Comparison of Robotic-assisted and Conventional Deep Inferior Epigastric Perforator Flaps: A Retrospective Cohort Study

Background: The deep inferior epigastric perforator (DIEP) flap is widely regarded as the gold standard for breast reconstruction. Recent advancements in robotic-assisted microsurgery have enabled perforator-to-perforator anastomoses. This study aimed to evaluate the conventional technique against the robotic-assisted approach, and the perforator-to-perforator method, to determine its noninferiority. Methods: Sixty-eight patients undergoing breast reconstruction with a DIEP flap between 2022 and 2024 were included. Primary exposure was classified according to the surgical technique used: conventional surgery without the Symani Surgical System, robotic-assisted microsurgery with conventional vessel anastomosis, and robotic-assisted perforator-to-perforator anastomosis. This study investigated outcomes such as surgical complications, hospital length of stay, and postoperative pain medication. Results: Twelve (17.6%) patients underwent robotic-assisted perforator-to-perforator anastomoses, 28 (41.2%) underwent robotic-assisted conventional microsurgical anastomosis, and 28 (41.2%) underwent nonrobotic microsurgical anastomosis. Patient demographics were well balanced across surgical methods. Overall, surgical complications were observed in 25% of patients, with no significant difference in complication rates between perforator-to-perforator anastomoses and conventional anastomoses ( P = 0.41). Additionally, the hospital length of stay did not differ significantly between groups ( P = 0.58). However, patients who underwent perforator-to-perforator surgery required significantly lower morphine equivalent doses postoperatively ( P = 0.001). Conclusions: This study demonstrated that robotic-assisted perforator-to-perforator anastomosis in DIEP flap breast reconstruction resulted in a significant reduction in postoperative analgesic pain medication and showed similar complication rates in comparison to conventional anastomosis.