Two patients recently underwent surgery on the same day at the Azienda Ospedaliero-Universitaria Pisana (Pisa University Hospital) for a neurinoma, a benign tumour that originates from the sheaths surrounding nerves.
In the first case, the tumour affected the musculocutaneous nerve, which controls the biceps and therefore elbow flexion.
In the second, it affected the superficial peroneal nerve, which supplies the peroneal muscles — the muscles that turn the foot outward and help stabilise the foot during weight-bearing — as well as sensation on the top of the foot.
Why the result was far from guaranteed
A neurinoma is benign, but it does not grow inside the nerve itself. Healthy nerve fibres do not simply surround the tumour; they lie against its surface, stretched and flattened over the mass. Removing the tumour therefore means isolating these fibres and separating them one by one without cutting them.
This is why the margin for error in this type of surgery is measured in tenths of a millimetre. At this scale, the physiological tremor of the hand — something that no surgeon, however experienced, can completely eliminate — stops being negligible and becomes the variable that can determine the difference between an intact nerve and permanent damage: a hand that can no longer feel, or a foot that can no longer be lifted.
In this type of surgery having a robotic platform that reduces physiological tremor and scales down the surgeon’s movements means having even more precise control during the most delicate stages of dissection, with a significant impact on preserving function.
Francesco Acerbi, Professor of Neurosurgery at the University of Pisa and Director of the Neurosurgery Unit at AOUP
The Symani system reduces physiological hand tremor and scales down the surgeon’s movements: a one-centimetre movement can be transformed into a shift of just half a millimetre in the surgical field. Thanks to its miniaturised, articulated instruments, the system allows surgeons to operate on blood vessels, lymphatic vessels and peripheral nerves measuring less than one millimetre. Every movement remains entirely under the surgeon’s control; the robot never operates autonomously.
However, a hand capable of working at a scale of tenths of a millimetre is of limited use if the surgeon’s vision cannot reach the same scale. For this reason, Symani was combined with an exoscope, which projects a highly magnified 3D 4K image of the surgical field onto a monitor. This makes it possible to distinguish the nerve fibres lying against the tumour individually. Continuous neurophysiological monitoring accompanied both procedures, mapping the nerve’s function in real time as it was freed from the tumour.
The procedures were performed by Francesco Acerbi and Elio Mazzapicchi, neurosurgeon, with support from AOUP’s Departmental Section of Plastic and Microsurgery, headed by Emanuele Cigna; the General and Emergency Surgery Unit, headed by Federico Coccolini; and AOUP’s Neuroanaesthesia and Intensive Care team, headed by Francesco De Masi. Intraoperative neurophysiological monitoring was conducted by Francesco Turco, neurologist.
Symani was inaugurated at Cisanello Hospital last May. It is the only supermicrosurgery platform in Tuscany and one of just three in Italy. The two procedures were performed just over two months after the platform became operational.
AOUP was among the first Italian hospitals to invest in robotic surgery, introducing its first da Vinci system in 2001. Today, its Multidisciplinary Robotic Surgery Centre has four da Vinci platforms and performs more than 1,800 procedures per year. With the addition of Symani, the number of robotic systems has risen to five.
“Pisa is certainly one of Europe’s leading centres for robotic surgery,” says Katia Belvedere, AOUP’s Director General. “The introduction of Symani renews our commitment to continuously investing in the most advanced technologies, making the most of them through the expertise of our professionals and clinical research. The result achieved just a few months after the platform became operational demonstrates how this path can quickly translate into new treatment possibilities for patients and contribute to the evolution of surgical practice.”
The two cases are currently the subject of a a scientific paper being prepared for an international journal.
