Robotic-Assisted Anastomosis in Orthoplastic Surgery: Preliminary Data.

BACKGROUND: The evolution of microsurgery has relied on advancements in operating microscopes and surgical instruments. Pioneering advancements, however, especially within the domain of "super-microsurgery", challenge the limits of human dexterity by dealing with anastomoses between vessels smaller than 0.8 mm. Based on these premises, the Symani robotic system was designed and developed. This platform utilizes teleoperation and motion-scaled movement to provide surgeons with precision and accuracy in manipulating millimetre and submillimetre-sized anatomical structures. In this study, we present our experience in performing robotic-assisted anastomoses using the Symani Surgical System in free flap reconstruction. METHODS: We present a comprehensive analysis of all reconstructive procedures involving microsurgical free flaps performed using the Symani robotic platform at the orthoplastic unit of the Rizzoli Orthopaedic Institute from 1 October 2022 to 1 May 2023. RESULTS: Sixteen microsurgical reconstructions using free flaps were performed, involving a total of 40 anastomoses on vessel calibres ranging from 0.6 mm to 2.5 mm. In each case, the anastomosis was executed with the assistance of the robotic platform, achieving a 100+% success rate in patent anastomoses, and no major complications occurred.Conclusion The Symani system has proven to be safe and reliable in performing microsurgical anastomoses. While this platform demonstrated successful in various vessel calibres, its most promising potential lies in anastomoses below the size of a millimetre. Larger patient cohorts and extended investigation periods will be essential to explore whether robotics in microsurgery offers advantages across all microsurgical procedures or should be reserved for selected cases.

Microsurgical robotic system enables the performance of microvascular anastomoses: a randomized in vivo preclinical trial.

Technical advances in microsurgery have enabled complex oncological reconstructions by performing free tissue transfers, nerve and lymphatic reconstructions. However, the manual abilities required to perform microsurgery can be affected by human fatigue and physiological tremor resulting in tissue damage and compromised outcomes. Robotic assistance has the potential to overcome issues of manual microsurgery by improving clinical value and anastomoses' outcomes. The Symani Surgical System, a robotic platform designed for microsurgery, was used in this in-vivo preclinical study using a rat animal model. The tests included anastomoses on veins and arteries performed by microsurgeons manually and robotically, with the latter approach using Symani. The anastomoses were assessed for patency, histopathology, and execution time. Patency results confirmed that the robotic and manual techniques for venous and arterial anastomoses were equivalent after anastomosis, however, the time to perform the anastomosis was longer with the use of the robot (p < 0.0001). Histological analysis showed less total average host reaction score at the anastomotic site in robotic anastomosis for both veins and arteries. This study demonstrates the equivalence of vessel patency after microsurgical anastomoses with the robotic system and with manual technique. Furthermore, robotic anastomosis has proven to be slightly superior to manual anastomosis in terms of decreased tissue damage, as shown by histological analysis.

First-in-Human Free Flap Tissue Reconstruction Using a Dedicated Microsurgical Robotic Platform.

BACKGROUND: Microsurgery has become standard of care for increasingly complex techniques in tissue harvest, replantation, reconstruction, allotransplantation, and supermicrosurgery on submillimetric vessels. As techniques become more challenging and are performed at smaller and smaller scale, there is greater potential application for robotic assistance in extreme motion scaling and tremor reduction. METHODS: The Symani Surgical System (Medical Microinstruments, S.p.A, Calci, Pisa, Italy), a robotic platform designed for microsurgery, was used in a robot-assisted microsurgical free flap reconstruction using a perforator-to-perforator flap technique. This procedure utilized robot-assisted anastomosis of an artery and vein. RESULTS: The procedure was completed successfully, with vessels fully patent immediately following and 20 minutes after anastomosis. The flap was viable, no re-exploration of the anastomosis was necessary postoperatively, and no flap loss occurred. CONCLUSIONS: This novel, dedicated robotic platform with wristed microsurgical instruments was shown to be feasible for carrying out robot-assisted anastomosis of veins and arteries less than 0.8 mm in diameter, in the domain of supermicrosurgery. The system has the potential to open the field of microsurgery to new clinicians and to facilitate new microsurgical applications that were previously rendered inaccessible by the limits of manual precision and physiological tremor.

