endoscopic-assisted harvest of pedicled and free latissimus dorsi ...

INTRODUCTION
The latissimus dorsi (LD) flap is a workhorse flap in
the reconstructive armamentarium of plastic surgeons
due to its versatility. It is an expendable muscle with
large surface, wide arc of rotation and convenient
ORIGINAL ARTICLES
ENDOSCOPIC-ASSISTED HARVEST OF PEDICLED AND
FREE LATISSIMUS DORSI MUSCLE IN PIGS
Nicolae Ghetu 1 , Ali-Alain Mojallal 2 , Daniela Emanuela Ghetu 1 , Venera Iliescu 3 , Vlad
Ionut Ilie 1 , Victor George Ilie 1 , Mihai Ionac 3 , Grigore Mihalache 1 , Dragos Pieptu 1,4
REZUMAT
Introducere: Muşchiul latissimus dorsi (LD) este frecvent utilizat pentru acoperirea de ţesuturi moi, mărire de volum şi reconstrucţie funcţională. Abordul
chirurgical larg predispune la cicatrici inestetice. Prelevarea endoscopică prin aborduri minime produce cicatrici estetice, durere postoperatorie redusă,
recuperarea rapidă şi creşterea satisfacţiei pacienţilor. Obiectiv: Studiul de faţă propune un model porcin de prelevare endoscopică a muşchiului LD,
pediculat şi liber. Modelul este evaluat pentru potenţialul de antrenament in tehnicile endoscopice. Material și metode: Treizeci şi nouă de muşchi LD
(18 bilaterali şi 21 unilaterali) au fost prelevaţi asistat-endoscopic la 30 porci, folosind o singură incizie pentru fiecare muşchi. Primele 2 cazuri au fost
convertite la recoltare clasică, datorită sângerării incontrolabile, şi excluse din studiu. Prelevarea s-a efectuat ca lambou pediculat în 17 cazuri (grupul 1) şi
ca muşchi liber în 20 de cazuri (grupul 2). S-a înregistrat durata operaţiei, accidentele intraoperatorii şi complicaţiile. Viabilitatea muşchiului a fost evaluată
la jumătate de oră şi la Rezultate: Durata medie operatorie a fost semnificativ diferită între cele două grupuri (p

described using an open harvesting technique. 31-36
Recently, a model for endoscopic-assisted muscle
harvesting training was described in pigs. 37
The aim of the present study is to assess the
potential of the swine model of endoscopic-assisted
LD harvesting. The muscle harvesting (as pedicled
and free flap) parallels the technique used in humans.
The learning curve, complications and results are
evaluated and the value of this model as a training tool
established.
MATERIAL AND METHODS
Prior to our study, detailed swine LD muscle
anatomy was taught and classic (open) harvest of
swine LD muscle was performed during flap dissection
training courses and learning sessions conducted by
the senior authors DP and MI. 31-36 The first author
had endoscopic experience limited to porcine gracilis
muscle harvest. 37
Operative instruments
A standard endoscopic setup (similar to
laparoscopic surgery cart) was used: light source, 10 mm
and 5 mm, 30 degrees angle endoscope, video camera,
high resolution video monitor and video recorder,
irrigation-suction device. The usual instrument set for
flap surgery and standard laparoscopic instruments
(forceps, cautery, scissors and hemoclips) were also
used. For the optical cavity development during
endoscopic dissection, an Emory-type retractor was
used.
Animal experiments
The protocols were approved by the Joint
Committee for Animal Research and Animal Care and
Ethic Committee of Pius Branzeu Center in Timisoara
and Center for Simulation and Training in Surgery in
Iasi. Animals were housed and treated in compliance
with the “Guide for the Care and Use of Laboratory
Animals”, published by the National Academy Press
(US NIH Publication No 85–23, revised 1996). The
animals were caged individually in the animal facility
of the research center, with 12 hourly day/night cycle
and with food and water ad libitum. They were fasted
for 12 hours preoperatively.
