A novel technique for robot assisted latissimus dorsi flap harvest

Accepted Manuscript A Novel Technique for Robot Assisted Latissimus Dorsi Flap Harvest Jae-Hyun Chung, MD, Hi-Jin You, MD, PhD, Hyon-Surk Kim, MD, Byung-Il Lee, MD PhD, Seung-Ha Park, MD PhD, Eul-Sik Yoon, MD PhD PII:

S1748-6815(15)00150-3

DOI:

10.1016/j.bjps.2015.03.021

Reference:

PRAS 4573

To appear in:

Journal of Plastic, Reconstructive & Aesthetic Surgery

Received Date: 30 December 2014 Revised Date:

15 March 2015

Accepted Date: 17 March 2015

Please cite this article as: Chung J-H, You H-J, Kim H-S, Lee B-I, Park S-H, Yoon E-S, A Novel Technique for Robot Assisted Latissimus Dorsi Flap Harvest, British Journal of Plastic Surgery (2015), doi: 10.1016/j.bjps.2015.03.021. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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A Novel Technique for Robot Assisted Latissimus Dorsi Flap

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Harvest

Jae-Hyun Chung, MD, Hi-Jin You, MD, PhD, Hyon-Surk Kim, MD, Byung-Il Lee MD, PhD,

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Seung-Ha Park, MD, PhD, Eul-Sik Yoon, MD, PhD

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Department of Plastic Surgery, Korea University College of Medicine, Seoul, Korea

Running head: Robot assisted latissimus dorsi muscle harvest

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2012)

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Presented at the Plastic Surgery The Meeting in San Diego, CA, USA (11-15 October

ACCEPTED MANUSCRIPT Corresponding Author:

Eul-Sik Yoon, MD, PhD

Korea University Anam Hospital 73 Inchon-ro, Seongbuk-gu, Seoul, 136-705, Korea Tel.: + 82 2 920 5368

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Fax: + 82 2 922 7437

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Department of Plastic Surgery

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E-mail: [email protected]

ACCEPTED MANUSCRIPT Financial Disclosures:

Funding: No funding for this study.

devices, or drugs mentioned in this manuscript.

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Financial Disclosure Statement: None of the authors has a financial interest in any of the products,

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Conflict of Interest Statement: The authors have no conflicts of interest to disclose in relation to the

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content of this article.

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A Novel Technique for Robot Assisted Latissimus Dorsi Flap Harvest

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Abstract

Background: A robotic surgery technique of harvesting the latissimus dorsi muscle flap has technical

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advantages over endoscopic harvest and cosmetic advantages over the open technique. The authors introduce a new transaxillary gasless technique using an articulated long retractor for robot assisted

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latissimus dorsi flap harvest.

Methods: Twelve robot assisted latissimus dorsi muscle flaps were harvested: 3 cases of delayed reconstruction following tissue expander insertion or breast conserving surgery; 4 cases of immediate reconstruction following nipple-sparing mastectomy; and 5 cases of chest wall deformity correction in

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patients with Poland syndrome. A specially designed articulated long retractor was used to maintain adequate working space and enable latissimus dorsi muscle dissection without gas insufflation. Results: Twelve muscle flaps were successfully harvested in 12 patients without converting to an

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open technique. The mean docking time was 54.6 minutes, and the mean operative time and robotic time were 400.4 minutes and 85.8 minutes, respectively. There were no donor site complications or

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flap problems. Average follow-up was 15.7 months. All patients were satisfied with their aesthetic results, especially the absence of visible scars. Conclusion: The novel robot assisted latissimus dorsi harvest technique is a safe alternative to the conventional method.

Level of Evidence: IV Keywords: Robot, da Vinci, Gasless technique, Latissimus dorsi

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Introduction

The latissimus dorsi muscle flap was one of the first methods proposed for breast reconstruction, initially used in 1977 by Schneider et al. 1, Muhlbauer and Olbrisch 2, and later popularized by

vascularity of the flap has increased its popularity.

