How To Prepare The Skin For Diep Flap Surgery

Plast Reconstr Surg Glob Open. 2019 January; 7(1): e2016.

100 Steps of a DIEP Flap—A Prospective Comparative Cohort Serial Demonstrating the Successful Implementation of Process Mapping in Microsurgery

Hrsikesa R. Sharma

From the ^*St Andrew's Centre for Plastic Surgery and Burns, Broomfield Infirmary, Mid Essex Hospital Services NHS Trust, Chelmsford, Essex, United Kingdom

^†Anglia Ruskin University Chelmsford Campus, Bishops Hall Lane, Chelmsford, United kingdom of great britain and northern ireland.

Warren Thousand. Rozen

From the ^*St Andrew's Centre for Plastic Surgery and Burns, Broomfield Infirmary, Mid Essex Hospital Services NHS Trust, Chelmsford, Essex, U.k.

^†Anglia Ruskin University Chelmsford Campus, Bishops Hall Lane, Chelmsford, Uk.

Bhagwat Mathur

From the ^*St Andrew'due south Middle for Plastic Surgery and Burns, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, Chelmsford, Essex, United Kingdom

^†Anglia Ruskin University Chelmsford Campus, Bishops Hall Lane, Chelmsford, United kingdom.

Venkat Ramakrishnan

From the ^*St Andrew's Centre for Plastic Surgery and Burns, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, Chelmsford, Essex, Britain

^†Anglia Ruskin University Chelmsford Campus, Bishops Hall Lane, Chelmsford, United Kingdom.

Received 2018 Sep 4; Accustomed 2018 Sep xviii.

Abstract

Background:

The demand to ameliorate the efficiency of microsurgical chest reconstruction is driven past increasing number of chest cancer and run a risk reducing cases, and the concurrent requirement for hospitals to cut costs. Businesses have successfully used process mapping as a tool to improve efficiency; however, process mapping has been sparsely used in surgery. This prospective accomplice written report has used procedure mapping to break down the individual components of a deep inferior epigastric artery perforator (DIEP) flap operation into a template of 100 streamlined steps.

Methods:

Through ascertainment of the senior author'due south compatible technique, refined from experience of over 5,000 cases, the DIEP flap operation was broken down into 100 private steps, all arranged in a logical sequence with which to maximize efficiency and outcome. This created a 100-step process-mapped template. After, 2 cohorts of 10 unilateral DIEP cases were prospectively timed. Ane cohort following this process mapped template and the other control group was blinded to the template.

Results:

The process-mapped cohort was 56.i minutes quicker than the control accomplice, despite the addition of symmetrizing surgery being performed concurrently in 4 out of the 10 cases. Furthermore, at that place was no render to theater in the procedure-mapped cohort versus one return to theater in the control cohort with no flap loss in either group.

Conclusions:

This report uniquely presents an approach to process map the DIEP flap operation and demonstrates its utility in improving operative efficiency, without compromising outcomes. It also illustrates the possibility of symmetrizing surgery existence carried out through parallel operating processes, without affecting overall operative times.

INTRODUCTION

Process mapping is an important technique used in a range of industries to facilitate work flow, and this is exemplified in health care, where an aging and increasing population meets increased cost demands of this changing demographic. Process mapping involves breaking down a procedure into smaller steps, each of which is further subdivided until all the individual components take been mapped. By carrying out each of the steps in an efficient and logical manner, outcomes may be assessed and improved. The leading Formula I motor sport teams, for instance, routinely and repeatedly are able to alter the iv tyres of their cars during pit stops in iii seconds. This involves a team of people each having individual roles that have been optimized, leading to a more efficient overall maneuver.