Pig’s sedation was achieved with ketamine (10-
15 mg/kg) and midazolam (0.5 mg/kg) or diazepam
(2 mg/kg); they were intubated after intravenous
infusion of thiopental (5-10 mg/kg). Anesthesia was
maintained with halothane 1-2% mixed with oxygen
2-4L/min. Isotonic solutions were perfused 5-10 ml/
kg/h.38 A total of 30 pigs (mean weight 26.3 kg, range
20-34 kg) underwent endoscopic-assisted harvest of
39 LD muscles (18 bilateral and 21 unilateral).
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146 TMJ 2010, Vol. 60, No. 2 - 3
Operating room setup
The pigs were positioned in lateral decubitus
with forelimb free. 32,33 The operator stood facing the
animal’s ventral side, with the assistant beside him; the
later handled the self-mounted Emory-type retractor
and pulled pig’s forelimb cranially and outward to
expose the pedicle. The video monitor was placed
at the opposite side of the operating table for both
operator and assistant to see the endoscopic images.
Landmarks
With the pig on the side and the forelimb flexed
cephalad, the skin fold on the posterior axillary’s line
was marked as the muscle anterior border, caudally
to the last ribs. (Fig. 1) The midpoint between the
olecranon to scapular apex line is another landmark for
the anterior border of the muscle. From this point, a
line was drawn posteriorly, 0.5 cm caudal from scapular
apex towards the midline – the LD cranial border.
Slightly lateral from the midline, a line was marked over
the lower 6 thoracic vertebras, and continued anteriorly,
around the last ribs, meeting with the anterior border
marking. Ten to twelve cm above the olecranon, the
pedicle entry point to the muscle was marked. From
the olecranon-apex midpoint, and 1 cm anteriorly, a 4-5
cm line marking the incision was drawn caudally. 31-34
Figure1. Swine LD muscle landmark.
The anatomy of swine LD muscle
The LD is a fan-shaped muscle on the pig’s
side, arising from the lower 4 ribs and through an
aponeurosis from lower 6 thoracic vertebrae and
inserting on the humerus (through a common tendon
with teres major). (Fig. 1) The anterior border of the
muscle can be identified on the posterior axillary fold,
at the midpoint between olecranon and the scapular
apex. From this point to the spine, coursing just
under the apex, is the LD cranial border; same point
united with spine landmark (upper 1/3 with lower
2/3 of spine) shows the LD muscle midline. On its
cranial-dorsal area, the LD is deep to the trapezius and
overlies serratus ventralis thoracis muscle. The anterior

order has loose connections to pectoralis profundus
ascendens muscle.
The LD is a Mathes and Nahai type V muscle, with
a dominant pedicle and multiple segmental pedicles
(perforators from intercostals arteries – IAP). The
dominant pedicle consists of the thoraco-dorsal artery
(from axillary artery via subscapular artery) and paired
venae comitantes (proximally often united to become
single subscapular vein). Cranially, the muscle curls
on itself in a mild gutter-shape aspect that holds the
vessels. Pedicle runs under teres major muscle, on the
fascia underneath LD. The artery, 1.2-1.5 mm diameter,
enters the muscle 6 cm distal to origin, or 10-12 cm
above the olecranon. Along the cephalic border of LD,
branches the arterial supply for teres major muscle. LD
motor innervation is provided by thoraco-dorsal nerve,
situated slightly cranial to the vascular pedicle. 31-34
Harvesting technique
After anesthesia administration, pig’s side and
forelimb were prepped and draped. The skin was
incised 4-5 cm and dissection proceeded through
subcutaneous fat layer and panniculus carnosus. The
anterior border of LD lies under the subpannicular
thin layer of translucent fat.
From incision site, dissection proceeds in the
usual open (classic) fashion, both above and under the
muscle. (Fig. 2) Once direct vision became limited, the
dissection the proceeds under endoscopic assistance,
monitored carefully on the screen. Supramuscular
dense attachments needed electric cautery dissection;
beneath muscle, loose connections allowed easier and
faster dissection. Small perforators and side-branches
(to teres major and serratus) were cauterized or clipped.
Figure 2. LD caudal border identified after incision. “OPEN” marks
classic dissection area.
Using Emory-type retractors, the apex of the
scapula was visualized, slightly cranial to LD border.
Systematic clockwise or anticlockwise dissection
helped maintain the correct plane and dissection of
the LD, from under the trapezius and teres major and
above the serratus muscle. Near the muscle vertebral
border, the IAPs must be carefully cauterized or
clipped to prevent bleeding; when bleeding occurred,
dissection was resumed after 5 minutes gentle pressure
and proper vessel hemoclips ligation. Irrigation-suction
can also be useful for bleeding vessel identification.
