Robot-assisted Microsurgery: Lessons Learned from 50 Consecutive Cases

Implementation Strategies and Ergonomic Factors in Robot-assisted Microsurgery

Robot-assisted surgery represents a significant innovation in reconstructive microsurgery, providing enhanced precision and reduced surgeon fatigue. This study examines the integration of robotic assistance in a series of 85 consecutive robot-assisted microsurgical (RAMS) operations. It aims to evaluate changes in the integration of RAMS during the implementation phase in a single institution. The study utilized a prospective database encompassing all robot-assisted microsurgical cases using the Symani surgical system from February until December 2023. A total of 85 robot-assisted operations were analyzed, showing a broad application across various types of reconstructive needs, predominantly in lower extremity repairs (n = 41). There were 68 free flap reconstructions (80.0%), ten nerve transfers (11.8%), four targeted muscle reinnervations (TMR; 4.7%), two lymphovenous anastomoses (2.4%) and one arterial reconstruction. The adoption of both traditional and digital exoscopic magnification systems was optimized for each surgical context. The operating room setup and infrastructural challenges for the different anatomic regions are presented. The introduction of robot-assisted surgery entailed overcoming challenges such as adapting to the lack of haptic feedback and navigating ergonomic constraints. Despite these hurdles, including higher operational costs and increased surgery durations, the precision and ergonomic benefits offered by robotic systems may be substantial. Potential solutions and tips to improve the operating times include frequent cleaning of the instruments, active surgical assistance, and rigorous presurgical planning of the logistical setup in the operating room. We showed that there is a preference for the utilization of digital exoscopes over conventional microscopes in RAMS, despite requiring more time per stitch when using the exoscope.

Expanding Applications and Future of Robotic Microsurgery

Robotic-assisted microsurgery has emerged as a transformative technology, offering enhanced precision for complex procedures across various fields, including lymphatic surgery, breast reconstruction, trauma, and neurosurgery. This paper reviews current advancements, applications, and potential future directions for robotic-assisted microsurgery. In lymphatic surgery, robotic systems such as Symani have improved precision in thoracic duct reconstruction and lymphatic vessel anastomoses, reducing morbidity despite longer surgery times. In breast reconstruction, robotic systems are being used to refine techniques like the miraDIEP approach, minimizing tissue damage and enhancing precision in individualized treatments. Trauma reconstruction, particularly for extremities, has also benefited from robotic assistance, enabling successful sutures in small vessels and nerves. Emerging applications in meningeal lymphatics show potential for treating neurodegenerative diseases through improved drainage. In neurosurgery, robots enhance precision in deep and narrow anatomic spaces, although advancements in specialized instruments are needed for full implementation. Future development of robotic microsurgery systems will focus on improved maneuverability, miniaturization, and integration of tools like augmented reality and haptic feedback. The goal is to combine robotic precision, data storage, and processing with human skills such as judgment and flexibility. Although robots are unlikely to replace surgeons, they are poised to play an increasingly significant role in enhancing surgical outcomes. As the technology evolves, further research and clinical trials are needed to refine robotic systems and validate their expanding applications in clinical practice.

Robot-assisted microsurgery: a single-center experience of 100 cases

The adoption of robot-assisted microsurgery (RAMS) is a cutting-edge advancement in the realm of microsurgery. The Symani Surgical System is CE approved and has recently gained FDA approval. It provides tremor elimination, motion scaling and improved ergonomics. This study reports on the first 100 consecutive cases of RAMS at a high-volume academic center, representing the largest series to date, and assesses its clinical application and efficacy. A prospective database captured all RAMS cases at a single institution between February 2023 and April 2024. Parameters recorded included patient demographics, surgical details, and outcomes. Surgeons completed a comprehensive 12 h training program to ensure adept use of the system. One-hundred patients with a mean age of 54 yrs were identified, predominantly male (66%). RAMS was performed in a wide range of procedures, notably free flaps (73%), nerve surgery (20%), and lymphovenous anastomoses (LVA) (6%). 159 anastomoses and coaptations were performed. Major complications occurred in 12 cases (12%). There were two complete free flap losses (2.7% of free flaps) and one partial free flap loss (1.4%). LVAs had significantly longer times per stitch than other types of anastomoses (p < 0.01). RAMS presents a viable alternative to traditional microsurgery with a commendable safety profile, marked by a 3% conversion rate to conventional techniques and complication rates that align with current literature. While challenges such as longer anastomosis times and higher costs exist, the results affirm the feasibility of RAMS in a high-volume microsurgical center.

