Development and evolution of a robotic surgical technique for the treatment of thoracic outlet syndrome.

OBJECTIVE: We describe the development and evolution of a surgical technique that uses the robotic da Vinci Surgical System (Intuitive Surgical, Inc, Sunnyvale, Calif) for the transaxillary approach to repair the disabling thoracic outlet syndrome (TOS). We report our patient outcomes associated with the use of this robotic technique. METHODS: We present a retrospective review and analysis of data collected from a 16-year experience of a single surgeon using a robotic surgical system and technique for TOS surgery. From the initial design of an endoscope attached to a microvideo camera in 1982 to the adoption of the monorobotic arm with integrated voice in 1998, the main objective of the transaxillary approach has always been to improve visualization of congenital cervical anomalies of the scalene muscles. From February 2003 to December 2018, we performed 412 transaxillary decompression procedures using the robotic da Vinci Surgical System. The surgical procedure has been described in further detail and includes the following steps: (1) positioning of the patient into a lateral decubitus position and using a monoarm retractor; (2) creation of a mini-incision in the axillary area and creation and maintenance of the subpectoral anatomic working space; (3) placement of endoscopic ports and engagement of the robotic instrumentation; (4) dissection of extrapleural and intrapleural soft tissue; (5) creation of the "floater" first rib; (6) excision of the cervical bands and first rib; and (7) placement of thoracostomy tubes for drainage and closure of the incisions. RESULTS: None of the patients died, and no patient experienced permanent neurovascular damage of the extremity. Of the 306 patients, 22 (5% of 441 operations) experienced complications. One patient developed postoperative scarring that required a redo operation with a robotic-assisted transaxillary approach. CONCLUSIONS: With its three-dimensional visual magnification of the anatomic area, the endoscopic robotic-assisted transaxillary approach offers safe and effective management of disabling TOS symptoms. The endoscope facilitates observation of the cervical bands and the mechanism (pathogenesis) of the neurovascular compression that causes TOS, thereby allowing complete excision of the first rib, cervical bands, and scalene muscle. We sought to develop and perfect this robotic approach. The present study was not intended to be a comparative study to nonrobotic TOS surgery.

Leiomyoma of the greater saphenous vein: a case report and review of the literature.

Greater saphenous vein tumors are exceedingly rare, whether benign or malignant. Leiomyoma is one of the benign vascular tumors that can present as a localized mass; however, the diagnosis cannot be made clinically. Multiple radiologic imagings are usually required, as well as histological examination, to make a definitive diagnosis. This tumor is treated by wide excision along with a normal portion of the vessel, and the recurrence rate is very low. We describe the case of a patient with great saphenous vein leiomyoma.

Laparoscopic aortorenal bypass in an acute porcine model under warm ischemia: feasibility study and resident training module.

BACKGROUND AND PURPOSE: Laparoscopic aortorenal bypass (LARB) in a human being has never been reported. Both the skills required and the concern over preserving renal parenchyma by minimizing ischemia time has limited laparoscopic renal revascularization. The limit of safe renal warm ischemia is 30 minutes, which, it may be argued, is too short to permit laparoscopic anastomosis by those who have never performed the procedure. We sought to demonstrate the feasibility of LARB by determining whether it can be performed under warm ischemia and entirely by a resident after sufficient training. We describe our training program and experience with LARB. MATERIALS AND METHODS: An LARB was performed in four pigs. There were no practice pigs, as data were collected on the first pig, which was intentionally euthanized postoperatively, while the remaining three were allowed to survive for 24 hours. All procedures were performed by a resident with limited previous training after a regimented program in a "dry laboratory," beginning with basic skills and progressing to LARB modeling using cadaver pig kidneys. RESULTS: The mean time needed for the graft-to-aorta anastomosis was 30.5 minutes (range 21-47 inutes). The renal arterial anastomosis was completed within 30 minutes in three of the four animals, including the first animal attempted (24, 32, 19, and 15 minutes, respectively). The mean total operative time was 3.1 hours. CONCLUSIONS: With continuing refinements in technique, LARB under warm ischemia is feasible and not only for an elite few surgeons with advanced skills. We believe any surgeon can become capable of performing this procedure. In addition, LARB provides a porcine model for training that includes both advanced skill and time endpoints.

Performance measurements in endolaparoscopic infrarenal aortic graft implantation using computer-enhanced instrumentation: a laboratory model for training.

BACKGROUND: Performance measurements in an endolaparoscopic aortic animal laboratory model have been reported since Dion's work (1995). The purpose of this paper is to report performance measurements using computer-enhanced surgical instrumentation in a porcine model. METHODS: From February 2000 to December 2002, training in robotic instrumentation consisted of implantation of infrarenal aortic grafts in 3 groups of 5 animals each. The time frame to complete all 15 procedures reflects 2 major difficulties: the need to schedule procedures based on the surgeon's time off from his solo practice and the availability of laboratory sites to complete the procedures. A full endolaparoscopic technique was used to perform 2 end-to-end anastomoses through an intraperitoneal approach. A different method of computer-enhanced instrumentation was used for each group of animals as follows: (1) AESOP robotic arm and HERMES integrated voice control instrumentation, (2) AESOP-HERMES-ZEUS robotic systems, (3) da Vinci robotic system. The aortic clamp time, total operative time, and blood loss were recorded for each procedure. Secondary endpoints included spinal cord ischemia, graft thrombosis, and bleeding. RESULTS: All animals tolerated the procedure. All grafts were patent and suture anastomoses intact. Two instances of bleeding, both of which were controlled laparoscopically, occurred. Aortic clamping time was significantly improved in Group 3 compared with that in Group 2 (P=0.008). CONCLUSION: The results of the first group reflect previous experience with the AESOP-HERMES instrumentation. However, the times of the ZEUS group and da Vinci group reflect initial exposure to the technology. The remote position of the surgeon at the console did not appear to affect the performance as shown in the last group. The da Vinci group provides an advantage compared with the ZEUS group. Both systems showed adaptability and versatility in controlling adverse bleeding encounters.

