Robot-assisted vascular surgery: literature review, clinical applications, and future perspectives

Abstract

Although robot-assisted surgical procedures using the da Vinci robotic system (Intuitive Surgical, Sunnyvale, CA) have been performed in more than 13 million procedures worldwide over the last two decades, the vascular surgical community has yet to fully embrace this approach (Intuitive Surgical Investor Presentation Q3 (2023) https://investor.intuitivesurgical.com/static-files/dd0f7e46-db67-4f10-90d9-d826df00554e . Accessed February 22, 2024). In the meantime, endovascular procedures revolutionized vascular care, serving as a minimally invasive alternative to traditional open surgery. In the pursuit of a percutaneous approach, shorter postoperative hospital stay, and fewer perioperative complications, the long-term durability of open surgical vascular reconstruction has been compromised (in Lancet 365:2179-2186, 2005; Patel in Lancet 388:2366-2374, 2016; Wanhainen in Eur J Vasc Endovasc Surg 57:8-93, 2019). The underlying question is whether the robotic-assisted laparoscopic vascular surgical approaches could deliver the robustness and longevity of open vascular surgical reconstruction, but with a minimally invasive delivery system. In the meantime, other surgical specialties have embraced robot-assisted laparoscopic technology and mastered the essential vascular skillsets along with minimally invasive robotic surgery. For example, surgical procedures such as renal transplantation, lung transplantation, and portal vein reconstruction are routinely being performed with robotic assistance that includes major vascular anastomoses (Emerson in J Heart Lung Transplant 43:158-161, 2024; Fei in J Vasc Surg Cases Innov Tech 9, 2023; Tzvetanov in Transplantation 106:479-488, 2022; Slagter in Int J Surg 99, 2022). Handling and dissection of major vascular structures come with the inherent risk of vascular injury, perhaps the most feared complication during such robotic procedures, possibly requiring emergent vascular surgical consultation. In this review article, we describe the impact of a minimally invasive, robotic approach covering the following topics: a brief history of robotic surgery, components and benefits of the robotic system as compared to laparoscopy, current literature on "vascular" applications of the robotic system, evolving training pathways and future perspectives.

Keywords: Laparoscopic surgery; Robotic surgery; Robotic-assisted laparoscopic vascular surgery; Vascular robotics; Vascular surgery.

Fig. 1

Evolution of Intuitive Surgical’s da Vinci Surgical Robot (Intuitive Surgical, Sunnyvale, CA, USA)

Fig. 2

A Intraoperative view of the median arcuate ligament (red arrow) causing a visible compression at the origin of the celiac artery. B 3D CTA reconstruction image of the same patient. The yellow arrow marks the compressed celiac artery

Fig. 3

Steps of a robotic renal vein transposition. A Rommel tourniquet on the supra- and infrarenal IVC, right renal vein, and laparoscopic bulldog clamp on the left renal vein and a lumbar vein. B Closing the defect of the IVC after the transection of the left renal vein. C Creation of the cavorenal anastomosis more distally. D Completed transposition of the left renal vein

Fig. 4

Robot-assisted IVC filter removal. In picture A and B protrusion of the filter’s struts can be appreciated on CT imaging, marked with a red arrow. C Intraoperative view of the infrarenal IVC with the protruding struts of the filter