Rhino-oropharingeal osteoradionecrotic soft-tissue and bony defect reconstruction with submental artery island flap: a case report.

BACKGROUND: The submental artery island flap is widely used in head and neck reconstruction, since it is easy and quick to harvest, and it can be successfully used for the coverage of perioral, intraoral and facial defects. We used this technique for the reconstruction of a complex soft-tissue and bony defect of rhino-oropharinx. CASE REPORT: Osteoradionecrosis of rhino-oropharingeal posterior wall with C2 necrotic body exposure occurred in a 77-year-old woman. After the failure of reconstruction with a Hadad-Bassagasteguy flap, a submental island flap with cervical spine stabilization was planned to be performed in a one-stage operation. The anterior arc of C1 and odontoid process of C2 were removed and, according to the defect size, a submental island flap was designed in an elliptical fashion. The flap was rotated 180° and tunnelized under the left parapharingeal-prevertebral space, then it was positioned in the rhino-oropharinx and fixed with reabsorbable sutures. The donor site was closed primarily. No peri- or post-operative complications occurred, neither in the recipient nor in the donor-site. At the latest follow-up, 15 months postoperatively, the patient was able to speak without any impairment and started swallowing rehabilitation with good results and an aesthetically satisfactory outcome. CONCLUSION: The submental island flap may be a reliable and versatile flap for reconstruction of head and neck defects, even though in the rhino-oropharingeal posterior wall.

New Robotic System with Wristed Microinstruments Allows Precise Reconstructive Microsurgery: Preclinical Study.

BACKGROUND: Microsurgery allows complex reconstruction of tissue defects after oncological resections or severe trauma. Performing these procedures may be limited by human tremor, precision, and manual dexterity. A new robot designed specifically for microsurgery with wristed microinstruments and motion scaling may reduce human tremor and thus enhance precision. This randomized controlled preclinical trial investigated whether this new robotic system can successfully perform microsurgical needle driving, suturing, and anastomosis. METHODS: Expert microsurgeons and novices completed six needle passage exercises and performed six anastomoses by hand and six with the new robot. Experienced microsurgeons blindly assessed the quality of the procedures. Precision in microneedle driving and stitch placement was assessed by calculating suturing distances and angulation. Performance of microsurgical anastomoses was assessed by time, learning curves, and the Anastomosis Lapse Index score for objective performance assessment. RESULTS: Refined precision in suturing was achieved with the robot when compared with the manual technique regarding suture distances (p = 0.02) and angulation (p < 0.01). The time required to perform microsurgical anastomoses was longer with the robot, however, both expert and novice microsurgeons reduced times with practice. The objective evaluation of the anastomoses performed by novices showed better results with the robot. CONCLUSIONS: This study demonstrated the feasibility of performing precise microsutures and anastomoses using a new robotic system. Compared to standard manual techniques, robotic procedures were longer in time, but showed greater precision.

Six-years experience in major scalp defect reconstruction with free flap: analysis of the results.

Introduction The purposes of this study were to report 10-years experiences in microsurgical reconstruction of major scalp defects, comparing outcomes, evaluating complications.  Materials and methods From November to July 2015, 10 consecutive patients underwent microsurgical procedures for severe scalp defects. Results The average age was 55,1 years ranging from 6 to 87 years. The mean follow-up was 16.7 months ranging from 12 to 24 months. The size of the lesions ranged from 9x10 to 16x20cm. The average hospital stay was 20 days ranging from 8 to 43 days. Mean operative times was 5.3 h ranging from 5 to 6.45 h. Free flaps included 8 Latissimus Dorsi flaps (LD) and 2 anterolateral thigh flaps (ALT). The superficial temporal vessels were used as recipient vessels in 9 cases while the superior Thyroid artery was used in remaining case. Discussion For large or complex lesions, the use of free flaps is mandatory. Nowadays LD and ALT flaps are among the most common reconstructive choices for scalp defects reconstructions. Older age does not contraindicate the operation procedure nevertheless in younger patients the size of vessels is proportionately larger and pristine.   Conclusion Microvascular free tissue transfer is the mainstay of scalp defects coverage. In our series early complications are less common and concerning than late complications and in fact reoperations are mainly required to manage these latter. Advanced age should be not consider a contraindication for free flap surgery and the procedure can be considered safe and reliable in both old and young population.

