SECTION II • Reconstructive Breast Surgery
49
Robotic-assisted autologous breast reconstruction
Introduction
Robotic surgical technology has become ubiquitous
throughout the various fields of minimally invasive sur-
gery owing to its enhanced precision, tremor elimina-
tion, motion scaling, high resolution, 3D optics, and a
user-friendly interface. These unique features inspired
the senior author to integrate it into plastic surgery, per-
forming the first clinical cases beginning in 2009,1 and
more specifically into breast reconstructive surgery. In
this subspecialty, minimizing skin incisions, improving
cosmesis, decreasing donor-site morbidity, and achiev-
ing a more delicate dissection of vascular pedicles are
important goals. The advantages offered by the robotic
platform help accomplish those goals. This chapter dis-
cusses the clinical application of robotic-assisted latissi-
mus dorsi harvest (RALDH) and robotic-assisted deep
inferior epigastric perforator flaps (RoboDIEP) for breast
reconstruction. We outline the advantages of the robotic
platform in breast reconstruction, describe the indica-
tions for its use, present the operative technique, and
discuss the limitations of this novel robotic approach.
We conclude with a few suggestions to improve the
learning curve of robotics among plastic surgeons and
facilitate its wider adoption.
Robotic-assisted latissimus dorsi
harvest (RALDH)
The latissimus dorsi (LD) muscle flap is a fundamental
tool in the armamentarium of reconstructive surgeons.2
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Karim A. Sarhane and Jesse C. Selber
It is widely used for breast reconstruction (both in pri-
mary and second- stage reconstruction after tissue
expansion). Its traditional harvest technique, however,
requires long and sometimes unsightly incisions. In
addition to a 15–40-cm skin incision over the back (to
reach the origin of the muscle along the thoracolumbar
fascia; Fig. 49.1), a second axillary incision is sometimes
needed to dissect the thoracodorsal pedicle and transfer
the flap.3,4 The LD flap is often used for secondary and
tertiary breast reconstruction and is typically harvested
with a skin component to replace missing or irradiated
breast skin. In some instances, however, only the mus-
cle is needed for reconstruction. Such instances include
implant coverage in two-stage, delayed-immediate
reconstruction for the irradiated breast;5 lower pole
support in direct-to-implant or stage I of a two-stage
breast reconstruction following nipple–areolar complex
(NAC)- sparing mastectomy;6 and in breast reconstruc-
tion following upper-outer quadrantectomy.
A minimally invasive harvest technique of the latissi-
mus flap, that obviates the need for unsightly and long
length incisions, has always been a desirable aim. The
endoscopic approach has been tested by multiple groups
and is currently still being used in select centers.7,8 It has,
however, a high rate of conversion to open because of
its multiple inherent technical challenges. These include
limited visualization around the curvature of the back,
lack of versatility of the dissecting instruments, chal-
lenges in identification and control of perforators,
inability to maintain an adequate optical window, dif-
ficulties in maintaining dissecting planes, and awkward
positioning of the operating surgeon. These factors led
many centers to abandon the technique.9,10
582 SECTION II CHAPTER 49 • Robotic-assisted autologous breast reconstruction
Figure 49.1 Traditional incision for harvest of the latissimus dorsi muscle can
be very long, to access both the pedicle and the muscle origin. (Reprinted with
permission from Selber, JC, Baumann DP, Holsinger FC. Robotic latissimus dorsi
muscle harvest. Plast Reconstr Surg. 2012; 129(6): 1305–1312.)
The robotic platform emerged as a novel technol-
ogy offering unique advantages that address most of
the shortcomings of the endoscopic approach. Its high-­
resolution 3D optics provide an outstanding picture
clarity. The seven degrees of freedom of its operating
