Allen B, et al.

, J Clin Stud Med Case Rep 2025, 12: 259

DOI: 10.24966/CSMC-8801/1000259

HSOA Journal of
Clinical Studies and Medical Case Reports
Review Article

The Present and Future Data on hernia/bulge reduction from robotic technique is limited and
not yet available.

of Robotic Surgery in Conclusion: Robotic breast reconstruction offers great potential

for improving breast reconstruction in terms of donor site morbid-
Breast Cancer and Breast ity, length of incision, hospital length of stay at the cost of longer
operating times, and in-creased technical skill/ specialization, but it

Reconstruction has yet to be proven on a large scale with long-term outcome data.
Multicenter, prospective clinical data and trials are needed to help
elucidate the potential for equivalence and superiority of the min-
Brett Allen*, Alexis Knutson, Noama Iftekhar, Casey Giles, Jar- imally invasive approach compared to standard open techniques,
rell Patterson, Joshua MacDavid M and Richard Baynosa but the future is prom-ising for robotic surgery in breast cancer and
breast reconstruction.
University of Nevada Las, USA
Keywords: DIEP; Da Vinci; Latissimus dorsi; Plastic surgery; Robot-
ic breast reconstruction; Robotic surgery
Abstract
Background: Breast cancer is the second most common cancer in
Abbreviations
women with an improving mortality rate and growing need for re- The following abbreviations are used in this manuscript:
construction following oncologic resection. Advancements in robotic
surgery and minimally invasive techniques have offered refinement MDPI: Multidisciplinary Digital Publishing Institute
to traditional open techniques of flap harvest for reconstruction, par-
ticularly regarding improved donor site morbidity. DOAJ: Directory of open access journals
Methods: The literature review was based on a pub-med database LD: Latissimus Dorsi
search using the keywords “Robotic breast reconstruction” in con-
junction with the Boolean operators “Flap,” “Latissimus,” and “DIEP” DIEP: Deep inferior epigastric perforator
to specify the search. 106 Results were generated, which were then
manually reviewed and condensed for a comprehensive stance on TAP/TAPP: Transabdominal pre-peritoneal
the current status, technique, variations, and outcomes for robotic
breast reconstruction. TEP: Total extra-peritoneal

Results: Robotic technique has been described for the latissimus TRAM: Transverse rectus abdominal muscle
dorsi (LD) and deep inferior epigastric perfo-rator (DIEP) flaps for
breast reconstruction. For LD, robotic flap harvest reduces donor site UNLV: University of Nevada Las Vegas
morbidity, incisional length, hospital length of stay, with similar com-
plication rates for seroma/hematoma/infection, and longer op-erative
CT: Computed Tomography
times. Robotic LD procedures have been described in conjunction SP: Single port
with single site nipple-sparing mas-tectomy and flap elevation lead-
ing to a full minimally invasive resection and reconstruction from one Introduction
lateral incision. Robotic DIEP harvest offers a considerably smaller
fascial incision/rectus muscle dissection and has a comparable com- One of the most common reconstructive challenges faced in the
plication rate to traditional technique with shorter hospital length of modern age is that of breast reconstruction. While the lifetime risk
stay, and improved pain, at the expense of longer operating times. of developing breast cancer is about 1 in 8 for women in the US, the
mortality rate has reduced by 58% through improved screening and
treatment advancements over the last half century [1]. With the ris-
*Corresponding author: Brett Allen, University of Nevada Las, USA, Email: ing frequency of breast cancer operations/ oncologic resections, the
[email protected] need for restorative surgeries is growing as well. In the US, the long
term trend of breast cancer has decreased mortality and decreased
Citation: Allen B, Knutson A, Iftekhar N, Giles C, Patterson J (2025 The Present severity at presentation largely attributable to improved screening,
and Future of Robotic Surgery in Breast Cancer and Breast Reconstruction. J
Clin Stud Med Case Rep 12: 0259.
treatment algorithms, and detection [1,2]. Oncologic breast surgery
has evolved from the early days of radical mastectomy to modified
Received: February 11, 2024; Accepted: February 26, 2025; Published: March radical mastectomy to skin-sparing mastectomy, to nipple-sparing
03, 2025 mastectomy [3]. Focus on preserving appearance and contour has
been paramount in the evolving trends of breast surgery. In the US,
Copyright: © 2025 Allen B, et al. This is an open-access article distributed under
the terms of the Creative Commons Attribution License, which permits unrestrict- access to breast reconstruction is assured by the Women’s Health and
ed use, distribution, and reproduction in any medium, provided the original author Cancer Rights Act (WHCRA) of 1998 [4]. Breast reconstruction tech-
and source are credited. niques have evolved with two main categories arising; Implant based
Citation: Allen B, Knutson A, Iftekhar N, Giles C, Patterson J (2025 The Present and Future of Robotic Surgery in Breast Cancer and Breast Reconstruction. J Clin
Stud Med Case Rep 12: 0259.