Pelvic ring reconstruction with double-barreled fibular free flap: A systematic review.

INTRODUCTION: Pelvic ring reconstruction after internal hemipelvectomy is an extremely challenging surgical procedure, and mandatory reconstruction is to provide a durable and pain-free functional outcome, especially for young, active patients. One of the most widely employed techniques is reconstruction with a double-barreled fibular free flap (DBF). The aim of our work was an in-depth analysis of the outcome of pelvic ring reconstruction performed using the above-mentioned method, in particular looking for a correlation between the fixation technique and either ambulation status or complications. MATERIALS AND METHODS: A systematic review was performed in November 2020 using PubMed and MedLine Ovid databases according to the PRISMA guidelines and the results were statistically analyzed. RESULTS: Studies were published between 1994 and 2015. A DBF was used in each case, with a total of 30 patients. Reconstruction was performed with screws in 13 cases, Cotrel-Dubousset rod fixation in 6, screws and plate in 5, screws with external fixation in 4, and ISOLA in 2. Follow-up time ranged from 3 to 131 months. Functional outcome was excellent in 4 patients and good in 26 patients. Statistical analysis showed no statistical evidence of existing correlation between fixation technique and complications (p = .873), while statistical correlation between age and fixation technique was found (p < .001). CONCLUSION: Reconstruction of pelvic ring with DBF provides an overall good functional outcome. Our data indicate that there is no statistical evidence of existing correlation between the fixation technique and either complications or ambulation status.

The role of VFG in wrist arthrodesis: Long term results in a series of 11 patients and literature review.

BACKGROUND: Total wrist fusion (TWF) is indicated for longstanding degenerative, posttraumatic and/or post-oncological conditions to provide pain relief and wrist stability at partial expense of wrist motion. PATIENTS AND METHODS: A total of 11 consecutive patients who had completed TWF with Vascularized Fibula Graft (VFG) for massive distal radius defects were identified retrospectively from our center using inpatient records. We evaluated bone fusion times and long term functional outcomes following the procedure. Post-operative grip strength (GS) and prono-supination were objectively measured. The new Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire was used to rate disability and symptoms; pre- and post- operative pain with the Visual Analog Scale (VAS) was assessed. A literature review of the present studies about TWF with VFG was performed, with the aim of comparing long-term functional results of the surgical techniques so far reported in the English literature. RESULTS: Our experience with TWF using VFG appeared slightly better than that found in the literature. The procedure was successful in all the cases, achieving bone union in 4,8 months on average. Complication rate was 27,2%, no flap loss was recorded. There were no wrist instability, deformation or dislocation; mean pronation/supination (P/S) was 57,5°/61,2° Average grip strength resulted 59% of the contralateral side. Mean recorded levels of visual analog scale (VAS) for pain postoperatively were 2,32 ± 0,792, which improved significantly from the pre-operatively value of 7,90 ± 0,79. Mean overall satisfaction was good and all the patients comfortably returned to normal activities. CONCLUSIONS: Wrist arthrodesis by means of VFG resulted to be an effective and reliable option in dealing with massive defects of distal radius with involvement of radio-carpal joint. Although the cohort analyzed is relatively small and definitive conclusions cannot be drawn, the long term radiographs and the overall functional outcomes encourage to use the described surgical option over other techniques, such as prosthetic replacement and non-vascularized bone grafts.

Radial forearm free flap in a patient with an unusual radial artery variation: a case report.

