Safety and efficacy of robot-assisted latissimus dorsi flap harvesting for immediate partial breast reconstruction following breast-conserving surgery

Introduction

Robot-assisted surgery has gained increasing popularity, driven by continual advancements in surgical techniques, improved ergonomics of robotic arms, and the development of supportive surgical instruments (1-3). The evolution of breast reconstruction techniques reflects a response to patients’ desires for aesthetically pleasing and natural-looking results. In this regard, considerable attention has been directed towards robot-assisted breast reconstruction methods using autologous tissue, with the latissimus dorsi muscle flap (LDMF) emerging as one of the favored techniques.

The traditional open approach for LDMF harvesting involves a lengthy incision, resulting in an unsightly scar. Consequently, efforts have been made to employ minimally invasive techniques to mitigate postoperative scarring. The laparoscopic approach for LDMF harvesting was first published in 1990 (4,5) and robot-assisted LDMF harvesting was introduced by Selber et al. (1) in 2012. Subsequently, in 2015, Chung et al. (6) reported an alternative method utilizing gasless robot-assisted LDMF harvesting.

From November 2016 to December 2019, the author carried out endoscopic LDMF harvests for immediate reconstruction in 16 female patients who had undergone partial mastectomy for breast cancer (7). Based on this experience, the author proceeded to using robot-assisted technique for immediate breast reconstruction. This has technical advantages over endoscopic techniques and cosmetic advantages over open methods. Accordingly, the objective of this research is to assess whether robot-assisted LDMF harvest can be safely and effectively utilized for immediate breast reconstruction following partial mastectomy in breast cancer patients. This article is presented in accordance with the SUPER reporting checklist (available at https://gs.amegroups.com/article/view/10.21037/gs-2025-226/rc).

Preoperative preparations and requirements

Study design and sample

This was a retrospective analysis of the medical records of 27 women who underwent immediate reconstruction after partial mastectomy, using robot-assisted LDMF harvesting at our hospital, between August 2019 and April 2024. The following variables were extracted for analysis: patient demographic characteristics, histopathologic tumor factors, operative data, postoperative complications, self-reported satisfaction with cosmesis, and oncologic safety. All procedures performed in this study were in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by the Institutional Review Board of Pusan National University Hospital (IRB No. 210-025-099). Publication of this article and accompanying images was waived from patient consent according to the Pusan National University Hospital Institutional Review Board because the study was retrospective in nature and all patient data were anonymized prior to analysis.

Indications for robot-assisted LDMF harvesting

Robot-assisted LDMF harvesting was indicated for patients who required immediate reconstruction after partial mastectomy, preferred autologous reconstruction, wished to avoid a back incision scar, and had no nipple infiltration. For small-volume resections, oncoplastic local tissue rearrangement was indeed considered. However, all patients included in this study either refused volume displacement techniques or preferred autologous reconstruction without additional scarring.

Preoperative evaluation

Tumor and breast volumes were estimated preoperatively using mammography, ultrasound, magnetic resonance imaging (MRI) and clinical examination. Full LDMF harvesting was selected to ensure sufficient tissue volume and flap perfusion. Split-LDMF techniques were not applied, as robotic articulation currently limits precise control for partial flaps.

Step-by-step description

Surgical techniques

The DA Vinci^® Si or Xi surgical system (Intuitive Surgical, Sunnyvale, CA, USA) was used for LDMF harvesting. All partial mastectomy and breast reconstruction procedures were performed by the same breast surgeon.

Preparation process before robot docking

Prior to the surgery, the areas for the partial mastectomy and LDMF harvesting were marked. An incision line with a gentle curve, spanning 7 to 8 cm, was designated in the axillary area (Figure 1A). Following induction of general anesthesia, patients were positioned supine with their arms extended laterally at a 90-degree angle. An incision was created in the axillary area following the pre-marked curve to perform an open partial mastectomy accompanied by either sentinel lymph node biopsy or axillary lymph node dissection (Figure 1A). After a partial mastectomy, the surgical cavity was packed with gauze. The anterior border of the latissimus dorsi muscle (LDM), thoracodorsal vessels, and nerves were then identified (Figure 1B). The thoracodorsal vascular bundle was localized, and the anterior margin of the LDM was surgically separated. To prevent muscle atrophy, the humeral insertion of the flap and thoracodorsal nerve was preserved without ligation or division. As depicted in Figure 1B, maximal preliminary separation of the LDMF was performed via an open approach to simplify subsequent robotic-assisted dissection.

