Minimally invasive breast surgery has gained traction with the increasing demand for better aesthetic outcomes in breast cancer treatment. With smaller and hidden incisions, these new techniques also allow for faster recovery, less pain and improved safety, with no compromise in oncological outcomes.

INTRODUCTION

Breast cancer is the most common cancer among women in Singapore. As surgical management of breast cancer has evolved rapidly over the past 20 to 30 years, the improved survival outcomes due to such advances in breast cancer treatment have made it imperative to consider the aesthetic outcomes of breast cancer survivors.

Prior to this, conventional surgical options were limited to either a mastectomy or breast-conserving surgery. Mastectomies underwent their own evolution, from Halsted radical mastectomy in the late 1800s to skin as well as nipple-sparing mastectomy with immediate reconstruction since the early 2000s.

On the other hand, breast-conserving surgery with breast radiotherapy changed the surgical principles of breast cancer treatment from extirpative to conservative with equivalent survival outcomes.

Following which, the demand for better aesthetic outcomes drove the development of  oncoplastic breast-conserving surgery, where glandular rearrangement or replacement coupled with thoughtfully placed incisions became the standard approach to breast-conserving surgery.

With increasing demand for improved aesthetic outcomes, minimally invasive breast surgery (MIBS) has gained much attention over the past two decades, from endoscopic-assisted breast surgery to, more recently, robotic-assisted breast surgery.1,2

This article aims to give an overview of MIBS and how this new alternative surgical option positions itself as the next frontier in the management of breast cancer.

WHAT IS MINIMALLY INVASIVE BREAST SURGERY?

MIBS essentially describes surgical techniques performed with the assistance of endoscopic instruments, and more recently, robotic surgical platforms.

Key features of this technique revolve around adequate yet small incision(s) placed in inconspicuous or hidden areas leading to better aesthetic outcomes, while not compromising on safety and allowing for immediate breast reconstruction to be performed through the same incision(s).

The use of endoscopic instruments or robotic surgical platforms helps to improve visualisation through better optics, thereby allowing for oncologic resection to take place through small incisions (Figure 1).

Minimally Invasive Breast Surgery: Smaller and hidden incisions allow for faster recovery and better cosmesis - CGH
Figure 1 Smaller and hidden incisions allow for faster recovery and better cosmesis

 

CATEGORIES OF MIBS

In line with the concept of MIBS2, there are two broad categories of surgical techniques, with or without the use of endoscopic instruments (Figure 2).

Under the non-endoscopic group, there are various techniques which can be employed, which include but are not limited to moving window and retraction with light handle retractors.

Endoscopic-assisted breast surgery (EABS) can be further divided into robotic-assisted and non-robotic-assisted techniques. Non-robotic-assisted techniques can be subdivided according to variations in instruments used, such as the use of an insufflation system, single versus multiple ports, and the use of 3-dimensional (3D) or 4K resolution systems.

 

Different Categories of MIBS Techniques - CGH
Figure 2

ADVANTAGES OF MIBS

  • Faster recovery – smaller incisions, less pain
    With smaller and well-hidden incisions (Figure 1), postoperative recovery has been reported to be shorter with improved patient and surgeon satisfaction3-7
  • Improved aesthetic outcomes – smaller and hidden incisions
    In a case series5 published by the author in 2020, minimally invasive oncological resection combined with reconstruction with latissimus dorsi (LD) flap provided better aesthetic outcomes as compared to conventional techniques (Figure 3)
  • Improved safety and precision of resection due to enhanced visualisation
  • No compromise in oncological outcome
  • Immediate breast reconstruction
    In addition to oncological resections, immediate breast reconstruction can also be performed in the same sitting with MIBS techniques

Comparison of endoscopic LD flap harvest vs conventional LD flap harvest - CGH
Figure 3 Comparison of patient A who had an endoscopic LD flap harvest (scars shown with white arrows), versus patient B who had a conventional LD flap harvest (scars shown with blue arrow)

WHO IS SUITABLE FOR MIBS?

The selection of patients for MIBS is similar to that of conventional surgery.

However, there are a few categories of conditions or patient groups who will reap the maximal benefits from MIBS.1,3-7

These include, but are not limited to:

  • Excision biopsy of large (> 4 cm) breast lumps
  • Wide excision / breast-conserving surgery for breast cancer
  • Mastectomy (nipple-sparing) for breast cancer, gynaecomastia
  • Sentinel lymph node biopsy
  • Reconstruction – autologous flap, implants

 

​THE MINIMALLY INVASIVE BREAST SURGERY SERVICE AT CHANGI GENERAL HOSPITAL

The Minimally Invasive Breast Surgery Service at Changi General Hospital (CGH) was set up in 2020 with the aim of providing patients with the option of minimally invasive surgery for both benign and malignant breast conditions. This service offers patients the whole range of MIBS techniques.

