Robot-assisted anterior lumbar interbody fusion in a Swine model in vivo test of the da vinci surgical-assisted spinal surgery system

Evaluating the Status and Promising Potential of Robotic Spinal Surgery Systems

The increasing frequency of cervical and lumbar spine disorders, driven by aging and evolving lifestyles, has led to a rise in spinal surgeries using pedicle screws. Robotic spinal surgery systems have emerged as a promising innovation, offering enhanced accuracy in screw placement and improved surgical outcomes. We focused on literature of this field from the past 5 years, and a comprehensive literature search was performed using PubMed and Google Scholar. Robotic spinal surgery systems have significantly impacted spinal procedures by improving pedicle screw placement accuracy and supporting various techniques. These systems facilitate personalized, minimally invasive, and low-radiation interventions, leading to greater precision, reduced patient risk, and decreased radiation exposure. Despite advantages, challenges such as high costs and a steep learning curve remain. Ongoing advancements are expected to further enhance these systems' role in spinal surgery.

Da Vinci Robotic Assistance for Anterolateral Lumbar Arthrodesis: Results of a French Multicentric Study

BACKGROUND

The da Vinci robot (DVR) is the most widely used robot in abdominal, urological, and gynecological surgery. Due to its minimally invasive approach, the DVR has demonstrated its effectiveness and improved safety in these different disciplines. The aim of our study was to report its use in an anterior approach of complex lumbar surgery.

METHODS

In a retrospective multicenter observational study, 10 robotic-assisted procedures were performed from March 2021 to May 2022. Six oblique lumbar interbody fusion procedures and 4 lumbar corpectomies were performed by anterolateral approach assisted by the DVR. The characteristics of the patients and the intraoperative and postoperative data were recorded.

RESULTS

Six men and 4 women underwent surgery (mean age 50.5 years; body mass index 28.6 kg/m2). No vascular injuries were reported, and no procedures required conversion to open surgery. Mean surgical time were 219 minutes for 1-level oblique lumbar interbody fusion (3 patients), 286 minutes for 2-level oblique lumbar interbody fusion (3 patients), and 390 minutes for corpectomy (4 patients). Four patients experienced nonserious adverse events due to lumbar plexus nerve damage. One patient had a vertebral body plate fracture requiring posterior revision surgery, and 1 patient had a psoas hematoma requiring transfusion. No abdominal wall complications or surgical site infection were found. Seven patients were reviewed at 12 months, none had complications, and all showed radiological evidence of fusion.

CONCLUSIONS

The use of the DVR in lumbar surgery allows a safe minimally invasive transperitoneal approach, but to date, only hybrid procedures have been performed.

Da Vinci Meets Globus Excelsius GPS: A Totally Robotic Minimally Invasive Anterior and Posterior Lumbar Fusion

BACKGROUND

Minimally invasive approaches to the spine via anterior and posterior approaches have been increasing in popularity, culminating in the development of robot-assisted spinal fusions. The da Vinci surgical robot has been used for anterior lumbar interbody fusion (ALIF), with promising results. Similarly, multiple spinal robots have been developed to assist placement of posterior pedicle screws. However, no previous cases have reported on using robots for both anterior and posterior fixation in a single surgery. We present a technical note on the first reported case of a totally robotic minimally invasive anterior and posterior lumbar fusion and instrumentation.

METHODS

A 65-year-old man with chronic low back pain and left greater than right lower extremity radiculopathy was found to have grade 1 spondylolisthesis at L5/S1 that worsened on standing upright. He underwent ALIF using a da Vinci robotic approach, followed by percutaneous posterior instrumented fusion with the Globus Excelsius GPS robot.

RESULTS

The patient did well postoperatively, with improvement of back and leg pain at 3 months follow-up. Radiography confirmed appropriate placement of the interbody cage and pedicle screws.

CONCLUSIONS

All-robotic placement of both ALIF and posterior lumbar pedicle fixation may be safe, feasible, and efficacious.

Retrospective analysis of robot-assisted laparoscopic transabdominal anterior approach for the treatment of lumbar paravertebral schwannoma

BACKGROUND

The main objective of this study was to investigate the impact of robot-assisted laparoscopic resection on paravertebral tumours using the anterior peritoneal approach.

