**3.1 Median arcuate ligament release**

Median arcuate ligament syndrome (MALS) is caused by compression of the celiac artery and plexus by the median arcuate ligament of the diaphragmatic crura [60]. In a normal population, the median arcuate ligament crosses the aorta anteriorly above the celiac origin between levels T11 and L1. However, in approximately 12–49% of the population, an anatomic variant exists in which the ligament passes inferiorly, causing compression of the celiac artery and ganglion. The majority of patients with this anatomical variant are asymptomatic due to a rich network of collateral vessels between the celiac and superior mesenteric arteries. However, a number of patients do develop symptoms despite the presence of collateral arteries, frequently presenting with a variety of abdominal symptoms including nausea, vomiting, postprandial epigastric pain, and weight loss [61]. Over the years, several different interventions have been proposed for symptomatic MALS using different approaches such as open surgery, laparoscopic surgery, endovascular angioplasty, or hybrid procedures combining laparoscopic and endovascular techniques [60]. Surgical release of the extrinsic compression caused by the median arcuate ligament remains the mainstay of therapy, with overall success rates ranging from 53 to 79% and a majority of patients reporting rapid postoperative symptom relief [62].

In more recent years, the robotic approach has been gaining popularity due to its technical advantages over conventional laparoscopic surgery. In 2007, Jaik et al. were the first to report a robotic-assisted MALR [63]. Since then, several other case series have been published. In a case series of 13 patients, Khrucharoen et al. analysed outcomes symptomatic patients undergoing robotic-assisted MALR. The authors found that robotic-assisted MALR is safe and feasible in selected patients an may be associated with reduced operative times [61]. In a follow-up study by the same group, laparoscopic and robotic-assisted MALR were compared for short- and intermediate-term clinical outcomes. In their retrospective study, a total of 34 patients were included (16 laparoscopic and 18 robotic cases) for further analysis.

Complete pain resolution was achieved in 37.5% in the laparoscopic group and in 44.4% in the robotic group (p = 0.93). The data showed no difference between conversion rates to open surgery, symptom recurrence rates, postoperative pain, and overall clinical improvement. However, median operative time was significantly shorter in the robotic group compared to the open group (179.5 versus 106 minutes, p < 0.001). The authors concluded that both laparoscopic and robotic-assisted MALR offer similar short- and intermediate-term outcomes, with a possible shorter operative time achievable by a robotic-assisted approach [64]. In another recent retrospective study by Fernstrum et al., 27 patients that underwent robotic MALR were included for analysis. Long-term improvement or resolution of symptoms and symptom recurrence was used as primary outcome. Their data showed mean operative times of 95 minutes and two cases of conversion to open surgery. Only one major complication occurred, which was an inadvertent arteriotomy of the celiac trunk that occurred while dividing a portion of the diaphragmatic fibres. After more than 30 days follow-up, 68% of patients had full symptom relief and 4% had partial symptom resolution. Furthermore, 4% of patients had no symptom resolution and 24% had symptom recurrence after an initial period of symptom resolution. The authors concluded that robotic MALR is a safe option for treatment of MALS with high-response rates [65].

## **3.2 Vascular bypass surgery**

Aortoiliac occlusive disease (AIOD) can result in symptoms such as claudication and critical ischemia of the lower extremities. Generally, AIOD is treated by either endovascular or open surgery, depending on the severity and location of the occlusion. Whereas for extensive AIOD patients are generally treated using an open approach, endovascular approaches with covered stents have also been introduced with success using the 'covered endovascular reconstruction of aortic bifurcation (CERAB) technique [66]. The main disadvantage of endovascular repair are the high costs for the patient, insurance companies or hospitals [67]. An alternative for open surgery or endovascular therapy is a laparoscopic reconstruction [68]. A number of laparoscopic techniques for treating AIOD have been developed over the last few years with the aim of reducing operative trauma and achieving faster postoperative recovery rates. However, performing laparoscopic aortic surgery and vascular anastomoses is very challenging and requires intensive training [69]. More recently, robotic-assisted approaches have been developed in order to overcome these limitations of the conventional laparoscopic approach. In a retrospective case-series by Jongkind et al., a total of 28 patients that underwent robotic-assisted laparoscopic surgery (RALS) for AIOD were included. In this group, 24 patients received robotic-assisted laparoscopic aortobifemoral bypass grafting and 4 patients received an aortoiliac endarterectomy. Their results showed a median operative time of 350 minutes and median aortic clamping time of 70 minutes. In 4 patients, conversion to open surgery was necessary. One patient died within 30 days postoperatively and 4 patients had non-lethal complications. The authors concluded that RALS is a feasible and durable technique for treating patients with AIOD [70].