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Bostwick et al. 3 The relative simplicity of the procedure coupled with the very reliable and consistent Despite these advantages, donor site problems

such as seroma or hematoma are frequently implicated as contributors to elongated periods of

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recovery and hospitalization. 6 In addition, the traditional harvest technique requires a posterior donor site incision with a length of 15–45 cm, including an axillary incision for pedicle harvest or transfer.

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Although the incision can be hidden either under the bra strap area or laterally, the scar tends to be long and frequently widens and hypertrophies with time.

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Minimally invasive techniques using endoscopic harvest of the latissimus dorsi muscle flap have been attempted and advanced by many surgeons. However, because of the two-dimensional view and the

Recently, Selber et al.

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8-12

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nonflexible instruments, this procedure is not easily amenable for latissimus dorsi flap harvest.

introduced a robotic surgery technique of harvesting the latissimus dorsi

muscle flap. Previous studies have reported that robotic surgery offers technical advantages over endoscopic harvest, and cosmetic advantages over the open technique.

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The present study aimed to introduce a new technique using an articulated long retractor for

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transaxillary gasless robot assisted latissimus dorsi muscle harvest. We hereby describe our experience.

Methods and Materials Patients This study was approved by the Institutional Review Board. We retrospectively reviewed all patients (n = 12) who underwent robot assisted latissimus dorsi muscle flap using transaxillary gasless technique between October 2012 and July 2014. All patients had been operated on by a single surgeon. Table 1 presents patient demographics and characteristics, as well as their surgical outcomes during

ACCEPTED MANUSCRIPT and after the operation. The study included the following 12 cases: 3 cases of delayed reconstruction following tissue expander insertion or breast conserving surgery, with a mastectomy scar on the inferolateral border of the breast; 4 cases of immediate reconstruction following nipple-sparing mastectomy, with a mastectomy incision on the lateral side of the breast made after planning and

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discussion with a breast surgeon; and 5 cases of chest wall deformity correction in patients with Poland syndrome—a rare congenital disorder characterized by underdevelopment or absence of

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unilateral pectoralis muscles.

Preoperative Designs

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The markings were performed with the patient standing. The anterior, middle, and posterior axillary lines were marked, as were the midline of the back and the tip of the scapula. The borders of the latissimus dorsi muscle were also marked, by palpating the muscle as follows: the anterior border was marked from the posterior axillary fold to the iliac crest; the superior border was marked from the tendinous insertion along the tip of the scapula to the posterior border; and the posterior border was

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marked approximately 4 cm lateral to the spine.

The preoperative design is the most important step in preparing for surgery. One of our actual preoperative designs, based on accumulated experience, is introduced in Figure 1. The incision line is

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marked by a 5–6 cm vertical incision along the middle axillary line starting from the middle axillary crease. In case of immediate breast reconstructions, the axillary lymph node dissection incision was

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used without the need for an additional incision. Two additional ports are marked for the robotic arms. These were placed at a mean distance of 3–5 cm from the anterior border of the muscle at the same level of the inframammary fold and umbilicus. The central camera arm was placed in the inframammary fold-level port, and the ipsilateral and contralateral robotic arms were placed in the axillary incision line and umbilical-level port. The latissimus dorsi muscle was divided into 2 zones by a baseline, extending from the point where the inframammary fold-level line and the anterior muscle border converge, to the scapular tip. Zone 1, the part proximal to the baseline, was to be dissected manually without robotic assistance; and zone 2, the remaining distal part of the muscle,

ACCEPTED MANUSCRIPT was to be dissected using the robotic surgery system.

Surgical Technique After general anesthesia with orotracheal intubation, the patient’s position was changed to a 45°

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ventrolateral decubitus position with the ipsilateral arm placed on an arm board. An axillary bar was placed in the contralateral axillary area and soft cushions were placed under the knee and heel to prevent formation of pressure ulcers.

