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From OncoLog, May 2013, Vol. 58, No. 5

Photo: Surgeons position the robot for breast reconstruction
Dr. Jesse Selber (right) observes as surgeons position the robot for a minimally invasive robotic latissimus dorsi muscle flap harvest and breast reconstruction.

Robotic Surgery Makes Tissue Harvest for Breast Reconstruction Less Invasive

By Jill Delsigne

A new minimally invasive robotic procedure enables surgeons to harvest latissimus dorsi muscle flaps for breast reconstruction with less scarring and discomfort than traditional techniques.

Breast reconstruction after a total or partial mastectomy often employs a pedicled latissimus dorsi muscle flap. The latissimus dorsi is an ideal muscle for breast reconstruction because it is large, flat, and able to cover an implant and because other muscles in the back can compensate for the loss of latissimus dorsi muscle function. However, in a traditional latissimus dorsi muscle harvesting procedure, the surgeon dissects through the skin and fat of the back to reach the muscle, leaving a large scar (15–40 cm) across the patient’s back, even when no skin is needed for the reconstruction. In addition to patients’ aesthetic concerns about such a large and visible scar, the tightness of the skin around the scar can be painful and can limit mobility.

To address these issues, Jesse C. Selber, M.D., an assistant professor in the Department of Plastic Surgery at The University of Texas MD Anderson Cancer Center, developed a robotic surgical procedure for latissimus dorsi muscle harvest that does not leave the conspicuous scars associated with the traditional technique. “It didn’t make sense that plastic surgeons—who should be the most concerned of any specialists about aesthetic outcomes—did not have tools to minimize the invasiveness of the procedures we do,” he said.

The robotic procedure

Photo: Robotic instruments inserted through surgical ports
During a tissue flap harvest procedure for breast reconstruction, robotic instruments and an endoscopic camera are inserted through ports placed in three small incisions.
Photo: Three-dimensional image shows muscle flap harvest
Three-dimensional optics facilitate delicate robotic surgical procedures such as the latissimus dorsi muscle flap harvest shown here. The robot’s dual controls allow one surgeon to operate the robotic surgical tools while a second surgeon provides guidance or points out critical structures using the blue arrows.

Dr. Selber’s robotic procedure involves making an incision of about 5 cm in the axilla. If the patient had a sentinel lymph node biopsy, the biopsy incision site can be reused to avoid creating any additional incisions and scarring.

Robotic arms are inserted into the patient through three ports. The first port is placed at the lower end of the axillary incision, and the next two are placed through smaller incisions made 12–13 cm apart in front of the edge of the latissimus dorsi muscle. The robot’s endoscopic camera is inserted through the middle port, which is about 1 cm wide. The other two ports, which are both about 8 mm wide, allow the passage of the robotic arms into the space where the muscle can be dissected. The tools used to harvest the flap are a Cadiere grasper, monopolar scissors, and an electrocautery clamp.

The surgeon controls the movements of the robotic arms through a console several feet from the patient. The camera feed provides three-dimensional, high-resolution images, enabling the surgeon to identify and avoid damaging the blood vessels that are necessary for the survival of the latissimus dorsi muscle. The surgeon uses the electrocautery clamp to minimize bleeding and dissect through the cobweb-like thoracolumbar fascia.

When the surgeon has separated the latissimus dorsi muscle from the surrounding tissue, the pedicled flap is transferred under the skin from the back into the breast while remaining connected to its blood supply at the pivot point in the axilla.

Advantages and limitations

Dr. Selber has performed this surgery in breast cancer patients who have had lateral lumpectomies and nipple-sparing mastectomies as well as in patients with a tissue expander who were preparing to receive radiation therapy and needed protection for the permanent implant. He has also used the robotic procedure to harvest latissimus dorsi free flaps in patients undergoing scalp or extremity reconstruction.

After performing more than a dozen robotic latissimus dorsi muscle flap harvests, Dr. Selber has not encountered any robot-specific complications, has not had any flap compromise, and has not ever had to convert to an open procedure.

