A novel surgical technique of use of the Goligher self-retaining retractor for microvascular anastomosis in reconstruction after minimally invasive mastectomy

Introduction

Background

Minimally invasive breast surgery (MIBS) techniques (1-4) have transformed the landscape of breast cancer surgery, aiming to achieve both oncological margins and aesthetic outcomes for patients. Autologous reconstruction is now recognised to have the most natural aesthetics and tactile results, and the free abdominal-based perforator flap has become the preferred method that allows close-to-ideal breast defect restoration. These techniques more commonly include mammary prostheses (5-7), lipofilling, omental flap reconstruction (8), latissimus dorsi flap reconstruction (9,10), deep inferior epigastric perforator (DIEP) flap (11), or a combination of methods (12).

Rationale

On the other hand, MIBS with immediate free abdominal-based perforator flap reconstruction has not been robustly explored because of two major limitations of the minimal-access approach: challenges with flap inset and shaping and the need for access to recipient vessels for microvascular anastomoses, namely the internal mammary artery (IMA), thoracodorsal (TD), or lateral thoracic artery. Meticulous execution of microvascular anastomosis is critical to successful breast reconstruction with free abdominal-based perforator flaps following mastectomy. However, achieving optimal exposure during this intricate phase remains a challenge with traditional retractors, which can affect precision and efficiency required. In response to this challenge, we propose a novel approach of using the Goligher self-retaining retractor for microvascular anastomosis in MIBS reconstruction.

Objective

With the use of the Goligher self-retaining retractor for microvascular anastomosis in MIBS reconstruction, we seek to address the challenge providing a steady and optimal exposure for micro-vascular anastomosis in the smaller operative field of post-minimally invasive mastectomy reconstruction. We present this article in accordance with the SUPER reporting checklist (available at https://gs.amegroups.com/article/view/10.21037/gs-24-262/rc).

Preoperative preparations and requirements

Instruments required for the set up (Figure 1) include the Goligher blade, Goligher bar, clamp for the Goligher bar, Kocher’s forceps and nylon tape.

Figure 1 Instruments required for set up (from left to right): Goligher retractor, Kocher’s forceps, Goligher bar, and clamp for Goligher bar.

Prior to surgery, the reconstructive surgeon and breast surgeon should discuss and confirm the marking of the incision. In order to access the IMA pedicle, an incision at the medial inframammary fold (IMF) is preferred. At the start of the surgery, the patient is positioned supine with an axillary roll, and a vertical Goligher bar is secured to the operating table on the contralateral side of the planned breast reconstruction (Figure 2), above the level of the patient’s shoulder. This would later help to ensure optimal access and minimise interference with the operating field. The patient is cleaned and draped, with sterile drapes covering the bar.

Figure 2 Goligher bar secured to operating table.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patients for publication of this article and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Step-by-step description

After the completion of endoscopic mastectomy, the Goligher blade is used to retract the superior skin flap at the IMF from the upper medial quadrant of the breast (Figure 3) and adjusted accordingly to allow optimal exposure of the operative field. It is then anchored tightly to the bar positioned on the contralateral side of the reconstruction via its accompanying chain with a nylon tape. This is further reinforced with a Kocher’s forceps to clamp the nylon tape in place, ensuring a steady, consistent sustained retraction to facilitate the microvascular anastomosis. The main surgeon is positioned on the ipsilateral side of the resection, with the assistant on the opposite side. We recommend positioning the microscope behind the assistant (Figure 4) as this allows the main surgeon more space for maneuvering. Alternatively, should there be space constraints, the microscope can also be positioned behind the main surgeon (Figure 5). After an optimal view is achieved, the IMA and accompanying veins are identified within the mastectomy via careful dissection. A 1 cm segment of rib is excised to allow a window for exposure and skeletonisation of the IMA pedicle.

Figure 3 Superior skin flap retracted along inframammary fold for optimal exposure of operative field.

Figure 4 Suggested operating room set up.

Figure 5 Alternative operating room set up.

We have adopted this technique in our institution for 6 patients post endoscopic total mastectomy. The average ischaemic time was 37.3 minutes (range, 22–50 minutes). 1 case required re-exploration, no flap failure occurred and no nipple/skin ischaemia/necrosis occurred. Our surgeons reported enhanced visibility, leading to more precise suturing and reduced operative times.

Postoperative considerations and tasks

After the microvascular anastomosis is completed, the Goligher retractor should be carefully removed to avoid disrupting the anastomosis. The anastomosis should be checked for lie and for any kinking that can affect the outcome of the flap.

Tips and pearls

However, should the surgeon require adjustment during the process for visibility and ease of surgery, adjustments can be easily made to the angle and position of the blade by releasing the attachments to the bar to allow adjustment before re-securing the blade to the bar. This provides opportunity for customisation and adjustments till the operative field is optimal.

Discussion

Surgical highlights

The adoption of the Goligher self-retaining retractor in microvascular anastomosis for abdominal-based flap breast reconstruction through an IMF incision introduces novel approach to optimizing surgical exposure. This technique leverages on the unique design of the Goligher retractor to enhance the surgeon’s ability to perform microvascular anastomosis.

Strengths and limitations

One of the key advantages of this self-retaining retractor is the stable and consistent retraction provided, which creates a suitable environment for microvascular anastomosis. The blade is securely attached to the Goligher bar, which is anchored to the bed, without the need for a human assistant who may eventually tire out during this process. In addition, by placing the Goligher bar on the contralateral side, we minimise interference with the surgical field and movement of the surgeon, enabling good access to the vascular pedicle. By positioning the vertical Goligher bar above the patient’s shoulder, the assistant microsurgeon is still able to use the operative microscope and assist in the microsurgery.

Comparison with other surgical techniques and researches

This method provides a continuous and steady retraction, doing away with the need for an assistant who may eventually tire out and affect the optimal view obtained at the start of positioning for micro-vascular anastomosis.

Implications and actions recommended

The Goligher retraction system is also available in most general surgery units, and this obviates the need to purchase specialized equipment to perform microsurgical anastomosis via the IMF incision.

Conclusions

In conclusion, using the Goligher self-retaining retractor for microvascular anastomosis during abdominal-based flap breast reconstruction through an inframammary incision represents an innovative approach that enhances exposure, precision and perhaps surgical outcomes in post-MIBS reconstruction.

Acknowledgments

Funding: None.

Footnote

Reporting Checklist: The authors have completed the SUPER reporting checklist. Available at https://gs.amegroups.com/article/view/10.21037/gs-24-262/rc

Peer Review File: Available at https://gs.amegroups.com/article/view/10.21037/gs-24-262/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://gs.amegroups.com/article/view/10.21037/gs-24-262/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patients for publication of this article and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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