Name: endoscopic bilateral nipple-sparing mastectomy via a single axillary incision with immediate pre-pectoral implant-based breast reconstruction
Uploaded: 2024-05-17T12:40:00
Duration: 13 min 35 s
Description: Watch this Scientific Journal Video about Endoscopic Bilateral Nipple-sparing Mastectomy via a Single Axillary Incision with Immediate Pre-pectoral Implant-based Breast Reconstruction at JoVE.com

This work was supported by National Key Clinical Discipline.

The study was approved by the Ethics Review Committee of The Sixth Affiliated Hospital, Sun Yat-sen University (No.2023ZSLYEC-171). Photographs and videos were utilized with informed consent duly obtained from the patients. The video is for educational purposes only.
1. Preoperative marking
<ol>
	<li>Mark the inferior fold of the axilla, the edge of the breast, and the inframammary fold of bilateral breasts (Figure 3).</li>
</ol>
2. Positioning and anesthesia
<ol>
	<li>Induce general anesthesia and perform tracheal intubation.</li>
	<li>Place the patient in a supine position with bilateral arms abducted at 90&#176;.</li>
	<li>Sterilize the surgical area with povidone-iodine skin disinfectant.</li>
	<li>Wrap the bilateral limbs with sterile drapes and fix them abducted at 90&#176;.</li>
</ol>
3. Sentinel lymph node biopsy (SLNB)
<ol>
	<li>Use a 1 mL syringe to aspirate a suspension mixture of carbon nanoparticles in saline, mixed in a 1:1 ratio to achieve a total volume of 1 mL, for the formulation of the sentinel lymph node tracer. Inject the tracer (0.3 mL) into the parenchyma of the outer upper quadrant of the breast at any 3 points, massage for 5 min, and wait for 5 min.</li>
	<li>Use a 10 mL syringe to aspirate a mixture of methylene blue and saline in a 1:5 ratio to a total volume of 10 mL and inject it into the circum-mammary ligaments of the breast, known as the breast footprint15, guided by ultrasound or preoperative marking to make the boundary and extent of dissection. 
	NOTE: Staining is not a necessary step in the surgery. It assists breast surgeons who have not yet overcome the learning curve to control the extent of dissection.</li>
	<li>Make an approximately 4 cm curved axillary incision along the line marked previously to complete SLNB under direct vision. 
	NOTE: The sentinel lymph node biopsy was examined to be negative by an intraoperative frozen section biopsy.
	<ol>
		<li>Perform a complete axillary lymph node dissection (ALND) with the removal of level I and II axillary lymph nodes if SLNB is positive.</li>
		<li>Ensure that the anterior edge of the incision is more than 1 cm from the anterior edge of the pectoralis major muscle and does not extend beyond the anterior axillary line. If necessary, the incision can be appropriately extended posteriorly.</li>
	</ol>
	</li>
</ol>
4. Air cavity building
<ol>
	<li>Bend the arm of the patient on the operation side and secure it to the head rack.</li>
	<li>Seek the lateral edge of the pectoralis major muscle from the axillary incision. Dissect the retro-mammary space for 2 cm and the subcutaneous flap for 3 cm under direct vision.</li>
	<li>Insert the wound protector into the incision, then connect with the four-trocar single port (Figure 4). Place a 12 mm trocar above, 10 mm trocar below, and two 5 mm trocars on both sides.</li>
	<li>Connect the 12 mm trocar with the constant pressure pneumoperitoneal device to construct a working space. Maintain the air cavity by applying CO2 insufflation at 8 mmHg pressure and 40 L/min air flow.</li>
	<li>Then insert an oblique-ended rigid endoscope measuring 5 mm in diameter with a viewing angle of 30&#176; through the 10 mm trocar.</li>
	<li>Insert an electric hook and laparoscopic grasping forceps through two 5 mm trocars, respectively.</li>
</ol>
5. Retromammary space dissection
<ol>
	<li>Use the circum-mammary ligaments as the boundary of the breast, paying attention to exposing and identifying ligamentous structures15. The integrity of the ligament can be ensured by staining, finger-press, and resistance from endoscopic instruments. 
	NOTE: The assistant can help with finger pressing during the operation. Additionally, the chief surgeon can temporarily suspend the endoscopic operation and do finger pressing for assessment. None of these procedures impacts observation under endoscopic vision.</li>
	<li>Perform the dissection by following the sequence shown in Figure 5. Dissect the retro-mammary space under endoscopic vision using the electric hook. Extend this dissection superiorly to the subclavian ligament, medially to the parasternal ligament, inferiorly to the inframammary fold, and laterally to the lateral border of the mammary gland. 
	NOTE: In this case, ductal carcinoma was confirmed preoperatively (see Figure 2), therefore, the pectoralis major fascia is completely preserved intraoperatively16,17. This approach serves a dual purpose: it minimizes surgical trauma and postoperative discomfort, thereby improving the patient&#39;s quality of life. Additionally, preserving the pectoralis major fascia allows for secure mesh fixation, preventing prosthesis displacement.</li>
</ol>
6. Subcutaneous layer dissection
<ol>
	<li>Pull the wound protector to reach the subcutaneous layer. 
	NOTE: The following measures can ensure that surgeons have reached the subcutaneous layer. Firstly, during the air cavity-building phase, a portion of the subcutaneous flap is dissected under direct vision. Secondly, through the magnifying effect of the endoscope, the superficial fascia of the breast can be clearly observed under endoscopic vision. Thirdly, the breast is suspended on the dermal layer through Cooper&#39;s ligaments, which can be observed under the endoscope, guiding surgeons into the dissection of the subcutaneous layer18.</li>
	<li>Follow the zoning dissection sequence (Figure 6) and perform the dissection with the electric hook in the following sequence: outer upper quadrant, inner upper quadrant, outer lower quadrant, retro nipple area, and inner lower quadrant.</li>
	<li>Use endoscopic scissors to&#160;cut off the root of the nipple, preventing NAC&#160;necrosis caused by thermal effects.</li>
	<li>Take a tissue biopsy specimen from the posterior margin of the nipple for intraoperative frozen sectioning.</li>
	<li>Utilize the electric hook to carefully dissociate the inner lower quadrant of the mammary gland.</li>
	<li>Remove the intact breast specimen through the axillary incision. 
	NOTE: Achieving hemostasis through a single port under endoscopic vision is difficult. Using the electric hook to achieve hemostasis may lead to eschar formation at the bleeding site, potentially hindering the observation of the bleeding point and posing a risk of skin burns.</li>
</ol>
7. Implant placement
<ol>
	<li>Weigh the breast specimen, measure the diameter of the implant cavity, and combine the preoperative measurements to select the appropriate prosthesis.</li>
	<li>Irrigate the implant cavity with 2,000 mL of warm, sterile distilled water.</li>
	<li>Adjust the implant cavity pressure to 5 mmHg to carefully inspect the implant cavity and complete hemostasis under endoscopic vision.</li>
	<li>Soak the implant cavity with 0.45%-0.55% povidone-iodine solution for 10 min, disinfect the surgical region, and change gloves.</li>
	<li>Cover the prosthesis fully with 2 meshes. Suture the meshes with 3-0 absorbable sutures and simple interrupted sutures for fixation.</li>
	<li>Insert the prosthesis into the implant cavity.</li>
</ol>
8. Drainage
<ol>
	<li>Place one drainage tube on each of the inframammary fold and axilla in the subcutaneous layer, maintained under low negative pressure suction.</li>
	<li>Close the axillary incision wound with 4-0 absorbable sutures (Figure 7).</li>
</ol>
9. Postoperative nursing
<ol>
	<li>Apply an elastic bandage to achieve pressure dressing of the breast and axilla.</li>
	<li>Perform proper pressure dressing at the axillary wound. 
	NOTE: It is mainly pressurized to the superior and inferior margins of the prosthesis rather than the nipple-areolar complex in order to prevent ischemic necrosis of the NAC.</li>
	<li>Administer proper prophylactic antibiotics for 24 h (1.5 g of cefuroxime dissolved in 100 mL of saline) administered intravenously.</li>
	<li>Pay attention to the blood circulation of the NAC when changing the wound dressing. Apply nitroglycerin around the NAC to promote blood circulation if necessary. Look at the color of the NAC, the presence of edema, and bruising.</li>
	<li>Maintain the patency of the drainage tubes; observe and record the color, nature, and drainage volume of the drainage fluid daily. If the drainage volume is less than 20 mL for 24 h for 3 days, remove the drainage tubes.</li>
	<li>Ask the patient to perform functional exercises of the upper limbs for 2 weeks postoperatively19.</li>
	<li>Ensure the patient wears a pressure garment for 3-6 months starting on the 2nd postoperative day.</li>
	<li>Ensure the patient performs breast implant displacement exercises for smooth implants20,21,22. 
	NOTE: The contralateral breast is operated in the same way.</li>
</ol>