After the LD dissection, the muscle origins were
addressed. From underneath the muscle, using a hookshape
cautery, the vertebral aponeurosis of LD was
cut. Caudally, the muscle was detached from the ribs,
and the anterior margin liberated in a caudal to cranial
direction from thin connections to the pectoralis
muscles. If this sequence is not followed, the muscle
will fall towards the spine, making the vertebral origin
section a difficult task.
Muscle was delivered through the incision, still
attached by pedicle and tendon. (Figs. 3, 4) Adequate
arc of rotation was provided by 2-3 cm open proximal
mobilization of tendon and pedicle. The donor site
was inspected for bleeding. Muscle was replaced,
bleeding and muscle viability checked again 30 minutes
later, donor site closed using 3/0 absorbable stitches
and pigs were returned to animal facility (if follow-up
intended) or euthanized.
Figure 3. Pedicled LD delivered through incision. LD outer surface shown.
Figure 4. Pedicled LD delivered through incision. LD undersurface shown.
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Nicolae Ghetu et al 147

Table I: endoscopic-assisted LD muscles harvested
Table 1. Endoscopic-assisted LD muscles harvested.
Pig no. Weight
Group 1
Group 2
Case
(kg) no.
time (min) complication
1 34 1 R 205 IAP injury Conversion Muscle viable
2 L 188 IAP injury Conversion “
2 25 3 R 181 VC injury Yes Seroma “
3 32 4 R 168 VC injury Yes “
4 24 5 R 165 Yes Seroma “
5 22 6 R 175 “
7 L 158 “
6 26 8 R 160 “
9 L 152 “
7 31 10 R 142 “
11 L 145 “
For the first 19 cases, the technique described
reproduces the endoscopic-assisted harvest of LD
to be used as a pedicled muscle (i.e. pedicled LD for
breast reconstruction).
For distinction with the subsequent cases, first 19
cases will be included in group 1. (Table 1)
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148 TMJ 2010, Vol. 60, No. 2 - 3
Side Operating
Intraoperative
1
Follow-up Complications Results
8 29 12 R 135 “
13 L 136 “
9 27 14 R 142 “
15 L 140 “
10 25 16 R 143 “
17 L 130 “
11 30 18 R 136 “
19 L 125 “
12 25 20 L 184 VC injury Yes Ecchymosis “
13 22 21 R 181 “
22 L 180 “
14 28 23 R 184 VC injury Yes Seroma “
15 24 24 L 175 “
16 21 25 R 181 “
17 27 26 L 176 “
18 29 27 L 172 “
19 23 28 R 165 “
20 24 29 R 164 Yes Seroma “
21 30 30 L 170 “
22 31 32 L 156 Yes Ecchymosis “
23 32 31 R 163 “
24 23 33 R 160 “
25 27 34 L 163 Yes “
26 29 35 R 159 “
27 21 36 R 162 Yes Seroma “
28 20 37 R 150 “
29 23 38 R 140 Yes “
30 25 39 R 135 “
Legend: IAP: intercostals artery perforator, VC: vena comitans, R: right, L: left
Starting with case #20, for the next 20 cases
(group 2), the LD muscle was harvested as a free flap.
Muscle dissection was performed in a similar fashion
and continued proximally.
The forelimb was pulled cranially and upward
and the submuscular plane cranial to the incision was

visualized. Open dissection for 3-4 cm (limited by the
incision direction) preceded the endoscopic dissection
of the pedicle - artery, vein/paired veins and nerve.
The pedicle was skeletonized up to the origin from the
axillary vessels. (Fig. 5) The tendon was isolated from
teres major tendon and cut. Half an hour later, the
muscle was inspected for viability. For one week followup,
LD was sutured to the serratus fascia in a position to
prevent pedicle kinking, compression or torsion. After
checking the donor site for bleeding, the incision was
closed by separate absorbable 3/0 stitches. Pigs were
returned to animal facility. If no follow-up intended,
pedicle was clipped near its origin and cut, the muscle
was delivered through the incision and measured.
Donor site was inspected for bleeding, closed with
absorbable stitches and pigs were euthanized.
Figure 5. LD pedicle dissected. Endoscopic view.
Operating times were recorded from incision
to skin closure but the 30 minutes observation
time was not included. Complications and muscle
anthropometric measurements were documented.
Neither drains nor dressings were used; antibiotics and
analgesics were administered for 3 days.
