From OncoLog, May 2013, Vol. 58,
Robotic Surgery Makes Tissue Harvest for Breast Reconstruction Less Invasive
By Jill Delsigne
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
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
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.
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.
information, contact Dr. Jesse Selber at 713-745-2310.
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