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W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Understanding+the+fascial+supporting+network+of+the+breast:+Key+ligamentous+structures+in+breast+augmentation+and+a+proposed+system+of+nomenclature.">Understanding the fascial supporting network of the breast: Key ligamentous structures in breast augmentation and a proposed system of nomenclature.</a> Plast Reconstr Surg. 133 (2), 273-281 (2014).</li><li>Zhang, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Video-assisted+transaxillary+nipple-sparing+mastectomy+and+immediate+implant-based+breast+reconstruction:+A+novel+and+promising+method.">Video-assisted transaxillary nipple-sparing mastectomy and immediate implant-based breast reconstruction: A novel and promising method.</a> Aesthetic Plast Surg. 46 (1), 91-98 (2022).</li></ol>

No conflict of interest.

Represented by mastectomy, conventional breast surgery often yields unsatisfactory cosmetic outcomes and can adversely affect the functioning of the affected upper limb. This situation can cause considerable psychological distress, ultimately resulting in a reduced postoperative quality of life for patients24,25,26. Minimally invasive surgery represents a pivotal advancement in modern surgical practices. With the introduction of endoscopic techniques, significant improvements have been made to address the shortcomings of conventional surgery. Simultaneously, breast reconstruction has gained popularity as it offers the ability to restore the breast contour in breast cancer patients24. It has been shown to reduce the incidence of postoperative depression among breast cancer patients and enhance their postoperative quality of life27. This aligns with the emerging paradigm of the &#34;biopsychosocial&#34; medical model. With the integration of endoscopic techniques and breast reconstruction, breast surgery has entered a novel phase characterized by a focus on humanization and the optimization of patient outcomes. These objectives stand as the central tenets we strive for and uphold.
When compared with conventional E-NSM with IBBR, the benefits of endoscopic nipple-sparing mastectomy via a single axillary incision with immediate pre-pectoral implant-based breast reconstruction are evident. Firstly, this approach allows for the completion of all surgical procedures through a discreet single axillary incision, ensuring minimal visibility and achieving favorable postoperative cosmetic outcomes11,28,29. Moreover, the technique of E-NSM disrupts the vertical blood supply system to the nipple-areola complex (NAC), relying exclusively on the dermal vascular network. Avoiding incisions on the breast skin reduces the likelihood of NAC and flap ischemic necrosis8,30,31,32. In comparison to subpectoral reconstruction, pre-pectoral reconstruction is simpler, resulting in a more natural breast contour and minimizing chest functional deficits and pain33. However, in the context of pre-pectoral reconstruction, the absence of protection from the pectoralis major muscle means that direct contact between implants or meshes and the breast surface incision could lead to prosthetic exposure or even loss. Such complications may arise due to flap infection or ischemic necrosis34,35. Hence, the technique we present not only ensures the safety of tumor management but also yields superior cosmetic outcomes and a higher postoperative quality of life.
Several critical technical aspects warrant attention. First, it is imperative to preoperatively demarcate the extent of the patient&#39;s breast. Experienced surgeons can preoperatively manually mark the extent of the breast, while less experienced surgeons can employ preoperative ultrasound to delineate the breast boundaries. The circummammary ligaments are considered the natural boundaries of the breast and can serve as anatomical landmarks for breast dissection15,36. They can be observed both preoperatively with ultrasound and intraoperatively under endoscopic vision. Second, follow the dissection sequence from the retromammary space to the subcutaneous layer of the breast, which is recognized as a convenient and efficient strategy37. Third, while conducting the dissection of the retromammary space, meticulous attention is required when separating along the edges of the breast. This can be assessed through the utilization of dyes, finger press, and the pressure feedback sensation from endoscopic instruments. Whether through preoperative marking or employing techniques such as dyeing to delineate the breast boundaries, the central aim remains to guide surgeons to expose and identify the circummammary ligaments and precisely excise mammary glands. This is crucial for breast reconstruction surgery and contributes to achieving favorable postoperative cosmetic outcomes36. Fourth, it is advisable to ensure consistent flap thickness during the dissection of the subcutaneous layer within the breast. A technique we employ involves turning off the operating room lights and observing the extent to which the endoscope&#39;s light source penetrates through the breast&#39;s surface skin within the cavity, thereby assessing the uniformity of flap thickness.
There are some limitations to this method. First, even though E-NSM with IBBR has garnered extensive adoption and is considered a relatively mature technique, there remains a dearth of high-level evidence from evidence-based medicine to definitively establish its safety. Additionally, within our institution, we exclusively employ the single-port method for conducting endoscopic breast surgery. This decision is rooted in the fact that the lead surgeon has successfully overcome the learning curve and holds the belief that the single-port approach can reduce the number of incisions, obscure scars, and diminish the occurrence of ischemic necrosis in both the NAC and flap. Nevertheless, it&#39;s important to note that this perspective is subjective and currently lacks controlled studies to substantiate our standpoint.
