Robotic Nerve Surgery: Brachial Plexus.

Management of closed brachial plexus injuries has traditionally favored conservative approaches with lengthy intervals between initial injury and surgical reconstruction. The complex anatomy of this region often requires large incisions with extensive dissection. Recently, the use of robotic systems in plastic and reconstructive surgery has been increasing, and robot-assisted brachial plexus reconstruction is a novel application that is currently being explored. Current literature describing this application is primarily comprised of feasibility studies using animal and cadaver models, and literature describing use in human subjects is limited. Advantages demonstrated by these early studies include the reduction of physiologic tremor, 3D visualization of anatomical structures, and ergonomic positioning; this allows for increased surgical dexterity and the ability to perform minimally invasive microsurgical procedures within the confined anatomical spaces of the brachial plexus. Limitations revolve around inadequate instrumentation, large learning curves, and increased costs that restrict the ability to perform these complex microsurgical procedures reliably and efficiently. As companies continue to develop instrumentation specific to robot-assisted microsurgery, more extensive longitudinal studies outlining long-term costs, changes in operating time, and functional outcomes will be required before a conclusion about the utility of these systems in brachial plexus surgery can be made.

Pediatric Microsurgery and Free-Tissue Transfer.

Advancements in microsurgery, along with increased microsurgical experience in pediatric patients, have made free-tissue transfer a reliable modality for pediatric bone and soft tissue reconstruction today. Free-tissue transfer is most commonly used in children for the coverage of large or complex defects resulting from traumatic, oncologic, or congenital etiologies. While flap success and complication rates between pediatric and adult populations are similar, special considerations must be taken into account within the pediatric population. In this article, we will describe common indications, technical nuances, and clinical considerations for the management of the pediatric free-tissue transfer patient.