Posterior Endoscopy of the Shoulder with the Aid of the Da Vinci Si Robot – A Cadaveric Feasibility Study

Acta of Shoulder and Elbow Surgery | Volume 2| Issue 1 | Jan-Jun 2017 | Page 36-39| Bijayendra Singh, N Bakti

Authors: Bijayendra Singh [1], N Bakti [1]

[1]Medway NHS Foundation Trust, Visiting Professor Canterbury Christchurch University.

Address of Correspondence
Prof. Bijayendra Singh,
Consultant Orthopaedic Surgeon,
Medway NHS Foundation Trust, Visiting Professor Canterbury Christchurch University, Medway, KENT
Emial:- bijayendrasingh@gmail.com

Abstract

Introduction: The objective of this study is to present a cadaveric study with new possibilities of using the surgical robot in the daily practice of the shoulder surgeon, verifying which structures can be better visualized and manipulated at the posterior side of the shoulder.
Material and methods: Two fresh cadaver shoulders were used. The positioning of the shoulder was as like in a prone decubitus, with an arm in a position similar to that of elevation at 900. An incision was made in the skin on the trapezius muscle, palpated about 2cm from the axilla. Another 2 incisions were made more cephalic, one medial and one lateral in the arm next to the axilla forming a triangle. Through these 3 portals, tweezers were introduced for dissection and access to the muscle fascia. A cavity is created, since there are no natural cavities in this space. A trocar is introduced into each of the incisions, into the cavity formed. In the first portal on the trapezius muscle was introduced the camera of the robot Da Vinci SI, 8mm with optics of 00, and in the lateral and medial portals were placed the robotic working instruments.
Carbon dioxide was inflated at a constant 8mm Hg pressure through the chamber portal into the working cavity, stretching the soft tissues and opening the cavity. The work arms used the Maryland and De Bakey type dissecting tweezers and scissors, dissecting the lateral border of the latissimus dorsi muscle until its insertion, triangular interval, radial nerve, quadrangular space, and axillary nerve.
Conclusion: In this study the visualization of the desired structures was possible, without neurovascular lesions, suggesting that the use of robotic endoscopy may be a viable option for visualization of the quadrangular space and axillary nerve, as well as the radial nerve and the latissimus dorsi tendon.

Introduction

Robotic surgery has been earning space and expanding its possibilities of use in the last years, it has been used for a long time [1, 2, 3], and is already present as routine in daily medical practice in several surgical specialties to treat many pathologies [4,5]. Within orthopedics, we highlight the use of robotics in microsurgery [6,7] and surgery of the shoulder and elbow [8, 9, 10].
The possibility of associating the robotic technology with endoscopy further increases the challenge and the possibility of less invasive treatment, allowing a faster recovery for the patient, consequently shorter time of hospitalization and less absence in work [11].
Advantages of this method include movement accuracy, high resolution imaging with three-dimensional vision, gas infusion rather than saline solution (better visualization), filtering of the surgeon’s tremor when manipulating objects, movement scaling and hand-free camera manipulation [12, 13, 14, 15]. In addition, there is the possibility of remote surgery (telesurgery) where the surgical team can treat a patient far away1, 2 or a surgical team may be composed of professionals located in different cities or countries, treating the same patient simultaneously.
Some shoulder pathologies that need to be surgically treated by the posterior side of the shoulder may need aggressive and traumatic exposure with extensive manipulation of soft tissues. The possibility to use a minimal invasive approach can potentially be important for both the time of rehabilitation and avoiding local soft tissue adhesions. In Addition, when performing a large posterior open approach, one needs the use of tensioned retractors in order to keep the surgeon’s field in a suitable manner. The use of these tensioned retractors can eventually damage the deeper muscle layer as well as other neurovascular structures [16, 17, 18, 19, 20].
The minimally invasive procedures have demonstrated decrease of adhesions, avoiding reoperations and physical therapies during long times. Indeed, this advantage mentioned above make these procedures cost-effectives [11].
Some examples of minimally invasive shoulder surgery, are the arthroscopy and endoscopy of the extra-articular anterior region of the shoulder are already been used for manipulation of the coracoid process for the arthroscopic Bristow-Latarjet procedure [21,22] and manipulation of the long head of the biceps tendon after its exit from the rotator interval, as for biceps tenodesis.
This study is following a tendency for less invasive approaches, once there are not many minimally invasive procedures publications for most of the posterior structures and pathologies of the shoulder.
In shoulder surgery, the use of robotic-assisted surgery for better identification of the quadrangular space of the shoulder, identification of the axillary and radial nerves, and better identification of the latissimus dorsi muscle has not yet been proposed. This would make it possible to perform procedures such as the release of compressive syndromes of the axillary and radial nerves and for make possible, muscular transfers, focusing the latissimus dorsi muscle.
The objective of this study is to evaluate the feasibility of this method for the practical and daily use in the posterior space of the shoulder, verifying which structures can be better visualized and manipulated.
This study aims to provide data that will allow the treatment of many pathologies such as Quadrangular space syndrome, radial nerve compressive neuropathies, and manipulation of the Latissimus Dorsi tendon by using this new technology.