Comparative Evaluation of Major Robotic Systems in Microanastomosis Procedures: A Systematic Review of Current Capabilities and Future Potential

Background/Objectives: Robotic-assisted surgery has revolutionised modern medicine, enabling greater precision and control, particularly in microsurgical procedures. This systematic review evaluates the current state of robotic-assisted surgery across various specialties, focusing on four major robotic systems: Symani, Da Vinci, ZEUS, and MUSA. Methods: The review systematically analyses the effectiveness of these systems in performing vascular, lymphatic, and nervous anastomoses, comparing key metrics such as procedure time, success rates, and learning curves against manual techniques. It includes 48 studies, highlighting the technological capabilities and limitations of these systems in direct comparisons. Results: Results indicate that while robotic procedures often take longer than manual methods, significant improvements in efficiency are observed as surgeons gain experience. Conclusions: Overall, this study provides insights into the future potential of robotic-assisted surgery and highlights areas that require further research. It ultimately aims to promote the application of robotic systems in cranial neurosurgery, with a particular focus on advancing neurovascular techniques, such as microsuturing for bypass procedures.

Clinical, Preclinical, and Educational Applications of Robotic-Assisted Flap Reconstruction and Microsurgery: A Systematic Review

INTRODUCTION

Microsurgery and super-microsurgery allow for highly technical reconstructive surgeries to be performed, with repairs of anatomical areas of less than 1 mm. Robotic-assisted surgery might allow for further advances within microsurgery, providing higher precision, accuracy, and scope to operate in previously inaccessible anatomical areas. However, robotics is not well-established within this field. We provide a summary of the clinical and preclinical uses of robotics within flap reconstruction and microsurgery, educational models, and the barriers to widespread implementation.

METHODS

A systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses was conducted of PubMed, Medline, and Embase. Preclinical, educational, and clinical articles were included.

RESULTS

One thousand five hundred and forty-two articles were screened; 87 articles met the inclusion criteria across flap harvest, flap/vessel pedicle dissection, vascular anastomosis, and nerve repair. The literature presents several potential benefits to the surgeon and patient such as high cosmetic satisfaction, minimally invasive access with reduced scarring (flap harvest), and low complication rates. Lack of haptic feedback was reported by authors to not impede the ability to perform vessel anastomosis; however, this required further investigation. A steep learning curve was identified, particularly for microsurgeons embarking upon robotic-assisted surgery.

CONCLUSION

Robotic-assisted surgery can potentially enhance microsurgery and flap reconstruction, with feasibility demonstrated within this review, up to anastomosis of 0.4 mm in diameter. However, there is a lack of sufficiently powered comparative studies, required to strengthen this statement. To increase accessibility to robotic surgery for plastic and reconstructive surgeons, educational opportunities must be developed with standardized assessment of skill acquisition.

Robotic microsurgery for pediatric peripheral nerve surgery

The technology of microsurgical robotic systems has shown potential benefit during the last decade for a variety of microsurgical procedures, such as vascular anastomoses, lymphatic anastomoses or nerve coaptation. At the same time, peripheral nerve surgery has produced ever more sophisticated nerve transfers in which the smallest nerve structures are connected to each other. Following obstetric brachial plexus injuries, nerve reconstruction surgery is often required in the first few years of life in order to improve the function of the affected arm, including nerve transfers to denervated muscles, which enable reinnervation of target muscles. In pediatric patients, these donor-nerve structures are even smaller than in adults, which further increases the demands to the microsurgeon. In this publication, we show the possible applications, capabilities and limitations of a dedicated microsurgical robotic system for nerve transfers in pediatric patients.

Technical Strategies and Learning Curve in Robotic-assisted Peripheral Nerve Surgery

Background

Robotic-assisted peripheral nerve surgery (RASPN) has emerged as a promising advancement in microsurgery, offering enhanced precision and tremor reduction for nerve coaptations. This study investigated the largest published patient collective in RASPN and provided specific technical aspects, operative setups, and a learning curve.

Methods

Data collection involved creating a prospective database that recorded surgical details such as surgery type, duration, nerve coaptation time, and number of stitches. The experienced surgeon first underwent a 12-hour training program utilizing the Symani robot system in combination with optical magnification tools before using the system clinically.

Results

The study included 19 patients who underwent robot-assisted peripheral nerve reconstruction. The cohort included six men (31.6%) and 13 women (68.4%), with an average age of 53.8 ± 18.4 years. The procedures included nerve transfers, targeted muscle reinnervation, neurotized free flaps, and autologous nerve grafts. Learning curve analysis revealed no significant reduction in time per stitch over the initial nine coaptations (4.9 ± 0.5 min) compared with the last 10 coaptations (5.5 ± 1.5 min).

