P.M. Porto de Meloa, b, J.C. Garciaa, E.F. de Souza Monteroc, T. AtikdE,G. Roberte, S. Faccae, P.-A. Liverneauxe,f, a Center for Advanced Studies in Orthopedics and Neurosurgery, São Paulo, Brazil b Neurosurgery Department, São Paulo Military Área Hospital, Brazilian Army, São Paulo, Brazil c Department of Surgery, LIM-62, FMUSP, University of São Paulo, São Paulo, Brazil d Central Jersey Hand Surgery, PA, Eatontown, NJ, USA e Department of Hand Surgery, Strasbourg University Hospitals, 10, avenue Baumann, 67403 Illkirch cedex, France f École européenne de chirurgie, université Paris Descartes, 45, rue des Saints-Pères, 75006 Paris, France
Abstract 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.
Résumé Les transferts chirurgicaux du nerf axillaire et du nerf du chef long du triceps brachial présentent deux obstacles : 1) les voies d?abord ne sont pas standardisées et 2) les nerfs sont, pour leur plus grande partie, abordés à travers de larges incisions. Le but de cette étude était d?explorer la faisabilité d?une voie d?abord endoscopique microchirurgicale. La face postérieure d?une épaule de cadavre a été abordée par l?intermédiaire de trois mini-incisions communiquant les unes avec les autres. La caméra du robot Da Vinci a été installée sur le trocart central et les bras instrumentaux sur les trocarts adjacents. Une insufflation de gaz a distendu les parties molles jusqu?à l?espace axillaire latéral. Les branches du nerf axillaire et le nerf du chef long du triceps brachial ont été identifiés. La dissection du tronc du nerf axillaire et de ses branches fut aisée. L?artère et les veines circonflexes humérales postérieures furent disséquées également sans difficulté. La découverte du nerf du chef long du triceps brachial fut plus difficile en raison de sa localisation plus profonde. Les propriétés des robots permettent la réalisation d?une microchirurgie conventionnelle : élimination du tremblement physiologique et démultiplication des mouvements. Ils facilitent de la même façon l?abord endoscopique des nerfs périphériques, comme dans notre étude celle des branches terminales du nerf axillaire et du nerf du chef long du triceps brachial.
Keywords Endoscopic microsurgery; Robot; Da Vinci Mots clés Chirurgie endoscopique; Robot; Da Vinci
Abstract Objective This study demonstrates the new technology of the robotic telesurgery on three brachial plexus reconstructions. We also discuss the implications, problems, and benefits of robotically assisted brachial plexus surgery.
Methods After the first experimental experience in a cadaveric model, the authors performed three brachial plexus reconstructions. The surgery followed the traditional brachial plexus approach. From the moment that nervous sutures would be performed, the Da Vinci® (Intuitive Surgical™, Sunnyvale, CA) equipment was docked at the patients, positioned behind the patient’s head, and the microsurgical steps were performed by using robotic telemanipulation.
Results The first procedure was performed in a cadaver to gain experience and establish a surgical protocol by using the robot. In all the three living patients, the goals of the surgical procedure were achieved using the telerobotic manipulation.
Conclusion Robot-assisted surgery allows performance of high-dexterity surgical operations with the help of robotic arms and it improves the surgery due to tremor filtration, motion scaling, and ergonomics. The benefit of using the robot on microsurgery was reached, but its entire potential was not realized because the instruments used on those first experimental and clinical cases were not specifically designed for microsurgery.
