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Jesse SELBER

MD Anderson Cancer Center
Houston, TX, United States
MD, MPH, FACS
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Robotic microsurgery: small vessel anastomosis
In 1902, Alexis Carrel developed the technique of end-to-end anastomosis of blood vessels. In 1960, Jules Jacobson described the use of the operating microscope for microvascular surgery. In the late 60’s, Harry Buncke developed the first micro-instruments, and small needles were swaged. Since then, very little has changed about microsurgery, in spite of increasing technical demands, including supermicrosurgery, perforator to perforator anastomosis and lymphatic anastomosis. The surgical robot affords super human levels of precision with high-fidelity, 3-dimensional magnification. This combination of attributes makes it exceedingly well suited for microsurgery. Robotic microsurgery combines the executive functions of the human mind with the precision of a machine. Specific advantages of the robotic platform for microsurgery include: 1) Superhuman precision - this comes in the form of 100% tremor elimination, and up to 5 to 1 motion scaling 2) Physician comfort – the ergonomics of microsurgery can be a challenge and the robot eliminates any physical discomfort or long-term sequel related to surgeon positioning 3) Reduction of physical constraint requirements – access to vessels can be a challenge and the ability to successfully perform an anastomosis requires wide exposure. The robot eliminates this need with long, thin, precise arms. Specific disadvantages include: 1) Lack of haptic feedback, 2) inferior optics as compared to the operating microscope and 3) instrumentation which is ill-suited to microsurgery. It is worth noting that all the advantages to robotic microsurgery are inherent to the field, while all of the disadvantages are platform-specific, and likely to be overcome in the near future.
Lecture
5 years ago
387 views
10 likes
0 comments
14:26
Robotic microsurgery: small vessel anastomosis
In 1902, Alexis Carrel developed the technique of end-to-end anastomosis of blood vessels. In 1960, Jules Jacobson described the use of the operating microscope for microvascular surgery. In the late 60’s, Harry Buncke developed the first micro-instruments, and small needles were swaged. Since then, very little has changed about microsurgery, in spite of increasing technical demands, including supermicrosurgery, perforator to perforator anastomosis and lymphatic anastomosis. The surgical robot affords super human levels of precision with high-fidelity, 3-dimensional magnification. This combination of attributes makes it exceedingly well suited for microsurgery. Robotic microsurgery combines the executive functions of the human mind with the precision of a machine. Specific advantages of the robotic platform for microsurgery include: 1) Superhuman precision - this comes in the form of 100% tremor elimination, and up to 5 to 1 motion scaling 2) Physician comfort – the ergonomics of microsurgery can be a challenge and the robot eliminates any physical discomfort or long-term sequel related to surgeon positioning 3) Reduction of physical constraint requirements – access to vessels can be a challenge and the ability to successfully perform an anastomosis requires wide exposure. The robot eliminates this need with long, thin, precise arms. Specific disadvantages include: 1) Lack of haptic feedback, 2) inferior optics as compared to the operating microscope and 3) instrumentation which is ill-suited to microsurgery. It is worth noting that all the advantages to robotic microsurgery are inherent to the field, while all of the disadvantages are platform-specific, and likely to be overcome in the near future.
Robotics muscle harvest
Free and pedicled muscle flaps have been in use by plastic surgeons for a variety of applications since World War I, and remain work horses in scalp, extremity, head, neck and breast reconstruction. Harvest of muscle flaps traditionally requires incisions that allow access to muscle origin, insertion and pedicle. Because some muscles such as the latissimus dorsi and rectus abdominis are large, incisions can be anywhere from 20 to 40 centimeters in length. These donor sites are conspicuously located on the abdomen and back, and are a source of morbidity in the form of cosmesis, seroma and hernia. Because of the desirability of minimally invasive harvest, endoscopic and laparoscopic techniques have been attempted, but have not achieved broad acceptance due to technical challenges related to exposure, retraction and lack of appropriately precise instrumentation. The robotic interface has supplied the necessary exposure and picture clarity through high resolution, three dimensional optics, and the necessary precision instrumentation through wristed motion at the instrument tips to accomplish both muscle and pedicle dissection. For this reason, robotic muscle harvest holds excellent promise in reducing donor site morbidity for these common reconstructive procedures. The author has designed and refined the technique to harvest the latissimus dorsi muscle. This approach involves a short axillary incision, two additional ports and insufflation. The entire muscle can be harvested and brought through the small incision, and has many uses as a free and pedicled flap, including partial breast reconstruction and implant coverage, as well as free flap applications. The rectus abdominis muscle can be harvested through three ports on the contralateral side of the muscle and uses an intraperitoneal approach. The muscle can then be used as a pedicled flap for abdominoperitoneal reconstruction and a free flap for scalp and extremity. Robotic harvest of both of these muscles is safe and effective, and has a significant role to play in the future of reconstructive surgery.
