1
|
Awad L, Bollen E, Reed B, Langridge BJ, Jasionowska S, Nikkhah D, Butler PEM, Ponniah A. Clinical, Preclinical, and Educational Applications of Robotic-Assisted Flap Reconstruction and Microsurgery: A Systematic Review. Microsurgery 2024; 44:e31246. [PMID: 39431616 DOI: 10.1002/micr.31246] [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: 05/15/2024] [Revised: 09/03/2024] [Accepted: 09/26/2024] [Indexed: 10/22/2024]
Abstract
INTRODUCTION Microsurgery and super-microsurgery allow for highly technical reconstructive surgeries to be performed, with repairs of anatomical areas of less than 1 mm. Robotic-assisted surgery might allow for further advances within microsurgery, providing higher precision, accuracy, and scope to operate in previously inaccessible anatomical areas. However, robotics is not well-established within this field. We provide a summary of the clinical and preclinical uses of robotics within flap reconstruction and microsurgery, educational models, and the barriers to widespread implementation. METHODS A systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses was conducted of PubMed, Medline, and Embase. Preclinical, educational, and clinical articles were included. RESULTS One thousand five hundred and forty-two articles were screened; 87 articles met the inclusion criteria across flap harvest, flap/vessel pedicle dissection, vascular anastomosis, and nerve repair. The literature presents several potential benefits to the surgeon and patient such as high cosmetic satisfaction, minimally invasive access with reduced scarring (flap harvest), and low complication rates. Lack of haptic feedback was reported by authors to not impede the ability to perform vessel anastomosis; however, this required further investigation. A steep learning curve was identified, particularly for microsurgeons embarking upon robotic-assisted surgery. CONCLUSION Robotic-assisted surgery can potentially enhance microsurgery and flap reconstruction, with feasibility demonstrated within this review, up to anastomosis of 0.4 mm in diameter. However, there is a lack of sufficiently powered comparative studies, required to strengthen this statement. To increase accessibility to robotic surgery for plastic and reconstructive surgeons, educational opportunities must be developed with standardized assessment of skill acquisition.
Collapse
Affiliation(s)
- Laura Awad
- Charles Wolfson Centre of Reconstructive Surgery, University College London, Royal Free Hospital, London, UK
- Department of Plastic Surgery, Royal Free Hospital, London, UK
- Department of Surgery and Interventional Sciences, University College London, Royal Free Hospital, London, UK
| | - Edward Bollen
- Charles Wolfson Centre of Reconstructive Surgery, University College London, Royal Free Hospital, London, UK
| | - Benedict Reed
- Charles Wolfson Centre of Reconstructive Surgery, University College London, Royal Free Hospital, London, UK
- Department of Plastic Surgery, Royal Free Hospital, London, UK
| | - Benjamin J Langridge
- Charles Wolfson Centre of Reconstructive Surgery, University College London, Royal Free Hospital, London, UK
- Department of Plastic Surgery, Royal Free Hospital, London, UK
- Department of Surgery and Interventional Sciences, University College London, Royal Free Hospital, London, UK
| | - Sara Jasionowska
- Charles Wolfson Centre of Reconstructive Surgery, University College London, Royal Free Hospital, London, UK
- Department of Plastic Surgery, Royal Free Hospital, London, UK
| | - Dariush Nikkhah
- Department of Plastic Surgery, Royal Free Hospital, London, UK
| | - Peter E M Butler
- Charles Wolfson Centre of Reconstructive Surgery, University College London, Royal Free Hospital, London, UK
- Department of Plastic Surgery, Royal Free Hospital, London, UK
- Department of Surgery and Interventional Sciences, University College London, Royal Free Hospital, London, UK
| | - Allan Ponniah
- Charles Wolfson Centre of Reconstructive Surgery, University College London, Royal Free Hospital, London, UK
- Department of Plastic Surgery, Royal Free Hospital, London, UK
| |
Collapse
|
2
|
Ruccia F, Mavilakandy A, Imtiaz H, Erskine J, Liew YY, Ali M, Khajuria A. The application of robotics in plastic and reconstructive surgery: A systematic review. Int J Med Robot 2024; 20:e2661. [PMID: 39004949 DOI: 10.1002/rcs.2661] [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: 03/08/2024] [Revised: 06/26/2024] [Accepted: 06/30/2024] [Indexed: 07/16/2024]
Abstract
BACKGROUND Robotic assisted surgery (RAS) has seen significant advancement in many surgical specialties, although the application of robotics in plastic and reconstructive surgery remains to be widely established. This systematic review aims to assess the role of RAS in plastic and reconstructive surgery. METHODS The review protocol was published and registered a priori as CRD42024507420. A comprehensive electronic search for relevant studies was performed in MEDLINE, Embase and Google scholar databases. RESULTS Overall, 132 studies were initially identified, of which, 44 studies satisfied the eligibility criteria with a cumulative total of 239 patients. RAS demonstrated a high degree of procedural success and anastomotic patency in microvascular procedures. There was no significant difference in periprocedural adverse events between robotic and manual procedures. CONCLUSION RAS can be feasibly implemented in plastic and reconstructive surgery with a good efficacy and safety profile, particularly for microsurgical anastomosis and trans-oral surgery.