Figure 1 Preparatory steps for LDMF harvesting. (A) Preoperative skin markings. Multiple tumors in the upper part of the right breast, extent of partial mastectomy, and a skin incision line in the axilla region are marked. (B) Anterior border of the latissimus dorsi muscle. Surgical forceps are pointing at the anterior border of the partially separated latissimus dorsi. (C,D) Position changes for LDMF harvesting. In the lateral decubitus position, the patient’s upper arms were positioned near the head of the patient. (E,F) The boundary of the latissimus dorsi muscle is marked, with dissection of the proximal portion of the LDMF. The location along the LDMF boundary is marked in a clockwise direction (E). LDMF was separated to the extent possible in advance, within the range that can be secured with the naked eye (F). LDMF, latissimus dorsi muscle flap.

Prior to docking the robot, a sufficient workspace was created. The prior axillary skin incision was closed temporarily with skin staples, and a sterile dressing was placed over the site. The patient’s position was then changed from the supine to the lateral decubitus position for LDMF harvesting, with the arm placed as close to the head as possible to create sufficient space to avoid collision between the robotic equipment and the patient and collision between the robot arms (Figure 1C,1D). For optimal LDMF harvest, the LDM boundaries were marked on the back (Figure 1C,1E): medial border at thoracolumbar spine, lateral along posterior axillary line, superior at scapular tip, and inferior at iliac crest. To ensure precise tracking of robotic instrument locations throughout surgery, the outlined margins were labeled with numbers in a clockwise sequence (Figure 1E). Accurate communication between the assistant and the surgeon is crucial to allow the surgeon to perform the surgery remotely while seated at the console.

The harvesting process started by detaching the LDMF to the greatest possible extent that could be directly observed through the existing axillary incision from the partial mastectomy. The LDM was carefully freed from adjacent subcutaneous adipose tissue and the serratus anterior muscle, beginning at its insertion and progressing toward the origin sites. Through this process, roughly one-third of the LDM was dissected to create sufficient space for introducing the endoscope and surgical instruments (Figure 1F). A second incision of 3–4 cm was created parallel to the mid-axillary line, at a point about 15–20 cm from the lower edge of the axillary fold (Figure 2A). The subcutaneous fat tissue around the incision, approximately 3 cm in radius, was separated from the muscle layer to enhance visibility and create a workspace for the robot arms (Figure 2B). In most cases, LDMF harvesting was possible using only this mid-axillary line incision; however, an additional port was required in some cases if the surgical procedure was complicated by limitations of the operative field or collision between the robot arms (Figure 2C). The authors made several attempts to determine the ideal incision location for port insertion, as follows: a method that uses only the axillary skin incision already made for partial mastectomy and axillary nodule surgery (resulting in only one scar) (Figure 2D). If unsuccessful, an additional independent skin incision, approximately 4 cm in length, was created below the axilla (resulting in two scars) (Figure 2E). If needed, an additional port can be inserted through the axillary incision (resulting in three scars) (Figure 2F). With the accumulation of surgical cases and experience, the author predominantly employs the second method. Due to frequent collisions between robot instruments in many cases, the first method tends to extend operation times and heighten surgical team fatigue. Meanwhile, the third method leads to an increase in scars, potentially diminishing cosmetic satisfaction.

Figure 2 Option of skin incisions for port placement for endoscopy and robot arm insertion. (A) A 3–4 cm long skin incision is made in the mid-axillary line, about 15–20 cm from the inferior side of the axillary fold. (B) To secure the field of vision and create a working area for the robot arm, the subcutaneous fat tissue from the deeper muscle layer can be separated to a radius of 3 cm or more. (C) An additional port can be inserted in the distal area to further improve the field of view or avoid collision between the robot arms. (D) The first method uses an axillary incision, creating only one scar. (E) The second method uses an axillary and one subaxillary incision, creating two scars. (F) The third method uses an axillary and two subaxillary incisions, creating three scars.

