Murariu Daniel, Chen Brian, Bailey Elizabeth, Nelson William, Fortunato Richard, Nosik Stanislav, Moreira Andrea
Department of Surgery, Allegheny Health Network, Pittsburgh, Pennsylvania.
Department of Plastic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
J Reconstr Microsurg. 2025 Jun;41(5):369-375. doi: 10.1055/s-0044-1788930. Epub 2024 Aug 27.
The deep inferior epigastric artery perforator (DIEP) flap is the gold standard for autologous breast reconstruction. However, the conventional procedure's anterior sheath division, from perforating vessels to the pedicle origin, risks weakening the abdominal wall's primary strength layer. Employing the da Vinci Xi Surgical System with indocyanine green dye and near-infrared fluorescence imaging, we refined a robotic technique for bilateral DIEP flap harvest. This approach enhances safety during vessel dissection, utilizing smaller fascial incisions. This study will present this technique in detail to microsurgeons interested in robotic DIEP flaps.
In a retrospective cohort study spanning July 2021 to September 2022, female patients undergoing robotic bilateral DIEP flap reconstruction were analyzed. Following suprafascial flap dissection, the surgical robot was docked to target the pelvis, identifying and exposing deep inferior epigastric vessels intracorporeally. Mobilization and division occurred at their bases, with retrieval through a minimal anterior fascial incision, minimizing disruption to the abdominal wall and its motor innervation.
The study comprised 23 patients (46 flaps), with a mean fascial length of 4.1 cm and mean pedicle length of 12.82 cm. Mesh usage was absent. Robotic time averaged 139 minutes, overall case length was 739 minutes, and the average length of stay was 3.9 days. Notably, no pedicle or intra-abdominal injuries were reported.
This technique ensures safe and efficient pedicle dissection in robotic DIEP flap harvests. Given the limited number of plastic surgeons adept in minimally invasive abdominal surgeries, we recommend collaborative efforts, with general surgeons initially assisting microsurgeons in adopting the robotic approach. This strategy facilitates a smooth transition until plastic surgeons attain confidence and competence in independent robotic dissection.
腹壁下动脉穿支（DIEP）皮瓣是自体乳房重建的金标准。然而，传统手术从穿支血管到蒂部起始处切开前鞘，有削弱腹壁主要强度层的风险。我们使用配备吲哚菁绿染料和近红外荧光成像的达芬奇Xi手术系统，改进了一种用于双侧DIEP皮瓣切取的机器人技术。这种方法在血管解剖过程中提高了安全性，同时使用更小的筋膜切口。本研究将向对机器人辅助DIEP皮瓣感兴趣的显微外科医生详细介绍该技术。
在一项回顾性队列研究中，分析了2021年7月至2022年9月期间接受机器人辅助双侧DIEP皮瓣重建的女性患者。在筋膜上进行皮瓣分离后，将手术机器人对接至骨盆，在体内识别并暴露腹壁下血管。在血管根部进行游离和切断，通过最小的前筋膜切口取出，将对腹壁及其运动神经支配的破坏降至最低。
该研究包括23例患者（46个皮瓣），平均筋膜长度为4.1厘米，平均蒂长度为12.82厘米。未使用补片。机器人手术时间平均为139分钟，总手术时长为739分钟，平均住院时长为3.9天。值得注意的是，未报告有蒂部或腹腔内损伤。
该技术确保了机器人辅助DIEP皮瓣切取过程中蒂部解剖的安全和高效。鉴于擅长微创腹部手术的整形外科医生数量有限，我们建议开展合作，最初由普通外科医生协助整形外科医生采用机器人手术方法。这种策略有助于顺利过渡，直到整形外科医生在独立进行机器人解剖方面获得信心和能力。
