Learning Curve for Robotic-Assisted Harvest of Deep Inferior Epigastric Perforator Flap: Comparison Between a General Surgeon and a Plastic Surgeon Performing the Robotic Dissection

摘要

INTRODUCTION: The deep inferior epigastric perforator (DIEP) flap is the preferred method for autologous breast reconstruction following mastectomy, though it risks development of hernia, bulge, or decreased core strength.1 Robotic-assisted surgery began in the 1980s and has quickly evolved to become gold standard in many fields.2 Robotics have also begun to be utilized in plastic surgery. We are successfully performing robotic-assisted intracorporeal harvest of DIEP vessels to limit abdominal wall morbidity through smaller fascial incisions and preservation of motor nerves when compared to standard DIEP.3 Traditional DIEP flap reconstruction is already a demanding and time-consuming operation, and surgeons with limited robotic experience may initially be hesitant to attempt robotic harvest. This study shows the expected learning curve (LC) for surgeons interested in incorporating this into their practice and to compare the LC between a single general surgeon (GS) and plastic surgeon (PS). METHODS: A retrospective cohort study was performed for patients who underwent robotic DIEP flap harvest from October 2021 through September 2022. We evaluated robotic pedicle dissection time (DT) and compared the times between a GS and PS. We calculated LC for each surgeon using the cumulative sum (CUSUM) method. CUSUM is the summation of differences between DT for each patient and the mean DT for all patients, CUSUM = ∑_(i=1)^n(xi-▁(µ)). LC was identified as the peak of the CUSUM curve. RESULTS: 44 flaps were performed during the collection period: 27 by the PS, 17 by the GS. There was no significant difference in DT between the GS (34.8 min) and PS (41.2 min) (p value=0.232), and while both surgeons saw a decrease in DT over time, the DT time for the GS decreased more quickly. Using the CUSUM method, we see the peak of the curve at patient 8 for the PS and the peak of the curve at patient 5 for the GS, after which cumulative DT decreased. There were no intraabdominal or pedicle injuries in any of these patients. CONCLUSION: As robotic harvest of DIEP flaps becomes accepted, surgeons who wish to incorporate our technique into their practice can expect to have a consistent decrease in their DT after 10 cases. Plastic surgeons can safely and proficiently uptake the minimally invasive technique with a similar learning curve compared to robotic trained general surgeons. References: 1. EA Bailey and SN Bishop. (2023). Minimally Invasive Surgery in Breast Reconstruction: The Past and Future. Breast Cancer Updates [Working Title]. Doi: 10.5772/intechopen.109503 2. G Garas and A Arora. Robotic Head and Neck Surgery: History, Technical Evolution and the Future. ORL 2018; 80(3-4):117-124. Doi: 10.1159/000489464 3. EA Bailey, B Chen, W Nelson, S Nosik, R Fortunato, A Moreira, D Murariu. Robotic versus Standard Harvest of Deep Inferior Epigastric Artery Perforator Flaps: Early Outcomes. PRS - Global Open 2022; 10(10S):p 64-65. Doi: 10.1097/01.GOX.0000898644.00762.77