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ANNPLA-1124; No. of Pages 8 Annales de chirurgie plastique esthétique (2015) xxx, xxx—xxx
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GENERAL REVIEW
Plastic and reconstructive robotic microsurgery — a review of current practices ´e — Microchirurgie plastique et reconstructrice robot-assiste ´ liminaire et revue de la litte ´ rature ´ rience pre expe D.B. Saleh a, M. Syed b, D. Kulendren b, V. Ramakrishnan b, P.A. Liverneaux c,* a
Department of Plastic and reconstructive surgery, Princess Alexandra Hospital, Brisbane 4101, Australia Saint-Andrew’s centre for burns and plastic surgery, Broomfield hospital, Chelmsford, UK c Hand Surgery Department, Strasbourg University Hospitals, FMTS, University of Strasbourg, Illkirch, Icube CNRS 7357, Illkirch, France b
Received 8 February 2015; accepted 17 March 2015
KEYWORDS Robotic reconstruction; Robotic microsurgery; Telemicrosurgery
MOTS CLÉS Reconstruction robot-assistée ;
Summary Introduction. — We sought to review the current state of robotics in this specialty. Methods. — 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. Results. — Overall, 28 publications specific to robotic plastic and reconstructive procedures were suitable for appraisal. Conclusion. — 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. # 2015 Elsevier Masson SAS. All rights reserved. Résumé Introduction. — Nous avons cherché à démontrer la faisabilité de la chirurgie microvasculaire robotique et examiné l’état actuel de la chirurgie robotique dans cette spécialité. Me ´thodes. — Entre juillet 2009 et juin 2010, cinq patientes ont été traités par des anastomoses microvasculaires en chirurgie robotique pour reconstruction différée du sein par lambeau libre.
* Corresponding author. Hand Surgery Department, Strasbourg University Hospitals, FMTS, University of Strasbourg, Illkirch, Icube CNRS 7357, 10, avenue Baumann, 67403, Illkirch, France. E-mail addresses: [email protected] (D.B. Saleh), [email protected] (M. Syed), [email protected] (D. Kulendren), [email protected] (V. Ramakrishnan), [email protected] (P.A. Liverneaux). http://dx.doi.org/10.1016/j.anplas.2015.03.005 0294-1260/# 2015 Elsevier Masson SAS. All rights reserved.
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Une recherche sur PubMed et Medline a été réalisée en utilisant des mots clés dans l’ensemble de la chirurgie plastique et reconstructrice. Re ´sultats. — L’âge moyen des patientes était de 55,4 années. Le temps d’anastomose robotique moyen était de 86 minutes. Il n’y avait pas d’erreurs d’organisation. Aucune complications intraou postopératoire concernant le lambeau n’a été rencontrée. En tout, 28 publications spécifiques aux procédures robotisées en chirurgie plastique et reconstructrice étaient éligibles à l’évaluation. Conclusion. — Notre expérience d’anastomose microvasculaire en chirurgie robotique est la plus grande cohorte de patients à ce jour et a été réalisée sans séquelles. Les preuves actuelles suggèrent que la chirurgie robotique est comparable aux méthodes standard malgré ses balbutiements. Les applications possibles sont nombreuses et pourraient se traduire par de meilleurs résultats pour les patients. # 2015 Elsevier Masson SAS. Tous droits réservés.
Introduction
Methods
Robotic surgery was first proposed by the National Aeronautics and Space Administration (NASA) as a means of providing surgical care remotely to astronauts [1]. Although this vision was not achieved, robotic assistance in many sectors began to flourish in the 1980s. In industry, robots were soon programmed to perform precise movements that replaced the relatively crude movements of humans. Arguably, clinical medicine has been decidedly slower in embracing robots, perhaps due to safety, cost and feasibility issues. However, the last decade has seen robotic surgery emerge as a standard means in some specialties to deliver surgeon directed minimally invasive surgery. Urological, gastrointestinal, endocrine, cardiac and aerodigestive tract robotic surgery is established. The most widely used robotic system is the Da Vinci Surgical System (Intuitive Surgical California USA) that currently utilises three-dimensional (3D) high definition (HD) magnification with seven degrees of freedom (DOF) [2]. In mechanics, a degree of freedom can be summarised as the displacement or deformation of a body part, for example, we humans have one degree of freedom at the elbow (flexion/extension). The ability to visualise the surgical field in 3D, with magnification and filtration for human physiological tremor is attractive as it enhances the surgical experience versus what we now accept as conventional endoscopic or open surgery. Endoscopes are limited by 2D visualisation and at the point of delivery, movements are restricted by a fixed scope and trocar. Hence, there is axial limitation in what the surgeon can achieve versus the freedom of his or her own arm [3]. Endoscopic plastic surgery is limited because of the few degrees of freedom afforded for complex soft tissue dissection and poor haptic feedback. Anecdotally plastic, hand and reconstructive surgery has been slower than most surgical specialties in embracing minimally invasive and robotic surgery. We have performed a review to ascertain what has been achieved in the field of robotic plastic and reconstructive surgery so far and what could be the future applications. Therefore, this review aimed to provide a comprehensive appraisal of all robotic plastic surgery study to date.
