Totally Extraperitoneal Endoscope-assisted Deep Inferior Epigastric Perforator Flap Harvest Using an Optical Trocar

Area of Science:

• Minimally Invasive Surgery
• Plastic and Reconstructive Surgery
• Surgical Technology

Background:

• Endoscope-assisted deep inferior epigastric perforator (E-DIEP) flap harvesting requires creating a retrorectus space for pedicle dissection.
• Conventional methods for retrorectus space creation (blind dissection, balloon dilation) carry risks of peritoneal breach, bleeding, and poor visualization.
• Totally extraperitoneal (TEP) approaches are preferred for reduced invasiveness but depend on safe retrorectus space creation.

Purpose of the Study:

• To introduce and evaluate a novel optical trocar-guided technique for establishing a safe retrorectus working space.
• To assess the feasibility and safety of this technique for E-DIEP pedicle dissection.
• To compare outcomes with conventional methods regarding peritoneal breach and complications.

Main Methods:

• A technique using an optical trocar (5x150mm trocar with a 0-degree laparoscope) was developed for direct visualization during retrorectus space creation.
• The optical trocar allowed controlled entry and subsequent blunt dissection to establish the working plane.
• A retrospective review of 10 consecutive patients undergoing E-DIEP pedicle dissection using this technique was performed.

Main Results:

• The retrorectus space was reproducibly created under stable direct visualization in all 10 patients.
• Mean retrorectus space creation time was 3.9 minutes, with pedicle dissection performed entirely extraperitoneally.
• No intraoperative peritoneal breaches, no conversions to transabdominal preperitoneal (TAPP) approach, and no abdominal wall complications (hernias, bulges) were observed during a median follow-up of 6.4 months.

Conclusions:

• Optical trocar-guided entry is a feasible and safe method for creating the retrorectus space in TEP E-DIEP pedicle dissection.
• This technique offers improved visualization and control, potentially mitigating risks associated with traditional retrorectus space creation methods.
• The approach facilitates minimally invasive E-DIEP surgery without compromising safety or leading to abdominal wall morbidity.