Delayed Bilateral DIEP flap Breast Reconstruction

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  •  Dr. Brown:
    • Gown – XL, XL Length
    • Gloves – 8 Indicator Glove, 7.5 Biogel Glove
  • Dr. Chandler:
    • Gown – L
    • Gloves – 5.5, 6.0 if 5.5 unavailable
  • Sean Kirby PA-C:
    • Gown – XL
    • Gloves – 7.5 Indicator Glove, 7 Nonlatex Glove
  • Pre-operative Medications (prescribed pre-0p)
    • Night before:
      • Scopolamine patch placed behind ear
      • Shower with Hibiclens for couple days before surgery 4% topical chlorhexidine soap.
    • At check in for surgery with a sip of water:
      • Tylenol 975mg PO x1
      • Gabapentin 600mg PO x1
      • Celebrex 400mg PO x1
    • Lovenox 40mg to be injected in preop prior to rolling to OR
  • Intra-operative Medications
    • Ancef 2 grams IV (ok if allergic to Penicillins).
    • Vancomycin 1g IV (if allergic to Ancef)
    • Infiltration Solution (PHARMACY TO PREPARE, IN PRE-OP ORDERS):
      • NS or LR 500 mL
      • Ropivicaine 300mg
      • Clonidine 0.3mg
      • Dexamethasone 4mg
    • Nitrobid ointment to rub on mastectomy skin flaps.  2 packs for each side.
    • Heparin 5000 units in 500mL normal saline (for microsurgery) – place in 10mL syringe with 24 angiocath tip
    • Papaverine 30mg/mL – 2mL in 3mL syringe – have in room but do not open
    • 2G if Vancomycin powder for abdominal closure
  • Post-operative Medications (Prescribed pre-op)
    • Tylenol 650mg PO q6 hours scheduled
    • Methocarbamol 1500mg PO q6 hours scheduled
    • Gabapentin 300mg PO PO q6 hours scheduled  (if not too expensive)
    • Cephalexin 500mg PO q6 hours scheduled for 4 doses starting after surgery
    • Celebrex 200mg PO BID scheduled (if not too expensive)
    • Pericolace 1 tab PO BID scheduled
    • Phenergan 25mg PO q8 hours PRN nausea
    • Oxycodone 5mg tabs, 1-3 tabs PO q4 hours PRN pain
    • Ibuprofen 600mg PO q6 hours scheduled, starting 48 hours after surgery
    • Aspirin
    • Lovenox
  • Anesthesia
    • Anesthesia choice
  • Patient Position
    • Supine, Able to sit up 90 degrees (make sure bed can do this)
  • Bed Attachments
    • Arm boards, Ulnar nerve pads, Kerlex
  • Patient Warming
    • Blanketrol, Arctic Sun, or underbody warmer
    • IV fluid warmer
  • DVT Prophylaxis
    • Bilateral SCDs in OR. ON and working BEFORE induction of anesthesia.
  • Foley Catheter
    • Yes – have tubing run down leg and secured in SCD
  • Instrument Sets
    • Major Plastic Set (DIEP Set)
    • Microsurgery Set
  • Surgical Packs
    • DIEP
  • Surgical Prep
    • Chloraprep x 5 – place in fluid warmer prior to use
  • Irrigation Solutions
    • Warmed Normal Saline
    • Sterile water in basin for washing instruments
    • Iodine/Antibiotic Solution:
      • Ancef 2g
      • Genamycin 160mg
      • 100mL of full strength 10% stock providone-iodine (This is PAINT not scrub)
      • Mixed into 1000cc Normal Saline
  • Blades
    • 10 x 3
  • Bovie
    • Short Protected ENT tip  x2
    • Long Protected ENT tip x 1
    • Set at coagulate 40 fulgurate /  cut 40 pure
    • Set other at 60/60
    • Will need two BOVIE and two BIPOLAR for case
  • Suture
    • 0 Prolene – largest taper needle x 2
    • 2-0 PDS Large taper x 10
    • 3-0 Monocryl Large cutting x 6
    • 3-0 v-Loc (absorbable) Long, Large Cutting x 4
    • 4-0 Plain Gut Large cutting (have in room, do not open)
    • 2-0 Nylon Large cutting x 4
    • 8-0 Nylon microsuture BV 130-5 – ETHICON ONLY, not Covidien
  • Drains
    • 10mm perforated flat JP drain, on trocar if available, 100mL bulb suction
  • Additional Supplies
    • Marking pen x 6
    • Paper Ruler
    • Freeman Retractor x 2
    • Lexsell Ronjour
    • Ventrio Mesh PAtch 11cm x 14 cm – TWO OF THEM
    • 18G Spinal needles and 60cc syringes for infiltration x 2
  • Dressing
    • Mastisol
    • Wide Long Steri strips
    • Bacitractin
    • Xeroform
    • Kerlex
    • Incisional wound vac – medium/large black or silver sponge
    • Adaptic x 5


Video of room set up on


PDF of Enhanced Recovery Article:




