Robotic-assisted Microsurgery Research Articles

Robotic-assisted microsurgery using the MUSA-robot: evaluation of the learning curve in three clinical pilot trials

Aim: Current microsurgical procedures are limited by the physiological tremor and dexterity of the surgeon. The MicroSurgical Assistant (MUSA, Microsure), the world’s first robotic platform for (super)microsurgery can aid in resolving issues encountered during microsurgery. This study presents an overview of the operating times and Structured Assessment of Microsurgery Skills (SAMS) scores to assess the duration and quality of microsurgical anastomoses for three microsurgical procedures currently performed using the MUSA. Methods: This study integrates data from one ongoing randomized controlled trial focusing on robotic-assisted lymphaticovenous anastomosis, along with findings from two separate prospective pilot studies concerning digital nerve repair and free tissue transplantation. SAMS scores and time needed per anastomosis were used to evaluate the quality and learning curve of the MUSA-assisted procedures. Results: Thirty-five robotic-assisted procedures were analyzed, including 18 lymphaticovenous anastomoses, 9 digital nerve repairs, and 8 free tissue transplantations. All procedures showed a trend of a decrease in the time needed to perform the procedure. Moreover, the mean overall SAMS scores for all three procedures were rated above ‘satisfactory’, with all procedures demonstrating a consistent trend of increasing SAMS scores over time. Conclusion: The evaluation of anastomosis’ quality in the initial cohorts of patients undergoing robotic-assisted microsurgery using MUSA indicates satisfying outcomes across all three types of procedures. The reduction in anastomosis time and the improvement in SAMS scores imply an ongoing learning process among the operating surgeons. Subsequent reports are expected to provide information on reaching a plateau phase in procedural efficiency.

Robotic-Assisted Microsurgery in Lymphatic Reconstruction.

Lymphatic reconstruction entails microsurgery of the smallest human vessels with little microsurgical error tolerance. Surgical outcomes are therefore tightly tied to microsurgical performances and can be restricted by physiologic tremor or muscle tiring throughout extensive procedures. Recently introduced highly specialized microsurgical robots are promising to help overcome these human limitations, particularly relevant for lymphatic microsurgery. Ideal indications and setups for these robotic systems, however, are not yet well established. Reviewing the first 5 years of clinical experience with these microsurgical robots revealed a total of 204 robotically performed lymphatic anastomoses. Most reported use cases (84.4%) involved microsurgical reconstructions of lymphatic flow at the upper and lower extremities, of which 42% of patients were treated for breast cancer-related lymphedema. Considering rising cancer incidences and survival rates, these numbers highlight the potential of robotic-assisted microsurgery for this patient group, whereas the concept of robotic-assisted microsurgery per se can aid surgeons to achieve a new level of microsurgical excellence.

Robotic-assisted Lymphovenous Anastomosis of the Central Lymphatic System.

Recent advances in robotic microsurgery have enabled the application of robotic technology in central lymphatic reconstruction. Although the use of microsurgical robots demands careful consideration of associated costs and potentially prolonged operating times, it may offer improved surgical approaches and enhanced accessibility to deeper anatomical structures such as the thoracic duct (TD). We report on successful reconstruction of the central lymphatic system using the Symani Surgical System in four patients with lesions of the central lymphatic system. The patients were of different age (range: 8 mo-60 y) and had variable conditions, including central conducting lymphatic anomaly and other rare anomalies of the central lymphatic pathways. Depending on the underlying pathology, a cervical access (n = 1) or median laparotomy (n = 3) was chosen to access the TD and perform anastomosis with a nearby vein. In all patients, anastomoses were patent, and chyle leakage decreased postoperatively. From a surgical perspective, the Symani Surgical System improved the precision of the microsurgeon and accessibility to the deep-lying TD. Considering the high morbidity and rarity of pathologies of the central lymphatic system, robotic-assisted microsurgery holds substantial promise in expanding and improving the microsurgical treatment for central lymphatic anomalies.

Fully Telemetric Robotic Microsurgery: Clinical Experience With 23 Cases.

