Dr Amborish Nath, Plastic surgeon

Robot assisted latissimus dorsi flap reconstruction of breast

Less scar in robotic harvest of latissimus dorsi
Conventional scar in after latissimus dorsi harvest

Introduction

The evolution of reconstructive surgery has witnessed significant advancements, particularly in the domain of breast reconstruction post-mastectomy. One of the major developments in this field is the application of robotic technology for latissimus dorsi (LD) flap harvest. A recent study published in Aesthetic Surgery Journal by Eo et al. (2024) compared three surgical approaches: conventional, endoscopic-assisted, and robot-assisted techniques, to assess outcomes in partial breast reconstruction following mastectomy.

This review delves into the findings of the study, its implications for plastic surgery, and the potential for further research and application.

The Latissimus Dorsi Flap in Breast Reconstruction

Since its introduction for breast reconstruction by Schneider in 1977, the LD flap has been widely used due to its reliability. However, the traditional method involves a large donor site incision, leading to visible scarring and donor site morbidity. The quest to minimize these drawbacks has led to the development of endoscopic and robotic-assisted techniques.

Study Overview

The study by Eo et al. (2024) was conducted at Kyungpook National University Chilgok Hospital, South Korea, and included 57 patients who underwent partial mastectomy followed by breast reconstruction with an LD muscle flap. Patients were divided into three groups:

  • Conventional Surgery Group (20 patients)
  • Endoscopic Surgery Group (17 patients)
  • Robot-Assisted Surgery Group (20 patients)

The study assessed key parameters, including total operation time, postoperative pain management, hospital stay, donor site drainage, complications, and patient satisfaction.

Key Findings

  1. Surgical Outcomes
    • The total operation time was longest for robotic surgery (394.4 minutes) compared to endoscopic (316.6 minutes) and conventional (279.8 minutes) methods.
    • However, robotic-assisted surgery resulted in less postoperative pain, with an average tramadol usage of 17.5 mg versus 45 mg (conventional) and 61.8 mg (endoscopic).
    • The hospital stay duration showed no significant difference among the three groups (p=0.225).
  2. Patient Satisfaction
    • Satisfaction scores regarding donor site scarring were highest for robotic-assisted surgery, followed by endoscopic and conventional approaches.
    • Satisfaction with pain levels at the donor site was comparable across all three methods (p=0.523).
    • Overall, robotic surgery scored higher in patient satisfaction metrics, suggesting superior aesthetic and recovery outcomes.
  3. Complications
    • The incidence of postoperative complications was similar across the three groups, with minor cases of seroma and wound dehiscence reported.
    • No infections or hematomas were observed.

Advantages of Robotic-Assisted Surgery

  • Enhanced Visualization: The robotic system provides a three-dimensional view, overcoming the limitations of the two-dimensional field of an endoscope.
  • Minimally Invasive: Reduces scarring and donor site morbidity compared to conventional surgery.
  • Better Instrument Control: Robotic arms allow for precise dissection and minimize tremors, improving surgical outcomes.
  • Higher Patient Satisfaction: The study confirmed better aesthetic results and lower postoperative discomfort.

Limitations and Future Research Scope

Despite its advantages, robotic-assisted LD flap harvest has limitations:

  • Longer Surgical Time: The learning curve and preparation time contribute to prolonged operation duration.
  • Limited Fat Harvest: Unlike conventional methods, robotic surgery does not allow for the simultaneous harvest of skin paddles, which may affect volume maintenance postoperatively.
  • Resource Constraints: Not all hospitals have access to robotic systems, making it an expensive alternative.

Potential Areas for Further Research:

  • Long-term follow-up studies assessing muscle atrophy and breast volume changes post-reconstruction.
  • Cost-effectiveness analysis comparing robotic, endoscopic, and conventional methods.
  • Optimization strategies to reduce operation time and enhance accessibility.

Conclusion

The study by Eo et al. (2024) highlights the promise of robotic-assisted breast reconstruction with LD flaps. While it presents superior patient satisfaction and reduced donor site morbidity, its widespread adoption is limited by cost and technical demands. As robotic technology advances, further refinements may position it as a standard approach for reconstructive surgery.

References

  1. Eo PS, Kim H, Lee JS, et al. Robot-assisted latissimus dorsi flap harvest for partial breast reconstruction: Comparison with endoscopic and conventional approaches. Aesthetic Surgery Journal. 2024;44(1):38–46. https://doi.org/10.1093/asj/sjad280

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