METHODS

A retrospective analysis to identify patients with paravertebral tumours. A total of 21 patients, who underwent robot-assisted laparoscopic transabdominal anterior approach surgery from March 2012 to August 2020.

RESULTS

The median operation time was 66.2 ± 14.5 min, with a range of 0-100 min. Intraoperative blood loss was minimal, with a median of 11.4 ± 7.9 mL and a range of 5-30 mL. The median tumour length was 4.8 ± 2.3 cm, ranging from 2.1 to 11.3 cm. Postoperative hospitalisation lasted for a median of 3.2 ± 0.9 days. During the 48-month follow-up period, no tumour recurrence or residual was observed in any patient.

CONCLUSIONS

Robot-assisted laparoscopic resection of lumbar paravertebral schwannoma proved to be a safe and viable surgical approach. It offers a relatively new treatment option for paraspinal schwannoma.

Identification of milling status based on vibration signals using artificial intelligence in robot-assisted cervical laminectomy

BACKGROUND

With advances in science and technology, the application of artificial intelligence in medicine has significantly progressed. The purpose of this study is to explore whether the k-nearest neighbors (KNN) machine learning method can identify three milling states based on vibration signals: cancellous bone (CCB), ventral cortical bone (VCB), and penetration (PT) in robot-assisted cervical laminectomy.

METHODS

Cervical laminectomies were performed on the cervical segments of eight pigs using a robot. First, the bilateral dorsal cortical bone and part of the CCB were milled with a 5 mm blade and then the bilateral laminae were milled to penetration with a 2 mm blade. During the milling process using the 2 mm blade, the vibration signals were collected by the acceleration sensor, and the harmonic components were extracted using fast Fourier transform. The feature vectors were constructed with vibration signal amplitudes of 0.5, 1.0, and 1.5 kHz and the KNN was then trained by the features vector to predict the milling states.

RESULTS

The amplitudes of the vibration signals between VCB and PT were statistically different at 0.5, 1.0, and 1.5 kHz (P < 0.05), and the amplitudes of the vibration signals between CCB and VCB were significantly different at 0.5 and 1.5 kHz (P < 0.05). The KNN recognition success rates for the CCB, VCB, and PT were 92%, 98%, and 100%, respectively. A total of 6% and 2% of the CCB cases were identified as VCB and PT, respectively; 2% of VCB cases were identified as PT.

CONCLUSIONS

The KNN can distinguish different milling states of a high-speed bur in robot-assisted cervical laminectomy based on vibration signals. This method is feasible for improving the safety of posterior cervical decompression surgery.

R2 advances in robotic-assisted spine surgery: comparative analysis of options, future directions, and bibliometric analysis of the literature

Spine surgery has undergone rapid advancements over the past several decades with the emergence of robotic and minimally invasive surgery (MIS). While conventional MIS spine surgery has had relative success, its complication profile has warranted continued efforts to improve clinical outcomes. We discuss the functional, clinical, and financial aspects of four robotic options for spinal pathologies, namely ROSA, Mazor X, Da Vinci, and ExcelsiusGPS, and conduct a bibliometric analysis to better understand current trends and applications of these robots as the field of robotic spine surgery continues to grow. An extensive search of English-language published literature on robotic-assisted spinal surgery was performed in Elsevier's Scopus database. A bibliometric analysis was then performed on the top 100 most cited papers. The search yielded articles regarding robotic-assisted spine surgery application, limitations, and functional outcomes secondary to spine pathology. Accuracy analyses of 1733 screw placements were reviewed. The top 100 papers were published between 1992 and 2020, with a significant increase from 2015 onwards. The top publishing institution was John Hopkins University (n = 8). The top contributing author was Dr. Isador H. Lieberman (n = 6). The USA (n = 34) had the most articles on robotic spinal surgery, followed by Germany (n = 12). This review examines robotic applications in spine surgery, including four available options: ROSA, Mazor X, Da Vinci, and ExcelsiusGPS. Publication output over time, surgical outcomes, screw accuracy, and cost-effectiveness of these technologies have been investigated here. Certain robots have functional, clinical, and financial differences worth noting. Given the dearth of existing literature reporting postoperative complications and long-term comparative outcomes, there is a clear need for further studies on this matter.

