Download PDF
J Reconstr Microsurg
DOI: 10.1055/s-0044-1788642
Original Article

A New Era in Perforator Flap Surgery for Breast Reconstruction: A Comparative Study of Robotic versus Standard Harvest of Bilateral Deep Inferior Epigastric Artery Perforator Flaps

Andrea Moreira 
1   Department of Surgery, Allegheny Health Network, Pittsburgh, Pennsylvania
2   Department of Plastic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
,
Elizabeth A. Bailey
2   Department of Plastic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
,
Brian Chen 
1   Department of Surgery, Allegheny Health Network, Pittsburgh, Pennsylvania
,
William Nelson
1   Department of Surgery, Allegheny Health Network, Pittsburgh, Pennsylvania
,
Jenna Li
1   Department of Surgery, Allegheny Health Network, Pittsburgh, Pennsylvania
,
Richard Fortunato
1   Department of Surgery, Allegheny Health Network, Pittsburgh, Pennsylvania
,
Stanislav Nosik
1   Department of Surgery, Allegheny Health Network, Pittsburgh, Pennsylvania
,
Daniel Murariu
1   Department of Surgery, Allegheny Health Network, Pittsburgh, Pennsylvania
2   Department of Plastic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
› Author Affiliations Funding None.
› Further Information
Also available at
    Permissions and Reprints

Abstract

Background Traditional deep inferior epigastric artery perforator (DIEP) flap harvest splits the anterior sheath, weakening the abdominal wall and predisposing patients to bulge or hernia. Abdominal wall morbidity may be decreased using minimally invasive techniques. We refined a transabdominal approach to the robotic harvest of bilateral DIEP flaps.

Methods A retrospective medical record study involving all patients who underwent bilateral or bipedicled robotic DIEP (rDIEP) or standard DIEP (sDIEP) flap harvest between July 2021 and September 2022. Outcomes included abdominal wall morbidity, total operative time, length of stay (LOS), and complications.

Results Forty-seven patients were included (48 sDIEP flaps, 46 rDIEP flaps) with no significant difference in patient characteristics. Fascial incision length in the rDIEP group was shorter (4.1 vs. 11.7 cm, p < 0.001). Mesh reinforcement of the abdominal wall was used in 13/24 sDIEP and none in rDIEP patients (p < 0.001). Operative time was longer in the rDIEP cohort (739 vs. 630 minutes, p = 0.013), although subanalysis showed no difference in the second half of the cohort. The average robotic dissection time was 135 minutes, which decreased significantly with the surgeon's experience. There were no intraoperative complications from using the robot. LOS was shorter with rDIEP but not statistically significant (3.9 vs. 4.3 days, p = 0.157).

Conclusion This study represents the most extensive cohort analysis of bilateral rDIEP flap harvest, offering a comprehensive comparison to traditional sDIEP. The initial results underscore the viability of robotic techniques for flap harvesting, highlighting potential advantages including reduced fascial incision length and decreased abdominal disruption. Furthermore, using robotics may obviate the necessity for fascial reinforcement with mesh.

Keywords

breast reconstruction - free flap - microsurgery - robotic surgery - DIEP flap

Note

This paper was presented as a poster presentation at the Ohio Valley Society of Plastic Surgeons (Louisville, KY, June 2022) and as Best Paper Award at PSTM22 in a podium presentation at the American Society of Plastic Surgeons (Boston, MA, October 2022).




