Large vessels: what is the robot's place in vascular surgery?
Epublication WebSurg.com, Apr 2014;14(04). URL: http://websurg.com/doi/lt03enthaveau002
Since 2006, our vascular surgery team has developed an original program in the field of minimally invasive aortic surgery; for all cases of aortic disease unsuitable for endovascular treatment, we propose an alternative way to open surgery: using the da Vinci® surgical robotic system to perform aorto-aortic, aortobi-iliac and aorto-bifemoral bypasses, in more than 95 patients to date. Contrarily to laparoscopy, the robot provides operating conditions, namely more comfort with a 3D vision, and operative steps very similar to open surgery. These key points account for a learning curve that is shorter than laparoscopy for aortic procedures. For the first time in the literature, the robot was used by our team to perform the entire procedure including the retroperitoneal approach, aortic exposure, and the prosthetic suture. We respect TASC recommendations for revascularizations by aorto-bifemoral bypasses, and surgery is always decided upon after failure of endovascular treatment. For aneurysms, robotic surgery is proposed if the case is not suitable for endograft, and after informed patient consent. The new design of the operating room with the robot, the training of the surgical team, the original design of the technique with placement of robotic ports, explain a mean operative time exceeding 6 hours, and a conversion rate with mini-lumbotomy of 30% of our learning curve in the first 30 cases. Currently, we treat more than 20 patients per year, with an average operative time of less than 5 hours, and with only 5% of surgical conversions by mini-lumbotomies. The progression of technology now allows us to clamp the suprarenal aorta and to perform cases of aneurysms with tubes or bifurcated grafts if we need to go on the primitive iliac arteries. Our clinical results show a primary patency rate of 96% at the first year, 94% at the third year, and 86% at the fifth year. No postoperative death was related to the aortic pathology, the mortality rate was 96% at the first year, 83% at the third year, and 76% at the fifth year. In addition, new surgical indications provide the opportunity to use the da Vinci® robot to deal with complex arterial disease: our team was able to treat cases of splenic aneurysms, with direct arterial reconstructions, arterial sutures performed entirely with the robot. Our experience shows that arterial surgery for large vessels is entirely feasible with the da Vinci® robot. This opens valuable future perspectives, which will depend on the improvement of surgical robotic systems available.