Brachial Plexus

  • Kiyohito Naito
  • Mickaël Ohana
  • Thierry Lequint
  • Sybille Facca
  • Philippe LiverneauxEmail author


Several interventions remain almost inaccessible to endoscopic surgery, such as brachial plexus injuries. Development of minimally invasive and robot-assisted surgical approaches has the potential to greatly improve the surgical outcome.

Our clinical experience is based on 12 cases of brachial plexus tele-endomicrosurgery operated using a da Vinci robot.

Considering the microsurgical gesture, all nerve repairs were achieved under excellent conditions. Considering the minimally invasive approach, results are yet inconclusive, with a need to convert to open surgery in 9 cases. The reasons for conversion were numerous: difficulties to maintain the resection cavity, unsuited instrumentation, blurring of the stereoscopic vision and major difficulties in visual identification of anatomical landmarks.

In brachial plexus surgery, tele-endomicrosurgery is feasible but faces major constraints regarding the creation, maintenance and navigation inside the working chamber. Adaptation of the endoscopic equipment and use of advanced techniques of augmented reality should address most of these problems.


Augmented Reality Brachial Plexus Volume Rendering Virtual Patient Nerve Repair 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Ayav A, Bresler L, Brunaud L, Boissel P (2004) Early results of one-year robotic surgery using the Da Vinci system to perform advanced laparoscopic procedures. J Gastrointest Surg 8(6):720–726PubMedCrossRefGoogle Scholar
  2. 2.
    Naito K, Facca S, Lequint T, Liverneaux P (2012) Oberlin’s procedure for restoration of elbow flexion with Da Vinci robot: 4 cases. Plast Reconstr Surg 129(3):707–11PubMedCrossRefGoogle Scholar
  3. 3.
    Novak CB, Anastakis DJ, Beaton DE, Mackinnon SE, Katz J (2010) Relationships among pain disability, pain intensity, illness intrusiveness, and upper extremity disability in patients with traumatic peripheral nerve injury. J Hand Surg 35(10):1633–1639CrossRefGoogle Scholar
  4. 4.
    Greenfield BH, Geist K (2011) Evaluation and treatment of brachial plexus lesions. In: Physical therapy of the shoulder, 5th edn. Churchill Livingstone, Saint Louis, pp 163–183Google Scholar
  5. 5.
    Bollini CA, Wikinski JA (2006) Anatomical review of the brachial plexus. Tech Reg Anesth Pain Manag 10(3):69–78Google Scholar
  6. 6.
    Gregory J, Cowey A, Jones M, Pickard S, Ford D (2009) The anatomy, investigations and management of adult brachial plexus injuries. Orthop Trauma 23(6):420–432CrossRefGoogle Scholar
  7. 7.
    Altaf F, Mannan K, Sinisi M, Birch R (2008) Severe brachial plexus injuries in rugby: mechanisms and management. Inj Extra 39(5):206–206CrossRefGoogle Scholar
  8. 8.
    Kosiyatrakul A, Jitprapaikulsarn S, Durand S, Oberlin C (2009) Recovery of brachial plexus injury after shoulder dislocation. Injury 40(12):1327–1329PubMedCrossRefGoogle Scholar
  9. 9.
    Shveiky D, Aseff JN, Iglesia CB (2010) Brachial plexus injury after laparoscopic and robotic surgery. J Minim Invasive Gynecol 17(4):414–420PubMedCrossRefGoogle Scholar
  10. 10.
    Pillai AK, Ferral H, Desai S, Paruchuri S, Asselmeier S, Perez-Gautrin R (2007) Brachial plexus injury related to patient positioning. J Vasc Interv Radiol 18(7):833–834PubMedCrossRefGoogle Scholar
  11. 11.
    Hiraki T, Gobara H, Mimura H, Sano Y, Toyooka S, Shibamoto K, Kishi R, Uka M, Kanazawa S (2010) Brachial nerve injury caused by percutaneous radiofrequency ablation of apical lung cancer: a report of four cases. J Vasc Interv Radiol 21(7):1129–1133PubMedCrossRefGoogle Scholar
  12. 12.
    Monteiro MJ, Altman K, Khandwala A (2010) Injury to the brachial plexus in neck dissections. Br J Oral Maxillofac Surg 48(3):197–198PubMedCrossRefGoogle Scholar
  13. 13.
    Castillo M (2005) Imaging the anatomy of the brachial plexus: review and self-assessment module. AJR Am J Roentgenol 185(6 Suppl):S196–S204PubMedCrossRefGoogle Scholar
  14. 14.
    Moser T, Kremer S, Holl N (2009) Imagerie du nerf peripherique: anatomie, techniques d’exploration et principales pathologies. J Radiol 90(10):1448–1448CrossRefGoogle Scholar