Collapse
Affiliation(s)
- Francesca Ruccia
- Department of Plastic Surgery, The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - Akash Mavilakandy
- Department of Internal Medicine, The University Hospitals of Leicester NHS Foundation Trust, Leicester, UK
| | - Hassan Imtiaz
- Poole General Hospital, University Hospitals Dorset NHS Foundation Trust, Poole, UK
| | - John Erskine
- Department of Internal Medicine, University Hospital Lewisham, Lewisham Greenwich NHS Trust, London, UK
| | - Yong Yie Liew
- Department of Neurosurgery, Lancashire Teaching Hospital NHS Foundation Trust, Preston, UK
| | - Meyada Ali
- The George Eliot Hospital NHS Trust, Nuneaton, UK
| | - Ankur Khajuria
- Kellogg College, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| |
Collapse
|
3
|
Awad L, Reed B, Bollen E, Langridge BJ, Jasionowska S, Butler PEM, Ponniah A. The emerging role of robotics in plastic and reconstructive surgery: a systematic review and meta-analysis. J Robot Surg 2024; 18:254. [PMID: 38878229 PMCID: PMC11180031 DOI: 10.1007/s11701-024-01987-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Accepted: 05/19/2024] [Indexed: 06/19/2024]
Abstract
The role of robotics has grown exponentially. There is an active interest amongst practitioners in the transferability of the potential benefits into plastic and reconstructive surgery; however, many plastic surgeons report lack of widespread implementation, training, or clinical exposure. We report the current evidence base, and surgical opportunities, alongside key barriers, and limitations to overcome, to develop the use of robotics within the field. This systematic review of PubMed, Medline, and Embase has been conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PROSPERO (ID: CRD42024524237). Preclinical, educational, and clinical articles were included, within the scope of plastic and reconstructive surgery. 2, 181, articles were screened; 176 articles met the inclusion criteria across lymph node dissection, flap and microsurgery, vaginoplasty, craniofacial reconstruction, abdominal wall reconstruction and transoral robotic surgery (TOR). A number of benefits have been reported including technical advantages such as better visualisation, improved precision and accuracy, and tremor reduction. Patient benefits include lower rate of complications and quicker recovery; however, there is a longer operative duration in some categories. Cost presents a significant barrier to implementation. Robotic surgery presents an exciting opportunity to improve patient outcomes and surgical ease of use, with feasibility for many subspecialities demonstrated in this review. However, further higher quality comparative research with careful case selection, which is adequately powered, as well as the inclusion of cost-analysis, is necessary to fully understand the true benefit for patient care, and justification for resource utilisation.
Collapse
Affiliation(s)
- Laura Awad
- Charles Wolfson Centre of Reconstructive Surgery, University College London, Royal Free Hospital, London, UK.
- Department of Plastic Surgery, Royal Free Hospital, London, UK.