Recently, there is an ongoing trend in plastic surgery with robotic-assisted microsurgery and supermicrosurgery devices being developed. Combining a telemetrically controlled robotic microscope with an also telemetrically controlled microsurgery robot unlocks synergistic effects with complete disconnection of the operating surgeon from the operating field. Here, we report the first clinical free flap reconstructions using this setup. Twenty-three surgeries were performed with the combined remote approach using the Symani Surgical System and the RoboticScope in open microsurgery procedures. Anastomosis time and ischemia time were recorded. The surgical performance for anastomoses was assessed using the modified Structured Assessment of Microsurgical Skills (SAMS) score. Subjective satisfaction was evaluated by the surgeons in comparison with conventional microsurgery. To evaluate the learning curve, the senior authors first four (first group) and last four (last group) procedures were compared. Overall, flap survival was 95.7%. The average arterial anastomosis time was 36.7 ± 10.9 min. Total time of surgery was 277.7 ± 63.8 min, and ischemia time was 100.6 ± 24.9 min. Most SAMS score parameters were significantly higher in the last group of surgical procedures compared with the first operations. Subjective satisfaction was equal or better with the combined robotic-assisted approach in most categories. Our data demonstrates safety and feasibility of the use of a combined remote approach. Robotic systems for microsurgical procedures may hold promising potential for improvement of surgical quality and open up new frontiers in microsurgery.

Safety and efficacy of Symani robotic-assisted microsurgery: Assessment of vascular anastomosis patency, thrombus, and stenosis in a randomized preclinical study

IntroductionThe Symani Surgical System undergoes scrutiny in this study as part of a series of preclinical investigations. Previous studies compared the precision of robotic-assisted anastomoses with manual techniques. This study aims to evaluate critical, histological and gross parameters at site of anastomosis and at distance in a rat model to provide insights into the safety and efficacy of robotic-assisted microsurgery, enhancing its potential for clinical adoption. Materials and MethodsExperienced microsurgeons performed arterial and venous anastomoses in sixteen Wistar rats, randomized in four treatment groups: robotic artery, robotic vein, manual artery, and manual vein. Various parameters were evaluated at two time-points (T0 and T30) on the day of the procedure and at Day 28(T28d). In the second phase of the study animals underwent necropsy, histopathologic analysis and micro-CT scans angiography imaging of anastomosis sites, major organs and distant target organs by a blinded assessor. ResultsPatency rates were 100% at T0 and T30 for all anastomoses, remaining so at T28d for the robotic subgroups, while decreasing to 87.5% for manual arterial anastomoses due to an obstructive thrombus. No evidence of clot migration. Blood flow parameters and procedure times did not significantly differ. The blinded semi-quantitative histological analysis revealed no significant disparities between robotic and manual anastomoses across various pathological indicators. No gross abnormalities were detected in musculoskeletal examinations. ConclusionThis preclinical study demonstrates the safety of the Symani Surgical System. Results suggest equivalence between robotic and manual techniques regarding thrombus formation at the anastomotic site and distal organs.

100 anastomoses: a two-year single-center experience with robotic-assisted micro- and supermicrosurgery for lymphatic reconstruction

Robotic-assisted microsurgery has gained significant attention in recent years following the introduction of two dedicated microsurgical robotic systems specifically designed for this purpose. These feature higher degrees of movement and motion scaling which are useful tools, especially when performing surgery in areas of the body which are difficult to access. Robotic-assisted microsurgery has been implemented in lymphatic surgery as well as soft tissue reconstructive surgery at our institution over the past 2.5 years. Our study gives an insight into the details and outcomes of the first 100 consecutive (super-) microsurgical anastomoses in peripheral and central lymphatic reconstruction performed with the Symani® Surgical System between 2021 and 2024. In total, 67 patients were treated, receiving robotic-assisted lymphatic reconstruction with lymphatic tissue transfer (LTT) and/or lymphovenous anastomoses (LVA)/lympholymphatic anastomoses (LLA). No anastomosis-associated complications were recorded postoperatively. The majority of patients reported a postoperative improvement of their lymphedema or central lymphatic disorder. In conclusion, we show the successful implementation of the Symani® Surgical System into our clinical practice of lymphatic reconstruction. Although the necessary intraoperative setup and the use of intrinsic motion scaling lead to a slight increase in operating time, the presented study demonstrates the advantages of robotic assistance which becomes particularly evident in lymphatic surgery due to the involved deep surgical sites and the need for supermicrosurgical techniques.

