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Laparoscopically harvested omental flap for immediate breast reconstruction
The American Journal of Surgery 192 (2006) 556 –558
Presentation
Laparoscopically harvested omental flap for immediate breast reconstruction Hisamitsu Zaha, M.D.a,*, Susumu Inamine, M.D.a, Takashi Naito, M.D.b, Hiroshi Nomura, M.D.b a
Department of Surgery, Nakagami Hospital, 6-25-5 Chibana, Okinawa, 904-2195, Japan Department of Plastic and Reconstructive Surgery, Nakagami Hospital, Okinawa, Japan
b
Manuscript received March 31, 2006; revised manuscript June 12, 2006 Presented at the 7th Annual Meeting of the American Society of Breast Surgeons, Baltimore, Maryland, April 5–9, 2006
Abstract Background: Breast cancer surgery and accompanying breast reconstruction have been diversified. We report our experience of immediate breast reconstruction using laparoscopically harvested omental flap (LHOF). Methods: During a 44-month period, 44 immediate breast reconstructions with LHOF were performed. Patients were followed up for complications and cosmetic results. Results: Forty cases of pedicled LHOF and 4 cases of free LHOF were performed after either nipplesparing mastectomy (n ⫽ 21) or breast-conservation treatment (n ⫽ 23). Morbidity included 1 minor vascular injury (2.3%) of the LHOF, 4 wound and graft infections (9.1%), and 1 epigastric hernia (2.3%). Cosmetic results were mostly satisfactory, with a soft breast that was natural in appearance. Donor-site scars were minimal. However, in 5 patients (12.5%), omental flap size was found to be inadequate during the procedure. Conclusions: Although there is a limit of volume, LHOF is an attractive autologous flap, which makes a natural soft breast and minimal deformity of the donor site. © 2006 Excerpta Medica Inc. All rights reserved. Keywords: Laparoscopy; Omental flap; Breast reconstruction
Breast cancer surgery has been diversified from breastconservation treatment (BCT) to skin-sparing mastectomy, areola-sparing mastectomy, and nipple-sparing mastectomy (NSM) because of the recent trend in reduction of surgery [1]. Accompanying simultaneous reconstruction has also diversified as tumor-specific immediate reconstruction [2]. In autologous reconstruction, the latissimus dorsi flap and transverse rectus abdominis myocutaneous flap play the main role. The disadvantage of these autologous tissues is the presence of donor-site morbidity and deformity. Laparoscopically harvested ometal flap (LHOF) compensates for these disadvantages associated with the donor site [3]. We report our experience of immediate breast reconstruction by using LHOF at our institution.
* Corresponding author. Tel.: ⫹81-98-939-1300; fax: ⫹81-98-9378699. E-mail address: [email protected]
Methods Immediate breast reconstruction with LHOF was applied to 44 patients with stage 0, I, or II breast cancer who underwent NSM or BCT between April 2002 and November 2005. For BCT, reconstruction with LHOF was applied when a 30% or wider region of the breast tissue was resected or cosmetic result was poor because of the tumor location in the lower medial region. Patients in whom tumor invasion in the nipple was suspected on preoperative imaging and who had a past history of upper abdominal laparotomy were excluded. Surgery was performed in a supine position under general anesthesia. A camera port (10-mm 30°) was inserted under the umbilicus, and additional 3 to 4 5-mm ports were placed. First, the omentum was dissected from the transverse colon, for which starting from a site slightly left of the center of the transverse colon made access to the lesser sac easier (Fig. 1A). Dissection was advanced leftward, and the left gastroepiploic vein and artery were divided near the
0002-9610/06/$ – see front matter © 2006 Excerpta Medica Inc. All rights reserved. doi:10.1016/j.amjsurg.2006.06.030
H. Zaha et al. / The American Journal of Surgery 192 (2006) 556 –558