A Pubmed and Medline search was performed using the following search terms alone and in combination: robot/ robotic plastic surgery, robotic reconstructive surgery, robotic microsurgery and robotic flap surgery. Abstracts were assessed for inclusion and articles cross-referenced. All types of study and research methods that included subjects (animal, human or cadaveric) were included for this comprehensive review. For each article, we extracted key data on the number of cases, subjects used, procedure type and common end-points, such as ‘‘microvascular patency’’. These data were heterogenous because end-points did differ across studies. The cumulative robotic experience with their limitations and implications for future applications are therefore discussed. Each paper was graded according to the center for evidence-based medicine [4].
Results The review search yielded a total of 338 articles. Non-plastic and reconstructive surgical papers were not considered for appraisal. For example, urological tract reconstruction was not included as one would not generally include this surgery under the umbrella of plastic and reconstructive surgery. The remaining 28 publications were analysed. Table 1 summarises these references. Fig. 1 provides a case breakdown of these studies included for review.
Discussion Tremor elimination Many types of tremor exist and are amplified on a microscopic level [5]. The only 3D study to quantify tremor change using wrist supports for microsurgery, showed a significant reduction with support [5]. In a similar study, ophthalmic surgeons had an instrument tip oscillation of up to 50 mm, which is equivalent to the diameter of retinal vessels requiring cannulation [6]. In this scenario, elimination of that tremor would be desirable. The applications of microsurgery continue to expand and tremor elimination is certainly attractive.
Please cite this article in press as: Saleh DB, et al. Plastic and reconstructive robotic microsurgery — a review of current practices. Ann Chir Plast Esthet (2015), http://dx.doi.org/10.1016/j.anplas.2015.03.005
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3
Summary of articles relevant to robotic plastic and reconstructive surgery reviewed.
Author
Reference number
Study
No of cases
Key points
Selber et al.
[35]
Cadaveric Latissimus dorsi harvest
10
Huart et al.
[31]
Cadaver pedicled hand flaps
2
Panchulidze et al.
[10]
Assessment of haptic feedback in standard knot tying using robot
24 surgeons assesses
Mantovani et al. Krapohl et al.
[26]
Cadaveric brachial plexus nerve grafting Microvascular anastomoses in rats
2
Knight et al.
[14]
Rat femoral microvascular anastomoses compared between robot and standard technique
61 (31 rat cases)
Karamanoukian et al.
[8]
Microvascular anastomoses in porcine model
80
Taleb et al.
[17]
Replantation porcine limbs
2
Li et al.
[11]
10
Boyd et al.
[38]
Microvascular rat femoral anastomoses Internal mammary harvest in breast reconstruction
Katz et al. Patel et al.
[16] [37]
Porcine free flap Rectus abdominus flap harvest
1 4 — Cadaveric 1 — Patient
Selber et al.
[28]
Latissimus dorsi harvest
7
Katz et al.
[15]
Canine microvascular anastomoses
6
Clemens et al.
[40]
Robotic LD harvest
17
Nectoux et al.
[27]
5
Naito et al.
[25]
Microneural repair in cadaver, rat and porcine models Oberlin procedures
Reproducible time for harvest. Technically easier than endoscopic harvest and cosmetically superior to open Better precision than standard technique. Longer procedural time (30%) due to inadequate instruments No difference between having eyes open or closed when completing a knot instrument tie refuting common criticism of poor haptic feedback with robot Feasible with no neural injury and ease of microneural surgery No quantitative outcomes reported. All microsurgical anastomoses were successful. Suggested could be useful to reduce tremor and need for assistance in such procedures Slower in robotic cases overall with no improvement versus open technique. Possible advantage of robot may be tremor filtration but did not translate as greater anastomosis success in this study Significantly longer microsurgical time with robot for experienced microsurgeons. Learning curve less when trainee surgeons assessed Robot offered superior ergonomics with longer warm ischaemic time Significantly longer surgical time versus conventional method A non-invasive method of delivering recipient vessels into wound for breast free tissue transfer. Avoids violation of ribs Successful free flap procedure Small cohort but apparent donor morbidity with small scar harvest. Comparable surgical time versus standard technique Demonstrated feasibility with small donor scar and learning curve reducing time for harvest All patent, long set-up times, no comparison to other methods No adverse outcomes versus open method in irradiated breast reconstruction cases Decreased tremor with improved accuracy Magnification and tremor reduction improving dissection accuracy. All cases successful but not compared to alternate methods
[13]
7
22
4
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D.B. Saleh et al. Table 1 (Continued )
Author
Reference number
Study
No of cases
Key points
Morita et al.
[5]
Rat carotid artery anastomosis
20
Le Roux et al.
[4]
Rat carotid arteriotomies
10
Smartt et al.
[32]
Cadeveric posterior pharyngeal flaps
3
Bonowitz et al.
[33]
Facial artery myomucosal flaps (FAMM) for oropharygeal reconstruction
5
Song et al.
[23]
Free flap reconstruction of head and neck oncological defects
5
Bonowitz et al.
[34]
4
Park et al.
[30]
Free flaps for oropharyngeal defects Robotic neck dissection and free flap reconstructions
Robert et al.
[10]
Cadaveric microvascular surgery
2
Porto de Melo et al.
[27]
Cadaveric peripheral nerve surgery
1
Ghanem et al.
[35]
4
Selber et al.