• Page 2 of 9 •

reconstruction and autologous flap-based reconstruction. Implant System and has since revolutionized modern surgery [18]. General
based reconstruction is the more traditional of the two with many advantages of robotic surgery include tremor elimination, enhanced
similar concepts from cosmetic breast augmentation. A major pitfall precision, improved ergonomic positioning, and 3D magnification.
with implant based reconstruction is the drawbacks associated with a Robotic surgery has been found to reduce morbidity for patients with
radiated field. There is a higher rate of scar tissue formation, capsular decreased intraoperative blood loss, shorter hospital stays, reduced
contracture, and long-term deformity and the optimal reconstructive pain, and faster recovery [19-21]. The da Vinci robotic platform’s use
strategy is delayed autologous reconstruction [5]. Autologous flap has expanded from laparoscopic abdominal/ pelvic based surgeries to
based reconstruction overcomes many of these flaws by bringing the the chest, head/neck, and soft tissues [22]. Robotics in plastic/recon-
patient’s vascularized non-radiated tissue/skin into the operative/ra- structive surgery is a relatively new concept with a slower embrace
diated field. Autologous reconstruction decreases the risk of capsule due to large spacial tissue defects and the vast majority of open and
formation/contracture, implant rupture/replacement, can provide ad- non-cavitary procedures. The initial utilization of robotic assistance
ditional skin, and can be neurotizednecrotized to restore a degree of in breast reconstruction was for the dissection of the internal mamma-
sensation. Drawbacks to autologous reconstruction include selective ry vessels followed by the traditional free flap approach in 2006 [23].
patient candidacy based on habitus, donor site anatomy, morbidity/ This particular technique offered increased length for the anastomosis
complications, longer operative times, and complications associated but did have a high hematoma complication risk.
with pedicle dissection and microsurgery [6]. Autologous reconstruc-
tion is favored in breast cancer patients having undergone radiation The robot was introduced to breast reconstruction in 2012 through
but is selective and contingent on the individual characteristics of a novel study that demonstrated improved outcomes, paving the way
each patient. for further expansion of robotic techniques in the field [17]. A review
of most contemporary literature reveals two promising techniques
There are two classes of flap-based reconstruction- free flaps and for robotic assisted breast reconstruction: the latissimus dorsi (LD)
pedicled flaps. Pedicled flaps are vascularized tissue elevated from flap and the deep inferior epigastric perforator (DIEP) flap [24,25].
a nearby body part and inset to the desired site with their original Furthermore, mastectomy techniques have also been developed using
blood supply intact. Free flaps are tissue from another body part with the robot platform to perform minimally invasive quadrantectomy,
the blood vessels being transected and re-anastomosed in a new con- partial mastectomy and nipple sparing mastectomy [26]. Advances
nection [7]. Latissimus Dorsi (LD) and Deep Inferior Epigastric Per- in the Da Vinci Sp (Single Port) robotic platform that have allowed
forator (DIEP) flaps have risen as the most common flaps for breast for advances culminating in true single incision mastectomy and LD
reconstruction. The LD flap is typically harvested as a pedicled flap reconstruction [27]. Overall, minimally invasive techniques are ap-
in conjunction with an implant but can also be used by itself for small pealing for lower donor site morbidity, lower hospital length of stay,
volume breast defects in the case of partial mastectomy/quadrantec- and improved cosmesis at the expense of operative time, and surgeon
tomy or in the case of Poland syndrome which includes agenesis of learning curve.
the pectoralis muscle and chest wall deformity [8,9]. The DIEP is a
myocutaneous flap first described in the early 1990s and popularized Materials and Methods
by Blondeel that ultimately replaced the pedicled and free transverse Literature review was conducted using a PubMed database search
rectus abdominis muscle flap (TRAM) [10-12]. The DIEP gained with the MESH terms “Robotic breast reconstruction” combined with
dominance for abdominal based reconstruction due to a lower donor the Boolean operators AND “Flap” AND “Latissimus”, OR “DIEP”
site morbidity, reduced risk of hernia/ bulge, bilateral capability, and to refine the search. The search was limited to studies published in
cosmesis with the appearance of abdominoplasty. The DIEP is the English and published before November 2024. A total of 106 results
gold standard today for fully autologous breast reconstruction, partic- were generated, which were then manually reviewed. Duplicates and
ularly useful in the setting of radiated fields. Additional more exotic non-contributory articles were removed with a remaining 73 articles.
options have arisen including the superior gluteal artery perforator These were further manually reviewed for a total of 26 articles re-
(SGAP) flap, profunda artery perforator flap (PAP), superficial inferi- porting operative data and summarized to provide a comprehensive
or epigastric perforator (SIEP), transverse upper gracilis (TUG) flap, overview of the current status, techniques, variations, and outcomes
and the lumbar artery perforator (LAP) flap although the DIEP is the of robotic breast reconstruction. Cadaveric studies were excluded.
most prolific option for total autologous reconstruction [13]. Of the studies fulfilling the inclusion criteria, there were case series,
Endoscopic flap harvest techniques have been developed to reduce case reports, and retrospective case control/ cohort reviews. Internal
morbidity and incisional length but are considered very technically review regarding ethics of the study was not necessary as all informa-
difficult with limitations in instrument mobility, 2 dimensional visu- tion was gathered from previously published and publicly available
alization, and have not gained much popularity as a result of tech- sources (Figure 1).
nical challenges [14-16]. The robotic approach allows for a similar Results
minimally invasive approach with greater dexterity and potential to
overcome the laparoscopic technical limitations [17]. Robotic-Assisted latissimus dorsi (LD) flap breast recon-
struction
The National Aeronautics and Space Administration (NASA)
and the United States military initially invested in robotic assisted The LD pedicled flap is a well-established option for breast re-
techniques in hopes of creating a “telepresence” surgery where the construction, particularly for patients not eligible for an abdominal
surgeon could be in a different place from the patient. However, due based autologous reconstruction [28]. LD flaps are often selected for
to technological and practical constraints, this effort was transferred patients with smaller body habitus and have an intact thoracodorsal
to Intuitive Surgical for their da Vinci platform. Robotic assisted sur- blood supply, which may be injured during the index oncologic oper-
gery was first approved by the FDA in 2000 for the da Vinci Surgical ation particularly if there was an axillary lymph node dissection [29].

J Clin Stud Med Case Rep ISSN: 2378-8801, Open Access Journal Volume 12 • Issue 1 • 1000259
DOI: 10.24966/CSMC-8801/1000259
Citation: Allen B, Knutson A, Iftekhar N, Giles C, Patterson J (2025 The Present and Future of Robotic Surgery in Breast Cancer and Breast Reconstruction. J Clin
Stud Med Case Rep 12: 0259.

