**2.3 First rib resection**

Thoracic outlet syndrome (TOS) is a complex disorder that comprises a myriad of possible symptoms which arise from compression of the brachial plexus, subclavian artery, and/or the subclavian vein. This compression generally occurs in the triangular space referred to as the thoracic outlet, which is located between the first rib, the clavicle, and the scalene muscles [42]. The majority of patients with TOS can be treated with non-surgical measures such as medication, posture correction, physical therapy, or taping. However, in a relatively small number of patients, these conservative treatments fail to alleviate the symptoms, often resulting in significant morbidity [43]. In these patients, or when vascular structures are involved, surgical decompression with removal of the first rib is usually necessary. Over the last decades, several types of surgical approaches and techniques have been described. Historically, extrathoracic approaches have used a supraclavicular or transaxillary incision to resect the first rib. Despite their well-documented effectiveness, many authors have asserted that these approaches are regularly associated with complications such as brachial plexus injury or vascular injury [44].

The intrathoracic approach using VATS has been the most popular approach in the last decade, owing to the theoretical advantage of fewer postoperative neurovascular complications and incomplete resections [45]. In recent years, the roboticassisted approach has rapidly gained ground as a viable alternative to VATS due to its superior optics and instrument control [44]. However, this remains a relatively new field with only a limited number of studies published reporting outcomes of RATS first rib resections. Data from retrospective studies and case series from the last decade suggests that the robotic approach is safe, effective, and non-inferior to the VATS approach [46]. In a recent single-center, prospective study by Burt et al. RATS first rib resection was compared to the conventional supraclavicular approach in 116 patients (66 RATS and 50 open surgery). Postoperative pain and analgesia need was significantly lower in the robotic approach group. Furthermore, RATS was associated with fewer cases of brachial plexus palsy and overall complication

rates [47]. Despite these promising results, there is still a lack of data from larger, prospective studies comparing RATS, VATS, and open approaches for first rib resections.

### **2.4 Sympathectomy**

Presently, hyperhidrosis is the main indication for sympathectomy, which can be performed through various surgical approaches, such as the posterior thoracic approach, transaxillary approach, transthoracic approach, VATS approach, and RATS approach. The sympathectomy itself is usually performed by ganglionectomy, clipping, or ablation of the dorsal sympathetic chain [48]. The extent to which the sympathectomy is performed is a controversial subject as it is correlated to the incidence of complications. More extended sympathectomy has been associated with higher rates of compensatory hyperhidrosis. Despite a lack of clear guidelines, the general consensus is to perform an interruption of T3 and T4 for palmar hyperhidrosis, and interruption of T4 and T5 palmar and axillary or palmar, axillary, and pedal hyperhidrosis [49].

A more precise variation of this technique is the selective postganglionic sympathectomy, which involves an interruption of only the postganglionic rami, leaving the sympathetic trunk and ganglia intact. The branches accompanying intercostal nerves 2–4 to the upper extremities are interrupted selectively [50]. Previous studies have shown that this technique of selective postganglionic sympathectomy has success rates up to 95% with only minimal rates of compensatory hyperhidrosis [51]. Only limited data is available regarding robotic selective sympathectomy. However, data from single-institution case series have shown that robotic-assisted selective (postganglionic) sympathectomy is a safe technique with favourable results [52, 53]. In a recent prospective case series by Gharagozloo et al., a total of 47 patients underwent two-staged bilateral robotic selective dorsal preganglionic and postganglionic sympathectomy. Their data showed excellent relief of hyperhidrosis, and minimal rates of compensatory hyperhidrosis and complications. The authors used a two-staged approach to allow the transient compensatory hyperhidrosis to dissipate and to obviate postoperative thoracic pain due to the use of robotic ports [48]. Despite a lack of larger prospective and randomised trials, the current evidence suggests that the robotic-assisted approach has the potential of accomplishing hyperselective sympathectomy with accuracy and minimal rates of compensatory hyperhidrosis and complications such as Horner's syndrome.

## **2.5 Diaphragmatic plication**

Diaphragmatic paralysis is an uncommon condition that is characterised by elevation of a hemidiaphragm. If symptomatic, patients often experience dyspnoea during exercise, orthopnoea, fatigue, insomnia, and an overall reduced quality of life. In adult patients, the most common causes of diaphragmatic paralysis are idiopathic, tumour invasion of the phrenic nerve, or damage to the phrenic nerve during cardiothoracic surgery [54]. Surgical treatment is indicated exclusively for symptomatic patients, and the preferred surgical technique is (hemi)diaphragmatic plication [55]. The traditional method is the open transthoracic plication, and is still widely used today. However, an increasing number of surgeons are moving towards less invasive approaches such as laparoscopy or thoracoscopy. VATS diaphragm plication has already demonstrated to be a safe and feasible technique for symptomatic patients [56, 57]. However, technical difficulties due to the limited workspace in the thorax and the elevated hemidiaphragm often lead to the adoption of a (mini)thoracotomy. Robotic-assisted surgery offers all the benefits of MIS while

**65**

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

**3. Robotic-assisted vascular surgery**

and outcomes of robotic-assisted vascular surgery.

