First-in-human application of robotic vascularized intercostal nerve grafts for thoracic sympathetic trunk reconstruction: a technical innovation

摘要

BACKGROUND: Post-sympathectomy complications affect thousands globally, yet reconstruction remains limited by donor site morbidity and inability to address extensive nerve defects. Extended sympathectomy procedures of the past created defects exceeding 10 cm-beyond the reach of conventional free nerve grafts. This study presents the first robotic technique for harvesting vascularized intercostal nerve grafts within the same operative field, potentially revolutionizing sympathetic trunk reconstruction. METHODS: This retrospective technical innovation study enrolled patients undergoing robot-assisted sympathetic trunk reconstruction from December 2023 to June 2025. Eight patients received either vascularized intercostal nerve grafts (n = 4) or propensity score-matched free intercostal nerve grafts (n = 4), with one additional patient receiving dual vascularized grafts for bilateral T1-T10 defects. Primary outcomes included technical feasibility, Visual Analog Scale symptom scores, and safety parameters. RESULTS: All vascularized procedures achieved 100% technical success with zero vascular complications. The vascularized group demonstrated remarkable improvements within 6 months: temperature regulation (9.0 vs. 3.75, P = 0.01), chest compensatory sweating (9.25 vs. 4.25, P = 0.04), back compensatory sweating (9.5 vs. 6.25, P < 0.01), and psychological symptom with loss of interest (4.25 vs. 1, P = 0.01) - outcomes typically requiring more than 6 months with conventional grafts. The dual-graft patient achieved complete reconstruction of previously "unreconstructable" bilateral defects spanning 9 intercostal levels, with 3-points improvement across all symptom domains. CONCLUSIONS: Robotic vascularized intercostal nerve grafting represents a paradigm shift in sympathetic reconstruction, eliminating donor site morbidity while accelerating recovery and enabling treatment of previously impossible extensive defects. This innovation may establish new standards for complex nerve reconstruction globally.