Artificial Intelligence and Robotics in Spine Surgery

STUDY DESIGN

Narrative review.

OBJECTIVES

Artificial intelligence (AI) and machine learning (ML) have emerged as disruptive technologies with the potential to drastically affect clinical decision making in spine surgery. AI can enhance the delivery of spine care in several arenas: (1) preoperative patient workup, patient selection, and outcome prediction; (2) quality and reproducibility of spine research; (3) perioperative surgical assistance and data tracking optimization; and (4) intraoperative surgical performance. The purpose of this narrative review is to concisely assemble, analyze, and discuss current trends and applications of AI and ML in conventional and robotic-assisted spine surgery.

METHODS

We conducted a comprehensive PubMed search of peer-reviewed articles that were published between 2006 and 2019 examining AI, ML, and robotics in spine surgery. Key findings were then compiled and summarized in this review.

RESULTS

The majority of the published AI literature in spine surgery has focused on predictive analytics and supervised image recognition for radiographic diagnosis. Several investigators have studied the use of AI/ML in the perioperative setting in small patient cohorts; pivotal trials are still pending.

CONCLUSIONS

Artificial intelligence has tremendous potential in revolutionizing comprehensive spine care. Evidence-based, predictive analytics can help surgeons improve preoperative patient selection, surgical indications, and individualized postoperative care. Robotic-assisted surgery, while still in early stages of development, has the potential to reduce surgeon fatigue and improve technical precision.

Design of a robot-assisted system for transforaminal percutaneous endoscopic lumbar surgeries: study protocol

Background

Transforaminal percutaneous endoscopic lumbar surgeries (PELS) for lumbar disc herniation and spinal stenosis are growing in popularity. However, there are some problems in the establishment of the working channel and foraminoplasty such as nerve and blood vessel injuries, more radiation exposure, and steeper learning curve. Rapid technological advancements have allowed robotic technology to assist surgeons in improving the accuracy and safety of surgeries. Therefore, the purpose of this study is to develop a robot-assisted system for transforaminal PELS, which can provide navigation and foraminoplasty.

Methods

The robot-assisted system consists of three systems: preoperative planning system, navigation system, and foraminoplasty system. In the preoperative planning system, 3D visualization of the surgical segment and surrounding tissues are realized using the multimodal image fusion technique of computed tomography and magnetic resonance imaging, and the working channel planning is carried out to reduce the risk for injury to vital blood vessels and nerves. In the navigation system, the robot can obtain visual perception ability from a visual receptor and automatically adjust the robotic platform and robot arm to the appropriate positions according to the patient’s position and preoperative plan. In addition, the robot can automatically register the surgical levels through intraoperative fluoroscopy. After that, the robot will provide navigation using the 6 degree-of-freedom (DOF) robot arm according to the preoperative planning system and guide the surgeon to complete the establishment of the working channel. In the foraminoplasty system, according to the foraminoplasty planning in the preoperative planning system, the robot performs foraminoplasty automatically using the high speed burr at the end of the robot arm. The system can provide real-time feedback on the working status of the bur through multi-mode sensors such as multidimensional force, position, and acceleration. Finally, a prototype of the system is constructed and performance tests are conducted.

Discussion

Our study will develop a robot-assisted system to perform transforaminal PELS, and this robot-assisted system can also be used for other percutaneous endoscopic spinal surgeries such as interlaminar PELS and percutaneous endoscopic cervical and thoracic surgeries through further research. The development of this robot-assisted system can be of great significance. First, the robot can improve the accuracy and efficiency of endoscopic spinal surgeries. In addition, it can avoid multiple intraoperative fluoroscopies, minimize exposure to both patients and the surgical staff, shorten the operative time, and improve the learning curve of beginners, which is beneficial to the popularization of percutaneous endoscopic spinal surgeries.

Robotic Surgical Approach to the Mesial Temporal Region: A Preliminary Three-Dimensional Cadaveric Study of Technical Feasibility

OBJECTIVE

Robotic surgical systems are used worldwide in various fields. In this study, we present the advantages and disadvantages of the most common robotic surgical system, the da Vinci Xi system, in the supracerebellar transtentorial approach to the mesial temporal region and discuss options for its integration into neurosurgery.

