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The Oberlin Procedure for Restoration of Elbow Flexion with the da Vinci Robot: Four Cases
Abstract
Unlabelled:
Robotics allows up to 40× visual magnification and 10× magnification of the surgeon's movements, and eliminates physiologic tremors. These properties should allow the development of mini-invasive limb surgery, especially of the brachial plexus. The purpose of this work was to test the feasibility of the restoration of elbow flexion according to the technique of Oberlin using a da Vinci robot. The authors' series included four patients (average age, 31 years) presenting with elbow flexion paralysis. They were operated on 8 months after injury using a da Vinci S robot. In three patients, the open technique (technique 1) was used, and the mini-invasive approach (technique 2) was used for the last one. Strength of elbow flexion was measured. After 1-year follow-up, all of the patients had recovered elbow flexion. No sensory or motor deficit was found in the ulnar nerve territory. There was no difficulty with technique 1; technique 2, however, required a conversion to technique 1 because of difficulty visualizing the operative field. The results of the authors' series show the feasibility of the robot-assisted technique for the Oberlin procedure. The lack of sensory feedback was not an issue. The development of specific retractors and instruments should improve the mini-invasive technique.
Clinical question/level of evidence:
Therapeutic, V.
... 3 Recently, surgical robotic systems have been used to perform microsurgery. [4][5][6] Surgical robots have certain properties that make them well suited to microsurgery, for example, they possess 3-dimensional vision, which can be magnified up to 25 times; their movements are up to 5 times more precise than those of surgeons; they possess 7 degrees of wrist articulation; they do not suffer from physiologic tremors; and they can achieve ergonomic surgical positions. 7 The possibility of robotic intercostal nerve harvesting has already been demonstrated in a pig model. ...
... However, we had no difficulty with this as reported in previous reports. 6 After the operation, there were no respiratory complications and no pain at the nerve-harvesting site. The patient could walk by himself from the day after the operation. ...
Recently, surgical robotic systems have been used to perform microsurgery. Surgical robots have certain properties that make them well suited to microsurgery; for example, they possess 3-dimensional vision, which can be magnified up to 25 times; their movements are up to 5 times more precise than those of surgeons; they possess 7 degrees of wrist articulation; they do not suffer from physiologic tremors; and they can achieve ergonomic surgical positions. The purpose of this study was to report the feasibility of robot-assisted intercostal nerve harvesting in a clinical case. A healthy 57-year-old man suffered a left plexus injury. On diagnosis of clavicular brachial plexus injury, the intercostal nerve transfer to the muscular cutaneous nerve to restore elbow flexion was performed with Da Vinci Xi robot. The harvesting of intercostal nerves using the conventional open approach involves significant surgical exposure, which can lead to perioperative complications. Robot-assisted intercostal nerve harvesting might reduce postoperative pain, shorten patients' hospital stays, lower complication rates, and produce better quality-of-life outcomes. There are many issues to be solved when performing robotic surgery on peripheral nerves in Japan. However, robot-assisted intercostal nerve harvesting was a feasible surgical procedure, and patient satisfaction was high.
... Another area of use of the robotic system is brachial plexus injuries [11,12]. Naito et al. [11] performed a robotic-assisted Oberlin procedure to provide elbow flexion. ...
... Another area of use of the robotic system is brachial plexus injuries [11,12]. Naito et al. [11] performed a robotic-assisted Oberlin procedure to provide elbow flexion. Myamoto et al. [12] performed nerve transfer to the deltoid muscle using the nerve to the long head of the triceps with a da Vinci robot in six cases. ...
This study describes the robotic harvesting of a free omental flap. The patient was a 58-year-old man who had undergone several previous operations due to osteomyelitis caused by trauma. There was a non-healing wound and purulent discharge in the distal pretibial region. The flap was harvested based on the right gastroepiploic artery using robotic facilities only. The flap was then transferred to the debrided defect in the pretibial region. Anastomoses were performed between the posterior tibial vessels and the pedicle of the flap. A split thickness skin graft was used to cover the omental flap. The operation lasted 2.5 h in total, including flap harvesting, microvascular anastomoses, inset and skin grafting. The postoperative period was uneventful and the patient was discharged on the 12th day postoperatively. The reliability of the technique is discussed in this report, together with a brief review of the use of robot surgery in reconstructive surgery in the literature.
... A total of eight preclinical studies and five clinical studies were identified, with the majority investigating the role of robotics in brachial plexus work ( Table 3) (34)(35)(36)(37)(38)(39)(40)(41)(42)(43)(44)(45)(46). Epineural nerve repair using robotic assistance has been shown to be technically feasible in animal models, with the benefits of reduced physiological tremor and improved vision of the surgical field noted (35). ...
... In those clinical studies identified, robotic assistance was successfully used to repair a brachial plexus (45), repair the sympathetic chain to treat Horner's syndrome (42), perform a thoracic sympathectomy for palmar hyperhidrosis (43), repair a peripheral nerve following tumor excision (46), and undertake an Oberlin procedure (44). Table 4 illustrates those articles relating to procedures in the upper limb, with three preclinical (47)(48)(49) and one clinical study identified (50). ...
Background
The use of robots in surgery has become commonplace in many specialties. In this systematic review, we report on the current uses of robotics in plastic and reconstructive surgery and looks to future roles for robotics in this arena.MethodsA systematic literature search of Medline, EMBASE, and Scopus was performed using appropriate search terms in order to identify all applications of robot-assistance in plastic and reconstructive surgery. All articles were reviewed by two authors and a qualitative synthesis performed of those articles that met the inclusion criteria. The systematic review and results were conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta Analysis (PRISMA) guidelines.ResultsA total of 7,904 articles were identified for title and abstract review. Sixty-eight studies met the inclusion criteria. Robotic assistance in plastic and reconstructive surgery is still in its infancy, with areas such as trans-oral robotic surgery and microvascular procedures the dominant areas of interest currently. A number of benefits have been shown over conventional open surgery, such as improved access and greater dexterity; however, these must be balanced against disadvantages such as the lack of haptic feedback and cost implications.Conclusion
The feasibility of robotic plastic surgery has been demonstrated in several specific indications. As technology, knowledge, and skills in this area improve, these techniques have the potential to contribute positively to patient and provider experience and outcomes.
... roboticmicrosurgeons.org) have reported their experiences in a variety of surgical fields. Some authors reported their experience of robotic microsurgical repair of nerve gaps [2][3][4] and resection of tumours [5], anastomosis of small vessels [6], and pig limb replantation [7] in open procedures. ...
... Concerning specific retractors, contrary to laparoscopic surgery where there is a natural cavity, the creation of an artificial space is mandatory in upper limb surgery. The cause of the failure was often attributable to inadequate carbon dioxide insufflation to compensate for the leakage through the incisions [3]. Certain authors propose the use of balloons to create the space [15], but the volume needed for this is incompatible with upper limb nerve surgery, which necessitates dissection of the nerve over several centimeters. ...
Robotic assisted microsurgery applications have expanded quickly and established in a variety of surgical fields. Some authors already reported their experience of robotic assisted microsurgical procedures. Current interest of robotic assisted microsurgery for microsurgical reconstruction is shifted to endoscopic telemicrosurgery because its small size of incisions, cosmetic advantage, less invasive surgical technics, decrease of internal scar tissues, short duration of hospitalization and cost effectiveness. We present here three clinical cases of endoscopic robotic assisted microsurgery.This study described our early experiences with the endoscopic robotic assisted microsurgical reconstruction. We also performed a review to ascertain what has been achieved in the field of endoscopic robotic assisted microsurgery so far and what could be the future applications.
... From this experimental result, we moved to our first clinical trial to test the feasibility of the restoration of elbow flexion by Oberlin procedure using the DaVinci robot. [4] All patients recovered elbow flexion and good functional results despite a slight difficulty in visualizing the operative field by an endoscopic approach. The development of specific retractors and instruments will probably ease these challenges. ...
... [8] Mantovani et al. [9,10] developed an effective minimally invasive approach to brachial plexus injury and showed the feasibility of using telerobotic manipulation to perform microsurgical root-to-root nerve repair of the brachial plexus with an endoscopic approach. In a cadaveric and experimental study, we already accomplished neurotization of the spinal accessory nerve to the motor branch of the musculocutaneous nerve, neurotization of the long portion of the triceps to the anterior branch of the axillary nerve, [11] neurotization of the motor nerve fascicle of the ulnar nerve on the musculocutaneous nerve, [4] neurolysis of the long thoracic nerve, and neurolysis of the intercostal nerve. [12] A series of eight clinical cases of nerve damage around the shoulder girdle were operated on using the DaVinci ® robot. ...