In conclusion, when considering specific patients, the endeavor to enhance practice for improved cosmetic outcomes and heightened patient satisfaction holds significant value. This endeavor encapsulates the ethos of humanistic care and aesthetics. Our collective aspirations encompass the pursuit of beauty and the assurance of maximizing patient benefits.

As breast cancer treatment continues to advance, an increasing number of breast surgeons are shifting their focus beyond solely addressing malignant tumors. They also place greater emphasis on addressing the post-treatment appearance and quality of life of their patients. Nipple-sparing mastectomy (NSM), characterized by comparable oncologic outcomes, favorable patient satisfaction, and cosmetic outcomes, has now become a standard surgical option for patients with bilateral early breast cancer and those undergoing prophylactic mastectomy1,2,3.
Endoscopic breast surgery (EBS) is an emerging and forward-looking surgical approach that is gaining popularity in both nipple-sparing mastectomy (NSM) and breast-conserving surgery. When compared to traditional breast surgery methods, EBS has demonstrated superior cosmetic outcomes, increased patient satisfaction owing to its less noticeable incisions, and similar levels of oncological safety4,5,6.
However, the conventional approach to endoscopic nipple-sparing mastectomy (E-NSM) with immediate implant-based breast reconstruction (IBBR) often requires two or more incisions, typically located in the axilla, anterior axillary line, and peri-areolar regions4,7. Unfortunately, this technique frequently yields suboptimal cosmetic outcomes. This is especially pronounced in cases involving peri-areolar incisions, where E-NSM eliminates the vertical blood supply route to the nipple-areola complex (NAC), relying solely on the dermal vascular network for nourishment8. This scenario potentially leads to ischemic necrosis in the NAC. Moreover, for pre-pectoral breast reconstruction, incisions on the breast surface can create openings for infection or flap ischemia, increasing the risk of prosthetic exposure, nipple necrosis, and even prosthesis loss7,9,10. Given the rapid advancements in endoscopic techniques and instrumentation, novel variations of E-NSM with IBBR predominantly focus on a single axillary incision and insufflation technique11,12. These innovations offer distinct advantages, including reduced risk of nipple necrosis, decreased patient discomfort leading to quicker recovery, significantly improved cosmetic outcomes, and optimized patient benefits, among others12,13.
This article provides a comprehensive description of the surgical procedures involved in endoscopic bilateral nipple-sparing mastectomy via a single axillary incision with immediate pre-pectoral implant-based breast reconstruction. The aim is to showcase the feasibility, exceptional cosmetic outcomes, and physiological considerations associated with this surgical approach.
To facilitate readers&#39; comprehension of the protocol, we present a representative case for elucidation. The patient was a 33-year-old female who exhibited bilateral breast lumps on ultrasound, categorized as BI-RADS 4, with relatively large-sized lumps (Figure 1). Histopathological confirmation through Mammotome-assisted minimally invasive resection identified bilateral ductal carcinoma in situ14 (Figure 2). This young woman had bilateral nipple asymmetry and a strong desire to rectify it. Given her passion for dance, she also had a significant demand for favorable cosmetic outcomes. After introducing our surgical plan, the patient ultimately opted to undergo endoscopic bilateral nipple-sparing mastectomy via a single axillary incision with immediate pre-pectoral implant-based breast reconstruction.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
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			<td>Carbon nanoparticles suspension injection</td>
			<td>LUMMY</td>
			<td>H20041829</td>
			<td></td>
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		<tr>
			<td>Drainage tube</td>
			<td>Yangtze River</td>
			<td>20142140359</td>
			<td></td>
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		<tr>
			<td>Electric hook</td>
			<td>TNKJ</td>
			<td>20222010212</td>
			<td></td>
		</tr>
		<tr>
			<td>Endoscopic scissors</td>
			<td>YOUSHI</td>
			<td>P20200702015</td>
			<td></td>
		</tr>
		<tr>
			<td>5-mm 35cm 30&#176; rigid endoscope</td>
			<td>Karl Storz</td>
			<td>26046BA</td>
			<td></td>
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		<tr>
			<td>Implant</td>
			<td>MENTOR</td>
			<td>9718984-037</td>
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			<td>Laparoscopic grasping forceps</td>
			<td>YOUSHI</td>
			<td>P20200108013</td>
			<td></td>
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			<td>Mesh</td>
			<td>pfm medical titanium gmbh</td>
			<td>20163131539</td>
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			<td>Methylene blue</td>
			<td>JUMPCAN</td>
			<td>H32024824</td>
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			<td>1 mL syringe (0.45&#215;16RWLB)</td>
			<td>WEGO</td>
			<td>20163141593</td>
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		<tr>
			<td>Single port</td>
			<td>SURGAID</td>
			<td>5012151092</td>
			<td></td>
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		<tr>
			<td>10 mL syringe (0.8&#215;38TWLB)</td>
			<td>WEGO</td>
			<td>20163141593</td>
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endoscopic bilateral nipple-sparing mastectomy via a single axillary incision with immediate pre-pectoral implant-based breast reconstruction