spleen. Attention was paid to the gastroepiploic vein and artery to avoid injuring them, and the branches were divided at sites as close to the stomach wall as possible (Fig. 1B). The omentum was dissected until passing the pyloric ring, and the roots of the right gastroepiploic vein and artery were confirmed. NSM was performed mainly by making an approximately 15-cm skin incision from the middle axillary line to the inframammary fold and a medial semicircular areolar incision. The absence of tumor invasion in the stump below the nipple was confirmed by intraoperative frozen section. For BCT, various skin incisions were used corresponding to tumor location. Sentinel lymph node biopsy and axillary dissection were performed as needed. When a pedicled flap was used, an approximately 2-finger–wide subcutaneous tunnel was prepared from the medial end of the inframammary fold toward the xiphoid process, and when it reached the white line, an approximately 2.5-finger–wide longitudinal incision was made to communicate with the abdominal cavity. The forceps were inserted into the abdominal cavity, and the pedicled omental flap was carefully pulled out, avoiding twisting. When a free flap was used, the roots of the right gastroepiploic vein and artery were clipped and resected. An approximately 4-cm transverse incision made in the right lower abdominal wall, and the flap was removed. The thoracodorsal vein and artery and the right gastroepiploic vein and artery were microanastomosed under a microscope in the axillary region. Both pedicled and free flaps were fixed to the major pectroral muscle with an absorbable suture at several sites to form a mound. All patients were evaluated for cosmesis by surgeons postoperatively every 3 months. The patients undergoing BCT were also evaluated for tumor control by using breast ultrasound and magnetic resonance imaging. Results The characteristics of patients undergoing immediate reconstruction with LHOF are listed in Table 1. Forty cases of pedicled LHOF and 4 cases of free LHOF were performed. Because tumor invasion in the nipple was noted on intraoperative frozen section in 3 patients treated with NSM, the nipple-areolar complex was resected, and surgery was changed to skin-sparing mastectomy. All omental flaps were laparoscopically harvested within 1 hour without conversion to an
Fig. 1. Laparoscopic procedures. All of dissection was completed with the Harmonic Scalpel (Ethicon Ecdo-Surgery Inc, Cincinnati, OH). (A) Dissecton from the transverse colon. (B) Dissection from the stomach wall.
557
Table 1 Characteristics of patients undergoing LHOF for IBR Patients undergoing LHOF for IBR (n ⫽ 44) Age (y) Mean Range Tumor size (n) Tis (Diffuse DCIS) T1 T2 Operative procedures (n) NSM BCT Operating time (min) Mean Range Operative blood loss (mL) Mean Range Follow-up (months) Median Range Chemotherapy Radiation therapy
% of total 47.2 27–67 6 2 36
13.6 4.5 81.8
21 23
47.7 52.3
270 210–350 250 80–310 25 4–48 30 12
68.2 27.3
IBR ⫽ immediate breast reconstruction; DCIS ⫽ ductal carcinoma in situ.
open procedure. Morbidity included 1 minor vascular injury of the omental flap (2.3%), 4 wound and graft infections that could be treated conservatively (9.1%), and 1 epigastic hernia (2.3%). There was no total graft loss. However, in 5 patients (12.5%), the omental flap size was found to be inadequate during the procedure and a latissimus dorsi myoflap was combined with the omental flap. Cosmetic results were mostly satisfactory, with a soft breast that was natural in appearance. Donor-site scars were minimal (Fig. 2). No size reduction of the reconstructed breast was noted during the follow-up period. Concomitant postoperative radiotherapy was performed in 12 patients, but no change was noted in the reconstructed breast. In 4 patients (9.1%), minor deformity of the reconstructed breast occurred through postoperative infectious complications. Although the follow-up period was short, neither local nor systemic recurrence has occurred so far in any patient. Comments Breast reconstruction using the omentum has been reported over a relatively long period [4], but its historically important role has come to an end because it required a relatively large laparotomy incision. However, progression of endoscopic surgery has allowed laparoscopic harvesting of an omental flap, facilitating autologous reconstruction with the least donor-site deformity [3,5,6]. The degree of the surgical wound is similar to that in laparoscopic cholecystectomy. Postoperative recovery is fast, and morbidity, such as bowel obstruction, is low. In our series, epigastric hernia occurred in 1 patient, but this was because of excessive extension of the subcutaneous tunnel for a large volume of the omentum. Currently, we apply a free omental flap when the omental volume is large and avoid subcutaneous tunnel-
558
H. Zaha et al. / The American Journal of Surgery 192 (2006) 556 –558
Fig. 2. (A) A pedicled LHOF for BCT. (B) Six months post-BCT with LHOF. The tumor was located in the lower medial region, and more than 30% of the breast tissue was resected. (C) A pedicled LHOF for NSM. (D) Ten months post-NSM. An arrow indicates one of the abdominal scars.
