First Series of Free Flap Reconstruction Using a Dedicated Robotic System in a Multidisciplinary Microsurgical Center

Abstract

Summary: Robotic microsurgery is a novel technology for microsurgical free flap transplantation in reconstructive surgery. Recently, the first free flap transplantation using a dedicated robotic system for microsurgery (Symani Surgical System; Medical Microinstruments) was published for a single reconstructive case. For broader future application, evaluating its potential benefits in different anatomical regions, anastomotic configurations, and clinical scenarios is necessary. In this world-wide first free flap series using this robotic system, we describe our experience with this new technology in a multidisciplinary microsurgical center. The robotic system was used for different free flaps in a range of reconstructive applications in plastic surgery, oral and maxillofacial surgery, and head and neck surgery. A total of 23 flaps were performed, with all 23 arterial and a selection of two venous anastomoses being performed with the robotic system. Time for anastomoses was significantly longer than commonly. Five of the arterial robotic anastomoses had to be redone. All but one flap survived. We could show that this new dedicated microsurgical robotic system is feasible for carrying out robot-assisted anastomoses in end-to-end, as well as end-to-side fashion under varying clinical conditions and in different microsurgical subspecialties. However, some drawbacks still need to be overcome, which are partly related to individual and institutional learning curves, to finally estimate the potential benefit for robotic free flap surgery. Multidisciplinary application of the robotic system may accelerate this process by putting together different microsurgical backgrounds, while economic burden of establishing this new technology is spread among several departments.

The emerging role of robotics in plastic and reconstructive surgery: a systematic review and meta-analysis

“…A total of eight articles described robotic flap pedicle or vessel dissection [ 73 – 80 ]. 16 articles detailed robotic free flap inset or anastomosis (vessel, nerve and lymphovascular) [ 34 , 81 – 95 ]. Two articles described robotic craniofacial techniques (mandibular contouring) [ 96 , 97 ].…”

“…Two training models in microvascular anastomosis reported a plateau in learning curve of robotic anastomosis by expert surgeons on synthetic silicone vessels and rat vessels to be 5 and 8 attempts, respectively [ 16 , 17 ]. Beier et al developed a 4-week training programme with synthetic 1 and 2 mm vessels, in which 10 successful anastomosis were deemed to be the benchmark for skill acquisition before progression to clinical practice [ 34 ].…”

Robot-assisted Microsurgery: Lessons Learned from 50 Consecutive Cases

“…The system has been successfully used in lymphatic surgery and free flap surgery. [9][10][11] A 2023 literature review of all articles investigating robotic microsurgery in plastic surgery highlighted the gap in the literature with only 19 relevant articles identified, of which only five directly compared the robotic and conventional approaches. 12 The majority of these studies were preclinical animal studies or case reports.…”

Robotisch-assistierte Lymphchirurgie

“…Zudem konnten wir zeigen, dass das Robotersystem auch für die epineurale Koaptation im Rahmen von Nervenrekonstruktionen eingesetzt werden kann [3]. Kürzlich haben auch weitere Autoren über den erfolgreichen Einsatz des Symani Surgical Systems für den mikrovaskulären Anschluss verschiedenster freier Lappenplastiken berichtet [20].…”