Publication History

Received: 21 February 2024

Accepted: 22 June 2024

Article published online:
05 August 2024

© 2024. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Uroskie TW, Colen LB. History of breast reconstruction. Semin Plast Surg 2004; 18 (02) 65-69
    Thieme ConnectPubMedSearch in Google Scholar
  • 2 Blondeel N, Vanderstraeten GG, Monstrey SJ. et al. The donor site morbidity of free DIEP flaps and free TRAM flaps for breast reconstruction. Br J Plast Surg 1997; 50 (05) 322-330
    CrossrefPubMedSearch in Google Scholar
  • 3 Bonde CT, Lund H, Fridberg M, Danneskiold-Samsoe B, Elberg JJ. Abdominal strength after breast reconstruction using a free abdominal flap. J Plast Reconstr Aesthet Surg 2007; 60 (05) 519-523
    CrossrefPubMedSearch in Google Scholar
  • 4 Man LX, Selber JC, Serletti JM. Abdominal wall following free TRAM or DIEP flap reconstruction: a meta-analysis and critical review. Plast Reconstr Surg 2009; 124 (03) 752-764
    CrossrefPubMedSearch in Google Scholar
  • 5 Seidenstuecker K, Legler U, Munder B, Andree C, Mahajan A, Witzel C. Myosonographic study of abdominal wall dynamics to assess donor site morbidity after microsurgical breast reconstruction with a DIEP or an ms-2 TRAM flap. J Plast Reconstr Aesthet Surg 2016; 69 (05) 598-603
    CrossrefPubMedSearch in Google Scholar
  • 6 Nahabedian MY, Momen B. Lower abdominal bulge after deep inferior epigastric perforator flap (DIEP) breast reconstruction. Ann Plast Surg 2005; 54 (02) 124-129
    CrossrefPubMedSearch in Google Scholar
  • 7 Shubinets V, Fox JP, Sarik JR, Kovach SJ, Fischer JP. Surgically treated hernia following abdominally based autologous breast reconstruction: prevalence, outcomes, and expenditures. Plast Reconstr Surg 2016; 137 (03) 749-757
    CrossrefPubMedSearch in Google Scholar
  • 8 Park JW, Lee H, Jeon BJ, Pyon JK, Mun GH. Assessment of the risk of bulge/hernia formation after abdomen-based microsurgical breast reconstruction with the aid of preoperative computed tomographic angiography-derived morphometric measurements. J Plast Reconstr Aesthet Surg 2020; 73 (09) 1665-1674
    CrossrefPubMedSearch in Google Scholar
  • 9 Haddock NT, Culver AJ, Teotia SS. Abdominal weakness, bulge, or hernia after DIEP flaps: an algorithm of management, prevention, and surgical repair with classification. J Plast Reconstr Aesthet Surg 2021; 74 (09) 2194-2201
    CrossrefPubMedSearch in Google Scholar
  • 10 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
    CrossrefPubMedSearch in Google Scholar
  • 11 Khan MTA, Won BW, Baumgardner K. et al. Literature review: robotic-assisted harvest of deep inferior epigastric flap for breast reconstruction. Ann Plast Surg 2022; 89 (06) 703-708
    CrossrefPubMedSearch in Google Scholar
  • 12 Nelson W, Murariu D, Moreira A. Indocyanine green guided near-infrared fluorescence (ICG-NIFR) enhances vascular anatomy in robotic assisted DIEP flap harvest. Plast Reconstr Surg 2024; 153 (04) 796-798
    PubMedSearch in Google Scholar
  • 13 Piper M, Ligh CA, Shakir S, Messa C, Soriano I, Kanchwala S. Minimally invasive robotic-assisted harvest of the deep inferior epigastric perforator flap for autologous breast reconstruction. J Plast Reconstr Aesthet Surg 2021; 74 (04) 890-930
    CrossrefPubMedSearch in Google Scholar