Microsurgery comprises a variety of surgical procedures such as neurovascular anastomoses, performed
under optical magnification and with fine instrumentation. While refinements have been made since
its advent in the 1960s, robotics offers the potential for major technological advancement. Endoscopic
telemicrosurgery is minimally invasive, robotically‑assisted microsurgery. This technique removes
some limitations of conventional microsurgery and enhances visual and manual dexterity. Vision is
enhanced through greater magnification, three‑dimensionality, and functionalization, all through an
endoscopic view. Manual dexterity is improved by suppression of physiological tremor and tremor
filtration, while permitting useful enhancement of movement amplitudes and tactile feedback forces.
Furthermore, better endoscopic ergonomics, new hand tools and the ability for multi‑manual and
remote work, confer a distinct advantage. Endoscopic telemicrosurgery is already in clinical use. Some
of the advantages above are incorporated into the DaVinci® robot, that is, used in brachial plexus surgery.
Conventional brachial plexus surgery requires large incisions for exploration and neurotization, with
its attending risks of unsightly scars, prolonged hospital stay, sepsis, and perineural adhesions that
interfere with nerve regrowth. Endoscopic telemicrosurgery limits the incisions and these risks, with
minimal compromise. Endoscopic telemicrosurgery, through the amplification of human capabilities
may pave the way for a major advancement in the microsurgical field.
... Naito et al. presented the implementation of an Oberlin procedure using the da Vinci robotic system [26] in three adult patients. They performed an open approach to the nerves in three cases, in one case they attempted an endoscopic, minimal invasive approach to the nerves. ...
The technology of microsurgical robotic systems has shown potential benefit during the last decade for a variety of microsurgical procedures, such as vascular anastomoses, lymphatic anastomoses or nerve coaptation. At the same time, peripheral nerve surgery has produced ever more sophisticated nerve transfers in which the smallest nerve structures are connected to each other. Following obstetric brachial plexus injuries, nerve reconstruction surgery is often required in the first few years of life in order to improve the function of the affected arm, including nerve transfers to denervated muscles, which enable reinnervation of target muscles. In pediatric patients, these donor-nerve structures are even smaller than in adults, which further increases the demands to the microsurgeon. In this publication, we show the possible applications, capabilities and limitations of a dedicated microsurgical robotic system for nerve transfers in pediatric patients.
... 7 Efforts have already been made to use the DaVinci system in microvascular surgery 8 and peripheral nerve surgery, the latter by using it for minimally invasive exploration and reconstruction of the brachial plexus 9,10 and nerve transfers. 11,12 However, significant limitations were observed, including poor visualization with lower magnification than conventional microscopes and nonmicrosurgical robotic instruments. In an extensive review by Chen et al, 13 robotic assisted microsurgery was analyzed, evaluating 19 studies, including brachial plexus reconstruction, different other peripheral nerve operations, animal studies, and cadaveric studies. ...
Microsurgical demands in peripheral nerve surgery are increasing. Because of the development of multiple simultaneous selective nerve transfers, the transposition of very small nerves and even single fascicles has evolved. Coaptation of these increasingly smaller structures require high skills in microsurgical techniques. In addition, the surgical situs often has very limited access and is difficult to reach with conventional microsurgical options. Robot technology, the Symani Surgical System (Medical Microinstruments, S.p.A, Calci, Pisa, Italy), was used for epineural coaptation of three donor nerves (intercostal nerves 4–6) to the long thoracic nerve and the thoracodorsal nerve as recipient nerves in a patient with brachial plexus palsy. The coaptations could be carried out successfully with the microsurgical robot technology. In combination with a high-magnification (up to 26×) 3D-exoscope, the epineural sutures could be placed very precisely and accurately. Using this new microsurgical robotic system, successful coaptation of very small nerve structures is possible. This opens possibilities for the microsurgeon to carry out even finer, more targeted and more complex nerve transfers, including procedures in anatomical regions that are difficult to reach.
... In 2012, Liverneaux and colleagues introduced four cases performing Oberlin's procedure (nerve transfer of branch of ulnar nerve to biceps motor branch) for elbow flexion reconstruction with the robotic da Vinci S (Intuitive Surgical, Inc., Sunnyvale, CA). 28 Three of them were opened by traditional incision and another one underwent minimally invasive technique with four skin incision approaches (three for robotic arms and one for the camera), which was eventually converted to open technique due to the insufflation difficulty. All four patients had good recovery of elbow flexion after 12 months scoring a grade of M3þ (British Medical Research Council Scale). ...
Background Robotic-assisted techniques are a tremendous revolution in modern surgery, and the advantages and indications were well discussed in different specialties. However, the use of robotic technique in plastic and reconstructive surgery is still very limited, especially in the field of peripheral nerve reconstruction. This study aims to identify current clinical applications for peripheral nerve reconstruction, and to evaluate the advantages and disadvantages to establish potential uses in the future.
Methods A review was conducted in the literatures from PubMed focusing on currently published robotic peripheral nerve intervention techniques. Eligible studies included related animal model, cadaveric and human studies. Reviews on robotic microsurgical technique unrelated to peripheral nerve intervention and non-English articles were excluded. The differences of wound assessment and nerve management between robotic-assisted and conventional approach were compared.
Results Total 19 studies including preclinical experimental researches and clinical reports were listed and classified into brachial plexus reconstruction, peripheral nerve tumors management, peripheral nerve decompression or repair, peripheral nerve harvesting, and sympathetic trunk reconstruction. There were three animal studies, four cadaveric studies, eight clinical series, and four studies demonstrating clinical, animal, or cadaveric studies simultaneously. In total 53 clinical cases, only 20 (37.7%) cases were successfully approached with minimal invasive and intervened robotically; 17 (32.1%) cases underwent conventional approach and the nerves were intervened robotically; 12 (22.6%) cases converted to open approach but still intervened the nerve by robot; and 4 (7.5%) cases failed to approach robotically and converted to open surgery entirely.
Conclusion Robotic-assisted surgery is still in the early stage in peripheral nerve surgery. We believe the use of the robotic system in this field will develop to become popular in the future, especially in the fields that need cooperation with other specialties to provide the solutions for challenging circumstances.
... A further manual reference check of these articles was performed to identify any additional studies for inclusion. Finally, 52 studies included in the analysis Bertelli & Ghizoni, 2008;Bertelli & Ghizoni, 2009;Bertelli & Ghizoni, 2010;Bhandari et al., 2009;Birch, Dunkerton, Bonney, & Jamieson, 1988;Brandt & Mackinnon, 1993;Cho et al., 2014;Cho et al., 2015;Coulet, Boretto, Lazerges, & Chammas, 2010;Dai, Lin, Han, & Zhoug, 1990;Estrella, 2011;Fogarty & Brennen, 2002;Franciosi, Modestti, & Mueller, 1998;Friedman et al., 1990;Gu, Cai, Xu, Peng, & Chen, 2003;Johnsen & Wolfe, 2016;Kakinoki et al., 2010;Leechavengvongs et al., 1998;Liu, Lao, & Zhao, 2015;Liu, Zhuang, Yu, Xiong, & Lao, 2018;Liverneaux et al., 2006;Malessy, de Ruiter, de Boer, & Thomeer, 2004;Malessy, van Duinen, Feirabend, & Thomeer, 1999;Maricq et al., 2014;Matsuyama, Okuchi, Akahane, Inada, & Murao, 2002;Merrell et al., 2001;Moses, Dai, Lowe, Chu, & Protopsaltis, 2018;Naito, Facca, Lequint, & Liverneaux, 2012;Nath, Lyons, & Bietz, 2006;Novak et al., 2002;Oberlin et al., 1994;Ogino & Naito, 1995;Potter & Ferris, 2017;Ray, Pet, Yee, & Mackinnon, 2011;Rezende et al., 2012;Richardson, 1997;Ruch, Friedman, & Nunley, 1995;Sedel, 1982;Shahriar-Kamrani, Jafari, & Guiti, 2005;Socolovsky, Martins, Di Masi, & Siqueira, 2012;Stiasny & Birkeland, 2015;Suzuki et al., 2011;Teboul, Kakkar, Ameur, Beaulieu, & Oberlin, 2004;Tu et al., 2014;Venkatramani, Bhardwaj, Faruquee, & Sabapathy, 2008;Wang, Rancy, Lee, Feinberg, & Wolfe, 2016;Xiao et al., 2014;Xu et al., 2008;Xu, Xu, & Gu, 2005;Yin et al., 2012;Zheng, Xu, Qiu, Xu, & Gu, 2010). Data extraction was performed from all of the papers ultimately selected as eligible for review. ...
