Robotic Intercostal Nerve Grafting

Video assisted thoracoscopic sympathectomy is an accepted therapy for hyperhydrosis that is socially debilitating. This procedure usually has excellent outcomes, but does have a small subset of patients who develop compensatory sweating so severe that it becomes more problematic than the initial hyperhydrosis. These patients suffer with pronounced sweating of the trunk, abdomen, buttocks and thighs.

• Robotic nerve grafting is shown being performed in an animal model. The procedure has hypothetical benefit for the reversal of sympathectomy performed or hyperhidrosis

The incidence is low given improved surgical technique and patient selection. A subset of these patients is so dissatisfied that they are candidates for a reversal procedure. Previous reversal procedures have required a traditional thoracotomy to allow reconstruction of the sympathetic chain with a sural nerve graft. Our experimental aim was to test the feasibility of using the Da Vinci Robot to perform a minimally invasive thoracic microsurgical reconstruction of the sympathetic chain. Robotic intercostal nerve grafting for reversal of thoracic sympathectomy is a procedure that is technically feasible. The device's tremor filtration, dexterity in small spaces and high magnification camera make this a viable minimally invasive option to reconstruct the sympathetic chain. The principles of neural microsurgery are also maintained with this approach. Future studies will evaluate the efficacy of the nerve graft in a survival model with functional nerve conduction studies and histologic evaluation.

Video Image Overlay in Robotic Surgery

A hypothetical advantage of the DaVinci Robot is that it is an information console that can incorporate various data sources to best serve the operating surgeon. Image overlay has thus far been explored only in virtual environments. The aim of our study was to evaluate the feasibility of real-time fluoroscopic overlay in a laboratory model and to provide a workable technique that could be readily incorporated into procedures using current technology.

• Limitations of fluoroscopic disparity are demonstrated in bench models attempting visual and radiographic overlay.

Image alignment can be achieved in a laboratory model only in one plane. A 0 degree laparoscope exactly aligned with the collimator causes a fluoroscopic blind-spot. Moreover, disparity in the superimposition of the robotic instruments increases in a uniform manner as the distances from the collimator changes, negating intraoperative overlay with current technology. A picture-in-picture manner of real-time fluoroscopic and video imaging with a 30 degree laparoscope proved optimal. Real time fluoroscopic and video overlay are not possible secondary to disparity in multiple planes. A picture-in-picture fluoroscopic/video combination was very helpful and will be used in future procedures.

Robotic-Assisted Natural Orifice Translumenal Surgery

• Two transgastric graspers are shown in the top right of the picture. These initial experiments attempted a plication of the hiatus using an endoscope for visualization spliced into the Da Vinci Console.

Natural Orifice Translumenal Endoscopic Surgery (NOTES) represents a minimally invasive surgical approach with the potential to further decrease the physiologic insult of operations previously performed with an open technique. The dexterous benefit of the Da Vinci surgical instruments is most significant within small spaces requiring extreme angulation. The aim of our study was to combine the hypothetical benefits of these two technologies and evaluate prospective roles for robotic-assisted NOTES. Triangulation of instruments is not possible with a hybrid robotic NOTES technique. The forced parallel proximity of the working arms of the Da Vinci robot while traveling down an intestinal tube resulted in external collisions that negated any benefit of the minimally invasive technique. Future experiments will concentrate on the hypothetical benefit employing trans-organ approaches with hybrid robotic-endoscopic instrumentation instead of a pure robotic NOTES approach.

Parkinsonian Movement Metrics

A surgeon’s progress during training in robotic surgery has been followed by subjective evaluation, without a systematically objective measure. In the stroke and Parkinson’s disease literature, movement metrics are routinely used to describe the quality of a patient’s movements in the affected extremity and to follow patient progress during physical rehabilitation.

• Quantification of surgical movements with MAT-LAB is much easier when looking at shape tracing such as the figure-of-eight demonstrated.
• Flight path data from surgical movements are recorded from the Da Vinci Robot API. This series demonstrates the difficulty with looking at a complex motion like knot-tying.

It is logical to apply these metrics to objectively assess movement qualities of surgeons who are training to use the DaVinci robot. Each task correlated best with a different movement smoothness measure, demonstrating that different aspects of motion are important for different tasks to be subjectively scored highly. Further evaluation of these jerk-based metrics is required to demonstrate their usefulness as reliable markers for progress during training.