  • 14 Struk S, Sarfati B, Leymarie N. et al. Robotic-assisted DIEP flap harvest: a feasibility study on cadaveric model. J Plast Reconstr Aesthet Surg 2018; 71 (02) 259-261
    CrossrefPubMedSearch in Google Scholar
  • 15 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
    CrossrefPubMedSearch in Google Scholar
  • 16 Selber JC. The robotic DIEP flap. Plast Reconstr Surg 2020; 145 (02) 340-343
    CrossrefPubMedSearch in Google Scholar
  • 17 Manrique OJ, Bustos SS, Mohan AT. et al. Robotic-assisted DIEP flap harvest for autologous breast reconstruction: a comparative feasibility study on a cadaveric model. J Reconstr Microsurg 2020; 36 (05) 362-368
    Thieme ConnectPubMedSearch in Google Scholar
  • 18 Choi JH, Song SY, Park HS. et al. Robotic DIEP flap harvest through a totally extraperitoneal approach using a single-port surgical robotic system. Plast Reconstr Surg 2021; 148 (02) 304-307
    CrossrefPubMedSearch in Google Scholar
  • 19 Lee MJ, Won J, Song SY. et al. Clinical outcomes following robotic versus conventional DIEP flap in breast reconstruction: a retrospective matched study. Front Oncol 2022; 12: 989231
    CrossrefPubMedSearch in Google Scholar
  • 20 Daar DA, Anzai LM, Vranis NM. et al. Robotic deep inferior epigastric perforator flap harvest in breast reconstruction. Microsurgery 2022; 42 (04) 319-325
    CrossrefPubMedSearch in Google Scholar
  • 21 Wittesaele W, Vandevoort M. Implementing the robotic deep inferior epigastric perforator flap in daily practice: a series of 10 cases. J Plast Reconstr Aesthet Surg 2022; 75 (08) 2577-2583
    CrossrefPubMedSearch in Google Scholar
  • 22 DellaCroce FJ, DellaCroce HC, Blum CA. et al. Myth-busting the DIEP flap and an introduction to the abdominal perforator exchange (APEX) breast reconstruction technique: a single-surgeon retrospective review. Plast Reconstr Surg 2019; 143 (04) 992-1008
    CrossrefPubMedSearch in Google Scholar
  • 23 Zoccali G, Farhadi J. Abdominal perforator exchange flap (APEX): a classification of pedicle rearrangements. Microsurgery 2021; 41 (07) 607-614
    CrossrefPubMedSearch in Google Scholar
  • 24 Borrero M, Hilaire HS, Allen R. Modern approaches to abdominal-based breast reconstruction. Clin Plast Surg 2023; 50 (02) 267-279
    CrossrefPubMedSearch in Google Scholar
  • 25 Borchardt RA, Tzizik D. Update on surgical site infections: the new CDC guidelines. JAAPA 2018; 31 (04) 52-54
    CrossrefPubMedSearch in Google Scholar
  • 26 Lane T. A short history of robotic surgery. Ann R Coll Surg Engl 2018; 100 (6_sup): 5-7
    CrossrefPubMedSearch in Google Scholar
  • 27 George EI, Brand TC, LaPorta A, Marescaux J, Satava RM. Origins of robotic surgery: from skepticism to standard of care. JSLS 2018; 22 (04) e2018
    CrossrefPubMedSearch in Google Scholar
  • 28 Kurlander DE, Le-Petross HT, Shuck JW, Butler CE, Selber JC. Robotic DIEP patient selection: analysis of CT angiography. Plast Reconstr Surg Glob Open 2021; 9 (12) e3970
    CrossrefPubMedSearch in Google Scholar
  • 29 Bishop SN, Selber JC. Minimally invasive robotic breast reconstruction surgery. Gland Surg 2021; 10 (01) 469-478
    CrossrefPubMedSearch in Google Scholar
  • 30 Shakir S, Spencer AB, Piper M, Kozak GM, Soriano IS, Kanchwala SK. Laparoscopy allows the harvest of the DIEP flap with shorter fascial incisions as compared to endoscopic harvest: a single surgeon retrospective cohort study. J Plast Reconstr Aesthet Surg 2021; 74 (06) 1203-1212