METHODS

Our study was conducted at the Advanced Simulation and Applied Endoscopic Surgery Training and Research Center and Anatomy Laboratory. Four formalin-fixed human cadaveric head specimens with red silicone dye injected into their arterial structures and blue silicone dye injected into their venous structures were used in the study. Dissections were performed in microscopic and robotic stages. All phases were photographed using a three-dimensional photographic technique.

RESULTS

The mesial temporal lobe could be accessed via the supracerebellar transtentorial route with the use of the robotic system. We show that the robotic system can be used in difficult approaches and narrow regions with a wider exposure and superior image quality than with the microscopic approach, improving the ergonomics for the surgeon. The shortcomings of robotic systems are examined and innovative solutions are offered.

CONCLUSIONS

This study shows the advantages and disadvantages of the robotic surgical approach to the mesial temporal region via the supracerebellar transtentorial route. Robotic surgical systems can play a major role in neurosurgical practices with the tools designed and the innovative solutions determined in this study. Nevertheless, further research and development of these systems and related instruments are necessary to ensure their wider implementation in neurosurgery.

Role of Robotics in Improving Surgical Outcome in Spinal Pathologies

BACKGROUND

The desire to improve accuracy and safety and to favor minimally invasive techniques has given rise to spinal robotic surgery, which has seen a steady increase in utilization in the past 2 decades. However, spinal surgery encompasses a large spectrum of operative techniques, and robotic surgery currently remains confined to assistance with the trajectory of pedicle screw insertion, which has been shown to be accurate and safe based on class II and III evidence. The role of robotics in improving surgical outcomes in spinal pathologies is less clear, however.

METHODS

This comprehensive review of the literature addresses the role of robotics in surgical outcomes in spinal pathologies with a focus on the various meta-analysis and prospective randomized trials published within the past 10 years in the field.

RESULTS

It appears that robotic spinal surgery might be useful for increasing accuracy and safety in spinal instrumentation and allows for a reduction in surgical time and radiation exposure for the patient, medical staff, and operator.

CONCLUSION

Robotic assisted surgery may thus open the door to minimally invasive surgery with greater security and confidence. In addition, the use of robotics facilitates tireless repeated movements with higher precision compared with humans. Nevertheless, it is clear that further studies are now necessary to demonstrate the role of this modern tool in cost-effectiveness and in improving clinical outcomes, such as reoperation rates for screw malpositioning.

Robotic-Assisted Spine Surgery: History, Efficacy, Cost, And Future Trends

Robot-assisted spine surgery has recently emerged as a viable tool to enable less invasive and higher precision surgery. The first-ever spine robot, the SpineAssist (Mazor Robotics Ltd., Caesarea, Israel), gained FDA approval in 2004. With its ability to provide real-time intraoperative navigation and rigid stereotaxy, robotic-assisted surgery has the potential to increase accuracy while decreasing radiation exposure, complication rates, operative time, and recovery time. Currently, robotic assistance is mainly restricted to spinal fusion and instrumentation procedures, but recent studies have demonstrated its use in increasingly complex procedures such as spinal tumor resections and ablations, vertebroplasties, and deformity correction. However, robots do require high initial costs and training, and thus, require justification for their incorporation into common practice. In this review, we discuss the history of spinal robots along as well as currently available systems. We then examine the literature to evaluate accuracy, operative time, complications, radiation exposure, and costs - comparing robotic-assisted to traditional fluoroscopy-assisted freehand approaches. Finally, we consider future applications for robots in spine surgery.

Robotic paravertebral schwannoma resection at extreme locations of the thoracic cavity

Solitary paravertebral schwannomas in the thoracic spine and lacking an intraspinal component are uncommon. These benign nerve sheath tumors are typically treated using complete resection with an excellent outcome. Resection of these tumors is achieved by an anterior approach via open thoracotomy or minimally invasive thoracoscopy, by a posterior approach via laminectomy, or by a combination of both approaches. These tumors most commonly occur in the midthoracic region, for which surgical removal is usually straightforward. The authors of this report describe 2 cases of paravertebral schwannoma at extreme locations of the posterior mediastinum, one at the superior sulcus and the other at the inferior sulcus of the thoracic cavity, for which the usual surgical approaches for safe resection can be challenging. The tumors were completely resected with robot-assisted thoracoscopic surgery. This report suggests that single-stage anterior surgery for this type of tumor in extreme locations is safe and effective with this novel minimally invasive technique.

