Robotic-Assisted Latissimus Dorsi Flap Harvesting for

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Robotic-Assisted Latissimus Dorsi Flap Harvesting for Delayed Breast Reconstruction ── A Report of Two Cases Wei-Chieh Liao1, Chi-Cheng Huang2, Ming-Lin Tsai2, Jian-Jr Lee1,3 Division of Plastic Surgery, Department of Surgery, Cathay General Hospital, Taipei, Taiwan1 Division of General Surgery, Department of Surgery, Cathay General Hospital, Taipei, Taiwan2 Department of Anatomy and Cell Biology, Taipei Medical University, Taipei, Taiwan3

Background: There are two major categories of breast reconstruction, prosthetic reconstruction and autologous tissue reconstruction. Compared with prosthetic reconstruction, autologous tissue reconstruction has the benefit of superior biocompatibility, but the limited tissue source, operative scar, and herniation make it an inferior method. A minimally invasive technique for breast reconstruction with or without prosthesis has the benefit of biocompatibility and very few surgical complications. Aim and Objectives: Robotic-assisted latissimus dorsi (LD) muscle flap breast reconstruction has technical superiority over endoscopic LD flap reconstruction. Compared to the open method, it has a superior cosmetic advantage. Here, we used a trans-axillary gasless technique with an articulated long retractor to enhance robotic flap harvesting. Materials and Methods: We present two cases of breast cancer after tissue expander implantation with a robotic-assisted LD muscle flap for breast reconstruction performed by a single surgeon. A short axillary incision for pedicle dissection and two additional ports for robotic instruments were created during flap harvesting. Results: The mean docking time was 42.5 min, and the total operative time and robotic time were 575 min and 350 min, respectively. Both LD flaps were harvested and transferred successfully without converting to open methods, and both achieved satisfactory results. The drawbacks are prolonged operative time and postoperative seroma formation. The seroma resolved after syringe aspiration performed twice at our outpatient department. Conclusions: Robotic harvesting of the LD muscle flap is a feasible and novel method for breast

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reconstruction. It offers technical advantages over endoscopic harvesting and esthetic advantages over the open technique. (J Taiwan Soc of Plast Surg 2016;25:358~368) Key words: breast reconstruction, robotic assisted, latissimus dorsi flap

Introduction The latissimus dorsi (LD) muscle flap used for breast reconstruction was first introduced by Schneider et al1. The blood supply of the LD comes mainly from the thoracodorsal artery, which is reliable; therefore, the incidence of flap loss is lower compared with other autologous tissue options, thus increasing its popularity2,3. The main complications of LD flap harvesting include seroma or hematoma formation over the donor site and fat necrosis resulting in partial flap loss. The traditional method of LD flap harvesting requires a posterior incision up to 45 cm, including an axillary incision for pedicle harvesting or flap transfer. Minimally invasive harvesting of the LD flap is a desirable goal for reconstruction. Endoscopic-assisted harvesting of the LD flap is frequently used because of the smaller incision and a more acceptable scar at the donor site. In addition, there are no statistically significant differences in the incidences of postoperative hematoma or seroma and donor site wound infection compared with traditional methods. This method also allows earlier and better movement of the upper extremity4, which promotes early rehabilitation and early recovery. However, the technical challenges of the endoscopic harvesting method, such as difficulty maintaining an optical window, nonflexible and nonturnable endoscopic instruments, two-dimensional view over the curvature of back, and others, have made this procedure difficult for LD flap harvesting4-8. Some centers in the United States have abandoned this harvesting procedure because of these reasons5-6. Robotic surgery has gained wide popularity in multiple surgical subspecialties due to the advantages of precision instrumentation and three-dimensional visualization compared to endoscopic techniques. These advantages are equally important for harvesting the LD flap. Plastic surgeons mostly operate on the body’s surface;

therefore, there have been few robotic applications in plastic surgery9. Selber et al. introduced the technique of robotic-assisted LD flap harvesting for breast reconstruction in 201210,11. In 2014, Chun et al. introduced an articulated long retractor to facilitate trans-axillary gasless robotic-assisted LD flap harvesting12. Here, we report two cases of delayed breast reconstruction using trans-axillary gasless roboticassisted LD flap harvesting.

