title: Endoscopic exploration and repair of brachial plexus with telerobotic manipulation: a cadaver trial.
abstract: OBJECTIVE
  The aim of this paper was to develop an effective minimally invasive approach to brachial plexus surgery and to determine the feasibility of using telerobotic manipulation to perform a diagnostic dissection and microsurgical repair of the brachial plexus utilizing an entirely endoscopic approach.
  
  
  METHODS
  The authors performed an endoscopic approach using 3 supraclavicular portals in 2 fresh human cadaver brachial plexuses with the aid of the da Vinci telemanipulation system. Dissection was facilitated inflating the area with CO(2) at 4 mm Hg pressure. The normal supraclavicular plexus was dissected in its entirety to confirm the feasibility of a complete supraclavicular brachial plexus diagnostic exploration. Subsequently, an artificial lesion to the upper trunk was created, and nerve graft reconstruction was performed. Images and video of the entire procedure were obtained and edited to illustrate the technique.
  
  
  RESULTS
  All supraclavicular structures of the brachial plexus could be safely dissected and identified, similar to the experience in open surgery. The reconstruction of the upper trunk with nerve graft was successfully completed using an epineural microsurgical suture technique performed exclusively with the aid of the robot. There were no instances of inadvertent macroscopic damage to the vascular and nervous structures involved.
  
  
  CONCLUSIONS
  An endoscopic approach to the brachial plexus is feasible. The use of the robot makes it possible to perform microsurgical procedures in a very small space with telemanipulation and minimally invasive techniques. The ability to perform a minimally invasive procedure to explore and repair a brachial plexus injury may provide a new option in the acute management of these injuries.
authors.affiliation: Department of Hand Surgery, Beneficência Portuguesa de São Paulo Hospital, São Paulo, Brazil. mantovani@sphandcenter.com
authors.forename: Gustavo
authors.initials: G
authors.lastname: Mantovani
authors.forename: Philippe
authors.initials: P
authors.lastname: Liverneaux
authors.forename: Jose Carlos
authors.initials: JC
authors.lastname: Garcia
authors.forename: Stacey H
authors.initials: SH
authors.lastname: Berner
authors.forename: Michael S
authors.initials: MS
authors.lastname: Bednar
authors.forename: Catherine J
authors.initials: CJ
authors.lastname: Mohr
mesh_terms: D001917:Brachial Plexus / Q000601:surgery*; D004724:Endoscopy / Q000379:methods*; D006801:Humans; D008866:Microsurgery / Q000379:methods*; D012371:Robotics; D025321:Surgery, Computer-Assisted / Q000379:methods*