• Page 3 of 9 •

seroma (10.9% versus 8.3%), infection (14.1 versus 8.3%), delayed

wound healing (7.8% versus 0), and capsular contracture (4.7% vs. 0),
although not statistically significant likely due to small sample size.
Robotic LD had a longer operative time on average 1 hour 32 minutes
compared to 58 minutes open. Decreased average hospital length of
stay 2.7 (2-3) in the robotic LD group vs. 3.4 (3-6) in the open. At
one year follow up, the robotic cohort had similar surgical complica-
tion rates, including seroma, capsular contracture, and wound healing
[31].

A trans-axillary gasless robotic LD harvest was described by

Chung et al. in 2015. A long retractor and 2 additional port sites were
used in 12 patients who underwent robotic LD flap reconstruction,
3 delayed breast reconstructions, 4 immediate reconstructions with
nipple sparing mastectomy, and 5 patients undergoing chest wall
reconstruction for Poland Syndrome. The average robotic time was
85.8 minutes, the average operative time was 400.4 minutes, average
docking time and robotic time decreased throughout the case series.
This study also reported survey based patient satisfaction scores av-
eraging 9.2/10 for breast symmetry, 9.9/10 for scar appearance, and
9.6/10 for general esthetic over a 15.7 month follow-up period [28].

Figure: 1 PubMed database search with the MESH terms “Robotic breast The first case report for immediate robotic LD harvest following
reconstruction” combined with the Boolean operators AND “Flap” AND robotic quadrantectomy was performed in 2018 by Lai et al. for a
“Latissimus”, OR “DIEP” to refine the search, followed by application of
inclusion criteria and manual review.
patient with T3N1M0 breast cancer who underwent neoadjuvant che-
motherapy followed by robotic left upper lateral quadrantectomy and
robotic latissimus flap harvest through an axillary incision and two
Traditionally, the open LD flap requires a long incision, 15-45 cm in port incisions. The robotic time was 267 minutes but had decreased
length, where the LD is carefully dissected, paying special attention to 97 and 90 minutes during subsequent author operations. This case
to the pedicle thoracodorsal artery and vein. Alternative endoscop- was complicated by donor site seroma that resolved with serial aspi-
ic harvest techniques have been described with similar complication ration outpatient [32].
rates, improved incisional length, and post-operative pain, but they
also face technical challenges with limited mobility and difficult dis- A series of 23 robotic nipple sparing mastectomy with robotic LD
section [14,15]. The pedicled latissimus flap is elevated and tunneled harvest was performed by Houvenaeghel et al in 2019. 17 With LD
under the skin to the mastectomy site to provide implant coverage flap alone, 6 with LD flap and implant. While this study focused pri-
and inframammary fold support. Multiple variations of the robotic marily on robotic nipple sparing mastectomy and difference in robotic
LD flap harvest exist with variations in port placement, insufflation, mastectomy dissection technique, it did highlight a learning curve of
and combination with robotic nipple sparing mastectomy. The major 10-11 operations to establish a consistent learning curve for robotic
advantages of robotic LD harvest are that it allows for a smaller inci- nipple sparing mastectomy and LD reconstruction. This was followed
sion, improved cosmesis, and decreased hospital length of stay. by a separate analysis of 80 robotic LD flaps with 71 immediate ro-
The first robotic-assisted LD flaps were completed by Selber et al. botic LD flap reconstructions and 8 delayed reconstructions. This se-
in 2012 in a case series (n=8) with promising results. The robotic har- ries was performed with a 4-7 cm axillary incision varying on habitus,
vest technique employed a short axillary incision for pedicle dissec- gel port, and two separate robotic trocars at 7 mmHg insufflation. Me-
tion and two to three additional ports with 10 mmHg insufflation for dian surgery time was 301 minutes. Complication rate of 41% with 29
robotic instrumentation as opposed to a 15-45 cm incision in the tradi- patients developing donor site seroma and 1 patient who developed a
tional open technique. The robot was used to elevate the LD from the donor site hematoma requiring reoperation. Average hospital stay of
proximal port sites and release it from its distal origin and insertion 4 days [33-36].
sites with drain placement at the port sites. In the case series, robotic
Houvenaeghel et al. published another study comparing open
time decreased from 2 hours 35 minutes to 1 hour 5 minutes from
LD harvest and robotic LD harvest in skin-sparing mastectomy with
the first to the last patient (Average 1 hour 51 minutes). One reported
immediate reconstruction. 46 robot 16 with implant, 59 open 7 with
complication of contralateral transient radial nerve palsy related to
implant). The open LD group had a higher rate of neoadjuvant che-
positioning. No donor site hematoma/seroma or skin complications
motherapy 50.8% vs. 19.6% p=0.001, previous radiation 66.1% vs
[30].
30.5% p<0.0001. Higher rate of sentinel node biopsy in the robot-
Clemens et al. published the next major robotic LD study in a ic group 53.5% vs. 22% open p=0.016. Median anesthesia/ surgical
2014 retrospective cohort study based on Selber’s technique which time was higher for robotic group 356.9/290.5 minutes compared to
evaluated 12 robotic LD flaps compared to 76 total open technique 327.5/259.7 minutes open. Breast implants with LD were associated
(TOT) flap harvest in patients undergoing treatment with immediate with longer operative times and slightly longer hospital stay. Similar
tissue expansion, similar levels of radiation, and timing for delayed complication rate but there was a difference in severity of compli-
reconstruction. Robotic flap harvest had a decreased complication cations upon univariate analysis with higher severity in the robotic
rate, 16.7% robotic vs. 37.5% TOT (p=0.31), including decreased cohort requiring reoperation (2 vs. 1 open) [37].

J Clin Stud Med Case Rep ISSN: 2378-8801, Open Access Journal Volume 12 • Issue 1 • 1000259
DOI: 10.24966/CSMC-8801/1000259
Citation: Allen B, Knutson A, Iftekhar N, Giles C, Patterson J (2025 The Present and Future of Robotic Surgery in Breast Cancer and Breast Reconstruction. J Clin
Stud Med Case Rep 12: 0259.

