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Robot-assisted Latissimus Dorsi Flap
Breast Reconstruction
Gasless Technique of Robotic-assisted LD Muscle Flap Harvest
Presenter : Jae-Hyun Chung, M.D.
Corresponding Author : Eul-Sik Yoon, M.D., Ph.D.*
Chul Park, M.D., Ph,D., Duck-Sun Ahn, M.D., Ph.D., Seung-Ha Park, M.D., Ph.D., Byung-Il Lee, M.D., Ph.D.
DEPARTMENT OF PLASTIC SURGERY
KOREA UNIVERSITY COLLEGE OF MEDICINE
ANAM HOSPITAL
SEOUL, KOREA
2013 ASPS E-POSTER Nothing to disclose
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Anatomy of LD muscle & Thoracic cavity
− LD muscle : outside of thoracic cavity (narrow cavity)
− Thoracic cavity contains critical organ, lung and heart.
Risk of Carbon dioxide Gas Insufflation
− Intraoperative hypothermia
− High thoracic pressure
↓ pulmonary venous flow, cardiac output, respiratory compliance
− Acid-base imbalance due to elevated PaCO2
− Increased post-op. complications
Objective of This Study
Need for Gasless Technique !!!
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Incision line
− Previous mastectomy scar
− 5~6cm vertical incision from
the anterior axillary crease
along the anterior axillary line.
Port insertion points
Zone I & II
− Zone I (manual dissection)
: proximal to scapular tip
− Zone II (robotic dissection)
: remained area
METHOD PREOPERATIVE DESIGN
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1. INCISION AND PORT PLACEMENT
2. PEDICLE ISOLATION
3. MANUAL DISSECTION
Vertical incision
Pedicle isolation
Muscle flap dissection
Articulated Long Retractor
• To maintain working space
• Attached to the operative bed
• enable to dissect nearly anterior
1/3 (Zone I) of the muscle without
endoscopic view despite more
anterior skin incision.
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4. ROBOTIC LD MUSCLE DISSECTION
1. Begins from the superoposterior border (C) along the undersurface in a clockwise direction.
2. Proceeds over the superficial surface .
3. Disinsert the muscle from the inferoposterior border (B).
C
B
A
D
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HARVESTED LD MUSCLE FLAP
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RESULT
Total 8 patients (M/F = 1/7)
Delayed reconstruction : 3 cases - 1 mastectomy(BCS) : breast deformity
- 2 implant rupture + capsular contracture
Immediate reconstruction : 3 cases
Chest wall deformity : 2 cases
(Poland syndrome)
Age : 19 ~ 51 yrs old (Median : 38 yrs old)
Mean BMI : 23.465 (20.2 ~27.8)
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RESULT
• Mean docking time : 59 min
• Mean operative time : 407 min
• Mean robotic time : 101 min
00:00
01:12
02:24
03:36
04:48
06:00
07:12
08:24
1 2 3 4 5 6 7 8
Docking Time 01:15 01:20 01:00 01:00 01:00 00:45 00:55 00:40
Robot Time 01:45 02:00 02:00 02:00 01:45 01:30 01:30 01:00
Op Time 06:20 06:30 07:30 07:30 07:30 06:00 07:00 06:00
• No major / minor complication
• Less Hospitalization : average 6.5 days
• Earlier Complete healing : average 13 days
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What’s the INDICATION for the
robotic LD flap?
DISCUSSION
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1. Poland Syndrome
1. Defect of Pectoralis muscle
− Muscle coverage is needed.
2. Congenital disorder (Young patients)
− Good aesthetic result and Minimizing
operative scar is very important.
Robotic LD muscle flap can be
an absolute indication!!!
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2. Implant failure Capsular Contracture
When changing implants, covering the new
implants only with skin flaps is not enough.
• Coverage of implant should be needed.
a. TRAM is contraindication.
b. Allogenic dermis is not enough to cover.
LD muscle flap is
the treatment of choice!!!
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3. Implant-based Reconstruction
Breast skin envelope is intact.
a. Nipple-sparing mastectomy
b. Breast conserving surgery (BCS)
• In the case of lateral lumpectomy defects
• breast deformity
c. Delayed reconstruction using Expander-based
reconstruction
LD muscle flap is substitute
for the allogenic dermis.
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PRE POST 7M
CASE I F/19
POLAND SYNDROME, LT.
Axillar Scar
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PRE POST 7M
CASE II F/38
IMMEDIATED RECON., RT.
Axillar Scar
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CONCLUSION
- The gasless technique of robot-assisted LD muscle flap using
the articulated long retractor is safer and less complex
technique than previous method.
- For young patients, especially in a case like Poland syndrome,
this method would be suggested as an absolute indication.
- Capsular contracture, Implant-based reconstruction and
partial breast reconstruction can be a relative indication.