Introduction
Posttraumatic brachial plexus (BP) palsy was used to be treated by reconstruction with nerve grafts. For the last two decades, nerve transfers have gained popularity and believed to be more effective than nerve grafting. The aim of this systematic review was to compare elbow flexion restoration with nerve transfers or nerve grafting after traumatic BP injury.
Methods
PRISMA‐IPD structure was used for 52 studies included. Patients were allocated as C5‐C6 (n = 285), C5‐C6‐C7 (n = 150), and total BP injury (n = 245) groups. In each group, two treatment modalities were compared, and effects of age and preoperative interval were analyzed.
Results
In C5‐C6 injuries, 93.1% of nerve transfer patients achieved elbow flexion force ≥M3, which was significantly better when compared to 69.2% of nerve graft patients (p < 0.001). For improved outcomes of nerve transfer patients, shorter preoperative interval was a significant factor in all injury patterns (p < 0.001 for C5‐C6 injuries and total BP injuries, p = 0.018 for C5‐C6‐C7 injuries), and young age was a significant factor in total BP injury pattern (p = 0.022).
Conclusions
Our analyses showed that nerve transfers appear superior to nerve graftings especially in patients with a C5‐C6 injury. Unnecessary delays in surgery must be prevented, and younger patients may have more chance for better recovery.
Level of evidence
Level II.
... No sensory or motor deficits were found in the ulnar nerve territory. [37] In another series of six patients with total deltoid muscle paralysis, a da Vinci-S robot was used to perform the Somsak procedure. In two cases, an endoscopic procedure was tried under carbon dioxide insufflation; however, as with the Oberlin procedure, the conversion to an open technique was needed. ...
... Four patients with elbow flexion paralysis were treated through a modified Oberlin procedure [42]. One 11 sensory deficit. ...
Introduction: This systematic review aims to study the feasibility, procedural, approaches, outcomes and complications of robot-assisted plastic and reconstructive surgery in patients and models.
Method: A systematic review was performed. Medline, Web of Science, Scopus, and Cochrane Library databases were searched. Articles investigating usage of surgeon-controlled robotic technology during plastic and reconstructive surgeries without manual intervention were eligible.
Results: Forty-one articles were included: 15 case series and 13 case reports, 8 cohort studies, 3 reviews and two surveys. Cohort size was 482, including: 426 patients (mean age: 54.9 years), 27 cadavers, 6 animal models, and 23 survey participants. All studies used the Da Vinci surgical system. The commonest procedure was transoral tumour resection. The commonest indication for reconstruction was head and neck squamous cell carcinoma (56%). The most frequently used flap was local musculo-mucosal (45%). Seventy-nine complications were reported.
Conclusions: Robot-assisted plastic and reconstructive surgery provides clinical outcomes comparable to conventional techniques. Advantages include reported improved cosmesis, functional outcomes and greater surgeon comfort. Disadvantages included longer operating and set-up times, a learning curve, breaking of microneedles, high monetary costs and authors consistently recommended improved end-effectors. All authors were optimistic about the use of robotics in plastic and reconstructive surgery.
... The Oberlin procedure for restoration of elbow flexion with the da Vinci robot: four cases 5) Our series included four patients presenting with elbow flexion paralysis. They underwent surgery at an average of 8 months after injury performed by the same surgeon under general anesthesia in supine position. ...
Telemicrosurgery applications have expanded quickly since the 1990s. The development of robotics has allowed a glimpse into new perspectives in nerve microsurgery. Minimally invasive surgery has quickly become the first therapeutic option in many operative indications, reducing postoperative complications and increasing patient comfort. Surgical robotics already proved useful, leading to numerous enhancements of the technique. We will introduce you how to make telemicrosurgery of the brachial plexus surgery with da Vinci robot in this review.
In Oberlin technique, our results demonstrate the feasibility of the robot-assisted surgery. The absence of sensory feedback was not a problem. The development of specific retractors should improve the mini-invasive technique.
In brachial plexus surgery, mini-invasive robot-assisted brachial plexus surgery has the double advantage of better cosmesis and improved functional outcome by decreased scarring. It was difficult to confirm with absolute certainty without electrical stimulation that the nerve identified and biopsied was the superior trunk of the brachial plexus. We had no other difficulties with this procedure. The workspace was perfectly maintained by low-pressure insufflations of CO2.
In telemicrosurgery, we think that there are many requiring ingenuity. More animal research and clinical study will be needed to develop the field of telemicrosurgery. We believe that Juntendo University will be able to do it and have to do it!!
Traditional open surgery for treating peripheral nerve disorders often leads to considerable trauma, scarring, and complications. However, with the ongoing advancements in microsurgical techniques, robotic-assisted minimally invasive surgery has emerged as a promising approach in the field of peripheral nerve disorder treatment. It combines innovative access techniques, such as the creation of artificial subcutaneous cavities, with telemanipulated instruments, enabling highly precise neurolysis, suturing, and grafting. Through incisions of less than 1 cm and enhanced three-dimensional visualization facilitated by CO ² insufflation, these procedures ensure superior visibility while minimizing tissue trauma. The clinical applications of this technology are diverse. For instance, neurolysis of the lateral cutaneous nerve of the thigh has shown promising results in the treatment of meralgia paresthetica, while experiments on the median nerve and ulnar nerve transposition highlight its potential for complex interventions. Techniques such as contralateral C7 root transfer or endoscopic repair of the brachial plexus further demonstrate that robotics can address the challenges of highly demanding pathologies, offering superior aesthetic and functional outcomes. Despite these advances, technological challenges remain, particularly in creating stable operative spaces and managing CO ² leakage. Additionally, the high cost of robotic systems limits their accessibility. To validate and generalize these techniques, large-scale clinical studies are needed. Furthermore, innovations such as augmented reality and artificial intelligence could further optimize these approaches. In conclusion, robot-assisted surgery of peripheral nerves provides significant benefits in terms of precision, safety, and aesthetic outcomes. With continued developments, it has the potential to redefine the standards of nerve surgery and transform the management of complex nerve lesions.
Background
Nerve reconstruction following brachial plexus injury (BPI) is a time-sensitive procedure, and surgical delay may negatively impact muscle reinnervation and outcomes. This study investigated the impact of surgical timing on elbow flexion strength in patients with BPI undergoing nerve transfer to restore elbow flexion.
Methods
Following PRISMA guidelines, MEDLINE, Embase, and the Cochrane Library databases were systematically searched. English-language studies investigating the single fascicular transfer (SFT) or double fascicular transfer (DFT) to restore elbow flexion in BPI were included. Data were analyzed to identify the predictors of elbow flexion strength: surgery timing, age, injury level, and SFT versus DFT.
Results
The literature search identified 1051 articles. Studies (n = 31) reporting data of individual patients who underwent SFT (n = 341) or DFT (n = 67) were included; the mean age was 29.6 ± 11.2 years, time from injury to surgery was 6.5 ± 5.0 months, and follow-up was 27.1 ± 24.3 months. Good elbow flexion strength was found: Medical Research Council grade greater than or equal to 3 in 352 (86.3%) and Medical Research Council grade greater than or equal to 4 in 288 (70.6%). In the adjusted analysis, poorer motor recovery was associated with increased age ( P = 0.02), surgical delay ( P < 0.0001), C5-7 injuries ( P < 0.01), and pan-plexus injuries ( P < 0.0001). A 32% reduction in the odds of favorable motor recovery was observed with a 3-month delay to surgery. Patients who had a nerve transfer 6 months or earlier from injury had 2.4 times the odds of favorable motor recovery ( P < 0.001).
Conclusions
SFT and DFT provide excellent elbow flexion strength in the majority of patients. Following nerve transfers in individuals with BPI, poorer motor recovery was observed with each 3-month delay to surgery.
Background
Robotic assisted surgery (RAS) has seen significant advancement in many surgical specialties, although the application of robotics in plastic and reconstructive surgery remains to be widely established. This systematic review aims to assess the role of RAS in plastic and reconstructive surgery.
Methods
The review protocol was published and registered a priori as CRD42024507420. A comprehensive electronic search for relevant studies was performed in MEDLINE, Embase and Google scholar databases.
Results
Overall, 132 studies were initially identified, of which, 44 studies satisfied the eligibility criteria with a cumulative total of 239 patients. RAS demonstrated a high degree of procedural success and anastomotic patency in microvascular procedures. There was no significant difference in periprocedural adverse events between robotic and manual procedures.
Conclusion
RAS can be feasibly implemented in plastic and reconstructive surgery with a good efficacy and safety profile, particularly for microsurgical anastomosis and trans‐oral surgery.
