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Skin sparing mastectomy and robotic latissimus dorsi-flap reconstruction through a single incision

  • Gilles HouvenaeghelEmail author
  • Marie Bannier
  • Sandrine Rua
  • Julien Barrou
  • Mellie Heinemann
  • Eric Lambaudie
  • Monique Cohen
Open Access
Research
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Abstract

Background

Robotic latissimus dorsi-flap reconstruction (RLDFR) after skin-sparing mastectomy (SSM) for breast cancer (BC) has been performed through a single nipple incision. We report results of SSM with RLDFR, mainly with analysis of feasibility, morbidity, indications, and technique standardization.

Methods

We determined characteristics of patients, previous treatment of BC, and type of reconstruction. Surgical technique, duration of surgery, and complication rate were reported according to three successive periods: P1–3.

Results

Forty RLDFR, with breast implant for 16 patients, with previous breast radiotherapy in 30% had been performed. In logistic regression, factors significantly associated with duration of surgery ≥ 300 min were P2 (OR 0.024, p = 0.004) and P3 (OR 0.012, p = 0.004) versus P1. The median mastectomy weight was 330 g and 460 g for BMI < and ≥ 23.5 (p = 0.025). Length of hospitalization was 4 days. Total complication rate was 20% (8/40): seven breast complications (four re-operations) and one RLDF complication with re-operation. Periods were significantly predictive of complications (p = 0.045).

Conclusion

SSM with RLDFR is feasible, safe, and reproducible. We reported a decrease of duration of surgery, length of post-operative hospitalization, and complication rate.

Keywords

Breast reconstruction Latissimus dorsi-flap Robotic surgery 

Introduction

Development of robotic surgery since several years was very important for prostatic cancer, gynecologic cancer, colo-rectal cancer, and thoracic and thyroid surgery [1, 2, 3]. Endoscopic non-robotic latissimus dorsi-flap breast reconstruction (LDFR) has been reported in several studies [4, 5, 6, 7, 8, 9].

Very few experiences were reported in the field of breast surgery, with a small number of series including very few patients on robotic mastectomy or LDFR [10, 11, 12, 13, 14]. Nipple-sparing mastectomy (NSM) with immediate robotic latissimus dorsi-flap (RLDF) reconstruction has been reported in seven patients in Selber et al.’s study [10] and in four cases in Chung et al.’s study [12]. Skin-sparing mastectomy (SSM) with LDF reconstruction was reported in 17 patients for delayed-immediate breast reconstruction after SSM and placement of a tissue expander [13] and in one patient for immediate breast reconstruction with 3D endoscopy using another incision than areolar incision [15]. In a recent French prospective cohort study, Immediate breast reconstruction (IBR) was performed with LDFR in 46.9% of cases (24.3% combined with an implant), with implant in 46.5%, and rectus abdominis musculo-cutaneous flap in 6.6% [16]. The aim of this study was to report results of SSM with robotic LDFR performed during 29 months, through the analysis of feasibility, morbidity, indications, and standardization of patient positioning and operative technique.

Material methods

A prospective cohort of patients undergoing SSM and robotic latissimus dorsi-flap reconstruction (RLDFR) over a period of 29 months (March 2016 to July 2018) was analyzed. All patients agreed to surgery with robotic assistance and received information on the procedure. The study protocol was approved by our institutional ethical committee.

We analyzed patient characteristics (age, body mass index (BMI), tobacco use, diabetes, ASA score, breast volume), previous treatment for breast cancer (BC) (sentinel lymph node biopsy (SLNB), axillary lymph node dissection (ALND), neo-adjuvant chemotherapy (NAC), previous breast radiotherapy), primary breast cancer (BC) or local recurrence, and type of reconstruction (LDFR with or without breast implant).

Surgical technique using da Vinci Si® Surgical System SI or XI (Intuitive Surgical, Sunnyvale, CA), number of trocars, skin incision, and duration of anesthesia and surgery were recorded according to period of treatment and associated surgical procedures (breast implant, LDFR, ALND, and contra-lateral breast surgery). Duration of anesthesia was defined as time from anesthesia induction to tracheal extubation and duration of surgery as time from skin incision to the end of skin suture including all associated procedures and changes in patient positioning. Three periods were established: P1 (year 2016), P2 (year 2017), and P3 (year 2018).

Complication rate was determined using Clavien-Dindo grading [17]. Re-operation rate, type of complication, and number of post-operative hospitalization days were reported.