arms allow an exceptional level of dexterity. Those fea-
tures are especially beneficial in flap harvest procedures
where maintaining consistent dissection planes, manip-
ulating fragile perforators and small nerves “atraumat-
ically”, and performing a safe dissection in tight spaces
(i.e. around the curvature of the back) are key for success.
With these features in mind, the senior author investi-
gated the use of the robot in the harvest of the LD mus-
cle flap. It was first tested it in a cadaver model in 2010,11
then applied successfully in a series of eight patients.6
The RALDH approach proved to be feasible and safe
with no major complications.12 Refinements in this
novel harvest technique have been introduced over the
years and it has now become an important component
of the delayed-immediate breast reconstruction protocol
for select patients at our institution.
Surgical anatomy of the latissimus dorsi
muscle flap
To reliably perform this technique, the robotic surgeon
needs to be familiar with the pertinent anatomy of the
upper back and axilla. The LD muscle (also known as
the “broadest muscle of the back”) is a large triangular
muscle that controls extension, adduction, and inter-
nal rotation of the shoulder joint. It originates from the
thoracolumbar fascia and inserts onto the humerus. It
is innervated by the thoracodorsal nerve (C6, C7, C8).
It is a type V flap with a dual blood supply: (1) the
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thoracodorsal branch of the subscapular artery; and (2)
the posterior paraspinous perforators. Because of the
multiple anastomoses between these two systems, the
entire muscle can remain viable if either of the two pedi-
cles is divided. To note, the thoracodorsal artery (length
ranging from 6.5 cm to 12 cm) travels from the axilla
to course over the anterior surface of the muscle, then
enters it from underneath, and divides into two or three
branches at its undersurface.
Patient selection
The ideal candidate for a RALDH is a patient with a low
body mass index (BMI), thin body habitus, and/or ath-
letic built (who does not have appropriate alternative
autologous donor sites for breast reconstruction). An
absolute contraindication is prior division of the tho-
racodorsal pedicle (during a prior lymphadenectomy,
thoracotomy, etc.) Relative contraindications include
comorbidities that will likely increase the wound/flap
complications rate that include, but are not limited to,
smoking, diabetes mellitus, end-stage renal disease, and
collagen vascular disease. It is indicated for patients
who have undergone external beam radiation therapy
with a tissue expander, have adequate skin expansion
(without high levels of capsular contracture and/or
very thin skin), and are not candidates for free flaps.6,13
Breast reconstruction protocol
Eligible patients are first presented in a multidisci-
plinary breast conference. The team is composed of
medical oncology, surgical oncology, radiation oncology,
and plastic and reconstructive surgery. Stage 1 surgery
involves skin-sparing mastectomy followed by imme-
diate placement of a tissue expander (with or without
a bioprosthetic mesh). Our approach is for patients to
undergo expansion every week during the 4–6 weeks
prior to external beam radiation therapy (EBRT). Just
prior to the initiation of EBRT, they are deflated to one-
third of their total fill capacity. One week post EBRT,
patients are re-expanded to their original volume. If
more volume is needed, expansion is continued post
EBRT but at a slower rate (i.e. every 2–3 weeks until the
anticipated volume is reached). The ideal volume needs
to accommodate both the final implant and the muscle
flap. If at that point, capsular contracture or thin skin
coverage has become a problem, but volume of expan-
sion is sufficient, a RALDH is performed 6 months after
completion of EBRT, to allow recovery and healing of
the soft tissue. If a free flap or a skin island is desired
or indicated, an alternative procedure is performed
instead.
 Robotic-assisted latissimus dorsi harvest (RALDH) 583

