Endoscopic Femoropopliteal Bypass Surgery Without Groin Incision: A Feasibility Study on Cadavers with the Da Vinci Single Port System

Introduction: Femoropopliteal bypass surgery (FPBS) is a standard surgical procedure but is still associated with complications, especially surgical site infections and groin seromas. This feasibility study aimed to investigate whether endoscopic, robot assisted surgery enabled FPBS with minimal surgical trauma and without a groin incision. Method: The da Vinci single port (SP) system (Intuitive Surgical, Sunnyvale, USA) was used to perform the novel technique of endoscopic FPBS on fresh frozen cadavers. For this novel technique, a 4 cm incision was made in the distal third of the medial thigh for supragenicular exposure of the proximal femoral artery. Thereafter, an end to side anastomosis between the common femoral artery and a polytetrafluoroethylene (PTFE) graft was performed endoscopically with the da Vinci SP system. Success of the procedure was defined by completion of the proximal bypass anastomosis and the avoidance of injuries to anatomic key structures. First evaluation of the technique was performed by assessment with a slightly modified Northwestern Objective Microanastomosis Assessment Tool (NOMAT) score. Results: Two proximal bypass anastomoses were successfully sutured without injury to the five pre-defined key anatomic structures. Skin to skin complete duration of the intervention including removal of the robotic system was 105 minutes and 92 minutes, respectively. The modified NOMAT score representing the efficiency of surgical handling and quality of the anastomosis was 29 of 45 and 37 of 45, respectively. Conclusion: The current study demonstrates that endoscopic, robot assisted FPBS was feasible within an acceptable timeframe and without injury to key anatomic structures. Further clinical development of endoscopic FPBS could enable minimally invasive bypass surgery including the advantages of conventional surgery but avoiding its limitations.