Reply: Minimally Invasive Laparoscopically Dissected Deep Inferior Epigastric Artery Perforator Flap: An Anatomical Feasibility Study and a First Clinical Case

Abstract

Sir: We thank Ogunleye et al. for their interest in our minimally invasive laparoscopically dissected deep inferior epigastric perforator (DIEP) flap harvest.1 Paris, France’s Plastic Surgery program seems in ferment on minimal invasive DIEP harvest. We initiated a laparoscopic DIEP harvest study in 2013 and we are proud that N. Stroumza, then resident in our program, developed his own approach.2 Our up-to-down totally extraperitoneal approach of the pedicle, with ports placed as for a totally extraperitoneal inguinal hernia cure, might be safer for controlling clip placement at the emergence of epigastric vessels. We wish to correct the order of steps mentioned listed in the table in the article by Ogunleye et al.: in our laparoscopic approach, port access and pedicle dissection are followed by suprafascial flap elevation, and finally perforator dissection. We salute Gundlapalli et al. for their robotically assisted clinical DIEP flap harvest.3 We performed robot-assisted DIEP harvests on cadavers in September of 2016 at Paris Descartes University’s Robotic Platform (Figs. 1 and 2), where Struk et al., from the Paris program, then also studied this approach.4 We first positioned the robot on the cadaver’s side, but the conflict with the robotic arms and chest restricted deep inferior epigastric pedicle dissection. We positioned the robot between the patient’s legs for our first clinical totally extraperitoneal DIEP robotic harvest performed on November 27, 2017. The 45-year-old patient presented a type 1 vessel pattern. (See Video, Supplemental Digital Content 1, which demonstrates totally extraperitoneal robot-assisted DIEP flap harvest in a first clinical case, available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, at https://links.lww.com/PRS/D78.) She signed an informed consent document for robotic DIEP harvest. Materials for our robotic approach are listed online. (See Document, Supplemental Digital Content 2, which shows specific materials for our robotic approach, https://links.lww.com/PRS/D79.) The patient was placed supine with both legs on dedicated lithotomy leg supports and ports were placed as reported.1 Extraperitoneal undermining with standard laparoscopy lasted 25 minutes. The robot was then docked and robotic dissection of the right deep inferior epigastric vessels was completed in 50 minutes. Two perforating vessels were dissected conventionally in 45 minutes through a 4-cm anterior rectus fascial incision, versus 12 cm average in our conventional harvest.5 Microsurgical inset on internal mammary vessels lasted 40 minutes, and flap ischemia was 55 minutes. The whole procedure lasted 7 hours, approximately 1.5 hours more than a conventional one.5 The procedure and outcomes, with little postoperative pain, were uneventful. The patient ambulated on postoperative day 1 and was discharged to home on day 5.Fig. 1.: Cadaveric study: da Vinci robot placed laterally.Fig. 2.: Cadaveric study: trocar placement.Video.: Supplemental Digital Content 1, which demonstrates totally extraperitoneal robot-assisted DIEP flap harvest in a first clinical case, is available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, at https://links.lww.com/PRS/D78.We performed the first totally extraperitoneal approach while using the robot, avoiding any intraabdominal access to prevent any bowel injury and later occlusions on flange, both of which are drawbacks underlined by Ogunleye et al. in their transperitoneal approach.3 Our robotic dissection of the deep inferior epigastric vessels with motion scaling and three-dimensional vision was more comfortable than our laparoscopic one. DIEP flaps then remain vascularized by contralateral perforating vessels. Our deep inferior epigastric vessels clip-section was performed at the beginning of our laparoscopic pedicle dissection and at the end for our robotic one. The timing of deep inferior epigastri