Page 28 - Read Online

Gousopoulos et al. Plast Aesthet Res 2023;10:7 https://dx.doi.org/10.20517/2347-9264.2022.101 Page 3 of 8

[16]
length, reducing the fascial incision to 1.5-3cm while achieving a pedicle length of 10-15cm . Given its
[17]
well-known abdominal donor site morbidity , this suggests an attractive approach to improve outcomes
after DIEP flap harvest.

ROBOTIC-ASSISTED HARVEST OF VASCULARIZED LYMPHATIC TISSUE
Autologous lymph node transplantation has widely gained acceptance in lymphedema reconstructive
surgery, particularly in advanced and primary lymphedema. In the process of refining the procedure, an
effort was paid to decrease the donor site morbidity and thus reduce the risk of causing lymphedema at the
harvesting site. Among the different options, the omentum presents an ideal donor for autologous
vascularized lymph node transfer. It is abundant in lymphatic tissue, offers a broad surface area and reliable
vascularity and eliminates the risk of donor-site lymphedema [18,19] .

The use of the omentum was initially limited due to the concern of complications related to intra-
abdominal manipulation and the need for laparotomy. The development of laparoscopic techniques clearly
improved the harvest and significantly reduced the associated complications. Reduced blood loss, reduced
post-operative pain, faster recovery and improved cosmesis are counting among the major benefits of this
less invasive technique. But the visualization is still imperfect, restricting the ability of fine dissection. The
inclusion of robotic harvest enabled a leap in the omentum flap harvest technique. The robotically assisted
harvest offers an unparalleled visualization of the tissue, thus supporting very precise tissue dissection and
pedicle preparation. What is more, the risk of damaging adjacent anatomical structures is minimized due to
the tremor amortization and increased motion of freedom. The inclusion of additional imaging tools, such
as fluorescent optics to visualize the blood and lymphatic vascular patterns, allows for improving the flap
design and harvest [20,21] .

Despite the longer operating times in comparison to the laparoscopically assisted surgery and the
specialized training needed, the robotic harvest presents a promising approach in lymph node harvest for
lymphatic reconstructive surgery.

ROBOTIC-ASSISTED MICROSURGERY AND SUPERMICROSURGERY IN LYMPHEDEMA
It is without a doubt that the development and establishment of the VLNT and LVA techniques have
drastically changed lymphedema treatment, particularly given that no pharmacological treatment is still
currently available and the conservative measurements cannot correct the underlying lymphatic vascular
compromise. Many prospective and retrospective studies highlight the positive outcomes of lymphatic
reconstructive surgery, namely volume and circumference reduction, improved quality of life and reduction
of compression garment use [18,22] . Both techniques are extremely refined and technically demanding, with
strong physical demand for the performing microsurgeon. A significant level of experience is necessary,
[23]
along with the acquisition of challenging surgical skills . Thus, technical improvements in the surgical
armamentarium used are needed to improve surgical outcomes.

With the urge to constantly improve and refine surgical techniques, the development of robotic-assisted
supermicrosurgery was introduced into lymphatic reconstructive surgery. Lymphatic microsurgeons are
confronted with the anastomosis of vessels with a diameter between 0.3 to 0.8 mm for the reconstruction of
lymphatic flow and the transplantation of pedicled lymph nodes in often hard-to-reach areas, e.g., the axilla.
In particular, for the performance of LVAs, extremely fine nylon sutures (11-0 or 12-0) on a 50 µm needle
are required, defining undoubtedly extremely technically demanding circumstances. Even for experienced
surgeons with outstanding skills and experience, the surgical performance is still limited by the precision
and dexterity of the human hands [12,24] .