• Page 4 of 9 •

Moon et al. published a 2020 case series of 21 robotic LD flaps robotic/endoscopic LD compared to open for posterior scar and over-
performed for Poland syndrome. This was the first case series ded- all, but no difference between robotic and endoscopic techniques [16].
icated to Poland syndrome reconstruction. 5-6 cm axillary incision
with 3 robotic ports and an axillary retractor. Lateral decubitus po- Robotic-Assisted Deep Inferior Epigastric Perforator
sitioning. Average hospital length of stay 7 days. Low complication (DIEP) Flap Breast Reconstruction
rate of 19% with 4x seromas and 1 axillary wound complication. 15
DIEP flap breast reconstruction has emerged as the gold standard
patients required re-operation 7x breast augmentations, 8x lipofilling
for autologous flap based reconstruction. The DIEP flap is based on
procedures, 4 contralateral breast surgeries [38].
perforating vessels from the deep inferior epigastric artery which pro-
Wincour et al. published a 2020 retrospective cohort study in vides blood supply extending from the external iliac artery/vein to
which 52 LD flaps were evaluated. 25 Robotic, 27 Open. Longer the abdominal wall musculature, subcutaneous adipose, and skin. The
operative times were observed with robotic technique averaging 388 DIEP is anastomosed to the internal mammary artery/vein in the chest
(245-519) vs. 311 (171-488) open. Similar complication rates were or to the thoracodorsal vessels laterally to achieve breast reconstruc-
reported although there was a notably higher rate of seroma 19% vs. tion. Robotic assistance has been applied in dissecting the recipients
0% open. Shorter hospital length of stay in the robotic group with internal mammary vessels as well as the establishment of the robotic
average of 2 vs 3 days. The authors also found a lower but not statis- DIEP harvest in dissecting the vascular pedicle [23]. One of the major
tically significant opioid use in the robotic group [39]. shortcomings in traditional DIEP harvest is abdominal rectus mus-
cle and anterior fascia damage to isolate the vascular pedicle leading
Joo et al published a 2021 case report using single incision robotic to increased rates of hernia and abdominal bulging despite fastidi-
NSM and Robotic LD using the Da Vinci SP system. 4.5 cm axillary ous primary closure. Rates of hernia/abdominal bulge have been re-
incision through which both procedures were performed. Comparable ported to be between 0.18% and 1.26% with associations with prior
time to other robotic LD flaps was observed and without additional abdominal surgery, pregnancy history, smoking and age [42]. The
ports. 100 minutes console time, 15 minute docking time, no compli- robotic DIEP harvest sets out to improve this complication rate. Two
cations, and above average breast -Q patient satisfaction score 67 vs. methods of minimally invasive DIEP harvest have been described; a
55/100 author average [27]. trans-abdominal preperitoneal (TAP) approach by Gundlapalli (2018)
and Selber (2020) and the total extraperitoneal (TEP) approach first
Cheon et al. published a 2022 retrospective case series from S.
described laparoscopically by Hivelin (2018). The difference being
Korea overview of 10 years of robotic LD flap harvest and evolu-
for the TAP approach, the peritoneal cavity is entered and the vessels
tion from DaVinci Si 2012-2014 to Xi 2014-2018 to SP 2018-2021.
are dissected with a peritoneal flap and the TEP approach uses in-
Technique had changed drastically from the Si and Xi multiport plat-
sufflation between the peritoneum and abdominal wall to isolate and
forms to single port system with retractor and 3 additional port place-
transect the vessels without entering the peritoneal cavity.
ments to single port with insufflation. Si 1 infection (7.7%), 5 seroma
(38.5%), 2 Donor site morbidity (15.4%), 8 wound problems (61.5%) The first robotic DIEP harvest was described by Gundlapalli et
Xi 2 infections (11.1%,) 6 seroma (33.3%), 1 flap loss (5.6%), 4 donor al. in a 2018 case report. A Robotic DIEP flap performed in a patient
site morbidities (22.2%), 10 wound related problems (55.6%), Sp 1 with previous neoadjuvant chemotherapy, modified radical right mas-
hematoma (10%), 2 seroma (20%), 2 donor site morbidities, (20%), tectomy, and adjuvant radiation. Left hemiabdomen DIEP flap was
2 wound related problems (20%). No significant difference in com- elevated with 1.5 cm fascial incision and 10 cm pedicle length with
plication rate between groups although it is notable that the SP group 20 minute robotic docking time and 40 minutes of console time. The
had a lower wound complication rate and seroma rate. Study applied authors claim 40 minutes is comparable with open pedicle dissection.
aesthetic scores from pre and postoperative photographs from 4 plas- Pedicle was dissected using a TAP technique with robotic running
tic surgeons with no significant difference between the groups [40]. suture closure of the peritoneum. Four robotic ports were placed on
the contralateral anterior axillary line. No immediate complication
Hwang et al. published a 2022 case series of 3 patients with Poland
occurred immediately at either the flap or donor site or at 9 month
syndrome who underwent chest wall reconstruction with Da Vinci SP
follow up. Cost analysis was $16300 patient charge for robotic proce-
system. 2 males, 1 female that had an implant and contralateral ro-
dure and $14800 for typical open procedure [24].
botic augmentation as well. No reported complications, 5 cm axillary
incision. Greatly reduced robotic docking time 8.67 minutes (4-14) Selber published a technique article outlining trans-abdominal
compared to previously reported averaging 23-55 minutes [41]. pre-peritoneal DIEP harvest (TAP). The described technique uses
three ports on the contralateral side identical to robotic rectus muscle
Eo et al. published a 2024 Korean single-institution first of its kind
flap port placement and a reported 1.5-3.0 cm fascial incision and
study comparing robotic, endoscopic and open LD reconstruction fol-
10-15 cm of pedicle length. Large emphasis was placed on pre-oper-
lowing partial mastectomy. 17 Endoscopic LD, 20 robotic, 20 open
ative planning with CTA and favorable perforator anatomy with short
cases were performed. Robotic technique used an axillary incision
intramuscular course and 1-2 closely grouped perforators. Authors
and single inferior port using the Da Vinci Si system. There was a
reported a subjective decrease in pain and hospital stay [43].
significantly longer average operative time for robotic (394.4) com-
pared to endoscopic (316.6) and open (279.8). Significantly higher Choi et al. Described the first extraperitoneal (TEP) DIEP harvest
robotic time than endoscopic operative time (robot 75.7+-30.7, En- in 2021 utilizing the Da Vinci SP system and placing the single robot
doscopic 34.5 +-12.9 p<0.001). No significant difference in opioid port through the neo-umbilicus. This method conserves the posterior
use among techniques. No significant difference in hospital length rectus sheath and does not enter the peritoneal cavity reducing the
of stay. No significant difference in complication rates. There was a risks associated with abdominal surgery (Bowel injury, adhesions,
significant difference in patient satisfaction using patient survey mod- etc.) 17 of 21 DIEP patients were performed with this method from
ified BREAST-Q scores, with higher rates of patient satisfaction for 9/2019-8/2020 with inclusion criteria being an intramuscular vascular
J Clin Stud Med Case Rep ISSN: 2378-8801, Open Access Journal Volume 12 • Issue 1 • 1000259
DOI: 10.24966/CSMC-8801/1000259
Citation: Allen B, Knutson A, Iftekhar N, Giles C, Patterson J (2025 The Present and Future of Robotic Surgery in Breast Cancer and Breast Reconstruction. J Clin
Stud Med Case Rep 12: 0259.

