Comparing Transabdominal and Totally Extraperitoneal Approaches for Minimally Invasive DIEP Flap Harvest: A Systematic Review.

[INTRODUCTION] Minimally invasive techniques for DIEP flap harvest, including transabdominal (TAPP) and totally extraperitoneal (TEP) approaches, have been reported to be beneficial in reducing morbidity; however, direct comparative synthesis between these methods remains scarce, limiting consensus on the optimal approach.

[METHOD] Following PRISMA guidelines, we searched MEDLINE, Embase, and Cochrane Central for prospective and retrospective studies on robotic or laparoscopic DIEP harvest in breast reconstruction. Cadaveric studies and non-DIEP procedures were excluded. Primary operative outcomes included harvest time, type of robot, fascial incision length, intramuscular length, and intraoperative complications, while secondary clinical outcomes were postoperative complications, length of stay, and pain. A structured narrative synthesis was conducted using pooled descriptive data, without inferential statistical analysis.

[RESULTS] Ten studies were included, including six describing TAPP harvest, two robotic TEP, and two laparoscopic TEP. Reported unilateral reconstruction times averaged 442.6 ± 63.4 min for TAPP and 460.3 ± 90.4 min for TEP, while bilateral procedures averaged 682.6 ± 115.1 min for TAPP compared with 453.0 ± 81.5 min for TEP. Fascial incisions were longer with TAPP (3.75 ± 1.34 cm) compared to TEP (2.59 ± 0.49 cm), and intramuscular pedicle dissection length was greater in TAPP (4.1 ± 0.7 vs. 2.25 ± 0.27 cm). No study reported bowel injury or postoperative ileus, and overall complication rates-including vessel avulsion, flap loss, infection, and seroma-were similar. Postoperative pain scores were 1.9 ± 0.9 in TAPP versus 2.3 ± 0.9 in TEP, while hospital stay averaged 3.9 ± 1.3 days for TAPP and 4.5 ± 0.9 days for TEP.

[CONCLUSION] Both TAPP and TEP appear safe and effective for minimally invasive DIEP flap harvest. Trends suggest bilateral TAPP requires longer operative times, while TEP results in shorter fascial incisions and had shorter intramuscular pedicle lengths. Pain and complication rates were comparable, although study heterogeneity and small sample sizes limit generalizability. Larger, prospective comparative studies are essential to better define technique selection.