Keywordsbrachial plexus – robotic microsurgery – robotic surgery
Ulnar nerve entrapment can be treated by a number of surgical techniques when necessary. Endoscopic techniques have recently been developed to access the ulnar nerve by use of a minimally invasive approach. However, these techniques have been considered difficult and, many times, dangerous procedures, reserved for experienced elbow arthroscopic surgeons only. We have developed a new endoscopic approach using the da Vinci robot (Intuitive Surgical, Sunnyvale, CA) that may be easier and safer. Standardization of the technique was previously developed in cadaveric models to achieve the required safety, reliability, and organization for this procedure, and the technique was then used in a live patient. In this patient the nerve entrapment symptoms remitted after the surgical procedure. The robotic surgical procedure presented a cosmetic advantage, as well as possibly reduced scar formation. This is the first note on this surgical procedure; the procedure needs to be tested and even evolved until a state-of-the-art standard is reached. The ulnar nerve stems from the medial cord of the brachial plexus, runs by the medial side of the arm, and rises from the arcade of Struthers in the medial triceps. In the elbow it enters the cubital tunnel. Just after its exit from the cubital tunnel, it enters the arcade of Osborne in the proximal forearm and runs through the medial forearm to the hand. Common areas of ulnar nerve compression are the arcade of Struthers, the medial intermuscular septum, the medial epicondyle, the narrow cubital tunnel, the arcade of Osborne (fibro-aponeurotic tissue connecting the humeral and ulnar heads of the flexor carpi ulnaris), and the aponeurosis of the deep flexor and pronator teres.2 Furthermore, during elbow flexion, traction forces on the ulnar nerve are major causes of increased intraneural pressure.3 The cubital tunnel changes from an oval to a flattened ellipse,4 where flexion pressures within the tunnel may increase by 7 times.5 In throwing athletes the ulnar nerve pressure can be enhanced up to 6-fold from the resting position to the cocked throwing position. The elevation of the pressure at these sites also can be related to some compressive pathologies, such as tumors,6 cysts,7and anconeus epitrochlearis,8 as well as other causes. When surgery is necessary, there are many surgical techniques available for both the nerve release and the nerve anteriorization.9 Endoscopic techniques have recently been developed to access the ulnar nerve, enabling the surgeon to use a minimally invasive approach. Some of these techniques have only been used in cadaveric models.10,11 Others have been considered very difficult and even dangerous procedures, reserved for highly experienced elbow arthroscopists only.12 New endoscopic techniques with new devices could make the endoscopic decompression and/or anteriorization of the ulnar nerve a safer and easier procedure. We suggest that the use of robotic technology can be an option to endoscopically access the ulnar nerve and its entrapment sites in an easier and safer manner.Go to:Surgical Technique The surgical technique was developed by adapting the open surgical technique of robotic anterior translocation of the ulnar nerve13 to endoscopy. We used a new docking and setup for the da Vinci robotic system (Intuitive Surgical, Sunnyvale, CA) based on the previous knowledge of endoscopic robotic techniques related to different surgical areas, such as urology and gynecology. Before we used the new surgical approach in a live patient, it was successfully tested in 2 cadaveric models. The patient underwent general anesthesia and was placed in the supine position with the left arm raised 170°, in a Trendelenburg position of 20°. The arm lay on the surgical table next to the patient (Fig 1).[Fig 1] Patient positioning.Because there are no natural cavities in the ulnar nerve pathway, its endoscopic access requires the creation of an initial cavity. A small cavity is created in the middle third of the arm. This cavity will be opened through a 1.2-cm portal, the exact length of the da Vinci robot’s cannula. Dissection of the cavity is performed just above the ulnar nerve with Metzenbaum scissors. Through this portal, an initial subcutaneous cavity is created and directly faces the ulnar nerve. Its dissection is directed to the distal arm (Figs 2 and and3).3). The 2 other portals are created in the division of the middle and distal thirds of the arm, 2 to 3 cm lateral and medial to the first portal. These 2 portals need to be 8 mm long to allow the cannulas of the robotic hands to pass. These cannulas need to be gently inserted in the direction of the cavity to avoid any lesion. Once the robotic hands are visible by the optics in the cavity, they can distally expand this cavity. Only these 3 portals are used. Optic portal.Sometimes, a needle can be used to certify the best location of the 2 aforementioned portals. It is important that the secure distance mentioned earlier be reached between the portals to avoid conflict of the robotic arms (Fig 4). The third robotic arm is not used in this procedure. The insufflation of air at a pressure of 10 mm Hg is used to avoid bleeding. Saline solution of 0.9% can be introduced and aspirated to clean the surgical field.[Fig 4] All portals at a secure distance.After docking the robot’s parts and creating the portals, the surgeon uses the console to operate the robot from a distance (Fig 5). The surgeon performs the surgery seated in an ergonomic position using the first and second fingers and 3-df robotic arms. These robotic arms allow wrist movements, improving the surgeon’s movement capabilities. The surgeon can scale the movement up to 5-fold, adding more precision to the robotic arms.[Fig 5] Position of surgeon at console.The robotic arms in our setup hold 8-mm curved scissors (Intuitive Surgical) and Maryland bipolar 8-mm forceps (Intuitive Surgical). Through this approach, the surgeon is able to access adherences that have formed next to the nerve path, open the medial posterior elbow capsule, and decompress the cubital tunnel as in an open procedure (Figs 6-8, Video 1).