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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.
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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
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2
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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.
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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
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Menichini G, Malzone G, Tamburello S, Andreoli AL, Mori F, Ballestín A, Shiraki T. Safety and efficacy of Symani robotic-assisted microsurgery: Assessment of vascular anastomosis patency, thrombus, and stenosis in a randomized preclinical study. J Plast Reconstr Aesthet Surg 2024; 96:1-10. [PMID: 38991409 DOI: 10.1016/j.bjps.2024.06.009] [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: 04/30/2024] [Revised: 06/04/2024] [Accepted: 06/06/2024] [Indexed: 07/13/2024]
Abstract
INTRODUCTION The Symani surgical system undergoes scrutiny in this study as part of a series of preclinical investigations. Previous studies compared the precision of robotic-assisted anastomoses with manual techniques. This study aimed to evaluate the critical, histological, and gross parameters at the site of anastomosis and at distant sites in a rat model to provide insights into the safety and efficacy of robotic-assisted microsurgery to enhance its potential for clinical adoption. MATERIALS AND METHODS Experienced microsurgeons performed arterial and venous anastomoses in 16 Wistar rats, randomized into four treatment groups: robotic artery, robotic vein, manual artery, and manual vein. Various parameters were evaluated at two time points (T0 and T30) on the day of the procedure and at Day 28 (T28d). In the second phase of the study, the animals underwent necropsy, histopathologic analysis, micro-CT scans, and angiography imaging of the anastomosis sites, major organs, and distant target organs by a blinded assessor. RESULTS Patency rates were 100% at T0 and T30 for all anastomoses and stayed at 100% on T28d for the robotic subgroups; however, it decreased to 87.5% for manual arterial anastomoses owing to a case of obstructive thrombus. No evidence of clot migration was observed. Blood flow parameters and procedure times did not differ significantly. The blinded semiquantitative histological analysis revealed no significant disparities between the robotic and manual anastomoses across various pathological indicators. No gross abnormalities were detected in musculoskeletal examinations. CONCLUSION This preclinical study demonstrated the safety of the Symani surgical system. Results suggest equivalence between robotic and manual techniques regarding thrombus formation at the anastomotic site and distal organs.
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Affiliation(s)
- Giulio Menichini
- Department of Plastic Reconstructive and Microsurgery, AOU Careggi, Florence, Italy.
| | - Gerardo Malzone
- Department of Plastic Reconstructive and Microsurgery, AOU Careggi, Florence, Italy.
| | - Sara Tamburello
- Department of Plastic Reconstructive and Microsurgery, AOU Careggi, Florence, Italy; University of Florence, Florence, Italy.
| | - Alice Letizia Andreoli
- Department of Plastic Reconstructive and Microsurgery, AOU Careggi, Florence, Italy; University of Florence, Florence, Italy.
| | | | - Alberto Ballestín
- Tumor Microenvironment Laboratory, Institut Curie, Orsay, Paris, France.
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Doersch KM, Li KA, Ajay D. Flaps and Grafts in Robotic Reconstructive Surgery. Curr Urol Rep 2024; 25:109-115. [PMID: 38514479 DOI: 10.1007/s11934-024-01201-z] [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] [Accepted: 03/11/2024] [Indexed: 03/23/2024]
Abstract
PURPOSE OF REVIEW The robotic approach is increasingly popular in reconstructive urology. Reconstructive surgeons have commonly used flaps and grafts for obliterating dead space including tissue interposition or as an alternative to mesh in addressing lower urinary tract dysfunction. Advantages of the robotic approach are less incisional pain, excellent visualization in the deep pelvis, and improved surgeon ergonomics. In this literature review, we describe flaps and grafts used in lower urinary tract robotic reconstructive urology, serving as an almanac for these techniques. RECENT FINDINGS Omental, peritoneal, vertical rectus abdominis musculocutaneous (VRAM), sigmoid epiploica, gracilis flaps, and Alloderm™ have been reported for tissue interposition during fistula repair. Fascia lata has been described as a mesh alternative for robotic sacrocolpopexy. Besides providing interposition, flaps support native tissue healing and blood supply. Grafts are easy to use with low patient morbidity, but rely on the blood supply at the recipient site. Robotic reconstruction is an emerging field, and more studies are needed to define the best uses for each flap and graft as well as strategies to maximize outcomes and minimize morbidity.
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Affiliation(s)
- Karen M Doersch
- Department of Urology, University of Rochester Medical Center, 601 Elmwood Avenue, Box 656, Rochester, NY 14610, USA.
| | - Kathleen A Li
- School of Medicine and Dentistry, University of Rochester, Rochester, NY, USA
| | - Divya Ajay
- Sidney Kimmel Center for Prostate and Urologic Cancers, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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5
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Sert G, Yıldızdal S, Güdeloğlu A, Selber J. Robotic harvest of the free gracilis muscle flap. J Plast Reconstr Aesthet Surg 2024; 90:323-325. [PMID: 38394840 DOI: 10.1016/j.bjps.2024.02.031] [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: 12/19/2023] [Accepted: 02/04/2024] [Indexed: 02/25/2024]
Abstract
The conventional approach to harvest of the gracilis muscle flap necessitates a medial thigh incision that is often related to several donor site complications. In this report we describe the robotic harvest of the free gracilis muscle flap in order to reduce the morbidity associated with the open incision. Through three ports, the robotic system (Da Vinci Xi, Intuitive Surgical) enables precise dissection of the gracilis muscle, the vascular pedicle, and the obturator nerve; thus, enhancing surgical control, optimizing visualization through magnification, aiding in detailed vascular pedicle dissection and minimizing human error. We believe that the technique of totally robotic harvest of the free gracilis muscle flap, herein introduced, is a feasible and effective approach, and confers specific advantages over traditional harvest technique.
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Affiliation(s)
- Gökhan Sert
- Hacettepe University, Faculty of Medicine, Department of Plastic Reconstructive and Aesthetic Surgery, Ankara, Türkiye.
| | - Süleyman Yıldızdal
- Hacettepe University, Faculty of Medicine, Department of Plastic Reconstructive and Aesthetic Surgery, Ankara, Türkiye
| | - Ahmet Güdeloğlu
- Hacettepe University, Faculty of Medicine, Department of Urology, Ankara, Türkiye
| | - Jesse Selber
- Department of Plastic Reconstructive and Aesthetic Surgery, Corewell Health East, Division of Plastic Surgery, Royal Oak, MI, USA
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Ernst J, Hahne JM, Markovic M, Schilling AF, Lorbeer L, Grade M, Felmerer G. Combining Surgical Innovations in Amputation Surgery-Robotic Harvest of the Rectus Abdominis Muscle, Transplantation and Targeted Muscle Reinnervation Improves Myocontrol Capability and Pain in a Transradial Amputee. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:2134. [PMID: 38138237 PMCID: PMC10744371 DOI: 10.3390/medicina59122134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 11/24/2023] [Accepted: 11/28/2023] [Indexed: 12/24/2023]
Abstract
Adding robotic surgery to bionic reconstruction might open a new dimension. The objective was to evaluate if a robotically harvested rectus abdominis (RA) transplant is a feasible procedure to improve soft-tissue coverage at the residual limb (RL) and serve as a recipient for up to three nerves due to its unique architecture and to allow the generation of additional signals for advanced myoelectric prosthesis control. A transradial amputee with insufficient soft-tissue coverage and painful neuromas underwent the interventions and was observed for 18 months. RA muscle was harvested using robotic-assisted surgery and transplanted to the RL, followed by end-to-end neurroraphy to the recipient nerves of the three muscle segments to reanimate radial, median, and ulnar nerve function. The transplanted muscle healed with partial necrosis of the skin mesh graft. Twelve months later, reliable, and spatially well-defined Hoffmann-Tinel signs were detectable at three segments of the RA muscle flap. No donor-site morbidities were present, and EMG activity could be detected in all three muscle segments. The linear discriminant analysis (LDA) classifier could reliably distinguish three classes within 1% error tolerance using only the three electrodes on the muscle transplant and up to five classes outside the muscle transplant. The combination of these surgical procedure advances with emerging (myo-)control technologies can easily be extended to different amputation levels to reduce RL complications and augment control sites with a limited surface area, thus facilitating the usability of advanced myoelectric prostheses.