- Department of Surgery and Interventional Sciences, University College London, Royal Free Hospital, London, UK.
| | - Benedict Reed
- Charles Wolfson Centre of Reconstructive Surgery, University College London, Royal Free Hospital, London, UK
- Department of Plastic Surgery, Royal Free Hospital, London, UK
| | - Edward Bollen
- Charles Wolfson Centre of Reconstructive Surgery, University College London, Royal Free Hospital, London, UK
| | - Benjamin J Langridge
- Charles Wolfson Centre of Reconstructive Surgery, University College London, Royal Free Hospital, London, UK
- Department of Plastic Surgery, Royal Free Hospital, London, UK
- Department of Surgery and Interventional Sciences, University College London, Royal Free Hospital, London, UK
| | - Sara Jasionowska
- Charles Wolfson Centre of Reconstructive Surgery, University College London, Royal Free Hospital, London, UK
- Department of Plastic Surgery, Royal Free Hospital, London, UK
| | - Peter E M Butler
- Charles Wolfson Centre of Reconstructive Surgery, University College London, Royal Free Hospital, London, UK
- Department of Plastic Surgery, Royal Free Hospital, London, UK
- Department of Surgery and Interventional Sciences, University College London, Royal Free Hospital, London, UK
| | - Allan Ponniah
- Charles Wolfson Centre of Reconstructive Surgery, University College London, Royal Free Hospital, London, UK
- Department of Plastic Surgery, Royal Free Hospital, London, UK
| |
Collapse
|
4
|
Khadanovich A, Trachtova D, Kaiser R, Benes M, Whitley A, Kachlik D. Anatomical considerations of the sural nerve in the distal leg: Side branch patterns and significance in nerve harvesting procedures. Ann Anat 2024; 254:152242. [PMID: 38458574 DOI: 10.1016/j.aanat.2024.152242] [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: 01/10/2024] [Revised: 02/08/2024] [Accepted: 03/05/2024] [Indexed: 03/10/2024]
Abstract
BACKGROUND The sural nerve is a somatosensory nerve that provides sensation to the posterolateral aspect of the lower leg and the lateral part of the ankle and foot. Due to its location and anatomical properties, it is often used as an autologous nerve graft. However, the nerve harvest can be complicated by the presence of side branches. The objective of this study was to investigate the anatomy of the sural nerve and to map its side branches. This information can be used to predict the localization of separate incisions during the stair-step incisions technique for nerve harvest, thereby reducing the risk of complications. METHODS The study involved the dissection of 50 adult cadaveric legs (25 left and 25 right) obtained from 27 Central European cadavers. The focus of the dissection was to identify the sural nerve, small saphenous vein, and surrounding anatomical structures. Detailed measurements were taken on the side branches of the sural nerve, tributaries of the small saphenous vein, and their interrelationship. RESULTS The average number of sural nerve side branches in a single leg was 4.2±1.9. These side branches were categorized into six groups based on their location and course: mediodistal, medioproximal, lateroproximal, laterodistal, medial perpendicular, and lateral perpendicular. Specific patterns of combination of these side branches were also identified and described. The branching point of the sural nerve was found to be 5.8±2.7 cm proximal to the lateral malleolus, whereas the small saphenous vein branching point was located more distally, 4.5 ± 2.8 cm proximal to the lateral malleolus. The highest density of sural nerve side branches was found 2.1-6.0 cm above the lateral malleolus. CONCLUSION This study presents valuable data about the relationship between the sural nerve and the surrounding anatomical structures in the distal part of the leg, including the identification of its side branches and their relevance during nerve harvest procedures. On the basis of the most frequent locations of side branches, a three-incision-technique for nerve harvest is proposed.