[22]
Transoral reconstruction of oropharangeal defects Transoral reconstruction of oropharyngeal defects
Significant accuracy versus standard microsurgery. Ability to achieve complex procedure through small operating field Precision and success similar between robot and standard microsurgery. Approximately double length of time for robotic arterial repair Mean operative time 105 minutes. All completed and feasible with adequate trans-oral access All cases were completed using the robot. Access was adequate. 3 of 5 cases required surgical revision for dehiscence. Useful in trans-oral resection cases All cases at least partially inset with the robot. Microvascular surgery done with microscope in 4 cases and robot in 1. Robotic case reduced surgical access incision and allowed shorter pedicle flap. No complications, no oncological sequalae to date Transoral. One arterial microanastomosis done robotically Robotic neck dissection and free flap reconstruction of the oropharynx. Microvascular surgery using microscope, robotic flap inset. High patient satisfaction Robotic access to forearm vessels to dissect and anastomose. Long operative time but feasible and no anastomotic leaks Robotic dissection of the axillary and long triceps nerves for the purpose of feasibility and potential applications in brachial plexus reconstruction Robotic inset of free flaps for oropharyngeal defects Robotics permitted easier flap insetting and hence avoided need for mandibulotomies. One case involved robotic micro-anastomosis
Microvascular and microneural surgery Previous failures of endoscopic microvascular surgery may have also deterred plastic hand and soft tissue reconstructive surgeons from attempting robotic surgery [7,8]. Study has shown transfer of skills in experienced microsurgeons is limited when compared to relative novices [9]. The acquisition of robotic microsurgical skills was faster in trainee surgeons [9].
7
5
A common criticism of endoscopic and robotic microsurgery is the lack of haptic feedback. Only one study has objectively assessed haptics and concluded it was not crucial to completing an accurately tied knot with a microsurgical suture [10]. Subjects tied knots and tightened them with eyes open and closed with robotic assistance. No difference in suture breakage and poor tightening was observed [10]. In the senior authors’ (PL, VR) experience, visual assessment of the knot helps avoid errors and possibly replaces the sensory
Please cite this article in press as: Saleh DB, et al. Plastic and reconstructive robotic microsurgery — a review of current practices. Ann Chir Plast Esthet (2015), http://dx.doi.org/10.1016/j.anplas.2015.03.005
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Plastic and reconstructive robotic microsurgery
Figure 1
A breakdown of the cumulative experience in robotic plastic and reconstructive surgery.
feedback when manipulating tissue with handheld instruments (Fig. 2). The first report of six robotic microvascular anastomoses in rats showed a significantly slower time to anastomosis versus conventional microsurgery, with no difference in technical failures or patency rates [11]. Rat carotid arteriotomy repair time was doubled using the robot, without a better patency rate in a similar study [12]. Subsequent study by Krapsohl et al. subjectively assessed feasibility of preparing and anastomosing rat vessels and found precise movements and tasks, for example, holding a microsuture, removed undesirable tremor [13]. A more recent objective study that compared 30 standard and 31 robot assisted anastomoses again showed excellent patency rates for both methods, but a significantly longer time for robotic cases [14]. These findings were mirrored in pig carotid repairs performed by experienced microsurgeons [9].
Figure 2
5
Robotic microanastomosis.
In contrast, Katz et al. showed a learning curve that resulted in a decrease of robotic anastomotic time from 67 to 20 minutes [15]. The same group reported a warm ischaemic time of 44 minutes for a free flap performed robotically in a pig [16]. Similar results were found using a robotic microanastomosis simulator where all five participants demonstrated a reduction in anastomotic time [17]. A similar study based on pig limb replantation demonstrated successful robotic revascularisation [18]. Morita et al. reported the only quantitative assessment of robotic versus freehand tasks in a microsurgical setting [19]. This group demonstrated pointing in a microsurgical field was significantly more accurate using the robot than freehand [19]. A simulated deep and superficial surgical field was created and robot assistance was more successful for the deep microvascular tasks [19]. Robert et al. used the robot to access the radial and ulnar arteries and dissect, divide and repair them in a cadaveric forearm [20]. The total procedure time was 120 minutes but the anastomoses had no leaks. Microvascular surgery relies on precise vessel preparation to avoid endothelial injury that could potentially increase the incidence of anastomotic failure [21]. Microvascular success already reaches 99% in large series and early experimental series for the robot are comparable [22—24]. Two microvascular anastomoses of a free tissue transfer for oropharyngeral reconstruction have been successful to date [25,26]. Rather than focus on warm ischaemic time, the authors utilised the robot to perform the anastomosis in a confined anatomical space avoiding access incisions, such as a mandibulotomy. The robot reduced the cervical incision and therefore, probably reduced morbidity [26]. Robotic microneurosurgery has been attempted parallel to microvascular surgery. Mantovani et al. explored the supraclavicular brachial plexus with successful nerve graft interposition using the robot in a cadaver [27]. The advantage reported was more precise neural dissection using the robot alone. Similarly, Nectoux et al. did not quantify any advantage over standard techniques, but postulated robotic
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microsurgery would improve the quality of nerve repair [28]. In the only human series of microneural repair in the upper limb to date, successful outcomes for Oberlin transfers were reported [29]. The authors were cautious to attribute these good outcomes solely to improved magnification and the absence of tremor, but felt they were clear advantages over standard methods. Members of the same group have also demonstrated it is feasible to use the robot to access the axillary nerve and nerve to long head triceps in a cadaver. [30]. In addition, previous study has reported faster operative dissection of soft tissues using the robot [31]. Robotic exploration of nerves through access ports is an interesting prospect, particularly for neural plexus and peripheral nerve exploration. Surgery is frequently the most accurate diagnostic and therapeutic modality in these complex patients. Reduced scarring and early diagnosis of the exact neural abnormality is attractive.