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A 5–6 cm vertical incision was made in the axilla, and a subcutaneous tissue connecting to the anterior border of the latissimus dorsi muscle was dissected. The thoracodorsal vessel in the axilla was

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subsequently identified and marked with a vessel loop. Meticulous dissection and skeletonization of the pedicle was not needed.

The muscle in zone 1 was dissected manually under loupe magnification. At this point, to maintain adequate working space, a specially designed articulated long retractor was inserted through the skin incision in the axilla and raised up using a lifting device attached to the operative bed. This retractor

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allowed dissection of nearly one-third of the anterior portion (zone 1) of the muscle under direct vision, despite a more anterior skin incision.

Three robotic arms were used for surgery (Figure 2). The additional 8-mm port incisions were made

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on premarked points. The camera and robotic arms were introduced through their respective incisions indicated in the preoperative design. After port placement, the robotic side cart (da Vinci S, Intuitive

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Surgical, Sunnyvale, CA, USA) was placed opposite from the operator side, posterior to the patient’s back. The 30° camera was placed on the central camera arm, and the monopolar curved scissors were placed on the right arm, with the fenestrated bipolar forceps on the left side arm. An additional port incision were made in the scapular tip area if needed. Dissection of the muscle in the remaining portion (zone 2) was performed in sequence. In brief, dissection began along the undersurface of the muscle from the scapular tip to the inferoposterior border. Dissection then proceeded over the superficial surface of the muscle, and the muscle was disinserted in the inferoposterior border area. Initial dissection along the undersurface facilitates easier

ACCEPTED MANUSCRIPT distinguishment of the boundary between the muscle and thoracolumbar fascia than that along the superficial surface. As shown in Figure 3, the release of the muscle enables its transposition anteriorly into the breast pocket. If additional length is required, the muscle can be disinserted partially from the humerus. After meticulous hemostasis, the robot can be undocked. Closed suction drains were placed

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through the port sites, and the incision site was closed, layer by layer. The patients were subsequently repositioned to the supine position for flap insetting and implant insertion.

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Survey of Patient Satisfaction

At the last follow up visit, we conducted a survey of all patients with follow-up periods longer than 6

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months concerning their satisfaction scores of 3 categories; symmetry, scar and general aesthetic result. Scores in each section ranged from 0 to 10 (0=worst result, 10=absolute satisfaction)

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Results

Twelve muscle flaps were successfully harvested in 12 patients. Our 12 cases were as follows: 3 cases of delayed reconstruction for the treatment of capsular contracture following an implant based

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reconstruction or breast deformity after breast conserving surgery; 4 cases of immediate reconstruction following nipple-sparing mastectomy; and 5 cases of chest wall deformity correction in

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patients with Poland syndrome. As described in Table 1, the mean age of the patients was 35.8 ± 11.8 years, and the mean body mass index was 23.1 ± 2.6 kg/m2. The mean docking time was 54.6 minutes, and the mean operative time and robotic time were 400.4 minutes and 85.8 minutes, respectively. Both the mean docking time and robotic time was gradually decreased. It should be noted that the times listed in Figure 4 reflect the total operative time, as most of our operations were combined with additional procedures. Augmentation mammoplasty of the contralateral breast was performed in 6 cases. Liposuction of the abdomen, flanks, thighs, or buttocks was performed in 7 cases.

ACCEPTED MANUSCRIPT All flaps were successfully harvested without technical difficulty. There were no conversions to conventional open surgery. The pedicled muscle flaps were used in combination with anatomically shaped silicone implants. All drains were removed within 10 days of surgery, and there were no donor site complications or flap problems. However, one patient complained of depression of the inner

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upper quadrant, breast symmetry was achieved with 3 consecutive fat injections. Figures 5-7 depict some of our cases.

Average follow-up period was 15.7 months (range, 6 to 26 months). The mean satisfaction score was

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9.2 for breast symmetry, 9.9 for scar and 9.6 for general aesthetic result; all patients were satisfied with their aesthetic results, especially the absence of visible scars on the back. A small, hidden scar

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was present in the axillary area.

