SRRSHwb-BDBCS: urinary catheter-directed breast-conserving surgery following vacuum-assisted breast biopsy—a step-by-step surgical technical guide

Introduction

Breast cancer is the most commonly diagnosed malignancy among women worldwide and remains a leading cause of cancer-related death. Compared with conventional core needle biopsy, vacuum-assisted breast biopsy (VABB) is widely established as a preferred diagnostic evaluation for breast lesions, offering larger tissue volumes and significantly reducing underestimation rates (1-6). This high diagnostic accuracy has solidified its role as a preferred method for sampling imaging-detected abnormalities, particularly those that are morphologically indeterminate (2,7,8). Beyond standard diagnosis, VABB is being increasingly utilized for large-volume excisional biopsy of low-suspicious lesions. In select centers, particularly in East Asia and parts of Europe, VABB serves as a minimally invasive approach alternative to open excision for Breast Imaging Reporting and Data System (BI-RADS) category 3 or 4A lesions (5,9-11). Additionally, VABB plays a growing role in assessing residual disease following neoadjuvant systemic therapy (NST) (12).

Despite these advantages, VABB creates a specific technical dilemma: complete removal of the target lesion eliminates the intraoperative landmarks required for subsequent surgical excision. This localization unreliability manifests in three distinct scenarios. First, the diagnostic VABB of small lesions may confirm malignancy when all sonographic evidence of the tumor is removed, leaving no residual mass for subsequent intraoperative guidance (13). Second, large-volume excisional biopsy of low-suspicious lesions (BI-RADS 3 or 4A) intentionally removes the entire nodule for definitive diagnosis. These low-suspicious nodules carry malignancy rates less than 10%. Thus, when malignancy is confirmed, the absence of a residual target complicates subsequent surgical resection (14). Third, post-NST VABB confirms residual cancer burden within fibrotic, architecturally distorted tumor beds where traditional localization fails (12).

Breast-conserving surgery (BCS) followed by adjuvant radiotherapy is a standard treatment for early-stage breast cancer, offering oncologic outcomes equivalent to those of mastectomy while preserving the breast and improving quality of life (15). Successful BCS fundamentally depends on precise intraoperative localization of the tumor to ensure complete excision with clear margins. This requirement for precision poses a particular challenge after VABB.

In all three scenarios, the removal or distortion of the original imaging target creates substantial uncertainty for BCS. The inability to reliably localize the original lesion site creates a significant clinical dilemma. Surgeons face the dual risks of violating oncologic principles by cutting directly into the tumor bed or performing excessively wide excisions that compromise cosmesis, particularly in patients with smaller breast volumes. Consequently, localization uncertainty drives surgical conservatism, as many patients unnecessarily undergo mastectomy (16).

Current localization strategies are associated with significant limitations. Intraprocedural clip placement poses a migration risk and offers poor ultrasound visualization (17-19). Immediate surgery after VABB may benefit from a palpable hematoma, which can provide some tactile guidance. However, the hematoma often extends beyond the true cavity boundaries or resolves rapidly within weeks, making it an unreliable landmark (20,21). Delayed marker placement requires additional preoperative procedures, increasing patient burden (22). All these conventional methods provide only a rough spatial localization without restoring tactile feedback, which makes margin control unpredictable during resection.

To bridge this gap, we developed a novel intraoperative localization technique utilizing a balloon urinary catheter. This approach, designated as SRRSHwb-BDBCS (Sir Run Run Shaw Hospital Wu-Bo balloon-directed breast-conserving surgery), reconstructs the biopsy cavity and needle tract without preoperative localization. Converting a nonlocalizable target into a reliable palpable landmark enables precise BCS across all VABB indications. This technical guide presents a comprehensive “how-to” manual based on our institutional experience and preliminary application at multiple centers. We present this article in accordance with the SUPER reporting checklist (available at https://bc.amegroups.com/article/view/10.21037/bc-26-0018/rc).

Preoperative preparations and requirements

Patient selection and indications

This technique is indicated for patients undergoing BCS following VABB who meet the following criteria: (I) histologically confirmed breast cancer (invasive ductal carcinoma or ductal carcinoma in situ) by VABB; (II) breast-conserving therapy indicated on the basis of comprehensive preoperative assessment including tumor size, breast volume, and patient preference.