Oncoplastic breast surgery, with its focus on improving cosmetic outcomes while maintaining oncological safety, has fundamentally transformed the landscape of breast cancer surgical treatment, giving rise to an array of techniques for breast reconstruction. Nipple-sparing mastectomy (NSM) with immediate implant-based breast reconstruction (IBBR) has emerged as a cornerstone in managing early breast cancer. Aligned with the principles of minimally invasive surgery, recent years have witnessed the widespread integration of endoscopic approaches in breast surgery, encompassing procedures like endoscopic breast-conserving surgery (E-BCS) and endoscopic nipple-sparing mastectomy (E-NSM), among others. Capitalizing on the advantages of inconspicuous and shorter incisions, improved visibility, and the avoidance of radiation therapy, the popularity of E-NSM with IBBR is on the rise. However, conventional E-NSM with IBBR often requires two or more incisions, which can result in suboptimal cosmetic outcomes and even prosthesis loss.This paper presents a comprehensive account of the intricate surgical procedures involved in endoscopic bilateral nipple-sparing mastectomy with immediate pre-pectoral implant-based breast reconstruction. The insights shared are drawn from the collective experience of our institution. Notable benefits associated with the described surgical approach encompass enhanced cosmetic outcomes, improved postoperative quality of life, and enhanced physiological functions attributable to the application of pre-pectoral implant-based breast reconstruction through a single incision.

