Microsurgical robotic suturing of sural nerve graft for sympathetic nerve reconstruction: a technical feasibility study

Abstract

Background: Endoscopic thoracic sympathectomy (ETS) may provide a permanent surgical cure for primary palmar hyperhidrosis. Unfortunately, some patients can experience intensive post-operative compensatory sweating (CS) that ultimately impairs quality of life. Sympathetic nerve reconstruction (SNR) may be used to counteract severe post-operative CS through the restoration of sympathetic pathways. In this case series, we describe the technical feasibility of a robot-assisted micro-peripheral nerve reconstruction method for achieving SNR in patients with post-operative CS. Methods: Between January 2017 and May 2019, seven cases with severe post-operative CS underwent robot-assisted SNR using a sural nerve graft. We report the pre-operative assessment, the surgical technique, and the clinical outcomes of the study patients.Results: The study sample consisted of five men and two women (median age: 41 years). Primary hyperhidrosis affected the face in one case and the palms in six patients. The median time between ETS and SNR was 20 years. All robotic surgery procedures were successfully accomplished, and neither conversion to open surgery nor the creation of additional ports were required. Sural nerve grafts (median length: 8 cm) were used in all cases, and the median operating time was 10.5 h. There was no operative mortality, with the median length of post-operative hospital stay being 4 days. One patient developed a post-operative pneumothorax-which was treated conservatively. Conclusions: Our case series demonstrates the safety and clinical feasibility of microsurgical robot-assisted sural nerve grafting for achieving SNR in patients with post-operative CS.

Robotic-Assisted Peripheral Nerve Surgery: A Systematic Review

“…There have been many preclinical studies conducted on animal and human cadaveric models discussing the feasibility of robotic-assisted peripheral nerve surgery, and clinical studies on the use of robot have been performed mostly on brachial plexus reconstructions. 15,19,25 In 2011, Mantovani et al performed the first exploration of supraclavicular brachial plexus and upper trunk reconstruction with nerve graft on a human cadaveric model. 26 In 2012, Garcia et al demonstrated three clinical brachial plexus reconstructions with robotic surgery, 27 two Chuang's level I avulsions from C6-T1 and C5-T1 and a C5-7 rupture.…”

“…39 Although a sympathectomy can be useful in the treatment of hyperhidrosis, it may disorient the balance of the body and cause many intolerable side effects. 15,40 Therefore, the reversal surgery, sympathetic trunk reconstruction, has been studied and attempted for decades. The results can be variable and not guaranteed under thoracoscopic approach.…”

“…In 2016, Connery reported the first three cases with robotic sympathetic trunk reconstruction, two of which were improved. 39 In 2019, Chang et al reported the use of modified techniques with the robotic-assisted sympathetic trunk reconstruction with discussion regarding coaptation of the sympathetic trunk and addressing the coaptation of the intercostal nerves 15 (►Fig. 3).…”

“…Although short follow-up period and limited number of cases, the positive subjective feedback was provided by patients in both studies. 15,39 Connery and Chang's studies concluded that using robotic-assisted STR was found to be much superior to conventional approaches. The Robot system provides minimally invasive and delicate microsurgery reconstruction.…”

“…As technology advances, robotic techniques represent a potential solution in this field. 15 Robotic-assisted approaches are a tremendous revolution in modern surgery. Compared with traditional surgery, robotic surgery is considered superior as (1) it is minimally invasive and causes less damage to the local tissue; (2) it allows a magnified three-dimensional high definition visualization of the surgical field; (3) endowrist instrumentation provides intuitive control; (4) it eliminates physiological hand tremors; (5) it enhances surgeon console ergonomics; and (6) it has a shorter learning curve.…”