Expanding Criteria for Totally Extraperitoneal Robotic DIEP Flap Harvest: A Case Report and Review of the Literature

Robotic-assisted deep inferior epigastric perforator (DIEP) flap harvest minimizes donor-site morbidity by reducing fascial disruption and preserving rectus muscle integrity. Traditional criteria for robotic DIEP have limited use to short intramuscular perforators, but this case demonstrates the feasibility of a totally extraperitoneal (TEP) approach in a patient with a long (91.6 mm) intramuscular perforator. Using a multi-port robotic system and a 3 cm anterior fascial incision, we successfully dissected a 17 cm pedicle without muscle sacrifice or mesh reinforcement. A literature review highlights the rarity of TEP techniques, especially for long perforators. This case supports expanding robotic DIEP criteria based on perforator anatomy rather than strict length cutoffs and illustrates the potential of TEP dissection to avoid intra-abdominal entry while preserving abdominal wall integrity.