Robot-assisted Microsurgery for Autologous Breast Reconstruction - Robotic Breast Reconstruction

With the introduction of novel surgical robots and surgical microscopes for the special needs of open microsurgery, the concept of robotic-assisted microsurgery is gaining popularity. While initial preclinical studies indicate a steep learning curve, favourable ergonomics and improved precision, albeit with an increased operating time, data on the clinical application of the new systems is still limited. This study describes our first clinical experience with robotic-assisted autologous breast reconstruction and outlines the opportunities and limitations of the approach. Our retrospective data analysis included a total of 28 patients who underwent unilateral robotic-assisted autologous breast reconstruction between July 2022 and August 2023. We applied a combined approach using the Symani Surgical System together with the RoboticScope. Descriptive evaluation of patient characteristics, surgical data and complications was performed. Average patient age was 54.3±11.1 years and average BMI was 26.5±3.5 kg/m2. Twenty-six patients received a DIEP flap and 2 patients received a PAP flap, the flaps being connected to the internal mammary artery in 22 cases, to a perforator of the internal mammary artery in 5 cases, and to a branch of the thoracodorsal artery in one case. The average incision-suture time was 267±89 min, with an average ischaemia time of 86±20 min and duration of the arterial anastomosis of 29±12 min. In two cases, immediate intraoperative anastomosis revision was performed, but no flap loss occurred. The results of this study demonstrate the safe feasibility of robot-assisted autologous breast reconstruction using a combination of Symani and RoboticScope. In the future, special attention should be paid to minimally invasive techniques of flap harvest and connecting vessel preparation.

Robotic-Assisted Microsurgery: Lessons Learned from 50 Consecutive Cases

Robotic-Assisted Microsurgery: Lessons Learned from 50 Consecutive Cases

Robotics in Microsurgery and Supermicrosurgery.

Microsurgery has changed the ability to perform highly precise and technical surgeries through the utilization of high-powered microscopes and specialized instruments to manipulate and repair anatomical structures as small as a few millimeters. Since the first human trials of robotic-assisted microsurgery in 2006, the expansion of microsurgery to supermicrosurgery (luminal diameter less than 1 mm) has enabled successful repair of previously inaccessible structures. Surgical robotic systems can offer two distinct operative advantages: (1) minimal access surgery-by entering body cavities through ports, flap harvest can be redesigned to affect a minimally invasive approach for flaps such as the rectus abdominis muscle, the latissimus flap, and the deep inferior epigastric perforator flap; and (2) precision-by eliminating physiologic tremor, improving ergonomics, increasing accessibility to difficult spaces, and providing motion scaling, precision is significantly enhanced. Robotic-assisted microsurgery is a promising application of robotics for the plastic surgeon and has played an important role in flap harvest, head and neck reconstruction, nerve reconstruction, gender-affirming surgery, and lymphatic reconstruction-all the while minimizing surgical morbidity. This article aims to review the history, technology, and application of microsurgery and supermicrosurgery in plastic surgery.

ROBOTIC PLATFORMS FOR MICROSURGERY: A SYSTEMATIC REVIEW

Abstract Introduction Microsurgery involves procedures that demand maximum precision and dexterity, as well as the absence of tremor. In this regard, new robotic-assisted microsurgery solutions have emerged in recent years. The objective of this review is to analyze the current status of the robotic platforms in microsurgery. Methods This systematic review has been focused on the PubMed database over the last seven years (2015–2022), using keywords related to robotic platforms for microsurgery. Articles including clinical/preclinical studies were considered, and non-English language articles, abstracts, conference proceedings, reviews and letters were excluded. Results A total of 324 articles were identified, 27 of which passed the eligibility criteria. Of the 14 platforms analyzed, da Vinci, MM3 and the easyMicro prototype incorporate their own vision system. The majority of the systems have tremor filtering and provide haptic feedback. The da Vinci system is the most widely used system in vascular and nerve microsurgery, reconstructive and lymph node dissection, eye surgery and urology. The MUSA and Symani systems have been used in reconstructive supermicrosurgery, the neuroarm in neurosurgery, the Surgical Robotic System and the easyMicro prototype in reconstructive and ocular surgery. The MM-3 (vascular), SMART (ocular) and smartARM (neurosurgery) have been tested in artificial models. Conclusions Among the platforms analyzed, da Vinci was the most widely used, specifically in ocular and reconstructive surgery. MUSA and neuroARM are rapidly progressing in reconstructive microsurgery and neurosurgery, respectively.

