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Gorji S, Wessel K, Dermietzel A, Aitzetmueller M, Wendenburg I, Varnava C, Klietz ML, Wiebringhaus P, Hirsch T, Kueckelhaus M. Fully Telemetric Robotic Microsurgery: Clinical Experience With 23 Cases. Microsurgery 2024; 44:e31227. [PMID: 39207211 DOI: 10.1002/micr.31227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 04/16/2024] [Accepted: 08/02/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND Recently, there is an ongoing trend in plastic surgery with robotic-assisted microsurgery and supermicrosurgery devices being developed. Combining a telemetrically controlled robotic microscope with an also telemetrically controlled microsurgery robot unlocks synergistic effects with complete disconnection of the operating surgeon from the operating field. Here, we report the first clinical free flap reconstructions using this setup. METHODS Twenty-three surgeries were performed with the combined remote approach using the Symani Surgical System and the RoboticScope in open microsurgery procedures. Anastomosis time and ischemia time were recorded. The surgical performance for anastomoses was assessed using the modified Structured Assessment of Microsurgical Skills (SAMS) score. Subjective satisfaction was evaluated by the surgeons in comparison with conventional microsurgery. To evaluate the learning curve, the senior authors first four (first group) and last four (last group) procedures were compared. RESULTS Overall, flap survival was 95.7%. The average arterial anastomosis time was 36.7 ± 10.9 min. Total time of surgery was 277.7 ± 63.8 min, and ischemia time was 100.6 ± 24.9 min. Most SAMS score parameters were significantly higher in the last group of surgical procedures compared with the first operations. Subjective satisfaction was equal or better with the combined robotic-assisted approach in most categories. CONCLUSIONS Our data demonstrates safety and feasibility of the use of a combined remote approach. Robotic systems for microsurgical procedures may hold promising potential for improvement of surgical quality and open up new frontiers in microsurgery.
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Affiliation(s)
- Shaghayegh Gorji
- Department of Plastic and Reconstructive Surgery, Institute of Musculoskeletal Medicine, University of Munster, Munster, Germany
- Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Fachklinik Hornheide, Munster, Germany
| | - Kai Wessel
- Department of Plastic and Reconstructive Surgery, Institute of Musculoskeletal Medicine, University of Munster, Munster, Germany
- Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Fachklinik Hornheide, Munster, Germany
| | - Alexander Dermietzel
- Department of Plastic and Reconstructive Surgery, Institute of Musculoskeletal Medicine, University of Munster, Munster, Germany
- Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Fachklinik Hornheide, Munster, Germany
- Division of Plastic Surgery, Department of Trauma, Hand and Reconstructive Surgery, University Hospital Munster, Munster, Germany
| | - Matthias Aitzetmueller
- Department of Plastic and Reconstructive Surgery, Institute of Musculoskeletal Medicine, University of Munster, Munster, Germany
- Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Fachklinik Hornheide, Munster, Germany
- Division of Plastic Surgery, Department of Trauma, Hand and Reconstructive Surgery, University Hospital Munster, Munster, Germany
| | - Isa Wendenburg
- Department of Plastic and Reconstructive Surgery, Institute of Musculoskeletal Medicine, University of Munster, Munster, Germany
- Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Fachklinik Hornheide, Munster, Germany
| | - Charalampos Varnava
- Department of Plastic and Reconstructive Surgery, Institute of Musculoskeletal Medicine, University of Munster, Munster, Germany
- Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Fachklinik Hornheide, Munster, Germany
- Division of Plastic Surgery, Department of Trauma, Hand and Reconstructive Surgery, University Hospital Munster, Munster, Germany
| | - Marie-Luise Klietz
- Department of Plastic and Reconstructive Surgery, Institute of Musculoskeletal Medicine, University of Munster, Munster, Germany
- Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Fachklinik Hornheide, Munster, Germany
- Division of Plastic Surgery, Department of Trauma, Hand and Reconstructive Surgery, University Hospital Munster, Munster, Germany
| | - Philipp Wiebringhaus
- Department of Plastic and Reconstructive Surgery, Institute of Musculoskeletal Medicine, University of Munster, Munster, Germany
- Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Fachklinik Hornheide, Munster, Germany
- Division of Plastic Surgery, Department of Trauma, Hand and Reconstructive Surgery, University Hospital Munster, Munster, Germany
| | - Tobias Hirsch
- Department of Plastic and Reconstructive Surgery, Institute of Musculoskeletal Medicine, University of Munster, Munster, Germany
- Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Fachklinik Hornheide, Munster, Germany
- Division of Plastic Surgery, Department of Trauma, Hand and Reconstructive Surgery, University Hospital Munster, Munster, Germany
| | - Maximilian Kueckelhaus
- Department of Plastic and Reconstructive Surgery, Institute of Musculoskeletal Medicine, University of Munster, Munster, Germany
- Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Fachklinik Hornheide, Munster, Germany
- Division of Plastic Surgery, Department of Trauma, Hand and Reconstructive Surgery, University Hospital Munster, Munster, Germany
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Kueckelhaus M. Minimally Invasive Robotic-assisted Perforator-to-Perforator DIEP Flap Breast Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5800. [PMID: 38741600 PMCID: PMC11090619 DOI: 10.1097/gox.0000000000005800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 03/18/2024] [Indexed: 05/16/2024]
Abstract
Reducing morbidity has been the goal of many reconstructive microsurgery efforts. Several techniques have been described for deep inferior epigastric perforator flap breast reconstruction to minimize abdominal donor-site morbidity. Although these techniques have certain tradeoffs, we designed a minimally invasive robot-assisted perforator-to-perforator approach to achieve minimal donor- and recipient-site morbidity. Simultaneous identification of the deep inferior epigastric artery (DIEA) and internal mammary artery (IMA) perforator was performed, followed by a small fascial incision around the dominant DIEA perforator. The IMA perforator was prepared for a prepectoral anastomosis. The short DIEA pedicle was dissected without further longitudinal fascial incision until an adequate diameter compared with the IMA perforator was reached, and a robot-assisted perforator-to-perforator anastomosis was performed prepectorally. All patients underwent reconstruction performed by a single surgeon. The smallest abdominal incision was 2.5 cm with a DIEP pedicle length of 6 cm. The average IMA perforator diameter was 1.14 mm (1.0 mm-1.2 mm). The average vein diameter was 2.0 mm (1.5-3.0 mm). The incision to closure lasted 330 minutes (313-348 minutes). Flap ischemia was 105 minutes (82-118 minutes), whereas the time for robot-assisted anastomosis was 25 minutes (22-30 minutes). All anastomoses were performed successfully. Our initial experience with robot-assisted perforator-to-perforator anastomosis for DIEP flap breast reconstruction demonstrates promise in achieving minimal patient morbidity. Raising only a very short pedicle can be compensated by adding the prepectoral IMA perforator length and enabling a good size match for small-caliber anastomosis. This technique combines important aspects of most minimally invasive DIEP flap harvests and insets.