Microsurgery, developed in the 1960s from experimental work in animals, has not undergone technological evolution until today. Robotics could lead to a major technological leap for two main reasons, the reduction of the size of the incisions thanks to the endoscopy and the improvement of the surgical act by the reduction of the movements.
Objectives:
Double fascicular transfer is argued to result in improved elbow flexion compared to the traditional ulnar fascicular transfer because it reinnervates both the biceps and the brachialis. This study seeks to determine if double fascicular transfer should be preferred over ulnar fascicular transfer to restore elbow flexion in patients with upper trunk brachial plexus injuries (BPI) by analyzing the current database of literature on the topic.
Methods:
A systematic review was conducted according to PRISMA guidelines. Inclusion criteria were studies reporting Medical Research Council (MRC) scores on individual patients undergoing ulnar fascicular transfer and double fascicular transfer (ulnar and median nerve fascicle donors). Patients were excluded if: age < 18 years old and follow-up <12 months. Demographics obtained include age, sex, extent of injury (C5-C6/C5-C7), preoperative interval, procedure type, and follow-up time. Outcomes included absolute MRC score and ability to achieve MRC score ≥3 and ≥4. Univariate and multivariate regression analyses were completed to evaluate predictors of postoperative outcomes.
Results:
Eighteen studies (176 patients) were included for pooled analysis. Patients that underwent double fascicular transfer had a higher percentage of patients attain a MRC score ≥ 4 compared to ulnar fascicular transfer subjects (83.0% vs. 63.3%, p = .013). Double fascicular transfer was a predictor of achieving high MRC scores (OR = 2.829, p = .015). Multivariate analysis showed that procedure type was the only near significant predictor of ability to obtain MRC ≥4 (OR: 2.338, p = .054).
Conclusions:
This analysis demonstrates that double fascicular transfer is associated with superior postoperative outcomes and should be performed for restoring elbow flexion.
Background: Elbow flexion after upper brachial plexus injury may be restored by a nerve transfer from the ulnar nerve to the biceps motor branch with an optional nerve transfer from the median nerve to the brachialis motor branch (single and double fascicular nerve transfer). This meta-analysis assesses the effectiveness of both techniques and the added value of additional reinnervation of the brachialis muscle.
Methods: Comprehensive searches were performed identifying studies concerning restoration of elbow flexion through single and double fascicular nerve transfers. Only C5-C6 lesion patients were included in quantitative analysis to prevent confounding by indication. Primary outcome was the proportion of patients reaching British Medical Research Council (BMRC) elbow flexion grade ≥ 3. Meta-analysis was performed with random effect models (REM).
Results: A total of 35 studies were included (n=688). In quantitative analysis 29 studies were included (n=341). After single fascicular nerve transfer 190/207 patients (REM: 95.6%; 95%CI: 92.9-98.2) and after double fascicular nerve transfer 128/134 patients reached MRC≥3 (REM: 97.5%; 95%CI: 95.0-100) (P=0.301). Significantly more double nerve transfer patients reached MRC≥4 if pre-operative delay was ≤ 6 months (84/101 vs. 49/51; p=0.035).
Conclusion: Additional reinnervation of the brachialis muscle did not result in a significantly more patients reaching MRC≥3 elbow flexion. Double fascicular nerve transfer may result in more patients reaching MRC≥4 in patients with a pre-operative delay under 6 months. The median nerve may be preserved or used for another nerve transfer without substantially impairing elbow flexion restoration.
Microsurgery, developed in the 1960s from experimental work in animals, has not undergone technological evolution until today. Robotics could lead to a major technological leap for two main reasons: the reduction of the size of the incisions thanks to the endoscopy and the improvement of the surgical act by the reduction of the movements.
Background:
Robotic surgical systems provide a clear, magnified 3-dimensional visualization as well as precise, stable instrumental movement, thereby minimizing technical difficulties that may be encountered in the surgical treatment of oropharyngeal tumors. This study assessed the outcomes of robotic-assisted free flap oropharyngeal reconstruction compared with those of conventional free flap reconstruction.
Materials and methods:
A retrospective review of 47 patients who underwent reconstructive operations using a free radial forearm fasciocutaneous flap for oropharyngeal defects was conducted over a 20-month period (May 2013-December 2014). Complications were evaluated for a robot-assisted reconstruction group and a conventional reconstruction group; postoperative complication rates and revision rates were further evaluated. The Functional Intraoral Glasgow Scale (FIGS) was adopted for functional outcome assessment.
Results:
This study recruited 47 people who underwent reconstructive operations using a free radial forearm fasciocutaneous flap for oropharyngeal defects (14 robot-assisted and 33 conventional reconstructions). The mean postoperative FIGS score was 10.29 ± 2.02 in the robot-assisted group (P = 0.010) and 8.42 ± 2.29 in the conventional group at 1 month postoperatively. The mean postoperative FIGS score was 12.57 ± 1.91 in the robot-assisted group (P = 0.005) and 9.91 ± 3.09 in the conventional group at 3 months postoperatively. Complication rates between the robot-assisted and conventional groups were similar for flap failure (P = 0.531), partial necrosis, wound infection, hematoma or seroma formation (P = 0.893), wound dehiscence, and fistula formation (P = 0.515). The number of flap revision operations requiring additional surgery (P = 0.627) was comparable between the cohorts.
Conclusions:
There is no significant difference in complications or revision rates between the robot-assisted and conventional oropharyngeal reconstructions. The functional postoperative outcomes of robot-assisted reconstructions are superior to those of conventional reconstructions. Robotic surgical systems provide a safe option with optimal postoperative oral function for the free flap reconstruction of oropharyngeal defects without lip or mandible splitting.
Robotic surgery has revolutionized minimally invasive surgery. Owing to its unique features and key advantages, robotic surgery is being used for complex cases across surgical specialties. It has been introduced into reconstructive surgery, and is being applied in microsurgery. Robotic surgery combines properties of conventional microsurgery, endoscopic surgery, and telesurgery. It holds great promise in expanding the boundaries of reconstructive microsurgery. However, there are constraints that limit its widespread use. We present the different clinical applications of robotic microsurgery, highlighting its advantages over conventional microsurgery, and outlining the main limitations that might prevent its widespread use.
The primary goal of the surgical treatment of upper brachial plexus injuries is to restore active elbow flexion. Accordingly, Oberlin's transfer has been frequently performed since 1994 and has influenced the development of other nerve transfers. However, the window of opportunity for nerve transfers remains a subject of controversy. The objective of this study was to assess magnetic resonance (MR) neurographic, clinical and electrophysiological long-term results after Oberlin's transfer. For this purpose, we performed a retrospective follow-up study. Six patients with upper brachial plexus or musculocutaneous nerve injuries were assessed; 2 were iatrogenic nerve injuries following shoulder arthroscopy or neurofibroma resection. Direct and indirect signs of neuropathy were objectified with MR neurography. Moreover, clinical and electrodiagnostic follow-up was performed and all patients completed the Disabilities of Arm, Shoulder and Hand score. Mean follow-up was 48 ± 21.9 (range, 20-73) months. Mean age was 40 ± 11.3 years and mean delay to surgery was 9 ± 3.2 months. All patients were satisfied with the functional results and the median Disabilities of Arm, Shoulder and Hand score was 21 (range, 1-57). Biceps strength was improved in 5 patients from Medical Research Council grade M0 to M4-5 and in one patient to M2-3. The donor nerve showed normal motor and sensory action potentials. Follow-up MR neurography demonstrated biceps reinnervation. Taken together, this study reports good long-term results after Oberlin's transfer. MR neurography represents an excellent, noninvasive preoperative planning tool and can be of high value in selected postoperative cases. The combined evaluation of nerves and muscles may help to indicate nerve transfers in delayed cases.
Da Vinci を用いたロボット手術は既に様々な外科領域で臨床応用されているが
整形外科領域では、いまだ臨床応用のめどが立っていない。Da Vinici○は様々な特性を有
しているが、最大の利点は内視鏡下での顕微鏡下手術にある。従来の顕微鏡下手術では腕神
経叢損傷で体幹深部での神経血管縫合操作を行う際に、大きな皮膚切開を要したが、Da
Vinci では小さなポータルのみでの手術が可能となる。Da Vinci が近い将来に本邦の整
形外科領域において使用可能となるために我々は今何をするべきかを考える時に来ている。
Robotic assistedmicrosurgery applications have expanded quickly and established in a variety of
surgical fields. Robotic assisted microsurgery offers the potential for major technological
advancement. Some authors already reported their experience of robotic assisted microsurgical
procedures . Current interest of robotic assisted microsurgery for microsurgical reconstruction is
shifted to endoscopic telemicrosurgery. We present here two clinical cases of robotic assisted
microsurgery（one robotic assisted external neurolysis and one endoscopic robotic assisted
external neurolysis）. Telemicrosurgery is minimally invasive, robotically-assisted microsurgery.