[Fig 6] Ulnar nerve (A) and cubital tunnel (B). Medial epicondyle (A), release of Osborne ligament (B), and location of Flexor Ulnaris Carpi (C). Medial epicondyle (A) and release of nerve lying in synovial liquid that came from posterior capsule’s medial release (B).The 3-dimensional view provided by the robot’s stereoscopic optics makes the learning curve for using the described technology very short. Anterior translocation of the ulnar nerve or its simple release is possible because the robotic arms present 3 df; therefore the movements are similar to those of free hands. After the development phase in the cadaveric models, 1 patient underwent the procedure. The patient, a 36-year-old woman, was informed that all data concerning her case would be submitted for publication, and she gave her written informed consent. The patient presented with elbow stiffness due to a radial head fracture. After arthroscopic release, arc of motion increased for both flexion and extension; however, the patient had ulnar nerve impingement symptoms. This situation occurred because of 2 complications: (1) a decrease in the cubital tunnel diameter, probably due to morphologic alterations of the medial collateral ligament and other fibrous structures of the cubital tunnel as part of the stiffness, and (2) scar formation due to the medial portal in the elbow, which was sometimes too close to the ulnar nerve. When the patient had an increase in flexion, the nerve entrapment became more evident. Posteromedial elbow pain during flexion movements during physical therapy prevented a greater increase in flexion. An electromyographic examination was performed, and the results showed major entrapment of the ulnar nerve in the cubital tunnel with no lesion. Therefore a procedure comprising posteromedial capsule and ulnar nerve release was performed. After surgery, elbow flexion could be increased without posteromedial pain and the ulnar nerve commitment signs and symptoms remitted.Go to:Discussion Telesurgery has been used widely in urology, gynecology, and other surgical specialties. Orthopaedic surgery has just recently added this technology for open brachial plexus reconstruction,14 as well as microsurgical nerve procedures.13,15,16 The advantages of robotic surgery are as follows: (1) Tremor filtration makes the surgical procedure stable and controlled. (2) Magnification of the image makes it possible for the surgeon to better explore the surgical field. (3) Scaling of surgical gestures is possible; the surgeon can scale the movement up to 5-fold to gain more precision. (4) The 3-dimensional view makes the procedures more intuitive and the learning curve shorter. This is made possible by use of the da Vinci stereoscopic optics. (5) The instruments have 3 df. The devices used in robotic surgery present movements similar to the natural movements performed by surgeons’ hands during open surgery; they even allow wrist movements. (6) Ergonomics is improved because the surgeon is out of the surgical field, seated in a comfortable position.13 Future technologies, which are currently under development, will also allow the surgeon to browse the Internet, ask the opinion of another colleague online during the surgical procedure, use just a single portal for endoscopic approaches, perform local microscopic examinations in real time by using a microscope docked to the robot, and use specific markers that will provide a more reliable identification of the target structures. The negative points and limitations of this new technology are as follows: high costs, absence of haptic feedback, the fact that the instruments have not been designed for orthopaedic procedures, and the absence of surgical procedure standards. However, it is suggested that the absence of haptic feedback does not influence the results of many kinds of soft-tissue operations.17 It is also expected that future robots will even be able to present scaled haptic feedback, solving this problem and improving this perception. Surgeons without specific training in robotic surgery can yield risks for patients undergoing these procedures. Thus the robotic manufacturer gives them an introductory course. This allows a safer and more rational use of the robot. Surgical risks can be mitigated by following a standardized protocol. We tested the described procedure in 2 cadaveric models before we tested it in a live patient so that we could standardize the robot docking, position the robotic arms, open a cavity, and create the portals. Regarding orthopaedic surgery, there is a long way to go because there is still a complete lack of standardization for orthopaedic surgery. The costs of the robotic hands are high but can be mitigated because they are designed to be used 10 times. The learning curve in telerobotic endoscopy is not long because the 3-dimensional view allows the visual depth, bringing the surgeon to the real visual world; moreover, the intuitive movements provided by the controls in the console replicate the real movements used during an open procedure. There are some limitations to this procedure related to small and thin patients because the surgeon is unable to reach an ideal size of cavity to introduce the robotic hands and the optics. Perhaps future robots will have smaller diameters, allowing universal use of this procedure. This is the first reported technique of an endoscopic robotic approach to access the ulnar nerve. This first elbow procedure was simple in order to better establish the portals and the endoscopic landmarks. The robotic surgical procedure presented a cosmetic advantage, as well as possibly reduced scar formation, in the live patient. An endoscopic robotic approach to the ulnar nerve is possible and can be a surgical option; however, knowledge of the regional endoscopic anatomy and training in robotic surgery are necessary to use this technology.
