Retromammary Approach for Video-assisted Endoscopic Resection of Benign Breast Tumors: Report of two Cases

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1 160 Formos J Surg 2009;42: Case Reports Retromammary Approach for Video-assisted Endoscopic Resection of Benign Breast Tumors: Report of two Cases Hsien Liu 1,2, Su-Chun Ng 1, Chih-Kun Huang 1, Chao-Ming Hung 1,Yaw-Sen Chen 1 Traditional breast surgery always leaves a scar not only on the breast but also on the mind of the patient. Endoscopic breast surgery, which was initially in cosmetic surgery, has made great progress in the past 10 years, and now is applied to resection of breast lesions, benign or malignant, in Western countries as well as in Asian countries, e.g., Japan, China mainland, Korea, and Hong Kong. In these previous reports, excellent cosmetic outcomes were achieved. Nevertheless, to the best of our knowledge, there are no such articles published in Taiwan. We hereby describe successful extirpation of multiple or large benign breast tumors in two young female patients, using endoscopic devices through a retromammary space approach. The patients were greatly satisfied with this method because of the final result of scar-free breasts. Video-assisted endoscopic breast surgery has made a great contribution to breast operations, and produces cosmetic effects that cannot be achieved by traditional surgery. Patients with multiple or large benign tumors, especially young females, are good candidates for this surgery. Key words: benign breast tumors, endoscopic surgery, cosmesis Endoscopic surgery has been well-established in abdominal surgery and chest surgery. A characteristic of endoscopic breast surgery that differentiates it from laparoscopic and thoracoscopic surgery is the creation of adequate operative working space. The early articles on the use of endoscopic surgery in breast-related operations were written by Kompatscher1 and Johnson et al 2, who performed breast augmentation via transumbilical insertion of saline-filled breast implants. Since then, endoscopic surgery has also been applied to deal with breast lesions. And due to great improvement of devices and technique, videoassisted endoscopic breast surgery has made great progress in Western countries as well as in Asian countries in the last decade. However, there were no written papers related to this field in Taiwan. Therefore, we would like to share our preliminary experience in this communication. Case Report Case 1 A 31-year-old Taiwanese woman in good condition came to our outpatient department due to two palpable masses inside her left breast. The tumors had been From the 1 Department of Surgery, E-DA Hospital / I-Shou University, 2 Department of Biological Sciences, National Sun Yat-Sen University, Kaohsiung County, Taiwan Received: August 26, 2008 Accepted: February 10, 2009 Address reprint request and correspondence to: Dr. Chao-Ming Hung, Department of Surgery, E-DA Hospital / I-Shou university, 1, Yi- Da Road, Jiau-shu Tsuen, Yan-chau Shiang, Kaohsiung County, Taiwan, Tel: ext 2976, Fax: , ed100459@edah.org.tw

2 Liu H, Ng SC, Huang CK, et al 161 present for more than two years. One tumor measured cm and was located at 5 o clock, 5 cm away from the nipple, and the other measured 2.1 x1.8 x1.0 cm and was located at 8 o clock, 7 cm away from the nipple, as indicated by breast ultrasound (Fig 1A). On palpation, the masses were smooth, elastic, mobile and tender. Breast sonography and fine needle aspiration cytology revealed benign lesions. On account of enlargement and mild pain, excision of these tumors was recommended. The patient expressed serious concern of the outer appearance of her breast. She wished to maintain a scarless breast. After obtaining informed consent, we performed excision of the breast masses via the endoscopic approach. Case 2 A 28-year-old unmarried Taiwanese woman came to our outpatient department due to one palpable mass inside her left breast. The mass had been present for more than 5 years. We found a bulging mass in the upper outer quardrant of the breast while perfoming physical examination (Fig 2). The tumor measured cm diameter, and was located at 2 o clock, 4 cm away from the left nipple by physical examination and breast ultrasound. We also performed fine needle aspiration cytology to rule out malignancy. Because of enlargement, excision of the tumor was also recommended. The patient also expressed serious concern of the outer appearance of her breast after operation because she planned to marry three months later. After obtaining informed consent, video-assisted endoscopic extirpation of the breast tumor was performed. Surgical procedure and result Under general anesthesia, the patients were placed in a left hemiventral decubitus position. A 12-mm incision was made at the left mid-axillary line, then two 5-mm incisions were made at the anterior axillary line, with one on the cranial side of the 12-mm incision and the other on the caudal side (Fig 3A). Then the 12-mm incision was further dissected. A Visiport was inserted via a 12-mm incision into the retromammary space under videoassistance. The dissecting balloon (Fig 3B) was inserted via the 12-mm incision into the retromammary space to dissect,and pressure was gradually applied by insufflating several times with an accompanying pump. After compression of the entire dissected area for approximately 3 minutes, the balloon was deflated and removed. A blunt-tip balloon trocar (Fig 3B) was inserted via the 12-mm incision, a CO2 tube was connected to the port, and the dissected space was insufflated at pressure of 8mmHg. The 5-mm 0 rigid scope was inserted from the trocar to check the dissected retromammary space (Fig 4A). Two 5-mm trocars were inserted via the previous 5-mm incisions into the dissected space. The retromammary space was further dissected to approach the tumor. The locations of tumors were identified by palpation, Fig 1. (A) Photograph of left breast, Case 1. (B) Gross appearance of left breast after operation, Case 1. Fig 2. Photograph of left breast, Case 2. Formos J Surg No 3

