RALP has shown a significant advantage with respect to length of stay and readmission rate. Based on the case-mix funding model RALP is poorly funded compared to its open equivalent. Queensland Health needs to plan on how robotic surgery is implemented and assess whether this technology is truly affordable in the public sector.

A 47-year-old female with previously diagnosed Klippel-Trenaunay syndrome (KTS) presented to a tertiary hospital emergency department with a painful wound on the medial aspect of her right leg. The wound was shallow with raised edges and surrounding erythema. It had arisen 2 weeks prior, subsequent to poorly fitting compression stockings. The right lower limb was hypertrophic with mild bilateral pitting oedema. She was admitted for management of the wound and resultant cellulitis under the Plastic and Reconstructive Surgery Unit.The diagnosis of KTS was made based on the presence of congenital right lower limb hypertrophy and cutaneous capillary malformations. The patient also developed high output heart failure and was recovering from a recent exacerbation.CT angiography showed enlarged vessels in the abdomen and right lower limb (Figs 1,2). Extensive arteriovenous malformations (AVMs) were seen in the right lower limb. Magnetic resonance imaging showed abnormal signal pattern within the subcutaneous fat with soft tissue overgrowth of the right thigh, leg and foot (Fig. 3). An aorto-iliac angiogram identified extensive diffuse AVMs from the internal iliac branches, common femoral, superficial femoral and popliteal arteries as well as all crural arteries with extensive venous shunting into the femoral and saphenous veins.The pain and erythema surrounding the wound improved with 48 h of intravenous antibiotics and leg elevation. Because of her high output heart failure, in conjunction with cardiology and interventional radiology, the patient underwent two sessions of embolisation of the extensive AVMs with a successful reduction in shunt volume and Fig. 1. 3D rendering of a CT angiogram showing the vessels of the abdomen and lower limb. There are extensive AVMs present in the right lower limb. Both the arterial and venous systems are enlarged.Fig. 2. (a) 3D volume rendered CT angiogram of the legs. (b) Axial CT through right leg. The blue arrows show the dilated cutaneous veins. The red arrows are AVMs from the tibioperoneal trunk to saphenous system.Fig. 3. Transverse MRI through right thigh showing marked thickening of the skin layer and overgrowth of underlying soft tissue. No significant abnormal signal in the femur.

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