Case Report Patients Here, we present two patients with breast cancer who underwent modified radical mastectomy (MRM) and immediate tissue expander implantation, followed by adjuvant chemotherapy. The first patient was a 47-year-old woman who underwent implantation of a 400-ml tissue expander after MRM; the tissue expander was filled to 355 mL at our outpatient department (Figure 1). Our second patient was a 55-year-old woman who underwent left MRM and implantation of a 550-mL tissue expander. We filled the tissue expander to 430 mL, and the tissue expander gradually protruded outside the pectoris major muscle (Figure 2), which led us to decide to perform LD muscle transfer to cover the silicone prosthesis. Both patients underwent delayed breast reconstruction with the robotic-assisted LD muscle flap procedure using the trans-axillary gasless technique in February 2016 and April 2016. Both surgeries were performed by a single surgeon. Table 1 reveals our patients’ demographics, characteristics, and surgical times.

Defining Landmarks We marked the anterior, middle, and posterior axillary lines, and the midline of the back and scapula

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tip. Markings were made with the patient standing. The borders of the LD muscle were also marked. 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 marked approximately 4 cm lateral to the spine. The LD muscle was divided into 2 zones by a baseline extending from the point where the inframammary fold level line meets the middle axillary line to the scapular tip (Figure 3). Zone I was partially above the baseline, and zone II was the remaining lower part of the muscle. First, we manually dissected zone I, and then we used the robotic surgery system for zone II.

and the pectoris muscle. Then, we removed the tissue expander. The subcutaneous space anterior to the anterior border of the muscle was dissected using electrocautery with a long tip and a lighted retractor. The thoracodorsal vessel was identified and marked with a vessel loop to facilitate easy visualization with the camera. The muscle in zone 1 was dissected manually under direct visualization. Then, we inserted a specially designed articulated long retractor, which was invented by Dr. Chung12, through port 1 and raised it with a lifting device attached to the operating table. Using the retractor, we dissected the entire zone 1 portion under direct visualization. Port 3 was also created with an 8-mm incision over the middle axillary line parallel to the umbilicus.

Positioning, Incision, and Port Placement

Robotic Docking and Dissection

Under general anesthesia, the patient’s position was changed to the lateral decubitus position 15 degrees prone to the operating table. The ipsilateral arm was placed on an arm board, with shoulder extension of 100 degrees from the trunk. The contralateral axillary area was placed on an axillary pillow to prevent nerve injury, and soft cushions were placed under the knee and heel to relieve pressure. The incision line was made 5 to 6 cm vertically along the mid-axillary line, starting from the axillary crease (port 1). Two additional ports were marked along the mid-axillary line at the same level of the inframammary fold and umbilicus (port 2 and port 3). The central camera was placed in port 2, and the left and right robotic arms were placed in port 1 and port 3, respectively (Figure 4). The retractor was also placed at port 1.

The camera and robotic arms were introduced through their respective incisions after port placement. The robotic side cart (da Vinci S, Intuitive Surgical, Sunnyvale, CA, USA) was positioned posterior to the patient (Figure 5). We used the 30-degree down scope attached to the central camera arm. During the first step, the monopolar-curved scissors was placed on the right arm, and the fenestrated bipolar forceps was placed on the left arm. The instruments could be exchanged alternatively as needed by the surgeon. The next step involved dissection of zone 2 using a robotic instrument. The dissection began along the undersurface of the muscle, from the scapular tip down to the inferior and posterior borders. Dissection then was performed over the superficial surface of the muscle. After the undersurface and upper surface were completely free, the muscle was detached from the inferior and posterior attachment, and its insertion into the humerus bone was also detached for further advancement. We preserved the thoracodorsal vessel and nerve for muscle survival and for prevention of subsequent muscle atrophy. The LD muscle was then released, thus enabling its transposition anteriorly into the breast pocket (Figure 6). The robotic surgical system was then undocked, and closed suction drains were placed through port 2 and port 3. The patients were subsequently repositioned into the supine position

Operative Procedure Incision and Port Placement An 8-mm incision was made over the middle axillary line, at the same level of the inframammary fold (port 2). Then, the port of the tissue expander was identified. We drained the liquid of the tissue expander first. The port 1 incision was 5 cm long, and we dissected the subcutaneous tissue connecting the skin 臺灣整形外科醫誌:民國 105 年/25 卷/4 期

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for flap insertion and implant insertion.