Operative procedure
Positioning and defining landmarks
The patient is placed in the decubitus position with the
ipsilateral arm prepped and placed on a sterile Mayo
stand. A bean bag is used for stabilization. An axillary
roll is placed. The borders of the LD muscle are then
marked: the anterior border is identified preoperatively
during active muscle contraction, the superior border
is marked from the tendinous insertion (at the tip of
the scapula) to the posterior border, and the posterior
border is typically around 4 cm lateral to the spine. The A
bed can be retroflexed in the middle to open the space
between the iliac crest and the lower part of the ribcage.
This is especially helpful at the extremes of dissection
whenever the arms line up with one another. When this
occurs, the arms will often hit the hip or the shoulder.
Retroflexion addresses this issue.

Incision and port locations

The patient’s previous mastectomy skin incision is
re-opened, and the tissue expander explanted. Then, the
lateral border of the LD muscle is identified through the
axilla, and a pencil Doppler is used to verify patency of
the thoracodorsal artery and vein. Four to six centime-
ters of pre-dissection is done on the superficial and deep
surfaces of the LD muscle (Fig. 49.2A).
The first port (12-mm port) is placed within the pre-
vious mastectomy incision, which is then closed (tem-
porarily) to achieve and maintain adequate insufflation.
The second and third ports are placed 8 cm away from
each other and from the first port, and 8 cm anterior to the
anterior border of the muscle. The distal, 8-mm port, will
be the only visible scar with the arm in repose (Fig. 49.2B).
Robotic docking and dissection
Following port placement, the robot (Da Vinci Xi,
Intuitive Surgical, Sunnyvale, CA, US) is brought in from
the posterior side of the patient, and then the arms are
docked. It is important to open the “elbows” or second
joint of the arms as much as possible and to position them
nearly parallel to the floor to avoid collisions during the
dissection. After docking, insufflation is started and set
at 10 mmHg (Fig. 49.3). Dissection begins on the under
surface of the muscle. To note, if dissection is instead
started in the subcutaneous plane, it will be impossible
to maintain an optical view underneath the muscle as
the insufflation will push the muscle down against the
chest wall. Monopolar scissors (dominant hand) and a
fenestrated bipolar grasper (non-dominant hand) are
B
Figure 49.2 Intraoperative views during RALDH. (A) Pre-dissection of latissimus
dorsi (LD) with exposure of thoracodorsal artery and vein. Note all dissection is
accomplished through anterior mastectomy incision with no additional skin incisions
required. (B) 12-mm and 8-mm ports are placed at the lateral border of the LD
muscle. (Reprinted with permission from Clemens MW, Kronowitz S, Selber JC.
Robotic-assisted latissimus dorsi harvest in delayed-immediate breast reconstruction.
Semin Plast Surg. 2014; 28(1):20–25.)
used for this dissection. Blood vessels are either cauter-
ized (using the bipolar) or clipped (using a robotic clip
applier). When the curvature of the back is encountered,
we recommend switching the camera to a 30°-down view
mode for better visualization. Throughout the surgery,
the bedside assistant can help by guiding the limits of
dissection and comparing the space that is being created
with the preoperative markings. After the undersurface
of the muscle is freed to its borders, dissection proceeds
over the anterior surface of the muscle. Switching to a
30°-down view mode is also recommended when the
curvature of the back is reached. Ideally, the deep and
superficial dissection reach the same borders. All that
is left at that point is releasing the insertion of the mus-
cle from the thoracolumbar fascia inferiorly and poste-
riorly. This can be done using the monopolar scissors.
A 30°-down view is also helpful here as it will enable
to “look over” the curvature of the back. As the muscle
is freed, it is continually “pulled” toward the axilla to