Robotic flap surgery Huart et al. attempted to execute Foucher flaps in cadaveric hands using a robot only [32] and succeeded albeit with a longer operative time. Robotic transoral tumour resection (TORs) in head and neck malignancy is now established. Trans-oral robotic reconstruction will preserve the benefits of a minimally invasive tumour resection. Smarrt et al. demonstrated posterior pharyngeal wall flaps were feasible in three cadaveric cases [33]. Bonowitz et al. used the robot to assist reconstruction of soft palatal defects using the facial artery myomucosal (FAMM) flap in five cases [34]. One advantage was better visualisation during flap dissection, however three cases experienced minor dehiscence which required surgical revision. Selber also performed robotic FAMM flap for an oro-pharyngeal defect, with no complications reported [25]. Robotic insetting of free flaps can preserve the mandible and allowed precise flap inset in the oropharynx that normally would be impossible [25,35,36]. Park et al. performed seven robotic assisted neck dissection and free flap reconstructions for oro-pharyngeal tumours [37]. Subjective patient satisfaction with surgical scars was reported [37]. A similar report of five cases also reported successful flap insetting transorally and neck dissection through a retroauricular incision [26]. However in both these small series, it is unclear whether the oncological outcomes match those of conventional methods. Selber has also shown robotic Latissimus Dorsi (LD) is feasible in cadavers with acceptable harvest times through port access incisions [38]. In seven clinical cases, Selber reported no donor haematoma or seroma [39]. A larger series compared 17 robotic LD harvests to a larger group of open LD harvest and showed a lower complication rate and no flap loss but this was not statistically significant [40]. Smaller or no donor scars with the access to the LD pedicle is an attractive means of dissecting a workhorse flap harvest. Patel et al. performed a trans-abdominal harvest of the rectus abdominus for free tissue transfer [41]. Despite relatively short follow-up, there was no abdominal wall contour deformity and no herniae or laxity reported [41]. It is plausible this approach could reduce not only functional abdominal morbidity but also quicker return to mobility.
The robot could improve access to recipient vessels for free tissue transfer. The only series reported in the literature details robotic harvest of the (recipient) internal mammary vessels for free tissue breast reconstruction [42]. This technique is certainly aesthetically attractive. However, there was a high complication rate of haematoma, two flap losses, pneumothorax and chest sepsis [42]. Perforator flap harvest has been attempted with endoscopic assistance [43], the perforator was identified and the integument marked accordingly. Subjective advantages stated were reduction in exploratory incisions to identify perforators and the enhanced safety of designing a bespoke flap [43]. Robotic dissection could be a faster means of perforator identification and accurate dissection for pedicled or free transfer. The ability to dissect soft tissues using 3D magnified macromovements could enhance microsurgical outcomes in a variety of settings. This has been demonstrated in robotic micro-urological surgery. In the only prospective randomised robotic microsurgical study, Schiff et al. compared standard and robotic rat vasovasostomy and vasoepididymostomy [31]. Operative time was faster for robotic cases and patency rates were superior in the robotic cohort, yet did not reach significance [31]. The only comparable human study of the same surgical procedure also illustrated a faster operative time using the robot [44]. Faster, more accurate and less morbid surgery could have an impact on overall health costs.
Cost-effectiveness Laparoscopic surgery was associated with a long learning curve and excessive initial healthcare costs in its infancy. As a result it was not adopted for many applications ([45]). The shorter learning curve for robotic assisted surgery could translate as a smaller overall initial cost to healthcare because a larger case load spreads costs over more patients quicker. Multi-specialty use of a robot would also spread the fixed cost of a robot across more patient episodes. There is no current study that has examined the potential economic viability of robotic plastic and reconstructive surgery.
Conclusion Robots will not replace surgeons. The robot is simply a sophisticated instrument to aid the surgeon in circumstances they see fit. The majority of focus within the robotic plastic surgical domain has been on microvascular surgery. Robotic surgery can be applied to all aspects of reconstructive practice. The combination of precise soft tissue dissection without the constraints of coarse traditional endoscopic methods is perhaps most appealing. Robotic neural surgery, flap harvest and inset, donor and recipient vessel dissection and nerve/vascular graft harvest could be performed with significantly reduced morbidity enhancing patient outcomes. Given the premium of evidence based surgery, accumulation of experience is vital and will require ongoing collaboration. However, current robotic surgical outcomes are at least on par with traditional methods with the limited evidence available. As robotics becomes cheaper, instrumentation
Please cite this article in press as: Saleh DB, et al. Plastic and reconstructive robotic microsurgery — a review of current practices. Ann Chir Plast Esthet (2015), http://dx.doi.org/10.1016/j.anplas.2015.03.005
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Disclosure of interest Philippe Liverneaux has conflicts of interest with Newclip Technics, Integra, Argomedical, iiN medical. The other authors declare that they have no conflicts of interest concerning this article.