ARTICLE Endoscopic exploration and repair of brachial plexus with telerobotic manipulation: a cadaver trial Laboratory investigation Gustavo Mantovani, M.D.1, Philippe Liverneaux, M.D., Ph.D.2, Jose Carlos Garcia Jr., M.D.3, Stacey H. Berner, M.D.4, Michael S. Bednar, M.D.5, and Catherine J. Mohr, M.D.6
1Department of Hand Surgery, ?Beneficência Portuguesa de São Paulo? Hospital; 3Division of Sports Medicine, Pontifical Catholic University of Campinas, São Paulo, Brazil; 2Department of Hand Surgery, Strasbourg University Hospitals, Illkirch, France; 4Department of Hand Surgery, Sinai Hospital of Baltimore, Maryland; 5Department of Orthopaedic Surgery, Loyola University, Maywood, Illinois; and 6Department of Surgery, Stanford School of Medicine, Stanford, California
OBJECT 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.
METHODS 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 CO2 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.
RESULTS 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.
CONCLUSIONS 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.
Objetivamos avaliar a viabilidade da vizualizacao endoscópica das estruturas nervosas que compõe o plexo braquial, estudar novos portais para sua abordagem, avaliar riscos de lesões iatrogenicas e realizar suturas robóticas em lesões de plexos de cadáver
Técnica cirúrgica: Foram utilizados 2 cadáveres humanos, explorando um total de 4 plexos braquiais. Os cadáveres foram deixados em decúbito dorsal horizontal. Realizamos 4 portais supra-claviculares baseados em trabalhos prévios de artroscopia do plexo braquial. Foi utilizado o robô Da Vinci SI®(Intuitive Co.) que apresenta 2 módulos: o console do cirurgião apresenta visão em 3 dimensões, possibilidade de aumento da visão em mais de 25 vezes e um designe ergonômico. Alguns componentes podem também obedecer ao comando de voz. O segundo módulo apresenta 3 mãos robóticas e a óptica. Ao invés de lançar mão de irrigação de solução salina preferimos infusão de ar.
Resultados:O procedimento cirúrgico proposto apresentou sucesso e algumas características do robô fazem da cirurgia um ato mais ergonômico para o cirurgião além de eliminar ocasionais tremores e magnificar a imagem. Obtivemos com os métodos acima uma boa vizualização do plexo braquial. A técnica descrita mostrou-se eﬁcaz na identiﬁção e vizualização de estruturas nervosas do plexo braquial e seu reparo. A dissecção e sutura robótica não causou lesões macroscópicas nas estruturas nervosas ou vasculares.
Conclusão: Esta primeira experiência na manipulação minimamente invasiva robótica do plexo braquial mostrou-se promissora e pode tornar-se clinicamente viável, requerendo no momento mais testes em cadáver e em animais vivos. Em humanos vivos a técnica robótica já foi utilizada em 1 paciente com lesão do plexo braquial mas ainda de forma aberta.
Are pedicled flaps feasible in roboticsurgery? Report of an anatomic study of the kite flap in conventional surgery versus robotic surgery
Are pedicled flaps feasible in roboticsurgery? Report of an anatomic study of the kite flap in conventional surgery versus robotic surgery.
Alexandra Huart, MD University Hospital, Reims, France Sybille Facca, MD Strasbourg University Hospitals, Illkirch, France Frédéric Lebailly, MD Strasbourg University Hospitals, Illkirch, France José Carlos Garcia, MD NÆON, Sao Paulo, Brazil Philippe André Liverneaux, MD, PhD firstname.lastname@example.org Strasbourg University Hospitals, Illkirch, France;EITS, European Institute of TeleSurgery, Strasbourg, France Abstract
Reconstruction of cutaneous defects of the hand has dramatically progressed. It should also benefit from the development of robot-assisted surgery. The aim of the present study was to consider the feasibility of a kite flap in robotic surgery. Two cadaver hands were used in this study, one for a conventional procedure, and one for a robotic surgical procedure using a da Vinci Si robot. The operative duration was measured, and all difficulties encountered during the procedures were reported. The total duration of the intervention was 19 minutes with the conventional procedure and 30 minutes with the robotic technique. Some difficulties were encountered, related both to lack of specific instrumentation and haptic feedback. Robotic surgery presents interesting advantages such as the suppression of physiological tremor, increased degrees of freedom, and enhanced precision and accuracy of hand maneuvers. In this study, it allowed the realization of a pedicled flap without any external help.
