Robotic-Assisted Microsurgery: Lessons Learned from 50 Consecutive Cases

Abstract

Background: Robotic-assisted surgery has shown significant promise in various fields of medicine, and its potential application in plastic and reconstructive surgery is currently being explored. We aim to present our experiences from the first 50 consecutive cases of robotic-assisted microsurgery using the Symani® surgical system. Methods: A prospective database was maintained, recording patient demographics, surgical details and outcomes for all cases of robot-assisted microsurgery. All surgeons underwent an intensive training program with the Symani® surgical system. Results: Our study cohort consisted of 50 patients who underwent robotic-assisted microsurgical reconstructions from February until June 2023. Free microsurgical tissue transfer was performed in 45 cases, targeted muscle reinnervation in four cases and lymphovenous anastomoses in one case (Figure 1). Six senior surgeons performed the surgeries (Cases per individual surgeon: 18, 9, 7, 6, 5, 5). In total, 94 robotic-assisted anastomoses and coaptations were performed. There were 46 venous and 30 arterial anastomoses (19 end-to-end, 11 end-to-side), 16 nerve coaptations and two lymphovenous anastomoses. Six cases involved perforator-to-perforator anastomoses. Size-mismatch anastomoses took significantly longer than size-matching anastomoses and were found in 37.8% (Figure 2). 98% of attempted anastomoses were completed using the robot. Intraoperative complications that required a conversion were encountered in four cases (1 technical difficulties, 3 non-patent arterial anastomoses). Minor complications occurred in three cases. Major complications were observed in six cases (6/50; 12.0%). In due to arterial thrombosis occurred on POD 1 (1 end-to-end, 2 end-to-side; takeback rate 6.7%). All flaps were successfully salvaged. No complete flap losses occurred. Conclusion: The study suggests that robotic-assisted microsurgery may be a feasible and effective modality for various microsurgical procedures, with outcomes comparable to traditional microsurgery. Despite potential challenges, such as increased operating times and high costs, the technology may offer significant advantages, including enhanced precision and reduced surgeon fatigue. There seems to be a rather shallow learning curve and a necessity for high caseloads or continuous training, since surgeons with less exposition did not decrease, but increase their operating times over the course of their first clinical cases (Figure 2). Further studies are needed to refine techniques and evaluate long-term outcomes.