General Surgeon does Mastectomies – if not already done
Dr. Brown prepares abdominal flaps during mastectomies (DIEP FLAP HARVEST MAYO)
Sean verifies all equipment and supplies, does orders – until Mastectomies done
Sean exposes IMA vessels while Dr. Brown continues flap harvest (CHEST VESSEL EXPOSURE MAYO)
SPY mastectomy flaps and DIEP flaps on abdomen – if institution has SPY
Dr. Brown finishes IMA vessel dissections & calls for coupler sizes to be opened
Sean de-epitheliaizes abdominal flaps preserving some skin for nipple recon while Dr. Brown finishes IMAs
Sean and Dr. Brown take a 15 min break while Flap harvest mayo and Chest Vessel Mayos are converted into Abdomen Closing Mayo and Breast Closing Mayo
Dr. Brown does micro while Sean closes abdomen
SPY flaps after transfer
Dr. Brown and Sean inset breast flaps and close skin. Inject TissuGlu.
Dr. Brown may peform liposuction of flanks and remove dog ears.
The first two Mayos cannot share instruments (DIEP & CHEST VESSEL)
The last three Mayos cannot share instruments
Microscope in Room and on right side of patient but out of the way, drape
Arctic Sun stuck to back or underbody Bair Hugger
Chux under patient for easy clean up at end
IV Fluid Warmer
Saline irrigation warmer
Head padded with gel donut or foam.
Arms out, well padded with foam sleds, kerlex secured.
Heels padded. Strap around thighs.
Hips able to flex
Lower body Bair Hugger, mid thighs down
Foley with temp sensor
Trim pubs
Chloraprep chin to pubis, bed to bed
Laparoscopic drape with plastic bags
All suction and cords off BOTTOM (feet). Bovies at foot of bed.
Two Bovies 60/60 hot and 20/20 cold. Label handpeice on field.
Two Bipolars 20
Two Suctions
Rolling stool on each side for Dr. Brown
Pencil doppelr box hanging on IV pole for anesthesia to turn on/off, sterile pencils and cord, lube
Synovis Flow Coupler box on IV pole ready to be hooked up
Set up Flap Harvest Mayo, Chest Vessel Exposure Mayo, Microsurgery Mayo
Dr. Brown – Long XL gown, 8 indicators, 7.5 Biogels
Sean –
Papaverine 60mg/2mL available, do not open
Electrolube and sponge on field
Disposable Kirwan Bipolar Forceps, 0.5mm, Ref# 19-3002AU
Ben Clough (850) 293-9986
Short protected tip on Bovie (ENT tip)
Tebbetts double ended breast retractor
Double prong skin hooks
Adsons with teeth x2
Micro Debakey (Synovis)
6 sharp Weitlaners (2 small, 2 medium, 2 large)
4 penetrating towel clamps
0-Vicryl suture on largest needle available
4 Lonestar retractors on hemostats
Small and medium automatic clip-appliers
Freer Elevator
Stevens Tenotomies x2 (Eriem / Micrens PR846-R) [email protected]
Facelift scissors
Marking pen
2 sharp Freeman Rake Retractors
Army-Navy x2
Large Richardson
Suture Scissors (straight mayo)
10 blade
11 blade
Lap sponges
Skin stapler (wide ?35mm)
Right angle (medium size)
Disposable Kirwan Bipolar Forceps, 0.5mm, Ref# 19-3002AU
Martin’s Arm Retractor (on bed)
Large Richardson retractor
Sharp Weitlaners x2 one medium, one large
Paper Ruler, Marking Pen
Short protected tip on Bovie (ENT tip)
Micro Debakey (Synovis
Regular short Debakeys
0-Vicryl suture on largest needle available x2
Small and medium automatic clip-appliers
Freer Elevator
Stevens Tenotomies x2 (Eriem / Micrens PR846-R) [email protected]
0-PDS or Maxon on largest needle (not looped)
2-0 Nylon drain suture x2
Round 15 blake drain with Trocar x2
Right angle (medium size)
Nylon Suture 8-0 BV 130-5
6 Weck Cell sponges (eye spears)
10mL syringe of hep saline on ~22G angiocath x2 (10,000 units in 500mL)
Rizutti (clamp applying forceps) Micro instrument Rep
Disposable bulldog vessel clamp – single (green) x1
<[email protected]>
Disposable bulldog vessel clamp – double (yellow) x1
Synovis Venous coupling device itself
Coupler measuring device (stick with knobs)
Couplers of varying sizes off field but available 2mm-3.5mm
Curved micro needle driver S&T B-18-8.2 x2
Curved micro scissors x2
Straight micro scissors
curved dilators
Striaght jewlers forceps x2
Straight platform forceps x2
Micro Debakey’s x2
Synovis Flow Coupler on back table

<[email protected]>
Merocel instrument sponge
Micro background
Quadruiple Antibiotic 1L saline + Vanc 2g, Ancef 2g + Baci 100,000 + Gent 160mg
5% Betatdine (10% paint with equal volume sterile water)
Ventrio Medium Oval Mesh 11x14cm x2. Soaking in Quadruple ABX solution.
#1 Stratafix PDS on CTX x3
0-PDS or larger on large taper needle. not looped x3.
0- Vicryl on large needle
2-0 PDS
3-0 Monocryl
Skin stapler (wide ?35mm)
15 Blake drain with Trocar x2. Hemavac suction.
2-0 Nylon x2
Needle Drivers x2
Adsons with teeth 2-1 with platform for grabbing needle x2
Suture Scissors x2
Marking Pen
11-blade for umbilical inset
Penetrating towel clamps x2
0-Vicryl on big needle
3-0 monocryl
3-0 monocryl V-lock or stratafix or quill, LONG, cutting needle
2-0 PDS
5-0 dyed nylon or prolene
Skin stapler (wide ?35mm)
Needle Drivers x2
Adsons with teeth 2-1 with platform for grabbing needle x2
Suture Scissors x2
Marking Pen
Facelift scissors
Penetrating towel clamps x2
Long skinny breast retractor or Richardson
Abdominal binder, tailored to not put pressure on breasts
Bra to go home with patient (not on body)
Fluffed Kerlex
Aspirin 300mg PR



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