Handchirurgie Mikrochirurgie Plastische Chirurgie最新文献

Background: Robotic-assisted harvest of the deep inferior epigastric perforator (DIEP) flap is an innovative modification of the traditional open preparation for autologous breast reconstruction. It is assumed that donor-site morbidity (herniae, bulging) is reduced by minimising the fascial incision length in robotic-assisted DIEP flap harvest.

Material & methods: This is the first report of a robotic-assisted DIEP harvest in Germany, which was performed in April 2023 at the University Hospital of Freiburg in an interdisciplinary approach of the Departments of Plastic Surgery, Urology and Gynaecology. To determine the value of this novel technique, we assessed the demand by retrospectively performing an analysis of potential patients and conducted a cost analysis based on the breast reconstructions with DIEP flap harvest performed between April 2021 and May 2023 at the Department of Plastic Surgery at Freiburg University Hospital. To this end, we carried out a retrospective analysis of preoperative CT angiographies to determine the proportion of patients suitable for a robotic-assisted procedure in a post-hoc analysis. Furthermore, we describe the basic robotic-assisted techniques and discuss the TEP and TAPP laparoscopic approaches.

Results: In line with the previously published literature, a short intramuscular course (≤25 mm) and a perforator diameter of≥1.5 mm and≥2.7 mm (subgroup) were defined as a crucial condition for the robotic-assisted procedure. We analysed 65 DIEP flaps harvested in 51 patients, of which 26 DIEP flaps in 22 patients met both criteria, i. e.≤25 mm intramuscular course and≥1.5 mm diameter of the perforator, while 10 DIEP flaps in 10 patients additionally met the criteria of the subgroup (≥2.7 mm diameter). Based on the intramuscular course of the perforators in the CT angiographies of those 26 DIEP flaps, a potential reduction of the fascial incision of 96.8±25.21 mm (mean±standard deviation) compared with the conventional surgical approach was calculated. The additional material costs in our case were EUR 986.01. However, ischaemia time was 33,5 minutes longer than the median of the comparative cohort.

Conclusion: The robotic-assisted procedure has already proven to be a feasible alternative in a suitable patient population. However, further studies are needed to confirm that robotic-assisted DIEP flap harvest actually reduces harvest site morbidity and thereby justifies the additional costs and complexity.

Surgical robotic systems specifically developed for microsurgery are increasingly being used in recent years, particularly in reconstructive lymphatic surgery. Currently, there are two robotic systems that are used in microsurgery. Both systems feature tremor reduction and motion scaling technologies, which are intended to optimise the surgeon's precision and dexterity. In the Department of Plastic Surgery and Hand Surgery at the University Hospital Zurich, the Symani Surgical System is used in many microsurgical and supermicrosurgical procedures. It is mainly used in reconstructive lymphatic surgery, especially for robotic-assisted lymphovenous anastomosis, microvascular anastomosis of lymph node flaps, and it is used in central lymphatic surgery. The robot enables smaller surgical approaches for deep anatomical structures with enhanced surgical precision. In combination with an exoscope, it can also improve the ergonomics of the microsurgeon.

Background: The evolution of microsurgery has relied on advancements in operating microscopes and surgical instruments. Pioneering advancements, however, especially within the domain of "super-microsurgery", challenge the limits of human dexterity by dealing with anastomoses between vessels smaller than 0.8 mm. Based on these premises, the Symani robotic system was designed and developed. This platform utilizes teleoperation and motion-scaled movement to provide surgeons with precision and accuracy in manipulating millimetre and submillimetre-sized anatomical structures. In this study, we present our experience in performing robotic-assisted anastomoses using the Symani Surgical System in free flap reconstruction.

Methods: We present a comprehensive analysis of all reconstructive procedures involving microsurgical free flaps performed using the Symani robotic platform at the orthoplastic unit of the Rizzoli Orthopaedic Institute from 1 October 2022 to 1 May 2023.

Results: Sixteen microsurgical reconstructions using free flaps were performed, involving a total of 40 anastomoses on vessel calibres ranging from 0.6 mm to 2.5 mm. In each case, the anastomosis was executed with the assistance of the robotic platform, achieving a 100+% success rate in patent anastomoses, and no major complications occurred.Conclusion The Symani system has proven to be safe and reliable in performing microsurgical anastomoses. While this platform demonstrated successful in various vessel calibres, its most promising potential lies in anastomoses below the size of a millimetre. Larger patient cohorts and extended investigation periods will be essential to explore whether robotics in microsurgery offers advantages across all microsurgical procedures or should be reserved for selected cases.

Background: In recent years, various robotic systems specifically designed for microsurgical tasks have been developed and approved. There is not much evidence for these systems to date. In our study, we examined the use of robot-assisted microsurgery in the reconstruction of the lower extremity.

Patients/material and methods: Data was prospectively collected between February and November 2023. The Symani robotic system was used in 42 robot-assisted microsurgical procedures on the lower extremity, and the results were evaluated and documented.

Results: The average age of the patients was 57±18 years. A total of 39 free flap reconstructions (95%), one lymphatic surgical procedure (3%) and two nerve transfers (5%) were performed. In total, 46 anastomoses and coaptations were carried out. This included six arterial end-to-end anastomoses (11%), seven arterial end-to-side anastomoses (13%), 36 venous end-to-end anastomoses (65%), two lymphovenous anastomoses (4%), and five epineural coaptations in the context of nerve transfers (9%). Arterial end-to-end anastomoses took an average of 26±12 minutes, and arterial end-to-side anastomoses took 42±21 minutes. The venous anastomoses took an average of 33±12 minutes. Epineural coaptations took an average of 24±13 minutes. In no procedure was there a need for a conversion to conventional hand suturing. There were two arterial thromboses (5%), one of which was successfully revised to save the flap. One total flap loss occurred, but there were no partial flap losses.