Discussion

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The introduction of robotic latissimus dorsi muscle harvest was an important breakthrough for the future of breast reconstruction.

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The preoperative design is easy to plan and effectively facilitates

the procedure, and the operation process is thorough and elaborate. Gas inflation probably is the only

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aspect of this technique which harbors any specific risk, which has been previously described in articles about robotic thyroidectomy. Gas inflation using CO2 may lead to intraoperative hypothermia,

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which is linked to a higher rate of postoperative complications including discomfort, pain, coagulopathy, and morbid cardiac events.

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Moreover, high thoracic pressure during the operation

may decrease pulmonary venous flow, cardiac output, and respiratory compliance, as well as possibly inducing acid-base imbalance due to hypercarbia.

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On the other hand, gasless methods do not carry

the risk of complications such as hypercapnia, respiratory acidosis, tachycardia, subcutaneous emphysema, and air embolism which are present in gas insufflation approaches.

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Therefore, robotic

thyroidectomy is evolving from a gas inflation technique to a gasless technique. Robotic latissimus dorsi muscle harvest is similar to robotic thyroidectomy in terms of the dissection plane structure. Thus, we consider our gasless technique as a significant advancement in the development of robotic

ACCEPTED MANUSCRIPT latissimus dorsi muscle flap harvest. Our preoperative design was based on trial and error. At first, we performed the operation as initially described.

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Although this setting was effective for dissecting the posterior and inferior borders, we

encountered some difficulties while dissecting the anterior border because the 3 arms overlap

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simultaneously. We subsequently changed the position of the camera from the inframammary foldlevel port to the axillary incision and also moved the robotic arm in the umbilicus level-port to the inframammary fold level-port, which facilitated dissection of the anterior border. In cases where arm

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overlapping still encumbers dissection even after port change, an additional port incision made in the scapular tip area can simplify matters.

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The specially designed articulated long retractor used in our gasless technique provided a wider working space and prevented injury of the robot arms. However, as the working space is too confined for simultaneously dissecting the muscle in all directions, we had to change the angle of the retractor at least once during the operation. As this process takes approximately 15 minutes, the total operative time increased. We are also in the process of developing a fan-shaped retractor which can improve

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narrow tenting during retraction, for more comfortable robotic dissection. Our indications for robot assisted latissimus dorsi flaps were classified into 3 areas: (1) Poland syndrome; (2) implant failure; and (3) implant-based reconstruction. First, we recommend this muscle

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flap in patients with Poland syndrome—a congenital disorder in which patients lack the pectoralis muscle. Since the operation is performed on such patients at a young age, they are generally more

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concerned about conspicuous scars; robot assisted latissimus dorsi flap harvest, leaving a much shorter scar compared to conventional open methods, can be a highly attractive option. Second, capsular contracture can be a relative indication. When exchanging implants, it is not sufficient to cover the new implants solely with a skin flap, which in many cases is already thinned; allogenic dermal matrices (ADM) have been used in these cases to create a more natural-appearing breast. However, covering the entire implant with a thin, expensive ADM is not generally feasible, and the use of ADMs also increases the risk of complications such as infection and seroma formation.

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our study, we used the latissimus dorsi muscle flap to cover the new implants. In the same manner,

ACCEPTED MANUSCRIPT implant-based or partial breast reconstruction can also be a relative indication. If the breast skin envelope is intact, the latissimus dorsi muscle flap can be used for breast reconstruction after nipplesparing mastectomy or breast-conserving surgery with residual breast deformity, as well as in delayed expander-based reconstruction. In these cases, the latissimus dorsi muscle flap is used as a substitute

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for ADM.

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Conclusions

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The transaxillary gasless robot assisted latissimus dorsi muscle flap technique using an articulated long retractor is a safe alternative to the conventional gas-insufflating method. This method is recommended in young patients, especially those with Poland syndrome. This method can also be used in implant-based reconstruction, partial breast reconstruction, and in cases with capsular

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contracture, as an alternative for allogeneic dermal matrices in fortifying a thinned skin envelope.

