Robot-assisted surgery of the shoulder girdle and brachial plexus

Abstract

New developments in the surgery of the brachial plexus include the use of less invasive surgical approaches and more precise techniques. The theoretical advantages of the use of robotics versus endoscopy are the disappearance of physiological tremor, three-dimensional vision, high definition, magnification, and superior ergonomics. On a fresh cadaver, a dissection space was created and maintained by insufflation of CO2. The supraclavicular brachial plexus was dissected using the da Vinci robot (Intuitive Surgical, Sunnyvale, CA). A segment of the C5 nerve root was grafted robotically. A series of eight clinical cases of nerve damage around the shoulder girdle were operated on using the da Vinci robot. The ability to perform successful microneural repair was confirmed in both the authors' clinical and experimental studies, but the entire potential of robotically assisted microneural surgery was not realized during these initial cases because an open incision was still required. Robotic-assisted surgery of the shoulder girdle and brachial plexus is still in its early stages. It would be ideal to have even finer and more suitable instruments to apply fibrin glue or electrostimulation in nerve surgery. Nevertheless, the prospects of minimally invasive techniques would allow acute and subacute surgical approach of traumatic brachial plexus palsy safely, without significant and cicatricial morbidity.

Keywords: brachial plexus; da Vinci robot; shoulder girdle; telemicrosurgery.

Fig. 1

Telemicrosurgical workstation with the da Vinci S robot (Intuitive Surgical, Sunnyvale, CA). To the left of the figure is the main console that allows the operator to control the articulated arms of the movable carriage which is in the middle arm of figure. Video column to the right of the figure (provided courtesy of Intuitive Surgical, Sunnyvale, CA).

Fig. 2

Preparation of a robot-assisted endoscopic repair of the right supraclavicular brachial plexus. (A) Introduction of a finger through one of the instrumental routes and subcutaneous detachment to prepare the workspace. (B) Three trocars in place. (C) Robot in place ready to operate. Note that the stand of the robot is at the head of the opposite side.

Fig. 3

Endoscopic view from the main console of a robot-assisted repair of the right supraclavicular brachial plexus. (A) View of the workspace, gradually enlarged by instrumental dissection. Note the bipolar “Maryland” clamps on either side of the operative field. (B) View of the workspace. Note the omohyoid muscle (black star). (C) View of the workspace. Note the jugular vein (black star). (D) View of the workspace. Note hemostasis done by clip placement on a branch of the jugular vein (black arrow). (E) View of the workspace. Note the phrenic nerve (black star). (F) View the workspace. Note the roots of the supraclavicular brachial plexus: C5 (white star), C6 (black star), C7 (black arrow). (G) View of the workspace. The C5 root was cut 2 cm to form a transplant model (black star). The black arrow shows the loss of nerve substance. (H) View of the workspace. Introduction of a 10/0 nylon carried through one of the two instrumental trocars. The needle is seized by a Black Diamond forceps. (I) View of the workspace. Note the passage of the needle through the proximal stump of the root C5. The black star shows the transplant model. (J) View of workspace. Note the first point of clamping of the proximal suture. The black star shows the transplant model. (K) View of workspace. View of the final graft. The white star shows the C5 portion upstream of the graft. The white star shows the C5 portion downstream of the graft.