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

Endoscope-assisted deep inferior epigastric perforator (E-DIEP) flap harvesting enables pedicle dissection through a shorter anterior rectus sheath incision. This can be performed using either a transabdominal preperitoneal (TAPP) or a totally extraperitoneal (TEP) approach. The TEP approach is less invasive because it avoids transperitoneal entry. However, conventional techniques for creating the retrorectus space, typically by blind finger dissection or balloon dilation, carry the risks of peritoneal breach, inadvertent vascular injury with unexpected bleeding, and loss of stable visualization. We developed a simple optical trocar-guided technique to establish a safe retrorectus space for E-DIEP pedicle dissection. In this approach, an optical trocar assembled from a 5 × 150 mm trocar and a 0-degree rigid laparoscope was inserted under direct visualization, allowing controlled entry into the retrorectus plane, followed by blunt dissection to create the working space. We retrospectively reviewed 10 consecutive patients treated with this technique to assess its feasibility, intraoperative peritoneal breach, conversion to the TAPP approach, and abdominal wall complications. In all cases, the retrorectus space was reproducibly created under stable visualization, with a mean creation time of only 3.9 minutes, and pedicle dissection was performed entirely within the extraperitoneal plane. None of the patients required conversion to the TAPP approach. No abdominal wall hernias or clinically evident bulges occurred during a median follow-up of 6.4 months. In this small case series, optical trocar-guided entry into the retrorectus space was considered a feasible approach for establishing a TEP working space during E-DIEP pedicle dissection.