VM85 - Robotic Intracorporeal Rectus Abdominis Muscle Flap Harvest

Purpose/Background: Perineal reconstruction following abdominoperineal resection (APR) is most commonly performed using vertical rectus abdominis muscle flaps (VRAM), gracilis flaps, and gluteal thigh flaps. The traditional VRAM is a myocutaneous flap supplied by the deep superior and inferior epigastric arteries and requires creation of a large laparotomy incision for harvesting. After rotation on the deep inferior epigastric artery pedicle, it is tunneled intraperitoneally or subcutaneously to reach the pelvis for perineal reconstruction. The fascial defect in the abdominal wall is then repaired with mesh. In certain patients, only a muscle flap is required for reconstruction without the cutaneous component and thus a large midline incision. This video demonstrates a minimally invasive method of harvesting an intracorporeal rectus abdominis muscle (IRAM) flap. Our patient is a 69 year-old man with locally advanced rectal cancer who first completed total neoadjuvant therapy prior to undergoing APR. As he did not require cutaneous reconstruction of the perineum, robotic IRAM flap was chosen to minimize surgical morbidity.

Methods/Interventions: In this video, we present a robotic approach to harvesting an IRAM flap with direct visualization of critical anatomic landmarks.

Results/Outcomes: The rectus muscle is isolated through an intracorporeal approach requiring two additional lateral ports in addition to standard port placement for APR. The deep inferior epigastric pedicle is carefully preserved to supply the IRAM flap, which is rotated into the pelvis and inset for pelvic floor reconstruction after removal of the APR specimen through the perineal incision.

Conclusion/Discussion: This robotic approach to flap harvesting negates the need for a large laparotomy incision, tunneling, and mesh placement, although it may prolong operative time as flap mobilization cannot be performed concurrently with total mesorectal excision. In the case presented, harvesting of the IRAM flap required 91 minutes. The patient has recovered well with an uncomplicated postoperative course and no evidence of disease on follow up.