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[44] Parekattil SJ, Gudeloglu A, Bramhbhatt J, Wharton J, Priola KB. Robotic assisted versus pure microsurgical vasectomy reversal: technique and prospective database control trial. J Reconstr Microsurg 2012;28:435—44. [45] Leddy LS, Lendvay TS, Satava RM. Robotic surgery; applications and cost effectiveness. Open Access Surg 2010;3:99—107.
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GENERAL REVIEW
Plastic and reconstructive robotic microsurgery — a review of current practices ´e — Microchirurgie plastique et reconstructrice robot-assiste ´ liminaire et revue de la litte ´ rature ´ rience pre expe D.B. Saleh a, M. Syed b, D. Kulendren b, V. Ramakrishnan b, P.A. Liverneaux c,* a
Department of Plastic and reconstructive surgery, Princess Alexandra Hospital, Brisbane 4101, Australia Saint-Andrew’s centre for burns and plastic surgery, Broomfield hospital, Chelmsford, UK c Hand Surgery Department, Strasbourg University Hospitals, FMTS, University of Strasbourg, Illkirch, Icube CNRS 7357, Illkirch, France b
Received 8 February 2015; accepted 17 March 2015
KEYWORDS Robotic reconstruction; Robotic microsurgery; Telemicrosurgery
MOTS CLÉS Reconstruction robot-assistée ;
Summary Introduction. — We sought to review the current state of robotics in this specialty. Methods. — 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. Results. — Overall, 28 publications specific to robotic plastic and reconstructive procedures were suitable for appraisal. Conclusion. — 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. # 2015 Elsevier Masson SAS. All rights reserved. Résumé Introduction. — Nous avons cherché à démontrer la faisabilité de la chirurgie microvasculaire robotique et examiné l’état actuel de la chirurgie robotique dans cette spécialité. Me ´thodes. — Entre juillet 2009 et juin 2010, cinq patientes ont été traités par des anastomoses microvasculaires en chirurgie robotique pour reconstruction différée du sein par lambeau libre.
* Corresponding author. Hand Surgery Department, Strasbourg University Hospitals, FMTS, University of Strasbourg, Illkirch, Icube CNRS 7357, 10, avenue Baumann, 67403, Illkirch, France. E-mail addresses: [email protected] (D.B. Saleh), [email protected] (M. Syed), [email protected] (D. Kulendren), [email protected] (V. Ramakrishnan), [email protected] (P.A. Liverneaux). http://dx.doi.org/10.1016/j.anplas.2015.03.005 0294-1260/# 2015 Elsevier Masson SAS. All rights reserved.
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Une recherche sur PubMed et Medline a été réalisée en utilisant des mots clés dans l’ensemble de la chirurgie plastique et reconstructrice. Re ´sultats. — L’âge moyen des patientes était de 55,4 années. Le temps d’anastomose robotique moyen était de 86 minutes. Il n’y avait pas d’erreurs d’organisation. Aucune complications intraou postopératoire concernant le lambeau n’a été rencontrée. En tout, 28 publications spécifiques aux procédures robotisées en chirurgie plastique et reconstructrice étaient éligibles à l’évaluation. Conclusion. — Notre expérience d’anastomose microvasculaire en chirurgie robotique est la plus grande cohorte de patients à ce jour et a été réalisée sans séquelles. Les preuves actuelles suggèrent que la chirurgie robotique est comparable aux méthodes standard malgré ses balbutiements. Les applications possibles sont nombreuses et pourraient se traduire par de meilleurs résultats pour les patients. # 2015 Elsevier Masson SAS. Tous droits réservés.
Introduction
Methods
Robotic surgery was first proposed by the National Aeronautics and Space Administration (NASA) as a means of providing surgical care remotely to astronauts [1]. Although this vision was not achieved, robotic assistance in many sectors began to flourish in the 1980s. In industry, robots were soon programmed to perform precise movements that replaced the relatively crude movements of humans. Arguably, clinical medicine has been decidedly slower in embracing robots, perhaps due to safety, cost and feasibility issues. However, the last decade has seen robotic surgery emerge as a standard means in some specialties to deliver surgeon directed minimally invasive surgery. Urological, gastrointestinal, endocrine, cardiac and aerodigestive tract robotic surgery is established. The most widely used robotic system is the Da Vinci Surgical System (Intuitive Surgical California USA) that currently utilises three-dimensional (3D) high definition (HD) magnification with seven degrees of freedom (DOF) [2]. In mechanics, a degree of freedom can be summarised as the displacement or deformation of a body part, for example, we humans have one degree of freedom at the elbow (flexion/extension). The ability to visualise the surgical field in 3D, with magnification and filtration for human physiological tremor is attractive as it enhances the surgical experience versus what we now accept as conventional endoscopic or open surgery. Endoscopes are limited by 2D visualisation and at the point of delivery, movements are restricted by a fixed scope and trocar. Hence, there is axial limitation in what the surgeon can achieve versus the freedom of his or her own arm [3]. Endoscopic plastic surgery is limited because of the few degrees of freedom afforded for complex soft tissue dissection and poor haptic feedback. Anecdotally plastic, hand and reconstructive surgery has been slower than most surgical specialties in embracing minimally invasive and robotic surgery. We have performed a review to ascertain what has been achieved in the field of robotic plastic and reconstructive surgery so far and what could be the future applications. Therefore, this review aimed to provide a comprehensive appraisal of all robotic plastic surgery study to date.