Collapse
Affiliation(s)
- Anhelina Khadanovich
- Department of Anatomy, Second Faculty of Medicine, Charles University, Prague, Czech Republic; Center for Endoscopic, Surgical and Clinical Anatomy (CESKA), Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Daniela Trachtova
- Department of Anatomy, Second Faculty of Medicine, Charles University, Prague, Czech Republic; Center for Endoscopic, Surgical and Clinical Anatomy (CESKA), Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Radek Kaiser
- Department of Anatomy, Second Faculty of Medicine, Charles University, Prague, Czech Republic; Center for Endoscopic, Surgical and Clinical Anatomy (CESKA), Second Faculty of Medicine, Charles University, Prague, Czech Republic; Spinal Surgery Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Michal Benes
- Department of Anatomy, Second Faculty of Medicine, Charles University, Prague, Czech Republic; Center for Endoscopic, Surgical and Clinical Anatomy (CESKA), Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Adam Whitley
- Department of Anatomy, Second Faculty of Medicine, Charles University, Prague, Czech Republic; Center for Endoscopic, Surgical and Clinical Anatomy (CESKA), Second Faculty of Medicine, Charles University, Prague, Czech Republic; Department of Surgery, University Hospital Královské Vinohrady, Prague, Czech Republic
| | - David Kachlik
- Department of Anatomy, Second Faculty of Medicine, Charles University, Prague, Czech Republic; Center for Endoscopic, Surgical and Clinical Anatomy (CESKA), Second Faculty of Medicine, Charles University, Prague, Czech Republic; Department of Health Studies, College of Polytechnics Jihlava, Czech Republic.
| |
Collapse
|
5
|
Raveglia F, Guttadauro A, Cioffi U, Sibilia MC, Petrella F. Is RATS Superior to VATS in Thoracic Autonomic Nervous System Surgery? J Clin Med 2024; 13:3193. [PMID: 38892902 PMCID: PMC11172593 DOI: 10.3390/jcm13113193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2024] [Revised: 05/22/2024] [Accepted: 05/24/2024] [Indexed: 06/21/2024] Open
Abstract
Technological development in the field of robotics has meant that, in recent years, more and more thoracic surgery departments have adopted this type of approach at the expense of VATS, and today robotic surgery boasts numerous applications in malignant and benign thoracic pathology. Because autonomic nervous system surgery is a high-precision surgery, it is conceivable that the application of RATS could lead to improved outcomes and reduced side effects, but its feasibility has not yet been thoroughly studied. This review identified three main areas of application: (1) standard thoracic sympathectomy, (2) selective procedures, and (3) nerve reconstruction. Regarding standard sympathectomy and its usual areas of application, such as the management of hyperhidrosis and some cardiac and vascular conditions, the use of RATS is almost anecdotal. Instead, its impact can be decisive if we consider selective techniques such as ramicotomy, optimizing selective surgery of the communicating gray branches, which appears to reduce the incidence of compensatory sweating only when performed with the utmost care. Regarding sympathetic nerve reconstruction, there are several studies, although not conclusive, that point to it as a possible solution to reverse surgical nerve interruption. In conclusion, the characteristics of RATS might make it preferable to other techniques and, particularly, VATS, but to date, the data in the literature are too weak to draw any evidence.
Collapse
Affiliation(s)
- Federico Raveglia
- Department of Thoracic Surgery, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, Italy; (M.C.S.); (F.P.)
| | - Angelo Guttadauro
- Department of Medicine and Surgery, School of Medicine and Surgery, University of Milano Bicocca, 20126 Milan, Italy;
| | - Ugo Cioffi
- Department of Surgery, School of Medicine and Surgery, University of Milan, 20122 Milano, Italy;
| | - Maria Chiara Sibilia
- Department of Thoracic Surgery, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, Italy; (M.C.S.); (F.P.)
| | - Francesco Petrella
- Department of Thoracic Surgery, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, Italy; (M.C.S.); (F.P.)
