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

Abstract

Sir: The authors read the study by Hivelin et al.1 on minimally invasive laparoscopically dissected deep inferior epigastric perforator (DIEP) flap with great interest. They have described a minimally invasive approach to DIEP flap harvest using laparoscopic dissection in a retrorectus plane. The approach is similar to that described by Stroumza et al.2 in a cadaveric model except for the horizontal arrangement of the port sites, versus the vertical orientation used by Hivelin et al.1 Also, in the study by Stroumza et al., the suprafascial flap was raised before laparoscopic dissection versus in this study where the inverse was the case. Of note, one of the cadaveric dissection cases was complicated by perforator injury during the port access phase, which might have been avoided by performing suprafascial flap elevation first. The pedicle dissection time was shorter in this study (30 minutes versus 70 minutes). Our team has described robot-assisted abdominal harvest of a DIEP flap in one patient through intraabdominal access after suprafascial elevation and identification/dissection of the perforator.3 The deep inferior epigastric artery pedicle was then accessed through a posterior fascial incision, which was repaired at the end of the procedure. Our pedicle dissection time and total procedure time were similar to those of Hivelin et al. Incidentally, a robot-assisted DIEP flap abdominal harvest in cadavers has also been recently described by Struk et al.,4 where the robot was used to accomplish pedicle dissection after suprafascial dissection as described by Stroumza et al. but the ports were placed in a horizontal arrangement and pedicle dissection was completed in the retrorectus plane. In our case, we found that the visibility afforded by a three-dimensional robotic microscope, maneuverability in the intraabdominal space, and tremor elimination by the robotic platform was critical for safe dissection, although with intraabdominal access, the risk of bowel injury and posterior fascia violation are drawbacks. All four approaches limited the length of the anterior rectus fascial incision and will ostensibly be more easily performed in a type 1 or extramuscular course DIEP vascular pattern. It is unclear which of the planes of dissection, order of operative steps, port access arrangement, and laparoscopic versus robotic instrumentation will prove to be superior as more cases are accrued, experience is gained, and comparative studies are performed (Table 1). However, the promise of minimally invasive DIEP abdominal flap harvest needs to be explored, as the potential for limiting donor-site morbidity, safer pedicle dissection, and faster patient recovery are apparent advantages that may be clinically valuable to patients in the future.Table 1.: Characteristics of Minimally Invasive DIEP Flap Harvest StudiesDISCLOSURE The authors have no conflicts of interest to disclose. Adeyemi A. Ogunleye, M.D., S.M.Vinay S. Gundlapalli, M.D.Division of Plastic Surgery Rana C. Pullatt, M.D.Division of Gastrointestinal/Laparoscopic Surgery Milton B. Armstrong, M.D.Kevin O. Delaney, M.D., M.B.A.Division of Plastic SurgeryDepartment of SurgeryMedical University of South CarolinaCharleston, S.C.