TRAM Flap Perforator Ligation and the Delay Phenomenon: Development of an Endoscopic/Laparoscopic Delay Procedure

Abstract

Despite its versatility in breast reconstruction, the TRAM flap is at times subject to ischemic compromise, especially in certain high risk populations. A preoperative delay procedure can decrease the likelihood of TRAM flap failure or fat necrosis, but the required extent of this delay procedure is not clearly defined. In an attempt to augment flap vascularity while reducing surgical dissection and morbidity, six distinct delay procedures and a nondelayed control were compared in a rat TRAM flap model (n = 8 for all groups). An important feature that was incorporated into several groups was the ligation of the contralateral rectus perforators through minimal skin incisions (endoscopic analogy, groups 4 to 7). The most effective delay procedure was the combination of contralateral rectus perforator ligation and ipsilateral dominant pedicle ligation (group 7), which was achieved with two minimal skin incisions and no significant flap undermining. This procedure reduced the flap necrosis from 63.2 +/- 5.8 percent (control) to 13.5 +/- 3.3 percent (p < 0.001). After completion of the animal studies, clinical application of a "minimally invasive" TRAM flap delay procedure was then undertaken in eight high risk patients with only modest ischemic compromise. Although the clinical experience is too early to draw definite conclusions, we feel that "endoscopic delay" has potential as a modality that will increase flap vascularity but minimize the morbidity of the preliminary procedure.

The extraperitoneal laparoscopic TRAM flap delay procedure: an alternative approach

“…Inferior epigastric vessels can be accessed through either intra-or extraperitoneal laparoscopic techniques [12][13][14][15]. Laparoscopic ligation of inferior epigastric vessels using intraperitoneal approach was first described in a series of ten patients in 1998 [15] and subsequently a larger case series using the same approach, published with good results [14].…”

Initial Experience With Laparoscopic Inferior Epigastric Vessel Ligation for Delayed Transverse Rectus Abdominus Musculocutaneous Flap Breast Reconstruction

“…7 We also found the anterior sheath to be more friable and edematous after open delay and because of this, the procedure was abandoned. All patients in our series were discharged home the same day following ligation except for 1 patient who also had a Nissen fundoplication that required an overnight stay in the hospital.…”

“…[7][8][9][10] To our knowledge, this is the first large series of laparoscopic delay. We used a 3-mm trocar in the umbilicus whenever possible.…”

“…Additional procedures in conjunction with vessel ligation were performed in 38 patients (sentinel node biopsy [27], bilateral oophorectomy [7], liver biopsy [2], breast biopsy [1], and Nissen fundoplication [1]). Median operative time for those patients undergoing ligation only was 32.6 minutes (range, 14-121 minutes).…”

Surgically Delayed TRAM Flap: Scientific Foundations and Clinical Applications

“…Furthermore, numerous clinical series confirm the efficacy and safety of the delay procedure in TRAM flap breast reconstruction. [24][25][26][27][28][29] These studies show that the ischemic complication rates in high-risk patients can be reduced by surgical delay.…”