We postulate that the aforementioned principles of process mapping can be successfully applied to surgical procedures, aiming to maximize efficiency and thus save time and costs. This will be benign for patients as they have shorter coldhearted times and may even have multiple procedures washed during the same operation every bit opposed to 2 separate operations. Furthermore, shorter operations may result in shorter waiting lists. Indeed, there has been a minor corporeality of data in the literature indicating the beneficial role of procedure mapping in surgery.^1–3 Notwithstanding, most of these have been associated with turnover between cases and minimizing interoperative time, that is, fourth dimension delays between dissimilar patients' operations in the same theater. Fong et al.^iv demonstrated that there is a paucity of evidence nearly intraoperative efficiency and process mapping merely ended work in this area this would help improve operative efficiency.

Non explored previously, we aim in the current report to employ a process mapping technique to the process of a deep inferior epigastric artery perforator (DIEP) flap^v operation for breast reconstruction. The DIEP flap is widely considered the aureate standard procedure in this setting, despite a lengthy operation, and variability in operator ease with the procedure. This was thus a suitable procedure for which to apply procedure mapping. It has been shown that 2 DIEP operations^vi can be carried inside daytime hours, and more recently our unit has shown that 3 can be carried out in a 12-hr working day^vii routinely. The use of process mapping seeks to identify the facets that may enable such efficiency to become more than mainstream.

PATIENTS AND METHODS

A prospective cohort written report was undertaken using a single establishment's analysis of procedure mapping in a cohort of patients undergoing DIEP flap breast reconstruction. The aims of this study comprised starting time to demonstrate the private steps of a DIEP flap operation, and second to demonstrate that past process mapping the DIEP flap, the efficiency of the operation is improved while not compromising on event.

The Study Design Was Equally Follows

Initially, the DIEP flap operation had to be procedure mapped into its individual steps which numbered 100. This was done past using the senior author'southward technique (a refinement to a uniform technique based on a total experience of over 5,000 cases of autologous chest reconstruction) as the footing to break down the DIEP flap performance into its individual steps.

This breakdown or procedure mapping of steps was achieved through observation of several consecutive unilateral DIEP flap operations of the senior writer. Each required private footstep was recorded from the moment the patient entered the anesthetic room to the moment they were woken up at the stop of the procedure. Collating these individual steps in sequence enabled united states to define a continuous stream of steps that would embrace the process mapping of the DIEP flap based upon the senior writer'southward refined technique. A template of the process mapped 100 steps of the DIEP flap is thus presented (encounter Results).

This template was then used to time 10 consecutive DIEP flap operations of a unmarried surgeon, the senior author. This accomplice is based upon the procedure mapping template. A 2nd cohort of 10 consecutive DIEP flap operations performed past a second senior surgeon, blinded to the process mapping template, was also timed using the template every bit a control. Results of timings between the 2 cohorts were compared and analyzed to test the aim.

To minimize bias, a unmarried investigator timed each instance using the template tool. But unilateral autologous DIEP reconstructions were included in this study.

Operative Technique

All included cases were carried out at St Andrew's Centre for Burns and Plastic Surgery, where over 250 DIEP flap cases are performed annually. Hospital upstanding clearance was sought and permission for this study to proceed was granted as it was likewise a review of current do of two senior surgeons and the study was deemed to pose no added danger/take chances to the patients as no changes to practice were made and only data documentation was required to carry out this study.

Each case had preoperative computed tomography angiography to select the "best" perforator for the flap. The senior surgeons in both cohorts was the master operating surgeon in flap raising and anastomosis with ii senior trainees profitable each example carrying out parallel components such as recipient vessel preparation and abdominal closure. Bilateral, bi-pedicled or stacked cases were excluded from this study. Both immediate and delayed cases were included and timings for mastectomy or excision of mastectomy scar and pocket cosmos were noted for involvement simply. The information nerveless were predominantly nonparametric; hence, statistical analysis was express.