Statistics

Main characteristics were reported using median, mean, and 95% confidence interval (CI95) for quantitative criteria. Comparisons were performed using χ2 for categorical variables, t test or Anova for continuous variables, and logistic binary regression with odds ratios, CI95 and, p value with SPSS® software version 16.0. We considered p value ≤ 0.05 as significant result.

Results

During the study period of 29 months, 119 patients were operated for breast surgery and/or RLDFR, 117 with da Vinci robot, and 2 with 3D endoscopy. Among these patients, we analyzed 40 patients with the same surgical procedure, SSM and RLDFR, performed by the same surgeon. Breast reconstruction was performed in 25 patients with autologous LDF associated with breast implant in 7 patients and in 15 patients with non-autologous LDF (without fat around LDF) associated with breast implant in 9 patients. The number of patients was 11, 18, and 11, respectively, for periods P1–P3. Chest sizes were 85, 90, 95, 100, and > 100, respectively, in 4, 10, 17, 6, and 3 patients. Patients’ characteristics are reported in Tables 1 and 2.
Table 1

Characteristics of all patients and according to periods of treatment

    

P1-2016

P2-2017

P3-2018

χ 2

Population

 

n

%

n

%

n

%

n

%

p

Number patients

 

40

 

11

27.5

18

45.0

11

27.5

 

Primary BC

 

35

87.5

7

63.6

17

94.4

11

100

0.017

Local recurrence

 

5

12.5

4

36.4

1

5.6

0

0

 

Tobacco

 

9

22.5

5

45.5

3

16.7

1

9.1

0.090

Diabete

 

3

7.5

2

18.2

1

5.6

0

0

0.247

ASA

1

18

45.0

5

45.5

6

33.3

7

63.6

0.252

2

21

52.5

5

45.5

12

66.7

4

36.4

 

3

1

2.5

1

9.1

0

0

0

0

 

Breast size

A–B

15

37.5

2

18.2

8

44.4

5

45.4

0.20

C

18

45.0

5

45.5

9

50.0

4

36.4

 

D–F

7

17.5

4

36.3

1

5.6

2

18.2

 

Prosthesis size

< 300

5

29.4

4

40.0

1

16.7

0

0

0.50

≥ 300

12

70.6

6

60.0

5

83.3

1

100

 

Previous radiotherapy

Yes

12

30.0

6

54.5

4

22.2

2

18.2

0.10

No

28

70.0

5

45.5

14

77.8

9

81.8

 

Neo adjuvant chemotherapy

 

7

17.5

2

18.2

3

16.7

2

18.2

0.992

Reconstruction

Autologous LDF

18

45.0

2

18.2

12

66.7

4

36.4

< 0.0001

Non-autologous LDF

6

15.0

0

0

0

0

6

54.5

 

LDF + implant

9

22.5

4

36.4

5

27.8

0

0

 

Autologous LDF + implant

7

17.5

5

45.5

1

5.6

1

9.1

 

Incision for RLDFR

Axillar

7

17.5

3

27.3

3

16.7

1

9.1

0.490

Areolar

33

82.5

8

72.7

15

83.3

10

90.9

 

BC

Invasive

29

72.5

8

72.7

14

77.8

7

63.6

0.710

DCIS

11

27.5

3

27.3

4

22.2

4

36.4

 

Number of surgical procedures

2

21

52.5

2

18.2

12

66.7

7

63.6

0.070

3

16

40.0

7

63.6

6

33.3

3

27.3

 

4

3

7.5

2

18.2

0

0

1

9.1

 

da Vinci system

SI

17

42.5

11

100

6

33.3

0

0

< 0.0001

XI

23

57.5

0

0

12

66.7

11

100

 

Number of arms

2

29

72.5

3

27.3

15

83.3

11

100

< 0.0001

3

11

27.5

8

72.7

3

16.7

0

0

 

Hospitalization days

< 4 days

13

32.5

0

0

8

44.4

5

45.5

0.026

≥ 4 days

27

67.5

11

100

10

55.6

6

54.5

 

Time of surgery

< 300 mn

26

65.0

1

9.1

15

83.3

10

90.9

< 0.0001

≥ 300 mn

14

35.0

10

90.9

3

16.7

1

9.1

 

Time of anesthesia

< 382 mn

26

65.0

2

18.2

14

77.8

10

90.9

0.001

≥ 382 mn

14

35.0

9

81.8

4

22.2

1

9.1

 

BMI

< 23.5

17

42.5

5

45.5

7

38.9

5

45.5

0.916

≥ 23.5

23

57.5

6

54.5

11

61.1

6

54.5

 

