Since I had my own DIEP flap breast reconstruction at PRMA in late 2014 performed by Dr. Minas Chrysopoulo I have been fascinated with this surgery. I feel one strong reason people choose the profession of microsurgery is out of passion. The satisfaction of what is accomplished each day must linger long after they leave work and in fact drive them to do better. I invite you to learn more from one such surgeon I met via social media, Dr. Joe Dusseldorp. Join me in learning more about robotic assisted DIEP flap breast reconstruction in Australia.
The Progress of DIEP Flap and Value of Robotic Assisted DIEP
Over time, I have seen so much progress in surgical procedures and robotic assisted DIEP is just one of them. Dr. Joe agrees and points out this is just ONE technique. His comment, “Surgery doesn’t change overnight. It’s lots of little incremental steps that ultimately progress us forward and this is just another one of those tools, another instrument that we use. It’s a pretty fancy one. To be honest, it’s an amazing piece of technology and it enables us to make another few percent improvement in certain circumstances.”
He points out it does not anatomically suite everyone but has a role to play in a fair proportion of patients potentially as a strategy to help improve the abdominal wall function and patient reported outcomes.
Dispelling some Myths
The word “robotics” has some connotations that go back to earlier movies and visuals of what it might be like. It is really a fancy camera and laparoscopic instrument. The robot is set up enabling microsurgeons to be accurate dissecting inside the abdominal space which is where the blood vessel runs that provides blood flow to the DIEP flap. Dr. Joe has published a paper on his work, and you can read more here.
He looked at publications from the U.S. It was those papers from Dr. Jesse C. Selber and Dr. Andrea Moreira who have both written about using the robotic assisted DIEP flap procedure. These cross-continental colleagues in microsurgery helped Dr. Joe learn the techniques of robotic assisted DIEP flaps. He points out not all hospitals have access to robots and he feels fortunate that there are two in his institution. He is grateful he had this new learning opportunity since robotic surgery is not part of plastic surgery training in residency. Dr. Joe was thrilled to take on the chance to add this to his microsurgical armamentarium.
Robotic Equipment Used in a DIEP Flap Procedure
Dr. Joe shares his slides and walks us through an explanation of the equipment he uses. We are fortunate in the video to see him in action in the surgical theater performing a robotic assisted DIEP flap breast reconstruction. Dr. Joe uses the Da Vinci Xi system. It consists of a tall tower, taller than Dr. Joe who stands at six feet two inches tall. There is also the console where the surgeon sits and operates. The console has two hand pieces with a lot of articulation that can be used much like a human hand. This is an improved advantage over typical laparoscopic arms that have only an open and close function.
The DIEP Flap Surgery in Progress
The surgical assistant stays at the operating table while Dr. Joe sits at the console. The robot is brought in after the operation has begun. The breast surgeon completes the mastectomy and Dr. Joe harvests the flap just to the point where the perforator has gone through the muscle. At this point, where he has a visual of the perforator, he only needs to make a 2 cm facial incision and slight opening in the muscle fiber without cutting any of the muscle fibers. He explains this is minimal invasiveness on the abdominal wall as you can see in the video below.
The ultimate scar you see on the outside does not change from a traditional DIEP. Using the robotic assisted DIEP is about what happens within the tissue of the abdominal wall because it is a less invasive procedure. The ports, he describes as “hollow tubes”, are strategically placed in small incisions to prepare for the harvesting of the perforators. He compares “docking” the robot to the patient like docking a space station. I invite you to watch the video along with Dr. Joe’s explanation of how he then uses the arms of the robot to dissect the perforators. I love his statement saying it is “a very elegant tool”. He can cauterize, clamp, and retrieve the blood vessel bringing it out through the tiny incision made earlier in the abdominal wall.
Further Details of the Robotic DIEP Flap from Australia
They use carbon dioxide to blow up the abdominal cavity to make a space to work. Dr. Joe says this is a decision you make with the patient at consult in an informed way. It is important to outweigh the risks and discuss what the early outcomes and benefits of robotic assisted DIEP are. The published articles from the U.S. from Dr. Selber who has been doing it for several years gives us credence to know there are very low complication rates when done with proper training. This is to benefit patients who are candidates for robotic assisted DIEP flap.
I am fascinated watching him pull the blood vessel through the tissue from the work of the robotic tools. He points out that Dr. Moreira informed him of the benefit of keeping one of the blood vessels attached to the tissue. With blood flow continuing to flow through the tissue, this decreases the chance of necrosis. Necrosis is when the tissue does not get the proper amount of blood flow. In DIEP flap, they measure this and call it ischemic time.
We also discuss the size of the retractor used in robotic assisted DIEP. Dr. Joe tells us the ones used in a traditional, non-robotic assisted DIEP are larger. The larger ones have the potential of disrupting the muscle more than the smaller ones. In some cases, this may lead to slower recovery or more muscle weakness. He goes on to explain that the sum of the abdominal incisions from the fascial incision to the small ports is less than in a traditional DIEP. Studies will tell over time but this seems it will cause less morbidity to the abdominal wall.
Final Thoughts on Robotic Assisted DIEP Flap
Early on it’s been really encouraging. He observes that patients have been able to experience better abdominal strength when this is measured during recovery. As Dr. Joe stated earlier, t’s only one strategy, and many can be employed. Not all patients make a good candidate. The key is thorough evaluation of the patient. The breast is the primary goal, and the abdominal area is the secondary goal but certainly important because DIEP flap involves the full torso area.
We both encourage surgeons who are motivated and have access to robots in their facility to give it a go. Dr. Joe is certainly glad he did and so are we!
Please log in to your YouTube account to view the video as it does have surgical photos and is age restricted by YouTube do to that.
This is a team sport. It is not a one man show. IT is a very joyful part of the process working with like-minded colleagues. It keeps it fun and interesting.
Dr. Joe Dusseldorp