Robotic, Intraperitoneal Harvest of the Rectus Abdominis Muscle

Background: The rectus abdominis muscle is a workhorse for free and pedicled muscle coverage. Traditional harvest violates the anterior rectus sheath and requires an abdominal incision. Robotic harvest can be reliably and efficiently performed using three ports and no additional incisions. Methods: Ten robotic rectus muscle harvests were performed at three institutions as free flaps for extremity coverage and pedicled flaps for minimally invasive pelvic surgery requiring soft-tissue reconstruction. Three contralateral ports and an intraperitoneal approach were used in each harvest. Demographic information, operative variables, and outcomes were recorded. Results: All cases were completed robotically by three surgeons at three different institutions. Four muscles were harvested as free flaps for lower extremity and six muscles were used as pedicled flaps, three for abdominopelvic defect reconstruction and two for protection of visceral repair following salvage prostatectomy or anterior pelvic exenteration. Average robotic setup time was 15 minutes. Average robotic harvest time was 45 minutes. Two 8-mm ports and one 12-mm port were used in each case. One patient developed a grade I decubitus ulcer during an extended operation. There were no other complications. All muscles were completely viable following harvest. There were no conversions to open technique, and no hernias or bulges were noted. Conclusions: Robotic rectus muscle harvest is safe, efficient, and reproducible. The anterior rectus sheath can be left completely intact, eliminating incisional morbidity. The cumulative incisional length can be less than 2 inches even for extensive, multiservice pelvic procedures. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.