Head and neck reconstruction poses unique challenges in rehabilitating surgical defects in terms of integrity, function, and form. The radial forearm free flap (RFFF) has been widely used for defect coverage, especially in the head and neck area, but its versatility allows it to be used for soft-tissue reconstruction in various parts of the body. The vascular features of the flap are quite constant and reliable. Nevertheless, abnormalities of the forearm vascular tree have been described over the decades. We report a case of intraoral reconstruction after verrucous carcinoma recurrence in a 74-year-old woman with an unusual forearm flap, which we called the median forearm free flap, based on a median branch of the radial artery that was preoperatively detected using handheld Doppler ultrasonography. The distally located skin paddle was predominantly supplied by the aberrant median vessel with its perforators. The flap was thus safely harvested with this atypical pedicle. Successful reconstruction of the intraoral defect was achieved, with an uneventful postoperative course.

Reconstruction after complete mandibular avulsion with double-paddle fibular free flap. A case report.

Reconstruction after maxillofacial trauma is extremely challenging. During the past several decades, the chimeric fibular-free flap has emerged as a leading reconstructive option for head and neck compound defects. This report describes a unique case of total mandibular reconstruction using a double-paddle osteocutaneous fibular free flap after facial traumatic injury. A 45-year-old man presented a severe maxillofacial trauma with complete mandibular avulsion. The shortest segment of a 24-cm fibular flap was used to reconstruct the symphysis while the longest segments were placed to rebuild the mandibular body. Microvascular anastomoses were performed with the external jugular vein and facial artery. The distal skin island (10 × 5 cm) was sutured to cover the endo-oral defect while the proximal one (12 × 6 cm) to restore the external tissues continuity of the facial lower third. The postoperative course was uneventful. One year after flap reconstruction, a first commissuroplasty was performed. After 3 months, secondary commissuroplasty was performed with an Estlander flap to rebuild the right lower lip. At latest follow-up, 60 months postoperatively, the patient was able to tolerate soft diet with maximal mouth opening of more than 4 cm; no impairment to mastication, deglutition, or phonation was observed. Speech was normal and the aesthetic outcome was judged good. Double-paddle fibular free flap allows reconstruction of extremely challenging defects, such in case of complete mandibular avulsion. The proximal perforator can provide extended soft-tissue coverage and greater volume than traditional osteocutaneous flaps, avoiding two flaps simultaneous harvest.

Reverse-flow latissimus dorsi myocutaneous flap in a multi-step approach for complex back defect reconstruction: A case report.

Reconstruction of complex back defects is challenging for reconstructive surgeons, as it should preserve function, provide adequate coverage, and minimize morbidity. We present a case of multiple-step reconstruction after resection of a large squamous cell carcinoma recurrence in a 68-year-old man, with local perforator flaps and a reverse-flow latissimus dorsi myocutaneous flap. After radical excision, four propeller perforator flaps were harvested to cover a 30 × 25 cm defect, based on the dorsal branch of the fifth posterior intercostal arteries (right 20 × 9 cm, left 17 × 9 cm) and on the superior gluteal arteries (right 20 × 11 cm, left 21 × 12 cm) bilaterally. In the second step, bilateral propeller perforator flaps based on the fourth lumbar arteries (right 18 × 13 cm, left 23 × 11 cm) were transposed to cover the residual loss of tissues. After 5 months, a recurrence occurred on the left midback. A wide en bloc excision of the last three ribs and pulmonary pleura was performed, and the synthetic mesh used for thoracic wall reconstruction was covered with an ipsilateral 20 × 10 cm reverse-flow latissimus dorsi myocutaneous flap based on the serratus anterior branch. All the flaps healed uneventfully and there were no donor-site complications. Two years postoperatively, the patient had a cosmetically acceptable result without any functional impairment. The reverse-flow latissimus dorsi myocutaneous flap can represent a salvage procedure in back complex defects reconstruction, especially when other local flaps have already been harvested in previous reconstructive procedures.

Extensor hallucis longus tendon and soft-tissue reconstruction with palmaris longus tendon included in a radial forearm free flap: A case report.

