Robotic Latissimus Dorsi Muscle Harvest

Abstract

Sir: The latissimus dorsi muscle has been a workhorse of reconstructive surgery since its original description by Iginio Tansini.1 Traditional harvest technique requires an incision resulting in a scar approximately 20 cm long. Minimally invasive harvest of the latissimus is a desirable goal. Endoscopic harvest has been attempted repeatedly,2,3 but because of technical challenges, all but a few centers have abandoned it.4,5 Robotic surgery has gained popularity because of precision instrumentation and superior visualization over laparoscopic and endoscopic techniques. These advantages are equally applicable to harvest of the latissimus dorsi. The purpose of this study was to determine whether this application was feasible and practical. Ten robotic latissimus dorsi muscle harvests were performed in eight cadavers from 2009 to 2010. All dissections were performed by a single surgeon (J.C.S.) using the da Vinci surgical robotic surgical platform. The patient is placed in the decubitus position. A 5-cm axillary incision is made at the axillary crease, along the posterior axillary fold, through which the thoracodorsal pedicle is identified and the anterior border of the latissimus muscle is dissected free. A space 5 cm anterior to the border of the muscle is also dissected for port placement. The axillary incision is closed temporarily over a 12-mm port to maintain insufflation. Next, the 12-mm camera port is placed through a 1-cm incision approximately 20 cm from the axillary fold and 6 to 7 cm anterior to the border of the muscle. The port is placed under direct vision through the axillary incision. The proximal, 5-mm port is then placed four fingerbreadths (8 cm) proximal to the camera port. The 0-degree endoscope is introduced and the distal, 5-mm port is placed four fingerbreadths distal to the camera port under endoscopic vision (Fig. 1).Fig. 1.: Ports 1, 2, and 3 are placed approximately 15, 23, and 31 cm from the axillary fold, and 4, 6, and 5 cm from the anterior border of the muscle, respectively. The first port introduced is the 12-mm camera port. The proximal, 5-mm port is then placed under direct vision approximately four fingerbreadths (8 cm) proximal to the camera port, and the distal port is placed four fingerbreadths distal to the camera port under endoscopic vision.After port placement, the robotic side cart is positioned and the arms are positioned nearly parallel to the plane of the floor. The ports are docked and insufflation is applied (Fig. 2). Dissection begins along the undersurface of the muscle (if dissection began in the subcutaneous plane, it would be impossible to maintain the optical window during the submuscular dissection). After the undersurface is dissected, the grasper is used to retract the anterior edge of the muscle, and dissection proceeds over its superficial surface. Once both superficial and deep dissection is complete, the monopolar scissors is used to divide the muscle along the inferoposterior border. Once liberated to the tip of the scapula, the muscle is delivered through the axillary incision (Fig. 3) (seeVideo 1, Supplemental Digital Content 1, which demonstrates the robotic latissimus harvest, https://links.lww.com/PRS/A368).Fig. 2.: After port placement, the robotic side cart is positioned on the back side of the bed and the arms are brought over the patient and into position, nearly parallel to the plane of the floor. The ports are docked and insufflation is applied.Fig. 3.: Once the muscle has been liberated proximal to the tip of the scapula, the muscle will be easily accessible through the axillary incision. This incision is then opened, and the muscle is delivered.Video.: Supplemental Digital Content 1 is an approximately 5-minute video of the robotic latissimus harvest, https://links.lww.com/PRS/A368. After the undersurface of the muscle is dissected to its borders, the grasper is used to pull the anterior edge of the muscle down, and dissection proceeds over the superficia