Follow-up
Vital signs, complications, ambulation and feeding
habits were inspected on a daily bases. One week
later, under general anesthesia, the incision site was
reopened and the muscle viability was checked and the
complications were noted.
Statistics
Student t-test was used to analyze the operating
times between the groups 1 and 2. P

comitant vein when inserting the retractor (2 cases);
in group 2, one comitant vein injury during pedicle
dissection (two cases). The bleeding was controlled
and injured vein clipped. The cases with VC injury
were deliberately included in follow-up group.
First day postoperatively, all animals resumed
ambulation and feeding habits, minimal functional
impairment was noticed for 1-2 days postoperatively.
Near the origin of LD muscle, small ecchymosis (two
cases) was noticed first day postoperatively that slightly
enlarged for the next 2 days; however, when donorsite
reopened at 1 week, there is no fresh bleeding at
inspection and no hematomas. (Fig. 7)
In five cases, non-infected seromas were found
and evacuated. All muscles were viable after 30 minutes
observation and after 1 week follow-up.
Muscles lengths ranged from 13/10 cm to 16/13
cm on the back table. (Fig. 8)
Figure 7. Ecchymosis at 1 week after LD endoscopic-assisted harvest.
Figure 8. Endoscopic-assisted harvested LD muscle free flap.
DISCUSSION
The LD is a workhorse for selected reconstructive
surgeries due to its versatility. It is successfully used,
either as a pedicled or free flap, in breast, chest wall,
spinal, head and neck, lower limb reconstruction and
scalp resurfacing. Large incisions make the muscle
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150 TMJ 2010, Vol. 60, No. 2 - 3
harvesting straightforward but leaves conspicuous
scars, decreasing patient satisfaction in the face of
otherwise excellent reconstructive results. 1-7
Since the early ‘90s, endoscopic-assisted
harvesting of LD muscle achieved shorter incisions
with less postoperative discomfort or pain, earlier
recovery from surgery and less expensive wound care;
edema, ecchymosis, seromas and infection rates were
not decreased in all studies. 8-30 The advantages have
encouraged surgeons to use the endoscopic method
but the reports are still scarce and have not gained the
same popularity within plastic surgery as it has in other
surgical specialties. The main hurdle is the additional
learning curve for endoscopic techniques; training
models and fewer opportunities when compared to
laparoscopy or arthroscopy. 39,40
The swine model of muscle myocutaneous LD was
described initially as an excellent model for research
in physiological, pathological and pharmacological
experiments. Later the similarities to human anatomy,
favorable position (quickly and easily elevated) and
large, accessible vascular pedicle made it an excellent
model for training of the surgical skills. This too has
been our experience. 31-37
The aim of this study was to evaluate the
endoscopic-assisted LD harvesting model in swine.
Two consecutive animal groups underwent the LD
harvesting as pedicled and free flap, respectively.
For all cases, each muscle was harvested through
single skin incision of 4-5 cm, adequate to comfortably
accommodate the instruments (endoscope, retractor,
forceps and electrocautery/scissor) and to retrieve the
muscle. 41 As Lin et al. advocate, if muscle size is smaller
than 20 cm, an additional incision is unnecessary. 17
Adherent fibrofatty tissue overlaying the muscle is
cut first, using electrocautery; if the undersurface is
dissected first, muscle contraction during outersurface
dissection would be too strong, increasing the chances
for tissue injury.
Anatomical and technical constraints need to be
overcome for successful operation. Rigid endoscopic
instruments accommodate poorly to the rigid and
convex chest wall. 12 Even if the instrument length
is adequate for the optical cavity length, the straight
instruments are not adapted to the three-dimensional
cavity requirements. Increased difficulty is encountered
in the areas most distant from the incision. 40,41 For
the first two cases, bleeding from intercostal artery
perforators was ineffectively addressed, also due to
inexperience in using irrigation-suction device; cases
were converted to classic harvest and excluded from
the study. For later cases, the use of long curved
electrocautery achieved better hemostasis and a 30

degree angled scope assisted vision over the thorax
convexity, where bleeding occurred. Systematic
steps to free the muscle must be followed: vertebral
aponeurosis, costal insertion and anterior margin;
otherwise muscle mass retracted towards the spine will
impair aponeurosis sectioning.
The longitudinal incision allowed access to distant
sites, but limited the access proximal to the pedicle.