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Affiliation(s)
- Maximilian Kueckelhaus
- From the Department of Plastic Surgery, University Hospital Muenster, Muenster, Germany
- Department of Plastic and Reconstructive Surgery, Institute of Musculoskeletal Medicine, Muenster University, Germany
- Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Fachklinik Hornheide, Muenster, Germany
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Friebel TR, Shanmugakrishnan RR, Zberea D, Morgan M, Hussain A, Ramakrishnan V. Internal mammary perforator vessels as recipient for microvascular breast reconstruction: Technique and outcomes in 161 flaps. J Plast Reconstr Aesthet Surg 2023; 85:454-462. [PMID: 37586312 DOI: 10.1016/j.bjps.2023.07.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 07/14/2023] [Accepted: 07/16/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND The use of internal mammary perforator (IMP) vessels as recipients for free flap breast reconstruction was first described in 1999. Despite numerous advantages over the internal mammary (IM) and thoracodorsal recipient vessels, their widespread use remains mired in concern. This paper describes our method of IMP vessel preparation and outcomes with regard to safety and reliability. METHODS To support the reliability of the IMP vessel preparation, a retrospective study on prospectively collected data of all free flap breast reconstruction patients between 1 July 2016 and 31 July 2019 was performed. Data were collected on patient demographics, type of reconstruction operative details and complications. RESULTS Out of the 450 flaps performed, the IMP vessels were used in 36% of the cases. Of these cases, 18% had received neo-adjuvant chemotherapy and 15% had a history of radiotherapy to the chest wall. In total, 161 flaps were performed to reconstruct 138 breasts (115 single and 23 stacked flaps). Three patients required a return to theatre, with one needing recipient vessel revision from the IMP to the IM vessels due to calibre mismatch. No mastectomy skin flap necrosis, free flap loss or significant fat necrosis were encountered. CONCLUSION This article describes an IM vessel preparation method that results in predictable outcomes in both single and stacked flap reconstructions with a low complication rate. Due to their reliability and versatility, we consider the IMP vessels a valuable attribute to the recipient vessel arsenal of any breast reconstruction microsurgeon.
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Affiliation(s)
- Thessa R Friebel
- St. Andrews Centre for Plastics and Burns, Court Road, Broomfield, Chelmsford CM17ET, United Kingdom.
| | - R Raja Shanmugakrishnan
- St. Andrews Centre for Plastics and Burns, Court Road, Broomfield, Chelmsford CM17ET, United Kingdom
| | - Diana Zberea
- St. Andrews Centre for Plastics and Burns, Court Road, Broomfield, Chelmsford CM17ET, United Kingdom
| | - Mary Morgan
- St. Andrews Centre for Plastics and Burns, Court Road, Broomfield, Chelmsford CM17ET, United Kingdom
| | - Amer Hussain
- St. Andrews Centre for Plastics and Burns, Court Road, Broomfield, Chelmsford CM17ET, United Kingdom
| | - Venkat Ramakrishnan
- St. Andrews Centre for Plastics and Burns, Court Road, Broomfield, Chelmsford CM17ET, United Kingdom
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Boonipat T, Ji L, Manrique OJ, Chen HC. Combined bipedicled latissimus dorsi and groin flap for anterior chest wall reconstruction. BMJ Case Rep 2019; 12:12/5/e227372. [PMID: 31079037 DOI: 10.1136/bcr-2018-227372] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
We provide a case report of reconstruction of a massive chest wall defect after recurrent phyllodes tumour resections. The reconstruction used a bipedicled groin and latissimus dorsi flap, with composite rib autologous reconstruction. The patient successfully recovered from the operation. Our case illustrates the applicability of this flap in the armamentarium of anterior chest wall reconstructive options.
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Affiliation(s)
- Thanapoom Boonipat
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Lou Ji
- Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, China
| | - Oscar J Manrique
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Hung-Chi Chen
- Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, China
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