  15. 15.
    Brophy RH, Wolfe SW (2005) Planning brachial plexus surgery: treatment options and priorities. Hand Clin 21(1):47–54PubMedCrossRefGoogle Scholar
  16. 16.
    Mullins GM, O’Sullivan SS, Neligan A, Daly S, Galvin RJ, Sweeney BJ, McNamara B (2007) Non-traumatic brachial plexopathies, clinical, radiological and neurophysiological findings from a tertiary centre. Clin Neurol Neurosurg 109(8):661–666PubMedCrossRefGoogle Scholar
  17. 17.
    Choi J-Y, Kang CH, Kim B-J, Park K-W, Yu S-W (2009) Brachial plexopathy following herpes zoster infection: two cases with MRI findings. J Neurol Sci 285(1–2):224–226PubMedCrossRefGoogle Scholar
  18. 18.
    Hof JJ, Kliot M, Slimp J, Haynor DR (2008) What’s new in MRI of peripheral nerve entrapment? Neurosurg Clin N Am 19(4):583–595PubMedCrossRefGoogle Scholar
  19. 19.
    Cotten A, Chantelot C, Duquesnoy B, Demondion X (2007) Imagerie des syndromes de la traversée cervicothoracobrachiale. Rev Rhum 74(4):333–338CrossRefGoogle Scholar
  20. 20.
    Lacour MC (2009) Intérêt de l’imagerie dans le diagnostic des plexopathies. Rev Neurol 165(12):1134–1139PubMedCrossRefGoogle Scholar
  21. 21.
    Giuffre JL, Kakar S, Bishop AT, Spinner RJ, Shin AY (2010) Current concepts of the treatment of adult brachial plexus injuries. J Hand Surg 35(4):678–688CrossRefGoogle Scholar
  22. 22.
    Mannan K, Carlstedt T (2006) Injuries to the brachial plexus. Surgery (Oxford) 24(12):409–414CrossRefGoogle Scholar
  23. 23.
    Parvizi J, Kim GK (2010) Brachial plexus injury. High Yield Orthopaedics. W.B. Saunders, Philadelphia, In, pp 68–69Google Scholar
  24. 24.
    Shenaq SM, Kim JYS, Bullocks J, Joseph GM, Robert DG, Sean GB (2006) Brachial plexus injuries. In: Current therapy in plastic surgery. W.B. Saunders, Philadelphia, pp 574–583CrossRefGoogle Scholar
  25. 25.
    Thornton DJA, Kay SPJ (2010) A clinical approach to the management of brachial plexus and peripheral nerve injury. Surgery (Oxford) 28(2):79–84CrossRefGoogle Scholar
  26. 26.
    Liverneaux PA, Diaz LC, Beaulieu J-Y, Durand S, Oberlin C (2006) Preliminary results of double nerve transfer to restore elbow flexion in upper type brachial plexus palsies. Plast Reconstr Surg 117(3):915–9PubMedCrossRefGoogle Scholar
  27. 27.
    Moten SC, Kypson AP, Chitwood WR Jr, Joseph AS Jr, Ashutosh T (2008) Use of robotics in other surgical specialties. In: Robotics in urologic surgery. W.B. Saunders, Philadelphia, pp 159–173CrossRefGoogle Scholar
  28. 28.
    Zacharopoulou C, Sananes N, Baulon E, Garbin O, Wattiez A (2010) Chirurgie robotique en gynécologie: état des connaissances. Revue de la littérature. J Gynecol Obstet Biol Reprod 39(6):444–452CrossRefGoogle Scholar
  29. 29.
    Kim HL, Schulam P (2004) The PAKY, HERMES, AESOP, ZEUS, and da Vinci robotic ­systems. Urol Clin North Am 31(4):659–669PubMedCrossRefGoogle Scholar
  30. 30.
    Byrn JC, Schluender S, Divino CM, Conrad J, Gurland B, Shlasko E, Szold A (2007) Three-dimensional imaging improves surgical performance for both novice and experienced operators using the da Vinci Robot System. Am J Surg 193(4):519–522PubMedCrossRefGoogle Scholar
  31. 31.
    Nectoux E, Taleb C, Liverneaux P (2009) Nerve repair in telemicrosurgery: an experimental study. J Reconstr Microsurg 25(4):261–265PubMedCrossRefGoogle Scholar
  32. 32.
    Marescaux J, Soler L, Rubino F (2005) Augmented reality for surgery and interventional therapy. Oper Tech Gen Surg 7(4):182–187CrossRefGoogle Scholar
  33. 33.
    Nicolau SA, Pennec X, Soler L, Buy X, Gangi A, Ayache N, Marescaux J (2009) An augmented reality system for liver thermal ablation: design and evaluation on clinical cases. Med Image Anal 13(3):494–506PubMedCrossRefGoogle Scholar
  34. 34.
    Freudenthal A, Stüdeli T, Lamata P, Samset E (2010) Collaborative co-design of emerging multi-technologies for surgery. J Biomed Inform 44(2):198–215PubMedCrossRefGoogle Scholar
  35. 35.
