An Innovative Approach to the Primary Surgical Delay Procedure for Pedicle TRAM Flap Breast Reconstruction

Sir: The preliminary delay of the pedicle transverse rectus abdominis musculocutaneous flap through ligation of the inferior epigastric vessels has been shown to augment the vascular supply and decrease ischemic flap complications.1,2 Several surgeons have developed minimally invasive laparoscopic techniques to minimize morbidity while maximizing flap outcomes.2–4 However, the laparoscopic techniques described have only addressed the deep inferior epigastric vessels.2–5 This report describes our laparoscopic technique designed to ligate both the superficial and deep inferior epigastric vessels simultaneously. Our preliminary flap delay procedure is often performed in conjunction with a sentinel lymph node biopsy by our general surgery colleagues or a bilateral salpingo-oophorectomy by the gynecology team. After induction of general anesthesia, the abdomen is prepared and draped in routine sterile fashion. Entrance into the peritoneal cavity is obtained by means of Veress needle insertion followed by trocar placement at the level of the umbilicus (Fig. 1). Pneumoperitoneum is established, and using a 30-degree laparoscope, initial examination of the intraabdominal cavity is performed to rule out the presence of iatrogenic injury or metastatic processes. With the patient in steep Trendelenburg position, the left and right internal inguinal rings are identified followed by identification of the deep inferior epigastric vessels at the superior medial aspect of the internal inguinal ring. The superficial inferior epigastric vessels are then identified by transillumination. Once both deep and superficial vessels are identified, a stab wound is made in the skin just over this area. A Vicryl-loaded Endoclose needle device (Ethicon, Inc., Somerville, N.J.) is then introduced into the peritoneal cavity first medial and then lateral to the superficial and deep vessels (Fig. 1). The ligature is tied extraabdominally, with the knot placed at the fascial level, thereby ligating both the superficial and deep inferior epigastric vessels. The procedure is then repeated on the contralateral side.Fig. 1.: Illustration of the trocar sites used to laparoscopically ligate both the superficial and deep epigastric vessels. The laparoscope is inserted at the level of the umbilicus. The Endoclose device is inserted at a site near the pubic rami over the superficial inferior epigastric vessels. The site that is superior to the umbilicus and lateral to the rectus sheath can be used as an additional port when simultaneous ligation of the deep and superficial epigastric vessels cannot be achieved.When the superficial and deep inferior epigastric vessels are not close enough to allow for simultaneous ligation, they are approached separately. This requires placement of an additional 5-mm working port lateral to the rectus muscle above the level of the umbilicus (Fig. 1). This additional port facilitates introduction of the LigaSure V 5-mm sealer/divider (Covidien, Boulder, Col.) to fuse and ligate the deep inferior epigastric vessels. After ensuring hemostasis, the ports are removed and incisions are closed in the usual fashion. When compared with the open procedure, the laparoscopic delay described here has resulted in significantly decreased abdominal tissue morbidity and has maintained improved flap outcomes. It avoids large incisions; wound complications such as seromas; and edematous, friable tissue, which are complications frequently encountered with the open delay technique. Our technique also addresses both the superficial and deep inferior epigastric vessels, thereby providing a potentially larger, more reliable skin paddle. Nita Nair, M.D. Section of Plastic Surgery Department of Surgery University of Michigan Medical Center Ann Arbor, Mich. Dunya M. Atisha, M.D. Section of Plastic Surgery Department of Surgery University of Michigan Medical Center Ann Arbor, Mich. Department of Surgery University of Iowa Hospitals and Clinics Iowa City, Iowa Rachel Streu, M.D., M.S. Section of Plastic Surgery Department of Surgery University of Michigan Medical Center Department of Surgery St. Joseph Mercy Hospital Ann Arbor, Mich. E. Dale Collins, M.D., M.S. Section of Plastic Surgery Department of Surgery Dartmouth Medical School Lebanon, N.H. Kathleen Diehl, M.D. Section of Surgical Oncology Department of Surgery Mark Pearlman, M.D. Department of Obstetrics and Gynecology Amy K. Alderman, M.D., M.P.H. Section of Plastic Surgery Department of Surgery University of Michigan Medical Center Ann Arbor, Mich. DISCLOSURE The authors have no financial or commercial interests related to this research. ACKNOWLEDGMENT This work was supported by a grant from the Robert Wood Johnson Foundation.

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