RESULTS

The 100 Steps of a DIEP Flap

Coldhearted Room

1. Checklist
2. Lines - venous
3. Laryngeal mask airway (equally opposed to endotracheal intervention)—bag and mask and airway control
iv. Oesophageal Doppler Insertion (No Arterial line routinely used)
5. Electrocardiography leads zipper and monitoring
6. Catheterization

Preparation and Draping

vii. Exposure of patient for surgical preparation and draping
eight. Positioning—knees and arm securing
ix. Flowtron/calf pumps and diathermy pad attachment
10. two diathermy machines prepare for 2 team operating
xi. Globe Health Organization patient and procedure check
12. Skin preparation
xiii. Sterile drapes secured
xiv. Checking of marker/remarking/mark/stapling of midline points

Initial Flap Raise

xv. Skin incision lower contralateral flap with scalpel
xvi. Dermal and subcutaneous dissection connected with hand held diathermy
17. SIEV identification
eighteen. SIEV dissected tenotomy forceps and ligaclipping/cauterization depending on caliber/size of vein
19. Autopsy down to Scarpa's fascia with hand held diathermy
20. Subscarpa'due south fascia dissection to rectus fascia
21. Skin incision upper contralateral flap
22. Dissection down to Scarpa'southward Fascia
23. Sub-Scarpa'due south dissection beveled cranially to rectus fascia for fat recruitment/volume recruitment and matching profile for closure
24. Lateral raise of flap off rectus fascia with manus held diathermy to just lateral to lateral row perforator level

Perforator Autopsy

25. Dissection down to and identification of perforator (matched to computed tomography) using bipolar diathermy and/or McIndoe's dissecting scissors
26. Umbilical release down to Fascia to assistance perforator dissection/superior access to perforator
27. Circling cuff/isolation of perforator to a higher place rectus fascia using tenotomy/McIndoe forceps
28. Rectus Fascia incised with Scalpel
29. Subfascial/intramuscular autopsy (musculus relaxant versus lignocaine) using McIndoe dissecting forceps and bipolar diathermy (low setting)
30. Submuscular dissection of perforator
31. Identification of DIEA artery
32. Proximal/superior ligation of DIEA artery with ligaclips
33. Distal/junior pedicle dissection to adequate length (pedicle length noted)
34. Autopsy of flap off rectus fascia across midline
35. Pedicle ligated and checking for backflow across midline versus. letting "breath"
36. Ipsilateral lower skin incision ipsilateral dermal and subcutaneous dissection
37. SIEV identification
38. SIEV dissected
39. Autopsy downward to rectus fascia
40. Superior ipsilateral pare incision
41. Autopsy down to Scarpa'southward fascia
42. Sub-Scarpa's dissection and fat recruitment
43. Lateral raise of flap off rectus fascia
44. Flap off
45. Hemostasis of pocket postmastectomy
46. Dissection to identify recipient vessels—internal mammary artery perforator versus thoracodorsal vessels versus internal mammary vessels
47. Macroscopic dissection of recipient vessels
48. Shaping/suturing of pocket
49. Drains
50. Hemostasis

Vessel Preparation and Flap Inset

51. Zone 4/3 discarding (Hartrampf and Holm)
52. Hemostasis
53. St Andrew's Coning suture of nether surface of flap using absorbable suture for project of flap/coning
54. De-epithelialization of flap
55. Hemostasis mail de-epithelialization

Abdominal Closure

56. Hemostasis subrectus fascia and musculus
57. Mesh (not sutured)
58. Muscle versus no muscle repair
59. Rectus Fascia closure using loop nylon suture
sixty. Bed break and check for closure tension
61. Abdominoplasty flap raise while checking closure tension (up to xiphisternum)
62. Insertion of one abdominal bleed using scalpel incision and drain secured
63. Hemostasis of abdomen
64. Neo-omphalus marking
65. Peel incision of neo-bellybutton in abdominoplasty flap
66. Cuff of Sub-Scarpa's fat release around neo-navel from underneath abdominoplasty flap
67. 2.0 Vicryl anchoring sutures between rectus fascia lateral to omphalus and dermal edge of neo-umbilical incision
68. Scarpa's fascia closure (iii either side and midline)
69. Dermal closure using barbed suture
70. Umbilical skin closure using v.0 monocryl subcuticlar/belly airtight
71. Preneo (Ethicon) tape and glue
72. Abdominal drain opened