Compared to humans, swine forelimb mobility is
anatomically limited, with impossible access to the
axilla without increasing the length of the incision.
(Fig. 9) Therefore, to maintain the skin incision to the
original size, group 2 underwent endoscopic dissection
of the thoraco-dorsal pedicle and muscle tendon. This
is different from reports in humans, where pedicle
dissection and tendon release are performed under
direct visual control. 8-30
Figure 9. Large incision for classic LD harvest.
The assistant is critical throughout the entire
operation. The same operating team developed the
gracilis endoscopic model, with the first author as
operator and four assistants randomly taking turns,
one for each case. Emory-type self-mounted retractor
was single-handedly maneuvered. Forceful retraction
was necessary, particularly near the muscle origin,
due to thick inelastic thoracic skin that increased the
tissue load on the retractor. The aponeurosis division
allowed progressive retractor withdrawal as dissection
advanced around the costal origin and the anterior
margin, reducing assistant fatigue. When group 2 was
initiated, assistant’s load increased, his free hand had
to constantly adapt forelimb position, in abduction
and cranial extension, opening the axilla virtual space
and allowing endoscopic dissection of the pedicle and
muscle tendon. Therefore surgeon-assistant, hand-eye
and left to right hand coordination, learned during
previous model training, were very helpful.
Group 2 differs from group 1 by the endoscopic
dissection and section of pedicle and muscle tendon
(free LD vs. pedicled LD). The performance in group
2 relies heavily on the experience accumulated during
group 1 phase. For both groups, the correlation of
operation time improvement to the number of cases
performed is approximated by linear regression, and
the process is rather monophasic. (Fig. 6) Conversely,
learning process of previous swine gracilis endoscopic
model had biphasic pattern, with a transition from
technique familiarization to skill mastering phase.
LD has no steep learning curve during the first cases:
familiarization phase for LD endoscopic harvesting
was achieved with previous model published
(gracilis). 37 The slightly steeper slope for group 1
shows that pedicled LD is faster, simpler and easier to
learn than free flap LD. Remarkably, group 2 maintain
similar linear trend, in spite of increased difficulty and
increased operating time.
Intraoperative accidents related to inadvertent
injury of one comitant vein, in early cases from each
group. For the first two cases, the pedicle position was
disregarded when operator introduced the retractor;
subsequent better visual control was assured. The last
two cases represent injury of one comitant vein, due
to inadequate evaluation of tissue elasticity. Team
brainstorming pointed out the pitfalls leading to the vein
injuries, and techniques introduced to prevent this. As a
result, further vein injuries were avoided. One comitant
vein proved sufficient for LD outflow, irrespective of
proximal or distal level of comitant vein injury.
With regard to the ecchymosis occurring in
two cases, no cause-effect could be established: no
accompanying seromas or hematomas were noted
and the comitant vein injury was non-contributory.
The initial ecchymosis appeared over the severed
IAP and spread as intercostal artery angiosome-type
pattern. Maximum intensity, along with small area
of skin necrosis, overlay the IAP. Porcine fixed-skin
has rudimentary panniculus carnosus and cutaneous
vascularization is tributary to the fasciocutaneous
perforators. 42 Therefore, we suspect the ecchymosis
occurrence tributary to skin vascularization pattern
rather than a complication or technical error. Seromas
were expected in the context of wide dissection and
no drainage was used.
Our study was not conceived to compare the
classic and endoscopic harvest in terms of technique
superiority; several clinical reports address this issue
competently and advocate the use of endoscopic
harvest for LD for known advantages. 8-30 Yet, the
operating times improve with each case, comparable
to operating times reported in clinical cases. Incision
length is considerably shorter and the results are good.
(Fig. 10) The pre-existing endoscopic facility made the
operation cost-effective.
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Nicolae Ghetu et al 151

Figure 10. Comparison between incisions of classic and endoscopic LD
harvest.
CONCLUSIONS
Endoscopic-assisted harvesting of the swine LD
muscle, as a pedicled or free flap, is a safe, reliable and
cost-effective technique. Previous familiarization with
endoscopic techniques makes the learning process
faster. The cohesive operating team yields steady
refinements of the operating skills, overcoming the
technical and anatomical constraints. This endoscopicassisted
harvesting of the swine LD muscle model is
an excellent learning model and will hopefully benefit
future clinical practice.
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