz, Germany) to keep the pressure at 8–10 mmHg. Endoscopic view was observed through a 30-degree 10-mm diameter straight-angled rigid endoscope (Karl Storz, Germany). Dissection was performed with an endograsper (Autosuture™, Norwalk, CT, USA), an endoscissors (ENDO MINI-SHEARS™ 5 mm Instrument With Unipolar Cautery, Norwalk, CT, USA) and the LIGASURE™ V (5 mm, Covidien, Mansfield, MA, USA). The optic system, all the trocars, and the endoscopic instruments were taken from the laparoscopy instrumentation box. No specific adaptations were performed.

The subcutaneous fatty tissue was tunneled to the direction of apex of the axilla after insertion of the SILS Port™. The dissection was started from medial boarder to the apex of the axilla by making sharp and slight blunt dissections for identifying the axillary vein [Figure 2a]. During the dissection, small vessels were cut with endoscissors that was connected to a diathermy device and the larger ones were closed and divided with the LIGASURE™ V. During medial dissection, the long thoracic nerve was seen on the chest wall and preserved. The dissection continues deep into the pectoralis major muscle, sweeping the interpectoral nodes laterally. Dissection commences from apex of the axilla over the axillary vein [Figure 2b]. The axillary content around the axillary vein was dissected by using the LIGASURE™ V [Figure 2c]. After exposing the axillary vein at apex of the axilla, lateral dissection was completed by sharp dissections with endoscissors [Figure 2d]. While dissecting the axillary content caudally from the axillary vein, the long thoracic and thoracodorsal nerves were preserved [Figure 3a]. Pulses of the subscapular artery could help to identify the thoracodorsal nerve. The fatty tissue of the axilla was dissected caudally along the anterior border of the latissimus dorsi muscle and divided after saving the neuronal structures. The nodes were dissected at levels 1, 2, and 3. During dissection procedure, landmarks of the axilla, the axillary vein in the apex, the latissimus dorsi muscles laterally, and the serratus muscles anteriorly and medially, were identified and principles of the conventional technique were also considered. A prototype external lift device could be used to maintain exposure in the subcutaneous space. The dissected axillary content was removed through the incision [Figure 3b]. After bleeding control, a Jackson Pratt drain was placed to the surgical field. The incision is closed with 4/0 vicryl and steristrips [Figure 3c]. Blood loss was 15 cc. The operating time was 90 min.

Figure 2

Steps of the single-port axillary dissection

Figure 3

(a) Operative field after axillary dissection; (b) the specimen extraction; (c) appearance of the skin incision on postoperative day 4

POSTOPERATIVE CARE

No postoperative complications had developed after surgery. The patient was discharged a day after surgery and the drain was removed postoperative day 2. In histopathological evaluation, 24 lymph nodes were identified and 1 node was infiltrated by the cancer cells. The patient received chemoradiotherapy after surgery.

DISCUSSION

Videoendoscopic interventions are newly used in breast surgery for breast-conserving surgery, skin-sparing total mastectomy, or axillary dissection.[3] After first application of videoendoscopic axillary dissection by Salvat et al.,[4] the techniques of videoendoscopy in breast surgery were improved by the cadaveric and clinical studies.[5-8] It has been reported that videoendoscopic axillary dissection lowers duration of drainage, operative blood loss.[6] Good functional and cosmetic results were reported after videoendoscopic axillary dissection. Videoendoscopy provides better view of the anatomy and eases the preservation of the neurovascular structures.[7] However, port-site recurrence and reduced harvested lymph node numbers according to open procedures could be the unwanted results of videoendoscopic axillary dissection, but there is not enough prospective randomized studies comparing open and videoendoscopic axillary dissection with oncologic and functional long-term results to reach a conclusion.[8] This operation was performed with the equipments that are used for laparoscopic surgery. Additionally, harvested lymph node number of the patient was quite acceptable. Single-port videoendoscopic axillary dissection could be more feasible with individual tools which will be designed for minimally invasive breast surgery. We only showed that videoendoscopic axillary dissection could be performed via single port. Single-port videoendoscopic axillary dissection could enrich the beneficial effects of the breast conserving surgery and other interventions of aesthetic breast surgery. We could not make any exact comment about the application of single port for videoendoscopic axillary dissection by reporting a case; further trials are needed with increased patient number. In our opinion, videoendoscopic single-port axillary dissection is a precise and improvable technique.