Implementing the Robotic deep inferior epigastric perforator Flap in daily practice: A series of 10 cases

The deep inferior epigastric perforator (DIEP) flap is the workhorse in microvascular breast reconstruction. Rectus muscle sacrifice or denervation and inappropriate rectus sheath closure are the main causes of abdominal wall morbidity. Robotic vessel dissection may limit fascial incision length below the arcuate line and rectus denervation. This study describes and focuses on the implementation and feasibility of this technique in daily surgical practice. A retrospective data collection of all robotic DIEP flap reconstructions between August 2020 and October 2021 was conducted at our university hospital. Primary outcome variables were flap success and intraoperative complications. Secondary variables included timing of the different robot-assisted stages, total operating time, and postoperative complications within 6 weeks. In total, 10 robotic DIEPs were performed using a multiport robotic system through the transabdominal preperitoneal approach. Nine short intramuscular (SIM) and 1 subfascial (SF) perforators were selected based on the preoperative imaging. There were no perioperative intra-abdominal complications or flap losses. Robotic installation ranges from 16 to 40 min. Mean robot-assisted operating time was 86 min, and mean operative time was 479 min. We present the largest case series of robotic DIEP flap reconstructions for delayed and immediate autologous breast reconstruction through a transabdominal preperitoneal approach. This technique is safe, reproducible, and feasible in a daily hospital setting. We have observed a steep learning curve associated with robotic vessel dissection. Future research may optimize surgical technique, assess possible benefit on abdominal wall morbidity, and evaluate cost-effectiveness.