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Affiliation(s)
- Jennifer Ernst
- Department of Trauma Surgery, Orthopedic Surgery and Plastic Surgery, University Medical Center Göttingen, 37075 Göttingen, Germany; (J.M.H.); (M.M.); (A.F.S.); (G.F.)
- Department of Trauma Surgery, Hannover Medical School, 30625 Hanover, Germany;
| | - Janne M. Hahne
- Department of Trauma Surgery, Orthopedic Surgery and Plastic Surgery, University Medical Center Göttingen, 37075 Göttingen, Germany; (J.M.H.); (M.M.); (A.F.S.); (G.F.)
| | - Marko Markovic
- Department of Trauma Surgery, Orthopedic Surgery and Plastic Surgery, University Medical Center Göttingen, 37075 Göttingen, Germany; (J.M.H.); (M.M.); (A.F.S.); (G.F.)
| | - Arndt F. Schilling
- Department of Trauma Surgery, Orthopedic Surgery and Plastic Surgery, University Medical Center Göttingen, 37075 Göttingen, Germany; (J.M.H.); (M.M.); (A.F.S.); (G.F.)
| | - Lisa Lorbeer
- Department of Trauma Surgery, Hannover Medical School, 30625 Hanover, Germany;
| | - Marian Grade
- Department of General, Visceral and Pediatric Surgery, University Medical Center Göttingen, 37075 Göttingen, Germany;
| | - Gunther Felmerer
- Department of Trauma Surgery, Orthopedic Surgery and Plastic Surgery, University Medical Center Göttingen, 37075 Göttingen, Germany; (J.M.H.); (M.M.); (A.F.S.); (G.F.)
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7
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Devriendt S, Van Praet L, Bislenghi G, D'Hoore AJL, Wolthuis AM. Laparoscopic Oblique Rectus Abdominis Myocutaneous Flap Harvest for Perineal Reconstruction After Abdominoperineal Resection. Dis Colon Rectum 2023; 66:e1134-e1137. [PMID: 37540020 DOI: 10.1097/dcr.0000000000002981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
BACKGROUND Treatment of perineal defects after abdominoperineal resection or salvage surgery for either locally advanced rectal cancer or anal carcinoma can be challenging. Myocutaneous flap reconstruction has proven to reduce perineal morbidity and abscess formation in the pelvis; however, it is associated with significant donor-site morbidity. To our knowledge, this is the first report of a laparoscopic oblique rectus abdominis myocutaneous flap harvesting for perineal reconstruction. This technical note aimed to demonstrate the feasibility of the technique. IMPACT OF INNOVATION Introduction of a laparoscopic technique in harvesting of this flap can potentially further reduce morbidity associated with this flap creation by minimizing abdominal wall trauma and obviating the need for laparotomy for tunneling of the flap intra-abdominally. TECHNOLOGY, MATERIALS, AND METHODS This report describes a technique using a 6-port laparoscopy, in which the harvesting of the myocutaneous flap was performed after a standardized abdominoperineal resection. The flap itself is passed through the rectus sheath toward the pelvis with the help of a retractor. PRELIMINARY RESULTS Two patients successfully underwent a laparoscopic oblique rectus abdominis flap reconstruction after abdominoperineal resection. CONCLUSION AND FUTURE DIRECTIONS This report describes our initial experience with laparoscopic harvesting of an oblique rectus abdominis flap for perineal reconstruction after abdominoperineal resection. We believe the technique is easy and reproducible for laparoscopic surgeons and can reduce donor-site morbidity. However, further studies will be needed to confirm this observation.
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Affiliation(s)
- Stefanie Devriendt
- Department of Abdominal Surgery, University Hospital Leuven, Leuven, Belgium
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King BW, McCarter JH, Burns HR, Soleimani S, Maricevich MA, Yu JZ. Robotics in Implant-Based and Autologous Breast Reconstruction. Semin Plast Surg 2023; 37:168-175. [PMID: 38444960 PMCID: PMC10911900 DOI: 10.1055/s-0043-1771235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2024]
Abstract
Autologous and implant-based breast reconstruction continues to evolve as new technology and mastectomy techniques become available. Robotic-assisted breast reconstruction represents a growing field within plastic surgery, with the potential to improve aesthetic and functional outcomes, as well as patient satisfaction. This article provides a review of indications, techniques, and outcome data supporting the use of robotic assistance in both implant-based and autologous breast reconstruction from surgeons around the world.
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Affiliation(s)
- Brody W. King
- Michael E. DeBakey Department of Surgery, Division of Plastic Surgery, Baylor College of Medicine, Houston, Texas
- Division of Plastic Surgery, Texas Children's Hospital, Houston, Texas
| | - Jacob H. McCarter
- Michael E. DeBakey Department of Surgery, Division of Plastic Surgery, Baylor College of Medicine, Houston, Texas
- Division of Plastic Surgery, Texas Children's Hospital, Houston, Texas
| | - Heather R. Burns
- Michael E. DeBakey Department of Surgery, Division of Plastic Surgery, Baylor College of Medicine, Houston, Texas
- Division of Plastic Surgery, Texas Children's Hospital, Houston, Texas
| | | | - Marco A. Maricevich
- Michael E. DeBakey Department of Surgery, Division of Plastic Surgery, Baylor College of Medicine, Houston, Texas
- Division of Plastic Surgery, Texas Children's Hospital, Houston, Texas
| | - Jessie Z. Yu
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Appel R, Shih L, Gimenez A, Bay C, Chai CYH, Maricevich M. Robotic Rectus Abdominis Harvest for Pelvic Reconstruction after Abdominoperineal Resection. Semin Plast Surg 2023; 37:188-192. [PMID: 38444961 PMCID: PMC10911893 DOI: 10.1055/s-0043-1771236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2024]
Abstract
The use of robotic surgical systems to perform abdominoperineal resection (APR) has recently become more prevalent. This minimally invasive approach produces fewer scars and potentially less morbidity for the patient. The rectus abdominis muscle is often used for reconstruction after APR if primary closure is not feasible or the surgical site is at high risk of wound complications. Since the traditional open harvest of this flap creates large incisions that negate the advantages of minimally invasive APR, there has been growing interest in harvesting the rectus abdominis in a similarly robotic fashion. This article reviews the technique, benefits, and limitations of this robotic technique. Compared to the traditional open harvest, robotic harvest of the rectus abdominis leaves smaller scars, provides technical benefits for the surgeon, and offers possible morbidity benefits for the patient. These advantages should be weighed against the added expense and learning curve inherent to robotic surgery.