Specific scenarios particularly suited for this technique include: (I) small lesions completely sampled during diagnostic biopsy; (II) low-suspicious (BI-RADS 3 or 4a) lesions removed by large-volume excisional biopsy that proved malignant; and (III) post-NST settings where VABB confirms residual disease within a fibrotic, ill-defined tumor bed. Notably, this technique is not intended for all patients. Its greatest value is in the three scenarios listed above, where tactile feedback and cavity delineation are otherwise lacking.

Contraindications

The contraindications for this technique include: (I) complete healing of the VABB cavity with tract obliteration due to a prolonged interval (more than 1 month) since biopsy, because the original needle tract cannot be reliably identified or recannulated and (II) patient refusal to undergo the procedure after being fully informed of its novel nature and potential risks.

Equipment and materials

The procedure requires standard breast surgery instruments plus specific equipment that have been optimized for this technique.

Balloon catheter selection

We recommend the use of a 14 Fr double-lumen open-ended urinary catheter (Figure 1A,1B). All patients in this series underwent VABB using the Mammotome system with an 8-gauge (8G) cutting needle (outer diameter approximately 4.2 mm). The resulting biopsy tract measured approximately 5–6 mm in diameter after the procedure, accommodates the 14 Fr urinary catheter (outer diameter 4.7 mm) without additional dilation. A stylet is used to give the catheter rigidity (Figure 1C,1D). In this specific design, the balloon is positioned closer to the catheter tip than the standard Foley catheter is. This anatomical configuration allows the inflated balloon to more accurately conform to the true three-dimensional shape of the biopsy cavity while the distal shaft reconstructs the needle tract.

Figure 1 Balloon catheter selection. (A) Photograph of a 14 Fr double-lumen open-ended urinary catheter with the balloon deflated. (B) The catheter with the balloon inflated with sterile saline, showing the close proximity between the balloon and the catheter tip. (C) The catheter and the stylet separately. (D) The stylet inserted into the catheter, providing rigidity for tract advancement.

Modified blunt bougie (Figure 2)

Figure 2 Modified blunt bougie. Photograph of the dual-purpose bougie, featuring a blunt rounded tip and a sharp tapered tip at the opposite end.

We developed a dual-purpose bougie to facilitate tract identification. Its blunt tip allows atraumatic dissection along the existing biopsy tract. If blunt probing fails due to fibrosis or early healing, the sharp tip can be advanced under ultrasound guidance directly into the biopsy cavity to create a new access path. This design provides a built-in contingency, ensuring successful catheter placement without the need for additional instruments.

All equipment should be sterile and available in the operating room prior to incision.

Preoperative imaging review

Prior to surgery, all pre-VABB images [ultrasound, mammography, or magnetic resonance imaging (MRI)] should be reviewed to determine: (I) the original lesion’s location and size; (II) the biopsy approach; (III) the estimated cavity depth from the skin surface; and (IV) the cavity’s relationship to critical recognizable structures (e.g., the pectoralis muscle and skin). If available, post-VABB imaging should be performed to confirm absence of a residual target and to assess for hematoma formation.

Patient preparation and positioning

The patient is placed in a supine position with the ipsilateral arm abducted at 90 degrees on an arm board, ensuring that the breast is accessible for both palpation and ultrasonography. General anesthesia or local anesthesia with sedation is administered on the basis of patient factors and anticipated procedure duration. The breast is prepared and draped in a standard sterile fashion, ensuring that the skin entry site from the prior VABB is visible within the surgical field.

Informed consent

Written informed consent from all individual participants was obtained that specifically acknowledges (I) the novel nature of the localization technique; (II) the potential need for conversion to mastectomy if cavity identification fails; and (III) the risks of standard BCS, including bleeding, infection, and positive margins, requiring re-excision.

All procedures performed in this study were in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by the Ethics Committee of Sir Run Run Shaw Hospital (approval No. 2022-0025). Written informed consent was obtained from all individual participants for the publication of this article, accompanying images and the video. A copy of the written consent is available for review by the editorial office of this journal.

