title: Single-incision transumbilical levels 1 and 2 axillary lymph node dissection using a flexible endoscope in human cadaveric models.
abstract: BACKGROUND
  The use of the flexible endoscope as a surgical platform potentially exposes a range of new surgical approaches and benefits yet to be fully defined. A new method using the flexible endoscope to undertake axillary dissection for breast cancer treatment is explored together with an investigation into its acceptability to the general public.
  
  
  METHODS
  Endoscopic axillary dissection via a transumbilical approach using the flexible endoscope passed subcutaneously from the umbilicus is described for four human cadaveric axillas. A questionnaire, validated by clinicians, explored the general public's reaction to the approach and how it might be influenced by potentially serious morbidity such as an increased rate of cancer recurrence.
  
  
  RESULTS
  All axillas were accessed successfully via the transumbilical approach. Levels 1 and 2 axillary dissection was attempted on four axillas. Scarring from previous axillary surgery prevented dissection in one case. In the remaining three cases, respectively 12, 11, and 14 lymph nodes were harvested. The operative times improved with each case, from 1080 to 390 min. A total of 127 people responded to the questionnaire, with 73 % preferring the described approach over the open and periareolar alternatives when morbidities were considered equivalent. When a hypothetical elevated risk of cancer recurrence was included with the transumbilical approach, one-fifth of the public still accepted the approach due to the likelihood of a superior cosmesis.
  
  
  CONCLUSIONS
  The use of the flexible endoscope for oncologically safe levels 1 and 2 axillary dissection is possible and would be acceptable to the general public if it were clinically approved. However, significant challenges with the current endoscopic equipment and relevant instrumentation limit the potential of the technique. Technical innovation in terms of new instrument design with improved ergonomics will reduce long operating times and fatigue, thus ensuring surgical acceptance of the flexible endoscope.
authors.affiliation: Hamlyn Centre for Robotic Surgery, Institute of Global Health Innovation, Imperial College London, 3rd Floor Patterson Centre, South Warf Road, Paddington, London W2 1NY, UK. j.clark@imperial.ac.uk
authors.forename: James
authors.initials: J
authors.lastname: Clark
authors.forename: Daniel Richard
authors.initials: DR
authors.lastname: Leff
authors.forename: Mikael
authors.initials: M
authors.lastname: Sodergren
authors.forename: Richard
authors.initials: R
authors.lastname: Newton
authors.forename: David
authors.initials: D
authors.lastname: Noonan
authors.forename: Robert
authors.initials: R
authors.lastname: Goldin
authors.forename: Ara
authors.initials: A
authors.lastname: Darzi
authors.forename: Guang-Zhong
authors.initials: GZ
authors.lastname: Yang
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001365:Axilla; D002102:Cadaver; D019723:Endoscopes; D004724:Endoscopy / Q000379:methods*; D004867:Equipment Design; D005260:Female; D006801:Humans; D008197:Lymph Node Excision / Q000379:methods*; D008297:Male; D008875:Middle Aged; D011639:Public Opinion; D011795:Surveys and Questionnaires; D014472:Umbilicus; D055815:Young Adult