3 162 Retromammary Endoscopic Breast Surgery Fig 3. (A) PDB (Preperitoneal dissection balloon) system (Tyco.) (right) 10-mm Blunt tip balloon trocar (Tyco.) (left) (B) Locations of port sites. Black arrow shows location of 12-mm incision in mid-axillary line and white arrows shows locations of 5-mm incisions in anterior axillary line. Fig 4. (A) Endoscopic visual field of retromammary space. P: pectoral major muscle; B: breast tissue (B) Dissection of intra-mammary tumor (left breast in Case 2). T: tumor; B: breast tissue. and intra-operative ultrasound. Then under videoassistance, we dissected the tumors with 5-mm grasping forceps, a monopolar coagulator, and a harmonic scalpel (Fig 4B). The resected masses were directly pulled out through the 12-mm incision. In case II, the mass was too large to pull out, so we put a small plastic bag into the dissected space. And the tumor was put into the bag and divided, then pulled out with the bag. After adequate hemostasis, one small drain tube was inserted into the retromammary space via one 5-mm incision. All incisions were closed with intradermal sutures. The pathologic reports showed that these tumors in both cases were fibroadenomas. The operative time was 120 minutes for case 1 and 100 minutes for case 2. Overall blood loss was minimal. There were no postoperative complications such as subcutaneous emphysema, subcutaneous hemorrhage, arm pain or skin burn in these cases (Fig 1B). The patients merely felt mild wound pain after operation. The patients were discharged on post-operative day 1. They returned to the clinic for follow-up and the wound became almost invisible later. The patients were extremely satisfied with the cosmetic result of the procedure. The two patients have been followed with an ultrasound scan and physical examination every 3 months, and after 15 months they are free of recurrence of the breast neoplasm. The scar-free cosmetic appearance of the breasts has been well maintained after the operations. Discussion Cosmetic factors in the traditional surgical treatment of breast diseases have long been neglected despite the fact that patients are highly concerned about the length of the incision. One of the advantages of endoscopic surgery is that it can be performed through a small remote incision made in an inconspicuous region. In endoscopic breast surgery, we can hide the incision in the axillary area. The wound was invisible from the front. Kitamura et al. 3 performed endoscopic extirpation of

