Introduction: The transverse rectus abdominis musculocutaneous (TRAM) flap has become the standard and most popular method for autogenous breast reconstruction. Ligation of the deep inferior epigastric vessels prior to TRAM flap reconstruction (delay procedure) was introduced to augment vascularity to the island flap through improved superior epigastric flow, thus decreasing flap morbidity.
Methods: A transverse infra-umbilical incision is made. The preperitoneal space is developed just posterior to the rectus muscle using a 10 mm balloon dissector (Autosuture; US Surgical Corporation, Norwalk, CT). A pneumoextraperitoneum is created up to 12 mm of Hg pressure. Two 5 mm trocars are inserted in the midline. The inferior epigastric vessels are identified by confirming arterial pulsation. A 2-3 cm length of inferior vascular pedicle is ligated with 3 clips both proximally and distally and then divided using laparoscopic scissors. After absolute hemostasis is confirmed the pneumoextraperitoneum is evacuated, and both fascia and skin are closed. The patient is discharged home the same day after an adequate postoperative recovery period.
Results: Over a 1-year period the Extraperitoneal Laparoscopic Technique (EPLT) was attempted successfully in seven of eight patients (all females) with an 87.5% success rate. The average patient age was 54.7 years. The mean operative time for the EPLT procedure was 52 minutes. In one case we converted to the transperitoneal approach as the initial balloon dissector violated the peritoneum. There where no other intraoperative or postoperative complications noted with this technique. When comparing the EPLT to the open technique we have observed a shorter operative time, reduced postoperative pain and reduced tissue edema and inflammation at the time of TRAM reconstruction.
Conclusion: The EPLT improves efficacy through the benefits of minimally invasive surgery while avoiding the risk of intraperitoneal injury. We have observed reduced operative times and postoperative pain, without compromising efficacy. The extraperitoneal laparoscopic delay procedure is a safe and effective method to improve flap vascularity in pre-TRAM reconstruction.
Program Number: P354