Lecture
5 years ago
165 views
4 likes
0 comments
17:18
Robotics muscle harvest
Free and pedicled muscle flaps have been in use by plastic surgeons for a variety of applications since World War I, and remain work horses in scalp, extremity, head, neck and breast reconstruction. Harvest of muscle flaps traditionally requires incisions that allow access to muscle origin, insertion and pedicle. Because some muscles such as the latissimus dorsi and rectus abdominis are large, incisions can be anywhere from 20 to 40 centimeters in length. These donor sites are conspicuously located on the abdomen and back, and are a source of morbidity in the form of cosmesis, seroma and hernia. Because of the desirability of minimally invasive harvest, endoscopic and laparoscopic techniques have been attempted, but have not achieved broad acceptance due to technical challenges related to exposure, retraction and lack of appropriately precise instrumentation. The robotic interface has supplied the necessary exposure and picture clarity through high resolution, three dimensional optics, and the necessary precision instrumentation through wristed motion at the instrument tips to accomplish both muscle and pedicle dissection. For this reason, robotic muscle harvest holds excellent promise in reducing donor site morbidity for these common reconstructive procedures. The author has designed and refined the technique to harvest the latissimus dorsi muscle. This approach involves a short axillary incision, two additional ports and insufflation. The entire muscle can be harvested and brought through the small incision, and has many uses as a free and pedicled flap, including partial breast reconstruction and implant coverage, as well as free flap applications. The rectus abdominis muscle can be harvested through three ports on the contralateral side of the muscle and uses an intraperitoneal approach. The muscle can then be used as a pedicled flap for abdominoperitoneal reconstruction and a free flap for scalp and extremity. Robotic harvest of both of these muscles is safe and effective, and has a significant role to play in the future of reconstructive surgery.
Transoral robotic surgery
Access to oropharyngeal tumors has traditionally been using a transmandibular, translabial approach. Unfortunately, mandibulotomies and large pharyngotomies can result in significant postoperative morbidity and functional compromise. Because of the morbidity involved in some of these more aggressive resections, and the proven efficacy of chemoradiation in the treatment of some oropharyngeal cancers, there has been a paradigm shift away from ablative surgery. As long-term follow-up on these “organ-sparing” protocols have begun to take shape, however, significant morbidity and mortality has emerged with these therapies as well. Trans-oral robotic resections and reconstructions can provide the benefits of locoregional control without the morbidity of wide pharyngeal access or high-dose radiation. It can also prevent the use of external facial incisions and morbidity related to division of the mandible including hardware complications such as fistula. In addition, it can reduce and occasionally eliminate the need for radiation and its associated problems such as osteoradionecrosis and a functionless larynx. Transoral robotic tumor resection provides a challenge to the plastic surgeon because the cylinder of the oropharynx remains closed, making access to the oropharyngeal anatomy very difficult, particularly between the uvula and the epiglottis. The surgical robot, when positioned transorally, can allow the reconstructive surgeon to inset a variety of free and local flaps to perform complex reconstructions in challenging areas and meet the reconstructive demands of transoral resections.
Lecture
5 years ago
224 views
9 likes
0 comments
17:18
Transoral robotic surgery
Access to oropharyngeal tumors has traditionally been using a transmandibular, translabial approach. Unfortunately, mandibulotomies and large pharyngotomies can result in significant postoperative morbidity and functional compromise. Because of the morbidity involved in some of these more aggressive resections, and the proven efficacy of chemoradiation in the treatment of some oropharyngeal cancers, there has been a paradigm shift away from ablative surgery. As long-term follow-up on these “organ-sparing” protocols have begun to take shape, however, significant morbidity and mortality has emerged with these therapies as well. Trans-oral robotic resections and reconstructions can provide the benefits of locoregional control without the morbidity of wide pharyngeal access or high-dose radiation. It can also prevent the use of external facial incisions and morbidity related to division of the mandible including hardware complications such as fistula. In addition, it can reduce and occasionally eliminate the need for radiation and its associated problems such as osteoradionecrosis and a functionless larynx. Transoral robotic tumor resection provides a challenge to the plastic surgeon because the cylinder of the oropharynx remains closed, making access to the oropharyngeal anatomy very difficult, particularly between the uvula and the epiglottis. The surgical robot, when positioned transorally, can allow the reconstructive surgeon to inset a variety of free and local flaps to perform complex reconstructions in challenging areas and meet the reconstructive demands of transoral resections.