brachial plexus surgery using the da vinci surgical robot is a new procedure . to evaluate the advantages and the restrictions of the technique , a cadaveric study of supraclavicular and axillary approaches was conducted .
we found that the axillary approach was useful and advantageous for lower roots , particularly for thoracic outlet syndrome ( tos ) .
this report will focus on the evaluation of axillary robotic approach as the advantages and disadvantages of supraclavicular robotic intervention have been widely discussed in the literature .
a human cadaver was subjected to this experiment in paris university ecole europenne de chirurgie anatomy laboratory and da vinci robot system was used .
the left arm was tucked along the side and the right arm was placed in a semiflexed position extending toward the anesthesia location near the head , supported by foam and blankets ( figure 1 ) .
a 6  cm long incision was made at the right axillar line , lateral to the edge of the pectoralis major muscle ( figure 2 ) .
a self - retaining chung retractor was placed into the incision to elevate the pectoralis major muscle flap .
the robot was docked as a camera ; right and left robotic arm were adapted in the incision area ( figure 3 ) . a 10  mm 0 downlooking scope , maryland forceps , and a curved scissors
the working space was maintained with the self - retaining retractor , without co2 insufflation ( figure 4 ) .
the subclavian artery was seen in front of the truncus and was positioned to the posterior of the working space .
subclavian artery was dissected from the plexus and truncus of the lower plexus was exposed with blunt dissection .
the plexus was exposed thoroughly from t1 to c7 levels . in this surgical setting , the operating surgeon , who has
a wide experience in open brachial surgery of the brachial plexus , reported that lower brachial plexus exposure was easier from the axillary working area and a more wide range of motion was achieved to manipulate the robotic tools compared to the supraclavicular exposure for lower part of the brachial plexus .
the development of robotic - assisted minimally invasive techniques began in urology , general surgery , and gynecology because of the generally large working spaces available in the abdomen for these types of surgeries [ 14 ] .
since then , other surgeons have sought to use robotic devices in other areas , such as the brachial plexus [ 5 , 6 ] .
brachial plexus dysfunction can be the result of shoulder trauma [ 7 , 8 ] .
it can also occur with tos , which encompasses three separate disorders involving compression of the subclavian artery , subclavian vein , or brachial plexus in the triangular space bordered by the first rib , clavicle , and scalene muscles [ 9 , 10 ] .
compression of the vessel - nerve package at the thoracic inlet has been treated with soft - tissue ( scalene muscle ) release and/or bone ( first rib ) resection .
surgical approaches to first rib resection may be transthoracic , transaxillary , supraclavicular , infraclavicular , or thoracoscopic [ 9 , 10 ] . however , these approaches are typically associated with incomplete resection of the most medial portion of the first rib and neurovascular complications .
theoretically , a minimally invasive transthoracic approach can obviate these problems , enabling complete resection of the offending portion of the first rib without neurovascular complication .
, respectively , reported successful results of robotic en bloc first rib resection for tos treatment via transthoracic and transaxillary approaches [ 9 , 11 ] .
's techniques were only bony interventions and as being intrathoracic these need to be lung collapsed and lung complication can be waiting risk .
although liverneaux et al . reported techniques and results of upper brachial plexus injury intervention via robotic surgery with a supraclavicular approach , they described the disadvantages as a narrow working space and difficulty to expose the c7 vertebra [ 1 , 5 , 12 ] . to our knowledge , this report is the first to objectively describe robotic axillar brachial plexus exposure .
thus , we discuss the theoretical and clinical advantages and disadvantages of the axillary approach in the present report .
the development of robot - assisted surgery has revealed new perspectives in peripheral nerve microsurgery . minimally invasive
robot - assisted surgery could lead to modification of the classic algorithm for the treatment of traumatic brachial plexus lesions [ 6 , 8 ] . to date , exploration of these lesions has not been attempted less than 3 months after the traumatic event because clinical examination can not provide an accurate diagnosis or reliable prognosis in these first weeks .
early intervention may enable initial assessment of the lesion and repair of potentially graftable nerve roots .
several robotics properties are particularly adapted to microsurgery , such as high - resolution three - dimensional ( 3d ) visualization with up to 40 magnification , up to 10-fold magnification of surgical movements , elimination of physiological tremors , and the provision of ergonomic work conditions for otherwise uncomfortable surgery .
robotic surgical systems allow high - definition magnified 3d visualization of the operative field , provide significant instrument maneuverability , even within a confined space , and may overcome the shortcomings of conventional approaches [ 2 , 5 ] .
axillary ( infraclavicular ) brachial plexus intervention via robotic surgery has not been described previously .
axillary intervention was previously performed as an open procedure to expose the plexus or resect the first rib for the treatment of tos .
martinez et al . described first rib resection via robotic surgery but not to address plexus injury without transthoracic exposure , a novel minimally invasive approach to the first rib from inside of the chest .
in addition , gharagozloo et al . reported first rib resection via transthoracic robotic surgery for paget - schroetter disease .
's techniques were considered more useful for lower brachial plexus viewing and assessing according to gharagozloo et al .
the experience of the whole surgical team with robotic technology is important for the procedure . during learning curve period ,
two staff surgeons are required to participate in all procedures to ensure the safety of the program [ 5 , 9 ] .
martinez et al . reported importance of the learning curve , not only for the surgeon but also for the entire surgical team and 180 minutes for the initial 10 cases .
reported exclusion criteria include a history of previous incision in the same area and obesity , which present difficulties in robotic surgery initiation .
other drawbacks of this new surgical approach are the increased cost of surgical equipment and longer operating time , especially during the learning curve period .
however , we believe that the avoidance of a classic incision leads to significant patient satisfaction for cosmetic reasons and we believe that demand for this procedure from a select group of patients justifies the exploration of alternative ways to avoid classic brachial plexus exposure .
this report presents our initial experience with robot - assisted axillary exposure of the brachial plexus region . in our opinion
robotic surgery will be used routinely in the future for brachial plexus surgery and particularly for tos that is caused by bone and/or soft tissue . however , newer dedicated surgical instruments need to be developed and further studies should be conducted to evaluate in vivo application and results of this novel approach .
 brachial plexus surgery using the da vinci surgical robot is a new procedure . 
 although the supraclavicular approach is a well known described and used procedure for robotic surgery , axillary approach was unknown for brachial plexus surgery . 
 a cadaveric study was planned to evaluate the robotic axillary approach for brachial plexus surgery . 
 our results showed that robotic surgery is a very useful method and should be used routinely for brachial plexus surgery and particularly for thoracic outlet syndrome . 
 however , we emphasize that new instruments should be designed and further studies are needed to evaluate in vivo results . 
1. Introduction
2. Discussion
3. Conclusion