Novel Port Placement in Robotic-assisted DIEP Flap Harvest Improves Visibility and Bilateral DIEP Access: Early Controlled Cohort Study

Abstract

Summary: To minimize donor-site damage, robot-assisted (RA) deep inferior epigastric perforator (DIEP) flap harvest has been suggested. Current robotic approaches favor port placement, which either does not allow a bilateral DIEP flap harvest through the same ports or necessitates additional scars. In this article, the authors propose a modification of port configuration. In a retrospective controlled cohort study, RA-DIEP and conventional DIEP surgery were compared. The perforator and pedicle were visualized conventionally until the level behind the rectus abdominis muscle. Next, the robotic system was installed to dissect the retromuscular pedicle. The authors assessed patient age; body mass index; history of smoking, diabetes mellitus, and hypertension; and additional surgical time. The length of the anterior rectus sheath (ARS) incision was measured. Pain was quantified using the visual analogue scale. Donor-site complications were assessed. Thirteen RA-DIEP flaps (11 unilateral and two bilateral) and 87 conventional DIEP flaps were harvested without flap loss. The bilateral DIEP flaps were raised without readjustments of the ports. The mean time for pedicle dissection was 53.2 ± 13.4 minutes. The length of the ARS incision was significantly shorter in the RA-DIEP group (2.67 ± 1.13 cm versus 8.14 ± 1.69 cm; 304.87% difference; P < 0.0001). There was no statistical difference in postoperative pain (day 1: 1.9 ± 0.9 versus 2.9 ± 1.6, P = 0.094; day 2: 1.8 ± 1.2 versus 2.3 ± 1.5, P = 0.319; day 3: 1.6 ± 0.9 versus 2.0 ± 1.3, P = 0.444). Preliminary results show that the authors’ RA-DIEP approach is safe and allows dissection of bilateral RA-DIEP flaps with short ARS incision lengths. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Robotics in Implant-Based and Autologous Breast Reconstruction

“…9 10 53 Tsai et al found a significantly reduced incision length (2.67 ± 1.13 cm) of the anterior rectus sheath in patients undergoing robotic DIEP reconstruction when compared to conventional DIEP patients (8.14 ± 1.69). 49 Additional studies describe similar findings, reporting fascial incisions measuring 1.5 to 4.3 cm. 9 10 46 49…”

“…49 Additional studies describe similar findings, reporting fascial incisions measuring 1.5 to 4.3 cm. 9 10 46 49…”

“…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).…”

“…9 Further studies reinforced the feasibility and success of robotic submuscular DIEP pedicle dissection and to date include two cadaver studies, four case reports, and four retrospective cohorts. 10,[43][44][45][46][47][48][49][50] Robot-assisted DIEP harvest allows pedicle dissection from a novel posterior, intra-abdominal approach. As the pedicle is dissected deep to the rectus muscle surface, the fascial incisions need only be 3 to 4 cm in order to allow delivery of the clipped pedicle once free.…”

“…51,53 Tsai et al have proposed a novel technique for port placement specifically for patients undergoing bilateral robotic DIEP reconstruction. 49 Bilateral ports are placed at the superior edges of the raised DIEP flap, which allows the surgeon to carry out robotic dissections of the bilateral flap pedicles through the same port locations, negating the need for additional incisions. The camera port is placed within the linea alba, 5 cm above the umbilicus, with bilateral working ports placed 10 cm laterally from the camera port.…”