Chapter 57: ENDOSCOPIC ROBOTIC DECOMPRESSION OF CUBITAL ULNAR NERVE

Publicado em: 15 de maio de 2020 por Dr. José Carlos Garcia Jr.
Categorias: Capítulos de Livros

Arthroscopy and Endoscopy of the Elbow, Wrist and Hand: Surgical anatomy and techniques

EDITORS: DEEPAK N BHATIA, GREGORY I BAIN, GARY POEHLING, BENJAMIN GRAVES

Introduction

The use of robotic surgery has expanded in several surgical specialties and has advantages over the traditional surgical methods. Within orthopedics, robotic surgery has been used in brachial plexus and neurologic releases. The association of the robotic technology and endoscopy have further expanded indications and procedures can now be performed with shorter time of hospitalization and minimally invasive approach.  Advantages of this method include: a) movement accuracy, b) high resolution imaging with three-dimensional vision, c) gas infusion rather than saline solution permits better visualization and less bleeding, d) filtering of the surgeon’s tremor when manipulating objects, e) movement scaling and f) hand-free camera manipulation. In addition, in future there is the possibility of remotely performing the surgery (telesurgery). 

The disadvantages and limitations of this new technology are: a) higher costs, b) lack of haptic feedback, c) instruments were not designed for orthopedic procedures, and d) limitation of the use of this procedure in patients with poor subcutaneous tissue. 

Indications and contraindications:

The procedure is performed for symptomatic ulnar nerve compression at the cubital tunnel after adequate conservative treatment has failed to provide relief. Non-robotic endoscopic technique for ulnar nerve decompression is an alternative to robotic endoscopic surgery.

Absolute contraindications include space-occupying lesions (tumors, osteophytes), long-standing elbow contractures requiring release, prior trauma with extensive scar formation or skin grafts, and prior open decompression with transposition of the ulnar nerve.

Subluxation of the ulnar nerve and inexperience with robotic technique are relative contraindications. 

Surgical Technique

  • Endoscopic robotic decompression of the ulnar nerve uses a new coupling and configuration for the robotic DaVinci® SI or Xi systems (Intuitive Surgical, Sunnyvale, CA) and is based on prior knowledge of endoscopic robotic techniques related to different surgical areas such as urology and gynecology.
  • The procedure is performed under general anesthesia. The patient is placed supine and the arm is raised 170º in the Trendelenburg position (Figure 1). A tourniquet may be used and is placed high on the arm.
  • Since there are no natural cavities in the ulnar nerve pathway, endoscopy in this region requires the creation of an initial cavity. Through a 1.2 cm portal (length of the da Vinci robot cannula) an initial subcutaneous cavity is created in the middle third of the arm with direct visualization of the nerve exit point in the Strüthers arcade. The dissection is performed using Metzenbaum scissors and is directed to the distal arm (Fig. 2). 
  • Two other portals are created at the junction of middle and distal thirds of the arm, and are located 3 to 5 cm lateral and medial to the first portal. (Fig.3) These two portals must be 8 mm long to allow robotic hand cannulas to pass through. The cannulas are gently passed into the cavity under endoscopic view in order to prevent injuries. Once the robotic hands are visible through the optics in the cavity, this cavity can be expanded distally towards the medial elbow. 
  • A needle can be used to identify the optimal location of the two robotic hand portals mentioned above. It is important to have a safe distance between the portals to avoid robotic arm conflict. The third robotic arm is not used in this procedure. 
  • Air insufflation at a pressure of 8-14 mm Hg is used to prevent bleeding. 0.9% saline may be introduced and aspirated to clear the surgical field when necessary.
  • Two different robotic hands can be used as follows: Maryland bipolar forceps 8mm (Intuitive Surgical, Sunnyvale, CA, USA) and a Curved Scissor 8mm (Intuitive Surgical, Sunnyvale, CA, USA). A Hot ShearsTM Monopolar Curved Scissor 8mm (Intuitive Surgical, Sunnyvale, CA, USA) can also be used (only as scissors and never as electrocautery device).
  • After fitting the cannulas and robotic hands, the surgeon uses the console to operate the robot remotely. 
  • Robotic arms have seven degrees of freedom and can reproduce hand and wrist movements, and this is an advantage when compared with other endoscopic methods. In addition, the surgeon can scale the movements improving precision to the robotic arms.
  • The nerve is followed and dissected in the subcutaneous space until the cubital tunnel is reached. The cubital tunnel is split and the nerve is released (Fig. 4) further distally down to the arcade of Osborne (fibro-aponeurotic tissue connecting the humeral and ulnar heads of the flexor carpi ulnaris) (Fig. 5)

Post-operative management and rehabilitation

An immobilizer is provoded for comfort for the first week, and thereafter mobilization and physiotherapy are initiated. Portal stitches are removed in 2-3 weeks depending on the healing process.

References

Ballantyne GH, Moll F. The da Vinci telerobotic surgical system: the virtual operative field and telepresence surgery. Surg Clin North Am. 2003; 83:1293-304.

Byrn JC, Schluender S, Divino CM, Conrad J,Gurland B, Shlasko E, et al. Three-dimensional imaging improves surgical performance for both novice and experienced operators using the da Vinci Robot System. Am J Surg. 2007; 193:519–22.

Gallotta V, Cicero C, Conte C, Vizzielli G, Petrillo M, Fagotti A et al. Robotic Versus Laparoscopic Staging for Early Ovarian Cancer: A Case Matched Control Study. J Minim Invasive Gynecol. 2017; 24(2):293-298.

Garcia JC. Nerve entrapment. In Liverneaux PA, Berner SH, Bednar MS, Parekattil SJ, Mantovani Ruggiero G, Selber JC (Eds). Telemicrosurgery. Springer, Paris; 2013. p.109-117

Garcia JC, Lebailly F, Mantovani G, Mendonça LA, Garcia JM and Liverneaux PA. Telerobotic Manipulation of the Brachial Plexus. J reconstr Microsurg 2012; 28(7):491-494. 

Garcia JC, Mantovani G, Gouzou S and Liverneaux P. Telerobotic anterior translocation of the ulnar nerve. Journal of Robotic Surgery. 2011; 5(2):153–156.

Garcia JC, Montero EFS. Endoscopic Robotic Decompression of the Ulnar Nerve at the Elbow. Arthroscopy Techniques. 2014; 3: 383-387.

Kavoussi LR, Moore RG, Partin AW, Bender JS, Zenilman ME, Satava, RM. Telerobotic assisted laparoscopic surgery: initial laboratory and clinical experience. Urology; 1994; 44(1): 15-9.

Melo PMP, Garcia JC, Montero EFS, Atik T, Robert EG, Facca S et al. Feasibility of an endoscopic approach to the axillary nerve and the nerve to the long head of the triceps brachii with the help of the Da Vinci Robot. Chirurgie de la Main. 2013; 32: 206-9.

Morgan JA, Thornton BA, Peacock JC, Hollingsworth KW, Smith CR, Oz MC, Argenziano M. Does robotic technology make minimally invasive cardiac surgery too expensive? A hospital cost analysis of robotic and conventional techniques. J Card Surg. 2005; 20(3):246-51.

Oldani A, Bellora P, Monni, M, Amato B, Gentilli S. Colorectal surgery in elderly patients: our experience with DaVinci Xi® System. Aging Clin Exp Res. 2017; 29(1):91-99.

Shademan A, Decker RS, Opfermann JD, Leonard SK, Axel K, Peter CW. Supervised autonomous robotic soft tissue surgery. Sci Transl Med. 2016; 8(337): 337ra64.