Results Two LD muscle flaps were successfully harvested from two patients who underwent delayed breast reconstruction. The body mass indices of the patients were 20.6 and 22.2 kg/m2 (Table 1). The mean docking time was 42.5 min, and the mean operative time and robotic time were 575 min and 350 min, respectively. All flaps were successfully harvested, and there was no conversion to conventional open surgery. In the first patient, her contralateral breast was relatively small and her LD flap was large enough to

reconstruct the side containing her lesion (Figure 7). In the second patient, we used a silicone implant in combination with the LD muscle flap for breast reconstruction because of the insufficient volume of LD muscle. All drains were removed within 3 days of surgery. However, seroma formation was noted in our second patient. Seroma aspiration was performed twice at our outpatient department, and it eventually resolved because of its self-limited nature. Both patients were satisfied with their esthetic results, especially the absence of visible back scars. Only a small, hidden scar was present in the axillary area (Figure 8).

Table 1. Patient characteristics and surgical outcomes Age

Body mass index (kg/m2)

Docking time (minutes)

Robot time (minutes)

Operation time (minutes)

1

47

20.6

50

300

510

2

55

22.2

35

400

640

Fig. 1. Patient 1. Right breast after modified radical mastectomy and tissue expander implantation.

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Fig. 2. Patient 2. Left breast after modified radical mastectomy and tissue expander implantation. The tissue expander is starting to protrude through the skin, and the pectoris major muscle over the left lateral aspect of the breast is herniated.

Fig. 3. Preoperative design. The borders of the latissimus dorsi (LD) muscle are marked and divided into 2 zones by a baseline extending from the point where the inframammary fold extends to the scapular tip. Zone I, proximal to the baseline, was dissected manually; zone II, distal to the baseline, was dissected using the robotic surgery system.

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Fig. 4. Port 1 is over the 5- to 6-cm vertical incision along the middle axillary line, starting from the middle axillary crease. Port 2 and port 3 are marked at a mean distance of 3 to 5 cm from the anterior border of the latissimus dorsi (LD) muscle at the same level of the inframammary fold and umbilicus. The central camera arm was placed in port 2, and the ipsilateral and contralateral robotic arms were placed in port 1 and port 3.

Fig. 5. (Above, Left) After port placement, the robotic side cart (da Vinci, Intuitive Surgical) with the two robotic arms and 30-degree camera is positioned posterior to the patient. (Above, right and Bottom) An articulated long retractor (Chung’s retractor) was inserted through the skin incision in the axilla and raised using a lifting device attached to the operating table. It allows robotic surgery to be performed without CO 2 gas insufflation.

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Fig. 6. We harvested the latissimus dorsi (LD) muscle through the axillary incision and enabled anterior transposition.

Fig. 7. (Left) Preoperative and (Right) postoperative views after robotic-assisted latissimus dorsi (LD) flap reconstruction.

Fig. 8. Patient 1. Post-operation 4 months. Port scars are small and hidden scar in the axillary area.

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Wei-Chieh Liao, Chi-Cheng Huang, Ming-Lin Tsai, Jian-Jr Lee

Discussion Methods of breast reconstruction include prosthetic reconstruction and autologous reconstruction. Options for autologous breast reconstruction include transverse rectus abdominus myocutaneous flap (TRAM), LD flap, deep inferior epigastric perforator (DIEP) flap, superficial inferior epigastric artery (SIEA) flap, gluteal artery perforator (GAP) flap, and transverse upper gracilis (TUG) flap. LD flaps are useful in patients who are not good candidates for an expander/ implant or TRAM flap reconstruction13,14. The LD flap is also an acceptable alternative for patients who require autologous tissue reconstruction, but who are not appropriate candidates for TRAM flaps. The traditional LD muscle flap harvesting procedure requires a long incision. Minimally invasive harvesting of the LD muscle is desirable to achieve an esthetic outcome. Endoscopic LD harvesting has been attempted by some groups, but it has not gained wide popularity among plastic surgeons5,6 due to difficulty maintaining an optical window, nonflexible and nonturnable endoscopic instruments, two-dimensional view over the curvature of back. Robotic surgery has emerged during the past two decades as an innovative, minimally invasive technology15. With enhanced precision, tremor elimination, motion scaling, high resolution, three-dimensional optics, flexible and rotatable instruments and an intuitive interface, it has found multiple applications across several surgical subspecialties. And we plastic surgeons could use the advantages of robotic surgery to harvest largest LD flap. In addition, it also has the advantages of less blood loss, less postoperative pain, lower infection rate, shorter hospital stay, less scarring, and more rapid recovery and return to activities of daily living16-18. Selber et al. introduced the robotic-assisted LD muscle flap procedure for breast reconstruction in 201211,19. Chung et al. used a gasless method for the robotic-assisted LD muscle flap procedure by using a specially designed articulated long retractor12, which avoids the risk of gas inflation complications such as hypercapnia, respiratory acidosis, tachycardia, subcutaneous emphysema, and air embolism20. In our