A Pubmed and Medline search was performed using the following search terms alone and in combination: robot/ robotic plastic surgery, robotic reconstructive surgery, robotic microsurgery and robotic flap surgery. Abstracts were assessed for inclusion and articles cross-referenced. All types of study and research methods that included subjects (animal, human or cadaveric) were included for this comprehensive review. For each article, we extracted key data on the number of cases, subjects used, procedure type and common end-points, such as ‘‘microvascular patency’’. These data were heterogenous because end-points did differ across studies. The cumulative robotic experience with their limitations and implications for future applications are therefore discussed. Each paper was graded according to the center for evidence-based medicine [4].
Results The review search yielded a total of 338 articles. Non-plastic and reconstructive surgical papers were not considered for appraisal. For example, urological tract reconstruction was not included as one would not generally include this surgery under the umbrella of plastic and reconstructive surgery. The remaining 28 publications were analysed. Table 1 summarises these references. Fig. 1 provides a case breakdown of these studies included for review.
Discussion Tremor elimination Many types of tremor exist and are amplified on a microscopic level [5]. The only 3D study to quantify tremor change using wrist supports for microsurgery, showed a significant reduction with support [5]. In a similar study, ophthalmic surgeons had an instrument tip oscillation of up to 50 mm, which is equivalent to the diameter of retinal vessels requiring cannulation [6]. In this scenario, elimination of that tremor would be desirable. The applications of microsurgery continue to expand and tremor elimination is certainly attractive.
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3
Summary of articles relevant to robotic plastic and reconstructive surgery reviewed.
Author
Reference number
Study
No of cases
Key points
Selber et al.
[35]
Cadaveric Latissimus dorsi harvest
10
Huart et al.
[31]
Cadaver pedicled hand flaps
2
Panchulidze et al.
[10]
Assessment of haptic feedback in standard knot tying using robot
24 surgeons assesses
Mantovani et al. Krapohl et al.
[26]
Cadaveric brachial plexus nerve grafting Microvascular anastomoses in rats
2
Knight et al.
[14]
Rat femoral microvascular anastomoses compared between robot and standard technique
61 (31 rat cases)
Karamanoukian et al.
[8]
Microvascular anastomoses in porcine model
80
Taleb et al.
[17]
Replantation porcine limbs
2
Li et al.
[11]
10
Boyd et al.
[38]
Microvascular rat femoral anastomoses Internal mammary harvest in breast reconstruction
Katz et al. Patel et al.
[16] [37]
Porcine free flap Rectus abdominus flap harvest
1 4 — Cadaveric 1 — Patient
Selber et al.
[28]
Latissimus dorsi harvest
7
Katz et al.
[15]
Canine microvascular anastomoses
6
Clemens et al.
[40]
Robotic LD harvest
17
Nectoux et al.
[27]
5
Naito et al.
[25]
Microneural repair in cadaver, rat and porcine models Oberlin procedures
Reproducible time for harvest. Technically easier than endoscopic harvest and cosmetically superior to open Better precision than standard technique. Longer procedural time (30%) due to inadequate instruments No difference between having eyes open or closed when completing a knot instrument tie refuting common criticism of poor haptic feedback with robot Feasible with no neural injury and ease of microneural surgery No quantitative outcomes reported. All microsurgical anastomoses were successful. Suggested could be useful to reduce tremor and need for assistance in such procedures Slower in robotic cases overall with no improvement versus open technique. Possible advantage of robot may be tremor filtration but did not translate as greater anastomosis success in this study Significantly longer microsurgical time with robot for experienced microsurgeons. Learning curve less when trainee surgeons assessed Robot offered superior ergonomics with longer warm ischaemic time Significantly longer surgical time versus conventional method A non-invasive method of delivering recipient vessels into wound for breast free tissue transfer. Avoids violation of ribs Successful free flap procedure Small cohort but apparent donor morbidity with small scar harvest. Comparable surgical time versus standard technique Demonstrated feasibility with small donor scar and learning curve reducing time for harvest All patent, long set-up times, no comparison to other methods No adverse outcomes versus open method in irradiated breast reconstruction cases Decreased tremor with improved accuracy Magnification and tremor reduction improving dissection accuracy. All cases successful but not compared to alternate methods
[13]
7
22
4
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D.B. Saleh et al. Table 1 (Continued )
Author
Reference number
Study
No of cases
Key points
Morita et al.
[5]
Rat carotid artery anastomosis
20
Le Roux et al.
[4]
Rat carotid arteriotomies
10
Smartt et al.
[32]
Cadeveric posterior pharyngeal flaps
3
Bonowitz et al.
[33]
Facial artery myomucosal flaps (FAMM) for oropharygeal reconstruction
5
Song et al.
[23]
Free flap reconstruction of head and neck oncological defects
5
Bonowitz et al.
[34]
4
Park et al.
[30]
Free flaps for oropharyngeal defects Robotic neck dissection and free flap reconstructions
Robert et al.
[10]
Cadaveric microvascular surgery
2
Porto de Melo et al.