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Affiliation(s)
- Richard Appel
- Division of Plastic Surgery, Baylor College of Medicine, Houston, Texas
| | - Linden Shih
- Division of Plastic Surgery, Baylor College of Medicine, Houston, Texas
| | - Alejandro Gimenez
- Division of Plastic Surgery, Baylor College of Medicine, Houston, Texas
| | - Caroline Bay
- Division of Plastic Surgery, Baylor College of Medicine, Houston, Texas
| | | | - Marco Maricevich
- Division of Plastic Surgery, Baylor College of Medicine, Houston, Texas
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Baruah U, Tak A, Barmon D, Begum D. Vulvar reconstruction in post-RT case using the versatile VRAM flap: reporting the rare extrapelvic approach. BMJ Case Rep 2023; 16:e254773. [PMID: 37028820 PMCID: PMC10083792 DOI: 10.1136/bcr-2023-254773] [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] [Indexed: 04/09/2023] Open
Abstract
Although primary vulvovaginal reconstruction following vulvectomy has a significant chance of improving patient outcomes, flap reconstruction is not a recognised component of the accepted standard of care for vulvar cancer. We provide a case of a patient who underwent successful vulvar reconstruction using the extrapelvic vertical rectus abdominis myocutaneous (VRAM) flap. This musculocutaneous flap offers adequate coverage and bulk to the perineal defect after excision in post-irradiated vulvar cancer.To proceed with sphincter-saving surgery, she was scheduled for neoadjuvant chemoradiation, as the lesion involved the urethra and perineal body. However, she experienced severe grade IV dermatitis after receiving 37 Gy of radiation. Though the lesion had reduced in size, it was still large enough to cause significant perineal deformity.We performed a vulvar reconstructive surgery using the uncommon but reliable extrapelvic VRAM flap. This well-vascularised VRAM flap is particularly useful in irradiated areas prone to poor healing. Postoperatively, the wound healed well and the patient underwent adjuvant therapy 6 weeks later. We emphasise the advantages of well-perfused muscle for the primary repair of prior irradiated perineal lesions.
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Affiliation(s)
- Upasana Baruah
- Gynaecologic Oncology, Dr Bhubaneswar Borooah Cancer Institute, Guwahati, Assam, India
| | - Apoorva Tak
- Gynaecologic Oncology, Dr Bhubaneswar Borooah Cancer Institute, Guwahati, Assam, India
| | - Debabrata Barmon
- Gynaecologic Oncology, Dr Bhubaneswar Borooah Cancer Institute, Guwahati, Assam, India
| | - Dimpy Begum
- Gynaecologic Oncology, Dr Bhubaneswar Borooah Cancer Institute, Guwahati, Assam, India
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Robotics in Plastic Surgery. CURRENT SURGERY REPORTS 2023. [DOI: 10.1007/s40137-022-00337-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
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12
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Dayaratna N, Ahmadi N, Mak C, Dusseldorp JR. Robotic-assisted deep inferior epigastric perforator (DIEP) flap harvest for breast reconstruction. ANZ J Surg 2022; 93:1072-1074. [PMID: 36226576 DOI: 10.1111/ans.18107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 09/29/2022] [Accepted: 10/01/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Nirmal Dayaratna
- Department of Breast Surgery, Chris O'Brien Lifehouse, Sydney, New South Wales, Australia.,Northern Clinical School, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Nariman Ahmadi
- Department of Urology, Chris O'Brien Lifehouse, Sydney, New South Wales, Australia
| | - Cindy Mak
- Department of Breast Surgery, Chris O'Brien Lifehouse, Sydney, New South Wales, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Joseph R Dusseldorp
- Department of Breast Surgery, Chris O'Brien Lifehouse, Sydney, New South Wales, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.,Department of Plastic Surgery, Concord Repatriation Hospital, Sydney, New South Wales, Australia
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13
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Reducing Complications and Expanding Use of Robotic Rectus Abdominis Muscle Harvest for Pelvic Reconstruction. Plast Reconstr Surg 2022; 150:190-195. [PMID: 35583937 DOI: 10.1097/prs.0000000000009233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
SUMMARY The rectus abdominis flap has long been a workhorse in perineal reconstruction. Although traditionally approached though an external incision, the morbid nature of the incision and subsequent violation of the anterior rectus sheath has encouraged innovation of minimally invasive approaches for harvest. In this study, we present our experience, evolution, and comparative outcomes of robotic rectus abdominis muscle harvest. A retrospective review of perineal reconstruction was performed for a 6-year period (2014 to 2019). Robotic rectus abdominis muscle flaps were compared to nonrobotic techniques performed during this time. Descriptive statistics and complication profiles were computed. The details of our surgical technique are also described. Thirty-six patients underwent perineal reconstruction. Sixteen were performed using the robotic rectus abdominis muscle and 20 with traditional repairs (12 vertical rectus abdominis myocutaneous flaps and eight gracilis flaps). Demographic profiles were similar between cohorts, including age, body mass index, smoking, diabetes, neoadjuvant radiation therapy, and need for vaginal wall repair. Six robotic patients underwent abdominal wall reinforcement with biological mesh. Length of stay, surgical times, and incidence of major complications were similar between cohorts with a trend toward increased minor complications in traditional reconstructions (55 percent versus 31 percent; p = 0.15). Robotic rectus abdominis muscle harvest is a powerful tool that continues to evolve the potential to mitigate common morbidities and complications of traditional repair and further enhance cosmetic outcomes. This study suggests that greater flexibility for reconstruction can be afforded with harvest of the posterior rectus sheath and complications avoided with prophylactic mesh reinforcement. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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14
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Ballestín A, Malzone G, Menichini G, Lucattelli E, Innocenti M. New Robotic System with Wristed Microinstruments Allows Precise Reconstructive Microsurgery: Preclinical Study. Ann Surg Oncol 2022; 29:7859-7867. [PMID: 35727461 DOI: 10.1245/s10434-022-12033-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 05/30/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Microsurgery allows complex reconstruction of tissue defects after oncological resections or severe trauma. Performing these procedures may be limited by human tremor, precision, and manual dexterity. A new robot designed specifically for microsurgery with wristed microinstruments and motion scaling may reduce human tremor and thus enhance precision. This randomized controlled preclinical trial investigated whether this new robotic system can successfully perform microsurgical needle driving, suturing, and anastomosis. METHODS Expert microsurgeons and novices completed six needle passage exercises and performed six anastomoses by hand and six with the new robot. Experienced microsurgeons blindly assessed the quality of the procedures. Precision in microneedle driving and stitch placement was assessed by calculating suturing distances and angulation. Performance of microsurgical anastomoses was assessed by time, learning curves, and the Anastomosis Lapse Index score for objective performance assessment. RESULTS Refined precision in suturing was achieved with the robot when compared with the manual technique regarding suture distances (p = 0.02) and angulation (p < 0.01). The time required to perform microsurgical anastomoses was longer with the robot, however, both expert and novice microsurgeons reduced times with practice. The objective evaluation of the anastomoses performed by novices showed better results with the robot. CONCLUSIONS This study demonstrated the feasibility of performing precise microsutures and anastomoses using a new robotic system. Compared to standard manual techniques, robotic procedures were longer in time, but showed greater precision.
