Minimally Invasive Techniques for Intercostal Nerve Transfer: A Technical Note on Thoracoscopic and Robotic Approaches.

Background and objectives: Brachial plexus injuries are a devastating and often life-altering event. For patients with flail limb and no intraplexal donors, intercostal (IC) to musculocutaneous nerve transfer allows for restoration of elbow flexion although the surgery can be long with a painful recovery. In this article, we demonstrate a minimal incision video-assisted thoracoscopic surgery (VATS) method and a robotic approach to IC harvesting for nerve to biceps brachii reanimation.

Methods: This study was performed on cadaveric donors. We initially used the VATS technique and placed 3 thoracoscopic ports at IC levels 9 and 10. IC nerve 3 was harvested thoracoscopically under direct video visualization. The nerve was carefully neurolysed at the anterior-most edge and exited at the third midaxillary IC space. The nerve to biceps brachii was isolated and neurolysed proximally. The third IC nerve was coapted to the nerve to biceps brachii. On a separate cadaver, we then performed the robotic IC nerve harvest, dissecting out IC nerves 3, 4, and 5.

Results: The VATS technique was used to successfully harvest the third IC nerve. The total harvest time of the single nerve was 55 minutes. The robotic intrathoracic approach was used to successfully harvest IC nerves 3, 4, and 5. The average harvest time for each of the 3 nerves was 27 minutes.

Conclusion: This demonstrates a cadaveric proof of concept for the minimally invasive intrathoracic approach to harvest IC nerves for brachial plexus injuries through both the VATS and robotic techniques. Future studies are warranted for intrathoracic approaches to reanimate other peripheral nerves.