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584 SECTION II CHAPTER 49 • Robotic-assisted autologous breast reconstruction
Figure 49.3 The robot is docked with the patient-side cart behind the patient and
the arms nearly parallel to the floor. This configuration aligns the arms with the plane
of the muscle. (Reprinted with permission from Selber, JC, Baumann DP, Holsinger
FC. Robotic latissimus dorsi muscle harvest. Plast Reconstr Surg. 2012; 129(6):
1305–1312.)
maintain a wide optical window and to keep tension at
the point of dissection.
Its humeral insertion is partially or completely
divided to allow its advancement and to decrease ani-
mation deformity. The thoracodorsal nerve is usually
left intact. Once the muscle is freed beyond the tip of
the scapula, it will be easily accessible through the axil-
lary incision. It is critical to identify the thoracodorsal
pedicle during the open portion of the dissection and
advance the instruments beyond it to avoid injury.
It is worth noting that whenever the inferior and supe-
rior extremes of the dissection are reached, the robotic
arm and camera become nearly parallel to each other
and may conflict with the patient’s hips or shoulder.
This can be avoided by subtle changes in the position of
the joints or entrance into the skin (with small clutches
to the arms) throughout the dissection. In addition, as
the dissection moves posteriorly, the arms will have to
be “burped” (i.e. lifting them slightly upwards toward
the ceiling) to account for the curvature of the back.
Undocking and extraction of the muscle
Once the muscle is freed from attachments except the
pedicle, the robot can be undocked. The robotic portion
of the procedure is complete. The axillary incision is
re-opened. The camera can be reintroduced (if needed)
to ensure adequate hemostasis. Drains are placed
though the two lower port sites and positioned at the
donor site. If needed, the tendinous insertion is released
further through the axillary incision under direct visu-
alization. Any remaining attachments are divided pos-
terosuperiorly. Usually there are a few attachments to
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B
Figure 49.4 (A) Transposition of latissimus dorsi (LD) muscle underneath a
subcutaneous skin bridge. (B) LD muscle achieves total muscle coverage over a
permanent silicone-shaped implant (410 FF 425 cc, Allergan Corporation, Irvine, CA,
US). Note previous port sites are utilized for drain placement. (Reprinted with permission
from Clemens MW, Kronowitz S, Selber JC. Robotic-assisted latissimus dorsi harvest in
delayed-immediate breast reconstruction. Semin Plast Surg. 2014; 28(1):20–25.)
the teres major in this area that can be released at that
stage. Since the muscle is being transferred as a pedi-
cled flap, most of the posterior insertion is divided, and
the muscle is delivered through the axillary incision,
and then into the mastectomy space in preparation for a
change to the supine position (Fig. 49.4A).
The pectoralis major muscle that has been providing
temporary coverage of the expander may be fibrosed
from radiation therapy and should not be transected.
Instead, it should be released from the skin envelope
and re-sutured to the chest wall. Release of the pectoralis
muscle from the mastectomy skin flap provides a non-
capsular surface for the latissimus flap to adhere. For
RALDH opposite a prosthetic reconstruction, the same
sized implant should be used for both breasts. Despite
the addition of the LD, the muscle volume becomes
negligible with atrophy and resolution of swelling. A
total LD muscle coverage of the implant from inframa-
mmary fold to clavicle should be performed (Fig. 49.4B).
Radiation therapy tends to elevate the inframammary
fold (IMF) and requires lowering in almost all cases.
Postoperative care
Deep venous thrombosis prophylaxis with low-­
molecular-weight heparin is started on postoperative
 Robotic-assisted latissimus dorsi harvest (RALDH) 585

Figure 49.5 Postoperative results: patient is 10 months postoperative and has now received nipple construction with areolar tattooing. Patient was noted to have a minor
contour defect of her donor site. Her postoperative course was without complication. (Reprinted with permission from Clemens MW, Kronowitz S, Selber JC. Robotic-assisted
latissimus dorsi harvest in delayed-immediate breast reconstruction. Semin Plast Surg. 2014; 28(1):20–25.)

day 1. Hospital length of stay is usually 2–3 days. Table 49.1 Patient characteristics and outcomes
Outpatient follow-up requires weekly office visits until
drain removal, then at 1 month, and every 3 months for Variable RALDH (n = 12) TOT (n = 64)
1 year, and then annually thereafter (Fig. 49.5). Average age (years) 54.3 56.1
Previous radiation (%) 100 100