Previous contra lateral BC

No

36

90.0

8

72.7

18

100

10

92.9

0.059

Yes

4

10.0

3

27.3

0

0

1

9.1

 

Previous homolateral BCT

No

21

52.5

5

45.5

10

55.6

6

54.5

0.859

Yes

19

47.5

6

54.5

8

44.4

5

45.5

 

Contra lateral breast surgery

No

38

95.0

11

100

17

94.4

10

90.9

0.613

Yes

2

5.0

0

0

1

5.6

1

9.1

 

BMI body mass index, SI da Vinci SI system, XI da Vinci XI system, LDF latissimus dorsi-flap, NSM nipple-sparing mastectomy, RLDFR robotic latissimus dorsi-flap reconstruction, BC breast cancer, DCIS ductal carcinomas in situ, BCT breast-conserving therapy

Table 2

Characteristics of patients and surgery

Population

All patients

Median

Mean

CI 95%

Range

Age

 

64.0

61.2

40.8–81.6

39–83

Mastectomy weight

 

358

445

345–546

72–1600

BMI

 

24.5

25.4

23.9–26.9

18.3–38.0

Duration of surgery

 

290

298

276–321

195–495

Duration of anesthesia

 

353

364

341–387

249–540

Hospital stay duration

 

4

4.38

3.89–4.86

2.0–8.0

Duration of surgery

P1

372

373

328–419

235–495

P2

271

280

257–302

215–410

P3

258

254

222–286

195–343

Duration of anesthesia

P1

428

438

393–483

313–540

P2

355

351

328–373

276–457

P3

323

313

281–345

249–404

Duration of surgery

SI

334

336

297–376

215–495

XI

266

270

248–292

195–410

Duration of anesthesia

SI

403

410

376–444

313–540

XI

331

330

307–353

249–457

Duration of surgery

2 surgical procedures

258

273

245–301

195–410

3 surgical procedures

301

318

281–354

215–495

4 surgical procedures

420

372

167–577

277–420

Duration of surgery

Autologous LDF

265

274

243–306

195–410

Non autologous LDF

262

268

225–312

219–343

LDF + implant

325

342

270–413

215–495

Autologous LDF + implant

334

330

293–366

270–372

Duration of anesthesia

Autologous LDF

339

341

308–374

249–506

Non-autologous LDF

327

327

276–378

252–404

LDF + implant

409

412

351–474

294–540

Autologous LDF + implant

403

394

353–435

342–451

Hospital stay duration

Autologous LDF

4

3.83

3.12–4.54

2.0–7.0

Non-autologous LDF

3

3.33

2.79–3.88

3.0–4.0

LDF + implant

5

4.89

3.99–5.79

3.0–7.0

Autologous LDF + implant

6

6.0

4.81–7.19

4.0–8.0

BMI

Autologous LDF

25.3

26.6

23.8–29.4

18.3–38.0

Non-autologous LDF

21.7

22.3

20.2–24.4

19.7–25.3

LDF + implant

26.2

26.1

23.3–28.9

20.3–31.6

Autologous LDF + implant

23.1

24.2

21.3–27.2

20.8–28.6

Mastectomy weight

Autologous LDF

340

503

298–708

100–1600

Non-autologous LDF

225

238

77–400

72–423

LDF + implant

370

409

281–536

201–696

Autologous LDF + implant

488

492

342–641

263–778

Hospital stay duration

P1

6

5.64

5.02–6.26

4.0–7.0

P2

4

3.83

3.19–4.48

2.0–7.0

P3

4

4.0

2.88–5.12

2.0–8.0

BMI body mass index, SI da Vinci SI system, XI da Vinci XI system, P (1–3) period (1–3), LDF latissimus dorsi-flap

Indications and type of reconstruction

Twelve patients had previous breast radiotherapy (30%, 12/40) including seven patients with SSM after NAC and radiotherapy (17.5%, 7/40). SSM was performed for five local BC recurrences with previous radiotherapy and 35 primary BC: 11 ductal carcinomas in situ (DCIS) and 29 invasive BC.

