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CLINICAL APPLICATIONS injury and showed the feasibility of using telerobotic
manipulation to perform microsurgical root‑to‑root
All properties mentioned above are not available with nerve repair of the brachial plexus with an endoscopic

the DaVinci robot. However, some of them already allow approach. In a cadaveric and experimental study, we
®
telemicrosurgical clinical applications. Among the many already accomplished neurotization of the spinal accessory
clinical applications, we describe its use in peripheral nerve to the motor branch of the musculocutaneous
nerve surgery. nerve, neurotization of the long portion of the triceps to
the anterior branch of the axillary nerve, neurotization
[11]
What has been done until now? of the motor nerve fascicle of the ulnar nerve on the
Our first experimental study using telemicrosurgery musculocutaneous nerve, neurolysis of the long thoracic
[4]
technique assessed the feasibility of peripheral nerve nerve, and neurolysis of the intercostal nerve. A series
[12]
[2]
repair. Regardless of the different type of anatomical of eight clinical cases of nerve damage around the
materials used (rat, pig, and human cadaver), the shoulder girdle were operated on using the DaVinci
®
telemanipulator removed the physiological tremor robot. Successful microneural repair was confirmed in
factor during anatomical epiperineural repairs. From all clinical studies. However, an open incision was still
this experimental result, we moved to our first
clinical trial to test the feasibility of the restoration of required. Robotic‑assisted surgery of the shoulder girdle
[13]
elbow flexion by Oberlin procedure using the DaVinci and brachial plexus is still in its early stages.
[4]
robot. All patients recovered elbow flexion and good What are the future fields of application in nerve
functional results despite a slight difficulty in visualizing surgery?
the operative field by an endoscopic approach. The In a recent experimental study, we reported on the
development of specific retractors and instruments will feasibility of robotic phrenic nerve harvest in a pig
probably ease these challenges. In a second clinical model. The advantages of using an endoscopic technique
[11]
trial, we presented a new approach to brachial plexus to harvest the phrenic nerve include a magnified, clear,
surgery using mini‑invasive robot‑assisted surgery to and illuminated visualization, a better remote access
perform a biopsy of an intraneural perineurioma in a incision site and an atraumatic technique. Robot‑assisted
12‑year‑old girl. Tigan et al. also studied the surgical neurolysis may be clinically useful for harvesting the
[5]
[6]
dissection of chronic peripheral nerve tumors using the phrenic nerve for brachial plexus reconstruction by the

telemicrosurgical technique to improve their results. Most thoracoscopic approach.
recently, robot‑assisted neurotization of deltoid muscle
using the nerve to the long head of the triceps was CONCLUSION
described as a feasible application for the restoration of
shoulder abduction after brachial plexus or axillary nerve Microsurgical techniques, magnification, and micro‑
injury. These results demonstrate that telemicrosurgery instruments, have not evolved since their first use in
[7]
allows very safe and precise peripheral nerve repairs by the 1960s. Endoscopic telemicrosurgery, through the
counteracting physiological tremor and by improving the amplification of human capabilities, may be the expected
view of the surgical field.
technological leap to introduce microsurgery in the
What are the clinical indications? 21st century.
From an anatomic positional point of view, brachial
plexus injuries are the most ideal indications for REFERENCES
telemicrosurgery. Brachial plexus injuries are caused
by stretching and excessive traction on the shoulder, 1. Brahmbhatt JV, Gudeloglu A, Liverneaux P, Parekattil SJ. Robotic microsurgery
usually during motorcycle accidents or childbirth. We optimization. Arch Plast Surg 2014;41:225‑30.
can distinguish total paralysis of the brachial plexus 2. Nectoux E, Taleb C, Liverneaux P. Nerve repair in telemicrosurgery: an
experimental study. J Reconstr Microsurg 2009;25:261‑5.
(most frequent lesions), paralysis of the upper C5‑C6 3. Panchulidze I, Berner S, Mantovani G, Liverneaux P. Is haptic feedback
and C5‑C6‑C7 roots, and paralysis of the lower C8‑T1 necessary to microsurgical suturing? Comparative study of 9/0 and 10/0
roots, which are rarer than total paralysis of the knot tying operated by 24 surgeons. Hand Surg 2011;16:1‑3.
brachial plexus. Telemicrosurgery can also be helpful 4. Naito K, Facca S, Lequint T, Liverneaux PA. The Oberlin procedure
to distinguish supraclavicular and infraclavicular plexus for restoration of elbow flexion with the da Vinci robot: four cases.
Plast Reconstr Surg 2012;129:707‑11.
lesions. Regardless on the type of plexus lesion, large 5. Lequint T, Naito K, Chaigne D, Facca S, Liverneaux P. Mini‑invasive
incisions are needed either to explore the plexus or to robot‑assisted surgery of the brachial plexus: a case of intraneuralperineurioma.
perform neurotizations from a healthy nerve in order to J Reconstr Microsurg 2012;28:473‑6.
reinnervate a paralyzed nerve. Apart from the unsightly 6. Tigan L, Miyamoto H, Hendriks S, Facca S, Liverneaux P. Interest of
appearance of these large incisions, and the lengthening of telemicrosurgery in peripheral nerve tumors: about a series of seven cases.
Chir Main 2014;33:13‑6.
hospitalization time, these large incisions involve risks of 7. Miyamoto H, Leechavengvongs S, Atik T, Facca S, Liverneaux P. Nerve
infection and perineural adherence that interfere with the transfer to the deltoid muscle using the nerve to the long head of
quality of nerve regrowth. Endoscopic telemicrosurgery the triceps with the da Vinci robot: six cases. J Reconstr Microsurg
allows interventions on peripheral nerves with minimally 8. 2014;30:375‑80.
Finley D, Sherman JH, Avila E, Bilsky M. Thorascopic resection of an apical
invasive incisions. Mantovani et al. [9,10] developed an paraspinalschwannoma using the da Vinci surgical system. J Neurol Surg A
[8]
effective minimally invasive approach to brachial plexus Cent Eur Neurosurg 2014;75:58‑63.
224 Plast Aesthet Res || Vol 2 || Issue 4 || Jul 15, 2015