The surgical procedure lasted for 4 h, with a recorded blood loss of 30 mL. Postoperative recovery proceeded without significant complications. Drainage tubes were removed on the 7th day post-surgery, and the patient was discharged on the 10th day (Figure 8). Subsequent to postoperative pathological analysis, ductal carcinoma in situ was confirmed in the residual mammary gland on the left side. At the same time, no cancer cells were observed in the right residual mammary gland. Final pathologic evaluations of both bilateral nipple bases and sentinel lymph nodes yielded negative results for malignancy. At the five-month mark after the operation, the patient expressed satisfaction with her breast&#39;s appearance (Figure 9).
Between June 2021 and October 2022, a cohort of 10 patients diagnosed with bilateral breast cancer (BBC) or necessitating contralateral prophylactic mastectomy (CPM) underwent endoscopic bilateral nipple-sparing mastectomy via a single axillary incision with immediate prepectoral implant-based breast reconstruction. The average age of the patients was 42 years, with an average body mass index (BMI) of 22.12 Kg/m2. The mean duration of the surgical procedure was 4.25 h, and the average volume of intraoperative blood loss measured 33 mL. The postoperative recovery of each patient was characterized by an uneventful course devoid of significant complications, and the typical duration of postoperative hospitalization averaged 11 days. Subsequently, all patients received regular follow-up care, with appointments scheduled every three months throughout the initial two years following surgery (Table 1). Notably, the Harris scores of three patients were rated as excellent, while seven patients received a rating of good 23. They universally expressed satisfaction with the postoperative cosmetic outcomes.
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/65392/65392fig01.jpg" /> 
Figure 1: Preoperative ultrasound imaging data from the patient. (A) The image reveals a solid nodule located at the 6 o&#39;clock position of the left breast. (B) The image reveals multiple calcifications located at the 10 o&#39;clock position of the right breast. <a href="https://www.jove.com/files/ftp_upload/65392/65392fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/65392/65392fig02.jpg" /> 
Figure 2: Preoperative histopathological result: The image shows ductal carcinoma in situ. <a href="https://www.jove.com/files/ftp_upload/65392/65392fig02large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 3" class="xfigimg" src="/files/ftp_upload/65392/65392fig03.jpg" /> 
Figure 3: Preoperative marking. The images show the inferior fold of axilla, edge of breast and inframammary fold of the bilateral breasts were marked. <a href="https://www.jove.com/files/ftp_upload/65392/65392fig03large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 4" class="xfigimg" src="/files/ftp_upload/65392/65392fig04.jpg" /> 
Figure 4: Surgical instruments. The image shows the wound protector, four-trocar single port, and electric hook. <a href="https://www.jove.com/files/ftp_upload/65392/65392fig04large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 5" class="xfigimg" src="/files/ftp_upload/65392/65392fig05.jpg" /> 
Figure 5: Dissection sequence. The image shows the dissection sequence in the retromammary space. <a href="https://www.jove.com/files/ftp_upload/65392/65392fig05large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 6" class="xfigimg" src="/files/ftp_upload/65392/65392fig06.jpg" /> 
Figure 6: Zoning dissection sequence. The image shows the dissection sequence in the subcutaneous layer. <a href="https://www.jove.com/files/ftp_upload/65392/65392fig06large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 7" class="xfigimg" src="/files/ftp_upload/65392/65392fig07.jpg" /> 
Figure 7: Postoperative result. The image shows that the implantation, drainage, and suture have been completed. <a href="https://www.jove.com/files/ftp_upload/65392/65392fig07large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 8" class="xfigimg" src="/files/ftp_upload/65392/65392fig08.jpg" /> 
Figure 8: Postoperative photos. The images show the postoperative recovery of the patient after the removal of the drainage tubes on the 8th postoperative day. <a href="https://www.jove.com/files/ftp_upload/65392/65392fig08large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 9" class="xfigimg" src="/files/ftp_upload/65392/65392fig09.jpg" /> 
Figure 9: Postoperative cosmetic outcomes. (A) The image shows preoperative breast appearance. (B) The image shows postoperative cosmetic outcomes after 5 months. <a href="https://www.jove.com/files/ftp_upload/65392/65392fig09large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Case</td>
			<td>Age (years)</td>
			<td>BMI (Kg/m2)</td>
			<td>Operative time (h)</td>
			<td>Blood loss (mL)</td>
			<td>Postoperative hospital stay (days)</td>
			<td>Operation reason</td>
		</tr>
		<tr>
			<td>1</td>
			<td>50</td>
			<td>20.20</td>
			<td>4</td>
			<td>20</td>
			<td>16</td>
			<td>CPM</td>
		</tr>
		<tr>
			<td>2</td>
			<td>42</td>
			<td>25.97</td>
			<td>3.5</td>
			<td>20</td>
			<td>11</td>
			<td>BBC</td>
		</tr>
		<tr>
			<td>3</td>
			<td>49</td>
			<td>27.34</td>
			<td>4</td>
			<td>20</td>
			<td>19</td>
			<td>CPM</td>
		</tr>
		<tr>
			<td>4</td>
			<td>34</td>
			<td>19.56</td>
			<td>4</td>
			<td>50</td>
			<td>7</td>
			<td>CPM</td>
		</tr>
		<tr>
			<td>5</td>
			<td>45</td>
			<td>20.31</td>
			<td>4.5</td>
			<td>50</td>
			<td>15</td>
			<td>BBC</td>
		</tr>
		<tr>
			<td>6</td>
			<td>51</td>
			<td>22.03</td>
			<td>4</td>
			<td>50</td>
			<td>6</td>
			<td>CPM</td>
		</tr>
		<tr>
			<td>7</td>
			<td>33</td>
			<td>18.75</td>
			<td>4</td>
			<td>20</td>
			<td>10</td>
			<td>CPM</td>
		</tr>
		<tr>
			<td>8</td>
			<td>45</td>
			<td>29.38</td>
			<td>6</td>
			<td>20</td>
			<td>10</td>
			<td>CPM</td>
		</tr>
		<tr>
			<td>9</td>
			<td>36</td>
			<td>16.53</td>
			<td>4.5</td>
			<td>50</td>
			<td>10</td>
			<td>CPM</td>
		</tr>
		<tr>
			<td>10</td>
			<td>33</td>
			<td>21.09</td>
			<td>4</td>
			<td>30</td>
			<td>10</td>
			<td>BBC</td>
		</tr>
		<tr>
			<td>Average</td>
			<td>42</td>
			<td>22.12</td>
			<td>4.25</td>
			<td>33</td>
			<td>11</td>
			<td></td>
		</tr>
	</tbody>
</table>
Table 1: Clinical parameters of 10 cases. Abbreviations: BMI=body mass index; CPM=contralateral prophylactic mastectomy; BBC=bilateral breast cancer.

Watch this Scientific Journal Video about Endoscopic Bilateral Nipple-sparing Mastectomy via a Single Axillary Incision with Immediate Pre-pectoral Implant-based Breast Reconstruction at JoVE.com

Endoscopic Bilateral Nipple-sparing Mastectomy via a Single Axillary Incision with Immediate Pre-pectoral Implant-based Breast Reconstruction

Here, we present detailed surgical procedures for endoscopic bilateral nipple-sparing mastectomy via a single axillary incision with immediate pre-pectoral implant-based breast reconstruction. This procedure is a secure and viable method for breast cancer patients.