Clinical cases and outcomes BMI 25.4 25.9

Comorbidities (%) 16.6 18.8
We performed a retrospective review of 146 consecu-
Smokers (%) 25 21.9
tive series of pedicled LD muscle flaps performed for
Stage 1 bioprosthetic 100 71.2
breast reconstruction, 17 of which were harvested with
mesh (%)
the Da Vinci robot. Out of these 146 patients, 76 had
Surg. complication (%) 16.7 37.5
received radiation therapy prior to reconstruction. We
studied those 76 patients: 64 patients (84.2%) under- Seroma 8.3 8.9
went the traditional open technique (average follow-up Delayed healing 0 7.8
16.4 ± 6.9 months) and 12 patients (15.8%) under- Infection 14.1 8.3
went RALDH (average follow-up 12.3 ± 8.3 months; Unplanned reoperation 8.3 12.5
Table 49.1). All patients received a stage 1 skin-sparing Capsular contracture 0 4.7
mastectomy with immediate tissue expander recon-
Ave. follow-up (months) 12.3 16.4
struction. Oncologic indications included invasive
BMI: body mass index; RALDH, robotic-assisted latissimus dorsi harvest;
ductal (85.5%) and invasive lobular carcinoma (14.5%). TOT, traditional open technique.
Patients received an average of 2.8 (range 0–4) expan- Reprinted with permission from Clemens MW, Kronowitz S, Selber JC. Robotic-
assisted latissimus dorsi harvest in delayed-immediate breast reconstruction.
sions initiated between 1 and 2 weeks postoperatively. Semin Plast Surg. 2014; 28(1):20–5.
Radiation therapy was on average 60 Gy with routine
inclusion of internal mammary nodes. Stage 2 recon-
struction with LD muscle harvest and placement of a following the open technique was 3.4 days (range,
permanent implant was performed at an average of 7.1 3–6 days) compared to 2.7 days (range 2–3 days) follow-
months (range 3–11 months). Average follow-up was ing the RALDH technique.
16.4 ± 6.9 months for the open technique patients, and Complication rates were statistically equivalent
12.3 ± 8.3 months for the RALDH patients. All pedi- between the two groups: 37.5% in the open technique
cled flaps resulted in successful breast reconstructions. versus 16.7% in the RALDH technique (P = 0.31).
Average harvest time in the open technique amounted Complications included seroma formation (10.9% vs.
to 58 min (range, 42 min to 1 h 38 minutes) compared 8.3%), wound infection (14.1 vs. 8.3%), delayed wound
with 1 h 32 min for the RALDH technique (range, 1 h healing (7.8% vs. 0), and capsular contracture (4.7%
5 min to 2 h 35 min). Average length of hospital stay vs. 0). No RALDH muscle flaps required converting to

