Fig. 32.1
Preparation of arobotically-asisted endoscopic repair of a right supraclavicular brachial plexus: (a) finger introduction into one of the instrumental approaches in order to perform a subcutaneous dissection preparing the working chamber. (b) The 3 trocars are set in place. (c) The robot ready to operate. Note that the “slave” base of the robot is situated at the cranial extremity on the opposite side
The supra-clavicular brachial plexus and adjacent anatomical structures were dissected: jugular vein, phrenic nerve, scaleni muscles, C4–C7 nerve roots. Haemostasis was obtained by using both electrocoagulation and surgical clips. An artificial lesion was performed by cutting a 2 cm gap in the C5 root. This “substance loss” was auto-grafted by matching both extremities with epiperineural 10/0 nylon stitches performed via the instrumental port. The entire procedure was filmed and recorded. No technical difficulties were noted (Fig. 32.2).
Fig. 32.2
Endoscopic view from the master console of a robotically-assisted repair of a right supraclavicular brachial plexus: (a) View of the working chamber, progressively widened by an instrumental dissection. Note on both sides of the operating field bipolar “Maryland” forceps. (b) View of the working chamber. The C5 root with its 2 cm gap section as an experimental graft model (black star). The black arrow points towards the substance loss. (c) View of the working chamber. Introduction of a 10/0 nylon thread with its support using one of the two instrumental trocars. The needle is held by a “Black diamond®” forceps (d) View of the working chamber. Note the needle through the proximal stump of the C5 root. The black star points the graft model described in G. (e) View of the working chamber. Final view of the graft. The white star shows the C5 root upstream of the graft and the black star the C5 root following the graft
Our results show that an endoscopic treatment of supra-clavicular palsies seems possible. Low pressure CO2 insufflation not only avoided both tissular coadaptation of the dissection and subcutaneous gaseous emphysema, but also provided comfortable working chamber. Using a surgical robot facilitated the dissection step, and allowed performance of microsurgical sutures in very comfortable conditions. Ideally, one should have available smaller instruments and instruments more adapted to nervous surgery such as fibrine glue or electrostimulation in order to perform such a procedure in routine clinical practice. Nonetheless, the perspective of having such minimally-invasive techniques coming in handy and available should allow surgical management in semi-emergency of traumatic brachial plexus palsies with maximal reliability.
Clinical Experience
Since the 90s, telesurgery has been routinely performed in cardiac, urologic, gynaecologic and digestive surgery. It has brought major progress in these fields: reduction of total procedure duration, enhancement of both precision and accuracy of the surgical gesture, decrease in blood loss, better surgical ergonomics. For all these reasons, we developed the concept of telemicrosurgery [20] and tried to apply the latter to surgical indications belonging to nervous microsurgery [21]. We report a series of 8 cases of nervous lesions at the scapulo-clavicular girdle operated with a DaVinci S® robot since 2009.
All patients were operated at the Hôpitaux Universitaires de Strasbourg (Strasbourg University Hospital) (Table 32.1). Our series comprised eight patients, all men, aged a mean 27 year (20–35). There were 2 complete brachial plexus palsies, 3 partial C5–C6 brachial plexus palsies and 2 in-continuity axillary nerve lesions, and at last one associated palsy of the axillary nerve and musculo-cutaneous nerve.
Table 32.1
Our clinical series of 8 scapulo-clavicular girdle palsies
Patient | Gender | Age | Side (R-L) | Lesion | Procedure | Follow-up (months) | BMRC score |
|---|---|---|---|---|---|---|---|
1 | M | 35 | L | Total brachial plexus | C5-Musculocutaneous graft | 22 | 0 |
2 | M | 23 | R | Total brachial plexus | XI- musculocutaneous graft | 18 | 2+ |
3 | M | 33 | L | Axillary nerve | Neurolysis | 12 | 5 |
4 | M | 20 | L | Axillary nerve | Neurolysis | 10 | 5 |
5 | M | 22 | R | C5-C6 roots | Oberlin procedure | 8 | 4 |
6
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