    Lee S-L, Lerotic M, Vitiello V, Giannarou S, Kwok K-W, Visentini-Scarzanella M, Yang G-Z (2010) From medical images to minimally invasive intervention: computer assistance for robotic surgery. Comput Med Imaging Graph 34(1):33–45PubMedCrossRefGoogle Scholar
  36. 36.
    Teber D, Guven S, Simpfendörfer T, Baumhauer M, Güven EO, Yencilek F, Gözen AS, Rassweiler J (2009) Augmented reality: a new tool to improve surgical accuracy during laparoscopic partial nephrectomy? Preliminary in vitro and in vivo results. Eur Urol 56(2):332–338PubMedCrossRefGoogle Scholar
  37. 37.
    Ukimura O, Gill IS (2009) Image-fusion, augmented reality, and predictive surgical navigation. Urol Clin North Am 36(2):115–123PubMedCrossRefGoogle Scholar
  38. 38.
    Tan GY, Goel RK, Kaouk JH, Tewari AK (2009) Technological advances in robotic-assisted laparoscopic surgery. Urol Clin North Am 36(2):237–249PubMedCrossRefGoogle Scholar
  39. 39.
    Archip N, Clatz O, Whalen S, Kacher D, Fedorov A, Kot A, Chrisochoides N, Jolesz F, Golby A, Black PM, Warfield SK (2007) Non-rigid alignment of pre-operative MRI, fMRI, and DT-MRI with intra-operative MRI for enhanced visualization and navigation in image-guided neurosurgery. Neuroimage 35(2):609–624PubMedCrossRefGoogle Scholar
  40. 40.
    Konishi K, Hashizume M, Nakamoto M, Kakeji Y, Yoshino I, Taketomi A, Sato Y, Tamura S, Maehara Y (2005) Augmented reality navigation system for endoscopic surgery based on three-dimensional ultrasound and computed tomography: application to 20 clinical cases. Int Congress Ser 1281:537–542CrossRefGoogle Scholar
  41. 41.
    Boyer B, Le Marec E, Ait-Ameur A, Hauret L, Dion A, Aterii-Tehau C (2003) Tomodensitométrie: principes, formation de l’image. Encycl Méd Chir (Elsevier, Paris), Radiodiagnostic 37-170(A-10):1–16Google Scholar
  42. 42.
    Vargas M, Nguyen D, Viallon M, Delavelle J (2009) Imagerie du plexus brachial (PB). J Radiol 90(10):1448–1448CrossRefGoogle Scholar
  43. 43.
    Ben Salem D, Couvreur G, Soichot P, Giroud M, Krausé D, Ricolfi F (2005) Apport de la sequence T2-STIR dans l’exploration des plexopathies brachiales demyelinisantes chroniques. J Radiol 86(10):1249–1249CrossRefGoogle Scholar
  44. 44.
    Viallon M, Vargas MI, Jlassi H, Lovblad KO, Delavelle J (2008) High-resolution and functional magnetic resonance imaging of the brachial plexus using an isotropic 3D T2 STIR (Short Term Inversion Recovery) SPACE sequence and diffusion tensor imaging. Eur Radiol 18(5):1018–1023PubMedCrossRefGoogle Scholar
  45. 45.
    Tagliafico A, Succio G, Neumaier CE, Baio G, Serafini G, Ghidara M, Calabrese M, Martinoli C (2012) Brachial plexus assessment with three-dimensional isotropic resolution fast spin echo MRI: comparison with conventional MRI at 3.0 T. Br J Radiol 85(1014):e110–6PubMedCrossRefGoogle Scholar
  46. 46.
    Hostettler A, George D, Rémond Y, Nicolau SA, Soler L, Marescaux J (2010) Bulk modulus and volume variation measurement of the liver and the kidneys in vivo using abdominal kinetics during free breathing. Comput Methods Programs Biomed 100(2):149–157PubMedCrossRefGoogle Scholar
  47. 47.
    Krucker J, Xu S, Glossop N, Viswanathan A, Borgert J, Schulz H, Wood BJ (2007) Electromagnetic tracking for thermal ablation and biopsy guidance: clinical evaluation of spatial accuracy. J Vasc Interv Radiol 18(9):1141–1150PubMedCrossRefGoogle Scholar
  48. 48.
    Yamanaka Y, Kamogawa J, Katagi R, Kodama K, Misaki H, Kamada K, Okuda S, Morino T, Ogata T, Yamamoto H (2010) 3-D MRI/CT fusion imaging of the lumbar spine. Skeletal Radiol 39(3):285–288PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag France 2013

Authors and Affiliations

  • Kiyohito Naito
    • 1
    • 2
  • Mickaël Ohana
    • 3
  • Thierry Lequint
    • 1
    • 4
  • Sybille Facca
    • 1
  • Philippe Liverneaux
    • 1
    • 5
    Email author
  1. 1.Department of Hand SurgeryStrasbourg University HospitalIllkirch, StrasbourgFrance
  2. 2.Department of OrthopeadicsJuntendo UniversityTokyoJapan
  3. 3.Department of RadiologyStrasbourg University HospitalStrasbourgFrance
  4. 4.Department of OrthopeadicsGrand HôpitalCharleroiBelgium
  5. 5.European Institute of TeleSurgery, IRCADStrasbourgFrance

Personalised recommendations