• Page 5 of 9 •

segment <5 cm. The described technique involved 1.5 cm incision case of disposable cost endoscopically, ∼$495 for TEP laparoscopic
on the ipsilateral linea semilunaris for blunt finger dissection in the harvest, and ∼$1487 for TAP robotic harvest. The average length of
extraperitoneal space followed by 2 cmx2 cm cross incision at the stay significantly differed, as subjects in the TAP robotic cohort re-
new umbilicus for the robot port. Muscular pedicle dissection is per- mained in the hospital for an average of 4.7 days versus 2.8 and 2.5
formed open, followed by robotic dissection to the origin at the ex- days in the endoscopic and TEP laparoscopic cohorts. This increased
ternal iliac. Average robotic time 65+-33 mins. Average surgery time length of stay in the robotic cohort is skewed by additional procedures
487+-93 mins. Metrics on complication rate, hospital length of stay, performed for robotic cohort patients. Overall the authors prefer lap-
comparison to open technique, or follow up were not published [44]. aroscopic TEP technique and the study has confounding variables as
the all patients in the robotic DIEP cohort also underwent concurrent
Kurlander et al. (including Selber) published a retrospective study intra-abdominal procedures [47].
analyzing preoperative CT angiogram for Robotic DIEP eligibility
from 2017-2021. CT angiograms were reviewed for 49 patients (98 Wittessaele et al. published a 2021 case series of 10 TAP robotic
hemiabdomens). Inadequate or no perforators were identified on CTA DIEP flaps. All flaps were unilateral with ipsilateral docking of the
in 18% of hemiabdomens. Mean predicted robotic and open DIEP robot and 3 ports. Average docking time was 27.5 minutes (16-40),
fascial incisions were 3.1 cm and 12.2 cm, respectively, giving robot- average fascial incision was 3 cm, average console time was 86 min-
ic approach fascial incision benefit of 9.1 cm (P < 0.001). The predict- utes (52-162), surgery duration was 479 (409-552). Patients were fol-
ed robotic incision avoided crossing the arcuate line in 71% of hemi- lowed up at 2 and 6 weeks. No intra-abdominal complication or flap
abdomens. Thirteen patients (28%) underwent robotic DIEP harvest. loss. 1x Hematoma occurred at the recipient site requiring evacuation.
Actual robotic fascial incision length averaged 3.5 cm, which was not Authors are supportive of robotic surgery, had no prior robotic expe-
significantly different from the mean predicted fascial incision length rience and are confident that with additional practice, operative time
(P = 0.374). Robotic DIEP flaps had fewer perforators (1.8 versus 2.6, will be comparable to open with considerably smaller fascial defect
P = 0.058). 27% of patients analyzed underwent robotic DIEP and [48].
the authors proposed more patients were eligible for the procedure
than those receiving. A large emphasis was also placed on having an Lee et al. published a 2022 retrospective cohort study comparing
anterior fascial incision above the arcuate line to minimize the risk of 186 open unilateral DEIP flaps to 21 unilateral TEP single port robotic
hernia with an intact posterior rectus sheath [45]. flaps. Technique was similar to previously described with single ro-
botic port at the neo-umbilicus. There was found to be a longer opera-
Piper et al. published 2021 four patient case series from UCSF for tive time in the robotic cohort (509+-71 vs. 438 +-83) but significant-
TAP robotic DIEPs. Notably the included patients also underwent an- ly decreased length of stay (7.92+-1.2 vs. 8.77 +-1.74), improved pain
other robotic intra-abdominal procedure at the same time as bilateral scores, less narcotic use and significantly higher scores for post-op-
DIEP harvest and breast reconstruction minimizing a need for a sec- erative psychosocial well-being (p=0.007), physical well-being of the
ond operation. The first patient also underwent gastric resection for chest (p=0.028), and physical well-being of the abdomen (p=0.02).
benign mass. Pedicle dissection time was 38 minutes, Hospital stay Complications were reported 5.3% (1) Flap loss, 5.3% (1) Fat necro-
was 10 days. The second patient was BRCA2 positive and underwent sis in the robotic cohort and 2.2% Flap loss (4), 1.1% (2) fat necrosis,
prophylactic oophorectomy during the same operation. DIEP pedicle 1.1% (2) Seroma, 6.5% (12) donor site wound problem in the open
dissection time was 42 minutes, she was discharged on hospital day 2. cohort [49,50].
3rd patient was BRCA2 positive and underwent robotic hysterectomy
Jung et al. published a 2022 case report of a patient that under-
and bilateral salpingo-oophorectomy. Pedicle dissection time was 52
went robotic nipple sparing mastectomy with immediate single port
minutes and hospital stay was 2 days. 4th patient BRCA2 positive and
TEP robotic DIEP. No complications, 7 day hospital stay and 7 month
underwent concurrent hysterectomy and bilateral salpingo-oophorec-
follow up. This was the first report of a fully robotic resection and
tomy. Pedicle dissection time was 48 minutes and she was discharged
immediate DIEP reconstruction using the Da Vinic SP system [50].
after 2 days of hospitalization. Notably, this was the first time a bilat-
eral DIEP flap harvest was performed with another intra-abdominal Bishop et al. published a 2022, 21 patient case series on multi-
procedure [46]. port TAP robotic DIEP reconstruction. 10% of patients had a prior
intra-abdominal surgery. Average fascial incision was 3.6 +-1.6 with
Shakir et al. performed a 2021 retrospective cohort analysis of en- an average pedicle length of 13.3 +-1, console time of 45+-9 minutes,
doscopic DIEP compared to laparoscopic TEP and Robotic TAP. 94 total surgery duration of 425+-70 unilateral, 511+-67 bilateral. Aver-
Patients underwent endoscopic DIEP harvest, 38 underwent TEP LAP age hospital stay was 3.8 days +-0.9. Average follow up of 5 months,
harvest, and 3 patients underwent robotic bilateral reconstruction. All 31.3%(5) Surgical site occurrence, 1x wound healing complication,
3 robotic patients underwent synchronous additional intra-abdominal no flap loss or hernia/ bulging. Post-operative pain analysis was per-
procedures at the time of operation; 2x abdominal hysterectomy and formed in which 5 patients had bilateral flaps, one harvested roboti-
bilateral salpingo-oophorectomy and 1 partial gastrectomy. Average cally and the other open and were blinded to which side was harvested
operative times varied from 249 minutes for a unilateral endoscop- robotically. 4/5 patients reported less pain on the robotic side with bi-
ic DIEP, 535 minutes for bilateral endoscopic harvest, 335 minutes lateral TAP blocks. Analysis of CTA positive predictability of fascial
for unilateral TEP laparoscopic harvest, 453 for bilateral TEP lap- incision was 86% accurate within 2 cm/75% standard difference of
aroscopic harvest, and 535 for bilateral TAP robotic harvest. 5/142 predicted fascial incision from CT scan, validating CTA as a reliable
Endoscopic and 2/67 TEP Lap patients had perforator injuries during pre-operative planning modality for robotic DIEP candidacy [51].
dissection 0/3 in robotic cohort. Endoscopic cohort had 1x arterial
thrombus, 3x venous congestion and TEP laparoscopic cohort had 1x Tsai et al. Published a 2023 retrospective cohort study comparing
venous congestion. No robotic complications reported. Cost analysis 13 (11 unilateral 2 bilateral) robotic DIEP flaps to 86 (62 unilateral, 24
was performed with additional increase of approximately ∼$234 per bilateral) open DIEP flaps. Robotic flaps were harvested in multiport