    CrossrefPubMedSearch in Google Scholar
  • 31 Vyas RM, Dickinson BP, Fastekjian JH, Watson JP, DaLio AL, Crisera CA. Risk factors for abdominal donor-site morbidity in free flap breast reconstruction. Plast Reconstr Surg 2008; 121 (05) 1519-1526
    CrossrefPubMedSearch in Google Scholar
  • 32 Garvey PB, Buchel EW, Pockaj BA. et al. DIEP and pedicled TRAM flaps: a comparison of outcomes. Plast Reconstr Surg 2006; 117 (06) 1711-1719 , discussion 1720–1721
    CrossrefPubMedSearch in Google Scholar
  • 33 Rhemtulla IA, Mauch JT, McCarty EB, Broach RB, Serletti JM, Kovach SJ. Incisional hernia incidence, repair techniques, and outcomes based on 1600 consecutive patients receiving abdominally based autologous breast reconstruction. Ann Plast Surg 2021; 87 (01) 85-90
    CrossrefPubMedSearch in Google Scholar
  • 34 Parmeshwar N, Lem M, Dugan CL, Piper M. Evaluating mesh use for abdominal donor site closure after deep inferior epigastric perforator flap breast reconstruction: a systematic review and meta-analysis. Microsurgery 2023; 43 (08) 855-864
    CrossrefPubMedSearch in Google Scholar
  • 35 Sartori A, De Luca M, Noaro G. et al. Rare intraoperative and postoperative complications after transabdominal laparoscopic hernia repair: results from the multicenter wall hernia group registry. J Laparoendosc Adv Surg Tech A 2021; 31 (03) 290-295
    CrossrefPubMedSearch in Google Scholar
  • 36 Brüggmann D, Tchartchian G, Wallwiener M, Münstedt K, Tinneberg HR, Hackethal A. Intra-abdominal adhesions: definition, origin, significance in surgical practice, and treatment options. Dtsch Arztebl Int 2010; 107 (44) 769-775
    PubMedSearch in Google Scholar
  • 37 Wee IJY, Kuo LJ, Ngu JC. A systematic review of the true benefit of robotic surgery: ergonomics. Int J Med Robot 2020; 16 (04) e2113
    CrossrefPubMedSearch in Google Scholar
  • 38 Lakhiani C, Fisher SM, Janhofer DE, Song DH. Ergonomics in microsurgery. J Surg Oncol 2018; 118 (05) 840-844
    CrossrefPubMedSearch in Google Scholar
  • 39 Wang T, Norasi H, Nguyen MD. et al. Intraoperative ergonomic assessment of exoscopes versus conventional DIEP flap. J Reconstr Microsurg 2023; 39 (06) 453-461
    Thieme ConnectPubMedSearch in Google Scholar
  • 40 Bishop SN, Asaad M, Liu J. et al. Robotic harvest of the deep inferior epigastric perforator flap for breast reconstruction: a case series. Plast Reconstr Surg 2022; 149 (05) 1073-1077
    CrossrefPubMedSearch in Google Scholar
  • 41 Nannapaneni S, Blears E, Bruce MK, Fortunato R, Murariu D. First reported cases of robotic assisted harvest of vertical rectus abdominis myocutaneous (VRAM) flap for pelvic wound coverage. Plast Reconstr Surg Glob Open 2022; 10 (1S): 17
    CrossrefPubMedSearch in Google Scholar
  • 42 Chen B, Gleeney A, Gerndt SP. et al. Oropharyngeal flap reconstruction with a single port robot: initial report on our case series. Plast Reconstr Surg Glob Open 2024; 12 (1 Suppl): 55
    CrossrefPubMedSearch in Google Scholar
  • 43 Martinez CA, Boutros SG. Outpatient microsurgical breast reconstruction. Plast Reconstr Surg Glob Open 2020; 8 (09) e3109
    CrossrefPubMedSearch in Google Scholar
  • 44 Feingold RS. Improving surgeon confidence in the DIEP flap: a strategy for reducing operative time with minimally invasive donor site. Ann Plast Surg 2009; 62 (05) 533-537
    CrossrefPubMedSearch in Google Scholar