Characterization of a novel caudal vertebral interbody fusion in a rat tail model: An implication for future material and mechanical testing

Background

Of the proposed animal interbody fusion models, rat caudal discs have gained popularity in disc research due to their strong resemblance to human discs with respect to geometry, composition and mechanical properties. The purpose of this study is to demonstrate an efficient, repeatable and easily accessible animal model of interbody fusion for future research into mechanical testing and graft materials.

Methods

Twelve 12-week-old female Sprague–Dawley (SD) rats underwent caudal interbody fusion of the third and fourth coccygeal vertebrae of the tail. Serial radiological evaluation, and histological evaluation and manual palpation after sacrifice were performed to assess the fusion quality. Mechanical testing of functional units (FUs) of non-operated and operated segments was compared using a three-point bending test.

Results

At postoperative 12 weeks, callus formation was observed at the fusion sites in all rats, with the mean radiological evaluations of 2.75/3 according to the Bransford classification. Newly formed bone tissue was also observed in all rats with the mean histological score of 5.85/7, according to the Emery grading system. No palpable gaps and obvious change of bending stiffness was observed in the operated segments. The mean bending stiffness of the FUs was statistically higher than that of the control FUs (26.57 ± 6.71 N/mm vs. 12.45 ± 3.21 N/mm, p < 0.01).

Conclusion

The rat caudal disc interbody fusion model proved to be an efficient, repeatable and easily accessible model. Future research into adjuvant treatments like growth factor injection and alternative fusion materials under conditions of osteoporosis using this model would be worthwhile.

Robotic-assisted minimally invasive surgery of the spine (RAMISS): a proof-of-concept study using carbon dioxide insufflation for multilevel posterior vertebral exposure via a sub-paraspinal muscle working space

BACKGROUND

Open posterior spinal procedures involve extensive soft tissue disruption, increased hospital length of stay, and disfiguring scars. Our aim was to demonstrate the feasibility of using robotic-assistance for minimally invasive exposure of the posterolateral spine with and without carbon dioxide (CO₂ ) insufflation.

METHODS

Sheep specimens underwent minimally invasive subperiosteal dissection of the spine during three trials. The da Vinci S Surgical system was used for access with and without working space support via CO₂ insufflation.

RESULTS

Without insufflation, a sub-paraspinal muscle tunnel measuring 16 cm was developed between two 5 cm incisions. With insufflation, the one-sided tunnel length was 12.5 cm but without the soft tissue trauma and obstructed visualization experienced without CO₂ .

CONCLUSIONS

The use of robot-assistance for minimally invasive access to the posterior spine appears to be feasible. The use of CO₂ insufflation greatly improved our ability to visualize and access the posterior vertebral elements.

da Vinci robot-assisted keyhole neurosurgery: a cadaver study on feasibility and safety

The goal of this cadaver study was to evaluate the feasibility and safety of da Vinci robot-assisted keyhole neurosurgery. Several keyhole craniotomies were fashioned including supraorbital subfrontal, retrosigmoid and supracerebellar infratentorial. In each case, a simple durotomy was performed, and the flap was retracted. The da Vinci surgical system was then used to perform arachnoid dissection towards the deep-seated intracranial cisterns. It was not possible to simultaneously pass the 12-mm endoscope and instruments through the keyhole craniotomy in any of the approaches performed, limiting visualization. The articulated instruments provided greater dexterity than existing tools, but the instrument arms could not be placed in parallel through the keyhole craniotomy and, therefore, could not be advanced to the deep cisterns without significant clashing. The da Vinci console offered considerable ergonomic advantages over the existing operating room arrangement, allowing the operating surgeon to remain non-sterile and seated comfortably throughout the procedure. However, the lack of haptic feedback was a notable limitation. In conclusion, while robotic platforms have the potential to greatly enhance the performance of transcranial approaches, there is strong justification for research into next-generation robots, better suited to keyhole neurosurgery.

