Robotic approach for lymphadenectomy of internal mammary lymph nodes in breast cancer: Five case reports

Internal mammary (IM) lymphadenopathies in breast cancer indicate a worse prognosis than axillary metastases, yet they are rarely assessed. Accurate staging is essential for treatment planning. Robotic biopsy offers a promising alternative to video-assisted thoracic surgery for precise histological sampling. This article outlines a systematic robot-assisted dissection approach to enhance staging accuracy and optimize breast cancer management.

At our institution, robotic lymphadenectomy of the IM chain was performed in 5 patients between July 2020 and December 2024. Patients were positioned in a 30° semi-supine position with a roll under the shoulder to elevate the chest. The camera port was inserted in the fifth intercostal space along the mid-axillary line, allowing a 0°, 12 mm robotic camera to inspect the chest cavity; CO₂ insufflation (8 L/minute, 8-10 mmHg) facilitated lung collapse and pneumo-mediastinum formation for improved dissection. Under direct vision, two additional operative ports were placed: One in the third intercostal space (anterior axillary line) and another in the fifth intercostal space (3-4 cm lateral to the parasternal line). The mean operative time was 118 minutes, with a median hospital stay of two days. No major complications occurred. Histology confirmed breast carcinoma metastases in three patients, while two had benign disease.

Robotic biopsy of IM lymph nodes is safe, feasible, and provides key information on breast cancer management, with very rare contraindications.