This technique removes some limitations of conventional microsurgery and enhances visual and
manual dexterity. Vision is enhanced through greater magnification, three-dimensionality, and
functionalization. Manual dexterity is improved by suppression of physiological tremor and tremor
filtration, while permitting useful enhancement of movement amplitudes and tactile feedback
forces . Conventional brachial plexus surgery requires large incisions for exploration and
neurotization, with its attending risks of unsightly scars, prolonged hospital stay, sepsis, and
perineural adhesions that interfere with nerve regrowth. Endoscopic telemicrosurgery limits the
incisions and these risks, with minimal compromise. Endoscopic telemicrosurgery, through the
amplification of human capabilities may pave the way for a major advancement in the microsurgical
field.We also performed a review to ascertain what has been achieved in the field of robotic assisted
microsurgery so far and what could be the future applications.
Telemicrosurgery requires specific installation, completely different than in conventional microsurgery: robot position with regard to both the patient and the surgeon, surgical approaches, dissection of and support of a convenient surgical cavity allowing enough space for both camera and surgical instruments to move unimpeded.
Installation of the microscope is far easier in conventional microsurgery than in robot in telemicrosurgery. In telemicrosurgery, the arms of the robot do not extend significantly beyond the robot’s body, but are aimed instead towards the body. The body of the robot needs to be installed facing the telemicrosurgeon, as if the robot was about to perform a conventional microsurgical procedure.
Telemicrosurgery can be performed either by open approach or by minimally invasive means. Using a conventional open approach, telemicrosurgery does not require any alteration in routine other than robot installation. Minimally invasive telemicrosurgery limits the potential for scar tissue formation. Surgical approaches and indications are subject to the same requirements as in conventional laparoscopic telesurgery. In telemicrosurgery, the surgical field is located inside a cavity which needs to be at first dissected and then maintained during the procedure.
Installation of a telemicrosurgical procedure is complex, and adherence to several principles is warranted.
Several interventions remain almost inaccessible to endoscopic surgery, such as brachial plexus injuries. Development of minimally invasive and robot-assisted surgical approaches has the potential to greatly improve the surgical outcome.
Our clinical experience is based on 12 cases of brachial plexus tele-endomicrosurgery operated using a da Vinci robot.
Considering the microsurgical gesture, all nerve repairs were achieved under excellent conditions. Considering the minimally invasive approach, results are yet inconclusive, with a need to convert to open surgery in 9 cases. The reasons for conversion were numerous: difficulties to maintain the resection cavity, unsuited instrumentation, blurring of the stereoscopic vision and major difficulties in visual identification of anatomical landmarks.
In brachial plexus surgery, tele-endomicrosurgery is feasible but faces major constraints regarding the creation, maintenance and navigation inside the working chamber. Adaptation of the endoscopic equipment and use of advanced techniques of augmented reality should address most of these problems.
The aim of this study was to report the feasibility of robotic intercostal nerve harvest in a pig model. A surgical robot, the da Vinci Model S system, was installed after the creation of 3 ports in the pig’s left chest. The posterior edges of the fourth, fifth, and sixth intercostal nerves were isolated at the level of the anterior axillary line. The anterior edges of the nerves were transected at the rib cartilage zone. Three intercostal nerve harvesting procedures, requiring an average of 33 minutes, were successfully performed in 3 pigs without major complications.
The advantages of robotic microsurgery for intercostal nerve harvest include elimination of physiological tremor, free movement of joint-equipped robotic arms, and amplification of the surgeon’s hand motion by as much as 5 times. Robot-assisted neurolysis may be clinically useful for intercostal nerve harvest for brachial plexus reconstruction.
Background:
The supraorbital keyhole approach has been used in anterior skull base tumor and aneurysm surgery. However, there are debates regarding the safety and limitations of this kind of approach.
Objective:
To determine the feasibility and potential benefits of surgical robotic technology in minimally invasive neurosurgery.
Methods:
Two fresh cadaver heads were studied with the da Vinci Surgical System with 0° and 30° stereoscopic endoscopes to visualize neuroanatomy. The ability of the system to suture and place clips under the keyhole approach was tested.
Results:
The da Vinci Surgical System was used throughout the supraorbital transeyebrow keyhole approach. With the use of standard microdissection techniques, the optic nerve, optic chiasm, carotid artery, and third cranial nerve were visualized. The sylvian fissure was then exposed from the proximal sylvian membrane to the distal M1 segment. With the EndoWrist microforceps, suturing can be achieved smoothly to close a defect created on the M2 artery. Although the benefits in adjusting clips during aneurysm surgery could be provided by an articulating applier, a proper robotic applier is not currently available.
Conclusion:
The minimally invasive supraorbital keyhole surgery can be achieved with the da Vinci Surgical System in cadaver models. This system provides neurosurgeons with broader vision and articulable instruments, which standard microsurgical systems do not provide. Further studies are necessary to evaluate the safety and benefits of using the da Vinci Surgical System in minimally invasive neurosurgery.
We sought to review the current state of robotics in this specialty.
A Pubmed and Medline search was performed using key search terms for a comprehensive review of the whole cross-section of plastic and reconstructive practice.
Overall, 28 publications specific to robotic plastic and reconstructive procedures were suitable for appraisal.
The current evidence suggests robotics is comparable to standard methods despite its infancy. The possible applications are wide and could translate into superior patient outcomes.
Copyright © 2015 Elsevier Masson SAS. All rights reserved.
The robotic surgical system provides a clear, magnified, 3-dimensional (3D) view as well as a precise and stable instrumental movement, which minimizes many technical difficulties that may be encountered in the surgical treatment of oropharyngeal tumors. A preliminary result of transoral robot-assisted free flap reconstruction of oropharyngeal cancer is presented herein.
Between May and December 2013, the Da Vinci Surgical System (Da Vinci Si, Intuitive Surgical, Sunnyvale, CA) was used in 5 (4 men and 1 woman) cases of oropharyngeal reconstruction. Robot-assisted reconstruction was performed for inset of the flap and for performing a venous anastomosis of the free radial forearm fasciocutaneous flap.
All of the reconstructive surgeries were successful without flap failure or take-backs. There were no wound infections or fistulas.
The application of a robotic surgical system seems to be a safe option in the free flap reconstruction of oropharyngeal defects without lip or mandible splitting.
Le but de cette étude était de rapporter la faisabilité du prélèvement du nerf phrénique avec un robot sur un modèle porcin. Un robot chirurgical (système da Vinci S™, Intuitive Surgical®, Sunnyvale, CA) a été installé avec trois trocarts sur l’hémithorax gauche d’un cochon. Le nerf phrénique a été sectionné distalement, là où il pénètre dans le diaphragme. Le prélèvement du nerf phrénique a été réalisé avec succès en 45 minutes sans complications majeures. Les avantages de la microchirurgie robotisée pour le prélèvement du nerf phrénique sont la mise à l’échelle du mouvement jusqu’à 5 fois, l’élimination de tremblement physiologique, et la liberté de mouvements des articulations des bras robotiques. La neurolyse robot-assistée peut être cliniquement utile pour le prélèvement du nerf phrénique dans la chirurgie de réparation des lésions du plexus brachial.
Background:
Nerve transfer to the deltoid muscle using the nerve to the long head of the triceps is a reliable method for restoration of deltoid function. The aim of this retrospective study was to report the results of nerve transfer to the deltoid muscle using the nerve to the long head of the triceps procedure using a robot.
Methods:
Our series included six patients (mean age 36.3 years) with total deltoid muscle paralysis. A da Vinci-S robot was placed in position. After dissection of the quadrilateral and triangular spaces, the anterior branch of the axillary nerve and the branch to the long head of the triceps were transected, and then robotically sutured with two 10-0 nylon stiches. In two cases, an endoscopic procedure was tried under carbon dioxide (CO2) insufflation.
Results:
In all patients except one, deltoid function against resistance (M4) was obtained at the last follow-up evaluation. The average shoulder abduction was 112 degrees. No weakness of elbow extension was observed. In two cases with the endoscopic technique, vision was blurred and conversion to open technique was performed.
Conclusion:
The advantages of robotic microsurgery are motion scaling and disappearance of physiological tremor. Reasons for failure of the endoscopic technique could be explained by insufficient pressure. We had no difficulty using the robot without the sensory feedback. The robot-assisted nerve transfer to deltoid muscle using the nerve to the long head of the triceps was a feasible application for restoration of shoulder abduction after brachial plexus or axillary nerve injury. Therapeutic Study. Level of Evidence IV.