Surgical team and learning curve

All procedures were performed by surgeons with expertise in breast ultrasound and VABB. Catheter placement was guided by real‑time ultrasound. The tasks of the anesthesiologist and scrub nurse are the same as those of the standard BCS. Key training elements include ultrasound identification of the original VABB tract, gentle advancement of the catheter, and controlled balloon inflation under both ultrasound and tactile feedback. Over-inflation should be avoided to prevent patient discomfort or skin tenting. Formal data on the learning curve and inter-surgeon reproducibility are not available from this small feasibility series. These data will be collected in our planned multicenter prospective study.

Step-by-step description (Video 1)

Step 1: initial localization and incision planning

Intraoperative breast ultrasound is performed to approximate the location of the prior VABB cavity and needle tract. The relationships among the biopsy site, the skin entry point, and any residual sonographic abnormalities are identified. The incision location is planned so as to allow optimal access to both the cavity and the needle tract.

Step 2: accessing the needle tract

The original VABB incision is gently opened using blunt dissection with a mosquito clamp. The modified blunt bougie is inserted through the skin entry site, advancing it gently along the expected path of the needle tract to identify and confirm the tract created by the prior VABB procedure.

Step 3: catheter insertion

A 14 Fr double-lumen open-ended urinary catheter is selected. Notably, the existing VABB tract was created by an 8G Mammotome needle (approximately 4.2 mm in diameter). A 14 Fr catheter (4.7 mm) passes through this tract without forced dilation because of tissue elasticity. The distance from the skin entry site to the estimated cavity depth is measured on the basis of preoperative imaging and intraoperative assessment (Figure 3). The catheter is advanced along the identified tract until the tip reaches the excision cavity. The catheter should advance smoothly without resistance. If resistance is encountered, reposition or gently dilate the tract using sequential bougies. Ensure that the balloon portion of the catheter is positioned within the cavity.

Figure 3 Step 3: measurement of catheter insertion depth. (A) Schematic diagram illustrating the measurement of the insertion depth from the skin entry site to the biopsy cavity based on preoperative imaging and intraoperative ultrasound assessment. The dashed line indicates the trajectory from the skin entry site to the biopsy cavity. (B) Intraoperative photograph demonstrating the use of the balloon catheter as a measuring tool to predict the required insertion depth; the catheter is held against the breast surface to estimate the length from the incision to the cavity.

Step 4: balloon inflation and cavity delineation

The balloon is inflated with 5–10 mL of sterile saline, and the volume is adjusted to the estimated size of the biopsy cavity (Figure 4). The inflation volume should be sufficient to create a firm, palpable structure but without causing excessive tension. For small cavities (less than 1.5 cm), 5 mL may suffice; for larger cavities (2–3 cm), 8–10 mL can be used. The inflated balloon serves two functions: it physically demarcates the three-dimensional volume of the biopsy cavity, and it tamponades any residual vascularity within the cavity walls. The balloon’s position is verified by palpation and ultrasound.

Figure 4 Step 4: balloon inflation and cavity delineation. (A) Schematic illustration of the catheter positioned within the biopsy cavity prior to inflation. (B) Schematic showing the balloon inflated with sterile saline to create a three-dimensional landmark that demarcates the cavity volume. (C) Intraoperative photograph demonstrating the inflated balloon visible, appearing as a distinct and spherical structure.

Step 5: surgical exposure

A definitive skin incision (typically 3–5 cm) overlying the catheter balloon is planned. Skin flaps are raised superficial to the mammary fascia, extending the dissection sufficiently to visualize the catheter’s entry point and the balloon. The inflated balloon should be readily visible as a distinct structure within the breast parenchyma, with the catheter shaft marking the trajectory from the skin to the cavity (Figure 5). If residual tumor is present, it will typically be found adjacent to or surrounding the biopsy cavity.

Figure 5 Step 5: surgical exposure. Intraoperative photograph showing the surgical field after skin incision and flap elevation, with the inflated catheter balloon clearly visible as a discrete structure within the breast tissue and the catheter shaft marking the trajectory from the skin entry point to the cavity.

Step 6: guided excision

With the catheter providing dual guidance, the balloon for the cavity and the shaft for the tract, a wide local excision is performed. The tissue is resected en bloc, aiming to include a 1 cm rim of grossly normal tissue around the cavity/tumor mass, and extending approximately 0.5 cm around the needle tract to ensure its complete removal (Figure 6).