Reconstruction of foot structures is challenging because of the need to restore both anatomy and function. Extensor hallucis longus (EHL) excision without reconstruction could result in a flexion deformity of the toe at the interphalangeal joint. In this report, we present a case of the use of a palmaris longus tendon included in a fasciocutaneous radial forearm free flap to reconstruct EHL tendon and soft tissues of the distal foot dorsum. A 41-year-old woman presented with a recurrence of myxoinflammatory fibroblastic sarcoma on the medial part of the left foot dorsum. The EHL tendon was sacrificed, leaving a soft-tissue defect of 14 × 5 cm and 14-cm tendon gap. A 14 × 5 cm radial forearm flap with a 16-cm section of palmaris longus tendon was harvested from the left forearm. Radial artery and its comitant vein were anastomosed with dorsalis pedis artery and vein. EHL tendon repair was performed from the composite mass to the proximal and distal stumps. No complication in the postoperative period occurred. At latest follow-up, 12 months postoperatively, the patient showed a normal joint function and was satisfied with the treatment. Palmaris longus tendon included in a radial forearm free flap could be recommended for combined soft tissue and tendon defects, particularly on the foot dorsum.

Free perforator flaps vs propeller flaps in lower limb reconstruction: A cost/effectiveness analysis on a series of 179 cases.

PURPOSE: The aim of this report is to compare free perforator flaps and propeller flaps in the coverage of lower limb soft tissue defects. PATIENTS AND METHODS: 179 patients (age between 5 and 92 years old), underwent soft tissue reconstruction of the lower limb between January 2009 and January 2015, either by free flap or propeller flap. The two groups were retrospectively evaluated in order to assess the outcome, complications and potential risk factors. Correlations between risk factors and presence/absence of failure or complications have been evaluated with descriptive statistical analysis and a set of logistic regression models. Finally, an economic analysis was conducted to evaluate the different tecniques. RESULTS: In a simple descriptive statistical analysis, the overall failure rate is 6% for free flaps and 3.7% for propeller flaps; the complication rates are 14% vs 21.5% and it increases as dimension increases. The logistic models relating failure and complications with potential risk factors do not show significant differences, whereas the economic analysis show that the average expense of free flaps is 5077.5€ per patient, 1595.6€ per patient for propeller flaps. CONCLUSIONS: Our results do not demonstrate significant differences between the two groups about correlation of risk factors or flap size with complication or failure. The surgical option choice should be taken only after accurate evaluation of the soft tissue surrounding the defect. Propeller flaps should be preferred in case of small/medium size defects in otherwise healthy extremities. Free perforator flaps should be the choice in large defects due to trauma or vascular diseases. The economic analysis suggests that propeller flap should be considered when possible.

Long-Term Functional Outcome After Surgical Treatment of Peroneal Intraneural Ganglion Cyst.

BACKGROUND: Intraneural ganglia are benign mucinous cystic formations that originate within the epineurium of peripheral nerves. Different treatments have been recommended, with an overall satisfactory outcome. In this paper, we aim to evaluate the long-term outcomes of surgical treatment of peroneal intraneural ganglia by reviewing our local institutional experience. METHODS: We performed a case series review of peroneal intraneural ganglia surgical treatment performed by the senior author. Demographic and surgical details were abstracted from the medical record for each patient. Electrodiagnostic studies and magnetic resonance imaging (MRI) were performed in all patients pre- and postoperatively. RESULTS: Eight men were enrolled, with an average age at time of surgery of 47.5 years (range 28-68 years). Motor testing revealed a preoperative deficit of dorsiflexion, eversion, and toe extension in 7 patients, with a median preoperative Medical Research Council (MRC) score of 0/5. Sensory loss in the distribution of the common peroneal nerve was present in 7 patients. Mean clinical follow-up time was 113 months (range 32-189 months). Significant pain relief was achieved in all patients. Overall neurologic function was improved, more so for motor function. The median postoperative dorsiflexion, eversion, and toe extension at last follow-up were MRC score of 5/5. No complications occurred postoperatively. There was no clinical evidence of intraneural recurrence, as confirmed in postoperative MRI. In 2 patients, an extraneural cystic formation was visible in the anterior muscular compartment. CONCLUSIONS: The data from our series support excellent long-term postoperative motor outcomes with a low recurrence rate. To avoid extraneural recurrence, resection of the superior tibiofibular joint is necessary.

Calcaneal reconstruction after total calcanectomy with iliac crest free flap.