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Affiliation(s)
- Alberto Ballestín
- Tumor Microenvironment Laboratory, UMR3347 CNRS / U1021 INSERM, Institut Curie, Orsay Paris, France. .,Department of Microsurgery, Jesús Usón Minimally Invasive Surgery Centre, Cáceres, Spain.
| | - Gerardo Malzone
- Plastic and Reconstructive Microsurgery, Careggi University Hospital, Florence, Italy
| | - Giulio Menichini
- Plastic and Reconstructive Microsurgery, Careggi University Hospital, Florence, Italy
| | - Elena Lucattelli
- Plastic and Reconstructive Microsurgery, Careggi University Hospital, Florence, Italy
| | - Marco Innocenti
- Plastic and Reconstructive Microsurgery, Careggi University Hospital, Florence, Italy
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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.
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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.
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Silva JB, Busnello CV, Cesarino MR, Xavier LF, Cavazzola LT. Existe espaço para a microcirurgia na cirurgia robótica? Rev Bras Ortop 2022; 57:709-717. [PMID: 36226217 PMCID: PMC9550381 DOI: 10.1055/s-0042-1744496] [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: 02/14/2021] [Accepted: 02/07/2022] [Indexed: 11/06/2022] Open
Abstract
Robotic surgery opened a new era of minimally-invasive procedures, through its improved precision, elimination of tremors, greater degrees of freedom, and other facilitating aspects. The field of robotic microsurgery showed great growth in recent years in particular, since robotics offers a potentially-ideal configuration to perform the sensitive manipulations required in microsurgery. We conducted a systematic review to assess the benefits of robotic surgery and its contributions to microsurgery, comparing it with other surgical techniques used in patients of all age groups. We assessed 25 articles found in the PubMed and Cochrane databases using the terms '
robotic surgery
' AND
microsurgery
, with a filter for studies published in the last five years, and studies conducted in humans and published in English or Portuguese. We concluded that there is plenty of room for robotic surgery in microsurgery, such as in male infertility procedures, neurological microsurgery, ocular and otological surgeries, and transoral, hepatobiliary, microvascular, plastic and reconstructive surgeries.
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Affiliation(s)
- Jefferson Braga Silva
- Escola de Medicina, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brasil
- Departamento de Cirurgia da Mão e Microcirurgia Reconstrutiva, Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brasil
| | - Catarina Vellinho Busnello
- Escola de Medicina, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brasil
| | - Matheus Ribeiro Cesarino
- Escola de Medicina, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brasil
| | - Luiza Fernandes Xavier
- Escola de Medicina, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brasil
| | - Leandro Totti Cavazzola
- Departamento de Cirurgia da Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brasil
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Daar DA, Anzai LM, Vranis NM, Schulster ML, Frey JD, Jun M, Zhao LC, Levine JP. Robotic deep inferior epigastric perforator flap harvest in breast reconstruction. Microsurgery 2022; 42:319-325. [PMID: 34984741 DOI: 10.1002/micr.30856] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 10/05/2021] [Accepted: 12/22/2021] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Reducing donor site morbidity after deep inferior epigastric artery perforator (DIEP) flap harvest relies mainly upon maintaining integrity of the anterior rectus sheath fascia. The purpose of this study is to describe our minimally-invasive technique for robotic DIEP flap harvest. METHODS A retrospective review of four patients undergoing seven robotic-assisted DIEP flaps from 2019 to 2020 was conducted. Average patient age and BMI were 52 years (range: 45-60 years) and 26.7 kg/m2 (range: 20.6-32.4 kg/m2 ), respectively. Average follow-up was 6.31 months (range: 5.73-7.27 months). Robotic flap harvest was performed with intramuscular perforator dissection in standard fashion, followed by the transabdominal preperitoneal (TAPP) approach to DIEP pedicle harvest using the da Vinci Xi robot. Data was collected on demographic information, perioperative characteristics. Primary outcomes included successful flap harvest as well as donor site morbidity (e.g., abdominal bulge, hernia, bowel obstruction, etc.). RESULTS All four patients underwent bilateral abdominally-based free flap reconstruction. Three patients received bilateral robotic DIEP flaps, and one patient underwent unilateral robotic DIEP flap reconstruction. The da Vinci Xi robot was used in all cases. Average flap weight and pedicle length were 522 g (range: 110-809 g) and 11.2 cm (range: 10-12 cm), respectively. There were no flap failures, and no patient experienced abdominal wall donor site morbidity on physical exam. CONCLUSION While further studies are needed to validate its use, this report represents the largest series of robotic DIEP flap harvests to date and is a valuable addition to the literature.
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Affiliation(s)
- David A Daar
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York, USA
| | - Lavinia M Anzai
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York, USA
| | - Neil M Vranis
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York, USA
| | - Michael L Schulster
- Department of Urology, New York University Langone Health, New York, New York, USA
| | - Jordan D Frey
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York, USA
| | - Min Jun
- Department of Urology, New York University Langone Health, New York, New York, USA
| | - Lee C Zhao
- Department of Urology, New York University Langone Health, New York, New York, USA
| | - Jamie P Levine
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York, USA
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Abstract
LEARNING OBJECTIVES After studying this article, the participant should be able to: 1. Understand variations of the myocutaneous rectus abdominis muscle flap as it is used for perineal reconstruction and discuss common and alternative options for perineal defect reconstruction. 2. Review primary options and alternatives to pressure sore reconstruction if the primary option is not available and recognize when pressure sore reconstruction is not feasible. 3. Highlight pertinent anatomy and techniques for the flaps described. SUMMARY Perineal reconstruction following tumor resection is often complicated by irradiated tissue and multiple comorbidities, making reconstruction challenging. Management of these conditions can have complication rates as high as 66 percent, which further compounds the costs and implications of managing these wounds. These complication rates can be significantly decreased using flap closure rather than primary closure. Pressure ulcers also occur in patients with poor overall health, multiple comorbidities, and often numerous prior failed reconstruction attempts. Comprehensive management of pressure sores is a significant burden to the health care system, at a cost of $9.1 to $11.6 billion per year. There exists an extensive body of literature describing the pathophysiology and management strategies for these problems. The focus of this article is to discuss best solutions for perineal and pressure ulcer reconstruction, and to explore alternative options for reconstruction.
