Minimally Invasive Laparoscopic Dissected - Deep Inferior Epigastric Artery Perforator Flap (MILD-DIEP): An Anatomic Feasibility Study and a First Clinical Case.

SUMMARY: The deep inferior epigastric perforator (DIEP) flap is a workhorse of breast reconstruction. Risks of herniation derive from violation of the rectus abdominis muscle anterior rectus sheath (ARS) and might be reduced by Minimally Invasive Laparoscopic Dissection (MILD) of the deep inferior epigastric vessels. We performed a feasibility study on five anatomical subjects and performed a secondary right breast reconstruction on a 67 year-old woman. A 30[degrees] laparoscope was used with laparoscopy ports inset to preserve the flap. Blunt preperitoneal dissection followed by CO2 insufflation allowed the deep inferior epigastric (DIE) pedicle to be dissected and clip-sectioned. The ARS was opened around the perforating vessels, and the flap was anastomosed on the internal mammary vessels. Length of incision in the ARS was compared between laparoscopic and conventional approaches. The mean incision length in the ARS was 3 cm versus 12 cm in the classic approach. Average duration of laparoscopic flap harvest was 50 minutes, including a mean of 30 minutes for DIE dissection. Adhesions led to a 1 cm peritoneal laceration in our first anatomical subject. There were no pre- or post-operative complications in the clinical case. The clinical procedure duration was 8h15 minutes with the ARS incision reduced from the conventional 12 cm to 5 cm. Flap ischemia lasted 50 minutes. The patient was discharged on postoperative day 5. This anatomic study and first successful laparoscopic assisted DIEP flap harvest prove that reduced trauma to the anterior rectus sheath is feasible and promising. (C)2017American Society of Plastic Surgeons

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