RLDFR with breast implant was performed in 40% of patients (16/40) (Table 3), in 58.3% (7/12) after previous radiotherapy. Mastectomy weight, breast cup size, and BMI according to the type of reconstruction are reported in Table 2.
Table 3

Results according to reconstruction type

  

RLDF without implant

RLDF + implant

χ 2

  

n

%

n

%

p

 Age

≤ 50 years

8

33.3

3

18.8

0.261

> 50 years

16

66.7

13

81.2

 

 Periods

P1

2

8.3

9

56.2

0.002

P2

12

50.0

6

37.5

 

P3

10

41.7

1

6.2

 

 Breast cup size

A–B

12

50.0

3

18.8

 

C

9

37.5

9

56.2

 

≥ D

3

12.5

4

25.0

 

 BMI

< 23.5

10

41.7

7

43.8

0.576

≥ 23.5

14

58.3

9

56.2

 

 Primary BC

 

23

95.8

12

75.0

0.073

 Local recurrence

 

1

4.2

4

25.0

 

 Previous radiotherapy

No

19

79.2

9

56.2

 

Yes

5

20.9

7

43.8

 

 Hospitalization days

< 4 days

12

50.0

1

6.2

0.004

≥ 4 days

12

50.0

15

93.8

 

 Duration of surgery

< 305 mn

20

83.3

6

37.5

0.004

≥ 305 mn

4

16.7

10

62.5

 

 Duration of anesthesia

< 382 mn

19

79.2

7

43.8

0.025

≥ 382 mn

5

20.8

9

56.2

 

 Mastectomy weight

≥ 330 g

12

52.2

4

25.0

0.085

> 330 g

11

47.8

12

75.0

 
  

Median

CI 95%

Median

CI 95%

 

 Age

 

58

51–63

65

53–67

 

 Mastectomy weight

 

329

280–611

439

357–532

 

 BMI

 

24.0

23.5–28.0

25.6

23.4–27.1

 

 Hospitalization days

 

4

3.18–4.30

5

4.68–6.07

 

BMI body mass index, BC breast cancer, RLDF robotic latissimus dorsi-flap

Robotic breast surgery was indicated in selected cases during the study period: 92 RLDF for IBR (40 SSM and 52 nipple sparing mastectomy) among 437 IBR (21%) and among 1193 patients who required a total mastectomy (7.7%). A selection of patients for RLDF was made according to patient’s wishes to avoid dorsal scar and to offer IBR without implant for patients who do not want implant breast reconstruction.

Surgery: (Fig. 1)

All patients were either first positioned in dorsal decubitus for SSM followed by a side decubitus for RLDFR. The anterior border of the LD muscle and the inferior mammary fold were designed and marked before incision. Incision around the nipple areolar complex was performed for SSM, and LDF dissection was performed in 33 patients through this incision and in 7 patients through a short axillar incision more often during P1 and P2 (Table 1).
Fig. 1

Surgical procedures

The beginning of the dissection for sub-cutaneous plan of LD muscle and a limited dissection under the incision along the anterior axillary line in order to introduced one robotic trocar about 6–7 cm under axillar basin (at the inferior mammary fold level) was performed.

Then, a Gelpoint® path single site device (Applied Medical) was inserted through the incision with two robotic trocars and one trocar for an Airseal® device insufflation (Applied Medical) also used by the assistant surgeon when necessary. We operated under low pressure (7 mmHg). Depending of the breast side, we inserted monopolar scissors and bipolar forceps into up and down robotic trocars with 0° camera in the middle robotic trocar.

Robotic surgery started with a superficial dissection of LD muscle from the middle of the muscle to the inferior part (5–6 cm under the inferior mammary fold) and to the superior part with a total section of the tendinous insertion. Then, we performed dissection underneath the LD muscle from the middle to the inferior part and to the level of vascular pedicle. The section of LD muscle was performed with monopolar scissors for posterior dorsal insertions, then at the inferior part of dissection, with progressive mobilization of muscle. Two drains were placed through the inferior infra-centimetric scar for the dorsal area and one for mastectomy.

Seventeen rights and 23 left SSM were realized. Robotic procedures were performed using SI daVinci system in 17 patients and XI system in 23 patients. We used 3 arms for 11 patients and 2 arms for 29 patients (72.5%): 3 arms 8/11 (72.37%) during 2016, 3/18 (16.7%) during 2017, and 0/11 during 2018 (p < 0.0001).

Concomitant with other surgical procedures, in 19 cases (47.5%), a previous partial ipsilateral breast resection had been performed. Axillary surgery was performed concomitantly in 23 cases (16 SLNB, 5 ALND, and 2 SLNB with ALND) (5 previous ALND for 5 local recurrences). A contra-lateral breast surgery was performed during the same operation in 2 (5%) patients.

