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We greatly thank Drs. van Wingerden and Totte for their interest in our article. We completely agree with their opinion that it is necessary to avoid an unplanned encounter with a vessel. The rectus muscle and the epigastric vessels (EGVs) should be preserved not only to avoid hemorrhagic complications but also to allow the potential for future reconstruction.
Accidental injury to abdominal wall vessels occurs in 0.2–2% of laparoscopic procedures [1]. Saber et al. [2] reported mapping of the EGVs based on 100 abdominal and pelvic computed tomography scans. They concluded that the EGVs usually are located in the area 4–8 cm from the midline and that avoiding the area determines the safe zone of entry to the anterior abdominal wall without risk of injury to the EGVs. In the upper abdomen, moreover, the EGVs are located in a narrower area 4–6 cm from the midline [1].
According to Saber’s analysis, our entry point of the port in the right upper quadrant at the level of a wedge of the rectus muscle [2] was away from the dangerous zone, so the possibility of injury to the EGVs may have been extremely low. We also agree that direct injury to the rectus muscle, however small the risk, should be avoided, and that the port should be sited slightly lateral to the wedge of the rectus muscle.
References
Zaha H, Inamine S (2010) Laparoscopically harvested omental flap: results for 96 patients. Surg Endosc 24(1):103–107
Saber AA, Meslemani AM, Davis R, Pimentel R (2004) Safety zones for anterior abdominal wall entry during laparoscopy: a CT scan mapping of epigastric vessels. Ann Surg 239:182–185
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Hisamitsu Zaha and Susumu Inamine have no conflicts of interest or financial ties to disclose.
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Zaha, H., Inamine, S. Preservation of the rectus muscle during laparoscopic harvesting of the omental flap. Surg Endosc 24, 2073 (2010). https://doi.org/10.1007/s00464-010-0934-0
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DOI: https://doi.org/10.1007/s00464-010-0934-0