J Clin Stud Med Case Rep ISSN: 2378-8801, Open Access Journal Volume 12 • Issue 1 • 1000259
DOI: 10.24966/CSMC-8801/1000259
Citation: Allen B, Knutson A, Iftekhar N, Giles C, Patterson J (2025 The Present and Future of Robotic Surgery in Breast Cancer and Breast Reconstruction. J Clin
Stud Med Case Rep 12: 0259.

• Page 6 of 9 •

TAP fashion with novel port placement described with a supra-umbil- Moreira et al. published a 2024 follow-up matched retrospective
ical camera port and bilateral instrument ports 10 cm from the midline cohort study to Murariu’s study comparing multiport TAPP robotic
at the corners of the skin incision near the linea semilunaris. This DIEP to open technique. Forty-seven patients were included (48 stan-
port placement does not require re-docking for contralateral pedicle dard DIEP flaps, 46 robotic DIEP flaps) with similar patient charac-
dissection for bilateral DIEP flaps. Preoperative imaging with CTA teristics and prior abdominal surgical histories. Fascial incision length
was used and criteria for robotic candidacy was <2.5 cm intramuscu- in the robotic DIEP group was shorter (4.1 vs. 11.7 cm, p < 0.001) with
lar pedicle course. Significantly shorter fascial incision was reported no significant difference in pedicle length (p=0.238). Mesh reinforce-
2.7+-1.1cm robotic vs 8.1+-1.7cm open (p<0.0001). Robotic time ment of the abdominal wall was used in 13/24 standard DIEPs and
was reported to be 53+-13 cm for pedicle dissection and 22+-3.5 cm none in robotic DIEP patients (p < 0.001). Operative time was longer
for peritoneal closure. Approximately 100 additional minutes of op- in the robotic DIEP cohort (739 vs. 630 minutes, p = 0.013), although
erating time were required for robotic DIEP with approximate cost sub-analysis showed no significant difference in the operative times
increase of $3500 in robotic instruments and disposables. 1 minor of the second half of the robotic cohort attributable to robotic expe-
wound healing complication reported in robotic cohort and 2 minor rience and learning curve. The average robotic dissection time was
wound healing complications were reported in the open cohort. Both 135 minutes, which decreased significantly with the surgeon’s ex-
cohorts had a 3 day ICU admission post-operatively for flap monitor-
perience. There were no intraoperative complications in the robotic
ing, before mobilization on hospital day 4. Follow up at 2, 4, and 12
weeks. No statistical difference in pain scores between robotic and cohort. Hospital length of stay was shorter with robotic DIEP, but
open cohorts on hospital day 1-3 [52]. not statistically significant (3.9 vs. 4.3 days, p = 0.157). Overall, the
study highlights the viability of robotic DIEP harvest with decreased
Murariu et al. published a 2024 retrospective cohort study con- fascial incision, similar immediate complication rates, decreased need
sisting of 46 bilateral robotic DIEP flaps (23 patients) outlining TAP for anterior rectus mesh use, and decreased robotic time with practice
multiport robotic flap harvest technique similar to that described by [56].
Tsai. 3 Ports (supraumbilical camera and bilateral instrument ports)
were used in conjunction with the first reported use of ICG dye in ro- Discussion
botic DIEP for pedicle identifications and dissection. Average fascial
incision of 4.1 cm, average pedicle length of 12.8. Average console Latissimus Dorsi and DIEP are two flaps currently being harvested
time of 139 minutes, average OR time of 739 minutes. Average hos- for breast reconstruction with robotic technology. Various techniques
pital stay of 3.9 days with 90 day follow up. No flap harvest/pedicle have been described using multiport vs. single port systems, variance
injuries occurred, there was one patient that had partial flap necro- of port placement, retraction vs. insufflation, TAP vs. TEP approach.
sis requiring a revision surgery and one patient with an abdominal Overall, the majority of literature has been published from single in-
wound complication. No cases of post-operative hernia or bulging. stitutions and have found improved cosmesis/patient satisfaction for
There were 2 instances where the case was converted to traditional robotic latissimus harvest with considerably smaller skin incision