A central concept of scientific advancement in the medical and surgical fields is the incorporation of successful emerging ideas and technologies throughout the scope of human endeavors. The field of automation and robotics is a pivotal representation of this concept. Arising in the mythology of Homer in the 4th century BC, the concept of automation and robotics grew exponentially over the millennia to provide the substrate for a paradigm shift in the current and future practice of neurosurgery. We trace the growth of this field from the seminal concepts of Homer and Aristotle to early incorporation into neurosurgical practice. Resulting changes provide drastic and welcome advances in areas of visualization, haptics, acoustics, dexterity, tremor reduction, motion scaling and surgical precision.
Surgery of the chronic peripheral nerve lesion should not only limit recurrence after excision, but it should also limit the sensory and motor sequelae. The aim of this work was to study the interest of telemicrosurgery to improve this result. Our series included 7 patients with peripheral nerve neuroma and tumors including two cases of hereditary neurofibromatosis. A Da Vinci S(®) robot equipped with microsurgical instruments was used for intraneural dissection. One case was performed with minimally invasive approach. At last follow-up, the pain decreased from 6/10 preoperatively to 3/10 postoperatively. The sensory deficit was stable except for two patients, whose sensory function was improved. No recurrence was noted. Telemicrosurgery seems to have two interests in the treatment of chronic peripheral nerve lesions: it reduces the size of incisions and increases the accuracy of surgery. These preliminary results suggest that surgical robots could play an essential role in microsurgery.
Surgery to transfer the axillary nerve and the nerve of the long head of the triceps presents two obstacles: 1) the access portals are not standardized and 2) the nerves are for their larger part approached through large incisions. The goal of this study was to explore the feasibility of an endoscopic microsurgical approach. The posterior aspect of a cadaver shoulder was approached through three communicating mini-incisions. The Da Vinci robot camera was installed on a central trocart, and the instrument arms on the adjacent trocarts. A gas insufflation distended the soft tissues up to the lateral axillary space. The branches of the axillary nerve and the nerve to the long head of the triceps brachii muscle were identified. The dissection of the axillary nerve trunk and its branches was easy. The posterior humeral circumflex veins and artery were dissected as well without any difficulty. Finding the nerve to the long head of the triceps brachii was found to be more challenging because of its deeper location. Robots properties allow performing conventional microsurgery: elimination of the physiologic tremor and multiplication of the movements. They also facilitate the endoscopic approach of the peripheral nerves, as seen in our results on the terminal branches of the axillary nerve and the nerve to the long head of the triceps brachii.
Robot assisted surgery is a technology that is being used frequently among multiple surgical specialties; robot assisted microsurgery (RAMS) and transoral robotic surgery (TORS) are applications relevant to plastic surgery that are being studied and clinically utilized. Advantages of RAMS include elimination of tremor and the ability to provide enhanced exposure. TORS facilitates oropharyngeal tumor excision and reconstruction without mandibular splitting. This article investigates current and potential uses of the surgical robot in plastic surgery as well as obstacles to its application.
The application of telerobotics in the biomedical field has grown rapidly and is showing very promising results. Robotically
assisted microsurgery and nerve manipulation are some of its latest innovations. The purpose of this article is to update
the community of shoulder and elbow surgeons on that field. Simple anterior subcutaneous translocation of the ulnar nerve
was first experimented in two cadavers, and then performed in one live patient who presented with cubital tunnel syndrome.
This procedure is the first reported case using the robot in elbow surgery. In this paper we attempt to analyze various aspects
related to human versus robotically assisted surgery.
KeywordsTelesurgery–Robotic surgery–Cubital tunnel–Ulnar nerve
The aim of this paper was to develop an effective minimally invasive approach to brachial plexus surgery and to determine the feasibility of using telerobotic manipulation to perform a diagnostic dissection and microsurgical repair of the brachial plexus utilizing an entirely endoscopic approach.
The authors performed an endoscopic approach using 3 supraclavicular portals in 2 fresh human cadaver brachial plexuses with the aid of the da Vinci telemanipulation system. Dissection was facilitated inflating the area with CO(2) at 4 mm Hg pressure. The normal supraclavicular plexus was dissected in its entirety to confirm the feasibility of a complete supraclavicular brachial plexus diagnostic exploration. Subsequently, an artificial lesion to the upper trunk was created, and nerve graft reconstruction was performed. Images and video of the entire procedure were obtained and edited to illustrate the technique.
All supraclavicular structures of the brachial plexus could be safely dissected and identified, similar to the experience in open surgery. The reconstruction of the upper trunk with nerve graft was successfully completed using an epineural microsurgical suture technique performed exclusively with the aid of the robot. There were no instances of inadvertent macroscopic damage to the vascular and nervous structures involved.
An endoscopic approach to the brachial plexus is feasible. The use of the robot makes it possible to perform microsurgical procedures in a very small space with telemanipulation and minimally invasive techniques. The ability to perform a minimally invasive procedure to explore and repair a brachial plexus injury may provide a new option in the acute management of these injuries.
Endoscopic assisted transaxillary first rib resection is a novel approach in the management of thoracic outlet syndrome. It allows safe identification of the different structures. The objective of our study is to assess the outcome of surgical treatment of thoracic outlet syndrome using this technique.
Between May 1999 and October 2005, 28 endoscopic assisted transaxillary first rib resections were performed on 20 patients with thoracic outlet syndrome in our vascular unit. This retrospective study included 14 females and 6 males with ages ranging between 16 and 53 years (median 37 years).
Prior to the operation, all patients had C spine X-ray and 45% (nine patients) had nerve conduction studies prior to the operation. Duration of symptoms ranged between 1 month and 15 years (median 36 months). Fifty-five percent of patients had neurological symptoms, 30% had mixed symptoms and only 15% had venous or arterial symptoms. Eight patients were given bilateral first rib excision. The average time between the two operations was 17.5 months (median 12 months). The postoperative stay in hospital ranged between 2 and 8 days (median 5 days). Follow-up ranged between 1 and 64 months (median 8 months). Eighty-two percent of patients (23 resections) had complete resolution of symptoms. Eighteen percent (5 resections) did not show any improvement of symptoms following surgery. Three complications were recorded, including haemothorax, bleeding and brachial plexus injury. The latter was due to traction injury during the operation.
Endoscopic assisted transaxillary first rib resection is a safe and effective procedure in the management of thoracic outlet syndrome. It also offers a great opportunity for teaching.
Telemicrosurgery (TMS) is a new technique inspired by telesurgery and conventional microsurgery (CMS). One of the difficulties of CMS is learning to control physiological tremor. TMS eliminates the physiological tremor, thus theoretically simplifying microsurgical procedures, but no tactile feedback is provided while tying knots. The objective of this study was to assess if the learning curve for performing microsurgical anastomosis for TMS than with CMS was comparable. Thirty earthworms were anastomosed with 10/0 nylon sutures. In this study 15 anastomoses were performed under operating microscope and 15 under Da Vinci S® robot (Intuitive Surgical, Sunnyvale, CA). A single operator without experience in either technique performed all anastomoses. The evaluation consisted of measuring the time to perform each stitch, as well as to complete the anastomosis. The integrity of the anastomosis was tested by injection of saline solution into the earthworm to assess permeability and watertightness. The average time to complete a single suture was 296 seconds in the CMS group and 529 seconds in the TMS group. Permeability and watertightness of anastomosis was 86.66% in both groups. Learning was faster with CMS than with TMS. For untrained surgeon, the absence of tactile feedback is a limiting factor with TMS, however, the benefits of the TMS are: three-dimensional high definition vision, abolition of physiological tremor, motion scaling of gestures down to 5 times, use of three instruments at once, and extreme mobility.
The functional recovery of hand prehension after complete brachial plexus avulsion injury (BPAI) remains an unsolved problem. The authors conducted a prospective study to elucidate a new method of resolving this injury.
Three patients with BPAI underwent a new procedure during which the full-length phrenic nerve was transferred to the medial root of the median nerve via endoscopic thoracic surgery support. All 3 patients were followed up for a postoperative period of > 3 years.
The power of the palmaris longus, flexor pollicis longus, and the flexor digitorum muscles of all 4 fingers reached Grade 3-4/5, and no symptoms of respiratory insufficiency occurred.
Neurotization of the phrenic nerve to the medial root of the median nerve via endoscopic thoracic surgery is a feasible means of early hand prehension recovery after complete BPAI.