Oncoplastic breast surgery, with its focus on improving cosmetic outcomes while maintaining oncological safety, has fundamentally transformed the ...

endoscopic-bilateral-nipple-sparing-mastectomy-via-single-axillary

Research

JoVE Journal

Medicine

Surgical Procedures for a Rat Model of Partial Orthotopic Liver Transplantation with Hepatic Arterial Reconstruction

Orthotopic liver transplantation (OLT) in rats using a whole or partial graft is an indispensable experimental model for transplantation research, such as studies on graft preservation and ischemia-reperfusion injury 1,2, immunological responses 3,4, hemodynamics 5,6, and small-for-size syndrome 7. The rat OLT is among the most difficult animal models in experimental surgery and demands advanced microsurgical skills that take a long time to learn. Consequently, the use of this model has been limited. Since the reliability and reproducibility of results are key components of the experiments in which such complex animal models are used, it is essential for surgeons who are involved in rat OLT to be trained in well-standardized and sophisticated procedures for this model.
While various techniques and modifications of OLT in rats have been reported 8 since the first model was described by Lee et al. 9 in 1973, the elimination of the hepatic arterial reconstruction 10 and the introduction of the cuff anastomosis technique by Kamada et al. 11 were a major advancement in this model, because they simplified the reconstruction procedures to a great degree. In the model by Kamada et al., the hepatic rearterialization was also eliminated. Since rats could survive without hepatic arterial flow after liver transplantation, there was considerable controversy over the value of hepatic arterialization. However, the physiological superiority of the arterialized model has been increasingly acknowledged, especially in terms of preserving the bile duct system 8,12 and the liver integrity 8,13,14.
In this article, we present detailed surgical procedures for a rat model of OLT with hepatic arterial reconstruction using a 50% partial graft after ex vivo liver resection. The reconstruction procedures for each vessel and the bile duct are performed by the following methods: a 7-0 polypropylene continuous suture for the supra- and infrahepatic vena cava; a cuff technique for the portal vein; and a stent technique for the hepatic artery and the bile duct.

Orthotopic liver transplantation in rats is an indispensable experimental model for biomedical research. Here we present our surgical procedures for orthotopic rat liver transplantation with hepatic arterial reconstruction using a 50% partial graft.

Orthotopic liver transplantation (OLT) in rats using a whole or partial graft is an indispensable experimental model for transplantation research, such as ...

Processing of Human Reduction Mammoplasty and Mastectomy Tissues for Cell Culture

Experimental examination of normal human mammary epithelial cell (HMEC) behavior, and how normal cells acquire abnormal properties, can be facilitated by in vitro culture systems that more accurately model in vivo biology. The use of human derived material for studying cellular differentiation, aging, senescence, and immortalization is particularly advantageous given the many significant molecular differences in these properties between human and commonly utilized rodent cells1-2. Mammary cells present a convenient model system because large quantities of normal and abnormal tissues are available due to the frequency of reduction mammoplasty and mastectomy surgeries.
The mammary gland consists of a complex admixture of many distinct cell types, e.g., epithelial, adipose, mesenchymal, endothelial. The epithelial cells are responsible for the differentiated mammary function of lactation, and are also the origin of the vast majority of human breast cancers. We have developed methods to process mammary gland surgical discard tissues into pure epithelial components as well as mesenchymal cells3. The processed material can be stored frozen indefinitely, or initiated into primary culture. Surgical discard material is transported to the laboratory and manually dissected to enrich for epithelial containing tissue. Subsequent digestion of the dissected tissue using collagenase and hyaluronidase strips stromal material from the epithelia at the basement membrane. The resulting small pieces of the epithelial tree (organoids) can be separated from the digested stroma by sequential filtration on membranes of fixed pore size. Depending upon pore size, fractions can be obtained consisting of larger ductal/alveolar pieces, smaller alveolar clusters, or stromal cells. We have observed superior growth when cultures are initiated as organoids rather than as dissociated single cells. Placement of organoids in culture using low-stress inducing media supports long-term growth of normal HMEC with markers of multiple lineage types (myoepithelial, luminal, progenitor)4-5. Sufficient numbers of cells can be obtained from one individual's tissue to allow extensive experimental examination using standardized cell batches, as well as interrogation using high throughput modalities.
Cultured HMEC have been employed in a wide variety of studies examining the normal processes governing growth, differentiation, aging, and senescence, and how these normal processes are altered during immortal and malignant transformation4-15,16. The effects of growth in the presence of extracellular matrix material, other cell types, and/or 3D culture can be compared with growth on plastic5,15. Cultured HMEC, starting with normal cells, provide an experimentally tractable system to examine factors that may propel or prevent human aging and carcinogenesis.

A method to process human mammary surgical discard material is described. Processed tissue, in the form of organoids, can be stored frozen indefinitely or placed in culture for long-term growth. This method enables experimental examination of normal human epithelial cell biology, and the effects of exogenous perturbations.

Experimental  examination of normal human mammary epithelial cell (HMEC) behavior, and how  normal cells acquire abnormal properties, can be facilitated ...

Initiation of Metastatic Breast Carcinoma by Targeting of the Ductal Epithelium with Adenovirus-Cre: A Novel Transgenic Mouse Model of Breast Cancer

Breast cancer is a heterogeneous disease involving complex cellular interactions between the developing tumor and immune system, eventually resulting in exponential tumor growth and metastasis to distal tissues and the collapse of anti-tumor immunity. Many useful animal models exist to study breast cancer, but none completely recapitulate the disease progression that occurs in humans. In order to gain a better understanding of the cellular interactions that result in the formation of latent metastasis and decreased survival, we have generated an inducible transgenic mouse model of YFP-expressing ductal carcinoma that develops after sexual maturity in immune-competent mice and is driven by consistent, endocrine-independent oncogene expression. Activation of YFP, ablation of p53, and expression of an oncogenic form of K-ras was achieved by the delivery of an adenovirus expressing Cre-recombinase into the mammary duct of sexually mature, virgin female mice. Tumors begin to appear 6 weeks after the initiation of oncogenic events. After tumors become apparent, they progress slowly for approximately two weeks before they begin to grow exponentially. After 7-8 weeks post-adenovirus injection, vasculature is observed connecting the tumor mass to distal lymph nodes, with eventual lymphovascular invasion of YFP+ tumor cells to the distal axillary lymph nodes. Infiltrating leukocyte populations are similar to those found in human breast carcinomas, including the presence of &#945;&#946; and &#947;&#948; T cells, macrophages and MDSCs. This unique model will facilitate the study of cellular and immunological mechanisms involved in latent metastasis and dormancy in addition to being useful for designing novel immunotherapeutic interventions to treat invasive breast cancer.

