Expanding the Criteria for Robotic Deep Inferior Epigastric Perforator Flaps: Case Report With Long Intramuscular Course

Phuyal D et al. Plast Reconstr Surg Glob Open 2025. PMID: 40678603

Key takeaways

• A robotic DIEP flap was successfully harvested with a 15 cm pedicle that included 9.1 cm intramuscular (IM) course with a 3.5 cm fascial incision.

• The robot was used to complete the deep IM dissection from inside the abdomen, eliminating the usual need to lengthen the fascial incision.

• This challenges the long‑held rule that candidate for robotic harvest should have a perforator with short IM courses  (usually < 4 cm).

Conventional robotic DIEP approach

1. Perforator isolation and intramuscular dissection performed open

2. Robot used to harvest sub-rectus pedicle from within the abdomen (TAP approach)

Green line = pedicle segment usually harvested robotically. A = intramuscular segment, B = sub‑rectus segment, C = entire pedicle length. The fascial incision that can be spared is B, calculated as C − A.

The primary benefit of the robot is to minimize the length of the anterior rectus fascial incision. Thus, traditionally, only patients with a short (<4 cm) intramuscular course were selected for robotic harvest, otherwise the benefit would be negated. The "spared" fascial incision length can be calculated but subtracting the IM length from the total pedicle length

Innovation

1. Perforator isolation and initial superficial intramuscular dissection was performed open (via 3.5cm fascial incision)

2. The robot was used to harvest the sub-rectus pedicle AND complete the intramuscular dissection from within the abdomen

If proven reproducible, this effectively upends the benefit equation and expands the candidacy of Robotic DIEPs to many more patients

Methods (case report)

• Patient: 43‑yo woman, BMI 30; delayed autologous reconstruction post‑radiation.

• Dominant perforator: medial row, 1.8 mm caliber; IM length = 9.1 cm.

• Access: 3.5 cm fascial incision; OptiView entry + three 8 mm robotic ports (TAP approach).

• Robot: da Vinci Xi; harvested pedicle from its origin to perforator, closing posterior sheath robotically.

Results

• Pedicle length 15 cm; IM portion 9.1 cm.

• Harvest 90 min; no mesh or muscle repair needed.

• Pain well‑controlled; discharge POD 3; no donor‑site or flap complications at 6 weeks.

Conclusion

Completing the intramuscular dissection robotically preserves the hallmark small fascia incision of robo‑DIEP harvest—even when perforators run nearly 10 cm through the rectus muscle—thereby removing IM‑length >4cm as a strict exclusion criterion and broadening patient eligibility.

Strengths & limitations

• Strength: First proof‑of‑concept that long IM courses are feasible without long fascial incisions.

• Limitations: Single patient; unknown learning curve/reproducibility. Unknown long‑term abdominal‑wall outcomes.

Clinical relevance

Surgeons can now consider robotic DIEP harvest for patients whose best perforators have long intramuscular paths, provided pre‑op imaging confirms a feasible trajectory for robotic intramuscular dissection.