Conclusions

The learning curve for RASPN was compared with early experiences with other surgical robots, emphasizing the importance of surgical proficiency and assistant training. Obstacles such as instrument grip strength and blood clot formation were highlighted, and suggestions for future advancements were proposed. RASPN presents an exciting opportunity to enhance precision; however, ongoing research and optimization are necessary to fully harness its benefits.

The Use of the Symani Surgical System® in Emergency Hand Trauma Care

Background: The use of robotic systems for microsurgery has gained popularity in recent years. Despite its drawbacks, such as increased learning time and lack of haptic feedback, robot-assisted microsurgery is beneficial for emergency care due to its reduced risk of tremor and fatigue. The Symani Surgical System® is 1 example of this advanced technology. The device offers a range of possibilities in the field of microsurgery by combining precision and dexterity, revolutionizing microsurgical procedures. This article explores the applications of the Symani in microsurgical procedures in emergency hand trauma care, highlighting its advantages and limitations. Material and Methods: We present the results of 62 anastomoses of blood vessels under .8 mm diameter after hand trauma. 31 anastomoses were conducted using the Symani Surgical System®, and the other 31 were done as a control group in hand-sewn technique. Study Sample: The patient characteristics, including sex, age, and risk factors, were matched. Results: We found no significant differences in the anastomosis surgery length when performed with the Symani (arterial 17.3 ± 1.9 min; venous 11.5 ± 1.3 min) vs the hand-sewn technique (arterial 16.1 ± 1.4 min; venous 10.2 ± 1.8 min). Additionally, the learning curve consistently decreased over time, with the 10th surgery taking 30% (arterial) less time. Conclusion: Our study indicates that robot-assisted microsurgery can help surgeons maintain a relaxed and focused state while producing results comparable to hand-sutured procedures in emergency care.

Learning curve of robotic assisted microsurgery in surgeons with different skill levels: a prospective preclinical study

Achieving precision in microsurgery requires skill, adequate instruments and magnification, as well as extensive training. Dedicated surgical robotic systems have enhanced and expanded the application of (super-)microsurgical techniques by introducing motion scaling and providing improved surgeon ergonomics. In this prospective preclinical trial, we analyzed the learning curve in robotic assisted microsurgery in 13 participants including medical students, residents, and attending physicians. Data on demographics as well as prior experience in surgery, microsurgery, and gaming were collected. In three study sessions, the participants performed nine microsurgical anastomoses each on 2 mm vessel models using the Symani® Surgical System in combination the VITOM 3D exoscope. A senior expert microsurgeon reviewed the de-identified and blinded videos and scored all anastomoses using a modified "Structured Assessment of Microsurgical Skills" (SARMS) score. All participants significantly reduced their time needed per anastomosis and their overall SARMS score, as well as individual scores for motion and speed throughout the trial. We saw a significant correlation of prior years of practice in surgery with the overall mean time and mean SARMS score. In a separate analysis of the three sessions, this influence could no longer be seen in the last session. Furthermore, we found no significant effect of gender, age, hand dominance, or gaming experience on speed and quality of the anastomoses. In this study of 117 robotic assisted anastomoses, a rapid improvement of performance of all participants with different surgical skills levels could be shown, serving as encouraging evidence for further research in the implementation of microsurgical robotic systems.

Systematic Review of Robotic-Assisted Peripheral and Central Lymphatic Surgery

BACKGROUND

Robotic-assisted lymphatic reconstruction has gained increasing interest over the past few years.

OBJECTIVES

The aim of this study was to systematically investigate the benefits of robotic-assisted lymphatic surgery based on currently published literature.

METHODS

A systematic review evaluating the feasibility, surgical aspects, and both objective and subjective improvements in patients with impairment of the peripheral or central lymphatic system was performed according to the PRISMA guidelines. The review was registered on PROSPERO.

RESULTS

The literature search yielded 328 articles after the removal of duplicates, followed by a full-text review of the 29 articles, out of which a total of 11 relevant articles were deemed eligible. Among these, seven used a retrospective design and four a prospective design. All studies included confirmed the feasibility of robotic-assisted lymphatic surgery and reported promising results concerning both technical aspects and patient-related outcomes. However, currently, only a limited number of studies directly compare the robotic-assisted approach to the manual approach, and these studies have limited statistical analyses.

CONCLUSION

Despite the heterogeneous measurands, all studies showed the feasibility of robotic-assisted lymphatic surgery, and seven provided promising data on patient-related outcomes. Additional studies are needed to further identify future directions in robotic-assisted lymphatic surgery.