Laparoscopy in patients following transverse rectus abdominis myocutaneous flap reconstruction

We report our technique and experience performing laparoscopic pelvic surgery on four women after transverse abdominus rectus myocutaneous flap (TRAM).

Examination under anesthesia is performed on all patients in the low lithotomy position parallel with the floor. The abdominal aorta is palpated and outlined. A pneumoperitoneum is created either by umbilical or left upper quadrant Veress placement. Patients with an acceptable umbilical location undergo port placement through the incision of the umbilical relocation. Other options include left upper quadrant or paramedian placement avoiding the ligamentum teres vessels. Lateral operative ports (5 mm) are placed with reference to the transverse incision present, the pelvic pathology, and the location of the umbilicus. Techniques of electrocautery, intra- and extracorporeal suturing and knot tying, and clips are preferred to minimize port size.

Following unilateral or bilateral TRAM reconstruction, four consecutive breast cancer survivors underwent successful laparoscopic-assisted vaginal hysterectomy with oophorectomy using the periumbilical incision for trocar placement. The only complication was a superficial skin breakdown from an adhesive allergy that required 6 weeks for complete resolution.

Laparoscopic pelvic surgery is feasible in women after TRAM reconstruction. Knowledge of anatomic and physiologic variations related to the TRAM procedure is necessary in planning a safe operation.