Activation of latent mutations with adenovirus-Cre into the mammary ductal system results in a clinically relevant metastatic breast cancer. Incorporation of a YFP promoter allows tracking of distal metastatic tumor cells. This model is useful to study latent metastasis, anti-tumor immunity, and for designing novel immunotherapies to treat breast cancer.

Breast cancer is a heterogeneous disease involving complex cellular interactions between the developing tumor and immune system, eventually resulting in ...

Topical Airway Anesthesia for Awake-endoscopic Intubation Using the Spray-as-you-go Technique with High Oxygen Flow

A patient&#39;s willingness to cooperate is an absolute precondition for successful awake intubation of the trachea. Whilst drug-sedation of patients can jeopardize their spontaneous breathing, topical anesthesia of the airway is a popular technique. The spray-as-you-go technique represents one of the simplest opportunities to anesthetize the airway mucosa. The application of local anesthetic through the working channel of the flexible endoscope is a widespread practice for anesthetists as well as pulmonologists. There is neither need for additional devices nor special training as a pre-requisite to perform this technique. However, a known clinical problem is the coughing and gagging reflex that may occur when the liquid anesthetic strikes the airway mucosa and other sensitive structures like the vocal cords. This can be avoided by the use of oxygen applied through the working channel with the aim of fogging the local anesthetic into finer particles. Furthermore, the oxygen flow provides a higher oxygen supply and contributes to a better view, dispersing mucus secretions and blood away from the lens. Using an atomizer with a high oxygen flow of 10 L/min we maximized these benefits, caused less coughing and had more satisfied and therefore cooperative patients. Possible, but very rare complications of using oxygen flow including gastric insufflation, organ rupture or barotrauma did not arise. We attribute the complication-free use of high oxygen flow to the design of the set, which permits flow and pressure release.

The topical anesthetic lidocaine was atomized using a high oxygen flow through the working channel of a flexible intubating endoscope to achieve topical airway anesthesia for awake endotracheal intubation. We prefer this modified spray-as-you-go technique for endoscopic intubation to classical bolus application because of higher patient satisfaction and better compliance.

A patient&#39;s willingness to cooperate is an absolute precondition for successful awake intubation of the trachea. Whilst drug-sedation of patients can ...

Generating a Murine Orthotopic Metastatic Breast Cancer Model and Performing Murine Radical Mastectomy

In vivo mouse models to assess breast cancer progression are essential for cancer research, including preclinical drug developments. However, the majority of the practical and technical details are commonly omitted in published manuscripts which, therefore, makes it challenging to reproduce the models, particularly when it involves surgical techniques. Bioluminescence technology allows for the evaluation of small amounts of cancer cells even when a tumor is not palpable. Utilizing luciferase-expressing cancer cells, we establish a breast cancer orthotopic inoculation technique with a high tumorigenesis rate. Lung metastasis is assessed utilizing an ex vivo technique. We, then, establish a mastectomy model with a low local recurrence rate to assess the metastatic tumor burden. Herein, we describe, in detail, the surgical techniques of orthotopic implantation and mastectomy for breast cancer with a high tumorigenesis rate and low local recurrence rates, respectively, to improve breast cancer model efficiency.

We introduce a murine orthotopic breast cancer model and radical mastectomy model with bioluminescence technology to quantify the tumor burden to mimic human breast cancer progression.

In vivo mouse models to assess breast cancer progression are essential for cancer research, including preclinical drug developments. However, the majority ...

Modified Single-Loop Reconstruction for Pancreaticoduodenectomy

Modified single-loop reconstruction in pancreaticoduodenectomy separates pancreatic secretion from bile. It is performed in cases of high-risk pancreatic remnants to reduce the severity of postoperative pancreatic fistulas and moreover the overall postoperative morbidity. This reconstruction technique is characterized by an extra-long jejunal loop for the construction of the pancreaticojejunostomy and hepaticojejunostomy. The longer distance between these anastomoses and an additional jejuno-jejunostomy between the afferent and efferent limb of the hepaticojejunostomy separate the fluids and prevent backflow of bile towards the pancreaticojejunostomy. Thus, the secretions cannot activate each other and aggravate an existing anastomotic leakage. We observed a reduced rate of severe postoperative pancreatic fistulas after modified single-loop reconstruction compared to conventional single loop reconstruction. The technique is easy to perform, safe, and less time-consuming than a traditional double-loop reconstruction.

The technique of modified single-loop reconstruction following pancreaticoduodenectomy separates pancreatic secretion from bile, thus reducing the severity of POPF without prolonging the duration of surgery.

Modified single-loop reconstruction in pancreaticoduodenectomy separates pancreatic secretion from bile. It is performed in cases of high-risk pancreatic ...