Robotics in keyhole transcranial endoscope-assisted microsurgery: a critical review of existing systems and proposed specifications for new robotic platforms

BACKGROUND

Over the past decade, advances in image guidance, endoscopy, and tube-shaft instruments have allowed for the further development of keyhole transcranial endoscope-assisted microsurgery, utilizing smaller craniotomies and minimizing exposure and manipulation of unaffected brain tissue. Although such approaches offer the possibility of shorter operating times, reduced morbidity and mortality, and improved long-term outcomes, the technical skills required to perform such surgery are inevitably greater than for traditional open surgical techniques, and they have not been widely adopted by neurosurgeons. Surgical robotics, which has the ability to improve visualization and increase dexterity, therefore has the potential to enhance surgical performance.

OBJECTIVE

To evaluate the role of surgical robots in keyhole transcranial endoscope-assisted microsurgery.

METHODS

The technical challenges faced by surgeons utilizing keyhole craniotomies were reviewed, and a thorough appraisal of presently available robotic systems was performed.

RESULTS

Surgical robotic systems have the potential to incorporate advances in augmented reality, stereoendoscopy, and jointed-wrist instruments, and therefore to significantly impact the field of keyhole neurosurgery. To date, over 30 robotic systems have been applied to neurosurgical procedures. The vast majority of these robots are best described as supervisory controlled, and are designed for stereotactic or image-guided surgery. Few telesurgical robots are suitable for keyhole neurosurgical approaches, and none are in widespread clinical use in the field.

CONCLUSION

New robotic platforms in minimally invasive neurosurgery must possess clear and unambiguous advantages over conventional approaches if they are to achieve significant clinical penetration.

Navigation, robotics, and intraoperative imaging in spinal surgery

Spinal navigation is a technique gaining increasing popularity. Different approaches as CT-based or intraoperative imaging-based navigation are available, requiring different methods of patient registration, bearing certain advantages and disadvantages. So far, a large number of studies assessed the accuracy of pedicle screw implantation in the cervical, thoracic, and lumbar spine, elucidating the advantages of image guidance. However, a clear proof of patient benefit is missing, so far. Spinal navigation is closely related to intraoperative 3D imaging providing an imaging dataset for navigational use and the opportunity for immediate intraoperative assessment of final screw position giving the option of immediate screw revision if necessary. Thus, postoperative imaging and a potential revision surgery for screw correction become dispensable.Different concept of spinal robotics as the DaVinci system and SpineAssist are under investigation.

The future of spine surgery: New horizons in the treatment of spinal disorders

Background and Methods:

As with any evolving surgical discipline, it is difficult to predict the future of the practice and science of spine surgery. In the last decade, there have been dramatic developments in both the techniques as well as the tools employed in the delivery of better outcomes to patients undergoing such surgery. In this article, we explore four specific areas in spine surgery: namely the role of minimally invasive spine surgery; motion preservation; robotic-aided surgery and neuro-navigation; and the use of biological substances to reduce the number of traditional and revision spine surgeries.

Results:

Minimally invasive spine surgery has flourished in the last decade with an increasing amount of surgeries being performed for a wide variety of degenerative, traumatic, and neoplastic processes. Particular progress in the development of a direct lateral approach as well as improvement of tubular retractors has been achieved. Improvements in motion preservation techniques have led to a significant number of patients achieving arthroplasty where fusion was the only option previously. Important caveats to the indications for arthroplasty are discussed. Both robotics and neuro-navigation have become further refined as tools to assist in spine surgery and have been demonstrated to increase accuracy in spinal instrumentation placement. There has much debate and refinement in the use of biologically active agents to aid and augment function in spine surgery. Biological agents targeted to the intervertebral disc space could increase function and halt degeneration in this anatomical region.

Conclusions:

Great improvements have been achieved in developing better techniques and tools in spine surgery. It is envisaged that progress in the four focus areas discussed will lead to better outcomes and reduced burdens on the future of both our patients and the health care system.

The da Vinci robotic surgical assisted anterior lumbar interbody fusion: technical development and case report

STUDY DESIGN

Technique development to use the da Vince Robotic Surgical System for anterior lumbar interbody fusion at L5-S1 is detailed. A case report is also presented.