Robot set-up and docking

The robotic cart was positioned behind the patient facing anteriorly, while the surgical assistant and scrub nurse were located on the patient’s anterior side. Placement of the console was adjusted to fit the spatial constraints of the operating room (Figure 3A). Once the surgical workspace was sufficiently established, a single-port device (Lapsingle^®; Sejong Medical, Paju, Republic of Korea) was inserted via the subaxillary incision (Figure 3B). Following that, carbon dioxide gas was introduced into the surgical site at a pressure of 7–15 mmHg to enhance visibility and create a suitable working environment. Assuming an imaginary triangle, a 30° downward-inclined endoscope was inserted at the triangle’s upper vertex, while the working ports for the robotic instruments were placed at the remaining two vertices (Figure 3C,3D). To address restricted visibility when working medially along the curved thoracic wall, the endoscope was positioned through the upper port. In certain cases, the inverted triangle’s position was applied to minimize collisions between the robot arms and surgical instruments while maintaining adequate visibility.

Figure 3 Docking of the robot. (A) Position of robotic equipment and patient. (B) A single port, inserted into the subaxillary incision. (C) Location of robot camera port [C] and main working instruments ports [1, 2], and assistant port [A]. (D) The axis of the arms is initially positioned parallel to the patient’s arm. (E,F) Main working instruments, including a left permanent cautery hook and right fenestrated bipolar forceps.

After these steps, the robot arms were docked in the ports (Figure 3D). A total of three robotic instruments—including a 30-degree angled endoscope, a permanent cautery hook, and fenestrated bipolar forceps—were employed, with an optional additional arm, forceps, or grasper utilized as required (Figure 3E,3F). The remaining port could be utilized by the surgical assistant for inserting gauze or suction to control bleeding and/or a laparoscopic instrument for muscle traction. The robot arms were initially aligned parallel to the patient’s arms and then adjusted cephalad or caudal during LDMF harvesting to ensure visibility and prevent collisions and iatrogenic injuries.

Robot-assisted harvesting of the LDMF

Following patient and operating room preparation and robot docking, LDM dissection was performed using a 2-step approach. The procedure began with submuscular dissection of the LDM, after which superficial dissection was performed along the subcutaneous layer. Starting the dissection at the subcutaneous layer may allow insufflation gas to enter the superficial compartment, resulting in difficulty sustaining a proper working space during subsequent submuscular dissection (1).

The robotic endoscope and surgical instruments were advanced beneath the LDM, allowing for complete detachment of the flap from the posterior thoracic wall. Meticulous submuscular dissection was carried out toward the medial and inferior aspects. Any perforating vessels encountered were coagulated with either a permanent cautery hook or fenestrated bipolar forceps. Dissection proceeded up to the margins of the LDM, exposing the aponeurotic insertion at its origin (Figure 4A). Once the underside of the muscle was dissected to its borders, the ports were repositioned into the subcutaneous plane to separate the subcutaneous fat layer from the LDM. An identical dissection technique was subsequently applied to another anatomical plane.

Figure 4 LDMF harvesting and breast reconstruction. (A) Robot-assisted submuscular plane dissection, extended until the borders of the design are reached and the tendinous insertion (aponeurosis) of the muscle origin site is visible. (B) The harvested LDMF is removed through the incision in the axillary region. A defect after partial mastectomy is observed on the anterior chest wall. (C) Restoration of the shape of the breast by filling the defect with the LDMF. (D) Appearance immediately after completion of breast reconstruction. For tumors located in the inner quadrant, partial mastectomy is performed by adding a periareolar skin incision, as necessary. LDMF, latissimus dorsi muscle flap.