Fully Endoscopic Mitral Valve Repair with Percutaneous Cannulation of Groin Vessels

Endoscopic mitral valve surgery (EMS) has become a standard of care at specialized heart centers, further reducing surgical trauma compared to a traditional minimally invasive, thoracotomy-based approach. Exposure of the groin vessels for the establishment of cardiopulmonary bypass (CPB) via surgical cutdown in minimally invasive surgery (MIS) may result in wound healing disorders or seroma formation. The avoidance of surgical exposure of the groin vessels by using fully percutaneous techniques for the insertion of a CPB cannula with the implementation of vascular pre-closure devices has the potential to reduce these complications and improve clinical results. Herein, we present the utilization of a novel plug based vacsular closure device with a resobable collagen plug and the absence of suture material for closure of the arterial access for CPB in MIS. While this device was initially predominantly used in transcatheter aortic valve implantation (TAVI) procedures, with its safety and feasibility shown, we herein show that it can be used in CPB cannulation, since it is capable of closing arterial access sites up to 25 French (Fr.) in size. This device may be suitable to significantly reduce groin complications in MIS and simplify the establishment of CPB. Here, we describe the fundamental steps of EMS, including percutaneous groin cannulation and decannulation using a vascular closure device.

This protocol demonstrates in detail how to perform fully endoscopic mitral valve surgery (EMS) with percutaneous cannulation of the groin vessels, using a percutaneous plug-based vascular closure device. Fundamental steps and useful instructions are described in detail for each step.

Endoscopic mitral valve surgery (EMS) has become a standard of care at specialized heart centers, further reducing surgical trauma compared to a ...

Transoral Robotic Total Thyroidectomy and Bilateral Central Regional Lymph Node Dissection for Papillary Thyroid Carcinoma

Currently, the common approaches to thyroid surgery include conventional thyroidectomy, bilateral axillo-breast, axillary, retroauricular, and oral vestibule approaches. Essentially, various approaches to thyroid surgery only move the traditional surgical incision to a more concealed position but still leave scars on the body surface. Among them, thyroid surgery via the oral vestibule approach can obtain the best cosmetic outcome through the shortest natural cavity. However, in the early time, thyroid surgery via the oral vestibule approach usually requires three incisions in the mouth and one axillary incision. We have introduced a robotic surgical system into thyroidectomy via the oral vestibule approach and successfully completed total thyroidectomy and bilateral central lymph node dissection. During the operation, only three incisions were made at the oral vestibule without an axillary incision. This article aims to present the unique three-port method of robotic thyroidectomy via oral vestibule for the treatment of patients with papillary thyroid cancer.

The transoral robotic total thyroidectomy and bilateral central regional lymph node dissection using three ports without axillary incision are feasible and safe for early-stage papillary thyroid carcinoma. Here we present the operative techniques of this operation.

Currently, the common approaches to thyroid surgery include conventional thyroidectomy, bilateral axillo-breast, axillary, retroauricular, and oral ...

Gasless Endoscopic Thyroidectomy via the Trans-Axillary Approach

For patients with early, low-risk papillary thyroid carcinoma, an increasing number are opting for endoscopic thyroid surgery due to its ability to achieve favorable therapeutic outcomes while maintaining excellent cosmetic results. Among the available endoscopic procedures, the Gasless Endoscopic Thyroidectomy Trans-axillary Approach (GETTA) has gained popularity among surgeons. This is attributed to its straightforward cavity construction, spacious operating area, precise visual field exposure, and manageable learning curve. However, few studies have provided detailed descriptions of the specific surgical steps involved in GETTA. Drawing from a synthesis of existing literature and our own clinical expertise, we present a comprehensive outline of the GETTA procedure. This process can be categorized into five distinct stages: positioning and incision planning; establishment of surgical cavities; identification and protection of the recurrent laryngeal nerve, inferior parathyroid gland, and central neck dissection; localization and preservation of the superior laryngeal nerve, superior parathyroid gland, and dissection of the thyroid's superior pole; transection of the thyroid isthmus followed by en bloc resection of the thyroid gland and central neck lymph nodes. The five-step approach of GETTA is easy to learn and can be adapted for resecting both benign and malignant thyroid and parathyroid diseases.

Gasless Endoscopic Thyroidectomy via the Trans-Axillary Approach

This protocol presents the procedure for conducting thyroidectomy using the gasless endoscopic thyroidectomy trans-axillary approach (GETTA).

For patients with early, low-risk papillary thyroid carcinoma, an increasing number are opting for endoscopic thyroid surgery due to its ability to ...

Strategies for Efficient Vascular Anastomosis in Mouse Liver Transplantation

Vascular Reconstruction with the Cuff Technique in Mouse Orthotopic Liver Transplantation

Mouse orthotopic liver transplantation is an effective methodology for investigating the underlying mechanisms of liver ischemia and reperfusion injury. However, the technical challenges pose a barrier to utilizing this valuable experimental model and passing on these skills to the next generation. The most challenging aspect of this procedure is vascular reconstruction, including the portal vein (PV), infrahepatic inferior vena cava (IHIVC), and suprahepatic inferior vena cava. The use of plastic cuffs, rather than sutures, allows for smoother PV and IHIVC reconstruction. Vessels are reconstructed by attaching a cuff made from an intravenous catheter to the tip of the graft vessel and interposing the cuff into the recipient vessel. The two most crucial aspects are properly visualizing the inner lumen of the vessel and avoiding the use of excessive force. Our aim is to provide a technical overview of vascular reconstructions using the cuff technique in recipient surgery. These technical tips for the cuff technique are expected to help microsurgeons facilitate vascular reconstruction and advance their research.

Author Spotlight: Exploring Cold Ischemia and Warm Reperfusion Injury in Fatty Liver Transplantation

This protocol provides technical information for vessel reconstruction using the cuff technique in mouse orthotopic liver transplantation.

Mouse orthotopic liver transplantation is an effective methodology for investigating the underlying mechanisms of liver ischemia and reperfusion injury. ...