[27]
Cadaveric peripheral nerve surgery
1
Ghanem et al.
[35]
4
Selber et al.
[22]
Transoral reconstruction of oropharangeal defects Transoral reconstruction of oropharyngeal defects
Significant accuracy versus standard microsurgery. Ability to achieve complex procedure through small operating field Precision and success similar between robot and standard microsurgery. Approximately double length of time for robotic arterial repair Mean operative time 105 minutes. All completed and feasible with adequate trans-oral access All cases were completed using the robot. Access was adequate. 3 of 5 cases required surgical revision for dehiscence. Useful in trans-oral resection cases All cases at least partially inset with the robot. Microvascular surgery done with microscope in 4 cases and robot in 1. Robotic case reduced surgical access incision and allowed shorter pedicle flap. No complications, no oncological sequalae to date Transoral. One arterial microanastomosis done robotically Robotic neck dissection and free flap reconstruction of the oropharynx. Microvascular surgery using microscope, robotic flap inset. High patient satisfaction Robotic access to forearm vessels to dissect and anastomose. Long operative time but feasible and no anastomotic leaks Robotic dissection of the axillary and long triceps nerves for the purpose of feasibility and potential applications in brachial plexus reconstruction Robotic inset of free flaps for oropharyngeal defects Robotics permitted easier flap insetting and hence avoided need for mandibulotomies. One case involved robotic micro-anastomosis
Microvascular and microneural surgery Previous failures of endoscopic microvascular surgery may have also deterred plastic hand and soft tissue reconstructive surgeons from attempting robotic surgery [7,8]. Study has shown transfer of skills in experienced microsurgeons is limited when compared to relative novices [9]. The acquisition of robotic microsurgical skills was faster in trainee surgeons [9].
7
5
A common criticism of endoscopic and robotic microsurgery is the lack of haptic feedback. Only one study has objectively assessed haptics and concluded it was not crucial to completing an accurately tied knot with a microsurgical suture [10]. Subjects tied knots and tightened them with eyes open and closed with robotic assistance. No difference in suture breakage and poor tightening was observed [10]. In the senior authors’ (PL, VR) experience, visual assessment of the knot helps avoid errors and possibly replaces the sensory
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Figure 1
A breakdown of the cumulative experience in robotic plastic and reconstructive surgery.
feedback when manipulating tissue with handheld instruments (Fig. 2). The first report of six robotic microvascular anastomoses in rats showed a significantly slower time to anastomosis versus conventional microsurgery, with no difference in technical failures or patency rates [11]. Rat carotid arteriotomy repair time was doubled using the robot, without a better patency rate in a similar study [12]. Subsequent study by Krapsohl et al. subjectively assessed feasibility of preparing and anastomosing rat vessels and found precise movements and tasks, for example, holding a microsuture, removed undesirable tremor [13]. A more recent objective study that compared 30 standard and 31 robot assisted anastomoses again showed excellent patency rates for both methods, but a significantly longer time for robotic cases [14]. These findings were mirrored in pig carotid repairs performed by experienced microsurgeons [9].
Figure 2
5
Robotic microanastomosis.
In contrast, Katz et al. showed a learning curve that resulted in a decrease of robotic anastomotic time from 67 to 20 minutes [15]. The same group reported a warm ischaemic time of 44 minutes for a free flap performed robotically in a pig [16]. Similar results were found using a robotic microanastomosis simulator where all five participants demonstrated a reduction in anastomotic time [17]. A similar study based on pig limb replantation demonstrated successful robotic revascularisation [18]. Morita et al. reported the only quantitative assessment of robotic versus freehand tasks in a microsurgical setting [19]. This group demonstrated pointing in a microsurgical field was significantly more accurate using the robot than freehand [19]. A simulated deep and superficial surgical field was created and robot assistance was more successful for the deep microvascular tasks [19]. Robert et al. used the robot to access the radial and ulnar arteries and dissect, divide and repair them in a cadaveric forearm [20]. The total procedure time was 120 minutes but the anastomoses had no leaks. Microvascular surgery relies on precise vessel preparation to avoid endothelial injury that could potentially increase the incidence of anastomotic failure [21]. Microvascular success already reaches 99% in large series and early experimental series for the robot are comparable [22—24]. Two microvascular anastomoses of a free tissue transfer for oropharyngeral reconstruction have been successful to date [25,26]. Rather than focus on warm ischaemic time, the authors utilised the robot to perform the anastomosis in a confined anatomical space avoiding access incisions, such as a mandibulotomy. The robot reduced the cervical incision and therefore, probably reduced morbidity [26]. Robotic microneurosurgery has been attempted parallel to microvascular surgery. Mantovani et al. explored the supraclavicular brachial plexus with successful nerve graft interposition using the robot in a cadaver [27]. The advantage reported was more precise neural dissection using the robot alone. Similarly, Nectoux et al. did not quantify any advantage over standard techniques, but postulated robotic
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microsurgery would improve the quality of nerve repair [28]. In the only human series of microneural repair in the upper limb to date, successful outcomes for Oberlin transfers were reported [29]. The authors were cautious to attribute these good outcomes solely to improved magnification and the absence of tremor, but felt they were clear advantages over standard methods. Members of the same group have also demonstrated it is feasible to use the robot to access the axillary nerve and nerve to long head triceps in a cadaver. [30]. In addition, previous study has reported faster operative dissection of soft tissues using the robot [31]. Robotic exploration of nerves through access ports is an interesting prospect, particularly for neural plexus and peripheral nerve exploration. Surgery is frequently the most accurate diagnostic and therapeutic modality in these complex patients. Reduced scarring and early diagnosis of the exact neural abnormality is attractive.
