Early Experience Using a New Robotic Microsurgical System for Lymphatic Surgery

Abstract

Summary: Robotic microsurgery has emerged as a new technology with potential benefits for reconstructive surgery. We report the first-in-human use of the Symani surgical system to perform lympho-venous and arterial anastomosis for lymphatic reconstruction. In five patients, 10 robot-assisted anastomoses were performed. Next to lympho-venous anastomoses, two patients received a free vascularized lymph node transfer. Motion scaling was set to 10×. Visualization was either achieved with a 3D system or an optical microscope. All anastomoses were patent as confirmed by ICG. Despite a longer time to perform the first anastomoses with the robot, we observed a decline in duration of anastomosis. Among the advantages of the system were a high accuracy in placing the stitches even in very small and fragile vessels or when performing anastomoses with size mismatches. The challenges encountered included the lack of a touch sensation and the necessity to develop a “see-feel.” This could be achieved surprisingly well because the force necessary to close dilator and needle holder via the manipulators was perceived as comparable to using conventional micro instruments. Our data confirm feasibility and safety of the robotic system to perform lymphatic surgery. Larger patient cohorts and inclusion of surgeons at different training levels will be necessary to investigate the true potential of robotics in microsurgery. In addition, robot-assisted surgery shows a promising potential in opening up new frontiers in reconstructive microsurgery (eg, the reliable performance of anastomoses on even smaller blood and lymphatic vessels or on structures deeper within the body cavities—eg, the thoracic duct).

Exploring the learning curve of a new robotic microsurgical system for microsurgery

“…The feasibility and safety of using this device for microsurgery in humans have been previously demonstrated by our group. A further step is to assess the potential and the challenges of this innovative tool 2 . It is well known that microsurgery requires a specific set of skills, but despite the extensive training, there are factors intrinsic to the human hand, like tremor, precision, and accuracy, that are subjective and can be influenced by the psychological and physical status of the surgeon 6 .…”

“…We have recently shown the feasibility and safety in performing micro- and supermicrosurgical anastomosis in lymphatic reconstruction with the system. 2 The Symani Surgical System® was also used for a free flap in a post-traumatic upper limb reconstruction by Innocenti and his team 5 .…”

A Novel Microsurgical Robot: Preliminary Feasibility Test in Ophthalmic Field

“…1 ) was designed to enhance reconstructive and microsurgery applications, and it received CE marking in 2019. 10 , 11…”

Robotic-Assisted Microsurgery and Its Future in Plastic Surgery

“…Thus far, this system has been used in five clinical cases for the pharynx and lower leg reconstruction (personal communication with MMI, cases presented at Barcelona Breast Meeting 2020). Additionally, Lindenblatt et al confirmed the usage of the Symani System in the field of plastic and reconstructive surgery by presenting successful Symani-assisted lympho–venous anastomosis and lymph node transfer [ 30 ].…”