Robotic-assisted microsurgery for an elective microsurgical practice

Abstract

Robotic-assisted microsurgery can be utilized for either intracorporal or extracorporeal surgical procedures. Three-dimensional high-definition magnification, a stable ergonomic platform, elimination of physiologic tremor, and motion scaling make the robotic platform attractive for microsurgeons for complex procedures. Additionally, robotic assistance enables the microsurgeon to take microsurgery to challenging intracorporeal locations in a minimally invasive manner. Recent adjunctive technological developments offer the robotic platform enhanced optical magnification, improved intraoperative imaging, and more precise ablation techniques for microsurgical procedures. The authors present the current state-of-the art tools available in the robotic-assisted microsurgical platform.

Keywords: Firefly; Vein Viewer; da Vinci robotic platform; flexible fiberoptic CO2 laser; intraoperative imaging; micro-Doppler probe; optical magnification; robotic microsurgery; robotic microsurgical instrumentation; water-jet dissection.

Fig. 1

VITOM lens-camera & Point-Setter Nitrogen powered arm system (Karl Storz Inc., Tuttlingen, Germany) for enhanced optical magnification. (A) Positioning of the VITOM lens-camera system during a robotic-assisted microsurgical vasectomy reversal. (B) The VITOM lens-camera is positioned by adjusting the Point-Setter nitrogen powered arm.

Fig. 2

Surgeon's view in the surgeon console during a robotic-assisted microsurgical vasoepididymostomy (for vasectomy reversal) showing three views: (A) Main view from the three-dimensional high-definition robot camera in the middle top (10–15× magnification). (B) Magnification view (40 × ) on the lower left-hand side from the optical phase-contrast microscope in the laboratory assessing the epididymal fluid for sperm. (C) View on the lower right-hand side from the VITOM optical magnification lens-camera (Karl Storz Inc., Tuttlingen, Germany; 16–25× magnification).

Fig. 3

The Firefly (Intuitive Surgical Inc., Sunnyvale, CA) imaging mode is being used to identify the renal arteries during an intra-abdominal renal case.

Fig. 4

The audible micro-Doppler sensing probe is being used to detect the testicular artery in the spermatic cord (Vascular Technology Inc., Nashua, NH).

Fig. 5

The micro-Doppler ultrasound probe is detecting varicose veins in the spermatic cord (Hitachi-Aloka, Wallingford, CT).

Fig. 6

Dilated varicose veins are seen under regular light (A) and then under near-infrared Vein Viewer light (B) the veins are dark (Christie Digital Systems, Cypress, CA).

Fig. 7

The flexible fiberoptic CO₂ laser probe is being used for dissection and ligation of the cremasteric muscle fibers during targeted microsurgical denervation of the spermatic cord (OmniGuide, Cambridge, MA).

Fig. 8

High-pressure water-jet hydrodissection is used to ablate residual nerve fibers around the vas deferens while preserving the vasa vasorum (ERBE Inc., Atlanta, GA).

Fig. 9

Utilization of the confocal laser endomicroscope probe (Cellvizio, Mauna Kea Technologies, Paris, France) to visualize the cremasteric muscle fibers and to try to detect any nerve fibers within the muscle during targeted microsurgical denervation of the spermatic cord.