Duration of procedure

Median anesthesia duration was 353 min and median surgery duration was 290 min (Table 2). The duration of the surgery for the successive patients is reported in Fig. 2. The number of surgical procedures performed (LDFR, breast implant, ALND, contra-lateral breast surgery) was ≥ 3 for 19 patients (47.5%) including 3 patients with 4 procedures. BMI was ≥ 23.5 in 57.5% of patients (23/40).
Fig. 2

Duration of surgery for 40 successive patients in chronologic order

In univariate analysis, duration of surgery were significantly different according to robot system used (p = 0.002), period P1 versus P2–3 (p < 0.0001 and non-significant between P2 and P3), number of robotic arms used (> for 3 arms: p < 0.0001), number of surgical procedures > 2 (p = 0.015) (non-significant for BMI < or ≥ 23.5: p = 0.790). In binary logistic regression including the 3 study periods and number of surgical procedures (> or ≤ 2), significant factors of duration of surgery ≥300mn were: P2 with a reduction in duration of surgery (OR 0.024, CI 0.002–0.298, p = 0.004) and P3 (OR: 0.012, CI 0.001–0.234, p = 0.004) versus P1 (number of surgical procedures: non-significant: p = 0.634). A strong correlation was observed between periods and robot system used and number of robotic arms.

In univariate analysis, the duration of anesthesia were significantly different according to the robot system used (p < 0.0001), number of robotic arms (> 3 arms, p < 0.0001), number of surgical procedures > 2 (p = 0.012), and period P1 versus P2–3 (p < 0.0001 and significance between P2 and P3, p = 0.043). In binary logistic regression including the three periods and the number of surgical procedures (> or ≤ 2), duration of anesthesia < or ≥ 382 mn differed significantly for the following periods: P2 (OR 0.062, CI 0.008–0.506, p = 0.009) and P3 (OR 0.022, CI 0.001–0.325, p = 0.006) versus P1 (number of surgical procedures—non-significant, p = 0.955).

Decrease rate of mean duration of surgery was 31.9% and decrease rate of mean duration of anesthesia was 28.5% from P1 to P3.

Pathologic results

The median mastectomy weight was 401 g: 330 g (CI 251–377, mean 314, range 100–527) for BMI <  23.5 and 460 g (CI 378–696, mean 537, range 72–1600) for BMI ≥ 23.5, respectively (p = 0.025). Median breast implant volume was 340 cc (range 225–395).

The median size of invasive BC was 25 mm (mean 42.3, CI 28.6–56.1, range 0.7–130) with 15 multifocal BC (20 ductal, 10 lobular, 1 other type, and 9 DCIS). Median DCIS size was 50.0 mm (mean 54.2, CI 22.2–86.2, range 1–120).

Post-operative treatment

Six patients (21.4%) underwent post-mastectomy radiotherapy among 28 patients without previous radiotherapy, 8 patients received adjuvant chemotherapy, 28 patients endocrine therapy, and 3 patients received trastuzumab.

Post-operative outcome

The median length of post-operative hospitalization was 4 days (Table 2): 13 patients < 4 days (32.5%) and 27 patients ≥ 4 days. Hospital stay ≥ 4 days was significantly associated with periods P1 versus P2–3 (11/11 for P1 and 16/29 for P2–3, p = 0.006), robot system used (p = 0.002), and type of reconstruction (p = 0.022). Others criteria analyzed were not significant: mastectomy weight, duration of anesthesia and surgery, previous radiotherapy (≥ 4 days 17/28 without and 10/12 with radiotherapy, non-significant), mastectomy for primary BC or local recurrence, BMI, age, and number of surgical procedures. In binary logistic regression, any factor was significant for post-operative hospitalization ≥ 4 days.

The total complication rate was 20% (eight patients): seven breast complications (three grade 1 and four grade 3: five hematomas, two infections) and one LDF complication (grade 3: dorsal bleeding). In univariate analysis, periods (P1, 5/11; P2, 2/18; and P3, 1/11) and robot system used (SI 5/17 and XI 3/23) were significantly associated with complications (respectively, 0.045 and 0.025), and all others factors were non-significant, particularly the type of reconstruction, BMI, and duration of surgery. Five re-operations (12.5%) were required (five grade 3): one for dorsal bleeding and four for breast complication (two hematomas and two infections with implant removal for one patient). Re-operations for dorsal bleeding and hematomas were made during hospitalization stay. For 14 patients, we observed dorsal seroma after drain removal that required one or several punctures. Patients were discharged before drain removal. Any conversion to an open technique for LDF dissection was required.