Robotic-assisted microsurgery in andrology: a systematic review.

Robot-assisted surgery is the gold standard of treatment in many fields of urology. In this systematic review, we aim to report its usage in andrology and to evaluate any advantages. A systematic search of the PubMed and Cochrane Library databases was conducted to identify articles referring to robotic-assisted microsurgery in andrology. The search strategy was in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and the Cochrane Handbook. The articles were then reviewed by two authors. A qualitative analysis of the articles that met the inclusion criteria was performed. Thirty-one articles that met the inclusion criteria were reviewed. The first results for robot-assisted vasovasostomy (RAVV) are encouraging as excellent patency rates, short operative times, and learning curves were achieved. Interestingly, patency rates were greater in some case series for RAVV than for microsurgical vasovasostomy, with a statistically significant difference. In addition, robot has been shown to be of great use in bypassing fibrotic changes in cases of iatrogenic vasal injuries, difficulties encountered with traditional microsurgery. In addition, the feasibility of robot-assisted microsurgery has been proven for varicocelectomy and microsurgical denervation of the spermatic cord, with acceptable improvement in sperm parameters and pain, respectively. The current evidence suggests that there are potential advantages of the use of robots in andrology. However, for robotic surgery to become incorporated into the daily use of the andrologists, large, multicenter randomized trials are needed. As robotics systems are becoming standard in urology practice, it is reasonable for one to believe that they will also find their place in andrology.

Robotic-assisted microsurgery for lymphedema treatment

The recent development of robotic-assisted microsurgery and supermicrosurgery has raised great expectations to support some of the most demanding microsurgical procedures, which are applied in lymphatic reconstructive surgery to restore lymphatic vascular integrity and treat lymphedema. Procedures such as the establishment of lymphovenous anastomosis (LVA), the harvest of lymph nodes from anatomic locations that reduce donor-side morbidity and the transplantation of the vascularized lymph node flaps (VLNT) present procedures necessitating extreme precision and dexterity in often difficult-to-reach areas, thus pushing the physical limitations of the performing microsurgeon. Despite being limited in number, recent preclinical and clinical studies of independent groups using different robotic systems demonstrate the feasibility of robotic technology to perform supermicrosurgical procedures successfully. The robotic assistance offers unparalleled precision, refining the surgical techniques and minimizing potential side effects, with clinical outcomes comparable to the conventional techniques. Although the relative disadvantages of robotic assistance mostly appear to be related to adequate training and the prolonged learning curve, the technology promises to revolutionize the field of supermicrosurgery and improve the clinical outcomes of lymphatic reconstructive surgery.

Leveraging robotics, artificial intelligence, and machine learning for enhanced disease diagnosis and treatment: Advanced integrative approaches for precision medicine