Conclusion: Using the Symani robotic system for microsurgical reconstruction of the lower extremity, we were able to demonstrate results that are comparable to conventional microsurgery.

Background: The European Society of Plastic, Reconstructive and Aesthetic Surgery (ESPRAS) comprises 40 national societies across Europe. In addition to ESPRAS, there are 8 different European Plastic Surgery societies representing Plastic Surgeons in Europe. The 4^th European Leadership Forum (ELF) of ESPRAS, held under the motto "Stronger together in Europe" in Munich in 2023, aimed to collect and disseminate information regarding the national member societies of ESPRAS and European societies for Plastic Surgeons. The purpose was to identify synergies and redundancies and promote improved cooperation and exchange to enhance coordinated decision-making at the European level.

Material and methods: An online survey was conducted regarding the organisational structures, objectives and challenges of national and European societies for Plastic Surgeons in Europe. This survey was distributed to official representatives (Presidents, Vice Presidents and General Secretaries) and delegates of national and European societies at the ELF meeting. Missing information was completed using data obtained from the official websites of the respective European societies. Preliminary results were discussed during the 4^th ELF meeting in Munich in March 2023.

Results: The ESPRAS survey included 22 national and 9 European Plastic Surgery societies representing more than 7000 Plastic Surgeons in Europe. Most national societies consist of less than 500 full members (median 182 members (interquartile range (IQR) 54-400); n=22). European societies, which covered the full spectrum or subspecialities, differed in membership types and congress cycles, with some requiring applications by individuals and others including national societies. The main purposes of the societies include research, representation against other disciplines, specialisation and education as well as more individual goals like patient care and policy regulation.

Conclusion: This ESPRAS survey offers key insights into the structures, requirements and challenges of national and European societies for Plastic Surgeons, highlighting the relevance of ongoing close exchange between the societies to foster professional advancement and reduce redundancies. Future efforts of the ELF will continue to further explore strategies for enhancing collaboration and harmonisation within the European Plastic Surgery landscape.

Background: With the introduction of novel surgical robots and surgical microscopes for the special needs of open microsurgery, the concept of robotic-assisted microsurgery is gaining popularity. While initial preclinical studies indicate a steep learning curve, favourable ergonomics and improved precision, albeit with an increased operating time, data on the clinical application of the new systems is still limited. This study describes our first clinical experience with robotic-assisted autologous breast reconstruction and outlines the opportunities and limitations of the approach.

Patients and methods: Our retrospective data analysis included a total of 28 patients who underwent unilateral robotic-assisted autologous breast reconstruction between July 2022 and August 2023. We applied a combined approach using the Symani Surgical System together with the RoboticScope. Descriptive evaluation of patient characteristics, surgical data and complications was performed.

Results: Average patient age was 54.3±11.1 years and average BMI was 26.5±3.5 kg/m². Twenty-six patients received a DIEP flap and 2 patients received a PAP flap, the flaps being connected to the internal mammary artery in 22 cases, to a perforator of the internal mammary artery in 5 cases, and to a branch of the thoracodorsal artery in one case. The average incision-suture time was 267±89 min, with an average ischaemia time of 86±20 min and duration of the arterial anastomosis of 29±12 min. In two cases, immediate intraoperative anastomosis revision was performed, but no flap loss occurred.

Conclusion: The results of this study demonstrate the safe feasibility of robot-assisted autologous breast reconstruction using a combination of Symani and RoboticScope. In the future, special attention should be paid to minimally invasive techniques of flap harvest and connecting vessel preparation.

Background: Patients affected by polyneuropathy often report pain, paraesthesia and numbness and are at risk of having an increased propensity to fall with the corresponding complications. In case of persistent symptoms after all conservative and medical treatment options have been exhausted, a nerve decompression in the lower leg as described by Dellon can lead to an improvement of the discomfort for many patients. This article presents our long-term results with Dellon's operation.

Methods: In this retrospective study, we included 33 patients with diabetic or idiopathic polyneuropathy in whom we performed Dellon's nerve decompression in the lower leg in the years 2011-2013. In 29 out of the 33 patients, we investigated the level of pain (according to the numeric rating scale NRS 0-10), paraesthesia, numbness, Hoffman-Tinel sign, and Semmes-Weinstein monofilaments three months postoperatively. 88 months postoperatively (range 78-111 months), we were able to contact 20 of the 33 patients with a questionnaire asking about their present pain level (NRS 0-10), satisfaction with the postoperative result (NRS 0-10, 0=most satisfied, 10=not satisfied at all) and whether the patients would recommend the surgical procedure to their friends or family.

Results: 1. Significant pain reduction three months postoperatively, NRS 4.5 to 2.2, (p=0.000). 2. Significant reduction of paraesthesia three months postoperatively from 84.8 to 24.2% (p=0.000) 3. Significant reduction of numbness three months postoperatively from 97% to 39% (p=0.000). 4. Significant improvement of sensitivity three months postoperatively from 91% no sensitivity to 28% no sensitivity (p=0.000). 5. Significant improvement of Hoffmann-Tinel sign three months postoperatively from 76% to 13% (p=0.000). 88 months postoperatively, we saw a significant pain reduction from an average preoperative pain level of NRS 4.5 to a postoperative pain level of 2.7 (p=0.048). 88 months postoperatively, 65% of the patients would recommend the surgical procedure to their family and friends, and patient satisfaction was high (NRS 3,4).

Conclusion: Our long-term results show that Dellon's nerve decompression in the lower extremities leads to a marked, lasting pain reduction and a functional improvement.