Robotic-Assisted DIEP Flap Harvest for Autologous Breast Reconstruction: A Comparative Feasibility Study on a Cadaveric Model

Abstract

Background The deep inferior epigastric perforator (DIEP) flap is the most common perforator flap for microsurgical breast reconstruction. Contrary to the conventional open approach, robotic-assisted DIEP flap harvest intends to preserve ARS integrity, thereby reducing the morbidity. We assessed the feasibility and compared performance outcomes of a robotic, cadaveric training model for DIEP flap harvest using two approaches: transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP).

Methods A robotics system (da Vinci Xi) was applied in conjunction with a cadaveric training model. Ports were placed in the abdominal wall to triangulate each DIEP flap. Surgical time and technical characteristics were recorded. Values were analyzed and compared.

Results Eight female cadavers (16 hemi-DIEP flaps) were dissected: 50% TAPP and 50% TEP approaches. Mean harvest time was 56 minutes (range: 48–74 minutes) and 65 minutes (range: 60–83 minutes) for TAPP versus TEP groups, respectively (p < 0.05). Mean pedicle dissection time was 36 minutes (range: 25–40 minutes) and 39 minutes (range: 30–42 minutes) for TAPP versus TEP groups, respectively (p > 0.05). Intra-abdominal contents were manipulated twice on average in the TAPP group versus 0 times in the TEP group (p < 0.05). One TAPP case had an injury to the bowel, and one TEP case was converted to conventional open due to pneumoperitoneum.

Conclusion Robotic-assisted DIEP flap harvest represents a technological enhancement for advanced regenerative plastic surgery. Our model demonstrated both TAPP and TEP are feasible, with TEP less invasive, preserving the posterior rectus sheath, and decreasing complication risks. However, there is a steeper and longer learning curve for TEP.

Keywords

robotics - robotic surgical procedures - plastic surgery - surgical flaps - deep inferior epigastric perforator flap - breast reconstruction

Authors' Contributions

All authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by O.J.M. and S.S.B. The first draft of the manuscript was written by S.S.B. and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

^* Both authors contributed equally to this manuscript and are co-first authors.

• References

• 1 Allen RJ, Treece P. Deep inferior epigastric perforator flap for breast reconstruction. Ann Plast Surg 1994; 32 (01) 32-38
• 2 Kwok AC, Simpson AM, Ye X, Tatro E, Agarwal JP. Immediate unilateral breast reconstruction using abdominally based flaps: analysis of 3,310 cases. J Reconstr Microsurg 2019; 35 (01) 74-82
• 3 Hedegard W, Niell B, Specht M, Winograd J, Rafferty E. Breast reconstruction with a deep inferior epigastric perforator flap: imaging appearances of the normal flap and common complications. AJR Am J Roentgenol 2013; 200 (01) W75-84
• 4 Rose J, Puckett Y. Breast reconstruction free flaps. In: StatPearls. Treasure Island, FL: StatPearls Publishing LLC; 2019
• 5 Knox ADC, Ho AL, Leung L. , et al. Comparison of outcomes following autologous breast reconstruction using the DIEP and pedicled TRAM flaps: A 12-year clinical retrospective study and literature review. Plast Reconstr Surg 2016; 138 (01) 16-28
• 6 Selber JC, Baumann DP, Holsinger FC. Robotic latissimus dorsi muscle harvest: a case series. Plast Reconstr Surg 2012; 129 (06) 1305-1312
• 7 Patel NV, Pedersen JC. Robotic harvest of the rectus abdominis muscle: a preclinical investigation and case report. J Reconstr Microsurg 2012; 28 (07) 477-480
• 8 Lazzaro RS, Guerges M, Kadosh B, Gulkarov I. Robotic harvest of intercostal muscle flap. J Thorac Cardiovasc Surg 2013; 146 (02) 486-487
• 9 Ibrahim AE, Sarhane KA, Pederson JC, Selber JC. Robotic harvest of the rectus abdominis muscle: principles and clinical applications. Semin Plast Surg 2014; 28 (01) 26-31
• 10 Ichihara S, Bodin F, Pedersen JC. , et al. Robotically assisted harvest of the latissimus dorsi muscle: A cadaver feasibility study and clinical test case. Hand Surg Rehabil 2016; 35 (02) 81-84
• 11 Hivelin M, Soprani A, Schaffer N, Hans S, Lantieri L. Minimally invasive laparoscopically dissected deep inferior epigastric artery perforator flap: an anatomical feasibility study and a first clinical case. Plast Reconstr Surg 2018; 141 (01) 33-39
• 12 Gundlapalli VS, Ogunleye AA, Scott K. , et al. Robotic-assisted deep inferior epigastric artery perforator flap abdominal harvest for breast reconstruction: A case report. Microsurgery 2018; 38 (06) 702-705
• 13 Benjoar MD, Berdah Y, Dubosq F. , et al. Reply: minimally invasive laparoscopically dissected deep inferior epigastric artery perforator flap : an anatomical feasibility study and a first clinical case. Plast Reconstr Surg 2018; 142 (05) 787e-789e
• 14 Stroumza N, Nail Barthelemy R, Majoulet L, Delchet O, Qassemyar Q, Atlan M. Endoscopic DIEP flap dissection (eDIEP): an experimental cadaveric study. J Plast Reconstr Aesthet Surg 2017; 70 (08) 1149-1151
• 15 Waked KWK, Hamdi MHM. Reply to the Editor: robotic-assisted DIEP flap harvest: a feasibility study on cadaveric model. J Plast Reconstr Aesthet Surg 2018; 71 (08) 1216-1230
• 16 Nehme J, Neville JJ, Bahsoun AN. The use of robotics in plastic and reconstructive surgery: A systematic review. JPRAS Open 2017; 13: 1-10
• 17 Dobbs TD, Cundy O, Samarendra H, Khan K, Whitaker IS. A systematic review of the role of robotics in plastic and reconstructive surgery-from inception to the future. Front Surg 2017; 4: 66
• 18 Zhu Q, Mao Z, Yu B, Jin J, Zheng M, Li J. Effects of persistent CO(2) insufflation during different laparoscopic inguinal hernioplasty: a prospective, randomized, controlled study. J Laparoendosc Adv Surg Tech A 2009; 19 (05) 611-614
• 19 Wei FX, Zhang YC, Han W, Zhang YL, Shao Y, Ni R. Transabdominal preperitoneal (TAPP) versus totally extraperitoneal (TEP) for laparoscopic hernia repair: a meta-analysis. Surg Laparosc Endosc Percutan Tech 2015; 25 (05) 375-383
• 20 Carter J, Duh QY. Laparoscopic repair of inguinal hernias. World J Surg 2011; 35 (07) 1519-1525
• 21 Gkegkes ID, Mamais IA, Iavazzo C. Robotics in general surgery: a systematic cost assessment. J Minim Access Surg 2017; 13 (04) 243-255
• 22 Park BS, Ryu DY, Son GM, Cho YH. Factors influencing on difficulty with laparoscopic total extraperitoneal repair according to learning period. Ann Surg Treat Res 2014; 87 (04) 203-208