| |
Collapse
|
6
|
Ravendran K, Babu B, Madouros N, Panagiotopoulos N. Robotic Sympathectomy for Hyperhidrosis. Cureus 2023; 15:e33885. [PMID: 36660238 PMCID: PMC9844667 DOI: 10.7759/cureus.33885] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2023] [Indexed: 01/19/2023] Open
Abstract
In hyperhidrosis, the body's sweat glands overact. Excessive sweating results from this overactivity, and for many hyperhidrosis patients, managing symptoms can be difficult in day-to-day life. Both surgical and non-surgical types of treatment are available for hyperhidrosis. Surgical treatments include microwave sympathectomy (video-assisted thoracic surgery and robotic). Da Vinci Si and Xi robotic systems are used. This review summarizes the outcomes, complications, advantages, and disadvantages of robotic sympathectomy. We conducted a literature search using PubMed, Cochrane, and Scopus. After analyzing nine articles, we found that robotic sympathectomy decreased compensatory hyperhidrosis with similar outcomes to other procedures. Robotic sympathectomy also reduced complications of Horner syndrome and has changed minimally invasive surgery significantly due to the reduction in tremors by a surgeon's hands to three-dimensional magnified views. It can potentially address the limitations of human video-assisted sympathectomy. However, the higher cost of robotic surgery, longer perioperative time due to the setting up of the machine, and higher training requirements are some of the disadvantages. The advantages of robotic sympathectomy are a reduction in compensatory sweating, better dexterity, loss of tremors, better visualization, and better accuracy. Although the overall success rates seem to be similar between robotic and video-assisted approaches, more studies are needed.
Collapse
Affiliation(s)
| | - Betsy Babu
- Medical School, Medical University of Sofia, Sofia, BGR
| | | | | |
Collapse
|
7
|
Jimenez C, Stanton E, Sung C, Wong AK. Does plastic surgery need a rewiring? A survey and systematic review on robotic-assisted surgery. JPRAS Open 2022; 33:76-91. [PMID: 35812356 PMCID: PMC9260262 DOI: 10.1016/j.jpra.2022.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 05/11/2022] [Indexed: 01/28/2023] Open
Abstract
Background This is a paucity of data regarding plastic surgeons' opinions on robotic-assisted surgery (RAS). We developed a questionnaire aimed to survey plastic surgeons regarding training in robotics, concerns about widespread implementation, and new research directions. Methods A survey was created using Google Forms and sent to practicing plastic surgeons and trainees. Responses regarding desired conference proceedings about robotics, robotic residency training, and perceived barriers to implementation were elicited. Survey responses were utilized to direct a systematic review on RAS in plastic surgery. Results The survey received 184 responses (20.4%; 184/900). The majority (92.8%) of respondents were/are plastic surgery residents, with the most common fellowships being microsurgery (39.2%). Overall, 89.7% of respondents support some integration of robotics in the future of plastic surgery, particularly in pelvic/perineum reconstruction (56.4%), abdominal reconstruction (46.5%), microsurgery (43.6%), and supermicrosurgery (44.2%). Many respondents (66.1%) report never using a robot in their careers. Respondents expressed notable barriers to widespread robotic implementation, with cost (73.0%) serving as the greatest obstacle. A total of 10 studies (pelvic/perineum = 3; abdominal = 3; microsurgery = 4) were included after full-text review. Conclusions Evidence from our survey and review supports the growing interest and utility of RAS within the plastic and reconstructive surgery (PRS) and mirrors the established trend in other surgical subspecialties. Cost analyses will prove critical to implementing RAS within PRS. With validated benefits, plastic surgery programs can begin creating dedicated curricula for RAS.
Collapse
Affiliation(s)
- Christian Jimenez
- Keck School of Medicine of USC, Los Angeles, CA,Division of Plastic and Reconstructive Surgery, Keck School of Medicine, Los Angeles, CA
| | - Eloise Stanton
- Keck School of Medicine of USC, Los Angeles, CA,Division of Plastic and Reconstructive Surgery, Keck School of Medicine, Los Angeles, CA
| | - Cynthia Sung
- Keck School of Medicine of USC, Los Angeles, CA,Division of Plastic and Reconstructive Surgery, Keck School of Medicine, Los Angeles, CA,Division of Plastic and Reconstructive Surgery, City of Hope National Medical Center, Duarte, CA
| | - Alex K. Wong
- Keck School of Medicine of USC, Los Angeles, CA,Division of Plastic and Reconstructive Surgery, Keck School of Medicine, Los Angeles, CA,Division of Plastic and Reconstructive Surgery, City of Hope National Medical Center, Duarte, CA,Corresponding author: Alex K. Wong, Division of Plastic and Reconstructive Surgery, City of Hope, 1500 E Duarte Rd, Duarte, CA 91010.
| |
Collapse
|