Microsurgery

73. Self retainers to proceeds access to recipient vessels (secured with op tape or held by assistant)
74. Flap positioning for micro: stapled/sutured
75. Microscopic venous autopsy and clamping
76. Groundwork insertion
77. Venous anastomosis (with or without coupler)
78. Microscopic Arterial Dissection with clamping
79. Arterial anastomosis including removal of clamps and checking for bleeding (micro ligaclips for small leak)
80. Acland's test to confirm menstruum of avenue and vein
81. Checking of venous bleeding from 2nd DIEV if present earlier clipping off
82. Cess of flap bleeding from dermal edge and side of flap
83. Hemostasis of flap

Breast/Flap Closure

84. Anchoring sutures for flap 2.0 Vicryl
85. Bank check pedicle for twisting/kinking
86. Circa pare paddle dermal release
87. Subcuticular closure of flap
88. Subcuticular closure of axillary wound if present/last sew
89. Preneo Tape and Gum (care non to encompass flap skin paddle with glue)
90. Drains opened
91. Check flap for capillary refill

Final Transfer

92. Wet and dry out clean of wounds
93. Removal of drapes
94. Rolling and transfer
95. Cleaning
96. Binder
97. Arm positioning
98. Check flap posttransfer
99. Pillow support for arm and knees
100. Wake patient upward

Process Mapping Study

The timing results of each ten-case cohort (process mapped versus control) were nerveless and compared (Tabular array 1), and the outcome of successful flap reconstruction was accomplished in all 20 cases.

Table 1.

Average Timing Data from x Accomplice one Cases (Process Mapped Group) Versus 10 Cohort 2 Cases (Blinded/Control Group)

An external file that holds a picture, illustration, etc. Object name is gox-7-e2016-g001.jpg

Demographics

Cohort 1 (Process Mapped) comprised half-dozen delayed and four immediate unilateral DIEP flaps. Of these, nine were correct-sided and one left-sided reconstructions. The boilerplate age was 46.4 years old (range, 31–58 years) and boilerplate BMI 29.25 (range, 24.half-dozen–38.5).

4 cases had additional symmetrizing (contralateral breast reduction ×3 and mastopexy ×1) procedures in their timing—iii delayed, and 1 firsthand. Of these, 1 delayed example needed an intraoperative vein graft from SIEV to Internal mammary perforator vein equally superficial venous system was dominant. At that place were zero returns to theater and no flap losses.

Cohort ii (control) comprised 3 delayed and 7 immediate unilateral DIEP flaps. Of these, 8 were right-sided and 2 left-sided reconstructions. The boilerplate age was 52 years onetime (range, 44–67 years), and the boilerplate BMI 28.3 (range, 22.ix–37.7). No cases had additional symmetrizing procedures. There was one render to theater: in which a delayed case needed a vein graft: cephalic turndown to SIEV. There were no flap losses.

Give-and-take

The current report demonstrated that the DIEP flap operation was able to be successfully procedure mapped into 100 steps, which were able to be consistently applied to the procedure across multiple surgeons. Moreover, the report was able to show that procedure mapping was useful in identifying areas of variability between surgeons, and areas for assessment inside the process of a single surgeon.

At that place were significant differences identified between different groups, when procedure mapping was applied to DIEP flap surgery as a means to identifying these differences. The aims of the report were thus realized, with specific processes able to be considered in improving efficiency and operative flow and therefore potentially for teaching and for surgical preparation,

In terms of identifying these differences, accomplice i, which was the process-mapped cohort, had an average skin to skin operative time of 163.i minutes compared with accomplice 2 (control cohort), which averaged 219.2 minutes. Though 4 out of the 10 cases in cohort 1 were firsthand DIEP flaps, which may be perceived as taking longer time, these 4 firsthand cases in fact averaged only 160 minutes peel to peel time.