Anteriorização Telerrobótica do Nervo Ulnar: Publicado no Journal of Robotic Surgery Volume 5, Number 2 (2011), 153-156, DOI: 10.1007/s11701-010-0226-7, e apresentado no congresso Brasileiro de cirurgia do ombro e cotovelo de 2010 e em aula dada no congresso mundial de microcirurgia e endoscopia robótica de Orlando-EUA 2011.
Telerobotic anterior translocation of the ulnar nerve Jose Carlos Garcia, Gustavo Mantovani, Stephanie Gouzou and Philippe Liveneaux
Abstract 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.
CBCOC A aplicação da telerrobotica no campo biomedico tem evoluído rapidamente e com resultados promissores. As microcirurgias robo-assistidas e a manipulação nervosa são algumas das mais recentes inovações da robótica médica abrindo um campo novo dentro da ortopedia e suas subespecialidades. A proposta desse trabalho é manter atualizados os cirurgiões do ombro e do cotovelo para o campo da robótica médica. Para tal utilizamos o procedimento de anteriorização subcutânea do nervo ulnar inicialmente em 2 cotovelos de cadáver e após isso em um paciente com síndrome do túnel cubital. O robo utlizado foi o Da Vinci SI®(Intuitive Co.) que apresenta 2 módulos: o console do cirurgião apresenta visão em 3 dimensões, possibilidade de aumento da visão em mais de 25 vezes e um designe ergonômico. Alguns componentes podem também obedecer ao comando de voz. O segundo módulo apresenta 3 mãos robóticas e a óptica. O procedimento cirúrgico proposto apresentou sucesso e algumas características do robô fazem da cirurgia um ato mais ergonômico para o cirurgião além de eliminar ocasionais tremores e magnificar a imagem. Contra o uso do robô ainda temos o alto custo, a falta de mãos robóticas especiais para procedimentos ortopédicos e a perda da sensibilidade tátil. Entretanto uma nova geração de robôs está sendo projetada para associar a sensibilidade tátil, a confrontação de exames auxiliares em 3d sobrepondo-os com imagens reais, possibilidade de acessar a internet, fazer teleconferência, pedir auxílio a outro cirurgião a distância, novos braços adaptados para as mais diversas possibilidades cirúrgicas e até mesmo a união da robótica com a navegação em próteses. Alguns centros universitários americanos e franceses já experimentaram a possibilidade de realizar artroplastias de grandes articulações em vivos com robótica e navegação. A Telecirurgia robótica pode ser uma opção futura de cirurgia com a diminuição de seu custo operacional e os novos avanços científicos.
Acesso Endoscópico Robótico Posterior do Ombro para transferência do grande dorsal e acesso do espaço quadrangular
Apresentado Congresso Brasileiro de Cirurgia do Ombro e do Cotovelo 2014 Fortaleza-CE
Acesso Endoscópico Robótico Posterior do Ombro para transferência do grande dorsal e acesso do espaço quadrangular Introdução O acesso posterior do ombro é reconhecidamente difícil e dependendo das estruturas a serem abordadas a via pode ser ampla e com importante perda sanguínea. Uma via minimamente invasiva possibilitaria melhor acesso para o espaço quadrangular, triangular, grande dorsal e redondo maior.
Métodos: Foram usados 4 ombros de de cadáver na Ècole Européene de Chirurgie de Paris para criação de uma via posterior do ombro que pudesse acessar todas as estruturas citadas acima e ainda ser usada para retirada de enxerto pedicura do grande dorsal.Para tal uma mobilidade maior das pinças que as regulares de endoscopia seria necessária, portanto foi utilizado o robô DaVinci®. Como não existem cavidades naturais nessa região, uma cavidade primária é criada pelo portal da óptica e aumentada pelo robô posteriormente com ajuda de suas pinças, por endoscopia.
Resultados. As estruturas alvo foram abordadas e manipuladas com sucesso. Foi realizada a liberação do espaço quadrangular, visualização do espaço triangular e da inserção do grande dorsal. Foi realizada dissecção completa do grande dorsal, mantendo seu pedículo, de forma que o mesmo também possa ser usado como enxerto vascularizado. Não foram observadas lesões a estruturas vásculo-nervosas importantes.