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Abstract
SUMMARY Vascularized tissue for obliteration of large pelvic dead spaces created by extirpative surgery has been shown to reduce complication rates. As more extensive resections are performed robotically, plastic surgeons have been challenged to reconstruct the resulting defects using a minimally invasive approach. The goal of this study was to report the authors' experience with robotic harvest of the rectus abdominis muscle for reconstruction of pelvic defects. The authors conducted a retrospective case series of patients who underwent robotic flap harvest following robotic extirpative surgery at their institution. Patient demographics, surgical characteristics, and postoperative outcomes were collected. These were compared to a retrospective cohort of patients who underwent open rectus abdominis muscle harvest. The authors identified seven male patients who underwent robotic flap harvest for pelvic reconstruction between 2013 and 2019. Their mean age was 66 ± 6 years and mean body mass index was 31 ± 5 kg/m2. Six patients (86 percent) had a history of radiation therapy and five patients (71 percent) received hormone therapy or chemotherapy. Surgical-site complications occurred in two patients. One patient developed ventral hernia. The donor-site complication rate was 19 percent (n = 18) in patients who underwent open rectus abdominis muscle harvest (n = 95). This study demonstrates the safety, efficacy, and reproducibility of robotic harvest of the rectus abdominis muscle in complex, multidisciplinary, minimally invasive pelvic surgery. The technique avoids violation of the anterior rectus sheath and wound complications related to open flap harvest, and early experience suggests reduced donor-site morbidity. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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20
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Reconstructive perineal surgery in the era of robotic surgical systems: Embracing the new technology. J Plast Reconstr Aesthet Surg 2020; 74:1101-1160. [PMID: 33218963 DOI: 10.1016/j.bjps.2020.10.093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Revised: 09/08/2020] [Accepted: 10/24/2020] [Indexed: 11/23/2022]
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22
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Abstract
INTRODUCTION As multidisciplinary treatment modalities for rectal cancer continue to evolve, neoadjuvant chemoradiation then surgical resection is a common approach. Robotic-assisted abdominoperineal resection is becoming more prevalent in part because of better visualization and instrument mobility within the pelvis. After abdominoperineal resection, postoperative perineal wound complications remain a significant risk. Pelvic reconstruction lowers this risk, and a pedicled rectus abdominis muscle flap is frequently used to achieve this. Traditional flap harvest requires laparotomy, resulting in violation of both rectus sheaths and a large midline scar. Robotic harvest of the rectus abdominis muscle for pelvic reconstruction after abdominoperineal resection is a novel approach with foreseeable benefits. TECHNIQUE After completion of abdominoperineal resection, 2 additional trocars are inserted in the lateral abdomen, and the robot is reoriented toward the posterior abdominal wall. The peritoneum and posterior rectus sheath are incised, and dissection is carried superiorly and inferiorly in a sagittal plane to reveal the rectus abdominis muscle. The muscle body is separated from the anterior rectus sheath. Once the inferior epigastric artery is identified, the superior pole of the muscle is transected. Continued lateral dissection ensures flap mobility for placement within the pelvis. After obtaining proper reach, the robot is undocked, and the flap is sutured in place through the perineal defect. RESULTS After trocar placement and robot repositioning, both the colorectal and plastic surgeons trade places at the console. Robotic flap harvest precludes the need for laparotomy. The anterior rectus sheath remains unviolated and the patient avoids an additional midline scar. The aforementioned benefits of robot-assisted abdominoperineal resection, namely increased visualization and maneuverability, were also found applicable when robotically harvesting this flap. CONCLUSIONS This technique exemplifies an additional minimally invasive technique for patients pursuing abdominoperineal resection. With knowledge of this novel approach, surgeons can better tailor their operations to benefit the patient.
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Haverland R, Rebecca AM, Hammond J, Yi J. A Case Series of Robot-assisted Rectus Abdominis Flap Harvest for Pelvic Reconstruction: A Single Institution Experience. J Minim Invasive Gynecol 2020; 28:245-248. [PMID: 32389736 DOI: 10.1016/j.jmig.2020.04.042] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 04/27/2020] [Accepted: 04/29/2020] [Indexed: 11/16/2022]
Abstract
STUDY OBJECTIVE To analyze outcomes and postoperative complications in patients undergoing robot-assisted rectus abdominis flap harvest for pelvic floor reconstruction. DESIGN Case series. SETTING Academic setting. PATIENTS Pelvic reconstruction surgery patients. INTERVENTIONS The rectus abdominis muscle flap can be used as a flap for pelvic reconstruction, providing a large volume of soft tissue that can be used in the treatment of many comorbid conditions, including genital fistulas, postradiation pelvic exenteration, and abdominoperineal resection defects. Intraperitoneal harvest of the rectus muscle using a robotic approach allows avoidance of laparotomy and subsequent disruption of the anterior rectus sheath, thus preserving the integrity of the abdominal wall. MEASUREMENTS AND MAIN RESULTS A retrospective analysis of patient demographic and clinical characteristics was performed for all patients who underwent robot-assisted rectus abdominis flap harvest for pelvic floor reconstruction at our institution from October 1, 2016, to October 31, 2018. The postoperative complications analyzed included bowel obstructions, surgical site infections, emergency room visits, and need for readmission. Six patients (4 women and 2 men), with a mean age of 69.2 years (range = 57-79 years) and median follow-up time of 9.2 months (range = 5-12 months), were included. Muscle flap harvest was performed on the right side in 4 patients and on the left in 2 patients. The indications for reconstructive surgery included vesicovaginal fistula, complex pelvic organ prolapse, anterior and posterior exenteration, partial and total vaginectomy, partial vulvectomy, and abdominoperineal resection. Two patients received neoadjuvant chemoradiation. One of the 6 cases was converted to laparotomy; however, this was not owing to the rectus harvest. Three patients experienced no complications after reconstruction; 1 patient reported occasional abdominal pain; 1 patient had intermittent bowel obstruction; and 1 patient developed a pelvic abscess, requiring readmission. All 6 patients achieved satisfactory healing of the pelvic wound after robot-assisted rectus abdominis flap inset. CONCLUSION Robot-assisted rectus abdominis flap harvest for pelvic floor reconstruction is a reliable means of defect closure, despite the presence of substantial comorbidities and risk factors in this patient cohort. Patient selection and counseling are crucial to optimize surgical outcomes in this complex population.
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Affiliation(s)
- Rachael Haverland
- Department of Medical and Surgical Gynecology (Drs. Haverland and Yi).
| | - Alanna M Rebecca
- Department of Surgery, Division of Plastic and Reconstructive Surgery (Dr. Rebecca)
| | - Jacob Hammond
- Department of Surgery (Dr. Hammond), Mayo Clinic, Phoenix, Arizona
| | - Johnny Yi
- Department of Medical and Surgical Gynecology (Drs. Haverland and Yi)
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25
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Kozusko SD, Liu X, Riccio CA, Chang J, Boyd LC, Kokkalis Z, Konofaos P. Selecting a free flap for soft tissue coverage in lower extremity reconstruction. Injury 2019; 50 Suppl 5:S32-S39. [PMID: 31711654 DOI: 10.1016/j.injury.2019.10.045] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Goals of lower extremity microvascular reconstruction (LEMR) include the restoration of function, prevention of infection, and optimal cosmesis. Indications for LEMR include large defects that are not amenable to pedicled options, a large zone of injury, and large complex defects. The novice microsurgeon should first master a handful of free flaps to develop an armamentarium of options for addressing such defects. The scope of this review is to provide free flap options for LEMR in any of the thirds of the lower leg. After reading this article, the reader will understand variations, advantages, disadvantages, indications, and tips for raising each of these flaps. METHODS Six most commonly used free flaps for LEMR are described in this paper, including the anterolateral thigh flap (ALT) and its variations, the radial forearm flap (RFFF), the lateral arm flap (LAF), the gracilis muscle flap, the rectus abdominis flap (RAF) and the latissimus dorsi flap and its variations. Indications, advantages, disadvantages and technique tips are discussed for each flap. Moreover, selection of the recipient vessels, preoperative management along with an algorithm are also provided. CONCLUSIONS The ALT flap is a workhorse in covering defects of the leg, foot, and ankle. It's the flap of choice at our institution, especially given the number of traumatic wounds seen as a result of motor vehicles, all-terrain vehicles (ATV), lawnmowers, and gunshot wounds (GSW). At times, the lower extremity zone of injury requires a distant donor site. The RAF can also provide coverage for large soft tissue defects but donor-site morbidity remains its main drawback. The LAF and RFFF provide two pliable options, one that provides pliable soft tissue with minimal donor site morbidity and another that provides a long pedicle. The free gracilis flap is an excellent choice for crossing the ankle joint. Lastly, the free latissimus dorsi is indicated for large defects of the lower extremity independently of the location.
