Robotic DIEP Flap Surgery: The Need for a Balanced Discussion of Intra-Abdominal Risks and Outcomes

Dear Sir,

We commend Choe et al for their technically detailed report on robotic-assisted deep inferior epigastric perforator (DIEP) flap harvest![1]

While we fully acknowledge the innovative potential of robotic surgery across various medical disciplines—and potentially in plastic surgery as well—we would like to emphasize that, despite the enthusiasm for advancing the field with new technologies, a thorough and balanced discussion of both advantages and potential complications, in accordance with scientific standards, is essential.[2] This should include a more critical consideration of what appears to be an underemphasized risk: the general surgical implications and differences between intra-abdominal and extraperitoneal dissections.

The authors present a detailed, technically well-illustrated account of robotic-assisted DIEP flap harvest using the Da Vinci system. The central argument is that this approach can reduce the length of the anterior rectus sheath incision, potentially minimizing donor site morbidity such as pain, bulging, and hernias. While this advantage is clinically relevant, the article heavily emphasizes fascial incision length reduction—for example, a mean of 3.7 cm in their Northwell series—without sufficiently addressing other surgical risks introduced by the intraperitoneal approach.

The robotic DIEP technique involves intentional entry into the peritoneal cavity, with pedicle dissection performed intraperitoneally. This naturally departs from standard extraperitoneal DIEP harvests, which maintain peritoneal integrity. We feel that some key concerns are not yet sufficiently addressed in the article, which include the risk of intra-abdominal complications (e.g., bowel injury, adhesions, and seroma), difficulty in patients with prior abdominal surgeries, where adhesions may limit robotic maneuverability or safe port placement, and loss of peritoneal barrier protection, possibly increasing postoperative discomfort or complications.

While the authors exclude patients with “extensive abdominal surgery,” they do not quantify or systematically discuss the implications of minor but multiple prior laparoscopic interventions, which are common in the target patient population. In addition, the port-site hernias are only minimally discussed but still pose a clinically relevant risk. Although the article devotes significant space to fascial-sparing benefits, it does not adequately account for the cumulative hernia risk introduced by the multiple 8-mm robotic ports. Four robotic ports are placed through the fascia, and although the authors suggest figure-of-eight closure, studies across laparoscopic literature consistently show that multiple port sites cumulatively elevate the risk of incisional hernias, especially in thin, scarred, or overweight patients. Port placement often overlaps with zones already compromised by previous procedures (e.g., gynecologic laparoscopy and cesarean sections), and this potentially trades an anterior fascial incision for four or more fascial punctures, which may not be risk-neutral. The authors describe that the posterior rectus sheath is intentionally opened—not widely severed but surgically incised—to gain access to the pedicle, and although it is subsequently sutured closed to restore abdominal wall integrity, a weakening of the posterior abdominal wall needs to be discussed, especially considering the additional impact of insufflation, port placement, and fascial port site closures. This trade-off is not critically examined in the article and represents a significant limitation of the technique's touted “minimally invasive” nature.[3]

The effect of gas insufflation and its physiologic and mechanical complications are not discussed in depth.[4] [5] The robotic approach relies on CO₂ insufflation at 10 to 15 mmHg, creating pneumoperitoneum for robotic access. However, the article does not address the gas-induced tissue stretch, which may obscure pedicle dissection due to thin tissues and low visibility in stretched planes. Gas insufflation may compromise capillary perfusion at high pressures and may lead to intraoperative bleeding from overstretched or fragile vessels (briefly mentioned as “slow flow bleeding” in the article that may obscure visualization). Surely gas leakage prevention using Bacitracin, Xeroform, and PDS sutures is a clever intraoperative measure, but it also suggests that gas control is fragile and requires complex workarounds—a detail that contradicts the notion of operational simplicity.

Last but not least, the ischemia time and operative duration need to be discussed. The robotic DIEP harvest increases ischemia time and total operative duration, especially for bilateral cases, given the console time averages of 75 minutes—excluding patient prep, port placement, and undocking. Also, overall operative time is significantly longer (robotic: 507 minutes vs. standard: 438 minutes), as acknowledged from other studies referenced in the article.[6] [7]

While the robotic-assisted DIEP flap technique is undeniably innovative, it is essential to apply critical scrutiny to avoid presenting a biased view that underrepresents key surgical and logistical challenges. Future studies should therefore include robust scientific data on hernia incidence at both fascial incisions and robotic port sites, quantitative assessment of flap ischemia time, and comprehensive cost-benefit analyses regarding outcomes, surgical efficiency, and resource utilization.

Publikationsverlauf

Eingereicht: 05. Juni 2025

Angenommen: 17. August 2025

Accepted Manuscript online:
27. August 2025

Artikel online veröffentlicht:
14. Oktober 2025

• References

• 1 Choe J, Aiello C, Yom J. et al. Embracing robotics in microsurgery: robotic-assisted deep inferior epigastric perforator flap breast reconstruction. J Reconstr Microsurg 2025; 41 (05) 450-458
• 2 Promny T, Huberth P, Müller-Seubert W. et al. The impact of technical innovations and donor-site mesh repair on autologous abdominal-based breast reconstruction-a retrospective analysis. J Clin Med 2024; 13 (08) 2165
• 3 de Beaux AC, East B. Thoughts on Trocar Site Hernia Prevention. Thoughts on trocar site hernia prevention. A narrative review. J Abdom Wall Surg 2022; 1: 11034
• 4 Dalli J, Montminy T, Ferguson M, Khan MF, Nolan K, Cahill RA. Impact of intra-abdominal insufflation pressure on gas leakage occurring during laparoscopy. Surg Endosc 2022; 36 (09) 7047-7055
• 5 Huntington CR, Prince J, Hazelbaker K. et al. Safety first: significant risk of air embolism in laparoscopic gasketless insufflation systems. Surg Endosc 2019; 33 (12) 3964-3969
• 6 Arellano JA, Comerci AJ, Liu HY. et al. Complications in prolonged intraoperative ischemia time in free flap breast reconstruction: a systematic review and meta-analysis. Aesthetic Plast Surg 2025; 49 (05) 1262-1270
• 7 Promny T, Arkudas A, Horch RE, Huberth P. Vascular considerations in autologous breast reconstruction using DIEP or MS-TRAM flaps: standard techniques, alternatives, and rescue strategies. 2025;