After finishing both the superficial and deep dissections, the LDM was separated from its attachment sites, including the thoracic and lumbar spine, iliac crest, and ribs. Prioritizing the dissection of the LDM’s attachments near the teres major muscle and the lower end of the scapula is essential. If this dissection is not first achieved before dissection of the inferior and medial borders of the LDM, it will be difficult to achieve due to absence of fixed points of attachment for control.

After ensuring all edges of the LDMF were freed except for the vascular pedicle, meticulous hemostasis and saline irrigation were carried out. The robotic system was undocked, and the single-port access device was subsequently removed. The detached LDM was extracted through the axillary skin incision (Figure 4B). Subsequently, the acquired pedicled LDMF was relocated into the breast pocket, moving from the back to the front of the chest wall (Figure 4C).

Breast reconstruction

Subsequently, the patient was repositioned from the lateral decubitus to the supine position. Subsequently, the temporarily stored LDMF was taken out from the breast pocket. Based on intraoperative findings from the frozen section analysis of sentinel lymph nodes, axillary lymph node dissection was carried out when indicated. If the intraoperative frozen section demonstrated atypical or malignant cells, further breast tissue was resected incrementally until clear margins were confirmed. After confirming a negative resection margin, the LDMF was used to fill the surgical cavity and to restore the breast shape. A closed suction drain was then positioned both in the breast and at the donor site. Subcutaneous layers were approximated with absorbable monofilament sutures, and final skin closure was completed with staples (Figure 4D).

Postoperative considerations and tasks

Postoperative complication assessment

The volume and properties of the drained fluid were assessed daily after surgery. The drain was removed when daily output fell below 50 mL. To minimize the risk of ascending infection, drains were routinely removed within two weeks. Donor site complications were monitored for up to six months after the procedure. Seroma, hematoma formation, and wound infection at the LDMF donor site were detected during outpatient visits through physical examination and ultrasonography. When necessary, seromas were managed by needle aspiration, and records were kept detailing both the aspirated volume and the frequency of occurrence.

Evaluation of cosmetic outcomes

Cosmetic satisfaction was assessed at 6–12 months postoperatively during outpatient visits using a five-point Likert scale (excellent–good–fair–poor–very poor) developed by our institution.

Postoperative outcomes

Pedicled LDMF was successfully harvested with robot assistance in all cases, without the need for conversion to an open technique, with no flap loss. A detailed overview of the clinicopathologic profiles for the 27 enrolled patients is provided in Table 1. The average age among the participants was 47.6±8.7 years.

Invasive ductal carcinoma represented the predominant histologic subtype, identified in 20 out of 27 cases (74.1%). The mean tumor size confirmed by preoperative imaging studies (mammography, ultrasonography, MRI) was 2.9±1.6 cm. The mean tumor size, including in situ and invasive cancer, confirmed by postoperative histology was 2.7±1.7 cm (0.0–7.3 cm). The distribution of pathologic tumor stages was as follows: stage 0, 18.5%; stage 1A, 44.4%; stage IIA, 18.5%; and stage IIB, 3.7%, stage IIIA, 14.8%. This included three patients who received neoadjuvant chemotherapy. They were confirmed as ypT0N0, ypTisN0, and ypT1N2, postoperatively, respectively.

The operative and postoperative details are reported in Table 2. The mean weight of the resected breast tissue, including the tumor, was 133.2±53.0 g, with the majority of tumors located in the upper outer quadrant (10/27 cases, 37%). Total surgical time, encompassing partial mastectomy, nodal surgery (sentinel biopsy or axillary dissection), LDMF harvest, and reconstructive steps, was 459.1±120.8 minutes. Of this time, the average time for robot docking was 30 min, with a mean flap harvesting time of 201.1±74.7 minutes. As the surgeon’s experience accumulates, the surgical time gradually decreases (Figure 5). Docking time decreased from an initial 40 to 20 minutes after the first 10 cases, reflecting the learning curve effect. The average total amount discharged through the placed drainage tube was 1,513.6±601.2 mL, and the average duration of drainage tube placement was 8.8±2.1 days. The mean hospital stay was 10.6±2.2 days, with all patients discharged after drain tube removal.

