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Page 2 of 8 Gousopoulos et al. Plast Aesthet Res 2023;10:7 https://dx.doi.org/10.20517/2347-9264.2022.101

INTRODUCTION
Lymphedema is defined as the insufficiency of the lymphatic system to efficiently drain interstitial fluid
from the periphery, resulting in edema. It is classified as primary or secondary, depending on the cause of
the lymphatic disorder; primary lymphedema is a rare genetic disorder, while secondary lymphedema may
[1]
occur following infection, trauma or iatrogenic intervention . Secondary lymphedema as a result of surgical
oncology is one of the most common yet underestimated side effects of the oncologic treatment. It is
estimated that approx. 20% of the patients receiving lymphadenectomy as part of their oncologic regime,
e.g., breast cancer, other gynecological tumors, urological malignancies, melanomas and sarcomas, will
develop lymphedema, with potentially increased risk for lower extremity lymphedema . While the gold
[2,3]
standard remains conservative decongestive therapy, lymphedema is increasingly treated surgically, as
lymphatic reconstructive surgery aims to reestablish the lymphatic network integrity using microsurgical
and supermicrosurgical techniques. Recent studies report improved outcomes when lymphedema is treated
earlier, as the fibroadipose tissue alterations contribute to the irreversible character of the disease .
[4,5]
Lymphatic reconstructive surgery for lymphedema includes the installation of lymphovenous anastomosis
[6]
(LVA) or transfer of vascularized lymphatic tissue (VLNT) . While LVAs redirect lymph into the venous
system, the transfer of vascularized lymph nodes supports lymphangiogenesis and allows lymph to drain
[7]
through the venous system . The efficacy of these surgical approaches in reducing the edema of the affected
extremities and improving the quality of life for the treated patients has been assessed in a number of
[8,9]
clinical studies, which have been summarized in comprehensive systematic reviews .
The progress in the development of novel surgical approaches has been supported by the improvement of
the surgical armamentarium and the use of robots in surgery has pushed the boundaries of medical
innovation. From the first reported use of the daVinci® Surgical Robotic System in a robotic-assisted
cholecystectomy twenty years ago , the daVinci® technology has been implemented in many surgical
[10]
specialties to accomplish highly complex minimally invasive interventions . The three-dimensional
[11]
stereoscopic vision, instruments with increased motion of freedom, scalable movements and elimination of
tremor offered by the robotic technology found a number of applications in plastic and reconstructive
surgery quickly . Despite these advantages, experimental studies indicated the drawbacks of this
[12]
technology in microsurgery due to the absence of dedicated, refined instruments of small size and subtle
handing that this type of surgery requires . The special and refined needs of reconstructive microsurgery
[13]
led to the development of specialized robotic systems for microsurgery and supermicrosurgery, which have
been found particularly useful in lymphatic reconstructive surgery [14,15] .

In this review, we will address the use of robotic surgery in the field of lymphatic reconstructive surgery. We
will provide an overview of the various robotic applications, their advantages and disadvantages, as well as
the future directions in robotic-assisted supermicrosurgery.

ROBOTIC-ASSISTED PLASTIC AND RECONSTRUCTIVE SURGERY
Robotic technology has been introduced into the field of plastic and reconstructive surgery with a number
of applications, ranging from flap harvest to nerve surgery and trans-oral robotic surgery .
[12]
In a constant effort to improve flap harvesting, robotic-assisted surgery was a promising tool. Decreasing
scaring, attempting a less traumatic dissection and increasing the pedicle length have been the driving
incentives. Muscle flap harvest has been attempted by different groups for isolated cases, suggesting the
feasibility of the method . In the particular case of the DIEP flap harvest for breast reconstruction, the
[12]
usage of a robot was found to enable a minimally invasive intra-abdominal dissection of the entire pedicle