**3.1 Median arcuate ligament release**

sive data regarding long-term outcomes are still missing.

simultaneously providing the surgeon the same dexterity as the open approach. Several case studies and small case-series have reported excellent outcomes with the robotic approach for diaphragmatic plication [58, 59]. However, robust and conclu-

In the last few decades, the field of vascular surgery has changed dramatically with the introduction of endovascular surgery. There has been a significant paradigm shift towards these endovascular approaches for the treatment of a wide array of venous and arterial diseases [8]. However, despite the fact that many vascular surgeons have been willing to embrace innovative, minimally-invasive techniques, the implementation of laparoscopic vascular surgery has only been a relatively minor success. This has mainly been due to the difficulties associated with laparoscopic vascular surgery such as the suturing of vascular anastomoses and long clamping times [9]. Furthermore, for an increasingly large number of procedures, an endovascular technique has been developed. However, with the advent of robotic-assisted approaches, new opportunities have risen for vascular surgeons, especially for disease states that are not amenable to endovascular interventions and for which current approaches are technically challenging or associated with significant morbidity. In this section, we will discuss the latest data regarding indications

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.

*Latest Developments in Medical Robotics Systems*

resections.

**2.4 Sympathectomy**

pedal hyperhidrosis [49].

**2.5 Diaphragmatic plication**

rates [47]. Despite these promising results, there is still a lack of data from larger, prospective studies comparing RATS, VATS, and open approaches for first rib

Presently, hyperhidrosis is the main indication for sympathectomy, which can be performed through various surgical approaches, such as the posterior thoracic approach, transaxillary approach, transthoracic approach, VATS approach, and RATS approach. The sympathectomy itself is usually performed by ganglionectomy, clipping, or ablation of the dorsal sympathetic chain [48]. The extent to which the sympathectomy is performed is a controversial subject as it is correlated to the incidence of complications. More extended sympathectomy has been associated with higher rates of compensatory hyperhidrosis. Despite a lack of clear guidelines, the general consensus is to perform an interruption of T3 and T4 for palmar hyperhidrosis, and interruption of T4 and T5 palmar and axillary or palmar, axillary, and

A more precise variation of this technique is the selective postganglionic sympathectomy, which involves an interruption of only the postganglionic rami, leaving the sympathetic trunk and ganglia intact. The branches accompanying intercostal nerves 2–4 to the upper extremities are interrupted selectively [50]. Previous studies have shown that this technique of selective postganglionic sympathectomy has success rates up to 95% with only minimal rates of compensatory hyperhidrosis [51]. Only limited data is available regarding robotic selective sympathectomy. However, data from single-institution case series have shown that robotic-assisted selective (postganglionic) sympathectomy is a safe technique with favourable results [52, 53]. In a recent prospective case series by Gharagozloo et al., a total of 47 patients underwent two-staged bilateral robotic selective dorsal preganglionic and postganglionic sympathectomy. Their data showed excellent relief of hyperhidrosis, and minimal rates of compensatory hyperhidrosis and complications. The authors used a two-staged approach to allow the transient compensatory hyperhidrosis to dissipate and to obviate postoperative thoracic pain due to the use of robotic ports [48]. Despite a lack of larger prospective and randomised trials, the current evidence suggests that the robotic-assisted approach has the potential of accomplishing hyperselective sympathectomy with accuracy and minimal rates of compensatory

hyperhidrosis and complications such as Horner's syndrome.

Diaphragmatic paralysis is an uncommon condition that is characterised by elevation of a hemidiaphragm. If symptomatic, patients often experience dyspnoea during exercise, orthopnoea, fatigue, insomnia, and an overall reduced quality of life. In adult patients, the most common causes of diaphragmatic paralysis are idiopathic, tumour invasion of the phrenic nerve, or damage to the phrenic nerve during cardiothoracic surgery [54]. Surgical treatment is indicated exclusively for symptomatic patients, and the preferred surgical technique is (hemi)diaphragmatic plication [55]. The traditional method is the open transthoracic plication, and is still widely used today. However, an increasing number of surgeons are moving towards less invasive approaches such as laparoscopy or thoracoscopy. VATS diaphragm plication has already demonstrated to be a safe and feasible technique for symptomatic patients [56, 57]. However, technical difficulties due to the limited workspace in the thorax and the elevated hemidiaphragm often lead to the adoption of a (mini)thoracotomy. Robotic-assisted surgery offers all the benefits of MIS while

**64**

simultaneously providing the surgeon the same dexterity as the open approach. Several case studies and small case-series have reported excellent outcomes with the robotic approach for diaphragmatic plication [58, 59]. However, robust and conclusive data regarding long-term outcomes are still missing.