Figure 5 Learning curves for surgical time of 27 patients. Duration of robotic LDMF harvesting only (solid line) and total operation (partial mastectomy, LDMF harvesting and breast reconstruction) (dotted line). Docking time decreased from approximately 40 to 20 minutes after the initial four cases, demonstrating the learning curve effect. LDMF, latissimus dorsi muscle flap.

Aside from seroma formation at the donor site, there were no other complications such as hematoma, infection, or flap necrosis, and no delays in starting adjuvant treatment. Seroma was identified through physical examination and ultrasound during outpatient visits over the 6-month after surgery in 21/27 (77.8%) of cases (Table 2). These cases were successfully managed on an out-patient status using needle aspiration, with a mean volume of aspirated fluid of 313.1±146.6 mL.

Postoperatively, patients underwent suitable adjuvant treatments—such as chemotherapy, radiotherapy, endocrine therapy, or targeted agents—tailored to tumor stage and subtype as determined by final histopathological assessment. No locoregional or systemic recurrence was observed over the mean postoperative follow-up period of 31.8±13.1 months.

Patient-reported cosmetic outcomes, evaluated after adjuvant chemotherapy or radiotherapy, is reported in Table 3. The overall patient-reported satisfaction was excellent in 70.4% of cases and good in another 18.5% of cases, with breast symmetry reported as being excellent in 81.5% of cases and good in 11.18% of cases. Satisfaction with absence of scarring was particularly high, with 88.9% reporting an excellent scar outcome and 7.4% a good outcome. In our cohort, single-, double-, and triple-incision approaches were used in 5, 18, and 4 patients, respectively. There was no statistically significant difference in patient-reported cosmetic satisfaction among these groups, although patients with a single incision tended to report slightly higher satisfaction regarding back scarring. No significant differences were observed in other postoperative outcomes according to the number of incisions. Representative before and after images are presented in Figure 6.

Figure 6 Pre- and post-operative appearance of four breast cancer patients (A-D). For each patient, the top panels show the before surgery photographs and the lower panels the completed reconstruction after chemotherapy and radiation therapy.

Tips and pearls

For surgeons who are new to this procedure, several key considerations can facilitate a safe and efficient operation. Patient selection is critical; those with moderate defects, particularly located in the outer quadrants, are the most suitable candidates for robot-assisted LDMF harvesting. Careful preoperative planning of port placement according to each patient’s body contour and the anatomical boundaries of the LDMF helps minimize instrument interference and enhance surgical precision. In addition, establishing sufficient working space and ensuring clear visualization through appropriate patient positioning before docking are essential to achieving smooth robotic movement and preventing intraoperative complications.

Discussion

The traditional method of breast reconstruction using an LDMF typically involves a dorsal incision at the donor site, measuring 15–20 cm in length, which can present aesthetic concerns for patients. To mitigate the need for such a large incision, a minimally invasive approach becomes necessary. Consequently, the author initiated endoscopy-assisted LDMF harvesting towards the end of 2016.

However, accessing the medial border of the LDM with laparoscopic cameras and instruments can prove challenging. The rigid chest wall impedes the maneuverability of these instruments as the muscle follows the curvature of the back. In essence, endoscopically assisted breast reconstruction encounters significant technical hurdles.

Concurrently, amidst the growing public interest in robotic surgery, and with insufficient evidence regarding the safety of robot-assisted mastectomy (8), the author initially implemented robotic surgery in breast reconstruction, an area less critical to oncologic safety. Moreover, the flexibility of robotic arms helps overcome the limitations posed by rigid laparoscopic instruments.

In multiport robotic platforms, instrument arms and the camera can experience mutual interference, particularly when operating near the medial or lateral boundaries of the surgical field. In contrast, single-port platforms like the da Vinci SP system (Intuitive Surgical, Sunnyvale, CA, USA) incorporate articulated robotic arms with expanded motion capabilities that help reduce collisions between instruments. Additionally, the flexible camera assists in providing a comprehensive view of all structures, eliminating blind spots, particularly in medial regions where the curvature of the back may hinder visibility (9). The simplified docking procedure offered by this new single-port robotic system is another advantage. Considering these advantages, single-port robotic systems represent a practical option that can deliver consistent results when harvesting the LDMF for breast reconstruction procedures.

