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Hammond et al. Plast Aesthet Res 2024;11:28 https://dx.doi.org/10.20517/2347-9264.2024.27 Page 3 of 10

PREOPERATIVE PLANNING
Adding robotics as an additional factor in the surgical equation necessitates a team approach in the care of
the breast reconstruction patient. Surgical outcomes are the direct result of the intraoperative team,
including the operating surgeons, scrub nurses and techs, anesthesia team, and circulating staff. Increasing
familiarity with robotic approaches among operating room staff through didactics, skills training, case
observation, bedside assisting, and mentorship optimizes the potential to successfully implement robotic
breast reconstruction for patient care [11,12] .

Robotic latissimus muscle flap and DIEP flap harvest can both be safely performed with careful preoperative
planning. While preoperative imaging may not be necessary for robotic latissimus muscle flap, a
preoperative computed tomographic angiography or magnetic resonance angiography is paramount in
planning a robotic DIEP flap [11-13] . Preoperative imaging allows for perforator selection and preoperative
decision making based on perforator anatomy, allowing for patient selection and reducing operative
times .
[13]

RELEVANT VASCULAR ANATOMY
Traditional latissimus muscle flap harvest requires a 15-45 cm longitudinal incision to facilitate exposure of
the thoracodorsal pedicle within the axilla and the thoracolumbar fascia. Utilizing a robotic approach, only
a short 5cm axillary incision is necessary for thoracodorsal pedicle identification and dissection. No
preoperative imaging is required for primary reconstruction, though imaging may be necessary in cases of
reoperation to confirm the presence of intact thoracodorsal vessels on a case-by-case basis.

Traditional DIEP flap harvest relies on an entirely anterior approach. Isolation of the DIEP pedicle down to
its origin requires a large fascial incision, with dissection of the vessel free from surrounding nerves and
musculature. This leads to significant abdominal wall disruption, especially below the arcuate line. For
robotic DIEP flap harvest, preoperative computed tomography angiography (CTA) is necessary to
determine if a patient’s perforator anatomy is conducive to a robotic approach. Ideal candidates for robotic
DIEP flap harvest have one-to-two dominant, closely-grouped DIEP perforators taking a short
intramuscular course [Figure 1] [11,12] . In circumstances whereby preoperative imaging reveals that anterior
perforator dissection below the arcuate line can be avoided, up to 70% of DIEP flap patients may be eligible
[13]
and benefit from a robotic approach . Utilizing a robotic approach, a posterior intraperitoneal perforator
dissection facilitates preservation of the abdominal wall by limiting the anterior fascial incision to the tissues
surrounding the pedicle. The fascial incision may be limited to only the length of the perforator’s
intramuscular course, which in some cases could be as small as 2 cm [Figure 2].

OPERATIVE TECHNIQUE
Robotic pedicled latissimus muscle flap
The borders of the latissimus dorsi muscle are marked preoperatively [Figure 3]. An axillary incision is
marked parallel to the thoracodorsal pedicle, and two port sites are marked; the first port site is marked four
finger breadths (8 cm) anterior to the anterior border of the muscle and four finger breadths inferior to the
axillary incision, while the second port site is marked four finger breadths (8 cm) distal to the second port
and anterior to the muscle. The patient is positioned in the lateral decubitus position with the ipsilateral arm
prepped and placed on a sterile Mayo stand. An axillary roll is placed below the contralateral arm to prevent
brachial plexopathy. In the setting of breast surgery, whereby a sentinel node or axillary lymphadenectomy
incision is already present, this incision may be used for thoracodorsal pedicle isolation and no additional
axillary incision is necessary. The thoracodorsal pedicle is isolated and marked with a vessel loop to facilitate
easy identification during robotic dissection. The subcutaneous space along the anterior border of the