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586 SECTION II CHAPTER 49 • Robotic-assisted autologous breast reconstruction
an open technique and all flaps resulted in a successful
breast reconstruction. Functional muscle strength and
range of motion testing of the donor site was not for-
mally assessed, but subjectively reported as normal for
all patients. For the robotic LD, all function and range
of movement (ROM) returned to baseline in 3 months.
Certain function improved from baseline, probably
related to scar release in the axilla.
The RoboDIEP: robotic-assisted deep
inferior epigastric perforator flaps for
breast reconstruction
The deep inferior epigastric perforator (DIEP) flap
became a mainstay of autologous breast reconstruction
shortly after its popularization in 1994 by Allen and
Treece.14 It is currently the most commonly performed
flap for microsurgical breast reconstruction owing to
its abundant volume, its muscle-sparing aspect and
its favorable donor site.15 However, despite its numer-
ous advantages over the transverse rectus abdominis
myocutaneous (TRAM) flap, it still carries some degree
of donor-site morbidity that is inherent to its traditional
open anterior harvest approach. In most cases and even
if only one perforator is selected, a long fascial incision
is required since the pedicle lies deep to the rectus mus-
cle. A significant portion of this fascial incision extends
below the arcuate line which further compromises the
structural integrity of the abdominal wall as there is no
posterior rectus sheath at this level (Fig. 49.6). In addi-
tion, since the rectus abdominis muscle needs to be
split or lifted laterally to facilitate harvesting the flap
(as the main pedicle runs underneath it), its fibers and
neurovascular bundles are at risk for injury during the
dissection. Damage to the neurovascular bundles will
de-functionalize the muscle and predisposes the patient
to bulge formation. Because these deformities lie below
the arcuate line and involve defunctionalized muscle,
they are very challenging to fix. To reduce the potential
for this morbidity, accessing the pedicle from a posterior
approach that obviates the need for long fascial incision
and that preserves the neurovascular bundles would be
favorable. Such technique would not only reduce post-
operative pain but should also maintain the functional
integrity of the abdominal corset, reducing ventral
bulge formation rate and decreasing long-term abdom-
inal discomfort.
The robotic platform, with its unique advantages (as
detailed above), offers a minimally invasive posterior
approach to harvest the DIEP flap. Its 3D magnified
vision, physiologic tremor filtering, and motion scaling
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Figure 49.6 Bilateral DIEP: patient’s left side (page right) open technique, patient’s
right side (page left) RoboDIEP technique. This figure demonstrates both favorable
versus unfavorable anatomy for a RoboDIEP. It also shows the amount of abdominal
morbidity that can be spared with favorable anatomy and a robotic approach.
allow a highly meticulous intra-abdominal isolation of
the entire pedicle without violating the fascia or rectus
muscle (except where the perforator exits the fascia)16
and without disturbing the nerves supplying the mus-
cle. The senior author has already optimized a robotic
technique to harvest the rectus abdominus flap12 and has
recently extrapolated this technique to harvest the DIEP
flap, having completed 25 robotic DIEPs during 2020.
Surgical anatomy of the DIEP flap
The external iliac artery gives rise to the deep inferior
epigastric artery (DIEA) at its terminal aspect. The DIEA
ascends from the level of the inguinal ligament, and
courses lateral to the rectus abdominis muscle toward
the umbilicus. It travels in between the two layers of the
transversalis fascia and penetrates the posterior aspect
of the rectus abdominis muscle.17 It then gives rise to an
average of five (plus or minus two) perforators. Most
of the perforating vessels are found within 2 cm cranial
and 6 cm caudal and between 1 cm and 6 cm around the
lateral aspect of the umbilicus.18,19 The medial perfora-
tors (which are farthest from the vascular pedicle) sup-
ply better blood flow to zone III and to zone IV. Their
dissection often involves a longer intramuscular course
with more extensive longitudinal muscle splitting.
Patient selection
Candidacy for the RoboDIEP is determined by preop-
erative imaging. The ideal patient has a single or two
closely grouped perforators that have a brief intra-
muscular course. If a larger number of perforators is
required or if the pedicle has a long intramuscular
 The RoboDIEP: robotic-assisted deep inferior epigastric perforator flaps for breast reconstruction 587

course, an open anterior approach dissection is recom-
mended because the posterior robotic approach offers
no substantial advantages here.
A simple mathematical equation, B = C−A, can be
used to estimate the potential benefit of the robotic
approach. B refers to “Benefit” (which is the decrease
in the fascial incision length); A refers to “length of
the intramuscular course” (determined on preopera-
tive imaging); and C refers to the “entire length of the
pedicle” (from its origin at the external iliac artery to
its branching point). As an example, if the pedicle “C”
measures 13.5 cm (which is the usual) and the intramus-
cular course “A” 3 cm, then the benefit “B” is 10.5 cm
(i.e., the spared length of the fascial incision). These sim-
ple metrics can be discussed with the patient during the
preoperative consultation and then verified intra-opera-
tively with photo documentation (Fig. 49.7).
Operative procedure
Positioning and defining landmarks
The patient is placed in a supine position. Bilateral arms
can be tucked or abducted after adequate padding. The
patient is well secured to the operating room table, with
a strap across the chest and another one over the thighs.
(Fig. 49.8). The “open” part of the RoboDIEP stops here
(there is no fascial incision to access the pedicle). At this
point, pneumoperitoneum is established. We typically
use a Veress needle (CONMED, Utica, NY, US) and set
insufflation at 10–15 mmHg using a 5-mm AirSeal can-
ula (CONMED, Utica, NY, US).
Three robotic 8-mm ports are then placed on the con-
tralateral side of the flap being harvested, along a line
extending from the anterior axillary line to the anterior
superior iliac spine (ASIS). They need to be as lateral to
the semilunar line as possible as this provides a wider
angle of view to dissect the deep inferior epigastric ped-
icle. The most superior port is placed close to the costal
margin and the most inferior port next to the ASIS. The
third port (camera port) is placed equidistant from the
first two (Fig. 49.9).
Robotic docking and dissection
The surgical robot is brought to the operating table at 90°
on the ipsilateral side of the flap. The arms are docked.
Monopolar scissors are used for the dominant hand