Figure 6 Step 6: guided excision. (A) Schematic diagram illustrating the wide local excision guided by the dual landmarks—the inflated balloon defining the cavity margins and the catheter shaft indicating the needle tract trajectory. (B) Intraoperative photograph demonstrating the en bloc resection of the tissue encompassing the catheter-guided cavity (dashed circle) and needle tract (dashed line).

Step 7: specimen orientation and margin assessment

The resected specimen should contain the biopsy cavity and the entire needle track (Figure 7). The surgical margins are immediately oriented using standard protocols. Intraoperative frozen section analysis is performed on the surfaces of the resected specimen. If a margin is positive, the involved margin is re-excise under direct visualization, and the cavity bed is used as a reference.

Figure 7 Step 7: specimen orientation and margin assessment. Intraoperative photograph showing the resected specimen containing the complete biopsy cavity and associated needle track with the catheter in situ, ready for orientation and intraoperative frozen section analysis of the surgical margins.

Step 8: cavity management and closure

The surgical cavity is irrigated with sterile saline. Hemostasis is achieved using electrocautery. A surgical clip is placed at the cavity base for future radiation therapy planning. The cavity wall is closed with absorbable sutures to eliminate dead space. The subcutaneous layer is closed with 3-0 absorbable interrupted sutures (e.g., Vicryl), and the skin is closed with 4-0 subcuticular absorbable sutures (e.g., Monocryl). No special intraoperative monitoring parameters beyond standard vital signs were needed. Closed-suction drainage is considered only for large excisions or extensive dissections.

Postoperative considerations and tasks

Immediate postoperative care

A standard pressure dressing is applied to minimize hematoma formation. The patient is monitored for signs of bleeding, infection, or skin ischemia.

Pathological correlations

Surgical specimens must be processed according to standard pathological protocols. Pathologists should verify the final margin status to confirm complete excision and assess for the presence of residual disease within the biopsy cavity. These comprehensive pathological findings are essential for formulating subsequent adjuvant treatment strategies, as determined by a multidisciplinary review by the tumor board.

Monitoring of complications

Specific complications related to this technique include: balloon rupture during excision (which results in harmless saline spillage) and catheter displacement during surgical manipulation (which is prevented by maintaining gentle traction). The primary technique-specific risk is tract misidentification, which can lead to off-target excision. Standard BCS complications (seroma, hematoma, infection) should be managed according to established protocols.

Tips and pearls

Optimal timing

BCS should be performed within 4 weeks of VABB to ensure tract patency. Beyond 4 weeks, fibrosis may obliterate the tract, making catheter passage difficult.

Tract identification

Precise cannulation of the original VABB tract is critical to avoid localization failure. Preoperatively, the image is carefully analyzed to confirm the exact trajectory and depth of the prior needle path.

Primary approach: the rounded blunt end of the modified bougie is advanced gently and steadily along the expected tract. Mild resistance confirms correct engagement of the fibrotic tract. The instrument should not be forced if significant resistance is encountered, as this indicates loss of the true tract or dense fibrosis.

Alternative approach: if the original tract cannot be identified with the blunt end after several attempts, withdraw the instrument and switch to the sharp tapered end. Under real-time ultrasound guidance, the sharp tip is carefully advanced to puncture directly into the biopsy cavity, creating a new tract for catheter placement. This maneuver is particularly valuable when the original tract is obliterated by post-biopsy fibrosis or hematoma organization.

Creating a false passage results in catheter malposition, failure to enter the biopsy cavity, and potential off-target excision. If the tract cannot be reliably identified after repeated attempts, it should be converted to an alternative surgical plan rather than risking erroneous surgical dissection.

Postoperative outcomes

The clinicopathologic characteristics of the six patients are summarized in Table 1. All patients underwent successful SRRSHwb-BDBCS without conversion to mastectomy. The clinical outcomes are presented in Table 2. The median operative time was 117 minutes (range, 85–195 minutes), and the median blood loss was 12.5 mL (range, 2–20 mL). The median hospital stay was 3 days (range, 2–6 days). No intraoperative or postoperative complications (e.g., hematoma, seroma, infection, or flap necrosis) were observed. All patients achieved negative resection margins on final pathology. At a median follow-up of 34 months (range, 23–42 months), no loco-regional recurrence or distant metastasis was recorded. Cosmetic outcomes were assessed by the surgeon as favorable in all cases, although a validated scale was not used.