OBJECTIVE

To evaluate and develop the da Vinci robotic assisted laparoscopic anterior lumbar stand-alone interbody fusion procedure.

SUMMARY OF BACKGROUND DATA

Anterior lumbar interbody fusion is a common procedure associated with potential morbidity related to the surgical approach. The da Vinci robot provides intra-abdominal dissection and visualization advantages compared with the traditional open and laparoscopic approach.

METHODS

The surgical techniques for approach to the anterior lumbar spine using the da Vinci robot were developed and modified progressively beginning with operative models followed by placement of an interbody fusion cage in the living porcine model. Development continued to progress with placement of fusion cage in a human cadaver, completed first in the laboratory setting and then in the operating room. Finally, the first patient with fusion completed using the da Vinci robot-assisted approach is presented.

RESULTS

The anterior transperitoneal approach to the lumbar spine is accomplished with enhanced visualization and dissection capability, with maintenance of pneumoperitoneum using the da Vinci robot. Blood loss is minimal. The visualization inside the disc space and surrounding structures was considered better than current open and laparoscopic techniques.

CONCLUSION

The da Vinci robot Surgical System technique continues to develop and is now described for the transperitoneal approach to the anterior lumbar spine.

LEVEL OF EVIDENCE

4.

Robotic Skull Base Surgery via Supraorbital Keyhole Approach

BACKGROUND:

The supraorbital keyhole approach has been used in anterior skull base tumor and aneurysm surgery. However, there are debates regarding the safety and limitations of this kind of approach.

OBJECTIVE:

To determine the feasibility and potential benefits of surgical robotic technology in minimally invasive neurosurgery.

METHODS:

Two fresh cadaver heads were studied with the da Vinci Surgical System with 0° and 30° stereoscopic endoscopes to visualize neuroanatomy. The ability of the system to suture and place clips under the keyhole approach was tested.

RESULTS:

The da Vinci Surgical System was used throughout the supraorbital transeyebrow keyhole approach. With the use of standard microdissection techniques, the optic nerve, optic chiasm, carotid artery, and third cranial nerve were visualized. The sylvian fissure was then exposed from the proximal sylvian membrane to the distal M1 segment. With the EndoWrist microforceps, suturing can be achieved smoothly to close a defect created on the M2 artery. Although the benefits in adjusting clips during aneurysm surgery could be provided by an articulating applier, a proper robotic applier is not currently available.

CONCLUSION:

The minimally invasive supraorbital keyhole surgery can be achieved with the da Vinci Surgical System in cadaver models. This system provides neurosurgeons with broader vision and articulable instruments, which standard microsurgical systems do not provide. Further studies are necessary to evaluate the safety and benefits of using the da Vinci Surgical System in minimally invasive neurosurgery.

Use of the da Vinci Minimally Invasive Robotic System for Resection of a Complicated Paraspinal Schwannoma With Thoracic Extension

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Robot-assisted transoral odontoidectomy : experiment in new minimally invasive technology, a cadaveric study

OBJECTIVE

In the field of spinal surgery, a few laboratory results or clinical cases about robotic spinal surgery have been reported. In vivo trials and development of related surgical instruments for spinal surgery are required before its clinical application. We investigated the use of the da Vinci® Surgical System in spinal surgery at the craniovertebral junction in a human cadaver to demonstrate the efficacy and pitfalls of robotic surgery.

METHODS

Dissection of pharyngeal wall to the exposure of C1 and odontoid process was performed with full robotic procedure. Although assistance of another surgeon was necessary for drilling and removal of odontoid process due to the lack of appropriate end-effectors, successful robotic procedures for dural sutures and exposing spinal cord proved its safety and dexterity.

RESULTS

Robot-assisted odontoidectomy was successfully performed in a human cadaver using the da Vinci® Surgical System with few robotic arm collisions and minimal soft tissue damages. Da Vinci® Surgical System manifested more dexterous movement than human hands in the deep and narrow oral cavity. Furthermore, sutures with robotic procedure in the oral cavity demonstrated the advantage over conventional procedure.

CONCLUSION

Presenting cadaveric study proved the probability of robot-assisted transoral approach. However, the development of robotic instruments specific to spinal surgery must first precede its clinical application.