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Affiliation(s)
- S D Kozusko
- Department of Plastic Surgery, University of Tennessee Health Science Center Memphis, TN, 38163, USA
| | - X Liu
- Department of Plastic Surgery, University of Tennessee Health Science Center Memphis, TN, 38163, USA
| | - C A Riccio
- Department of Plastic Surgery, University of Tennessee Health Science Center Memphis, TN, 38163, USA
| | - J Chang
- College of Medicine, University of Tennessee Health Science Center, Memphis, TN 38163, USA
| | - L C Boyd
- College of Medicine, University of Tennessee Health Science Center, Memphis, TN 38163, USA
| | - Z Kokkalis
- Department of Orthopaedic Surgery, University of Patras, Patra, Greece
| | - P Konofaos
- Department of Plastic Surgery, University of Tennessee Health Science Center Memphis, TN, 38163, USA.
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Anoveros‐Barrera A, Bhullar AS, Stretch C, Esfandiari N, Dunichand‐Hoedl AR, Martins KJ, Bigam D, Khadaroo RG, McMullen T, Bathe OF, Damaraju S, Skipworth RJ, Putman CT, Baracos VE, Mazurak VC. Clinical and biological characterization of skeletal muscle tissue biopsies of surgical cancer patients. J Cachexia Sarcopenia Muscle 2019; 10:1356-1377. [PMID: 31307124 PMCID: PMC9536086 DOI: 10.1002/jcsm.12466] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 05/10/2019] [Accepted: 05/28/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Researchers increasingly use intraoperative muscle biopsy to investigate mechanisms of skeletal muscle atrophy in patients with cancer. Muscles have been assessed for morphological, cellular, and biochemical features. The aim of this study was to conduct a state-of-the-science review of this literature and, secondly, to evaluate clinical and biological variation in biopsies of rectus abdominis (RA) muscle from a cohort of patients with malignancies. METHODS Literature was searched for reports on muscle biopsies from patients with a cancer diagnosis. Quality of reports and risk of bias were assessed. Data abstracted included patient characteristics and diagnoses, sample size, tissue collection and biobanking procedures, and results. A cohort of cancer patients (n = 190, 88% gastrointestinal malignancies), who underwent open abdominal surgery as part of their clinical care, consented to RA biopsy from the site of incision. Computed tomography (CT) scans were used to quantify total abdominal muscle and RA cross-sectional areas and radiodensity. Biopsies were assessed for muscle fibre area (μm2 ), fibre types, myosin heavy chain isoforms, and expression of genes selected for their involvement in catabolic pathways of muscle. RESULTS Muscle biopsy occurred in 59 studies (total N = 1585 participants). RA was biopsied intraoperatively in 40 studies (67%), followed by quadriceps (26%; percutaneous biopsy) and other muscles (7%). Cancer site and stage, % of male participants, and age were highly variable between studies. Details regarding patient medical history and biopsy procedures were frequently absent. Lack of description of the population(s) sampled and low sample size contributed to low quality and risk of bias. Weight-losing cases were compared with weight stable cancer or healthy controls without considering a measure of muscle mass in 21 out of 44 studies. In the cohort of patients providing biopsy for this study, 78% of patients had preoperative CT scans and a high proportion (64%) met published criteria for sarcopenia. Fibre type distribution in RA was type I (46% ± 13), hybrid type I/IIA (1% ± 1), type IIA (36% ± 10), hybrid type IIA/D (15% ± 14), and type IID (2% ± 5). Sexual dimorphism was prominent in RA CT cross-sectional area, mean fibre cross-sectional area, and in expression of genes associated with muscle growth, apoptosis, and inflammation (P < 0.05). Medical history revealed multiple co-morbid conditions and medications. CONCLUSIONS Continued collaboration between researchers and cancer surgeons enables a more complete understanding of mechanisms of cancer-associated muscle atrophy. Standardization of biobanking practices, tissue manipulation, patient characterization, and classification will enhance the consistency, reliability, and comparability of future studies.
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Affiliation(s)
- Ana Anoveros‐Barrera
- Department of Agricultural, Food and Nutritional Science, Faculty of Agricultural, Life and Environmental SciencesUniversity of AlbertaEdmontonABCanada
| | - Amritpal S. Bhullar
- Department of Agricultural, Food and Nutritional Science, Faculty of Agricultural, Life and Environmental SciencesUniversity of AlbertaEdmontonABCanada
| | | | - Nina Esfandiari
- Department of Oncology, Faculty of Medicine and DentistryUniversity of AlbertaEdmontonABCanada
| | - Abha R. Dunichand‐Hoedl
- Department of Agricultural, Food and Nutritional Science, Faculty of Agricultural, Life and Environmental SciencesUniversity of AlbertaEdmontonABCanada
| | - Karen J.B. Martins
- Department of Agricultural, Food and Nutritional Science, Faculty of Agricultural, Life and Environmental SciencesUniversity of AlbertaEdmontonABCanada
| | - David Bigam
- Department of Surgery, Faculty of Medicine and DentistryUniversity of AlbertaEdmontonABCanada
| | - Rachel G. Khadaroo
- Department of Surgery, Faculty of Medicine and DentistryUniversity of AlbertaEdmontonABCanada
| | - Todd McMullen
- Department of Surgery, Faculty of Medicine and DentistryUniversity of AlbertaEdmontonABCanada
| | - Oliver F. Bathe
- Department of OncologyUniversity of CalgaryCalgaryABCanada
- Department of SurgeryUniversity of CalgaryCalgaryABCanada
| | - Sambasivarao Damaraju
- Department of Laboratory Medicine and PathologyUniversity of AlbertaEdmontonABCanada
- Department of Oncology, Faculty of Medicine and DentistryUniversity of AlbertaEdmontonABCanada
| | | | - Charles T. Putman
- Faculty of Kinesiology, Sport, and Recreation, Faculty of Medicine and DentistryUniversity of AlbertaEdmontonABCanada
| | - Vickie E. Baracos
- Department of Oncology, Faculty of Medicine and DentistryUniversity of AlbertaEdmontonABCanada
| | - Vera C. Mazurak
- Department of Agricultural, Food and Nutritional Science, Faculty of Agricultural, Life and Environmental SciencesUniversity of AlbertaEdmontonABCanada
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Özkan Ö, Özkan Ö, Çinpolat A, Arıcı C, Bektaş G, Can Ubur M. Robotic harvesting of the omental flap: a case report and mini-review of the use of robots in reconstructive surgery. J Robot Surg 2019; 13:539-543. [PMID: 30911884 DOI: 10.1007/s11701-019-00949-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Accepted: 03/20/2019] [Indexed: 10/27/2022]
Abstract
This study describes the robotic harvesting of a free omental flap. The patient was a 58-year-old man who had undergone several previous operations due to osteomyelitis caused by trauma. There was a non-healing wound and purulent discharge in the distal pretibial region. The flap was harvested based on the right gastroepiploic artery using robotic facilities only. The flap was then transferred to the debrided defect in the pretibial region. Anastomoses were performed between the posterior tibial vessels and the pedicle of the flap. A split thickness skin graft was used to cover the omental flap. The operation lasted 2.5 h in total, including flap harvesting, microvascular anastomoses, inset and skin grafting. The postoperative period was uneventful and the patient was discharged on the 12th day postoperatively. The reliability of the technique is discussed in this report, together with a brief review of the use of robot surgery in reconstructive surgery in the literature.