Discussion

This initial series demonstrates that urinary catheter-directed localization is a feasible and effective technique for enabling BCS following VABB. In all six patients, the method successfully facilitated precise excision of the biopsy cavity and needle tract, achieving negative surgical margins and no procedural complications. The significance of this technique lies in its ability to resolve a fundamental paradox inherent in VABB practice: the diagnostic or therapeutic removal of the target lesion eliminates the surgeon's ability to localize the tumor bed. The clinical value of this approach manifests distinctly across the three scenarios where VABB creates localization challenges.

When small malignant tumors are sampled during diagnostic VABB, the sonographic “complete excision” renders the primary lesion difficult to identify by ultrasound. Furthermore, post-procedural changes such as edema, architectural distortion, and inflammation further obscure the biopsy cavity (23). A short interval between MRI and VABB may further increase the false-positive rate for diagnosing residual disease, potentially delaying definitive surgery (23,24). Without reliable cavity delineation, surgeons face the dual risks. They may inadvertently cut into the tumor bed, violating the principle of non-tumor touch. Alternatively, concern over margins may lead to excessively wide excisions that compromise cosmesis, particularly in patients with smaller breast volumes. The SRRSHwb-BDBCS method resolves this dilemma by physically reconstructing the three-dimensional volume of the biopsy cavity through a balloon urinary catheter inflation, and the SRRSHwb-BDBCS method creates a palpable landmark that provides real-time intraoperative tactile guidance. This enables precise en bloc resection with adequate oncologic margins without excessive tissue sacrifice.

A particularly distinctive application arises in patients who undergo VABB as a minimally invasive alternative to open excision for low-suspicion nodules (BI-RADS 3 or 4A). In centers employing this strategy (5,9-11), the goal is to reduce the morbidity of open surgery for likely benign disease while obtaining a definitive histopathological diagnosis through complete lesion removal. However, the inherent malignancy risk (less than 10%) creates a clinical paradox: the complete excision that avoids unnecessary open surgery simultaneously eliminates the target needed for subsequent resection if malignancy is confirmed. Surgeons may opt for mastectomy over BCS to ensure oncologic safety. This trend is reflected in the low BCS rates for VABB-diagnosed cancers. Retrospective data from multiple breast centers in Zhejiang Province report a 21% rate of BCS for patients with breast cancer diagnosed by VABB (16). Our technique bridges this critical gap in the clinical pathway by enabling precise localization of the excision cavity without preoperative markers. This enhances surgical confidence in pursuing BCS, thereby preserving the minimally invasive continuum. Patients initially avoid open diagnostic excision but can undergo definitive therapeutic resection with clear margins when indicated, without resorting to mastectomy due to localization failure.

Similarly, post-NST VABB frequently confirms residual disease within a fibrotic tumor bed where distorted anatomy and indistinct margins render localization unreliable (12). This uncertainty often compels surgeons to abandon BCS in favor of mastectomy to ensure oncologic safety. By conforming to the irregular fibrotic cavity and providing reliable tactile guidance, the balloon catheter restores the feasibility of precise tumor bed resection, enabling BCS in patients who would otherwise undergo unnecessary mastectomy.

Compared with existing strategies, this approach offers distinct practical advantages. Marker clip placement provides a reliable spatial cue when placed at the time of the VABB (17). However, it provides only a rough spatial cue but not tactile feedback. Clip placement also suffers from well-documented risks of migration and poor sonographic visualization (18,19). Hematoma‑guided surgery is simple and costfree. However, the hematoma is temporary and resolves within weeks. It often extends beyond the true cavity, leading to either incomplete or excessive resection (20,21). Wire localization is widely available and precise. However, delayed wire placement requires a preoperative procedure and delays definitive surgery (22). Additional procedures cause patient discomfort. In contrast, our balloon‑guided technique offers distinct advantages. The primary value of this technique is the restoration, which enables precise margin control. It is performed entirely during the BCS procedure, avoiding additional preoperative visits. It uses a low-cost catheter that is universally accessible.

However, the technique has several limitations. It requires a patent VABB tract, ideally within 4 weeks after biopsy. The balloon size must be adjusted to the cavity volume. A learning curve has not yet been established. Additionally, the method relies on the ability to identify or recreate the biopsy tract. When the tract is completely obliterated (e.g., >1 month after VABB) or if the original tract cannot be identified even after ultrasound-guided sharp puncture, the surgeon should convert to an alternative localization method such as wire‑guided or clip-guided excision rather than persisting with this technique.