Other studies and case series have found similar clinical outcomes and complication rates. In another relatively recent retrospective study, 310 patients that underwent robotic-assisted vascular surgery were included for analysis. In this patient population, 224 patients underwent robotic-assisted surgery for treatment of occlusive disease, which included robotic ilio-femoral bypass, aorto-femoral bypass, and aorto-iliac thromboendarterectomy with prosthetic patch. Median clamping time and anastomosis times were 37 and 24 minutes, respectively. Mean total operative time was 194 minutes. In 2 cases (0.9%), a conversion to open

**67**

case series [73].

**4. Costs of robotic surgery**

*Robotic Surgery for the Thoracic and Vascular Surgeon DOI: http://dx.doi.org/10.5772/intechopen.97598*

**3.3 Aortic aneurysm surgery**

for several types of aortic aneurysm repairs.

surgery was necessary. Lastly, median hospital LOS was 5 days. The authors concluded that the greatest advantage of these robotic-assisted procedures was the speed and relative ease with which vascular anastomoses could be performed [9]. This offers significant benefits regarding temporary lower limb ischemia times during aortic clamping. Despite the lack of large-scale clinical studies, the currently available data suggests that robotic-assisted approaches can play a significant role in treating arterial occlusive disease. These robotic approaches can even be combined with endovascular or open approaches into hybrid procedures, thus making it a

One of the greatest paradigm shifts towards MIS in the last decade has taken place in the field to the of aortic aneurysm surgery. With the introduction of endovascular approaches, the number of open aneurysm repairs has decreased dramatically, having steadily been replaced by endovascular aneurysm repair (EVAR) [71, 72]. Nevertheless, for patients that do not qualify for endovascular repair or with complications following endovascular repair, surgical repair of the aneurysm is often necessary. For this subset of patients, a minimal invasive approach may be an appealing alternative to the conventional open repair. Although laparoscopic techniques have been described for aortic aneurysm repair, this approach remains somewhat unappealing to many surgeons due to the steep learning curve [71]. Another possibility is the robotic-assisted approach for aneurysm repair, which is able to overcome the kinematics limitations of laparoscopy. Previous retrospective studies and case series have already shown the feasibility of the robotic approach

In a study by Stádler et al., 65 patients that underwent robotic-assisted aortoiliac aneurysm surgery were included in a retrospective analysis of outcomes after robotic-assisted vascular procedures. Median operative time and aortic cross clamping time were 253 and 93 minutes, respectively. Overall mortality was 1.6%, median conversion rate was 13%, and no major non-lethal postoperative complications were noted. Furthermore, median hospital LOS was 7 days. The results regarding operative times and outcomes are similar to the conventional open repair technique, with the added benefits of MIS [9]. In addition to this, robotic-assisted surgery could also have a specific role in type-II endoleaks, the most frequent complication after EVAR. Currently these types of leaks are treated with surgical ligation or endovascular embolization, the latter being the first-line treatment option. However, endovascular embolizations of endoleaks has high recurrence rates. With the robotic approach, these endoleaks can be repaired more easily than with a laparoscopic approach, while simultaneously providing a more definitive solution for the endoleak. Morelli et al. showed that this technique is feasible in their recent

Despite the increasing popularity of robotic-assisted approaches worldwide, concerns have been raised regarding the high costs of acquiring and maintaining robotic systems [16]. In addition, stapling devices in robotic surgery often come at a high price, necessitating many centres to use standard manual or electronic stapling devices by the table surgeon instead of the console surgeon. Several studies have attempted to perform cost-analysis studies of robotic surgery compared to open and laparoscopic/thoracoscopic approaches. However, there are often significant

versatile and potentially useful tool for the modern vascular surgeon.

surgery was necessary. Lastly, median hospital LOS was 5 days. The authors concluded that the greatest advantage of these robotic-assisted procedures was the speed and relative ease with which vascular anastomoses could be performed [9]. This offers significant benefits regarding temporary lower limb ischemia times during aortic clamping. Despite the lack of large-scale clinical studies, the currently available data suggests that robotic-assisted approaches can play a significant role in treating arterial occlusive disease. These robotic approaches can even be combined with endovascular or open approaches into hybrid procedures, thus making it a versatile and potentially useful tool for the modern vascular surgeon.
