New inside out harvest of flaps
Epublication WebSurg.com, Apr 2014;14(04). URL: http://websurg.com/doi/lt03enpedersen001
Background: The rectus abdominis muscle is a workhorse for free and pedicled muscle coverage. Traditional harvesting damages the anterior rectus sheath and requires an abdominal incision. Robotic harvesting can be reliably and efficiently performed using three ports, and no additional incisions. This method, better known as the “inside out” harvest has shown to remarkably reduce the morbidity and facilitate a more accurate dissection of the rectus muscle. Methods: Ten robotic rectus muscle harvests were performed at three institutions as free flaps for extremity coverage and pedicled flaps for minimally invasive pelvic surgery requiring soft tissue reconstruction. Three contralateral ports and an intraperitoneal approach were used in each harvest. In half of the free flap cases, a small pubic hairline incision was used to remove the muscle. In the other half, the muscle was removed using a laparoscopic “gallbladder bag.” Basic demographic information, operative variables, and outcomes were recorded. Results All cases were completed robotically by three different surgeons at three institutions. Four muscles were harvested for free flaps for lower extremity and 6 muscles were used as pedicled flaps, three for APR reconstruction and two for protection of visceral repair following radical cystoprostatectomy. Average robotic set-up time was 15 minutes. Average robotic harvest time was 45 minutes. Two 8mm ports and one 12mm port were in each case. One patient developed a grade I decubitus ulcer during surgery. There were no other complications. All muscles were completely viable following harvest. There were no conversions to open technique. No hernias noted. Conclusions Robotic rectus muscle harvesting is safe, efficient and reproducible. The anterior rectus sheath can be left completely intact, eliminating incisional morbidity, and the cumulative incisional length can be less than two inches for extensive, multi-service pelvic procedures, thus minimizing morbidity and perhaps shortening length of stay compared to open techniques.