Conclusão: A cirurgia robótica para a região posterior do ombro é factível. Por essa técnica enxerto do grande dorsal já foi retirado em vivos para cobertura de grandes defeitos. As outra aplicações como abordagens do espaço quadrangular, triangular e da inserção do tendão grande dorsal para transferências do mesmo, ainda precisam ser realizadas em vivos. A abordagem do espaço triangular pode ser usada para neurotizar o ramo do nervo radial para cabeça lateral do tríceps no axilar, usado em algumas paralisias do deltóide. O espaço quadrangular é abordada na neurotização citada acima e para síndrome do espaço quadrangular o tratamento
Robotic surgery has been used for a long time, it is earning space and expanding of use to daily medical practice in several surgical specialties with advantages over the traditional surgical methods. This technical Note presents an endoscopic robotic posterior shoulder approach that allow the surgeon to perform Latissimus Dorsi transfer endoscopically.
This technical note aims to present the using of the DaVinci®(Intuitive Surgical, Sunnyvale, CA, USA) robot for transfers related to rotator cuff tears.
Robotic surgery has been used for a long time1-2, it is earning space and expanding of use to daily medical practice in several surgical specialties with advantages over the traditional surgical methods3,4. Within orthopedics, we highlight the use of robotics in brachial plexus6,7 and neurologic releases7-9.
The association of the robotic technology with endoscopy have further allowed a faster recovery for the patient for many applications with shorter time of hospitalization and minimally invasive approache10.
Advantages of this method include movement accuracy, high resolution imaging with three-dimensional vision, gas infusion rather than saline solution (better visualization), filtering of the surgeon’s tremor when manipulating objects, movement scaling and hand-free camera manipulation11-14. In addition for future, there is the possibility of remote surgery (telesurgery) where the surgical team can treat a patient far away1, 2 or a surgical team may be composed of professionals located in different cities or countries, treating the same patient simultaneously.
Some shoulder pathologies that will need posterior shoulder approach may need aggressive and traumatic exposure with extensive manipulation of soft tissues. The possibility to use a minimal invasive approach can potentially be important for both the time of rehabilitation and avoiding local soft tissue adhesions. In Addition, when performing a large posterior open approach, one needs the use of tensioned retractors in order to keep the surgeon’s field in a suitable manner. The use of these tensioned retractors can eventually damage the deeper muscle layer as well as other neurovascular structures15,16.
The minimally invasive procedures have demonstrated decrease of adhesions, avoiding reoperations and physical therapies during long times. Indeed, this advantage mentioned above make these procedures cost-effectives10.
There are few descriptions using the aid of robotics in the area of orthopedics, especially in shoulder surgery, a practice already widespread in other surgical areas, but which have been gaining space and recent publications17-19.
In shoulder surgery, the use of robotic-assisted surgery for better identification of the quadrangular space of the shoulder, identification of the axillary and radial nerves, and better identification of the latissimus dorsi muscle was done in a cadaver trial before20.
The visualization and partial manipulation of the latissimus dorsi muscle has already been reported, in order to aid the transportation of the muscular pedicle, with technique that was used as reference for our study19.
Axillary nerve identification has also been described9, making a contribution to our study and confirming the viability of the method.
Regarding bleeding, studies in live patients have shown that the air insufflation have been effective on avoiding it8.
This technical note is based on previous cadaveric trials20 and aims to present the using of the DaVinci®(Intuitive Surgical, Sunnyvale, CA, USA) robot for transfers of the latissimus dorsi tendon to humeral head we have already performed in four live patients for massive rotator cuff tears.
Indications, pre-operative evaluation and imaging
This procedure has the same indications of the traditional open transfer of the Latissimus dorsi tendon, patients with massive rotator cuff tears with poor biologic characteristics of the tendon. Fat infiltration degrees 3 and 4 of Goutallier with a retraction of more than 4cm in patients under 60 years presenting active subscapularis tendon is the ideal surgical indication.
Patients will present pain and difficulty or impossibility for shoulder elevation and abduction. The youngest the patient is, better tends to be the result.
Patient is left in ventral decubitus, the arm being maintained in a position similar to 90o elevation.
