Isolated post laparoscopic DIEA injury in bilateral DIEP breast reconstruction
- Theodore Paul Pezas ,
- Samer Saour and
- Farida Ali
- Department of Plastic Surgery, St George's University Hospital, St George's University Hospitals NHS Foundation Trust, London, UK
- Correspondence to Theodore Paul Pezas; theodorepezas@doctors.org.uk
Abstract
Scarring from previous open abdominal surgery in patients undergoing autologous deep inferior epigastric perforator (DIEP) breast reconstruction has been reported to increase overall flap and donor site complication rates. The evidence to date demonstrates that it can be performed safely although with significantly higher postoperative donor site morbidity. It would seem logical that minimal access laparoscopic surgery is less likely to be associated with increased risks to flap vascularity or donor-site complications; however, there is little evidence available in the literature about the impact of previous laparoscopic surgery to the DIEP harvest site. The typical positions for port placement in standard laparoscopic procedures are usually distant from ideal perforator locations reducing the risk of perforator damage. We present a case of unilateral isolated injury to the proximal deep inferior epigastric artery (DIEA) following previous laparoscopic abdominal surgery in a patient undergoing bilateral mastectomy and breast reconstruction with bilateral free DIEP flaps.
Background
Bilateral immediate breast reconstruction with bilateral free DIEP flaps postmastectomy in a patient with unilateral isolated injury to the proximal DIEA following previous laparoscopic abdominal surgery has not been previously described.
Case presentation
We present a case of unilateral isolated injury to the proximal DIEA following previous laparoscopic abdominal surgery in a middle-aged woman undergoing bilateral mastectomy and immediate breast reconstruction with bilateral free DIEP flaps. Her previous surgical history included previous laparoscopic cholecystectomy, oophorectomy and hysterectomy abroad in her 20s. On examination of her abdomen, a 1.5 cm well-healed laparoscopy scar was noted in the right iliac fossa (figure 1). The scar was soft and flat with no tethering. As part of the patient’s preoperative counselling, the potential for vascular injury relating to her previous laparoscopic surgery site scarring was highlighted as was the need for alternative reconstructive options in the event of flap non-viability.
Previous laparoscopic port site scar overlying right hemi-DIEP pedicle. DIEP, deep inferior epigastric perforator.
Investigations
Preoperative CT angiography (figure 2) demonstrated good calibre left-sided medial and lateral row perforators with a favourable intramuscular course. On the right side, the lateral row perforators were dominant but flow appeared to be interrupted proximally at the level of the source vessels (figure 3).
CT angiogram (coronal section) demonstrating good calibre left-sided perforators and absence of flow of right-sided perforators at level of laparoscopic scarring.
CT angiogram (sagittal section) demonstrating absence of flow of right-sided perforators at level of laparoscopic scarring.
Treatment
Intraoperatively, the right-sided lateral row perforator was identified and dissected proximally towards its origin from the external iliac artery. Midway in its course, the right DIEA pedicle was encapsulated in a short segment of scar with localised adhesion to the peritoneum, corresponding to the right iliac fossa laparoscopic port site. This also mirrored the location of interruption in the proximal flow on CT angiography. Further dissection of the pedicle revealed an isolated division of the DIEA with preservation of both venae comitantes (figure 4). The artery was dissected and primary end-to-end anastomosis performed (figures 5 and 6) with restoration of flow without undue tension, thus eliminating the need for a vein graft. Once adequate flap perfusion was confirmed (figure 7), the flap was divided and transferred to the breast, anastomosing the proximal DIEA and deep inferior epigastric vein (DIEV) to the right internal mammary artery and vein, respectively.
Dissected pedicle showing isolated division of DIEA with preservation of both venae comitantes. DIEA, deep inferior epigastric artery.
Previously divided DIEA ends prepared for primary anastomosis. DIEA, deep inferior epigastric artery.
Primary end-to-end anastomosis of previously divided DIEA. DIEA, deep inferior epigastric artery.
Perfusion of right hemi-DIEP following primary anastomosis as evidenced by skin paddle colour and dermal bleeding of surrounding de-epithelialised areas. DIEP, deep inferior epigastric perforator.