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Affiliation(s)
- Ömer Özkan
- Department of Plastic, Reconstructive and Aesthetic Surgery, Akdeniz University Hospital, Antalya, Turkey.
| | - Özlenen Özkan
- Department of Plastic, Reconstructive and Aesthetic Surgery, Akdeniz University Hospital, Antalya, Turkey
| | - Anı Çinpolat
- Reconstructive and Aesthetic Surgery, Private Clinic, Plastic, Istanbul, Turkey
| | - Cumhur Arıcı
- Department of General Surgery, Akdeniz University Hospital, Antalya, Turkey
| | - Gamze Bektaş
- Reconstructive and Aesthetic Surgery, Private Clinic, Plastic, Istanbul, Turkey
| | - Mehmet Can Ubur
- Department of Plastic, Reconstructive and Aesthetic Surgery, Akdeniz University Hospital, Antalya, Turkey
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Boyd LC, Bond GA, Hamidian Jahromi A, Kozusko SD, Kokkalis Z, Konofaos P. Microvascular reconstruction of pediatric lower extremity trauma using free tissue transfer. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2019; 29:285-293. [DOI: 10.1007/s00590-019-02367-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 01/03/2019] [Indexed: 11/28/2022]
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van Mulken TJM, Schols RM, Qiu SS, Brouwers K, Hoekstra LT, Booi DI, Cau R, Schoenmakers F, Scharmga AMJ, van der Hulst RRWJ. Robotic (super) microsurgery: Feasibility of a new master-slave platform in an in vivo animal model and future directions. J Surg Oncol 2018; 118:826-831. [PMID: 30114335 PMCID: PMC6221079 DOI: 10.1002/jso.25195] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 07/10/2018] [Indexed: 12/20/2022]
Abstract
Advanced microsurgical procedures are currently limited by human precision and manual dexterity. The potential of robotics in microsurgery is highlighted, including a general overview of applications of robotic assistance in microsurgery and its introduction in different surgical specialties. A new robotic platform especially designed for (super) microsurgery is presented. Results of an in vivo animal study underline its feasibility and encourage further development toward clinical studies. Future directions of robotic microsurgery are proposed.
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Affiliation(s)
- Tom J M van Mulken
- Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Rutger M Schols
- Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Shan S Qiu
- Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Kaj Brouwers
- Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Lisette T Hoekstra
- Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Darren I Booi
- Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Raimondo Cau
- Department of Medical Robotics Technologies, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Ferry Schoenmakers
- Department of Medical Robotics Technologies, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Andrea M J Scharmga
- Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Rene R W J van der Hulst
- Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
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Struk S, Qassemyar Q, Leymarie N, Honart JF, Alkhashnam H, De Fremicourt K, Conversano A, Schaff JB, Rimareix F, Kolb F, Sarfati B. The ongoing emergence of robotics in plastic and reconstructive surgery. ANN CHIR PLAST ESTH 2018; 63:105-112. [DOI: 10.1016/j.anplas.2018.01.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Accepted: 01/02/2018] [Indexed: 12/25/2022]
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Tan YPA, Liverneaux P, Wong JKF. Current Limitations of Surgical Robotics in Reconstructive Plastic Microsurgery. Front Surg 2018; 5:22. [PMID: 29740585 PMCID: PMC5931136 DOI: 10.3389/fsurg.2018.00022] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 02/27/2018] [Indexed: 12/27/2022] Open
Abstract
Surgical robots have the potential to provide surgeons with increased capabilities, such as removing physiologic tremor, scaling motion and increasing manual dexterity. Several surgical specialties have subsequently integrated robotic surgery into common clinical practice. Plastic and reconstructive microsurgical procedures have not yet benefitted significantly from technical developments observed over the last two decades. Several studies have successfully demonstrated the feasibility of utilising surgical robots in plastic surgery procedures, yet limited work has been done to identify and analyse current barriers that have prevented wide-scale adaptation of surgical robots for microsurgery. Therefore, a systematic review using PubMed, MEDLINE, Embase and Web of Science databases was performed, in order to evaluate current state of surgical robotics within the field of reconstructive microsurgery and their limitations. Despite the theoretical potential of surgical robots, current commercially available robotic systems are suboptimal for plastic or reconstructive microsurgery. Absence of bespoke microsurgical instruments, increases in operating time, and high costs associated with robotic-assisted provide a barrier to using such systems effectively for reconstructive microsurgery. Consequently, surgical robots provide currently little overall advantage over conventional microsurgery. Nevertheless, if current barriers can be addressed and systems are specifically designed for microsurgery, surgical robots may have the potential of meaningful impact on clinical outcomes within this surgical subspeciality.
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Affiliation(s)
- Youri P. A. Tan
- The Manchester Centre for Plastic Surgery and Burns, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Philippe Liverneaux
- Department of Hand Surgery, University Hospital of Strasbourg, FMTS, University of Strasbourg, Icube CNRS, Illkirch, France
| | - Jason K. F. Wong
- The Manchester Centre for Plastic Surgery and Burns, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- Blond McIndoe Laboratories, Division of Cell Matrix Biology and Regenerative Medicine, University of Manchester, Manchester, United Kingdom
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Louis V, Chih-Sheng L, Chevallier D, Selber JC, Xavier F, Liverneaux PA. A porcine model for robotic training harvest of the rectus abdominis muscle. ANN CHIR PLAST ESTH 2017; 63:113-116. [PMID: 29287780 DOI: 10.1016/j.anplas.2017.11.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2017] [Accepted: 11/30/2017] [Indexed: 11/17/2022]
Abstract
Conventional open surgical approaches for the harvesting of the rectus abdominis muscle carry a high risk of morbidity. It is possible to reduce these risks by using laparoscopy or robot-assisted techniques. This work hypothesizes that a porcine model could be used for learning the robot-assisted collection of the rectus abdominis. The rectus abdominis was taken in 3 stages in 3 pigs: installation of the robot, surgical approaches with 4 trocars, dissection and collection of the muscle. The average operating time was 1h20min and the average muscular length was 16cm. Our results showed a learning curve for the robot-assisted harvesting of the rectus abdominis on a porcine model.