Material and Methods

Two fresh cadaver shoulders were used for the study, and in both anatomical pieces, the same procedure was followed: the shoulder was positioned as if in a ventral decubitus, the arm being maintained in a position similar to 900 elevation.
An incision was made in the skin, about 1 centimeter, in the lateral border of the trapezius muscle, palpated about 2-3cm from the axilla. Two other incisions were made more cephalic, one medial and one lateral in the arm near the axilla forming a triangle (Fig. 1). Through these 3 portals, tweezers were introduced to access the muscular fascia where a cavity was formed through blunt dissection. This space was made for triangulation as an initial working cavity, once there are no natural cavities in this space.

A trocar and a canula were introduced into each of the incisions, in a common direction in the cavity formed. In the first portal on the trapezius, the camera of the Da Vinci SI robot (Intuitive Surgical, Sunnyvale, CA, USA), with an optic of 00, is introduced.
Carbon dioxide was inflated at a constant 8mm Hg pressure through the chamber portal into the working cavity, stretching the soft tissues and opening the cavity. The work arms used Maryland Bipolar Forceps 8mm (Intuitive Surgical, Sunnyvale, CA, USA), DeBakey Forceps 8mm (Intuitive Surgical, Sunnyvale, CA, USA) and Hot ShearsTM Monopolar Curved Scissor 8mm (Intuitive Surgical, Sunnyvale, CA, USA).
The first objective was to clean the area around the camera so that we could initiate the best dissection and identification of the initial working cavity. After this first stage, we began the search for the superior border of the latissimus dorsi muscle. Once it was found we dissected its superior border laterally, until its entrance deep into the medial border of the long head of the triceps and looking to the lateral border of the lateral head of the triceps, it is possible to visualize the triangular interval, between the teres major muscle/Latissimus Dorsi(cephalic), the long head of the triceps (medially) and lateral head of the triceps originating in the humerus (laterally). In this muscular interval it was possible to visualize the radial nerve (Fig. 2).

Continuing the dissection laterally in direction to the axilla, and deep into the deltoid muscle, and in the cephalic direction and superficially to the tendon of the teres major muscle, to its upper border, the quadrangular space was visualized, between the teres major muscle (caudal), teres minor (cephalic), long head of the triceps muscle (medially) and the humerus (laterally). In this space the axillary nerve could be visualized and identified in its path from anterior to posterior (Fig. 3).

Returning to the upper border of the latissimus dorsi muscle, a point taken as the initial reference for the identification of the triangular interval, it was possible to follow its superior border laterally, and deeply to the long head of the triceps, until the insertion in the medial and antero-medial region in the diaphysis of the Humerus (at this time associating the internal rotation movement of the humerus, to make easily the visualization of its insertional region in the humerus.
All structures visualized and described above: limits of quadrangular space and triangular interval, axillary nerve, radial nerve were identified. After the robotic procedures an open approach was performed to confirm that there was no lesion of any structure (as tendons, vessels or nerves).

Results

As a result of this study, a successful visualization and manipulation of all target structures was obtained.
The study showed that it is possible to perform the procedures minimally invasively in the posterior region of the shoulder, with the help of the DaVinci robot (Intuitive Surgical, Sunnyvale, CA, USA)
There were no muscular or neurovascular lesions identified in this study.

Discussion

The visualization of the desired structures was achieved, and after dissection and detailed identification of the structures it was confirmed that all structures described did not present visually identifiable lesions, which adds reproducibility to the method, although the postoperative functional evaluation is not possible in an anatomical model.
There are few similar studies in the area of ​​orthopedics, especially in shoulder and elbow surgery using the aid of robotics, a practice already more widespread in other surgical areas, but which have been gaining space and recent publications23, 24, 25.
The described neurovascular structures were identified in this study, in the similarly as that they were comparatively identified in other studies in the literature10, 23, 24, 25.
The visualization and partial manipulation of the latissimus dorsi muscle has already been reported, in order to aid the transportation of the muscular pedicle, with technique that was used as reference for our study25.
Axillary nerve identification has also been described6, 7, 10, making a contribution to our study and confirms the viability of the method.
The reproducibility of the method described here may aid in performing procedures for shoulder muscle transfers using robotic assistance.
Regarding bleeding, studies in live patients have shown that the air insufflation have been effective on avoiding bleeding9.
We hope to encourage further studies in the area, both in improve identification of anatomical structures and performance of procedures in anatomical models (cadavers), as well as the clinical applicability in the treatment of pathologies in the posterior region of the shoulder.

Conclusion

In this study the visualization of the desired structures was possible, without neurovascular lesions, suggesting that the use of robotic endoscopy may be a viable, safe and non-invasive option for visualization of the quadrangular space, axillary nerve, radial nerve and the dorsal muscle tendon.

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