Novel Axillary Approach for Brachial Plexus in Robotic Surgery: A Cadaveric Experiment

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 Brachial plexus surgery using the da Vinci surgical robot is a new procedure [1]. 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. 1.1. Surgical Procedure A human cadaver was subjected to this experiment in Paris University Ecole Europèenne de Chirurgie anatomy laboratory and da Vinci robot system was used. The cadaver was placed supine on the operating table. 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). Blunt dissection was performed to create the working space area. 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 00 downlooking scope, Maryland forceps, and a curved scissors were introduced through the incision. The working space was maintained with the self-retaining retractor, without CO2 insufflation (Figure 4). First rib was found; C8-T1 and lower truncus were identified. Figure 1: The picture showing setup position of the cadaver. Figure 2: The picture showing the incision. Figure 3: The picture showing the setup position of the robot. Figure 4: The picture showing the anatomical exposure of the lower part of the brachial plexus. A-lower truncal level, B-subclavian artery,