The inferior border of the Latissimus Dorsi can be localized by palpation. A draw of the muscle is done in the skin based on its inferior border and its known anatomy. A central line of the Latissimus Dorsi is also drawn. An 1cm incision is made in the skin, 10 to 15cm from the axilla, the central portal. Two other portals are made 5-7cm perpendicular medial and lateral to the central line. These portals are located 7-10cm from the axilla. The central portal is used to insert the optics and through the other two portals the robotic hands were introduced to access the muscular fascia where a cavity was formed through blunt dissection.This space was made for triangulation as an initial working cavity, once there are no natural cavities in this region.
A trocar and a canula are introduced into each of the incisions, in a common direction in the cavity the surgeon created (Fig. 1). In the first portal on the trapezius, the camera of the DaVinci® SI or Xi robot (Intuitive Surgical, Sunnyvale, CA, USA), with an optic of 300(Fig.2) is introduced.
Carbon dioxide was inflated at a constant 8-14mmHg pressure through the chamber portal into the working cavity, stretching the soft tissues and opening the cavity. The robotic arms used a Cadieri Forceps 8mm (Intuitive Surgical, Sunnyvale, CA, USA) and a Hot ShearsTM Monopolar Curved Scissor 8mm (Intuitive Surgical, Sunnyvale, CA, USA).
The first objective was to clean the area around the camera so that a best dissection and identification of the initial working cavity is done. After this first stage, we search for the superior border of the latissimus dorsi muscle and its division with teres major. Dissection using this muscular plane is done until its entrance deep into the medial border of the long head of the triceps(Fig. 3).
The Latissimus is released and separated from the teres major(Fig. 4), the radial nerve is just below the latissimus and it is possible to visualize it but not required (Fig. 5). One needs to take care the neurovascular pedicle in order to not damage it. A 0 Vicryl™ J318(Johnson & Johnson-São Paulo-Brazil) is inserted by the cephalic robotic hand’s portal. The latissimus dorsi tendon is sutured by using a Cadieri and a DeBakey Forceps(Intuitive Surgical, Sunnyvale, CA, USA)(Fig. 6)(Video. 1). The sutured tendon is pulled out of the body through the central portal of the optics using a gastric forceps.
A small 3-5cm incision is done on the lateral deltoid and using the finger a dissection of the subdeltoid space reaches the cavity created by the robot. A long gastric grasper is inserted through the cephalic robotic hand’s portal until it reaches the subdeltoid space. A guide polyester 5.0 wire is passed by using this grasper, leaving optics portal(Fig. 7).
The humeral head is drilled and 2 anchors are inserted. These anchor wires will pass from the deltoid approach to the optics portal using the 5.0 polyester wire as a guide.
The tendon is sutured to the anchor wires using a Krakow(Fig. 8) and passes to subacromial space pulled by the anchor wires, and a standard tendon to bone suture is done. More anchors and sutures can be done after the tendon lies the humeral head.
Portals and deltoid lateral approach are sutured.
A sling is used for 5 weeks. Pendular movements and passive elevation until 90º are allowed 2 weeks after surgery. After this period the active exercises isometric external rotation and elevation begin. In more two weeks isokinetic and proprioception movements begin. A scapular retraction and shoulder extension need to be stimulated in the initial movements, once Latissimus dorsi can also be activated during these movements. Better evolutions are present in patients with better active movements before the surgery.
Pearls and pitfalls are summarized on table. 1. Advantages and Disadvantages are summarized on table. 2.
Traditional approaches for the latissimus dorsi are wide requiring big posterior incisions with cosmetic and scar formation implications.
Previous cadaveric and live patient studies were used to stablish principles for the robotic latissimus dorsi transfer presented on this technical note.
The authors aim to present a surgical technique that can be improved and even be used for other orthopedic applications with future introduction new robots, new robotic arms and smaller optics.
There are few studies assessing the latissimus dorsi using the aid of robotics, all of them access the muscle and the origin of the latissimus for free flaps17-20. This is the first in vivo robotic assisted shoulder surgical procedure done for transfer of the latissimus dorsi insertion to improve function after rotator cuff tears. Tendon, neurovascular structures, quadrangular space were robotically identified in cadaver trials by the author before in other trials, thus surgical viability and safety of the procedure were previously checked9,20.
Other robotic orthopedic applications in live patients have also demonstrated that the air insufflation effectiveness on better bleeding conctrol8.
The viability of the robotic introduction in shoulder surgery was shown by the authors that hope to encourage further studies in the area.
