Robotic‐assisted deep inferior epigastric perforator (<scp>DIEP</scp>) flap harvest for breast reconstruction

Abstract

A refinement to deep inferior epigastric perforator (DIEP) flap harvest that may limit fascial incision length and dissection of the rectus abdominis muscle is by use of robotic-assisted surgery (RAS).1 In this technique, the sub-muscular portion of the DIEP pedicle is dissected using laparoscopic ports and robotic instrumentation. Herein, we present the first experience of a robotic-assisted DIEP flap harvest in Australia and New Zealand. A 46-year-old female with BRCA1 gene mutation underwent a bilateral nipple-sparing mastectomy and immediate autologous breast reconstruction following right breast-conserving surgery and radiation 1 year prior for triple-negative breast cancer. She had sufficient abdominal donor-site laxity from two prior pregnancies to enable bilateral DIEP flap reconstruction. Routine preoperative imaging identified a single dominant perforator with a 4 cm intramuscular course on the left side (Fig. 1) and a large superficial inferior epigastric artery (SIEA) on the right. Based on preoperative imaging, she was deemed a candidate for a robotic-assisted flap harvest of the left hemi-abdomen and likely SIEA flap harvest of the right hemi-abdomen. Informed consent was obtained for the bilateral autologous tissue-based breast reconstruction and robotic-assisted DIEP flap dissection on one or both sides as indicated. Bilateral nipple-sparing mastectomies were performed, and hemi-abdominal flaps were raised, leaving only the perforators and SIEAs attached to the flaps. On the right, an SIEA flap was raised, and on the left, the target perforator was islanded, making a 5 cm fascial incision and 4 cm muscle fibre split until reaching the sub-muscular space. The robotic-assisted dissection of the sub-muscular portion of the DIEP pedicle was conducted using the da Vinci Xi Surgical System (Intuitive Surgical, Sunnyvale, CA) by an intra-peritoneal approach. Pneumoperitoneum was established, and a 10 mm camera port, two 8 mm instrument ports and a 5 mm assistant port were placed into the linea alba, linea semilunaris 5 cm above the umbilicus and right external oblique, respectively (Fig. 2a, Supplementary Video). The robot was docked on the patient's right (Fig. 2b). Two surgeon consoles were utilized, enabling simultaneous dissection by an experienced DIEP flap surgeon, senior author (J. D), and a robotic surgeon proctor (N. A). The pedicle was dissected using bipolar-activated Maryland's forceps and monopolar-activated scissors from proximal to distal (Fig. 2c). A small length of posterior sheath above the arcuate line was incised. The DIEA pedicle was ligated at its origin, liberating 9 cm of additional pedicle length (Fig. 2d, Supplementary Video). The pedicle was delivered through the muscle opening (Fig. 2e,f), and the left hemi-abdominal flap remained well perfused throughout. Once the recipient site's internal mammary vessels were prepared, the superior continuation of the DIEP pedicle was ligated, and the procedure continued as for a conventional DIEP flap reconstruction. Total operative time was 11 h 20 min (including 92 min robotic dissection with mentoring and proctorship time and a 16 min docking time). There were no intra-operative complications, and in the immediate postoperative period, she had minimal abdominal pain, a rapid progress to full mobilization and required less analgesia than routine DIEP patients (Fig. 3). At the 3-month follow-up, no complications were identified, including no abdominal wall hernia or bulge. Her abdominal functional assessment was similar to baseline, performing an unsupported situp with knees flexed and bilateral straight leg raise without difficulty, and showing improvements across all BREAST-Q domains. Compared to other laparoscopic techniques, RAS provides improved dexterity and range-of-motion.2 While an initial learning curve exists, in our experience, robotic-assisted efficiency improves quickly with successive cases, with robotic dissection time and overall operat