Robotically assisted telemanipulators are often criticised for their lack of direct haptic feedback. However, robotically assisted microsurgical sutures have already been achieved successfully. The aim of this study was to demonstrate that haptic feedback is not necessary in microsurgery.
Our series included 24 surgeons of whom 14 were micro-surgeons. Each of them had to tighten a 9/0 and a 10/0 pre-tied nylon thread until getting the sensation of optimal knot tying. The procedure was performed four times, with open and closed eyes. The quality of knot tying was evaluated (fully tied, fairly or incompletely tied, or broken thread).
The results obtained with the eyes open were significantly better. Neither the material size, nor the surgeon's expertise was shown to have an impact on knot tying quality.
Our results demonstrate the uselessness of haptic feedback in microsurgery.
To describe novel robotic laparoendoscopic single-site surgery (R-LESS) instruments, and present the initial laboratory experience in urology.
The VeSPA surgical instruments (Intuitive Surgical, Sunnyvale, CA) were designed to be used with the DaVinci Si surgical system. A multichannel port and curved cannulae were inserted through a single 3.5-cm umbilical incision. The port allowed 1 scope, 2 robotic instruments, and a 5- to 12-mm assistant instrument. Four pyeloplasties (right 2, left 2), 4 partial nephrectomies (right 2, left 2), and 8 nephrectomies (right 4, left 4) were performed in 4 female farm pigs (mean weight, 34.5 kg). Technical feasibility and efficiency were assessed in addition to perioperative outcomes.
All 16 R-LESS procedures were performed successfully without the addition of laparoscopic ports or open conversion. Mean total operative time was 110 minutes (range, 82-127), and mean blood loss was 20 mL (range, 10-100). Mean warm ischemia time for partial nephrectomy was 14.8 minutes (range, 12-20). There were no intraoperative complications. No robotic system failures occurred, and robotic instrument clashing was found to be minimal. One needle driver malfunctioned and assistant movement was limited.
R-LESS kidney surgery using the VeSPA instruments is feasible and efficient in the porcine model. The system offers a wide range of motion, instrument and scope stability, improved ergonomics, and minimal instrument clashing. Although preliminary experience is encouraging, further refinements are expected to optimize urological applications of this robotic technology.
A minimally invasive endoscopic approach has been successfully applied to surgical treatment of cubital tunnel syndrome. This procedure allows for smaller incisions with faster recovery time. This article details relevant surgical anatomy, indications, contraindications, surgical technique, complications, and postoperative management.
We treated 20 patients with cubital tunnel syndrome by anterior transposition of the ulnar nerve with endoscopic assistance. Five elbows were classified preoperatively as McGowan's stage 1, 11 as stage 2 and four as stage 3. Excellent outcomes were obtained in nine and good in eight patients. Three patients had fair results. Improvement of symptoms occurred in all patients. There were no serious complications. All ulnar nerves remained anteriorly transposed.
Robotics has spread over many surgical fields over the last decade: orthopaedic, cardiovascular, urologic, gynaecologic surgery and various other types of surgery. There are five different types of robots: passive, semiactive and active robots, telemanipulators and simulators. Hand surgery is at a crossroad between orthopaedic surgery, plastic surgery and microsurgery; it has to deal with fixing all sorts of tissues from bone to soft tissues. To our knowledge, there is not any paper focusing on potential clinical applications in this realm, even though robotics could be helpful for hand surgery. One must point out the numerous works on bone tissue with regard to passive robots (such as fluoroscopic navigation as an ancillary for percutaneous screwing in the scaphoid bone). Telemanipulators, especially in microsurgery, can improve surgical motion by suppressing physiological tremor thanks to movement demultiplication (experimental vascular and nervous sutures previously published). To date, the robotic technology has not yet become simple-to-use, cheap and flawless but in the future, it will probably be of great technical help, and even allow remote-controlled surgery overseas.
Since the development of microsurgery in the 1960s, the prognosis of peripheral nerve lesions has greatly improved. However this new technique's evolution has remained limited by human factors, in particular by physiological tremor. Telesurgery, a technique used in other surgical fields, was developed in the 1990s. This study assesses the feasibility of peripheral nerve repair using telemicrosurgery. Anatomical material from three subjects of different species (rat, pig, and human) was used. The telesurgical step of the procedure was performed with a Da Vinci S robot (Intuitive Surgical, Inc., Sunnyvale, CA). Four anatomical epiperineural repairs were performed. Another neurotrophic repair was performed with a nerve regrowth guide. Regardless of the type of repair performed, the telemanipulator removed the physiological tremor factor. The suture needle was distorted when held by two clamps at a time. Repairs were all performed without any damaging twisting movements of both nerve ends. Our results demonstrated that telesurgery allows very safe and precise peripheral nerve repairs by counteracting physiological tremor and by improving the overview of the surgical field, either with an anatomical or a neurotrophic technique.
Peritoneal insufflation to 15 mmHg diminishes venous return and reduces cardiac output. Such changes may be dangerous in patients with a poor cardiac reserve. The aim of this study was to investigate the hemodynamic effects of high (15 mmHg) and low (7 mmHg) intraabdominal pressure during laparoscopic cholestectomy (LC) METHODS: Twenty patients were randomized to either high- or low-pressure capnoperitoneum. Anesthesia was standardized, and the end-tidal CO2 was maintained at 4.5 kPa. Arterial blood pressure was measured invasively. Heart rate, stroke volume, and cardiac output were measured by transesophageal doppler.
There were 10 patients in each group. In the high-pressure group, heart rate (HR) and mean arterial blood pressure (MABP) increased during insufflation. Stroke volume (SV) and cardiac output were depressed by a maximum of 26% and 28% (SV 0.1 > p > 0.05, cardiac output p > 0. 1). In the low-pressure group, insufflation produced a rise in MABP and a peak rise in both stroke volume and cardiac output of 10% and 28%, respectively (p < 0.05).
Low-pressure pneumoperitoneum is feasible for LC and minimizes the adverse hemodynamic effects of peritoneal insufflation.
Carbon dioxide (CO(2)) is currently the insufflation gas of choice for laparoscopy. It fulfills most of the requirements for an ideal insufflation gas, being colorless, noninflammable, and rapidly excreted from the circulation. However, its use is associated with adverse cardiorespiratory effects, especially in patients with preexisting cardiorespiratory compromise.
The descriptive review of relevant literature, moreover, has been proposed that it increases the incidence of port site (wound) metastases from abdominal cancers when used during oncological surgery. In addition, it may cause postoperative pain due to peritoneal irritation, and its use is associated with physiological and immunological impairment. Hence, there is scope for the investigation of alternative insufflation gases. Other possibilities include gasless laparoscopy, helium, nitrous oxide, (N(2)O), and argon. Helium insufflation has been used extensively in animal models but only to a limited extent in humans. In experimental studies, it has been shown to produce fewer changes in cardiorespiratory and intraperitoneal immunological status than CO(2) insufflation, and its use is associated with less spread of tumors to port sites in a variety of small animal tumor models. However, helium also has the potential for some adverse effects. Helium pneumothorax probably resolves more slowly than CO(2) pneumothorax, and helium gas embolism is tolerated poorly in animal models. The clinical significance of these potential problems has yet to be determined.
Although the use of alternative gases appears to be promising, further evaluation is needed within both clinical and laboratory settings before their routine clinical use can be supported.
Technology for endoscopic surgery has developed rapidly during the last decade. Applications of endoscopic techniques to orthopaedic surgery have been made possible by the use of balloon dissectors. Balloon dissectors create an optical cavity by separating fascial layers of a constant anatomic plane called the fascial cleft. The optical cavity can be maintained with either carbon dioxide (CO2) insufflation or manual retractors. The authors of the present study have developed a safe, reliable technique using a balloon dissector to create such optical cavities in the extremities, pelvis, and acetabulum to facilitate minimally invasive surgery in these areas. The authors' clinical work and fresh cadaver dissection confirms that the fascial cleft is a universal anatomic constant. It can be accessed quickly to facilitate endoscopic procedures, such as bone grafting for delayed unions, tissue expansion for reconstructive surgery, sural nerve harvesting for nerve cable grafting, and microvascular tissue transfer harvesting and flap prefabrication for extremity reconstruction. Twenty-five cases, each with an average follow-up of 34 months, are presented. Indications, results, and complications of balloon-assisted endoscopic surgery are described.
The indications for and timing of brachial plexus exploration in closed injuries are controversial. The time-consuming surgery proves its worth in some cases, whereas spontaneous regeneration might have been possible in others. The differentiation is difficult, because no investigational method reveals the exact morphological correlates of the nerve lesions. Minimally invasive, direct observation of the structures is a possible solution. Here we describe our surgical technique and the anatomic features of the normal brachial plexus appreciated with the endoscope.