Robotics in vascular surgery.

The procedure for surgical correction of aortic disease has gone relatively unchanged over the last 50 years, requiring a xiphoid pubic incision as well as shifting of the abdominal viscera. These maneuvers produce significant pathophysiologic changes that consequently affect intraoperative and postoperative care and recovery. In approaching minimally invasive aortic surgery, advances in computer-enhanced technology have the potential to revolutionize aortic surgery and improve patient safety. A MEDLINE search specific to robotic aortic vascular procedures was performed and produced 7 articles (3 animal model and 4 clinical application). Robotically assisted technology became available for use in 2000. Since that time, computer-enhanced technology for aortic anastomoses has been applied successfully in the animal model. Early application in the clinical setting for aortoiliac disease also has been successfully initiated. Robotic technology provides the vascular surgeon with the ability to perform the delicate tissue handling necessary for aortic procedures. Based on their knowledge of current procedures, surgeons must redesign their surgical strategies to adapt to this computer-enhanced methodology.

A porcine model for endolaparoscopic abdominal aortic repair and endoscopic training.

OBJECTIVES: The goals of this laboratory model were to evaluate the performance of the surgical team and endolaparoscopic techniques in the porcine model of infrarenal abdominal aortic repair. METHODS: Twenty-four pigs underwent full endolaparoscopic aorto-aortic graft implantation with voice-activated computerized robotics. The first group of 10 pigs (acute) was sacrificed while under anesthesia at 0.5 hours (5 animals) and 2 hours (5 animals). The second group of 14 pigs (survival) were recovered from anesthesia and maintained for 7 hours (5 pigs) and 7 days (9 pigs) prior to sacrifice. Survival animals were observed for evidence of hind limb dysfunction. All grafts were visually inspected at autopsy. RESULTS: All animals survived the operation. All grafts were successfully implanted, and all were patent with intact anastomoses at autopsy. Mean aortic clamp time for each group was as follows: acute, 92.9 +/- 28.04 minutes; survival, 59.6 +/- 13.8 minutes; P=0.0008. Total operative time for each group was as follows: acute, 179 +/- 39.6 minutes; survival, 164.6 +/- 48 minutes; P=0.44 ns. Estimated blood loss for each group was as follows: acute, 214 -/+ 437.8 mL; survival 169.2 +/- 271 mL; P=0.76 ns. from respiratory arrest; 1 animal suffered motor sensory dysfunction of the hind limbs (spinal cord ischemia); significant bleeding occurred in 6 of 24 pigs; 8 of the 9 seven-day survivors required minimal pain medication and had normal hind limb function. CONCLUSIONS: The reduction in aortic clamp time, total operative time, and blood loss as the study progressed indicate the feasibility of this surgical protocol and the maturation of the learning process, which is paramount in prevention of 2 main sources of morbidity: bleeding and spinal cord ischemia. The reduction in aortic clamp time between the acute and survival groups was dramatic and statistically significant. An intensive formal training program combining dry and live surgical laboratories is deemed essential for the development of endoscopic skill sets necessary for this challenging procedure.

Computer-assisted instrumentation during endoscopic transaxillary first rib resection for thoracic outlet syndrome: a safe alternate approach.

UNLABELLED: The purpose of this article is to discuss the feasibility of using computer-enhanced instrumentation to improve visualization and therefore patient safety during transaxillary first rib resection. From November 1998 to July 2005, 105 patients who had failed conservative treatment underwent 131 procedures for thoracic outlet decompression. Eighty-nine endoscopic transaxillary first rib resections were completed using Aesop/Hermes integrated voice control instrumentation (Computer Motion, Goleta, CA). Since February 2003, dissection in 42 procedures was performed using the daVinci Surgical System (Intuitive Surgical, Inc, Sunnyvale, CA). The surgical findings with cervical bands correlated with the preoperative symptoms. One hundred percent of patients with a combination of neurogenic and arterial thoracic outlet syndrome (TOS) requiring cervical rib resection had Roos type I and/or II bands. Additional surgical findings included the following: combination of neurogenic and arterial TOS without cervical ribs or neurogenic TOS alone had type III, IV, or V bands, and patients with venous compression (100%) had type VII bands. No mortalities or permanent neurovascular injuries occurred. There was a 6.1% postoperative complication rate. Persistent myofibrositis was found in 34% of patients with ongoing symptoms. CONCLUSION: The daVinci three-dimensional optical imaging system enhances visualization, thereby promoting telemanipulation of soft tissue structures in a relatively inaccessible working space. Endoscopic computerized instrumentation in transaxillary first rib resection decreases the risk of neurovascular injury, promotes complete decompression, and therefore provides a safe alternative to standard first rib resections.