associated complications. Omental flaps are softer than any other autologous tissues and undergo less atrophy, unlike muscle flaps. Because omental flaps are soft and can be shaped freely, they represent optimum filling tissue for irregular shapes after wide resection in BCT [6]. The neck of the omental flap is long and can be easily fitted into any region of the breast, making vascular anastomosis of the free flap in the axillary region simple. As for the biggest disadvantage of omental flaps, preoperative estimation of the omental volume is not possible, and the volume may be insufficient when the breast to be reconstructed is large [3]. Concomitant implantation is also available [3]. Although we informed the patients preoperatively for the possibility of using concomitant implantation or latissimus dorsi flap, we usually excluded NSM cases requiring a large breast reconstruction from the indication. Immediate breast reconstruction with LHOF provides a soft reconstructed breast with less donor-site deformity and is useful as tumor-specific immediate reconstruction for
NSM applied to a medium-size breast and BCT with extensive resection. References [1] Simmons RM, Hollenbeck ST, LaTrenta GS. Two-year follow-up of areola-sparing mastectomy with immediate reconstruction. Am J Surg 2004;188:403– 6. [2] Audretsh W, Rezai M, Kolotas C, et al. Tumor-specific immediate reconstruction (TSIR) in breast cancer patients. Perspect Plast Surg 1998;11:71–106. [3] Cothier-Savey I, Tamtawi B, Franck D, et al. Immediate breast reconstruction using laparoscopically harvested omental flap. Plast Recontr Surg 2001;107:1156 – 63. [4] Kiricuta I. L’emploi du épiploon dans la chirurgie du sein cancéreux. Presse Med 1963;71:15–7. [5] Saltz R, Stowers R, Smith M, Gadacz TR. Laparoscopically harvested omental free flap to cover a large soft tissue defect. Ann Surg 1993; 217:542– 6. [6] Jimenez AG, St. Germain P, Sirois M, et al. Free omental flap for skin-sparing breast reconstruction harvested laparoscopically. Plast Recontr Surg 2002;110:545–51.
Presentation
Laparoscopically harvested omental flap for immediate breast reconstruction Hisamitsu Zaha, M.D.a,*, Susumu Inamine, M.D.a, Takashi Naito, M.D.b, Hiroshi Nomura, M.D.b a
Department of Surgery, Nakagami Hospital, 6-25-5 Chibana, Okinawa, 904-2195, Japan Department of Plastic and Reconstructive Surgery, Nakagami Hospital, Okinawa, Japan
b
Manuscript received March 31, 2006; revised manuscript June 12, 2006 Presented at the 7th Annual Meeting of the American Society of Breast Surgeons, Baltimore, Maryland, April 5–9, 2006
Abstract Background: Breast cancer surgery and accompanying breast reconstruction have been diversified. We report our experience of immediate breast reconstruction using laparoscopically harvested omental flap (LHOF). Methods: During a 44-month period, 44 immediate breast reconstructions with LHOF were performed. Patients were followed up for complications and cosmetic results. Results: Forty cases of pedicled LHOF and 4 cases of free LHOF were performed after either nipplesparing mastectomy (n ⫽ 21) or breast-conservation treatment (n ⫽ 23). Morbidity included 1 minor vascular injury (2.3%) of the LHOF, 4 wound and graft infections (9.1%), and 1 epigastric hernia (2.3%). Cosmetic results were mostly satisfactory, with a soft breast that was natural in appearance. Donor-site scars were minimal. However, in 5 patients (12.5%), omental flap size was found to be inadequate during the procedure. Conclusions: Although there is a limit of volume, LHOF is an attractive autologous flap, which makes a natural soft breast and minimal deformity of the donor site. © 2006 Excerpta Medica Inc. All rights reserved. Keywords: Laparoscopy; Omental flap; Breast reconstruction
Breast cancer surgery has been diversified from breastconservation treatment (BCT) to skin-sparing mastectomy, areola-sparing mastectomy, and nipple-sparing mastectomy (NSM) because of the recent trend in reduction of surgery [1]. Accompanying simultaneous reconstruction has also diversified as tumor-specific immediate reconstruction [2]. In autologous reconstruction, the latissimus dorsi flap and transverse rectus abdominis myocutaneous flap play the main role. The disadvantage of these autologous tissues is the presence of donor-site morbidity and deformity. Laparoscopically harvested ometal flap (LHOF) compensates for these disadvantages associated with the donor site [3]. We report our experience of immediate breast reconstruction by using LHOF at our institution.
