Robotic-Assisted DIEP Flap Harvest for Autologous Breast Reconstruction: A Comparative Feasibility Study on a Cadaveric Model

Abstract

Background The deep inferior epigastric perforator (DIEP) flap is the most common perforator flap for microsurgical breast reconstruction. Contrary to the conventional open approach, robotic-assisted DIEP flap harvest intends to preserve ARS integrity, thereby reducing the morbidity. We assessed the feasibility and compared performance outcomes of a robotic, cadaveric training model for DIEP flap harvest using two approaches: transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP). Methods A robotics system (da Vinci Xi) was applied in conjunction with a cadaveric training model. Ports were placed in the abdominal wall to triangulate each DIEP flap. Surgical time and technical characteristics were recorded. Values were analyzed and compared. Results Eight female cadavers (16 hemi-DIEP flaps) were dissected: 50% TAPP and 50% TEP approaches. Mean harvest time was 56 minutes (range: 48–74 minutes) and 65 minutes (range: 60–83 minutes) for TAPP versus TEP groups, respectively (p < 0.05). Mean pedicle dissection time was 36 minutes (range: 25–40 minutes) and 39 minutes (range: 30–42 minutes) for TAPP versus TEP groups, respectively (p > 0.05). Intra-abdominal contents were manipulated twice on average in the TAPP group versus 0 times in the TEP group (p < 0.05). One TAPP case had an injury to the bowel, and one TEP case was converted to conventional open due to pneumoperitoneum. Conclusion Robotic-assisted DIEP flap harvest represents a technological enhancement for advanced regenerative plastic surgery. Our model demonstrated both TAPP and TEP are feasible, with TEP less invasive, preserving the posterior rectus sheath, and decreasing complication risks. However, there is a steeper and longer learning curve for TEP.

Robotics in Implant-Based and Autologous Breast Reconstruction

“…46 Reports of timing for robotic DIEP pedicle harvest range from an average of 35.8 to 86 minutes. 9,43,45,49 Of those currently reported, average dissected pedicle length ranges from 10 to 13 cm. 9,10, 53 Tsai et al found a significantly reduced incision length (2.67 AE 1.13 cm) of the anterior rectus sheath in patients undergoing robotic DIEP reconstruction when compared to conventional DIEP patients (8.14 AE 1.69).…”

“…While cadaveric studies have emphasized supraumbilical port placement, lateral port placement, as is utilized for robotic rectus harvest, was adapted by Selber for robotic DIEP harvest. 43,48,51,53,54 Lateral port placement allows for improved visualization and operative access during pedicle dissection and is gaining favor as the preferred method for robot-assisted DIEP pedicle. 51,53 Tsai et al have proposed a novel technique for port placement specifically for patients undergoing bilateral robotic DIEP reconstruction.…”

Minimally Invasive Surgery in Breast Reconstruction: The Past and Future

“…Other groups have reported success with other approaches including use of a single port site and TEP approach [18,19]. Many initial case series have focused on unilateral flap harvest; however, surgeons have begun to adapt the technique to allow bilateral flap dissection [20].…”

Robotic DIEP Patient Selection: Analysis of CT Angiography

“…This dramatically improves morbidity compared with the 8-13 cm fascial incision and muscle division required of the traditional open DIEP flap harvest technique. [2][3][4] In our practice, preoperative CT pelvic angiogram (CTA) of the lower abdomen is obtained for most patients being evaluated for DIEP flap breast reconstruction. If CTA shows a sizeable perforator with short intramuscular course, the patient is offered robotic DIEP flap reconstruction.…”

“…This dramatically improves morbidity compared with the 8–13 cm fascial incision and muscle division required of the traditional open DIEP flap harvest technique. 2–4…”