140 - The da Vinci Robotic Surgical Assisted Anterior Lumbar Interbody Fusio...

#140 The da Vinci Robotic Surgical Assisted Anterior Lumbar Interbody Fusion: Technical Development and Case Report

MIS Techniques and Outcomes

Poster Presented by: J. Brooks

Author(s):

W.C. Peppelman, D.O. (1)
W. Beutler, M.D. (1)
J. Brooks (1)

(1) Pennsylvania Spine Institute, Harrisburg, PA, USA

Abstract

Purpose: Anterior lumbar interbody fusion is a common procedure that has evolved with significant improvement in surgical technique in recent years. Modern stand-alone interbody construct systems offer excellent maintenance of disc space height with high probability of radiographic and clinical success in carefully selected surgical patients. However, ALIF requires manipulation and retraction of intraperitoneal and retroperitoneal structures with associated possibility of surgical morbidity. The evolution of general surgery techniques for intraperitoneal procedures has firmly established the benefit of laparoscopy over open exposure for many indications. The expected advantages of robot assisted ALIF would be similar to that described in the general surgical, urologic, and gynecologic experience which establish decreased hospitalization time, lower morbidity, lower blood loss, and lower complication rate associated with the use of the robot. The rationale for robotic dissection includes 3-dimensional imaging and improved surgical dexterity from motion scaling and tremor filtering. Technique development to utilize the da Vince Robotic Surgical System for Anterior Lumbar Interbody Fusion at L5-S1 is detailed. This report describes the development of the technique beyond the porcine model to that of clinical use. A case report is also presented.

Methods: The surgical techniques for approach to the anterior lumbar spine utilizing the da Vinci robot were developed and modified progressively beginning with operative models followed by placement of an interbody fusion cage in the living porcine model. The most important problem overall was how to maintain pneumoperitoneum during the discectomy and the utilization of the instrumentation required to place the interbody cage. Development continued with placement of fusion cage in a human cadaver, completed first in the laboratory setting, then in the operating room. Finally, the first patient with fusion completed utilizing the da Vinci robot assisted approach is presented.

Findings: The anterior transperitoneal approach to the lumbar spine is accomplished with enhanced visualization and dissection capability with maintenance of pneumoperitoneum using the da Vinci robot.The longest incision was 3 cm. Blood loss was minimal. There was no evidence of post-operative ileus. The patient was discharged home after 23-hour observation. The visualization inside the disc space and surrounding structures was considered enhanced as compared to current open and laparoscopic techniques.

Conclusions: The da Vinci robot surgical system technique continues to develop and is now described for the transperitoneal approach to the anterior lumbar spine. Robotic assisted ALIF offers significant potential advantages as compared to both standard open and laparoscopic techniques. Maintenance of pneumoperitoneum throughout the ALIF procedure is expected to additionally decrease patient morbidity as compared to an open approach. In addition, this report describes to the authors' knowledge, the first patient case report of a da Vinci robot assisted laparoscopic anterior lumbar interbody fusion.