Robotic flap surgery Huart et al. attempted to execute Foucher flaps in cadaveric hands using a robot only [32] and succeeded albeit with a longer operative time. Robotic transoral tumour resection (TORs) in head and neck malignancy is now established. Trans-oral robotic reconstruction will preserve the benefits of a minimally invasive tumour resection. Smarrt et al. demonstrated posterior pharyngeal wall flaps were feasible in three cadaveric cases [33]. Bonowitz et al. used the robot to assist reconstruction of soft palatal defects using the facial artery myomucosal (FAMM) flap in five cases [34]. One advantage was better visualisation during flap dissection, however three cases experienced minor dehiscence which required surgical revision. Selber also performed robotic FAMM flap for an oro-pharyngeal defect, with no complications reported [25]. Robotic insetting of free flaps can preserve the mandible and allowed precise flap inset in the oropharynx that normally would be impossible [25,35,36]. Park et al. performed seven robotic assisted neck dissection and free flap reconstructions for oro-pharyngeal tumours [37]. Subjective patient satisfaction with surgical scars was reported [37]. A similar report of five cases also reported successful flap insetting transorally and neck dissection through a retroauricular incision [26]. However in both these small series, it is unclear whether the oncological outcomes match those of conventional methods. Selber has also shown robotic Latissimus Dorsi (LD) is feasible in cadavers with acceptable harvest times through port access incisions [38]. In seven clinical cases, Selber reported no donor haematoma or seroma [39]. A larger series compared 17 robotic LD harvests to a larger group of open LD harvest and showed a lower complication rate and no flap loss but this was not statistically significant [40]. Smaller or no donor scars with the access to the LD pedicle is an attractive means of dissecting a workhorse flap harvest. Patel et al. performed a trans-abdominal harvest of the rectus abdominus for free tissue transfer [41]. Despite relatively short follow-up, there was no abdominal wall contour deformity and no herniae or laxity reported [41]. It is plausible this approach could reduce not only functional abdominal morbidity but also quicker return to mobility.
The robot could improve access to recipient vessels for free tissue transfer. The only series reported in the literature details robotic harvest of the (recipient) internal mammary vessels for free tissue breast reconstruction [42]. This technique is certainly aesthetically attractive. However, there was a high complication rate of haematoma, two flap losses, pneumothorax and chest sepsis [42]. Perforator flap harvest has been attempted with endoscopic assistance [43], the perforator was identified and the integument marked accordingly. Subjective advantages stated were reduction in exploratory incisions to identify perforators and the enhanced safety of designing a bespoke flap [43]. Robotic dissection could be a faster means of perforator identification and accurate dissection for pedicled or free transfer. The ability to dissect soft tissues using 3D magnified macromovements could enhance microsurgical outcomes in a variety of settings. This has been demonstrated in robotic micro-urological surgery. In the only prospective randomised robotic microsurgical study, Schiff et al. compared standard and robotic rat vasovasostomy and vasoepididymostomy [31]. Operative time was faster for robotic cases and patency rates were superior in the robotic cohort, yet did not reach significance [31]. The only comparable human study of the same surgical procedure also illustrated a faster operative time using the robot [44]. Faster, more accurate and less morbid surgery could have an impact on overall health costs.
Cost-effectiveness Laparoscopic surgery was associated with a long learning curve and excessive initial healthcare costs in its infancy. As a result it was not adopted for many applications ([45]). The shorter learning curve for robotic assisted surgery could translate as a smaller overall initial cost to healthcare because a larger case load spreads costs over more patients quicker. Multi-specialty use of a robot would also spread the fixed cost of a robot across more patient episodes. There is no current study that has examined the potential economic viability of robotic plastic and reconstructive surgery.
Conclusion Robots will not replace surgeons. The robot is simply a sophisticated instrument to aid the surgeon in circumstances they see fit. The majority of focus within the robotic plastic surgical domain has been on microvascular surgery. Robotic surgery can be applied to all aspects of reconstructive practice. The combination of precise soft tissue dissection without the constraints of coarse traditional endoscopic methods is perhaps most appealing. Robotic neural surgery, flap harvest and inset, donor and recipient vessel dissection and nerve/vascular graft harvest could be performed with significantly reduced morbidity enhancing patient outcomes. Given the premium of evidence based surgery, accumulation of experience is vital and will require ongoing collaboration. However, current robotic surgical outcomes are at least on par with traditional methods with the limited evidence available. As robotics becomes cheaper, instrumentation
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Disclosure of interest Philippe Liverneaux has conflicts of interest with Newclip Technics, Integra, Argomedical, iiN medical. The other authors declare that they have no conflicts of interest concerning this article.
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Please cite this article in press as: Saleh DB, et al. Plastic and reconstructive robotic microsurgery — a review of current practices. Ann Chir Plast Esthet (2015), http://dx.doi.org/10.1016/j.anplas.2015.03.005