technique, one was due to dense intraperitoneal adhesions prevent- while retaining similar flap efficacy and complication rates. Robotic
ing safe identification and dissection robotically, and one with a prior technology allows for the possibility of a single axillary incision for
hematoma following C-section obscuring the anatomy and requiring robotic nipple sparing mastectomy and reconstruction with ipsilateral
traditional dissection on one side. Overall, this study establishes mul- LD. For DIEP flaps, robotic harvest has shown consistently smaller
tiport TAP robotic DIEP as a valid technique to minimize fascial inci- fascial incision during pedicle dissection with similar complication
sional length. Authors recommend assistance with a general surgeon rates to the open technique. There is a limited patient population that
for robotic portion until comfortable with robotic pedicle dissection qualifies for robotic DIEP requiring a short intramuscular perforator
and the novel use of indocyanine green dye (ICG) fluorescence to course, and 2 maximum perforators. Long-term data for reduction
assist in identification of pedicle vessels [53,54]. abdominal bulge and hernia has yet to be seen, but preliminary data
is promising. Robotic TAP DIEP harvest can also be combined with
Moreira et al. published a 2024 retrospective cohort study evaluat- other robotic intra-abdominal procedures at the same time if needed.
ing the learning curve for a plastic surgeon compared to robotics cer- The Da Vinci SP (Single Port) system has shown great promise in the
tified general surgeon in TAP multiport robotic DIEP pedicle dissec- TEP DIEP harvest, sparing intra-abdominal complications with small
tion. Using the cumulative sum method, there were 44 flap dissections fascial incisions, although has limited approval for use in the US.
performed, 27 by the plastic surgeon and 17 by the general surgeon. Overall, robotic flap harvest has been shown to have similar efficacy
There was no significant difference in dissection time between the GS as traditional techniques, similar immediate complications, improved
(34.8 minutes) and PS (44.6 minutes) (P = 0.366). Both surgeons saw cosmesis, slightly higher cost, increased operating time that decreases
a decrease in dissection time with increasing number of cases. Cumu- with surgeon experience/learning curve, with long-term complica-
lative sum peaked at patient 9 for the PS and patient 5 for the GS, after tions yet to be seen.
which dissection time consistently decreased to significantly faster
dissection times at the end of the study period. 7 patients had a bilat- Future advances in robotic reconstructive surgery are likely going
eral procedure where one surgeon performed the dissection on each to be guided by innovative systems, such as the Da Vinci SP (Single
side, but the sample size was too small to be amenable for meaning- Port) System, Microsure MUSA, MMI Symani microsurgery robotic
ful analysis. There were no intra-abdominal injuries, pedicle injuries, system, BHS Roboticscope digital microscope. Robotic systems have
conversion to open, flap losses or long-term complications of hernia/ been used for head and neck reconstruction anastomoses with limited
bulge after 1 year of follow up. After 10 flap harvests, comparable space, peripheral nerve/brachial plexus repair, and with lymphaticov-
operative times between plastic and general surgeons were achieved. enous bypass procedures for lymphedema treatment [57]. The next
Overall, this study shows feasibility of robotics in plastic surgery with forefront in robotic microsurgery/reconstruction is in its infancy with
a short learning curve for robotic training, high level of safety and the use of novel systems to perform microsurgery and supermicrosur-
improved donor site morbidity after approximately 10 cases [55]. gery < 1mm on blood vessels, lymphatics, and nerves. The Symani
J Clin Stud Med Case Rep ISSN: 2378-8801, Open Access Journal Volume 12 • Issue 1 • 1000259
DOI: 10.24966/CSMC-8801/1000259
Citation: Allen B, Knutson A, Iftekhar N, Giles C, Patterson J (2025 The Present and Future of Robotic Surgery in Breast Cancer and Breast Reconstruction. J Clin
Stud Med Case Rep 12: 0259.

