Surgical Theater, a Novel Technology, Enhances 3-dimensional Mapping for Robotic-assisted Deep Inferior Epigastric Perforator Free Flap

Abstract

Background: Computed tomography angiography (CTA) is useful in deep inferior epigastric perforator (DIEP) flap planning. Limitations include that 2-dimensional analysis can be difficult to interpret and the resolution of 3-dimensional (3D) images can be too low. Merging with Surgical Theater software provides high-resolution 3D visualization of the vasculature, which may improve preoperative planning. Methods: Surgical Theater and conventional CTA were combined for preoperative DIEP flap planning. Technical rendering details are explained, receiver operating characteristic curves are identified, and use in robotic-assisted DIEP flap planning is described. Results: Seven patients were presented. The mean times of 3D mapping and intraoperative perforator identification and selection were 30.8 ± 4.7 and 36 ± 8.2 minutes, respectively. One dominant perforator was identified that was not visible on CTA and was concordant with intraoperative findings. Receiver operating characteristics metrics include sensitivity of 95%, specificity of 93%, positive predictive value of 91%, and negative predictive value of 96%. The rotational capabilities of 3D images allow easier interpretation of intramuscular course and branching patterns. Conclusions: Combining Surgical Theater with conventional CTA in DIEP flap breast reconstruction provides advantages over CTA alone, including high-fidelity visualization of the course of the DIEP vasculature from multiple views with image rotation in space, which may enhance perforator identification. This technology is particularly helpful in identifying candidates for robotic-assisted DIEP flaps, which is particularly dependent on preoperative imaging. The learning curve is shorter than that for interpreting 2-dimensional imaging, and building 3D images is quick, making adoption straightforward. The potential use of multiple surgical services makes the capital expense cost-effective.