Robotic surgical systems in plastic and reconstructive surgery

Abstract

To the Editor: Owing to robotic surgery has the advantages of being accurate, stable, and easy to control, the use of robotic systems in surgery is increasing. Despite this progress, the adoption of robotic technology in plastic and reconstructive surgery has been slower than many other specialties. Recent research has shown promise for the use of robotic assistance in plastic surgery, reconstructive surgery, and microsurgery. Figure 1 summarized the main applications of robotic surgical systems in plastic and reconstructive surgery, which can be divided in the following five aspects: microsurgery, breast reconstruction, transoral robotic surgery, maxillofacial surgery, and hair transplantation.Figure 1: The application of robot surgical systems in plastic and reconstructive surgery.RNSM: Robotic nipple-sparing areolar mastectomy; IBR: Immediate breast reconstruction; DIEP: Deep inferior epigastric artery perforator.Microsurgery is a branch of plastic surgery that requires high accuracy. The robotic surgical approach offers several advantages, such as improved three-dimensional (3D) visualization, dexterity of wristed instruments, and tremor elimination, thereby greatly promoting the development of microsurgery. Several companies are currently developing robotic systems exclusively designed for microsurgery, and their main clinical application is robotic microvascular and microneural surgery. In 2000, ten 1-mm femoral arteries in rats were successfully anastomosed using a four-degree telemanipulator at up to 30× magnification, promoting the development and later clinical application of daVinci surgical system in robot-assisted microvascular anastomosis. In the confined anatomical space, the clinicians can use the robot to perform the anastomosis with better suture effects and less complications. The development of microneurosurgery is almost parallel to that of microvascular surgery. In 2009, the daVinci robot was innovatively used to repair peripheral nerves with 10–0 nylon. Subsequently, the feasibility of robot-assisted intraneural dissection and reconstruction in patients with peripheral nerve tumors and shoulder girdle nerve injuries was gradually demonstrated in the clinic. In recent years, the indications for robotic surgery have expanded to supermicrosurgery, such as lymphedema surgical procedures including vascularized lymph node transfer (VLNT) or lymphaticovenous anastomoses (LVA), which require high precision and manual dexterity. Robot-assisted surgical systems can reduce issues related to human fatigue, accessibility, and ergonomic posture. The MUSA (MicroSure, Eindhoven, The Netherlands), the first dedicated robotic platform designed for microsurgery, was developed in 2014.[1] This system is small and light, can be installed on the operating table and microscope, and is compatible with existing microinstruments. van Mulken et al[1] confirmed the safety and feasibility of the MUSA in a preclinical test and carried out a randomized pilot study investigating patient outcomes and the quality of anastomosis in robot-assisted surgery for the treatment of breast cancer-related lymphedema (BCRL). The results showed improved patient outcomes and the absence of serious adverse events, and proved that it was feasible to complete supermicrosurgical anastomoses in patients with BCRL using the MUSA. Robotic surgical systems are also used in the minimally invasive treatment of breast cancer and immediate breast reconstruction (IBR). In 2015, Toesca et al[2] first applied the daVinci robot platform for robotic nipple-sparing areolar mastectomy (RNSM) combined with IBR and later assessed the feasibility, reproducibility and safety. At present, medical centers in many countries have begun to carry out relevant research on RNSM combined with IBR. Current results show that, compared with conventional and endoscopic surgery, robot-assisted surgery has the characteristics of a clear operation field, flexible operation, less bleeding