• Page 7 of 9 •

system is starting to be used for these applications with movement Funding

scaling 7-20 fold, tremor elimination, robotic technology is advanc-
ing to a point where it will outperform even the most skilled surgeons This research received no external funding.
based on physiologic limitations [58-60]. The Symani system has Institutional Review Board Statement
started to be used in Europe over the last few years and has recently
gained FDA approval in the US in April 2024. It has been shown to Ethical review and approval were waived for this study due to en-
have similar efficacy as hand-sewn anastomoses in emergent hand re- tirety of data and literature reviewed being previously published, pub-
construction with promising results after a learning curve of 10 cases licly available, and no experimentation/procedures were performed
with 30% increase in speed [61]. The MUSA system has been used involving humans/animals.
for supermicrosurgical lymphaticovenous bypass to treat breast can-
cer associated lymphedema and shown to be non-inferior to manual Data Availability Statement
bypass at one year follow up [62]. There is great potential for the use
of new robotic systems, taking robotic reconstructive surgery to new Data available in a publicly accessible repository: The original
heights. data presented in the study are openly available within the PubMed
database at [pubmed.ncbi.nlm.nih.gov]. Individual source reference
Conclusion information is located within the citations of the reference section.
Robotic plastic surgery and flap harvesting for breast reconstruc- Acknowledgments
tion is still in its early stages. There is great promise shown in reduc-
ing donor site morbidity, complications, and incision while retaining Not applicable
a similar or improved degree of cosmesis, lower complication rate,
and quality for the result at the expense of cost and operative time.
Conflicts of Interest
The two flaps being used for breast reconstruction robotically are the The authors declare no conflicts of interest. Study was self-funded
Latissimus Dorsi and the DIEP flap. The major advantage to the LD in association with the University of Nevada Las-Vegas.
is a smaller incision leading to a lower wound complication rate and
improved cosmesis. The major advantage of a robotic DIEP is a more Disclaimer/Publisher’s Note
precise and less traumatic harvest of the inferior epigastric perforator
The statements, opinions and data contained in all publications
vessels minimizing the fascial defect, potentially leading to a reduc-
are solely those of the individual author(s) and contributor(s) and not
tion in hernia and abdominal bulging post-operatively due to preser-
of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim re-
vation of fascia and anterior rectus sheath.
sponsibility for any injury to people or property resulting from any
Limitations and Future Directions ideas, methods, instructions or products referred to in the content.

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J Clin Stud Med Case Rep ISSN: 2378-8801, Open Access Journal Volume 12 • Issue 1 • 1000259
DOI: 10.24966/CSMC-8801/1000259
Citation: Allen B, Knutson A, Iftekhar N, Giles C, Patterson J (2025 The Present and Future of Robotic Surgery in Breast Cancer and Breast Reconstruction. J Clin
Stud Med Case Rep 12: 0259.

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Journal Of Alzheimers & Neurodegenerative Diseases | ISSN: 2572-9608 Journal Of Non Invasive Vascular Investigation | ISSN: 2572-7400

Journal Of Anesthesia & Clinical Care | ISSN: 2378-8879 Journal Of Nuclear Medicine Radiology & Radiation Therapy | ISSN: 2572-7419

Journal Of Angiology & Vascular Surgery | ISSN: 2572-7397 Journal Of Obesity & Weight Loss | ISSN: 2473-7372

Journal Of Animal Research & Veterinary Science | ISSN: 2639-3751 Journal Of Ophthalmology & Clinical Research | ISSN: 2378-8887

Journal Of Aquaculture & Fisheries | ISSN: 2576-5523 Journal Of Orthopedic Research & Physiotherapy | ISSN: 2381-2052

Journal Of Atmospheric & Earth Sciences | ISSN: 2689-8780 Journal Of Otolaryngology Head & Neck Surgery | ISSN: 2573-010X

Journal Of Biotech Research & Biochemistry Journal Of Pathology Clinical & Medical Research

Journal Of Brain & Neuroscience Research Journal Of Pharmacology Pharmaceutics & Pharmacovigilance | ISSN: 2639-5649

Journal Of Cancer Biology & Treatment | ISSN: 2470-7546 Journal Of Physical Medicine Rehabilitation & Disabilities | ISSN: 2381-8670

Journal Of Cardiology Study & Research | ISSN: 2640-768X Journal Of Plant Science Current Research | ISSN: 2639-3743

Journal Of Cell Biology & Cell Metabolism | ISSN: 2381-1943 Journal Of Practical & Professional Nursing | ISSN: 2639-5681

Journal Of Clinical Dermatology & Therapy | ISSN: 2378-8771 Journal Of Protein Research & Bioinformatics

Journal Of Clinical Immunology & Immunotherapy | ISSN: 2378-8844 Journal Of Psychiatry Depression & Anxiety | ISSN: 2573-0150

Journal Of Clinical Studies & Medical Case Reports | ISSN: 2378-8801 Journal Of Pulmonary Medicine & Respiratory Research | ISSN: 2573-0177

Journal Of Community Medicine & Public Health Care | ISSN: 2381-1978 Journal Of Reproductive Medicine Gynaecology & Obstetrics | ISSN: 2574-2574

Journal Of Cytology & Tissue Biology | ISSN: 2378-9107 Journal Of Stem Cells Research Development & Therapy | ISSN: 2381-2060

Journal Of Dairy Research & Technology | ISSN: 2688-9315 Journal Of Surgery Current Trends & Innovations | ISSN: 2578-7284

Journal Of Dentistry Oral Health & Cosmesis | ISSN: 2473-6783 Journal Of Toxicology Current Research | ISSN: 2639-3735

Journal Of Diabetes & Metabolic Disorders | ISSN: 2381-201X Journal Of Translational Science And Research

Journal Of Emergency Medicine Trauma & Surgical Care | ISSN: 2378-8798 Journal Of Vaccines Research & Vaccination | ISSN: 2573-0193

Journal Of Environmental Science Current Research | ISSN: 2643-5020 Journal Of Virology & Antivirals

Journal Of Food Science & Nutrition | ISSN: 2470-1076 Sports Medicine And Injury Care Journal | ISSN: 2689-8829

Journal Of Forensic Legal & Investigative Sciences | ISSN: 2473-733X Trends In Anatomy & Physiology | ISSN: 2640-7752

Journal Of Gastroenterology & Hepatology Research | ISSN: 2574-2566

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