Discussion

The purpose of this study was to assess feasibility of RLFR through a single incision around NAC required for SSM. The reproducibility of this procedure has been illustrated by no conversion to open technique, and a short axillar incision was used in 17.5% of patients particularly at the beginning of the experience. The safety of RLDFR has been also shown with only one complication for dorsal bleeding which required re-operation performed through the same incision (2.5%). We observed a significant decrease of the duration of surgery throughout the learning curve after the first period with 11 procedures. The mean duration of the whole procedure for the third period was 254 min and the robotic procedure currently lasts for approximately 45–60 min.

Very few experiences were reported for RLDF immediate breast reconstruction with no more than 17 procedures [9, 10, 11, 12]. The main differences in robotic surgical technique that should be underlined included a single incision realized around NAC for SSM and the use of a single site trocar. In Selber et al.’s study [10], seven patients were reported with RLDF reconstruction performed through an axillar incision for NSM without the use of a single site trocar. Chung et al. [12] reported 12 RLDF procedures through a 5–6-cm axillar incision without CO2 gas insufflation for three delayed breast reconstructions, four IBRs with NSM, and five cases of chest wall deformity. Clemens et al. [13] reported 17 RLDFRs in delayed-immediate breast reconstruction after SSM and placement of a tissue expander through anterior mastectomy incision without a single site trocar.

Endoscopic non-robotic LDFR was reported in several studies [4, 5, 6, 7, 8], and in 2007, Missana et al. reported a study including 52 patients [4] and more recently by others with smaller series [6, 7, 8]. Nakajima et al. [8] reported a study with 168 LDF video-assisted reconstructions but only for reconstruction after partial mastectomy. Finally, Dejode and Barranger [15] reported one case of endoscopic 3D latissimus dorsi-flap harvesting for SSM with immediate breast reconstruction.

The endoscopic approach decreases donor-site morbidity [18] but the manual control of a two dimensional in-line endoscopic camera with limited internal mobility produces an inadequate optical window around the curvature of the thorax and the rigid-tip instruments also are inadequate to work along the curvature of the thorax. The use of 3D endoscopic surgery offers a magnified view but without the seven degrees of freedom of motion at the tips of the robotic instruments.

For patients with previous radiotherapy for local recurrence or after NAC and radiotherapy [19, 20, 21], the latissimus dorsi-muscle nourishes and protects the thin skin. In these cases, RLDFR can be associated with implant according to breast size and according to patient’s choice. One or several lipofillings were next proposed in order to obtain a good cosmetic result and sufficient breast volume. SSM was proposed for patients who want an IBR for whom NSM was not indicated (NAC involvement or tumor-NAC distance < 2 cm). Latissimus dorsi-flap reconstruction was offered in selected cases according to patient’s choice and particularly for patients who do not want reconstruction with breast implant (60% without implant in our study). More and more centers offer breast implant reconstruction with acellular dermal matrix (ADM). However, covering the entire implant with a thin, expensive ADM is not generally feasible, and the use of ADMs also increases the risk of complications such as infection and seroma [22].

Conclusion

SSM with RLDFR is feasible, safe, and reproducible with a single incision for NAC resection. We reported with progressive learning curve a decrease of the duration of surgery, length of post-operative hospitalization, and complication rate. The robotic procedure currently lasts for approximately 45–60 min. Only one complication was related with RLDFR with re-operation for bleeding. After this technique standardization, we proposed to develop this procedure with several surgeons of our department using the double robotic console.

Notes

Acknowledgements

Not applicable.

Authors’ contributions

Data collection and analysis were performed by GH, MB, SR, JB, and MC. Others authors contributed to the literature studies analysis for discussion and participation to surgical procedures. All authors read and approved the final manuscript in its present form.

Funding

This work did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Ethics approval and consent to participate

This work was approved by our institutional review board (IPC—Comité d’Orientation Stratégique).

All procedures performed in this study involving human participants were done in accordance with the French ethical standards and with the 2008 Helsinki declaration.

All included patients provided written informed consent before surgery, including the use of their data for research.

Consent for publication

Not applicable

Competing interests

The authors declare that they have no competing interests.

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© The Author(s). 2019

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors and Affiliations

  1. 1.Department of Surgical OncologyPaoli Calmettes Institute and CRCM, CNRS, INSERM, Aix Marseille UniversitéMarseilleFrance
  2. 2.Department of Surgical OncologyPaoli Calmettes InstituteMarseilleFrance

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