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References

1. Schneider WJ, Hill HL, Jr., Brown RG. Latissimus dorsi myocutaneous flap for breast

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reconstruction. Br J Plast Surg 1977: 30: 277-81. 2. Muhlbauer W, Olbrisch R. The latissimus dorsi myocutaneous flap for breast reconstruction. Chir Plast 1977: 4: 27.

3. Bostwick J, 3rd, Vasconez LO, Jurkiewicz MJ. Breast reconstruction after a radical mastectomy.

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Plast Reconstr Surg 1978: 61: 682-93.

abstract vi-vii.

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4. Hammond DC. Latissimus dorsi flap breast reconstruction. Clin Plast Surg 2007: 34: 75-82;

5. Hammond DC. Latissimus dorsi flap breast reconstruction. Plast Reconstr Surg 2009: 124: 1055-63. 6. Russell RC, Pribaz J, Zook EG, et al. Functional evaluation of latissimus dorsi donor site. Plast Reconstr Surg 1986: 78: 336-44.

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7. Moore TS, Farrell LD. Latissimus dorsi myocutaneous flap for breast reconstruction: long-term results. Plast Reconstr Surg 1992: 89: 666-72; discussion 73-4. 8. Fine NA, Orgill DP, Pribaz JJ. Early clinical experience in endoscopic-assisted muscle flap harvest.

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Ann Plast Surg 1994: 33: 465-9; discussion 69-72.

9. Friedlander L, Sundin J. Minimally invasive harvesting of the latissimus dorsi. Plast Reconstr Surg

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1994: 94: 881-4.

10. Lin CH, Wei FC, Levin LS, Chen MC. Donor-site morbidity comparison between endoscopically assisted and traditional harvest of free latissimus dorsi muscle flap. Plast Reconstr Surg 1999: 104: 1070-7; quiz 78.

11. Miller MJ, Robb GL. Endoscopic technique for free flap harvesting. Clin Plast Surg 1995: 22: 755-73. 12. Pomel C, Missana MC, Lasser P. Endoscopic harvesting of the latissimus dorsi flap in breast reconstructive surgery. Feasibility study and review of the literature. Ann Chir 2002: 127: 337-42. 13. Selber JC, Baumann DP, Holsinger CF. Robotic harvest of the latissimus dorsi muscle: laboratory

ACCEPTED MANUSCRIPT and clinical experience. J Reconstr Microsurg 2012: 28: 457-64. 14. Selber JC, Baumann DP, Holsinger FC. Robotic latissimus dorsi muscle harvest: a case series. Plast Reconstr Surg 2012: 129: 1305-12. 15. Jacobs VR, Kiechle M, Morrison JE, Jr. Carbon dioxide gas heating inside laparoscopic

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insufflators has no effect. JSLS 2005: 9: 208-12.

16. Daskalakis M, Scheffel O, Weiner RA. High flow insufflation for the maintenance of the pneumoperitoneum during bariatric surgery. Obes Facts 2009: 2 Suppl 1: 37-40.

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17. Kang SW, Jeong JJ, Yun JS, et al. Gasless endoscopic thyroidectomy using trans-axillary approach; surgical outcome of 581 patients. Endocr J 2009: 56: 361-9.

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18. Chun YS, Verma K, Rosen H, et al. Implant-based breast reconstruction using acellular dermal matrix and the risk of postoperative complications. Plast Reconstr Surg 2010: 125: 429-36. 19. Hoppe IC, Yueh JH, Wei CH, et al. Complications following expander/implant breast reconstruction utilizing acellular dermal matrix: a systematic review and meta-analysis. Eplasty 2011: 11: e40.

