Robotic surgery of special interest to head-to-toe plastic surgeons

Plastic surgeons are often considered head-to-toe surgeons by virtue of operating on the whole body, on all groups of patients, and in emergency, as well as elective cases. One commonality in plastic surgery procedures is delicacy, requiring the highest levels of precision and meticulousness for optimal outcomes. Also, many techniques are performed on high-risk patients in whom minimal surgical morbidity is even more desirable owing to the consequences of complications. With the improved da Vinci robot technology, and its increasing clinical application in the fields of minimally-invasive general, urologic, and cardiothoracic surgery7, it has become evident that robots might benefit the challenging field of reconstructive plastic surgery. Computer-enhanced technology and robotic precision are able to provide a level of surgical precision never previously attained in the history of surgery8; this is also known as ‘supra-human’ precision. The robotic arms filter the fine tremors of the human hand, in addition to providing motion scaling of up to five times in amplitude reduction. This combination of attributes results in a tremendous enhancement of the surgeon’s delicate control of the instruments and tissue, allowing intricate procedures to be performed with more confidence. These robotic advantages, in addition to better ergonomics and visual acuity, has rendered many surgical approaches that were previously technically difficult or unfeasible, now possible.

Increased dexterity

Improved dexterity is achieved in a number of ways. Robotic instruments are capable of increased degrees of freedom, which greatly improve the surgeon’s ability to carefully handle arteries, veins, nerves, and other tissues. These instruments are also free of the fulcrum effect that makes manipulation more intuitive than laparoscopy. In addition, the robot is designed in a way to annul the surgeons’ tremor on the end-effector arms through sophisticated hardware and software filters. Furthermore, these systems can scale down movements (i.e. gross movements of the control sticks are transformed into micro-movements on the patient side9).

Enhanced hand-eye coordination

The robotic vision system provides high definition, and 3D optics at 10-times magnification. The 3D view with depth perception is far beyond what a conventional operating room camera (e.g. laparoscopic camera) can offer. The high resolution images, coupled with the increased degrees of freedom and enhanced dexterity, boost the surgeon’s ability to identify and dissect fine anatomic structures and to perform microanastomoses with more certainty and confidence.

Ergonomic positioning

Another significant highlight of the robot is ergonomic positioning. With the surgeon sitting at a remote, comfortably-designed station, this system eliminates the need to twist and turn in awkward positions — especially when performing subtle procedures in a narrow visual field. In microsurgery, surgeons spend a lot of time working around structures to fit their hands in space. Robotic microsurgery eliminates the need to work around tracheostomy tubes, under the mandible or over large flaps.

Smooth patient recovery

For patients, the results of robotic-assisted surgery, by virtue of its minimally-invasive nature, include decreased postoperative pain, risk of infection and blood loss, in addition to a potential shorter hospital stay, faster recovery, and quicker return to normal daily activities. This is particularly seen in multi-service robotic cases that include intra-abdominal or pelvic work in combination with reconstructive procedures. These are typically associated with blood loss, transfusions, the need for epidurals, and long hospitalisations and immobility. Anecdotally, combined robotic procedures have reduced these drawbacks.

Applications of robotic surgery in plastic surgery

Head and neck surgery: oropharyngeal reconstruction

Traditional upper aerodigestive tract oncologic reconstructive surgery relies on local and free-flap coverage. The difficultly in accessing deep oropharyngeal tumours has required adding a morbid procedure to increase visualisation for optimal tumour extirpation and flap inset, such as lip splitting and/or mandibulotomy; these result in speech and swallowing dysfunction, as well as poor aesthetic outcomes10–13.

