Robotic-Assisted Vascular Surgery: A Clinical Perspective

Abstract

This literature review provides a comprehensive clinical perspective on the current and potential role of robotic-assisted surgery within vascular practice. It outlines the historical development and technical components of surgical robotic platforms, particularly the da Vinci system, and reviews published evidence on robotic-assisted vascular procedures. It also examines the advantages and limitations of robotic approaches compared to open and endovascular techniques, the current absence of dedicated robotic tools for vascular use, and the growing need for structured training pathways.

Keywords: da Vinci; laparoscopic; minimally invasive; robotic surgery; robotic vascular anastomosis; vascular surgery.

Figure 1

Robotic platform evolution and system components. (A) Timeline illustrating the evolution of robotic surgical platforms from 1999 to 2024. The da Vinci system, originally released in 1999, has undergone several major generational upgrades, including the da Vinci S (2006), Si (2009), Xi (2014), SP (2018), and the most recent da Vinci 5 (2024). The figure also includes other systems such as Robolenz (2005) and the Sina platforms (2013, 2017) to highlight concurrent innovations in robotic surgery. (B) Overview of the core components of the da Vinci Surgical System, which consists of three primary units: the Patient Cart, which holds the robotic arms that execute the surgical tasks; the Surgeon Console, where the surgeon sits and controls the instruments using hand and foot controls while viewing the operative field in 3D; and the Vision Cart, which houses the optical and processing equipment and facilitates communication between the system components.

Figure 2

Robotic aortobifemoral bypass: port placement and key operative steps. (A) Schematic of port placement for robotic aortic exposure. Four 8 mm robotic instrument ports and three 12 mm assistant ports are positioned across the left abdomen to allow access for robotic instruments and laparoscopic assistance during aortic dissection and bypass construction. (B) Intraoperative image demonstrating placement of proximal and distal aortic clamps using laparoscopic clamps to control the infrarenal aorta. (C) Robotic removal of intraluminal thrombus from the diseased segment of the aorta following arteriotomy, facilitating a clean landing zone for proximal anastomosis. (D) Robotic tunneling of the bifurcated Dacron graft limbs to the bilateral groins, using a combination of blunt dissection and laparoscopic assistance to ensure proper positioning without kinking. (E) Final view of the completed aortobifemoral bypass with a proximal end-to-side anastomosis to the native aorta and bilateral limb tunneling to femoral targets, demonstrating hemostasis and appropriate graft orientation.

Figure 3

Robotic ligation of type ii endoleak vessels. (A) Port placement strategy for robotic retroperitoneal exposure in the treatment of type II endoleaks originating from the inferior mesenteric artery, left-sided or posterior lumbar arteries, or the median sacral artery. A combination of 8 mm robotic ports (black) and 12 mm assistant ports (purple) are positioned to allow optimal triangulation for left lower quadrant and midline retroperitoneal access. (B) Intraoperative image showing robotic exposure of the inferior mesenteric artery, dissected free from surrounding retroperitoneal tissue in preparation for ligation. (C) Robotic ligation of a left-sided lumbar artery contributing to persistent type II endoleak, with clear visualization of vascular control and surrounding tissue dissection.

Figure 4

Robotic resection and reconstruction for splenic artery aneurysm. (A) Port placement schematic for robotic splenic artery aneurysm resection. Four 8 mm robotic ports and one 12 mm assistant port are placed across the upper abdomen to allow optimal exposure and instrument access to the splenic artery along the superior border of the pancreas. (B) Intraoperative view showing careful dissection and identification of the splenic artery aneurysm, with vascular control obtained proximally and distally using vessel loops. (C) Following aneurysm resection, the robotic instruments begin end-to-end anastomosis of the splenic artery using fine suture, reestablishing in-line flow. (D) Near completion of the end-to-end splenic artery reconstruction. (E) The resected splenic artery aneurysm specimen being retrieved into an endo-catch bag for removal from the abdominal cavity.

Figure 5

Robotic median arcuate ligament release. (A) Port placement schematic for robotic-assisted median arcuate ligament release. Four 8 mm robotic ports, one 5 mm port in the right upper quadrant for placement of liver retractor, and one 12 mm assistant port to facilitate precise dissection along the diaphragmatic crura and access to the supraceliac aorta and celiac axis. (B) Intraoperative view demonstrating completed dissection with clear exposure of the supraceliac aorta and the origin of the celiac artery following division of the median arcuate ligament and thorough neurolysis of the celiac plexus.

Figure 6

Robotic left renal vein transposition for nutcracker syndrome. (A) Port placement schematic for robotic-assisted left renal vein transposition. Four 8 mm robotic ports and two 12 mm assistant ports are positioned across the mid to lower abdomen to allow optimal access and visualization of the infrarenal IVC and left renal vein. (B) Intraoperative view showing careful dissection and identification of the left renal vein and infrarenal IVC, with vascular control established to facilitate safe mobilization. (C) Mobilization and positioning of the left renal vein for transposition, demonstrating alignment for a tension-free anastomosis to the infrarenal IVC. (D) Robotic construction of the end-to-side anastomosis between the left renal vein and the IVC using fine monofilament suture, ensuring unobstructed venous outflow. (E) Completed left renal vein transposition with hemostatic anastomosis and restored anatomic orientation, confirming resolution of the compression. IVC: inferior vena cava

Figure 7

Robotic IVC filter retrieval. (A) Intraoperative view showing robotic exposure of the infrahepatic IVC with identification of IVC filter legs protruding through the caval wall, often associated with surrounding fibrosis or inflammation. (B) Placement of vessel loops and vascular clips for proximal and distal control of the IVC to ensure safe cavotomy. (C) Cavotomy with initial opening of the IVC reveals the embedded filter struts and associated synechiae. (D) Robotic-assisted removal of the IVC filter from within the IVC lumen using atraumatic graspers and dissection techniques to safely extract the device while minimizing damage to the caval wall. (E) Port placement schematic for robotic-assisted IVC filter retrieval. Four 8 mm robotic ports and two 12 mm assistant ports are placed across the lower and lateral abdomen to provide adequate access and triangulation for precise vascular dissection and suturing. IVC: inferior vena cava