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study, the gasless method was used with Chung’s retractor, which also provided a wider working space and prevented injury of the robot arms. However, we still encountered some difficulties while dissecting the anterior border because the 3 arms overlap at times. We exchanged the instruments of the robotic arms alternatively to resolve the problem. In our opinion, the presence of an assistant at the bedside who is familiar with the mechanics of robotic surgery while performing the surgery is helpful. At the inferior and superior extremes of the dissection, the robotic arms and camera were nearly parallel and could conflict with one another or could be compromised by the convexity of the patient’s hip or shoulder. These undesirable interactions need to be monitored and subtle modifications of arm positioning need to be performed by the assistant. The senior author performed cadaver dissections in six Taiwanese male and two female subjects before performing this surgery and measured the size of the LD muscles in a total of 16 muscle flaps. We found that the average size of the LD muscle in Taiwanese people is 292 cm3, with an average of 303 cm3 for males and an average of 258 cm3 for females. Regarding vessel length (thoracodorsal artery), the average lengths were 9.0 cm for male subjects and 8.8 cm for female subjects. There were no significant differences in results between the two sexes. Due to the fact that our results were collected from some cadavers, there would be some data differences when compared with a living population undergoing breast reconstruction. First, the average age for the cadavers was 72, and that of the living population was much younger, usually between 45 and 64 years21. Another difference is the size of LD muscle. Compared with living persons, cadavers have smaller LD muscles as a result of formalin use. Therefore, the LD muscle flap will be appropriate only for breast cancer patients who have relatively small breasts or who have received breast preservation mastectomy. For those who have larger breasts, we plan to use a silicone prosthesis in conjunction with the LD flap or intramuscular fat graft to achieve breast symmetry. Many experts have different opinions regarding JTSPS 2016. Vol 25‧No.4

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whether to preserve the thoracodorsal nerves. Some believe that preserving the nerves would lead to some muscle contractures later, and that by cutting the thoracodorsal nerve there would be no problem with muscle atrophy22. However, others think that keeping the nerves could avoid muscle atrophy, and that the problem of muscle contracture could be relieved after some time23. Here, we chose to preserve the nerve in both our patients; so far, there has been no muscle contracture.

9. Selber JC. Transoral robotic reconstruction of oropharyngeal defects: a case series. Plast Reconstr Surg. 2010 Dec;126 (6):1978-87. 10.Selber JC, Baumann DP, Holsinger CF. Robotic harvest of the latissimus dorsi muscle: laboratory and clinical experience. J Reconstr Microsurg. 2012 Sep;28(7):457-64. 11. Selber JC. Robotic latissimus dorsi muscle harvest. Plast Reconstr Surg. 2011 Aug;128(2):88e-90e. 12. Chung JH, You HJ, Kim HS et al. A novel technique for robot assisted latissimus dorsi flap harvest. J Plast Reconstr Aesthet Surg. 2015 Jul;68(7):966-72.

Summary

13. Spear SL, Boehmler JH, Taylor NS et al. The role of the latissimus dorsi flap in reconstruction of the irradiated

Robotic-assisted LD muscle flap harvesting a trans-axillary gasless method is feasible reproducible. It offers technical advantages endoscopic harvesting and cosmetic advantages the open technique.

with and over over

breast. Plast Reconstr Surg. 2007 Jan;119(1):1-9. 14. Menke H, Erkens M, Olbrisch RR. Evolving concepts in breast reconstruction with latissimus dorsi flaps: results and follow-up of 121 consecutive patients. Ann Plast Surg. 2001 Aug;47(2):107-14. 15. Ibrahim AE, Sarhane KA, Baroud JS et al. Robotics in

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Endourol. 2011 May;25(5):787-92. 17. Martin AD, Nunez RN, Castle EP. Robot-assisted radical cystectomy versus open radical cystectomy: a complete cost analysis. Urology. 2011 Mar;77(3):621-5.

