Philippe Liverneaux

Nerve Repair in Telemicrosurgery: An Experimental Study

Since the development of microsurgery in the 1960s, the prognosis of peripheral nerve lesions has greatly improved. However this new techniques evolution has remained limited by human factors, in particular by physiological tremor. Telesurgery, a technique used in other surgical fields, was developed in the 1990s. This study assesses the feasibility of peripheral nerve repair using telemicrosurgery. Anatomical material from three subjects of different species (rat, pig, and human) was used. The telesurgical step of the procedure was performed with a Da Vinci S robot (Intuitive Surgical, Inc., Sunnyvale, CA). Four anatomical epiperineural repairs were performed. Another neurotrophic repair was performed with a nerve regrowth guide. Regardless of the type of repair performed, the telemanipulator removed the physiological tremor factor. The suture needle was distorted when held by two clamps at a time. Repairs were all performed without any damaging twisting movements of both nerve ends. Our results demonstrated that telesurgery allows very safe and precise peripheral nerve repairs by counteracting physiological tremor and by improving the overview of the surgical field, either with an anatomical or a neurotrophic technique.

Telemicrosurgery: A feasibility study in a rat model

Telesurgery is frequently used in cardiac, urologic, gynaecologic or digestive surgery. Significant advances are due to this technology: reduction of the operative time, safety and precision of the surgical gesture, reduction of bleeding and more comfort for the surgeon. However, no telesurgical experiment has been reported yet in microsurgery with 10-0 nylon sutures. The aim of the present work was to assess the feasibility of vascular anastomosis by a telemicrosurgical technique. The material used for this experiment consisted of two Wistar rats, a standard set of surgical instruments and a Da Vinci S (Intuitive Surgical) telemanipulation system. Rats were prepared in compliance with the current regulation. The rat tail was approached by cutaneous incision. The following surgical steps were carried out by telemicrosurgery: dissection, fitting of a vascular clamp, section of the artery and suture by 10-0 nylon separate stitches. Following anastomoses, patency tests were carried out and showed the suture effectiveness. The procedure lasted one hour in both cases. Physiologic tremor was abolished by the telemicrosurgical interface. In this study, the operators pronosupination amplitude was 360 degrees . Optical magnification was the same as with a conventional operative microscope. The adjunction of a third articulated arm improved the ergonomics of the working space. Preliminary results are in favour of the feasibility of telemicrosurgery. The learning curve was astonishingly short. It remains to be used in human clinical practice.

Endoscopic exploration and repair of brachial plexus with telerobotic manipulation: a cadaver trial

OBJECTnThe aim of this paper was to develop an effective minimally invasive approach to brachial plexus surgery and to determine the feasibility of using telerobotic manipulation to perform a diagnostic dissection and microsurgical repair of the brachial plexus utilizing an entirely endoscopic approach.nnnMETHODSnThe authors performed an endoscopic approach using 3 supraclavicular portals in 2 fresh human cadaver brachial plexuses with the aid of the da Vinci telemanipulation system. Dissection was facilitated inflating the area with CO(2) at 4 mm Hg pressure. The normal supraclavicular plexus was dissected in its entirety to confirm the feasibility of a complete supraclavicular brachial plexus diagnostic exploration. Subsequently, an artificial lesion to the upper trunk was created, and nerve graft reconstruction was performed. Images and video of the entire procedure were obtained and edited to illustrate the technique.nnnRESULTSnAll supraclavicular structures of the brachial plexus could be safely dissected and identified, similar to the experience in open surgery. The reconstruction of the upper trunk with nerve graft was successfully completed using an epineural microsurgical suture technique performed exclusively with the aid of the robot. There were no instances of inadvertent macroscopic damage to the vascular and nervous structures involved.nnnCONCLUSIONSnAn endoscopic approach to the brachial plexus is feasible. The use of the robot makes it possible to perform microsurgical procedures in a very small space with telemanipulation and minimally invasive techniques. The ability to perform a minimally invasive procedure to explore and repair a brachial plexus injury may provide a new option in the acute management of these injuries.

Treatment of complex proximal interphalangeal joint fractures using a new dynamic external fixator: 15 cases.

The management of proximal interphalangeal joint fractures of the fingers is difficult. Dynamic traction splinting systems are cumbersome and the Suzuki fixator does not prevent secondary fracture displacement. Fifteen cases were treated with a new dynamic external fixator with distraction, the Ligamentotaxor. In two cases, additional fixation was required with a screw. After 10 months, grip strength scored 85.7% compared with the contralateral hand, flexion achieved 76.3 degrees and the extension deficit was 19.6 degrees . The visual analogical scale pain level (VAS) was 1.9 and the Quick DASH score totalled 16.9. Revision treatment was needed for sepsis for one patient. A case of secondary fracture displacement was corrected in the outpatient clinic. Consolidation was achieved in all cases. In conclusion, despite imperfect outcomes for these complex fractures, we believe that the Ligamentotaxor technique is useful.

