The Endoscopic Latissimus Dorsi Flap Harvest: Advantages and Technical Drawbacks

Dear Editor:

We read with great interest the article of Guven et al. ¹ on presenting their series of endoscopic harvesting of latissimus dorsi (LD) flap with the electrothermal bipolar vessel sealer (EBVS; Ligasure). After its introduction in the 1990s, the endoscopic harvesting of LD muscle flap was used in orthopedic surgery, ² postoncologic breast reconstruction, ³ breast reconstruction in Poland anomaly, ⁴ free flap reconstruction with LD flap, ⁵ and pediatric surgery. ⁶

Surgeons were inspired by the potential advantages of the endoscopic technique, which include improved visualization of deep structures, shortened hospital stay, decreased postoperative pain, and limited incisions. ²

Although postoperative pain was suggested to be less important after endoscopic harvest compared with the classic open technique, Vasconez stated that postoperative pain was comparable in both traditional and endocopic LD harvests. ⁷ The smaller scar in endoscopic harvest, which lead to decreased scar formation and a better cosmetic outcome, represents a clear advantage, especially in young women, but that was again put into question. ⁷

In this sense and after the initial enthusiasm, the endoscopic LD harvesting could not gain enough popularity and be established as the preferred approach because of several drawbacks. These are essentially technical difficulties independent from the indications and the type of surgery.

First, it is difficult to create an adequate optical cavity because of the lack of sufficient elasticity of the skin and soft tissues. In our hands this was the most important problem to solve. Several methods were used for this—external traction of the skin and soft tissues by traction sutures, internal retraction by light retractors and/or saline-filled balloon retractors, the combination of external and internal retraction, ⁴ insuflation of CO₂. ³ Neither of these seems to create conveniently a comfortable optic space for LD flap harvesting.

The second point was the difficulty with hemostasis and sectioning of the muscle in its most distal and medial parts. Using the classic bipolar and monopolar cauterization, the percentage of revision due to bleeding was reported as high as 4% in certain series. ³ As shown by Guven et al., the use of EBVS will probably improve the technical aspect of hemostasis and muscle division. We have used the ultrasound endoscopic scalpel with the impression that it facilitates hemostasis and muscle sectioning in comparison to classic bipolar and monopolar cauterization. The other point is that EBVS probably decreases the amount of seroma formation. This is important, because some reports underline that there is no difference in seroma formation between the classic and endoscopic techniques. ⁷ Personally, we feel that the large undermining created in LD harvesting is more important for seroma formation than the technique used for hemostasis. Moreover, in both open and endoscopic techniques the undermined surface remains virtually the same.

Finally, the mentioned technical difficulties imply a steep learning curve with longer operative times in the beginning; this discouraged a lot of surgeons, who returned to the classic open approach. ⁷ However, today the operating time for an endoscopic approach is not much different form that of the open technique in the hands of surgeons experienced with the former.

In the field of breast reconstruction, with the broadening of the indications of skin-sparing mastectomy, ⁸ the endoscopic LD flap technique will probably gain increasing importance.

In conclusion, the endoscopic harvesting of the LD muscle presents advantages consisting of improved visualization of deep structures, shortened hospital stay, decreased postoperative pain, and limited incisions.

However, despite the progress of surgical techniques over the years, the technical difficulties in dissecting the LD flap are not entirely resolved. In this sense, we thank Dr. Guven et al. for their important contribution and efforts in improving the endoscopic harvest of LD flap.