Outcome and follow-up
Postoperatively, the decision to proceed with primary anastomosis was explained to the patient which, on balance, was felt to be in her best interests given the good flow demonstrated into and out of the flap intraoperatively. During her inpatient stay, the flap remained well perfused, as evidenced by good colour of the monitoring flap skin paddle (subsequently removed at a later date) and strong Doppler signals demonstrated throughout the patient’s postoperative recovery. The patient was seen in the senior author’s clinic 6 months following her operation and both flaps were noted to have healed without complication.
Discussion
Several authors have reported successful outcomes in patients undergoing transverse rectus abdominis muscle (TRAM)/DIEP breast reconstruction following previous abdominal surgery.1–3 Johnson reported successful breast reconstruction using a delayed pedicled TRAM following previous laparoscopic ventral hernia repair due to concerns relating to flap vascularity.4 Orfaniotis et al reported a series of three patients with previous DIEA injuries from open abdominal surgery who were still able to successfully undergo bilateral DIEP breast reconstructions: one as a muscle-sparing TRAM based on the deep superior epigastric artery (DSEA) blood supply in light of previous damage to the DIEA and superficial inferior epigastric artery (SIEA) likely related to previous open hysterectomy; one similarly based on the DSEA due to previous injury to DIEA and SIEA but drained through the superficial circumflex iliac vein due to previous injury to DIEV and superficial inferior epigastric veins from a Pfannenstiel incision as part of a previous Caesarean section; and one with a thrombosed, multi-lumen DIEP pedicle requiring shortening and pedicle reanastomosis as a result of previous open appendicectomy.5
Our case adds to the current literature by demonstrating that scarring from previous routine laparoscopic abdominal surgery associated with localised source vessel damage in patients undergoing DIEP breast reconstruction need not act as a deterrent to performing bilateral free DIEP flap breast reconstruction. While commonly used incisions for both open and laparoscopic abdominal surgery have the potential to threaten DIEP flap vascularity (figure 8), the blind nature of laparoscopic trocar insertion makes the possibility of unintended pedicle injury less predictable, as compared with open approaches which are generally performed under direct vision, despite the difference in incision size. Careful consideration should be given to vascular abnormalities detected on preoperative planning CT angiography6 7 in the presence of previous abdominal scarring, so that strategies to overcome these unlikely findings form part of the operative plan. Had our source vessel not been available for reanastomosis, use of a vein graft or creation of an arteriovenous loop could have been used as alternative strategies to re-establish flap blood flow; the latter acting as a shunt to distant, healthy blood vessels that can be divided immediately or in a delayed fashion and provide alternative recipient vessels close to the area requiring reconstruction.8
Relating DIEP flap blood supply (A) to commonly used incisions for both open (B) and laparoscopic (C) abdominal surgery. Open incisions: Kocher (red), Mercedes Benz (green), Lanz (yellow), Gridiron (pink), Midline/Lower Midline Laparotomy (orange), Paramedian (dark blue), Transverse (light blue), Rutherford-Morrison (brown). Laparoscopic trocar port sites: common—12, 3, 6 and 9 o'clock positions (red), additional—left and right subcostal (green). Laparoscopic trocar site located at 9 o'clock corresponded with patient’s isolated DIEA injury (see figure 1). DIEA, deep inferior epigastric artery; DIEP, deep inferior epigastric perforator.
Learning points
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Bilateral deep inferior epigastric perforator breast reconstruction can still be considered in patients with scarring from previous routine laparoscopic abdominal surgery associated with localised source vessel damage.
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Careful consideration should be given to vascular abnormalities detected on preoperative planning CT angiography in the presence of previous abdominal scarring, so that strategies to overcome these unlikely findings form part of the operative plan.
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Strategies can include use of a vein graft, creation of an arteriovenous loop or primary anastomosis as demonstrated in the above case.
Ethics statements
Patient consent for publication
Footnotes
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Contributors TPP wrote the manuscript under the supervision of senior author FA. SS provided some of the photography for the report.
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Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
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Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.
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Competing interests None declared.
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Provenance and peer review Not commissioned; externally peer reviewed.
- © BMJ Publishing Group Limited 2022. No commercial re-use. See rights and permissions. Published by BMJ.
References
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