4 Liu H, Ng SC, Huang CK, et al 163 benign breast tumors via an extra-mammary incision on 6 patients. The average operation time was 3 hours and 20 minutes. As for our cases, they were seen in our early experience, and therefore the total operating time was relatively long (around 100~120 minutes), slightly longer than in traditional breast surgery, but we believe that the time will be shortened after overcoming the leraning curve. This hasbeen observed in other types of endoscopic surgery. The good cosmetic results and patient s satisfaction justify the time and effort spent to perform endoscopic breast excision. Luo CY et al 4 reported on 72 benign breast masses of 64 patients were mastoscopically extirpated under local venous anesthesia. In our cases, the patient received general anesthesia due to extensive dissection of the retromammary space. We use such an approach mainly to larger breast tumors, usually those larger than 3 centimeters. In these patients, general anesthesia is justified. Otherwise we do not expose our patients to additional anesthesia risk. According to Osanai et al, 5 the advantage of the retromammary space approach is that the tumor can be reached by securing a working space with this technique, regardless of the location of the tumor. In our cases, the tumors were located at the inferior outer quardrant and inferior inner quardrant of the left breast in case I, and upper outer quardrant in case II, and we were able to extirpate these tumors at different locations simultaneously without limitation. As in other types of endoscopic surgery, the post-operative pain is mild without necessity for strong analgesia. In our cases, all the breast tumors were fibroadenomas. With suspected phyllodes tumors, the resected mass should include a thin normal tissue cuff around the tumor. The resected margin may be defined by fine needle localization and ultrasound during operation. In some previous articles, 6~13 endoscopic breast surgery was also applied to the treatment of early stage breast cancer. This type of surgery produces good cosmetic results, but the long-term oncologic effects need further investigation. Before overcoming the leraning curve, we focus the operation on benign lesions at present. Other new techniques, such as radiofrequency ablation (RFA) and surgery with the mammotome have also been applied to treat benign breast tumors. Both the techniques are minimally invasive and almost scar-free, but the capability of the methods in dealing with larger tumors is limited. With endoscopic breast surgery, we can excise larger tumors without limitation. In order to keep pace with the evolution of surgical techniques in the modern countries, endoscopic breast surgery should be welcomed and accepted in combination with conventional methods to nurture and further improve the technical aspects of surgery, instead of being regarded as a competing technology. Endoscopic breast surgery is expected to become an indispensable and integral part of breast surgery in the near future, especially in an era with higher feminine self-awareness. Patients with multiple or large benign tumors, especially young females, are good candidates for this surgery. References 1. Kompatscher P: Endoscopic capsulotomy of capsular contracture after breast augmentation: a very challenging therapeutic approach. Plast Reconstr Surg.1992;90: Johnson GW, Christ JE: The endoscopic breast augmentation : the transumbilical insertion of saline-filled breast implants. Plast Reconstr Surg.1993;92: Kitamura K, Hashizume M, Sugimachi K, et al: Early experience of endoscopic extirpation of benign breast tumors via an extra-mammary incision. Am J Surg.1998;176: Luo CY, Xue L, Lin H, et al: Mastoscopic extirpation of benign breast masses by small and concealing incision. Zhonghua Yi Xue Za Zhi. 2003;83: Osanai T, Nihei Z, Ichikawa W, et al: Endoscopic resection of benign breast tumors: Retromammary space approach. Surg Laparosc Endosc Percutan Tech 2002;12: Tamaki Y, Nakano Y, Sekimoto M, et al: Transaxillary endoscopic partial mastectomy for comparatively early-stage breast cancer. An early experience. Surg Laparosc Endosc 1998;8: Tamaki Y, Sakita I, Monden M: Endoscopic partial mastectomy for breast cancer. Nippon Rinsho. 2000;58: Tamaki Y, Sakita I, Miyoshi Y, et al: Transareolar endoscopyassisted partial mastectomy: a preliminary report of six cases. Surg Laparosc Endosc Percutan Tech. 2001;11: Kitamura K, Ishida M, Inoue H, et al: Early results of an endoscope-assisted subcutaneous mastectomy and reconstruction for breast cancer. Surgery. 2002;131(1 Suppl):S Owaki T, Yoshinaka H, Ehi K, et al: Endoscopic quadrantectomy for breast cancer with sentinel lymph node navigation via a small axillary incision. Breast.2005;14: Fukuma E: Endoscopic breast surgery for breast cancer. Nippon Geka Gakkai Zasshi. 2006;107: Lee EK, Kook SH, Park YL, et al: Endoscopy-assisted breastconserving surgery for early breast cancer. World J Surg. 2006;30: Yamashita K, Shimizu K: Endoscopic video-assisted breast surgery: procedures and short-term results. J Nippon Med Sch. 2006;73: Formos J Surg No 3

5 164 Retromammary Endoscopic Breast Surgery 1, standard procedure