Twenty-one brachial plexus in 11 fresh cadavers were investigated. Endoscopic exploration was performed at the supraclavicular and infraclavicular levels. The method involves insertion of an optic shaft-integrated retractor through a stab wound; retraction of landmark muscles produces a working space, into which other instruments are introduced for dissection. After completion of endoscopic surgery, open dissection was performed to verify the endoscopically identified structures and to assess iatrogenic injuries.
The omohyoid muscle is a reliable landmark in the supraclavicular region, beneath which the suprascapular nerve can be observed. Following the suprascapular nerve proximally leads to the plexus trunks. Infraclavicular exploration first reveals the axillary artery. The plexus and its nerves are traced around this artery. The anatomic features were constant in all cases, with variations in fat accumulation depending on the corporeal constitution. We detected iatrogenic injuries to the medial circumflex humeral vessels in two cases. No nerve injuries were observed.
The endoscopic technique combined with intraoperative nerve stimulation studies might provide important information on the type of morphological damage in closed brachial plexus injuries and thus might become an important tool for determination of the surgical treatment strategy. Clinical work is under way.
Restoration of elbow flexion is the main objective in the treatment of brachial plexus palsies affecting the upper roots. Transfer of the ulnar nerve to the nerve of the biceps has given satisfactory results, but the restored biceps is often weak in cases with avulsions of the C5-C6-C7 roots, in elderly patients, and after long preoperative delays. The authors decided to investigate a double nerve transfer: one or more fascicles of the ulnar nerve to the nerve to the biceps and a fascicle of the median nerve to the motor branch to the brachialis muscle.
The authors operated on 15 patients using this technique. The authors have follow-up of more than 6 months in 10 of them. Six had C5-C6 injuries, three had C5-C6-C7 palsies, and one had sustained an infraclavicular injury. The average age was 27.2 years. The average delay before surgery was 6.6 months. The average follow-up was 12.1 months.
Grade 4 elbow flexion was restored in each of the 10 patients. In 10 cases, the patients were able to lift 1 to 5 kg. There was no secondary deficit in grip strength or sensation.
The results of this technique compare favorably with those of other methods. The percentage of success and the strength of elbow flexion restored were increased without any morbidity. This technique will probably reduce the need for secondary procedures to augment elbow flexion. The authors propose double nerve transfer as a standard procedure in C5-C6 and C5-C6-C7 injuries.
Transfer of training refers to the ability to transfer acquired skills from one discipline to another. This study aims to determine whether experience in traditional freehand microsurgery facilitates mastery of robotic microsurgery.
Microsurgical anastomoses of coronary arteries harvested from explanted pig models were used to demonstrate whether prior experience with microsurgery is required in learning robot-assisted microsuturing. Eighty microsurgical anastomoses were performed. Three fully trained vascular surgeons (n = 3) (Group A) and 5 midlevel surgical residents (n = 5) (Group B) performed the anastomoses. Each subject performed 5 freehand and 5 robotic-assisted (Zeus robotic system) anastomoses. Anastomosis time and integrity of anastomoses were recorded, including errors of management (EOM) (breaking suture, breaking knots, breaking or damaging needles).
For fully trained surgeons, all anastomoses in the robotic-assisted group were mechanically intact. There was significantly increased anastomosis time with the robot (Robot: 14 minutes, versus freehand: 7.2 minutes, P < 0.01). The robotic-assisted anastomoses were associated with a higher EOM (Robot: 1.2, versus freehand: 0.3, P < 0.01). Surgical trainees had longer anastomosis times with robotic assistance (Robot: 14.8 minutes, versus freehand, 12.7 minutes; P < 0.01) and increased EOM (Robot: 1.6, versus freehand: 1.0; P < 0.05).Overall, surgical trainees and fully trained vascular surgeons had longer anastomotic times with robotic assistance [Robot: 14.0 versus 14.8 minutes; P = not significant (NS)], and EOM (Robot: 1.6, versus freehand: 1.2; P = NS) were not significantly different.
The technical feasibility of performing a safe and efficient robotic-assisted microsurgical anastomosis in explanted vessels was repeatedly tested and demonstrated in this study within reasonable time required for the anastomosis. Compared with conventional microanastomosis, both fully trained surgeons and residents demonstrated an ability to master the robotically assisted procedure with similarly longer anastomosis times and EOM. This study indicates that robotically assisted microanastomosis can be mastered equally well by surgical trainees and fully trained vascular surgeons.
We describe a novel all-arthroscopic technique for suprascapular nerve (SSN) decompression and present our preliminary results for this procedure.
A prospective series of 10 patients with preoperative electromyographic findings consistent with chronic SSN compression, posterior shoulder pain, and subjective weakness were treated with arthroscopic SSN decompression. There were 8 men and 2 women, with a mean age of 50 years. The mean follow-up was 15 months (range, 6 to 27 months). In 8 of 10 patients, we performed an electromyographic examination postoperatively to evaluate nerve recovery after decompression. The clinical outcomes measures used to assess preoperative and postoperative function were the visual analog scale for pain, the Constant score, strength testing of the supraspinatus and infraspinatus, and a subjective satisfaction questionnaire. In all patients preoperative and postoperative computed tomography arthrograms were obtained to document the absence of a rotator cuff tear.
There were no complications resulting from SSN decompression. Of 10 patients, 8 had postoperative electromyography at a mean of 6 months after SSN release and 2 refused to undergo this study after surgery. Of the 8 postoperative electromyograms, 7 had complete normalization of the latency in the motor fibers of the SSN and normalization of the voluntary motor action potential for the supraspinatus and infraspinatus muscles. Two of the electromyograms showed evidence of partial recovery. The preoperative and postoperative Constant scores for these patients were 60.3 and 83.4, respectively (P < .001). All patients returned to their normal work and sports activity at a mean of 3 weeks (range, 2 days to 3 months). The abduction and external rotation strength also significantly improved. At the time of last follow-up, 9 patients graded their clinical outcome as excellent and responded that they had complete relief of pain. One of the study subjects reported a satisfactory result with moderate relief of pain.
Arthroscopic release of the SSN can be performed safely and effectively. All of the patients in this preliminary study had improvement in their postoperative electromyographic findings and had marked improvement in pain relief and function.
Level IV, therapeutic case series.
To compare 5 laparoscopic insufflators with different gas flow rates with regard to accuracy of preset pressure setting versus real intraoperative intraabdominal pressure.
Prospective study (Canadian Task Force classification II-2).
Fayette Medical Center, Alabama.
Five patients undergoing laparoscopic cholecystectomy.
Intraoperative intraabdominal and system pressure measurements during comparable laparoscopic procedures.
Actual intraabdominal pressure was measured and compared between 5 different 10 to 20 L/min insufflators (Storz Laparoflator and Endoflator, Richard Wolf, BEI Medical and Snowden & Pencer) with a computer-based online data acquisition system. At a nominal pressure of 10 mm Hg, the mean intraabdominal pressure during the entire procedure was measured to be between 9.68 and 11.45 mm Hg. The mean intraabdominal pressure during laparoscopy for the insufflators showed a margin of error of 14.5%, with maximum intraabdominal pressure peaks measured between 14.65 and 17.87 mm Hg.
Within an error margin of <15% of the preset intraabdominal pressure setting, the insufflators evaluated can be considered pressure reliable. Although intraabdominal pressure peaks exceeding the nominal pressure temporarily reached up to 78.7% of the setting, no apparent complications were observed. Excessive pressure peaks seen in the previous reported laboratory model could not be confirmed during in vivo application.
Suprascapular nerve release is often performed for entrapment syndromes and to release pressure on the nerve associated with arthroscopic rotator cuff repair. Previous descriptions use basket forceps or scissors through a separate portal. This report describes an arthroscopic technique inserting a 14-gauge needle percutaneously in the superior suprascapular area while viewing through a standard posterior portal. A shaver through the lateral portal clears the acromion and distal clavicle of soft tissue and exposes the coracoclavicular ligaments. The medial border of the coracoclavicular ligaments (conoid ligament) is identified and then followed inferiorly to its coracoid attachment. The shaver removes the adipose tissue for better visualization and depresses and retracts the supraspinatus muscle. The transverse scapular ligament is located with the suprascapular artery coursing across its superior surface. A 14-gauge beveled needle is inserted in the "soft spot" medial to the junction of the scapular spine and clavicle. This insertion site is located approximately 7 cm medial to the lateral border of the acromion. The transverse scapular ligament is horizontal at this location and can be divided with the needle tip via an anterior-posterior sweeping motion, avoiding the suprascapular artery and decompressing the suprascapular nerve.