The limitations of this technique are cost of the robot, robotic hands and its scisures. Necessity of specific training on robotic surgery, that is currently costly and not available in many hospitals, can also limits its current use.
In this moment surgical time is longer than in the open procedure, however this situation tends to improve on time.
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Robotic transfer of the Latissimus Dorsi Tendon from NAEON Institute Sao Paulo Brazil
Portals are done 10-15cm from the latissimus dorsi insertion, 1 central; 1 superior and 1 inferior.
As no natural cavities are present in this area one can gently create a subcutaneous cavity.
The optics trocart is the central, superior and inferior are dedicated to the robotic hands.
This is an external view of the initial subcutaneous and muscular dissection
This is how the surgical site is presented by the robot, but in 3 dimensions.
After a wide dissection the teres major on the left is separated from the latissimus dorsi on the right
The tendon is cut from its humeral insertion
Latissimus is mobilized and separated from the teres major
Care must be taken because as you can see the radial nerve lies just under the tendon
Knowing where the nerve it is easier to release the muscular part or the Latissimus dorsi
The released tendon is sutured
The needle and the wire pass through the optics portal
The deltoid approach is done and a guide polyester wire is also inserted from subdeltoid to the optics portal
Anchors are inserted in the humeral head through the same deltoid approach and their wires are passed by using the guide polyester to the optics portal.
The wires of the suture anchors are sutured on the tendon and the tendon is pulled through cavity until the subdeltoid space and the final fixation in the bone is done
Fig. 1. Patient in ventral decubitus: A and B: Robotic hand trocaters, C: Optics Trocater, D: Shoulder, E: Robotic Exterior Hand, F: Robotic Exterior Hand for Optics.
Fig. 2. Robotic Optics 30º with 2 cameras allowing a stereoscopic view.
Fig. 3. Optics within the central portal. TM:Teres Major, LD: Latissimus Dorsi
Fig. 4. Optics within the central portal. TM: Teres Major, LD: Latissimus Dorsi released
Fig. 5. Optics within the central portal. A: Radial Nerve, B: Teres Major insertion, C: Latissimus Dorsi retracted.
Fig. 6. Optics within the central portal.TLH: Trices Long Head, LD: Latissimus Dorsi, TM: Teres Major
Fig. 7. Patient in ventral decubitus, shoulder and scapular area exposed A: Polyester guide wire through the deltoid approach, B: Gastric forceps, C: Wires where the Latissimus Dorsi was sutured, D: Polyester guide wire exit
Fig. 8. Patient in ventral decubitus, shoulder and scapular area exposed A: Latissimus dorsi sutured with the suture anchor wires, B: The other parts of the suture anchor wires, these will pull the tendon to the humeral head.
Table. 1 Pearls and Pitfalls
Table. 2 Advantages and disadvantages comparing Robotic versus Arthroscopic versus Open surgeries for Latissimus Dorsi transfer.
Robotically Assisted Harvest of the Latissimus Dorsi Muscle: A Cadaver Feasibility Study and Clinical Test Case
The applications of robotic surgery have quickly spread into a variety of surgical fields. Interest in robotic endoscopic surgery is high because of the small size of the incisions, cosmetic advantages, less invasive surgical techniques, decreased scar tissue, shorter duration of hospitalization and increased cost-effectiveness. We will describe an anatomical feasibility study and a clinical test case of robotically assisted pedicled transposition of the latissimus dorsi muscle.
Objective: This study demonstrates the new technology of the robotic telesurgery on three brachial plexus reconstructions. We also discuss the implications, problems, and benefits of robotically assisted brachial plexus surgery.
Methods: After the first experimental experience in a cadaveric model, the authors performed three brachial plexus reconstructions. The surgery followed the traditional brachial plexus approach. From the moment that nervous sutures would be performed, the Da Vinci® (Intuitive Surgical™, Sunnyvale, CA) equipment was docked at the patients, positioned behind the patient’s head, and the microsurgical steps were performed by using robotic telemanipulation.
Results: The first procedure was performed in a cadaver to gain experience and establish a surgical protocol by using the robot. In all the three living patients, the goals of the surgical procedure were achieved using the telerobotic manipulation.
Conclusion: Robot-assisted surgery allows performance of high-dexterity surgical operations with the help of robotic arms and it improves the surgery due to tremor filtration, motion scaling, and ergonomics. The benefit of using the robot on microsurgery was reached, but its entire potential was not realized because the instruments used on those first experimental and clinical cases were not specifically designed for microsurgery.
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