The flap raise was quicker in cohort 1 than accomplice 2. However, too equally removing redundant steps this could also be partly explained by the fact that the average length of pedicle in accomplice one was 10.1 cm compared with 14 cm in cohort ii. This is considering cohort 1 had anastomoses with internal mammary and internal mammary perforators and thoracodorsal recipients and therefore would non require as long a pedicle on boilerplate every bit if they had solely been anastomosed to the thoracodorsal axis as was the case throughout cohort 2. This is known as the short pedicle raise.

The greatest difference in times betwixt the two cohorts was the intestinal closure. Cohort 1 uses a few sutures to close the Scarpa'due south fascia and then a barbed suture to shut the dermis with tape for the epidermis and on boilerplate took 43.vii minutes for closure. This is in comparison to the standard 3-layer closure used in cohort 2, which took 82.8 minutes on average. This demonstrated that with equal results and no wound healing problems of donor sites of 2 groups, the process mapping arroyo of cohort 1 is the more than efficient arroyo to abdominal closure saving on average 39.1 minutes by streamlining the procedure of abdominal donor-site closure.

Overall, the process-mapping accomplice 1 has saved on average 56.i minutes per operative time compared with the command cohort 2 group and demonstrate that process mapping the DIEP operation has improved efficiency. With no flap loss or return to theater in the process mapping cohort, it has also demonstrated that this increased efficiency has been accomplished without compromise to patient upshot. Moreover, four/ten cases in accomplice 1 had additional symmetrizing procedures (breast reduction/mastopexy) carried out concurrently compared with 0/10 cases in cohort 2. This demonstrates that boosted procedures tin can be performed at the same time without increasing overall operative time significantly past using parallel operating techniques.

With increasing number of patients requiring chest reconstruction, there is a tightening of wellness care service bag strings. In this climate, as the clinicians performing these microsurgical procedures, it is mandatory that nosotros look at the efficiency of ourselves conveying them out and understand whatsoever areas for improvement of quality of care. The principle of procedure mapping tin exist used in a like style for all types of surgical procedures to maximize these benefits of reducing operative and therefore anesthetic time for the patients while likewise having time and cost benefits for the hospitals/trusts.¹⁴

Using the tools of process mapping, nosotros have successfully broken downwardly the DIEP performance in to a 100 steps. This has been used to create a template for the DIEP flap operation. Two cohort groups, one process-mapped and a control grouping, were timed for 10 unilateral DIEP flap reconstructions. The results from this have demonstrated that, by process mapping, efficiency of this operation has been improved. This has been achieved past carrying out the individual steps of the performance in a logical streamed manner with removal of redundant steps. This will hopefully dispel the impression of the DIEP flap operation being a long and complex operation to beingness a reproducibly straight-forward process when following the 100 steps. In addition to this, with the appropriate use of teamwork some of these steps can be carried out concurrently and therefore save even more time. The summative effect of this will be first to reduce the operative time of what was deemed to be a long operation for the patient to around 4 hours on boilerplate^vii and thus reduce anesthetic time. 2nd, by saving time and with the efficient apply of ii or more teams boosted procedures (eg, contralateral symmetrizing breast reductions) may be performed concurrently thus negating the requirement of a 2nd operation and anesthetic for a patient. 3rd, reducing the operative time reproducibly to under four hours may enable multiple cases to be operated on in a day^6,seven and thus maximize the employ of theater time and as a result save costs while at the same fourth dimension help with waiting lists. Further studies into procedure mapping the DIEP flap are likely to show its value in training past identifying the steps of most time variance thus elucidating areas of potential preparation focus and identifying any common areas of back-up for trainees.

CONCLUSIONS

Procedure mapping can be applied to DIEP flap surgery, as a ways to evaluating operative efficiency and didactics. The 100 steps of the DIEP flap, as defined through evaluation of the operative approach of an experienced surgeon, are reproducible, are able to evaluate steps that have depression or loftier variation between surgeons, and can exist used to identify nonoperative steps betwixt processes. The employ of process mapping may thus be used to improve surgical technique, efficiency and in the future surgical training.

