A novel technique combining laparoscopic and endovascular approaches using image fusion guidance for anterior embolization of type II endoleak

Robotics and Digital Surgery. Toward a Uniquely Differentiated Specialty

Digital surgery is a composite term whereby computing power underpins the procedure and the operating environment. It includes advanced visualization, enhanced instrumentation, data capture, data analytics with artificial intelligence/machine learning, connectivity via telepresence, and robotic surgical platforms1, 2. This represents a powerful tool which will incrementally increase efficiency and accuracy, with the possibility of remote intervention3, 4, 5. Robotic surgery is the epitome of digital surgery including many of the elements described above. Every movement represents a mathematical formulation. All robotic movements can be recorded, reviewed, and used to train the next generation algorithms. Ultimately, there is the vision of autonomous, image guided robotic movement6. While we as vascular surgeons have embraced the power of imaging and image integration into our procedures and begun the exploration of endovascular robotics7-11, other subspecialties have exploded in their use of surgical robots. In this address, I will present our re-evaluation of surgical robotics, discuss our fledgling efforts to incorporate endovascular skills and open techniques in parallel with a surgical robotic platform, and emphasize how we can create a uniquely differentiated vascular specialty.

Technical details and preliminary results of a full robotic type II endoleak treatment with the da Vinci Xi

Type II endoleak (T2E) represents a frequent and often challenging complication of endovascular aneurysm repair (EVAR). Endovascular treatment is the standard and most used strategy, but the recurrence after it remains high, especially due to lumbar arteries (LA) and inferior mesenteric artery (IMA) feeding. While conventional laparoscopy has been considered as an emerging method, robotic surgery is not reported yet for this indication. We herein describe our technique of minimally invasive T2E repair using a full robotic approach with the da Vinci Xi, reporting our preliminary experience with the first two patients who underwent this operation at our Institution. The procedure comprises two phases. The first phase consists of IMA ligation, left colon mobilization and infra-renal exposure of the anterior longitudinal ligament of the column and of the left side of the sac. The second phase entails the posterior aneurysm mobilization and the selective clipping of LA responsible of the T2E, as identified by the pre-operative CT scan. No intra-operative complications occurred and the average length of surgery was 183 min. The average length of hospitalization was 2.5 days. Robotic T2E repair can be considered a safe procedure and the da Vinci Xi, thanks to its increased dexterity and flexibility, allows to easily perform this multi-target operation (IMA and LA). The articulated instruments with motion scaling and tremor filtering facilitate a gently vascular dissection and an easy IMA and LA identification, dissection, and ligation. The TilePro function permits the operator to control from the console, with intra-operative color-Doppler ultrasound, the absence of residual endoleaks.