The ever-growing burden of disease necessitates a paradigm shift in healthcare towards a more precise and data-driven approach. This paper delves into the transformative potential of integrating robotics, artificial intelligence (AI), and machine learning (ML) to revolutionize disease diagnosis and treatment. We explore advanced integrative approaches that synergistically combine robotic automation, AI-powered diagnostic tools, and ML-based predictive models to usher in the era of precision medicine. The realm of robotic systems for surgical intervention is experiencing a significant renaissance. We discuss the development and application of next-generation robotic surgical platforms. These platforms boast enhanced dexterity, improved visualization through high-definition 3D cameras, and tremor filtration capabilities, leading to minimally invasive procedures with superior precision, reduced blood loss, and faster patient recovery. We delve into the integration of haptic feedback technology that allows surgeons to experience realistic tissue manipulation, further enhancing surgical control and decision-making. Additionally, the paper explores the burgeoning field of robotic-assisted microsurgery, where miniature robots provide unparalleled access and manipulation at the cellular level, paving the way for groundbreaking advancements in areas like neurosurgery and ophthalmology. Artificial intelligence (AI) is rapidly transforming the landscape of disease diagnosis. We investigate the application of AI algorithms, particularly deep learning architectures like convolutional neural networks (CNNs), in analysing medical images for Computer-Aided Diagnosis (CAD). These algorithms, trained on vast datasets of medical scans, can achieve near-human or even superhuman levels of accuracy in identifying subtle anomalies and disease signatures within radiology images, mammograms, and pathology slides. We discuss the potential of AI-powered CAD systems to support radiologists in early disease detection, improve diagnostic accuracy, and streamline workflow efficiency. Furthermore, the paper explores the promise of AI-driven natural language processing (NLP) for analysing electronic health records (EHRs) to uncover hidden patterns and identify patients at high risk for specific diseases. This allows for proactive intervention and preventative measures tailored to individual patient needs. Machine learning (ML) plays a pivotal role in enabling personalized treatment plans. We delve into the development of robust ML models that leverage large-scale, heterogeneous healthcare datasets. These datasets encompass patient demographics, medical history, genetic information, treatment response data, and real-world clinical outcomes. By analysing such complex datasets, ML algorithms can uncover intricate relationships between patient characteristics, disease progression, and treatment efficacy. This empowers clinicians to generate personalized treatment plans that optimize therapeutic response and minimize side effects. We also discuss the potential of ML for predicting patient response to specific medications and therapies, allowing for the implementation of stratified medicine approaches. This ensures that patients receive the most effective treatment based on their unique biological makeup and disease profile. The paper underscores the importance of real-world applications and case studies in validating the transformative potential of this integrated approach. We present case studies demonstrating the successful utilization of robotic surgery in complex oncological procedures, leading to improved patient outcomes and reduced healthcare costs. Additionally, we showcase the efficacy of AI-powered CAD systems in detecting early-stage cancers, enabling timely intervention and potentially life-saving outcomes. We emphasize the need for robust data collection and standardized protocols to ensure the generalizability and scalability of these novel technologies. The impact of this integrative approach on patient outcomes and healthcare efficiency is meticulously examined. We highlight the potential for robotic surgery to minimize surgical complications, reduce hospitalization times, and improve patient recovery rates. Additionally, AI-powered diagnostic tools can facilitate faster and more accurate diagnoses, enabling earlier intervention and potentially leading to better long-term health outcomes for patients. Furthermore, ML-driven predictive models promote personalized treatments, potentially leading to improved treatment efficacy and cost savings through reduced unnecessary interventions. This paper comprehensively analyses the transformative potential of integrating robotics, AI, and ML to revolutionize disease diagnosis and treatment. By leveraging these advanced technologies, we can usher in a new era of precision medicine, characterized by personalized treatment plans, improved patient outcomes, and enhanced healthcare efficiency. However, this paradigm shift necessitates addressing challenges like data privacy, regulatory frameworks, and equitable access to these technologies. By fostering interdisciplinary collaboration between engineers, clinicians, and data scientists, we can ensure the responsible and ethical development of these powerful tools, ultimately paving the way for a healthier future for all.

Robotic-Assisted Microsurgery and Its Future in Plastic Surgery.

Within the last 20 years, robotic-assisted surgeries have been implemented as routine procedures in many surgical fields, except in plastic surgery. Although several case series report promising results, technical and economic aspects have prevented its translation into clinical routine. This review is based on a PubMed and Google Scholar database search, including case reports, case series, clinical and preclinical trials, as well as patents. Past, recent approaches, ongoing patents, as well as eight specific systems for robotic-assisted microsurgery and their potential to be translated into a clinical routine, are described. They may lay the ground for a novel field within plastic surgery. This review provides an overview of the emerging technologies and clinical and preclinical studies and discusses the potential of robotic assistance in the field of plastic surgery.

Robotic-assisted microvascular surgery: skill acquisition in a rat model.

