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Brazil and India – A New Collaboration through Acta of Shoulder and Elbow Surgery

January 10, 2017/0 Comments/in Vol 2| Issue 1| Jan-June 2017 /by ASESADMIN2016

Author: Ashish Babhulkar [1].

[1]Deenanath Mangeshkar Hospital, Pune, India

Address of Correspondence
Dr. Ashish Babhulkar
Head of Dept. Shoulder & Sports Injuries
Deenanath Mangeshkar Hospital, Pune, India
Email:docshoulder@gmail.com

Felix Ano Novo & a Happy new year to all. The beginning of a new year 2017 – brings us fresh challenges. Shoulder surgery has evolved from multiple surgery options in the past for say – Shoulder dislocation – to just a couple of options between a Bankart or a Latarjet. This is surely a sign of maturity and one would assume, culmination of our search for questions and solutions.
That is as far from truth as Trump is from Obama. As we establish gold standards for Rotator cuff repair & Bankart repair, we are faced with more complex issues with irreparable cuff tears and mega glenoid bone loss. Similarly, a shoulder surgeon is faced with diverse options in treating irreparable cuff tears in symptomatic patients. Lat Dorsi transfers, Allografts, human dermal matrix graft, and now superior capsular reconstruction & ultimate “solution” of a Reverse shoulder arthroplasty are few of the alternatives. Each is no doubt an ingenious procedure but how does a surgeon discern the best and most appropriate procedure for a given patient & given age for that patient. What leads a Japanese surgeon and my friend Teruhisa Mihata to relentlessly pursue Superior capsule reconstruction1, over a reverse Shoulder Arthroplasty or Lat Dorsi Transfer?
For a minute, if we accept the most complex instability is glenoid bone loss – As a surgeon I am faced with the options of an Open Latarjet – Congruent arc Vs conventional Latarjet, Iliac crest bone graft and Open Vs ArthroLatarjet. With each procedure being impressively successful, it’s virtually impossible to pick the exact effective procedure. With success rates in excess of 88%, what dictates a procedures superiority over the other2?
It will statistically be impossible for any double blinded study without an immeasurable sample size, to choose between the best type of Latarjet. So, whilst we wait for time to unravel the answers for the long-term results of say Superior capsular reconstruction or Arthrolatarjet, we ought to research and publish even more.
Am afraid, I shall finish with more questions than answers. However, that is exactly the scientific probity that I beseech of you. That is exactly why ACTA of Shoulder & Elbow must provoke your intelligence and seek more research articles.
The challenge in fact is multifold. One, to achieve research on a massive sample size to show a 1% difference between different techniques of cuff repair & Bankart techniques that are already Gold standards. Second, to achieve any amount of sample size for rarely done procedures such as Superior capsule reconstruction & Lat dorsi transfer is a daunting task. Third & finally, to wait for a longitudinal study over 30 years to find out that a given procedure was inappropriate.
Brazil & India – the emerging world, face similar challenges. Insurance shortage, economic depravation and rural healthcare deficit are gripping problems that developing countries face. In the midst of these healthcare challenges, we have innovated, delivered top class cutting edge treatment and continue to grow at such a rapid pace that the industry is compelled to stop and pay attention to such emerging countries. Data collection, pursuit of research and compulsive publication of techniques and basic sciences is our fundamental need.
Unlike the adage, “Cannot teach an old dog new tricks”, all of us, as Shoulder surgeons, must learn new techniques & tricks, as the final word for these unsolved issues is still not written. Surgical Skill and medical research are both joined at the hip and cannot exist without the other.
As the popular saying in Hindi – – Diligence is the mother of good luck.

Ashish Babhulkar
Head of Dept. Shoulder & Sports Injuries
Deenanath Mangeshkar Hospital, Pune, India

References

1. Mihata Teruhisa, Thay Q. Lee, Ph.D., Chisato Watanabe, Kunimoto Fukunishi, Mutsumi Ohue, Tomoyuki Tsujimura, Mitsuo Kinoshita: Clinical Results of Arthroscopic Superior Capsule Reconstruction for Irreparable Rotator Cuff Tears.Arthroscopy , Volume 29 , Issue 3 , 459 – 470.
2. Allain J., Goutallier D., Glorian C. Long term results of the Latarjet procedure for the treatment of anterior instability of the shoulder. J Bone Joint Surg Am. 1998; 80: pp841-852.

How to Cite this article: Babhulkar A. Brazil and India – A New Collaboration through Acta of Shoulder and Elbow Surgery. Acta of Shoulder and Elbow Surgery Jan – June 2017;2(1):1-2.

Dr. Ashish Babhulkar

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

January 10, 2017/0 Comments/in Vol 2| Issue 1| Jan-June 2017 /by ASESADMIN2016

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.