More than 50 patients have benefitted from MIBS since its inception. Surgical outcomes were comparable to that of conventional surgery, but with the advantage of improved patient satisfaction and aesthetic outcomes.

 

HOW TO REFER

To refer patients who may require surgery for both benign and malignant conditions, for suitability assessment and further workup, GPs can call the GP Appointment Hotline at 6788 3003.

REFERENCES

  1. Mok CW, Lai HW. Endoscopic-assisted surgery in the management of breast cancer: 20 years review of trend, techniques and outcomes. Breast. 2019. doi:10.1016/j.breast.2019.05.013
  2. Mok CW, Lai HW. Evolution of minimal access breast surgery. Gland Surg. 2019 Dec;8(6):784-793. doi: 10.21037/gs.2019.11.16. PMID: 32042687; PMCID: PMC6989909.
  3. Lai HW, Chen ST, Mok CW, Lin SL, Tai CM, Chen DR, Kuo SJ. Single-port 3-dimensional Videoscope-assisted Endoscopic Nipple-sparing Mastectomy in the Management of Breast Cancer. Plast Reconstr Surg Glob Open. 2019 Aug 19;7(8):e2367. doi: 10.1097/GOX.0000000000002367. PMID: 31592384; PMCID: PMC6756665.
  4. Lai HW, Chen ST, Mok CW, Lin YJ, Wu HK, Lin SL, Chen DR, Kuo SJ. Robotic versus conventional nipple sparing mastectomy and immediate gel implant breast reconstruction in the management of breast cancer- A case control comparison study with analysis of clinical outcome, medical cost, and patient-reported cosmetic results. J Plast Reconstr Aesthet Surg. 2020 Aug;73(8):1514-1525. doi: 10.1016/j.bjps.2020.02.021. Epub 2020 Feb 18. PMID: 32238306.
  5. Mok CW, Hing JXJ, Tan SM. Latissimus dorsi flap: safe, reliable and versatile workhorse flap in the era of minimally invasive breast surgery—a case series. Ann Breast Surg 2020;4:30.
  6. Lai HW, Mok CW, Chang YT, Chen DR, Kuo SJ, Chen ST. Endoscopic assisted breast conserving surgery for breast cancer: Clinical outcome, learning curve, and patient reported aesthetic results from preliminary 100 procedures. Eur J Surg Oncol. 2020 Aug;46(8):1446-1455. doi: 10.1016/j. ejso.2020.02.020. Epub 2020 Feb 20. PMID: 32115333.
  7. Lai HW, Chen ST, Liao CY, Mok CW, Lin YJ, Chen DR, Kuo SJ. Oncologic Outcome of Endoscopic Assisted Breast Surgery Compared with Conventional Approach in Breast Cancer: An Analysis of 3426 Primary Operable Breast Cancer Patients from Single Institute with and Without Propensity Score Matching. Ann Surg Oncol. 2021 May 11. doi: 10.1245/s10434-021-09950-8. Epub ahead of print. PMID: 33974198.

 

Dr Mok Chi Wei is a Consultant at the Department of Breast Surgery, Changi General Hospital with a sub-specialty interest in breast surgery. His clinical practice is mainly in breast diseases, both benign and malignant. He completed his advanced training in oncoplastic and minimally invasive (endoscopic- and robotic-assisted) breast surgery and to date, he is one of the few handful of breast surgeons in the region to be trained in the full spectrum of minimally invasive breast surgery techniques.

Apart from his clinical commitments, he is also a Clinical Assistant Professor with Duke-NUS Medical School and has published extensively in breast cancer-related topics. His passion to teach and impart his skills had led to the publication of the first medical textbook/atlas on minimally invasive (endoscopic- and robotic-assisted) breast surgery under Elsevier in January 2020.

GPs who would like more information about this procedure, please contact Dr Mok at mok.chi.wei@singhealth.com.sg.

 

GP Appointment Hotline: 6788 3003

Changi General Hospital is one of five clinical sites of the SingHealth Duke-NUS Breast Centre, a multidisciplinary centre treating the full spectrum of breast conditions.

GPs can call the SingHealth Duke-NUS Breast Centre for appointments at the following hotlines: 
Singapore General Hospital: 6326 6060
Changi General Hospital: 6788 3003
Sengkang General Hospital: 6930 6000
KK Women's and Children's Hospital: 6692 2984
National Cancer Centre Singapore: 6436 8288