Suhail K Kanchwala, MD, Ian S Soriano, MD, FACS, FASMBS. Pennsylvania Hospital
INTRODUCTION: Abdominally-based free-flap breast reconstruction has evolved to provide patients with an acceptable autologous reconstruction while minimizing morbidity at the abdominal donor site. To further reduce surgical morbidity of the abdominal wall, the authors introduced a laparoscopic-assisted totally-extraperitoneal (Lap TEP) harvest of the deep inferior epigastric (DIE) vessels as an adjunct to a two-staged single-perforator free-flap (SPFF) DIEP delay.
METHODS: Since March 2018, all patients opting for a two-stage SPFF DIEP delay as their method of breast reconstruction underwent lap-assisted TEP harvest of the DIE vessels. During Stage 1, the abdominal flap(s) is delayed on a single-perforator identified pre-operatively via abdominal CT-angiography. During Stage 2, the delayed perforator is dissected to the main pedicle via a 2-3cm fascial incision. The upper-abdominal donor-site flap is raised off the abdominal wall to the xiphoid-costal margin. Following established Lap TEP hernia technique, a supra-umbilical incision is made to place a balloon dissector to create the pre-peritoneal working space. The balloon dissector is replaced with a balloon trocar and two additional ports are then placed along the linea alba. The deep inferior epigastric (DIE) vessels are dissected from the underside of the rectus from the external iliac vessels to the delayed perforator while preserving the thoracolumbar motor nerves above. The DIE pedicle is ligated, pneumoperitoneum is released, and the vessels delivered through the minimal-access fascial incision which is closed with figure-of-eight sutures. The single-perforator DIEP flap(s) is then transferred to the chest to recreate the breast mound(s). Patients are placed on a non-narcotic ERAS protocol post-operatively.
RESULTS: Since March 2018, Lap-assisted TEP harvest of the DIE vessels have been performed on 20 patients with 28 flaps harvested. Average length of fascial incision was 2.8cm. No patient required narcotics during their hospital stay. Average inpatient length of stay was 2 days following Stage-2 of the two-staged SPFF DIEP delay. There was no complete or partial flap loss.
CONCLUSION: Laparoscopic-assisted totally extra-peritoneal (TEP) harvest of the deep inferior epigastric vessels as part of a two-staged single-perforator free-flap DIEP delay is a safe and reproducible minimally invasive approach that preserves abdominal wall integrity. This approach also helps reduce abdominal donor-site discomfort and reduces length-of-stay.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 95674
Program Number: S151
Presentation Session: MIS Medley
Presentation Type: Podium