* Corresponding author. Tel.: ⫹81-98-939-1300; fax: ⫹81-98-9378699. E-mail address: [email protected]
Methods Immediate breast reconstruction with LHOF was applied to 44 patients with stage 0, I, or II breast cancer who underwent NSM or BCT between April 2002 and November 2005. For BCT, reconstruction with LHOF was applied when a 30% or wider region of the breast tissue was resected or cosmetic result was poor because of the tumor location in the lower medial region. Patients in whom tumor invasion in the nipple was suspected on preoperative imaging and who had a past history of upper abdominal laparotomy were excluded. Surgery was performed in a supine position under general anesthesia. A camera port (10-mm 30°) was inserted under the umbilicus, and additional 3 to 4 5-mm ports were placed. First, the omentum was dissected from the transverse colon, for which starting from a site slightly left of the center of the transverse colon made access to the lesser sac easier (Fig. 1A). Dissection was advanced leftward, and the left gastroepiploic vein and artery were divided near the
0002-9610/06/$ – see front matter © 2006 Excerpta Medica Inc. All rights reserved. doi:10.1016/j.amjsurg.2006.06.030
H. Zaha et al. / The American Journal of Surgery 192 (2006) 556 –558
spleen. Attention was paid to the gastroepiploic vein and artery to avoid injuring them, and the branches were divided at sites as close to the stomach wall as possible (Fig. 1B). The omentum was dissected until passing the pyloric ring, and the roots of the right gastroepiploic vein and artery were confirmed. NSM was performed mainly by making an approximately 15-cm skin incision from the middle axillary line to the inframammary fold and a medial semicircular areolar incision. The absence of tumor invasion in the stump below the nipple was confirmed by intraoperative frozen section. For BCT, various skin incisions were used corresponding to tumor location. Sentinel lymph node biopsy and axillary dissection were performed as needed. When a pedicled flap was used, an approximately 2-finger–wide subcutaneous tunnel was prepared from the medial end of the inframammary fold toward the xiphoid process, and when it reached the white line, an approximately 2.5-finger–wide longitudinal incision was made to communicate with the abdominal cavity. The forceps were inserted into the abdominal cavity, and the pedicled omental flap was carefully pulled out, avoiding twisting. When a free flap was used, the roots of the right gastroepiploic vein and artery were clipped and resected. An approximately 4-cm transverse incision made in the right lower abdominal wall, and the flap was removed. The thoracodorsal vein and artery and the right gastroepiploic vein and artery were microanastomosed under a microscope in the axillary region. Both pedicled and free flaps were fixed to the major pectroral muscle with an absorbable suture at several sites to form a mound. All patients were evaluated for cosmesis by surgeons postoperatively every 3 months. The patients undergoing BCT were also evaluated for tumor control by using breast ultrasound and magnetic resonance imaging. Results The characteristics of patients undergoing immediate reconstruction with LHOF are listed in Table 1. Forty cases of pedicled LHOF and 4 cases of free LHOF were performed. Because tumor invasion in the nipple was noted on intraoperative frozen section in 3 patients treated with NSM, the nipple-areolar complex was resected, and surgery was changed to skin-sparing mastectomy. All omental flaps were laparoscopically harvested within 1 hour without conversion to an
Fig. 1. Laparoscopic procedures. All of dissection was completed with the Harmonic Scalpel (Ethicon Ecdo-Surgery Inc, Cincinnati, OH). (A) Dissecton from the transverse colon. (B) Dissection from the stomach wall.
