**4. Future possibilities**

As techniques continue to be refined for both minimally invasive mastectomy and minimally invasive flap harvest, the next natural step may be to combine the two. In 2020, French surgeons published their experience with combined robotic mastectomy and robotic pedicled LD flap harvest [28]. In their cohort, 35 patients underwent both robotic NSM and robotic LD flap harvest. Similar to the technique outlined above, they used a gel mono-trocar device placed via a 4-6 cm incision in the anterior axillary line. They dissected and removed the breast parenchyma then repositioned and used the same incision and trocar to mobilize the latissimus muscle. The muscle was then transposed and appropriately fixated the chest wall within the mastectomy cavity with or without an underlying implant.

Another permutation of this could combine robotic mastectomy with free flap breast reconstruction. A major limitation to this approach is the requirement for the surgical robot to have the capability to perform microvascular anastomosis. Currently, the dominant robotic system, the da Vinci surgical system, has optics and instruments that were not designed for tissue handling at this scale. Recently two robotic systems dedicated to microsurgery have been developed: MUSA by MicroSure and Symani by MMI [29]. These robots have the ability to handle delicate tissue all while eliminating tremor and providing motion scaling. This is a crucial advance, not only for microsurgery, but for the ability to perform supermicrosurgery which is defined as connecting vessels between 0.3 and 0.8 mm, commonly required during lymphedema surgery. Preclinical studies of the MUSA system illustrated that it is possible to use this platform to perform microsurgical anastomosis although overall time for anastomosis completion was longer and dexterity scores were lower using the robot compared to manual microsurgical anastomosis [30].

The first-in-human use of MUSA system to perform supermicrosurgical lymphovenous anastomosis (LVA) for the treatment of lymphedema was reported by a group in the Netherlands in 2020 [31]. They randomized 20 patients to robotic versus manual LVA. In this initial study, time to perform supermicrosurgical anastomosis was shorter in the manual group; however, they did note a steep decline in

#### *Minimally Invasive Surgery in Breast Reconstruction: The Past and Future DOI: http://dx.doi.org/10.5772/intechopen.109503*

the time required for robotic-assisted LVA during the course of the study. All LVA's were patent at the end of the procedure. Additionally, no adverse events occurred attributable to use of the surgical robot during the procedure; therefore, the authors concluded that use of the platform for supermicrosurgical anastomosis was feasible and safe. Subsequent studies by other groups using the Symani robot have seen similar promising results [32].

Whether these microsurgical robots will be integrated into simultaneous robotic mastectomy and breast reconstruction remains to be seen. Unlike the da Vinci surgical robot, they were designed to maximize surgeon precision while operating on minute and delicate structures rather than to minimize the invasiveness of the procedure. Thus, in their current iteration, they are ideal for open surgery, but their utility may be limited in a deep body cavity.

## **5. Conclusions**

While initial studies evaluating minimally invasive techniques for breast cancer surgery and breast reconstruction illustrate their feasibility, their use remains controversial. Studies of rNSM consistently report low rates of mastectomy flap compromise and high patient satisfaction, yet the primary goal of the operation is oncologic control. At this time, the number of patients who have undergone this procedure is low and the length of follow-up short. Further studies will be needed to decisively establish the oncologic safety of this approach [33]. Similarly, larger studies and longer follow-up will be required to fully see the effect of minimally invasive flap harvest on donor site morbidity.

Another concern is the cost associated with the use of the surgical robot. This includes the cost of the console, disposable instrumentation, service contracts, and the operative time associated with a longer operative procedure. These costs may be offset by shortened hospital length of stay, but that has yet to be seen in any of the studies cited above. Laparoscopy is less expensive compared to the surgical robot; however, laparoscopy is more difficult in a small operative space as the instruments only provide 4-degrees of freedom of movement compared to the 7-degrees of freedom afforded by the da Vinci platform.

There is a learning curve that will have to be addressed prior to any surgeon attempting to perform these minimally invasive techniques. As most plastic surgery trainees complete integrated residency programs, they seldom encounter cases using laparoscopy or the surgical robot beyond the early years of their training, thus they are unlikely to have the opportunity to become proficient. Even breast surgeons, who must complete a residency in general surgery, may have variable exposure as robotic skills as these are not currently required for board certification unlike laparoscopy and endoscopy. This challenge is not insurmountable as numerous studies have shown rapid skill acquisition and validated tools have been developed to assess robotic microsurgical skill [25, 34].

In summary, minimally invasive breast cancer surgery and breast reconstruction is currently only offered at select centers. Further studies regarding the safety and efficacy of these techniques as well as surgeon training will be required before they are likely to gain widespread adoption. If this occurs, minimally invasive breast cancer surgery and reconstruction can truly serve as the next step in the quest for a further reduction in surgical morbidity and improved patient outcomes beyond the current standard of care.