The primary factors contributing to the prolonged mean total operative time observed in this study can be attributed to several key reasons. Initially, the surgery necessitates two positional changes for the patient throughout the procedure. Specifically, partial mastectomy is conducted with the patient in the supine position, followed by LMDF harvesting in the lateral decubitus position, and concluding with breast reconstruction performed again in the supine position. Secondly, the extended duration is a result of the experimentation involved in implementing a novel surgical approach to LDMF harvesting. Prior to standardizing the surgical technique, various methods were explored and applied, leading to trial and error. Through this iterative process, the surgical procedure has now been refined and standardized, with LDMF harvesting typically taking approximately 2 hours. For comparison, the conventional open technique typically requires 1.5 hours.

In this novel surgical approach, the duration of drain tube placement is prolonged, potentially leading to an extended hospital stay. This longer drainage period did not delay the initiation of adjuvant therapies, including chemotherapy, radiation therapy, targeted therapy, or endocrine therapy. Despite a higher incidence of seroma formation following drain tube removal, this issue can be readily addressed through needle aspiration during outpatient care, and typically resolves as wound healing progresses within a maximum of 2 months post-surgery. Although not currently implemented, the utilization of robot arms for quilting sutures at the donor site is anticipated to aid in reducing the occurrence of seroma. Moreover, both in the short and long term, significant complications such as flap loss, infection, and hematoma have not been observed.

Drawing from the author’s experience and in agreement with previous reports (10), robotic LDMF harvesting can be applied in several clinical scenarios, including oncoplastic reconstruction after partial mastectomy (11), as an alternative to acellular dermal matrix for implant coverage, and for breast mound reconstruction in patients with small breasts undergoing nipple-sparing mastectomy (12).

In cases of partial breast reconstruction, the volume of the robotically harvested LDMF is generally sufficient to correct the defect after breast-conserving surgery. However, in patients who underwent partial mastectomy with a large defect, or in those with originally large breasts who required total mastectomy, additional procedures such as lipofilling or implant augmentation may be considered to achieve adequate volume and symmetry.

Despite the clear advantages of robot-assisted harvesting, several limitations remain, including the high initial investment and maintenance costs of the da Vinci robotic platform and the current lack of Food and Drug Administration (FDA) approval for robotic mastectomy and reconstruction. Although the procedure costs roughly twice as much as the endoscopic approach—mainly due to system usage fees—these expenses may be justified in appropriately selected patients, given its benefits of reduced donor-site scarring, improved ergonomics, and greater patient satisfaction.

Integration of robotic platforms for both tumor resection and reconstruction may provide single-setting oncoplastic solutions once oncologic safety is validated. Comparative studies among open, endoscopic, and robotic LDMF harvesting will be essential to confirm long-term cost-effectiveness and clinical benefit.

Conclusions

Robot-assisted LDMF harvesting is a safe and effective option for partial breast reconstruction, providing high patient satisfaction and minimal scarring.

Acknowledgments

None.

Footnote

Reporting Checklist: The author has completed the SUPER reporting checklist. Available at https://gs.amegroups.com/article/view/10.21037/gs-2025-226/rc

Peer Review File: Available at https://gs.amegroups.com/article/view/10.21037/gs-2025-226/prf

Funding: This work was supported by a 2-Year Research Grant of Pusan National University.

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://gs.amegroups.com/article/view/10.21037/gs-2025-226/coif). The author has no conflicts of interest to declare.

Ethical Statement: The author is 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 Declaration of Helsinki and its subsequent amendments. This study was approved by the Institutional Review Board of Pusan National University Hospital (IRB No. 210-025-099). Publication of this article and accompanying images was waived from patient consent according to the Pusan National University Hospital Institutional Review Board because the study was retrospective in nature and all patient data were anonymized prior to analysis.

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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