The dissemination of robotic plastic surgery techniques has been slowed by the limited access to robotic equipment in the operating room and the difficulty of learning to use the equipment effectively. In addition to learning how to operate the robot, surgeons also must be able to troubleshoot when the machine does not function optimally or when circumstances require a modification of the procedure. Dr. Selber practiced his robotic plastic surgery procedure for 2 years in the laboratory to perfect his technique before attempting it on a patient. After several successful procedures, he began training other surgeons to use the technique.

So far, Dr. Selber has begun to train three other MD Anderson plastic surgeons—in addition to the fellows he works with—in robotic tissue harvest. The robot’s dual-console set-up allows the surgeon who is being trained to see exactly what the operating surgeon sees, and control of the operating instruments can be switched back and forth to gradually increase the trainee’s responsibility. In Dr. Selber’s experience, as surgeons practice this technique, robotic harvest time decreases from more than 2 hours to about 1 hour.

The U.S. Food and Drug Administration (FDA) has not approved the use of robotic surgical instruments for harvesting tissue for breast reconstruction, and patients are informed that such use is considered off-label. However, Dr. Selber has demonstrated that his robotic flap harvest technique is safe and effective, and he and MD Anderson have submitted an application to the FDA for an investigational device exemption so they can begin a clinical trial that would create a path to the procedure’s approval.

Dr. Selber is also developing microsurgical techniques that take advantage of the robot’s enhanced precision and optics; these include robotic techniques for suturing small blood vessels and anastomosing lymphatics.

FURTHER READING

Liverneaux PA, Berner SH, Bednar MS, Parekattil SJ, Ruggiero GM, Selber JC, eds. Telemicrosurgery: Robot Assisted Microsurgery. New York: Springer; 2013.

Selber JC, Baumann DP, Holsinger FC. Robotic harvest of the latissimus dorsi muscle: laboratory and clinical experience. J Reconstr Microsurg 2012; 28:457–464.

Selber JC, Baumann DP, Holsinger FC. Robotic latissimus dorsi muscle harvest: a case series. Plast Reconstr Surg 2012;129:1305–1312.

Robot-Assisted Surgery

Much of the technology used in robotic surgery was developed by the National Aeronautics and Space Administration to provide medical treatment for astronauts in space and by the Defense Advanced Research Projects Agency to provide remote surgical care for soldiers. However, both of these government agencies decided not to pursue the technology. Instead, private companies continued to develop the technology.

The da Vinci Surgical System, approved by the U.S. Food and Drug Administration (FDA) in 2000, is currently the world’s most widely used robotic surgical system. The da Vinci system is used in more than 2,000 hospitals, including MD Anderson. Physicians have applied this technology to numerous procedures, including prostatectomies (see OncoLog, March 2012), gynecological procedures, and cardiac valve repair.

Although commonly referred to as a robot, the system is under the surgeon’s control at all times. “This isn’t like I, Robot,” said Jesse C. Selber, M.D., who has performed numerous robotic surgeries. “The robot has no autonomy; it is a tool controlled by the surgeon, like any other surgical implement.”

The robot enhances visibility and precision in operations and reduces the surgeon’s fatigue during long procedures. The robot’s camera provides high-resolution, three-dimensional images at 10x magnification, which allows the surgeon to clearly see microscopic details during the surgery. The robotic console translates the movements of the surgeon’s hands to the robotic tools. The robot’s 5:1 motion scaling miniaturizes the surgeon’s hand movements, allowing precise movements in the surgical field. The surgeon can also control the pressure of clamps and other instruments. With these powerful, sensitive tools, the robot can hold a needle the size of an eyelash, without wavering, to stitch tiny blood vessels together.

Because the consoles and robot are connected remotely, it is possible for surgeons to perform surgeries remotely using robots in other hospitals. “Operation Lindbergh,” the first transatlantic surgical procedure, occurred in 2001, when a surgeon in New York successfully performed a cholecystectomy on a patient in Strasbourg, France, using robotic and telecommunications technology. However, the FDA has not approved this type of remote surgery owing to concerns about the ways in which unforeseen emergencies would be handled if the surgeon were not physically present. Dr. Selber hopes that this kind of remote surgery will one day be approved. With the proper training, he said, the on-site surgical team could abort the robotic surgery in the event of an emergency and carry on with a traditional operation.

For more information, contact Dr. Jesse Selber at 713-745-2310.

Other articles in OncoLog, May 2013 issue:

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