INTRODUCTION: Calcaneal tumors being a rare occurrence, surgical options and outcomes are not well-known. Extensive defects following wide resection, especially in weight-bearing areas, still remain a challenge and different reconstructive techniques have been proposed. The aim of this report was to analyze the clinical and functional long-term outcomes of heel reconstruction using an iliac crest free flap. PATIENTS AND METHODS: Four patients who underwent calcaneal reconstruction between 1999 and 2012 were included. Two were females and mean age was 27 years, ranging 18-42 years. Each patient underwent total calcanectomy, for two osteoblastomas, one osteosarcoma, and one Ewing's sarcoma. An iliac crest flap was harvested and shaped to fit the residual space. After the articular cartilage at recipient site was debrided, the flap was fixed to the talus and the cuboid. RESULTS: The average size of the flaps was 2 x 7 x 5 cm. Postoperatively wound dehiscence, screw breaking, and graft fracture healed conservatively. All the arthrodesis healed successfully and no donor site complication occurred. At an average follow-up of 13 years (range 6-19 years) any patient claimed pain, evident limp or limitation of daily activities. Computerized pedobarographic examination and gait analysis revealed a satisfactory result and an acceptable weight-bearing area in the reconstructed limb in each patient. CONCLUSIONS: Calcaneal reconstruction with iliac crest free flap is likely to provide good chances of a long-lasting result, especially in young patients. Particularly, it provides the possibility to adequately shape the graft to fit the bone loss while using the crest as the weight-bearing surface.

Short and long-term results of sternectomy for sternal tumours.

BACKGROUND: We analyzed our experience in sternal resections (SRs) for primary or secondary neoplasm focusing on technical aspects of reconstruction, post-operative outcomes and long term survival. METHODS: From January 2005 to December 2015, 36 patients (24 males, 67%) underwent surgical excision of primary (chondrosarcoma n=18 patients, 50%; osteosarcoma n=2, 6%; Ewing sarcoma n=1, 3%; other n=2, 6%) or secondary (breast cancer n=7, 19%; kidney carcinoma n=2, 6%) sternal tumour. We performed n=30 partial sternectomy and n=6 total sternectomy with en-bloc resection of the sternocostal cartilages in all patient and extended resection in 7 patients. Stability was obtained with prosthetic material, rigid and non-rigid and a muscular flap: rigid material [Strasbourg Thoracic Osteosynthesis System (STRATOS), MedXpert GmbH] and muscle flap n=11 (30.6%); polytetrafluoroethylene patch and muscle flap n=6 (16.7%); muscle flap alone n=19 (52.8%). RESULTS: The 30-day mortality rate was 0, overall complication rate was 19%. The median ICU stay was 1.5 days and mean hospital stay was 10.6±5.9 days. We obtained a complete (R0) resection in all patients. Overall survival (OS) at 5 and 10 years were 59% and 40%; in the group of primary neoplasm OS rate at 5 and 10 years was 79% and 54%. Disease free survival (DFS) rate at 5 years was 61%. Higher grading was identified as negative prognostic factor. CONCLUSIONS: Wide radical resections of anterior chest wall are basilar in a multimodality treatment for primary or metastatic neoplasm of the sternum. Stabilization with titanium bars and clips provides rigidity of chest wall with good functional results.

BAG3 promotes pancreatic ductal adenocarcinoma growth by activating stromal macrophages.

The incidence and death rate of pancreatic ductal adenocarcinoma (PDAC) have increased in recent years, therefore the identification of novel targets for treatment is extremely important. Interactions between cancer and stromal cells are critically involved in tumour formation and development of metastasis. Here we report that PDAC cells secrete BAG3, which binds and activates macrophages, inducing their activation and the secretion of PDAC supporting factors. We also identify IFITM-2 as a BAG3 receptor and show that it signals through PI3K and the p38 MAPK pathways. Finally, we show that the use of an anti-BAG3 antibody results in reduced tumour growth and prevents metastasis formation in three different mouse models. In conclusion, we identify a paracrine loop involved in PDAC growth and metastatic spreading, and show that an anti-BAG3 antibody has therapeutic potential.