Experience with Robotic-assisted Microsurgery

ver the past decade, Da Vinci Surgical System has made great strides in surgery. It has been widely applied in urology, gynecology, bariatric surgery, hepatobiliary surgery, thoracoscopic surgery, cardiac surgery, neurological surgery, and transoral otolaryngologic neoplasm resection. However, its application in plastic and reconstructive surgery still in the preliminary stages of development. I went to Hong Kong in April 2013 for the robotic surgical system training program and was awarded console surgeon certificate. I started using the Da Vinci Surgical System since May 2013 and applied it to patients who needed free flap reconstruction after the oropharyngeal cancer resection. All the tumors resected without the lip-splitting and mandibulotomy, and the defects were reconstructed by free radial forearm fasciocutaneous flaps. The microvascular anastomoses of the radial artery to the recipient artery, and one venae comitante to the recipient vein in the neck area were performed using a standard operating microscope. The anastomosis of another venae comitante to the recipient vein was performed robotically (Figure 1). Adequate microsurgery training is necessary to perform this procedure. I used visual cues to determine the tension while tying the knots. It is a crucial fact that a superior tactile sense of microsurgical manipulation is essential for this maneuver. The lack of haptic feedback when performing vascular anastomosis can be overcome by practicing visual cues. With the existing limited experience (1 artery and 9 veins), it is possible to perform microsurgical vascular suture using Da Vinci system, which achieves a patent and successful microvascular anastomosis. With the invention of finer devices, the standard operating microscope may be replaced by Da Vinci robotic surgical system. Then, using 4-0 Monocryl sutures, which were manipulated by the Da Vinci system, the revascularized radial forearm flap was inset into the deepest portion of the oropharyngeal defect (Figure 2). Interrupted sutures were delivered by robotic arm-powered needle drivers (2 Black Diamond micro needle drivers, Intuitive Surgical). The Da Vinci Surgical System made it possible to reach difficult areas without using the jaw-splitting approach. Besides, it provided a high-resolution 3D stereoscopic view of the back of the mouth and throat. In our study, we recruited 47 people who underwent reconstructive operations using a free radial forearm fasciocutaneous flap for oropharyngeal defects (14 robot-assisted and 33 conventional reconstructions). Our study revealed that there was no significant difference in complications or revision rates between the robot-assisted and conventional oropharyngeal reconstructions. The functional outcomes of robot-assisted reconstructions were superior to those of conventional reconstructions. The functional outcomes were assessed using the Functional Intraoral O SciTeMed Publishing Group EDITORIAL