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20. Kim JY, Davila AA, Persing S, et al. A meta-analysis of human acellular dermis and submuscular tissue expander breast reconstruction. Plast Reconstr Surg 2012: 129: 28-41. 21. Lanier ST, Wang ED, Chen JJ, et al. The effect of acellular dermal matrix use on complication

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rates in tissue expander/implant breast reconstruction. Ann Plast Surg 2010: 64: 674-8. 22. Antony AK, McCarthy CM, Cordeiro PG, et al. Acellular human dermis implantation in 153

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immediate two-stage tissue expander breast reconstructions: determining the incidence and significant predictors of complications. Plast Reconstr Surg 2010: 125: 1606-14. 23. Sbitany H, Serletti JM. Acellular dermis-assisted prosthetic breast reconstruction: a systematic and critical review of efficacy and associated morbidity. Plast Reconstr Surg 2011: 128: 1162-9.

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Figure Legends

Fig. 1. Preoperative design. The borders of the latissimus dorsi muscle are marked according to

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anatomic landmarks. A 5–6 cm vertical incision is marked along the middle axillary line. Two additional ports are marked 3–5 cm anterior to the anterior border of the muscle at the same level of the inframammary fold and umbilicus. The tip of the scapula is also marked for an additional port. The latissimus dorsi muscle is divided into 2 zones by a baseline extending from the point where the

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inframammary fold-extended line and the anterior muscle border converge, to the scapular tip. Zone I, proximal to the baseline, is dissected manually; zone II, distal to the baseline, is dissected using the

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robotic surgery system.

Fig. 2. (a) Two ports are in place. (b) Docking the robot. The articulated long retractor is applied with the robotic surgery system. This simple retractor allows robotic surgery to be performed without CO2 gas insufflation. (c) An port is inserted through the scapular tip incision.

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Fig. 3. The entire latissimus dorsi muscle is harvested and dissected through axillary incision. Fig. 4. Graph presenting total operative time and robotic time. As most of our operations were combined with additional procedures (e.g. augmentation mammoplasty or liposuction), total operative time was considerably longer than the actual robotic-use time.

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Fig. 5. Case 6. A 38-year-old female patient with left breast cancer. The patient received nipple-

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sparing mastectomy and immediate reconstruction with the robot assisted latissimus dorsi muscle flap and insertion of a silicone implant. Augmentation mammoplasty of the contralateral breast was performed Photographs taken preoperatively and at the 1-year follow-up examination. Fig 6. Case 4. A 37-year-old male patient with right-sided Poland syndrome. Photographs taken preoperatively and at 1-year follow-up examination.

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Tables

Age

Sex

Body Mass

Follow-up

Docking

Robot

Index (kg/m2)

periods

time

time

(months)

(minutes)

(minutes)

1

49

F

23.7

26

75

2

2

37

F

25.2

26

80

3

3

19

F

21.8

22

4

3

37

M

27.8

20

5

1

51

F

22.3

18

6

2

38

F

22.8

16

7

1

47

F

20.2

8

2

42

F

9

3

21

10

2

11 12

Satisfaction-

Satisfaction-

time

general

scar**

symmetry**

(minutes)

outcomes**

380

10

10

9

120

390

8

10

7

120

450

10

10

10

60

120

450

10

10

10

60

105

450

9

10

8

45

90

360

10

10

10

15

55

90

420

9

10

9

23.8

14

40

60

360

10

10

9

M

24.5

10

40

60

375

10

10

10

44

F

19.4

9

50

360

10

10

10

3

19

M

19.5

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40

6

40

50

390

9

9

9

3

25

M

25.6

6

60

60

420

10

10

9

23.1

15.7

54.6

85.8

400.4

9.6

9.9

9.2

35.8

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60

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Mean

Satisfaction-

105

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1

Operation

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Indication*

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Table 1. Patient characteristics and surgical outcomes.

* Indications : 1. Delayed reconstruction (Breast conserving surgery, Capsular contracture), 2. Immediate reconstruction (Nipple sparing mastectomy, Breast conserving surgery), 3. Poland syndrome ** Satisfaction results were rated on a 10-point scale (0=worst, 10=best)

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