腔镜辅助下行乳腺癌切除后斜行带蒂腹直肌肌皮瓣即刻乳房再造术

Endoscopic nipple-sparing mastectomy with immediate breast reconstruction using oblique pedicled rectus abdominis myocutaneous flap

目的探讨在腔镜技术辅助下完成乳腺癌病灶切除, 以斜行带蒂腹直肌肌皮瓣即刻再造乳房的临床价值及治疗效果。方法回顾性分析2023年5至9月湖南省肿瘤医院收治的乳腺癌切除后以斜行带蒂腹直肌肌皮瓣即刻再造乳房的患者资料。手术方法:首先采用腔镜技术通过侧胸切口完成腋窝前哨淋巴结活检和乳腺癌皮下腺体切除术, 然后制备去表皮的单侧斜行带蒂腹直肌肌皮瓣, 直视下分离腹直肌肌蒂表面的皮下隧道, 进一步在腔镜辅助下分离腹直肌肌蒂到乳房深面的皮下隧道, 转移斜行带蒂腹直肌肌皮瓣再造乳房。术后观察皮瓣成活情况, 出院后加强抗瘢痕治疗和功能康复锻炼, 对再造乳房外形、供受区切口瘢痕情况、腹壁功能、肿瘤复发及转移情况等进行随访。结果共纳入8例女性单侧乳腺癌患者, 年龄27~52岁, 平均41.7岁;体重指数为19.1~22.5 kg/m^(2);均为早期乳腺癌。术中切除乳房组织平均质量为245 g(220~285 g), 侧胸切口长度为6.9~9.5 cm, 平均7.7 cm, 3例采用同侧、5例采用对侧斜行带蒂腹直肌肌皮瓣再造乳房, 皮瓣长(20.4±0.7) cm、宽(10.8±1.5) cm、厚(5.4±0.9) cm, 皮瓣切取体积为19.7 cm×9.2 cm×4.4 cm~21.2 cm×11.8 cm×5.9 cm。所有皮瓣血运良好, 无需额外吻合血管, 全部顺利成活。术后随访8~10个月, 平均8.7个月, 再造乳房外形良好, 质地满意, 无皮瓣挛缩变形, 与健侧乳房外形基本对称;皮瓣供区及乳房受区切口愈合良好, 仅遗留线性瘢痕, 腹壁功能无明显影响。随访期间患者均未见肿瘤复发或转移。结论腔镜技术有助于最大程度地保留乳房皮肤组织的完整性, 减少瘢痕, 同时可协助分离皮下隧道便于带蒂腹直肌肌皮瓣转位再造乳房;对于乳房中等偏小且下腹部皮下组织量较富裕的患者, 制备单侧斜行带蒂腹直肌肌皮瓣再造乳房可获得较好的效果, 且不会额外增加供区损伤, 在提高手术安全性的同时明显降低手术难度。

Objective To explore the clinical value and therapeutic effects of endoscopic nipple-sparing mastectomy combined with immediate breast reconstruction using an oblique pedicled rectus abdominis myocutaneous flap(ORAMF).Methods The data of patients admitted to Hunan Cancer Hospital from May to September 2023 who underwent breast cancer resection followed by immediate breast reconstruction with ORAMF were analyzed retrospectively.Surgical methods:firstly,axillary anterior sentinel lymph node biopsy and subcutaneous glandular excision for breast cancer were performed through a lateral chest incision using an endoscopic technique.Subsequently,a unilateral ORAMF was prepared by removing the epidermis and creating subcutaneous tunnels on the surface of the rectus abdominis myocutaneous flap under direct visualization.The subcutaneous tunnel of the flap was then extended to the deep surface of the breast with the assistance of an endoscope,allowing for the transfer of the ORAMF to reconstruct the breast.Post surgery,the flap survival was monitored,and after discharge,patients received enhanced anti-scar treatment and functional rehabilitation exercises.Follow-up assessments included the evaluation of the reconstructed breast shape,incision scarring in both the donor and recipient areas,abdominal wall function,tumor recurrence and metastasis.Results A total of 8 female patients with unilateral breast cancer were included in this study,aged between 27 and 52 years,with a mean age of 41.7 years old.The body mass index of the patients ranged from 19.1 to 22.5 kg/m^(2).All patients had early-stage breast cancer.During the operation the average mass of the resected breast was 245 g(ranging from 220 to 285 g).The length of the lateral thoracotomy incision varied from 6.9 to 9.5 cm,with a mean length of 7.7 cm.In 3 cases,the ipsilateral ORAMF was used for breast reconstruction,while in 5 cases,the contralateral ORAMF was utilized.The dimensions of the flap were as follows:length(20.4±0.7)cm,width(10.8±1.5)cm,thickness(5.4±0.9)cm,with the volume of the flap cutting ranging from 19.7 cm×9.2 cm×4.4 cm to 21.2 cm×11.8 cm×5.9 cm.All of the flaps exhibited good blood supply and survived successfully without the need for additional anastomotic vessels.The patients were followed up for a period of 8 to 10 months post-operation,with an average follow-up of 8.7 months.The reconstructed breasts maintained a good shape and texture,showing no contracture or deformation of the flap,and were generally symmetrical with the healthy breast.The incisions in both the flap donor area and the recipient area had healed well,leaving only linear scars,and the function of the abdominal wall was not significantly compromised.No recurrence or metastasis was observed during the follow-up period.Conclusion The endoscopic technique helps to preserve the integrity of the breast skin tissue to the greatest extent possible,reducing scarring and assisting in the creation of subcutaneous tunnels to facilitate the transposition of the ORAMF for breast reconstruction.For carefully selected patients with moderately small breasts and ample subcutaneous tissue in the lower abdomen,the preparation of a unilateral ORAMF for breast reconstruction can yield superior results.This approach minimizes additional damage to the donor area,enhancing the safety of the surgery while significantly reducing the complexity of the operation.