IS HAPTIC FEEDBACK NECESSARY TO MICROSURGICAL SUTURING? COMPARATIVE STUDY OF 9/0 AND 10/0 KNOT TYING OPERATED BY 24 SURGEONS

Robotically assisted telemanipulators are often criticised for their lack of direct haptic feedback. However, robotically assisted microsurgical sutures have already been achieved successfully. The aim of this study was to demonstrate that haptic feedback is not necessary in microsurgery. Our series included 24 surgeons of whom 14 were micro-surgeons. Each of them had to tighten a 9/0 and a 10/0 pre-tied nylon thread until getting the sensation of optimal knot tying. The procedure was performed four times, with open and closed eyes. The quality of knot tying was evaluated (fully tied, fairly or incompletely tied, or broken thread). The results obtained with the eyes open were significantly better. Neither the material size, nor the surgeons expertise was shown to have an impact on knot tying quality. Our results demonstrate the uselessness of haptic feedback in microsurgery.

Telemicrosurgery: Robot assisted microsurgery

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Microsurgery and telemicrosurgery training: a comparative study.

Telemicrosurgery (TMS) is a new technique inspired by telesurgery and conventional microsurgery (CMS). One of the difficulties of CMS is learning to control physiological tremor. TMS eliminates the physiological tremor, thus theoretically simplifying microsurgical procedures, but no tactile feedback is provided while tying knots. The objective of this study was to assess if the learning curve for performing microsurgical anastomosis for TMS than with CMS was comparable. Thirty earthworms were anastomosed with 10/0 nylon sutures. In this study 15 anastomoses were performed under operating microscope and 15 under Da Vinci S® robot (Intuitive Surgical, Sunnyvale, CA). A single operator without experience in either technique performed all anastomoses. The evaluation consisted of measuring the time to perform each stitch, as well as to complete the anastomosis. The integrity of the anastomosis was tested by injection of saline solution into the earthworm to assess permeability and watertightness. The average time to complete a single suture was 296 seconds in the CMS group and 529 seconds in the TMS group. Permeability and watertightness of anastomosis was 86.66% in both groups. Learning was faster with CMS than with TMS. For untrained surgeon, the absence of tactile feedback is a limiting factor with TMS, however, the benefits of the TMS are: three-dimensional high definition vision, abolition of physiological tremor, motion scaling of gestures down to 5 times, use of three instruments at once, and extreme mobility.

ARTHROSCOPIC ASSISTED PERCUTANEOUS SCREW FIXATION OF BENNETT'S FRACTURE

Several techniques are used for fixation of Bennetts fractures. The aim of this study was to assess a technique of arthroscopic-assisted reduction and percutaneous cannulated screw fixation of Bennetts fractures. Seven patients (mean age 29 years) with three fractures Type I and four fractures Type II according to Gedda were operated under arthroscopic lavage, fluoroscopic screw fixation, and arthroscopic control of the joint reduction. Arthroscopy, showed satisfactory joint reduction in all cases. At 4.5 months, the mean pain score was 1 (0-4), QuickDASH 15 (0-61), and Kapandji score 9 (5-10). Compared to the contralateral side, first web opening was 86% (58-100), key pinch 73% (45-89), grip strength, and 85% (40-100). Four secondary displacements were noted, two of which had a step of more than 1 mm. Our results showed that the use of arthroscopy for percutaneous screw fixation of Bennetts fractures facilitates joint reduction but does not guarantee stability of fixation.

Robot-assisted free toe pulp transfer: feasibility study.

The current tendency of microsurgery is heading toward supermicrosurgery and microsurgery assisted by robotics. The aim of this work was to study the feasibility of a free hallux hemipulp transfer with a surgical robot in a cadaveric model. We used a human body. The intervention was realized by a Da Vinci SI® robot (Intuitive Surgical™, Sunnyvale, CA) in two stages: first taking off the medial hallux hemipulp, then transferring the hallux hemipulp to the radial thumb hemipulp. The intervention lasted 1 hour 59 minutes, exclusively with the Da Vinci SI® robot, without any interruption or outside intervention. Despite the absence of sensory feedback and an intervention 25% longer than in conventional microsurgery, we have demonstrated the feasibility of free hallux hemipulp transfer with a surgical robot. In the future, it is likely that the added benefits of the robot (physiological tremor suppression, user-friendly ergonomics, ultraprecise control of the instruments) will make the robot an indispensable tool for the surgeon.

Possibility of Fixation of a Distal Radius Fracture With a Volar Locking Plate Through a 10 mm Approach.

The management of distal radius fractures has dramatically improved due to the development of a locking plate system. In addition, mini-invasive surgery has been performed in a lot of surgical fields in recent years. The aim of the present study is to investigate the possibility of fixation of a distal radius fracture with a volar locking plate through a 10 mm approach. Eighteen patients with distal radius fracture (mean age: 66 y; range, 28 to 88 y; 8 males and 10 females) were operated on using a volar locking plate. The incision for plating was always 10 mm long. The clinical, cosmetic, and radiologic outcomes were investigated. At 3 months’ follow-up, the range of motion of the wrist joint was 67.5 degrees in flexion, 65.6 degrees in extension, 88.3 degrees in pronation, and 88.3 degrees in supination. The % grip strength compared to the healthy side ranged from 35% to 100%. The VAS, Q-DASH, and modified Mayo scores were 0.7, 8.5, and 93.3, respectively (excellent in all 18 patients). Bone union was achieved on plain x-ray radiography and cosmetic problems were satisfied in all patients. Our results suggest that it is possible to achieve fixation of a distal radius fracture with a volar locking plate through a 10 mm approach. However, its applicability to surgery must be carefully examined. If any difficulties in plate installation or approach occur during this intervention, it will be necessary to consider switching to a conventional approach. We believe that surgeons must not adhere to a mini-invasive approach.