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Surg. 1999 Sep;104(4):1070-7 5. Fine NA, Orgill DP, Pribaz JJ. Early clinical experience in endoscopic-assisted muscle flap harvest. Ann Plast Surg. 1994 Nov;33(5):465-9. 6. Van Buskirk ER, Rehnke RD, Montgomery RL et al. Endoscopic harvest of the latissimus dorsi muscle using the balloon dissection technique. Plast Reconstr Surg. 1997 Mar;99(3):899-903. 7. Friedlander L, Sundin J. Minimally invasive harvesting of the latissimus dorsi. Plast Reconstr Surg. 1994 Nov;94(6): 881-4. 8. Miller MJ, Robb GL. Endoscopic technique for free flap harvesting. Clin Plast Surg. 1995 Oct;22(4):755-73.

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19. Selber JC, Baumann DP, Holsinger FC. Robotic latissimus dorsi muscle harvest: a case series. Plast Reconstr Surg. 2012 Jun;129(6):1305-12. 20. Kang SW, Jeong JJ, Yun JS et al. Gasless endoscopic thyroidectomy using trans-axillary approach; surgical outcome of 581 patients. Endocr J. 2009;56(3):361-9. 21. Pien I, Caccavale S, Cheung MC et al. Evolving Trends in Autologous Breast Reconstruction: Is the Deep Inferior Epigastric Artery Perforator Flap Taking Over? Ann Plast Surg. 2016 May;76(5):489-93. 22. Szychta P, Butterworth M, Dixon M et al. Breast reconstruction

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23. Kaariainen M, Giordano S, Kauhanen S et al. No need to cut the nerve in LD reconstruction to avoid jumping of the

breast: a prospective randomized study. J Plast Reconstr Aesthet Surg. 2014 Aug;67(8):1106-10.

Reprints request from: Jian-Jr Lee, M.D. Division of Plastic Surgery, Department of Surgery, Cathay General Hospital Address: No. 280 Renai Rd. Sec.4, Taipei, Taiwan Tel: 886-2-27082121 ext 8820 E-mail: [email protected]

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以達文西機器手臂取闊背肌皮瓣進行乳房重建手術 ── 病 例 報 告 廖偉捷 黃其晟 蔡明霖 李建智



景: 乳房重建手術按照材料來源,大略分為自體組織重建和義乳重建兩個方向。自體 組織 有 相容 性高 , 與原來組織近似的效果,但會有額外大傷口跟手術時間較長的缺點。而利用義乳重建,好處是沒有額 外傷口、手術時間也較短,但是組織相容性較低跟衍生的可能併發症、如感染排斥和夾膜攣縮。利用 微創手術使用自體組織進行乳房重建,可兼顧組織相容高以及傷口小的優點。 目的及目標: 以達文西機器手臂取闊背肌皮瓣進行乳房重建手術與使用內視鏡手術比起來,具有技術及視野上 的優勢。與傳統開放式取闊背肌皮瓣手術相較之下具有比較美觀傷口的優點。在我們案例當中,我們 是利用掛鉤式牽引器進行經腋下無充氣方式來進行機器手臂手術。 材料及方法: 兩位乳癌患者在接受改良式乳房根除手術後進行組織擴張器的置放,之後由單一整形外科醫師進 行達文西機器手臂取闊背肌皮瓣進行乳房重建手術。術中除腋下一個五到六公分的傷口外還有兩個大 約一點五公分傷口。 結 果: 達文西機器手臂器械對接平均時間為 42.5 分鐘,機器手臂平均操作時間為 350 分鐘,總手術時間 平均為 575 分鐘。兩位患者的闊背肌皮瓣都成功地由機器手臂取下並且轉移作爲乳房重建。缺點是較 長的手術時間以及其中一位患者於術後產生背部皮下積水(組織液)的情形,但是在門診抽除兩次即 消除。 結 論: 以達文西機器手臂取闊背肌皮瓣進行乳房重建手術是一種可行性高及新穎的乳房重建方式,與內 視鏡手術比起來具有較高的技術層次,並且在美觀上優於傳統的開放式手術。

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