Footnotes

Published online fifteen January 2019.

Disclosure: The authors have no financial involvement to declare in relation to the content of this commodity. The Commodity Processing Accuse was paid for by the authors.

REFERENCES

1. Taner MT. Awarding of Six Sigma methodology to a cataract surgery unit. Int J Health Care Qual Assur. 2013;26:768–785. [PubMed] [Google Scholar]

two. Cima RR, Brown MJ, Hebl JR, et al. Use of lean and 6 sigma methodology to improve operating room efficiency in a high-book tertiary-care academic medical center. J Am Coll Surg. 2011;213:83–92; discussion 93–4. doi: ten.1016/j.jamcollsurg.2011.02.009. Epub 2011 Mar 21. PMID: 21420879. [PubMed] [Google Scholar]

3. Schraagen JM, Schouten T, Smit M, et al. Assessing and improving teamwork in cardiac surgery. Qual Saf Health Care. 2010;19:e29. [PubMed] [Google Scholar]

4. Fong AJ, Smith M, Langerman A. Efficiency improvement in the operating room. J Surg Res. 2016;204:371–383. [PubMed] [Google Scholar]

5. Allen RJ, Treece P. Deep inferior epigastric perforator flap for breast reconstruction. Ann Plast Surg. 1994;32:32–38. [PubMed] [Google Scholar]

6. Acosta R, Enajat M, Rozen WM, et al. Performing two DIEP flaps in a working solar day: an achievable and reproducible practice. J Plast Reconstr Aesthet Surg. 2010;63:648–654. [PubMed] [Google Scholar]

7. Marsh D, Patel NG, Rozen WM, et al. 3 routine free flaps per solar day in a unmarried operating theatre: principles of a process mapping arroyo to improving surgical efficiency. Gland Surg. 2016;5:107–114. [PMC costless article] [PubMed] [Google Scholar]

8. Figus A, Wade RG, Oakey S, et al. Intraoperative esophageal Doppler hemodynamic monitoring in costless perforator flap surgery. Ann Plast Surg. 2013;70:301–307. [PubMed] [Google Scholar]

ix. Marsh DJ, Patel N, Ramakrishnan VV. Confirming perforator patency and cross midline arterial arborisation in DIEP flap surgery. J Plast Reconstr Aesthet Surg. 2014;67:1300–1301. [PubMed] [Google Scholar]

ten. Hartrampf CR, Scheflan Grand, Black PW. Breast reconstruction with a transverse intestinal isle flap. Plast Reconstr Surg. 1982;69:216–225. [PubMed] [Google Scholar]

11. Holm C, Mayr M, Höfter E, et al. Perfusion zones of the DIEP flap revisited: a clinical study. Plast Reconstr Surg. 2006;117:37–43. [PubMed] [Google Scholar]

12. Blondeel PN, Richter D, Stoff A, et al. A comparison of a new pare closure device and intradermal sutures in the closure of full-thickness surgical incisions. Plast Reconstr Surg. 2012;130:843–850. PMID: 23018695. [PubMed] [Google Scholar]

13. Fitzgerald O'Connor E, Rozen WM, Chowdhry The microvascular anastomotic coupler for venous anastomoses in complimentary flap breast reconstruction improves outcomes. Gland Surg. 2016;5:88–92. doi: 10.3978/j.issn.2227-684X.2015.05.14. PMID: 27047776. [PMC costless commodity] [PubMed] [Google Scholar]

fourteen. Paget JT, Young KC, Wilson SM. Accurately costing unilateral delayed DIEP flap chest reconstruction. J Plast Reconstr Aesthet Surg. 2013;66:926–930. [PubMed] [Google Scholar]

Articles from Plastic and Reconstructive Surgery Global Open up are provided here courtesy of Wolters Kluwer Health

Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6382232/

Posted by: caudlefreat1966.blogspot.com