557
Table 1 Characteristics of patients undergoing LHOF for IBR Patients undergoing LHOF for IBR (n ⫽ 44) Age (y) Mean Range Tumor size (n) Tis (Diffuse DCIS) T1 T2 Operative procedures (n) NSM BCT Operating time (min) Mean Range Operative blood loss (mL) Mean Range Follow-up (months) Median Range Chemotherapy Radiation therapy
% of total 47.2 27–67 6 2 36
13.6 4.5 81.8
21 23
47.7 52.3
270 210–350 250 80–310 25 4–48 30 12
68.2 27.3
IBR ⫽ immediate breast reconstruction; DCIS ⫽ ductal carcinoma in situ.
open procedure. Morbidity included 1 minor vascular injury of the omental flap (2.3%), 4 wound and graft infections that could be treated conservatively (9.1%), and 1 epigastic hernia (2.3%). There was no total graft loss. However, in 5 patients (12.5%), the omental flap size was found to be inadequate during the procedure and a latissimus dorsi myoflap was combined with the omental flap. Cosmetic results were mostly satisfactory, with a soft breast that was natural in appearance. Donor-site scars were minimal (Fig. 2). No size reduction of the reconstructed breast was noted during the follow-up period. Concomitant postoperative radiotherapy was performed in 12 patients, but no change was noted in the reconstructed breast. In 4 patients (9.1%), minor deformity of the reconstructed breast occurred through postoperative infectious complications. Although the follow-up period was short, neither local nor systemic recurrence has occurred so far in any patient. Comments Breast reconstruction using the omentum has been reported over a relatively long period [4], but its historically important role has come to an end because it required a relatively large laparotomy incision. However, progression of endoscopic surgery has allowed laparoscopic harvesting of an omental flap, facilitating autologous reconstruction with the least donor-site deformity [3,5,6]. The degree of the surgical wound is similar to that in laparoscopic cholecystectomy. Postoperative recovery is fast, and morbidity, such as bowel obstruction, is low. In our series, epigastric hernia occurred in 1 patient, but this was because of excessive extension of the subcutaneous tunnel for a large volume of the omentum. Currently, we apply a free omental flap when the omental volume is large and avoid subcutaneous tunnel-
558
H. Zaha et al. / The American Journal of Surgery 192 (2006) 556 –558
Fig. 2. (A) A pedicled LHOF for BCT. (B) Six months post-BCT with LHOF. The tumor was located in the lower medial region, and more than 30% of the breast tissue was resected. (C) A pedicled LHOF for NSM. (D) Ten months post-NSM. An arrow indicates one of the abdominal scars.
associated complications. Omental flaps are softer than any other autologous tissues and undergo less atrophy, unlike muscle flaps. Because omental flaps are soft and can be shaped freely, they represent optimum filling tissue for irregular shapes after wide resection in BCT [6]. The neck of the omental flap is long and can be easily fitted into any region of the breast, making vascular anastomosis of the free flap in the axillary region simple. As for the biggest disadvantage of omental flaps, preoperative estimation of the omental volume is not possible, and the volume may be insufficient when the breast to be reconstructed is large [3]. Concomitant implantation is also available [3]. Although we informed the patients preoperatively for the possibility of using concomitant implantation or latissimus dorsi flap, we usually excluded NSM cases requiring a large breast reconstruction from the indication. Immediate breast reconstruction with LHOF provides a soft reconstructed breast with less donor-site deformity and is useful as tumor-specific immediate reconstruction for
NSM applied to a medium-size breast and BCT with extensive resection. References [1] Simmons RM, Hollenbeck ST, LaTrenta GS. Two-year follow-up of areola-sparing mastectomy with immediate reconstruction. Am J Surg 2004;188:403– 6. [2] Audretsh W, Rezai M, Kolotas C, et al. Tumor-specific immediate reconstruction (TSIR) in breast cancer patients. Perspect Plast Surg 1998;11:71–106. [3] Cothier-Savey I, Tamtawi B, Franck D, et al. Immediate breast reconstruction using laparoscopically harvested omental flap. Plast Recontr Surg 2001;107:1156 – 63. [4] Kiricuta I. L’emploi du épiploon dans la chirurgie du sein cancéreux. Presse Med 1963;71:15–7. [5] Saltz R, Stowers R, Smith M, Gadacz TR. Laparoscopically harvested omental free flap to cover a large soft tissue defect. Ann Surg 1993; 217:542– 6. [6] Jimenez AG, St. Germain P, Sirois M, et al. Free omental flap for skin-sparing breast reconstruction harvested laparoscopically. Plast Recontr Surg 2002;110:545–51.