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Affiliation(s)
- V Louis
- Department of Hand Surgery, SOS main, CCOM, University Hospital of Strasbourg, FMTS, University of Strasbourg, Icube CNRS 7357, 10, avenue Baumann, 67400 Illkirch, France
| | - L Chih-Sheng
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
| | - D Chevallier
- Service d'urologie et C3M unité Inserm 1065, hôpital universitaire Pasteur 2, 06001 Nice, France
| | - J C Selber
- Department of Plastic Surgery, University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - F Xavier
- Orthopedic Surgery, Biomedical Engineering, New York, NY, USA
| | - P A Liverneaux
- Department of Hand Surgery, SOS main, CCOM, University Hospital of Strasbourg, FMTS, University of Strasbourg, Icube CNRS 7357, 10, avenue Baumann, 67400 Illkirch, France.
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Functional Outcomes and Complications of Robot-Assisted Free Flap Oropharyngeal Reconstruction. Ann Plast Surg 2017; 78:S76-S82. [PMID: 28195893 DOI: 10.1097/sap.0000000000001010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Robotic surgical systems provide a clear, magnified 3-dimensional visualization as well as precise, stable instrumental movement, thereby minimizing technical difficulties that may be encountered in the surgical treatment of oropharyngeal tumors. This study assessed the outcomes of robotic-assisted free flap oropharyngeal reconstruction compared with those of conventional free flap reconstruction. MATERIALS AND METHODS A retrospective review of 47 patients who underwent reconstructive operations using a free radial forearm fasciocutaneous flap for oropharyngeal defects was conducted over a 20-month period (May 2013-December 2014). Complications were evaluated for a robot-assisted reconstruction group and a conventional reconstruction group; postoperative complication rates and revision rates were further evaluated. The Functional Intraoral Glasgow Scale (FIGS) was adopted for functional outcome assessment. RESULTS This study recruited 47 people who underwent reconstructive operations using a free radial forearm fasciocutaneous flap for oropharyngeal defects (14 robot-assisted and 33 conventional reconstructions). The mean postoperative FIGS score was 10.29 ± 2.02 in the robot-assisted group (P = 0.010) and 8.42 ± 2.29 in the conventional group at 1 month postoperatively. The mean postoperative FIGS score was 12.57 ± 1.91 in the robot-assisted group (P = 0.005) and 9.91 ± 3.09 in the conventional group at 3 months postoperatively. Complication rates between the robot-assisted and conventional groups were similar for flap failure (P = 0.531), partial necrosis, wound infection, hematoma or seroma formation (P = 0.893), wound dehiscence, and fistula formation (P = 0.515). The number of flap revision operations requiring additional surgery (P = 0.627) was comparable between the cohorts. CONCLUSIONS There is no significant difference in complications or revision rates between the robot-assisted and conventional oropharyngeal reconstructions. The functional postoperative outcomes of robot-assisted reconstructions are superior to those of conventional reconstructions. Robotic surgical systems provide a safe option with optimal postoperative oral function for the free flap reconstruction of oropharyngeal defects without lip or mandible splitting.
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Laparoscopic Harvest of the Rectus Abdominis for Perineal Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2017; 5:e1581. [PMID: 29263976 PMCID: PMC5732682 DOI: 10.1097/gox.0000000000001581] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 09/29/2017] [Indexed: 12/05/2022]
Abstract
Supplemental Digital Content is available in the text. The rectus abdominis is a workhorse flap for perineal reconstruction, in particular after abdominoperineal resection (APR). Laparoscopic and robotic techniques for abdominoperineal surgery are becoming more common. The open harvest of the rectus abdominis negates the advantages of these minimally invasive approaches. (Sentence relating to advantages of laparoscopic rectus deleted here.) We present our early experience with laparoscopic harvest of the rectus muscle for perineal reconstruction. Three laparoscopic unilateral rectus abdominis muscle harvests were performed for perineal reconstruction following minimally invasive colorectal and urological procedures. The 2 patients who underwent APR also had planned external perineal skin reconstruction with local flaps. (Sentence deleted here to shorten abstract.) All rectus muscle harvests were performed laparoscopically. Two were for perineal reconstruction following laparoscopic APR, and 1 was for anterior vaginal wall reconstruction. This was done with 4 ports positioned on the contralateral abdomen. The average laparoscopic harvest time was 60–90 minutes. The rectus muscle remained viable in all cases. One patient developed partial necrosis of a posterior thigh fasciocutaneous flap after cancer recurrence. There were no pelvic abscesses, or abdominal wall hernias. Laparoscopic harvest of the rectus appears to be a cost-effective, reliable, and reproducible procedure for perineal with minimal donor-site morbidity. Larger clinical studies are needed to further establish the efficacy and advantages of the laparoscopic rectus for perineal reconstruction.
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Nehme J, Neville JJ, Bahsoun AN. The use of robotics in plastic and reconstructive surgery: A systematic review. JPRAS Open 2017. [DOI: 10.1016/j.jpra.2017.03.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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Stroumza N, Nail Barthelemy R, Majoulet L, Delchet O, Qassemyar Q, Atlan M. Endoscopic DIEP flap dissection (eDIEP): An experimental cadaveric study. J Plast Reconstr Aesthet Surg 2017; 70:1149-1151. [DOI: 10.1016/j.bjps.2017.05.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2016] [Revised: 04/12/2017] [Accepted: 05/11/2017] [Indexed: 11/30/2022]
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Aijaz T, Singhal D, Tan SA, Iqbal A. A novel method of minimally invasive rectus abdominis muscle flap harvest: Laparoscopic surgeons take note. J Minim Access Surg 2017; 13:146-147. [PMID: 28281481 PMCID: PMC5363123 DOI: 10.4103/0972-9941.186688] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
The rectus abdominis muscle (RAM) is a workhorse flap to fill or repair abdominal defects. A drawback of an open RAM harvest is donor site morbidity, and minimally invasive techniques for flap harvesting have been previously proposed but involve vertical division of the rectus fascia. We present a case of a 52-year-old woman with a recurrent rectovaginal fistula in a radiated field treated with a laparoscopic low anterior resection with simultaneous RAM flap harvest utilising a single Pfannenstiel incision. Our novel modified laparoscopic-assisted RAM harvest technique prevents longitudinal violation of the anterior and posterior rectus sheaths, thereby promoting a quick recovery, improved cosmesis and decreased post-operative morbidity.
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Affiliation(s)
- Tabish Aijaz
- Research Fellow, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Dhruv Singhal
- Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Sanda A Tan
- Department of Surgery, Division of General Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Atif Iqbal
- Department of Surgery, Division of General Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
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Discussion: Infant Robotic Cleft Palate Surgery: A Feasibility Assessment Using a Realistic Cleft Palate Simulator. Plast Reconstr Surg 2017; 139:466e-467e. [PMID: 28121880 DOI: 10.1097/prs.0000000000003021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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