Incision and port locations

Before port placement, the RoboDIEP starts with ele-
vation of the abdominal flaps similar to the traditional
open technique. The pre-selected perforator is located,
and a small fascial incision is made around the perfora-
tor. Dissection is carried down to only where the perfo-
rator emerges from the deep surface of the rectus muscle

Quantifying the Benefit

Figure 49.8 RoboDIEP fascial incision is only necessary around the perforator/s.

A B
C

B = C - A = The length of fascial incision spared by robotic approach

Figure 49.7 A simple equation to measure the benefit of the RoboDIEP. B refers to
“benefit” (which is the decrease in the fascial incision length); A refers to “length
of the intramuscular course” (determined on preoperative imaging); and C refers
to the “entire length of the pedicle” (from its origin at the external iliac artery to its
branching point). Figure 49.9 Port placement in the RoboDIEP after raising of the abdominal flap.

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588 SECTION II CHAPTER 49 • Robotic-assisted autologous breast reconstruction
and a fenestrated bipolar grasper for the non-dominant
hand. The deep inferior epigastric vessels are identified
through the thin peritoneum, coursing along the under
surface of the rectus. The peritoneum is opened sharply,
and the pedicle dissected starting from its origin at the
external iliac vessels. The dissection proceeds cephalad
to isolate the pedicle off of the rectus muscle, reach-
ing the opening in the fascia that was made during the
initial perforator dissection. Some gas will leak as the
fascial opening is reached, but this is easily controlled
using a moist lap pad. If larger branches of the vascular
pedicle are identified, a robotic Vessel Sealer (analogous
to the LigaSure device) is used.
Flap extraction and closure
Once the pedicle is completely dissected, it is clipped
(using a robotic clip applier), divided, and extracted
through the fascial aperture. The posterior rectus sheath
and peritoneal defect are then closed using 0 V-Loc
barbed suture (Medtronic). During closure, insufflation
is decreased to 8 mmHg to decrease tension on the suture
line and facilitate approximation of the edges. The da
Vinci Xi system can rotate around the patient without
moving the base. This feature is important in bilateral
reconstructions where a separate docking procedure is
required for each side. After the flap is extracted, the
ports are removed, the fascial incisions closed, and the
rest of the case continues as a routine DIEP.
Postoperative care
Deep venous thrombosis prophylaxis with low-
molecular-weight heparin is started on postopera-
tive day 1. Hospital length of stay is usually 2–3 days.
Outpatient follow-up requires weekly office visits until
drain removal, then at 1 month, and every 3 months for
1 year, and then annually thereafter.
Clinical outcomes
In our early experience (first 20 cases), robotic time aver-
aged 45 min, fascial incision length averaged 2–3 cm and
pedicle length averaged 13–14 cm. Total case time was
similar to the open approach. We were able to decrease
the fascial incision length, observe less postoperative
pain, decrease the hospital length of stay and enhance
overall recovery. We anticipate decreased ventral her-
nia and bulge rates with the significantly decreased fas-
cial incision length and reduced muscular dissection.
Long-term analysis with a comparison to the traditional
harvest technique will be critical to demonstrate a long-
term benefit.
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Limitations
To move forward with these two advantageous breast
reconstruction techniques, one must address the lim-
itations facing their dissemination to a broader pop-
ulation of plastic surgeons. An important concern is
cost. A new DaVinci Xi system costs approximately
2 million dollars. It is important to note, however,
that the robotic platform is purchased by hospitals
primarily for other established robotic procedures
(prostatectomy, colectomy, hernia repair, etc.). Cost is a
nuanced issue and cost “to whom” must be addressed.
For the patient, all robotic procedures have been pre-­
authorized by the insurance company. So, while the
insurance company sees additional costs, the patient
does not. In addition, the technical fees for robot rooms
are billed out at a higher rate than a regular OR, so
the facility (hospital, university, surgicenter owner,
etc.) has a higher revenue per unit time. This gives a
robotic procedure a higher average contribution mar-
gin (revenue minus expense) than a traditional DIEP,
even though the expenses are higher. This is the same
for other robotic procedures, as well, which is why
hospitals continue to invest in surgical robots. The
CPT code, 19634, is unchanged, so the surgeon sees
the same revenue, although this is likely to change in
the future. In summary: RoboDIEP for the patient is
expense neutral, for the insurance company it carries
increased expense, for the hospital, increased revenue,
and for the provider it is revenue neutral.
A formal cost–benefit analysis is needed to better
assess the “cost” of eliminating long skin and fascial
incisions in breast reconstruction.
Another significant factor directly affecting the
­widespread adoption of these techniques is their “teach-
ability.” There are a few barriers to teaching this tech-
nique to plastic surgeons. One is the need for a dedicated
training pathway to learn how to operate the surgical
robot. To use the robotic platform safely and effectively,
one must understand the many subtilities associated
with it. The surgeon must be comfortable, not only with
its basic operating machinery, but also with how to trou-
bleshoot the system if the surgery is not proceeding as
expected. This will not be a major issue for plastic sur-
geons who recently completed a general surgery train-
ing. But for those plastic surgeons with minimal to no
exposure to robotic surgery, dedicating personal time
and energy to learn the robot is essential. Fortunately,
Intuitive does have a multitude of learning programs
(online and hands-on) for surgeons wishing to start
robotic surgery. We also welcome, at our institution, sur-
geons that are interested in observing those cases.