Microsurgery is a technically demanding field with long learning curves. Robotic-assisted microsurgery has the ability to decrease these learning curves. We, therefore, sought to assess the feasibility of robotic-assisted microvascular surgery in a rat model, and whether this could be translated into a worthwhile skills acquisition exercise for residents. Twenty-eight rats underwent microvascular anastomosis. Procedures were performed by a trained microvascular surgeon with no robotic experience (n=14), or a trained robotic surgeon with no microvascular experience (n=14). Anesthetized rats were subjected to complete transection and end-to-end anastomosis of the abdominal aorta using 10-0 prolene. Manually (n=6) and robotic-assisted (n=8) procedures were performed by both surgeons. A successful procedure required a patent anastomosis and no bleeding. After approximately 35days, angiography and histopathological studies of the anastomoses were performed. Median times for robotic-assisted anastomoses were 37.5 (34.2-42.7)min for the microsurgeon and 38.5 (32.7-52)min for robotic surgeon. In the manual group, it took 17 (13.5-23)min for microsurgeon and 44 (34.5-60)min for robotic surgeon. Within the robotic-assisted group, there was a trend toward improvement in both surgeons, but greater in the microsurgeon. Robotic-assisted microvascular anastomosis in a rat model is a feasible skill acquisition exercise. By eliminating the need for a skilled microsurgical assistant, as well as, improved microsurgical technology, the robotic system may prove to be a crucial player in future microsurgical skill training.

Experience with Robotic-assisted Microsurgery

Experience with Robotic-assisted Microsurgery

Awareness of the ideal recommendations among the members of the Robotic-Assisted Microsurgery and Endoscopic Society (RAMSES)

Awareness of the ideal recommendations among the members of the Robotic-Assisted Microsurgery and Endoscopic Society (RAMSES)

Robotics in Neurosurgery: Evolution, Current Challenges, and Compromises.

Advances in technology have pushed the boundaries of neurosurgery. Surgeons play a major role in the neurosurgical field, but robotic systems challenge the current status quo. Robotic-assisted surgery has revolutionized several surgical fields, yet robotic-assisted neurosurgery is limited by available technology. The literature on the current robotic systems in neurosurgery and the challenges and compromises of robotic design are reviewed and discussed. Several robotic systems are currently in use, but the application of these systems is limited in the field of neurosurgery. Most robotic systems are suited to assist in stereotactic procedures. Current research and development teams focus on robotic-assisted microsurgery and minimally invasive surgery. The tasks of miniaturizing the current tools and maximizing control challenge manufacturers and hinder progress. Furthermore, loss of haptic feedback, proprioception, and visualization increase the time it takes for users to master robotic systems. Robotic-assisted surgery is a promising field in neurosurgery, but improvements and breakthroughs in minimally invasive and endoscopic robotic-assisted surgical systems must occur before robotic assistance becomes commonplace in the neurosurgical field.

Robot-Assisted Pterygium Surgery: Feasibility Study in a Nonliving Porcine Model.

This study aims to investigate the feasibility of pterygium surgery using the DaVinci Si HD robotic surgical system, and to describe a porcine model for pterygium surgery and evaluate its usefulness. The pterygium models were constructed using enucleated pig eyes and cold cuts. Robotically-assisted pterygium surgeries in nonliving biological pterygium models were performed using the DaVinci Si HD robotic surgical system. Twelve models were prepared, and 12 pterygium excision and conjunctival autografts were performed. The DaVinci system provided the necessary dexterity to perform delicate ocular surface surgery and robotic tools were safe for the tissues. The mean duration of the surgical procedures was 36 minutes. There were no intraoperative complications and no unexpected events. Robotic-assisted pterygium surgery is technically feasible for porcine eyes using the DaVinci Si HD robotic surgical system. The pterygium model that we describe could be of interest for surgical training. Little research has been done in robotic microsurgery. Animal experimentation will allow the advantages of robotic-assisted microsurgery to be identified, while underlining the improvements and innovations necessary for clinical use.

Robotic-assisted microsurgery for an elective microsurgical practice.

Robotic-assisted microsurgery can be utilized for either intracorporal or extracorporeal surgical procedures. Three-dimensional high-definition magnification, a stable ergonomic platform, elimination of physiologic tremor, and motion scaling make the robotic platform attractive for microsurgeons for complex procedures. Additionally, robotic assistance enables the microsurgeon to take microsurgery to challenging intracorporeal locations in a minimally invasive manner. Recent adjunctive technological developments offer the robotic platform enhanced optical magnification, improved intraoperative imaging, and more precise ablation techniques for microsurgical procedures. The authors present the current state-of-the art tools available in the robotic-assisted microsurgical platform.