Robotic deep inferior epigastric perforator flap harvest in breast reconstruction

Abstract

Introduction Reducing donor site morbidity after deep inferior epigastric artery perforator (DIEP) flap harvest relies mainly upon maintaining integrity of the anterior rectus sheath fascia. The purpose of this study is to describe our minimally‐invasive technique for robotic DIEP flap harvest. Methods A retrospective review of four patients undergoing seven robotic‐assisted DIEP flaps from 2019 to 2020 was conducted. Average patient age and BMI were 52 years (range: 45–60 years) and 26.7 kg/m2 (range: 20.6–32.4 kg/m2), respectively. Average follow‐up was 6.31 months (range: 5.73–7.27 months). Robotic flap harvest was performed with intramuscular perforator dissection in standard fashion, followed by the transabdominal preperitoneal (TAPP) approach to DIEP pedicle harvest using the da Vinci Xi robot. Data was collected on demographic information, perioperative characteristics. Primary outcomes included successful flap harvest as well as donor site morbidity (e.g., abdominal bulge, hernia, bowel obstruction, etc.). Results All four patients underwent bilateral abdominally‐based free flap reconstruction. Three patients received bilateral robotic DIEP flaps, and one patient underwent unilateral robotic DIEP flap reconstruction. The da Vinci Xi robot was used in all cases. Average flap weight and pedicle length were 522 g (range: 110–809 g) and 11.2 cm (range: 10–12 cm), respectively. There were no flap failures, and no patient experienced abdominal wall donor site morbidity on physical exam. Conclusion While further studies are needed to validate its use, this report represents the largest series of robotic DIEP flap harvests to date and is a valuable addition to the literature.

Literature Review

“…They suggested that having too many perforators or one with a long intramuscular course would require a larger intramuscular dissection, which would ultimately diminish any benefits of the robotic approach. Daar et al 18 also reported a retrospective review of 4 patients (7 total DIEP flap reconstructions) in whom they performed this same TAPP approach 9,13,18 . They report an average total operative time of 11.96 hours (range, 10–14 hours) and an average length of hospital stay of 3.7 days.…”

“…16 Furthermore, by allowing the surgeon to follow the pedicle in an inside-out fashion, the robotic platform also allows for limited dissection through the muscle and neurovascular plane. 18 Unfortunately, the long-term outcomes of the robot-assisted DIEP harvest is not yet available for us to definitive ascertain whether a limited dissection improves abdominal wall morbidity. However, based on previous literatures on the rate of port site herniation, it can be hypothesized that by preservation, the fascial neurovascular supply and avoiding denervation to the donor site-the robotic approach has the potential to better preserve the integrity of the abdominal wall.…”

“…Also, another notable limitation is the fact that all included studies were performed at single centers and involved surgeons who had significant experience with robotic surgery greater than that of the average plastic surgeon. 18 Current literature has shown that robot-assisted DIEP harvest is both technically feasible and has advantages over open and laparoscopic methods. More research is needed, with possible future directions examining long-term rate of complications compared with open surgery, detailed cost-benefit analysis, and feasibility of teaching these techniques to non-robotic-trained plastic surgeons.…”

“…The robotic platform has been postulated to have the potential for reducing the risk of developing postoperative abdominal bulge and ventral hernia by allowing surgeons to harvest the DIEP vascular pedicle through smaller fascial defects (1–3 cm in size) 16 . Furthermore, by allowing the surgeon to follow the pedicle in an inside-out fashion, the robotic platform also allows for limited dissection through the muscle and neurovascular plane 18 . Unfortunately, the long-term outcomes of the robot-assisted DIEP harvest is not yet available for us to definitive ascertain whether a limited dissection improves abdominal wall morbidity.…”

“…Daar et al 18 also reported a retrospective review of 4 patients (7 total DIEP flap reconstructions) in whom they performed this same TAPP approach. 9,13,18 They report an average total operative time of 11.96 hours (range, 10-14 hours) and an average length of hospital stay of 3.7 days. All patients were able to start a regular diet on postoperative day 1 with no postoperative ileus reported.…”