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Thadeus L. Trus, MD; E. Dale Collins, MD; Christopher Demas, MD; Carolyn Kerrigan, MD

Arch Surg. 2007;142:362-364.

Hypothesis  Transverse rectus abdominus musculocutaneous (TRAM) flap breast reconstruction provides excellent cosmetic results. Pedicle flap viability is greatly enhanced by prereconstruction inferior epigastric vessel ligation, which encourages collateral arterial flow (delayed TRAM). We report our initial experience with laparoscopic inferior epigastric vessel ligation.

Design  Prospective case series.

Setting  Tertiary academic center.

Patients  Female patients with breast cancer who chose pedicle TRAM reconstruction.

Interventions  Vessel ligations were performed 7 to 14 days prior to reconstruction. Abdominal access was achieved with a 3-mm umbilical trocar. A 5-mm trocar was placed lateral to the rectus sheath in the right lower quadrant. Five-millimeter Teflon clips were used to ligate the vessels near their origin.

Main Outcome Measures  Complications of surgery and subsequent flap viability.

Results  From January 2001 to July 2006, 130 patients had laparoscopic inferior epigastric vessel ligation, of whom 123 patients had bilateral ligation. Additional procedures in conjunction with vessel ligation were performed in 38 patients (sentinel node biopsy [27], bilateral oophorectomy [7], liver biopsy [2], breast biopsy [1], and Nissen fundoplication [1]). Median operative time for those patients undergoing ligation only was 32.6 minutes (range, 14-121 minutes). The inferior epigastric vessels were not identified in 2 patients. Metastatic breast cancer involving the liver was found in 1 patient. There were no conversions or complications. Subsequent TRAM flap viability was excellent in most cases, with 1 complete flap necrosis in a high-risk, morbidly obese patient.

Conclusion  Laparoscopic inferior epigastric vessel ligation for delayed TRAM flap breast reconstruction is a safe, effective procedure.

Author Affiliations: University of Rochester Medical Center, Rochester, NY (Dr Trus), and Dartmouth-Hitchcock Medical Center, Lebanon, NH (Drs Collins, Demas, and Kerrigan).