From animal models into clinical application, transoral robotic surgery (TORS) was introduced in 2003 by Mcleod et al14, and has since provided a number of key advantages in tumour resection surgeries. Improved optics and enhanced instrumentation allowed multiple degrees of rotation with greater freedom of movement inside a narrow cavity, with better exposure of anatomic landmarks in a 3D view. This has obviated the need for additional incisions and jaw splitting manoeuvres (used in the traditional approach). The TORS concept was further developed by Hockstein et al15 and Weinstein et al16, 17, who demonstrated wide access to the laryngopharynx in cadaveric and animal models, respectively. In 2006, Hockstein introduced the first clinical application of TORS for oropharyngeal cancer in 3 patients with satisfying outcomes18. This was followed by a number of small series from different institutions19–22; ultimately, the superior ability of TORS for en bloc resection of tumours while preserving vital functions, such as speech and swallow, became evident. Consequently, in 2009, TORS obtained FDA approval for selected benign and malignant tumours of the head and neck, and has since grown to enter multiple centres around the world for tumour resection.

Parallel to the advances in robotic resection of deep oropharyngeal tumours, trans-oral robotic reconstructive surgery (TORRS) of oropharyngeal defects surfaced. After resecting such tumours and creating substantial defects, there is a clinical need for a reliable reconstructive technique of the oropharynx using preferentially vascularised tissues, as this aids in optimal functional recovery10. Introduced by Mukhija et al in 2009 in an animal then cadaveric model23, trans-oral oropharyngeal reconstruction proved to be a viable option after tumour resection, as it allowed flap inset in narrow areas inside the oropharynx where direct visualisation is not possible. Furthermore, microvascular anastomoses was enhanced owing to markedly decreased tremulousness. This has allowed the robot to gain popularity in this reconstructive field10.

In 2010, Selber reported early favourable results of five robotic-assisted oropharyngeal reconstruction of heterogeneous defects using different types of flaps24. Deformities ranged from small tonsillar fossa defects to more extensive ones extending from the tip of the tongue to the epiglottis. Reconstruction was performed using local as well as free flaps. The main advantage of using the robot in these cases was the ability to inset the flap in locations that are not easily reachable using conventional reconstructive techniques (i.e. without splitting the lip or performing a mandibulotomy). Also, the first robotic microvascular anastomosis was performed in this series, and showed distinct advantages of the robot for microsurgery: 100% tremor elimination, motion scaling (up to 5:1), and the possibility to work with full precision in confined spaces. However, some disadvantages were noted, and these included inferior optics as compared with operative microscopes, relatively unrefined instruments, and a lack of haptic feedback25. Nevertheless, microanastomosis was performed entirely using the robot, without the need for any additional hand-thrown sutures, and resulted in a 100% success rate.

Genden et al introduced the two earliest case reports of TORS microvascular reconstruction consisting of two radial forearm free flaps for different patients with complex orophayngeal defects25. In both cases, flaps were inset robotically, but the microanastomosis was performed in the standard hand-thrown fashion.

Later in 2012, Genden et al published a larger case series (31 cases) on primary TORS reconstruction26. The majority of cases were local advancement flaps and six were free flaps (radial forearm) mainly performed for extensive wounds and/or radiation salvage. All free flaps were inset robotically, but the anastomosis was also performed in the standard fashion. Ghanem reported four cases of different complexity treated with free flap in a relatively similar fashion to Genden’s reconstruction27.

Given the relative infancy of these procedures, clear guidelines on the timing of reconstruction is still lacking. Recently, however, Selber et al introduced, through a small series of 20 patients undergoing TORS, an algorithm based on tumour location, tumour extent, prior treatment, and patient specific criteria24. The study included 13 free flaps and seven local flaps. Microvascular anastomosis was performed in four of these cases, with no microvascular thrombosis, or free flap failures10. In 2013, Song et al published a series of five patients who underwent free-flap reconstructions (four radial forearm and one anterolateral thigh)28. Flap inset and microanastomosis were performed robotically. No complications such as flap necrosis, haematoma, or wound dehiscence were noted28.

TORS for oropharyngeal, hypopharyngeal and laryngeal tumours seems to be a viable treatment option, with equivalent or potentially superior oncologic outcomes as compared with chemoradiation therapy. In addition, TORS is safe, feasible and effective even for large tumours26, 29.