Robotic Assistance in Microvascular Surgery

Abstract

The introduction of minimally invasive surgery in the early 1990s has rapidly changed the performance of surgical procedures in a wide range of surgical specialities. Postoperative pain, discomfort and morbidity are caused by trauma created by trying to gain access to the area of surgery, rather than by the surgical procedure itself. Through the application of minimally invasive surgery, several advantages are offered to the patient. Decreased postoperative pain, shorter hospitalisation, a more rapid return to work, improved cosmetics and reduced risk of wound infection and other post-operative complications are achieved by the performance of laparoscopy [1-5]. However, laparoscopic surgery also has it's limitations. The most important disadvantage is that only a two-dimensional image of the operating field can be provided, with a decreased depth perception as a result. Through experience, processing of monocular cues can be learned and depth perception improved. The adaptation of monocular cues, however, is a learning process through which performance times are significantly improved [6]. These adaptations are accounted for the increased mental fatigue and strain found with two-dimensional imaging. Other important limitations of laparoscopy are the limited manoeuvrability of effecter instruments, small working spaces, fixed angles at the trocar level to place sutures and the loss of direct contact with organs causing insufficient tactile information [1, 3, 6, 7]. Furthermore, the surgeon's tremor is amplified by the long instruments, which causes the use of laparoscopy in microsurgery to be problematic. Through all these limitations, a steep learning curve exists for the performance of laparoscopy [8]. Nowadays, minimally invasive surgery is widely applied in general surgery, gynaecology, urology and thoracic surgery. There is only little use of it in the divisions of plastic surgery, cardiothoracic surgery and vascular interventional surgery. Despite the technical advantages, laparoscopy is more difficult to be performed and more skills are required from a surgeon than with the performance of traditional surgery. The use of laparoscopy is especially problematic in microsurgery. A solution to all these problems can be provided by robotic surgery. Research has shown that robotic surgery is superior to traditional laparoscopy [8, 9]. By the participants of this study it was felt that robotic surgery was easier to learn than traditional laparoscopy. However, application of robotic surgery for the purpose of performing microsurgery is only in the first stage of development. This is unfortunate, while utilisation of robots in microsurgery offers the possibility to work really precise. An area where that feature is really important is the performance of microvascular surgery. Up to now, there has been only little experience with robotic surgery in this area.

Robotics in plastic surgery, a review

“…Its arms are well suited for micro-and macro-manipulations with excellent controllability in deep seated defects during oropharyngeal reconstruction, around bulky external fixators in traumatic limb reconstructions and in the axilla during breast reconstruction [25]. Moreover, microvascular anastomosis and free tissue transfers have been successfully performed free TRAM flaps [39]. At the microscopic level, vessels sutured with robotic assistance have showed less wall damage, mostly due to elimination of hand tremor [40].…”

“…This may be theoretically reduced by the use of robotic surgery in performing the most tedious step of free flap transfer, namely microvascular anastomosis [38]. Given that an experienced microsurgeon operates at an accuracy of 50 μm, robot assistance refines this accuracy to 5-10 μm [39]. The latter has even allowed microvascular anastomosis to be easily performed by telemanipulator assistance, as demonstrated by many researchers around the world.…”

“…The time to perform this anastomosis was about 40 min, which is significantly longer than the standard technique (around 20 min). Conclusions from this attempt was that the potential advantages of robotic surgery were not yet translated into a clear practical advantage such as decreased operating time [39].…”

Methodology in Conventional Head and Neck Reconstruction Following Robotic Cancer Surgery: A Bridgehead Robotic Head and Neck Reconstruction

“…While many more surgeons have become more comfortable with performing vascular anastomosis, there are limited microsurgical instruments for robotic surgery. 10 26 27 28 29 Thus, there is an increasing need for development of diverse robot instruments. 10 26 …”

“… 10 26 27 28 29 Thus, there is an increasing need for development of diverse robot instruments. 10 26 …”