Potential risks and complications of this technique include rupture of the balloon during excision, which can result in harmless saline spillage without clinical consequences. Catheter displacement during surgical manipulation can be prevented by maintaining gentle traction. If the original VABB tract cannot be identified, the creation of a false passage may lead to inaccurate localization. Local infection or delayed wound healing, though not observed in our series, are possible. Seroma and hematoma, which are standard complications of BCS, may also occur. Patients should be informed of these possibilities, and larger studies are needed to determine their true incidence.

Successful implementation requires attention to specific technical details. Ideally, the procedure should ideally be performed within 4 weeks of VABB to ensure tract patency before fibrosis obliterates the pathway. The dual-ended bougie design provides a contingency for tract identification, allowing blunt dissection to follow the original tract initially, with sharp ultrasound-guided puncture available when fibrosis or healing prevents tract identification. This versatility ensures reliability across the spectrum of post-VABB anatomies, from fresh cavities to fibrotic beds.

This report represents a retrospective, single-center study with a small cohort. While this technique theoretically reduces the risk of margin violation and excessive tissue resection by providing intraoperative guidance, these potential benefits should be interpreted with caution given the small sample size and lack of comparative data. Future studies are needed to validate oncologic safety and cosmetic outcomes. While short-term oncologic outcomes are promising, larger prospective studies with long-term follow-up are essential to confirm local recurrence rates. To address the limited evidence of this feasibility study, we are planning a multi-center prospective randomized controlled trial to compare SRRSHwb-BDBCS with standard localization methods. That trial will evaluate oncologic safety (margin status, local recurrence), cosmetic outcomes (validated patient-reported scales), and cost-effectiveness. The present technical guide provides the foundation for that larger study. Additionally, the method relies on the ability to identify or recreate the biopsy tract. Cases with complete tract obliteration due to prolonged intervals or severe inflammatory responses may require conversion to alternative surgical plans. As this technique continues to be adopted across multiple institutions in Zhejiang Province, further multi-center prospective evaluation will clarify its role in the broader algorithm of localization strategies.

Nevertheless, the SRRSHwb-BDBCS technique represents a practical, innovative solution to the “missing target” problem inherent in post-VABB breast cancer management. Converting a non-localizable target into a navigable and palpable structure enables precise BCS across the full spectrum of VABB indications, preserving both oncologic safety and cosmetic outcomes for patients who would otherwise undergo mastectomy due to localization uncertainty.

On the basis of its demonstrated utility and to formally acknowledge its provenance, we designate this technique “SRRSHwb-BDBCS (Sir Run Run Shaw Hospital Wu-Bo balloon-directed breast-conserving surgery)”, honoring the institutional platform and the pivotal intellectual contributions of Professor Jinmin Wu (Wu) and Professor Linbo Wang (Bo). This nomenclature reflects the academic lineage and collaborative innovation underlying this practical solution to a defined clinical problem in breast cancer surgery.

Conclusions

The SRRSHwb-BDBCS technique is a practical and innovative technique that may facilitate accurate BCS after VABB by providing intuitive, three-dimensional intraoperative guidance and restoring tactile feedback. It offers the potential for improved margin control and cosmetic results, but further studies with larger cohorts and objective outcome measures are needed to confirm these advantages.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the SUPER reporting checklist. Available at https://bc.amegroups.com/article/view/10.21037/bc-26-0018/rc

Peer Review File: Available at https://bc.amegroups.com/article/view/10.21037/bc-26-0018/prf

Funding: This work was supported by the National Natural Science Foundation of China (Nos. 81672729, 81972597, 81602471, and 81972453), Zhejiang Provincial Natural Science Foundation of China (Nos. LR22H160011, LY19H160059, and LY19H160055), Zheng Shu Medical Elite Scholarship Fund, and Healthcare Innovative Talents Grant of Zhejiang Province (No. 2021RC016).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://bc.amegroups.com/article/view/10.21037/bc-26-0018/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by the Ethics Committee of Sir Run Run Shaw Hospital (approval No. 2022-0025). Written informed consent was obtained from all individual participants for the publication of this article, accompanying images and the video. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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