The da Vinci Robotic Surgical Assisted Anterior Lumbar Interbody Fusion

Technical Development and Case Report

William J. Beutler, MD; Walter C. Peppelman, Jr, DO; Luciano A. DiMarco, DO


Spine. 2013;38(4):356-363. 

In This Article

Abstract and Introduction


Study Design. Technique development to use the da Vince Robotic Surgical System for anterior lumbar interbody fusion at L5–S1 is detailed. A case report is also presented.

Objective. To evaluate and develop the da Vinci robotic assisted laparoscopic anterior lumbar stand-alone interbody fusion procedure.

Summary of Background Data. Anterior lumbar interbody fusion is a common procedure associated with potential morbidity related to the surgical approach. The da Vinci robot provides intra-abdominal dissection and visualization advantages compared with the traditional open and laparoscopic approach.

Methods. The surgical techniques for approach to the anterior lumbar spine using the da Vinci robot were developed and modified progressively beginning with operative models followed by placement of an interbody fusion cage in the living porcine model. Development continued to progress with placement of fusion cage in a human cadaver, completed first in the laboratory setting and then in the operating room. Finally, the first patient with fusion completed using the da Vinci robot–assisted approach is presented.

Results. The anterior transperitoneal approach to the lumbar spine is accomplished with enhanced visualization and dissection capability, with maintenance of pneumoperitoneum using the da Vinci robot. Blood loss is minimal. The visualization inside the disc space and surrounding structures was considered better than current open and laparoscopic techniques.

Conclusion. The da Vinci robot Surgical System technique continues to develop and is now described for the transperitoneal approach to the anterior lumbar spine.


Anterior lumbar interbody fusion (ALIF) is a common procedure for treatment of various conditions that require stabilization of the anterior lumbar spine. Advantages of ALIF compared with posterior fusion include maximum exposure of the disc space for optimal placement of interbody devices to enhance fusion potential and a low risk of neurological injury.[1,2] Disadvantages of the transperitoneal approach include the potential morbidity associated with the retraction and dissection of the gastrointestinal, genitourinary, and vascular structures.[3,4] The introduction of cylindrical interbody cages in the 1990s popularized the procedure.[5] Cylindrical cages and dowels also stimulated interest in a laparoscopic approach.[6,7] The theoretical advantages of a laparoscopic approach include a shorter hospital stay and decreased pain compared with an open ALIF.[6] However, the laparoscopic ALIF was found to have a higher rate of retrograde ejaculation.[7] Fusion rates have been described to be similar to the open procedure.[8,9]

Current anterior interbody cage design seeks to provide far greater conformity to the disc space than the cylindrical design. Coupled with anterior instrumentation, either as a stand-alone construct or with plate placement anterior to the vertebral bodies, contemporary interbody fusion constructs offer enhanced stabilization. Optimal placement of interbody devices is achieved with total anterior discectomy and sizing attentive to endplate anatomy. Laparoscopic placement of larger, flatter devices requires a different set of techniques from that developed for laparoscopic placement of cylindrical devices. However, recognition of the potential advantages of a laparoscopic approach would be expected to initiate development of such techniques.

The da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA) is a master-slave telemanipulator robot that received Food and Drug Administration approval for general surgery in 2000 (Figure 1). The system has seen adoption in complex procedures that require increased dexterity in confined workspaces. The da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA) has achieved widespread use and application in multiple surgical disciplines and procedures. The advantages of the da Vinci robot for cholecystectomy,[10] otolaryngology,[11] gynecology,[12] and urology[13] have been established. The use of the robot in the posterior spine has also been described.[14] The development of techniques for approach to the anterior spine has been reported in a swine model.[15,16] The rationale for robotic dissection includes 3-dimensional imaging and improved surgical dexterity from motion scaling and tremor filtering. It has also been hypothesized that the development of robotic laparoscopy has shortened the laparoscopic learning curve because it has 7 df (the seventh degree is the grasping function of the instrument).[13]

Figure 1.

Robot control console.

This report delineates advanced development of robotic assisted laparoscopic techniques for the anterior approach to the lumbar spine. Newly available gel ports and laparoscopic instrumentation, together with the rapid development, familiarity, and expansion of general surgical robotic skills, prompted our advancement of techniques to use the advantages of the da Vinci Surgical System for the ALIF approach. This report describes the development of the technique beyond the porcine model to that of clinical use. In addition, this report describes to the authors' knowledge, the first patient case report of a da Vinci robot–assisted laparoscopic ALIF.