Laparoscopy in patients following transverse rectus abdominis myocutaneousflap reconstruction

Background: We report our technique and experience per forming laparoscopic pelvic surgery on four women after transverse abdominus rectus myocutaneou s flap (TRAM). Technique: Examination under anesthesia is performed on all patients in the low lithotomy position parallel with the floor. The abdominal aorta is pal pated and outlined. A pneumoperitoneum is created either by umbilical or le ft upper quadrant Veress placement, patients with an acceptable umbilical l ocation undergo port placement through the incision of the umbilical reloca tion. Other options include left upper quadrant or paramedian placement avo iding the ligamentum teres vessels. Lateral operative ports (5 mm) are plac ed with reference to the transverse incision present, the pelvic pathology, and the location of the umbilicus. Techniques of electrocautery, intra- an d extracorporeal suturing and knot tying, and clips are preferred to minimi ze port size. Experience: Following unilateral or bilateral TRAM reconstruction, four con secutive breast cancer survivors underwent successful laparoscopic-assisted vaginal hysterectomy with oophorectomy using the periumbilical incision fo r trocar placement. The only complication was a superficial skin breakdown from an adhesive allergy that required 6 weeks for complete resolution. Conclusion: Laparoscopic pelvic surgery is feasible in women after TRAM rec onstruction. Knowledge of anatomic and physiologic variations related to th e TRAM procedure is necessary in planning a safe operation. (Obstet Gynecol 2000;96:132-5. (C) 2000 by The American College of Obstetricians and Gynec ologists.).