Robotic DIEP Patient Selection: Analysis of CT Angiography

Abstract

Background: Preoperative CTA is widely used and extensively studied for planning of DIEP flap breast reconstruction. However, its utility in planning robotic DIEP harvest is undescribed. Methods: The authors conducted a retrospective study of consecutive patients presenting to the clinics of select plastic surgeons between 2017 and 2021 for abdominally based autologous breast reconstruction. CTA measurements of intramuscular perforator distance and perforator-to-external iliac distance were used as predicted robotic and open fascial incision lengths, respectively. It was documented if the predicted robotic incision would avoid crossing the arcuate line. Operative notes were reviewed for fascial incision length and number of perforators harvested. Predicted and actual robotic fascial incision lengths were compared. Results: CTAs were reviewed for 49 patients (98 hemiabdomens). Inadequate or no perforators were identified on CTA in 18% of hemiabdomens. Mean predicted robotic and open DIEP fascial incisions were 3.1 cm and 12.2 cm, respectively, giving robotic approach fascial incision benefit of 9.1 cm ( P < 0.001). The predicted robotic incision avoided crossing the arcuate line in 71% of hemiabdomens. Thirteen patients (28%) underwent robotic DIEP harvest. Actual robotic fascial incision length averaged 3.5 cm, which was not significantly different from the mean predicted fascial incision length ( P = 0.374). Robotic DIEP flaps had fewer perforators (1.8 versus 2.6, P = 0.058). Conclusion: CTA is useful for identifying patients with anatomy favorable for robotic DIEP flap harvest.

Robotic-Assisted Microsurgery and Its Future in Plastic Surgery

“…While the venous anastomosis was performed manually, arterial anastomosis of the deep inferior epigastric artery to the internal mammary artery was performed by the surgeon using the da Vinci. Since then, harvesting of free flaps such as the DIEP has been performed multiple times using the da Vinci [ 11 , 12 , 13 , 14 ].…”

“…Bishop et al [ 21 ] described the outcome of 21 patients 12 months postoperatively after harvesting DIEP vessels by using a small posterior incision as a safe and reliable technique. Other studies have described the benefits of a minimal fascial incision for flap harvesting when compared with the traditional approach [ 11 , 12 , 13 , 14 ].…”

Robotics in Plastic Surgery: It’s Here

“…23,24 For autologous breast reconstruction, robotic pedicle dissection of the deep inferior epigastric perforator flap can be performed using a transabdominal approach from the posterior surface of the abdominal wall, thus reducing the length of the fascial incision of the anterior rectus sheath. 9,25,26 Robotic surgery has allowed for improved visualization, precision, and flexibility in complex ventral hernia repairs compared with standard laparoscopic approaches. 27 Robot-assisted transabdominal preperitoneal surgery for large ventral hernias allows for a dissection in threedimensional space and minimally invasive mesh placement.…”

“…23,24 For autologous breast reconstruction, robotic pedicle dissection of the deep inferior epigastric perforator flap can be performed using a transabdominal approach from the posterior surface of the abdominal wall, thus reducing the length of the fascial incision of the anterior rectus sheath. 9,25,26…”

Robotics in Implant-Based and Autologous Breast Reconstruction

“…47 52 Robotic DIEP candidates must also have pedicles with short intramuscular courses, with studies reporting anywhere from 2.5 to 5 cm as ideal. 47 52…”