Additionally, although our specialty is behind the
curve on this, laparoscopy is not a substitute for the
robotic approach. With respect to laparoscopic instru-
mentation, it is now well documented that the level of
precision and dexterity provided by the robotic system
based on motion scaling, tremor elimination and 7° of
wristed motion allow for much finer vascular dissection
than laparoscopic instrumentation. This is demonstrated
in multiple other specialties such as hepatobiliary where
complete Whipple procedures can be performed roboti-
cally, including biliary and vascular anastomoses. These
more precise applications are not possible using lapa-
roscopic instrumentation. For those “outsourcing” the
robotic or laparoscopic portion of the case to a general
surgeon or urologist, it is important to ensure that the
operative surgeon has skill in microvascular procedures
because extreme finesse is required.
Finally, we are entering the era of robotic nipple
sparing mastectomy.20 Our institution is involved in a
multi-center trial to evaluate the benefit of this tech-
nique, which has already been adopted throughout the
world.21 Not only is there a natural reduced hurdle to
use the robot for cases already involving its use, but
the axillary incision facilitates a robotic LD approach or
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Conclusion 589
RoboDIEP approach with anastomosis to the thoraco-
dorsal vessels. It should also be noted that the microsur-
gical portion of this case can also be done robotically,22
allowing for robotic applications for resection, flap har-
vest and microsurgery to be used in continuity through-
out the course of a case.
Conclusion
Robotic surgery has many substantial advantages
when applied in breast reconstructive surgery. The
ideal candidates for RALDH are patients with low BMI,
undergoing two-stage delayed-immediate breast recon-
structions, and who do not have suitable abdominally
based flaps. The ideal patients for a RoboDIEP have a
single or closely grouped perforators with a short intra-
muscular pedicle course. Both approaches are safe, and
result in smaller incisions and scars, faster recovery, and
improved complication profile. However, they carry a
modest increase in cost and operative time. We are con-
fident that the surgical robot will continue to expand in
plastic surgery, and that it will eventually become an
essential tool for the reconstructive surgeon.

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