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Page 4 of 8 Gousopoulos et al. Plast Aesthet Res 2023;10:7 https://dx.doi.org/10.20517/2347-9264.2022.101

Robotic supermicrosurgery facilitates these procedures, helping microsurgeons overcome these limitations.
Robotic assistance provides complete tremor amortization and motion scaling up to 20x. This leads to
increased precision and unparalleled steadiness, particularly when handling or preparing extremely small
and fragile lymphatic vessels or performing anastomosis with size mismatch or in deeper body cavities. The
presence of flexible, free-moving robotic arms and seven degrees of freedom enables the deployment of the
robot even in deeper and less accessible anatomic locations. While the microsurgery robots are compatible
with existing operation microscopes, three-dimensional visualisations systems, also referred to as exoscopes,
may contibute in a better spacial vision in light of the the absent “haptic” feedback. Additionally, the recent
development of robotic systems without fixed joysticks but with a remote console further improves the
[15]
surgeon’s ergonomic position and endurance performance.

Currently, there are two robotic microsurgery systems available. The robotic system MUSA® (MicroSure,
Eindhoven, The Netherlands) developed in 2014 is the first available system of its kind . It is equipped
[25]
with dedicated supermicrosurgical instruments. However, it is mounted to the surgical table with fixed
joysticks. Its feasibility for microsurgery has been demonstrated in both preclinical and clinical models [14,25] .
The second available system is the Symani® Surgical System [Medical Microinstruments (MMI), Pisa, Italy]
which was designed the second available system is the Symani® Surgical System (Medical Microinstruments
(MMI), Wilmington, DE, USA) which was designed to provide movable manipulators istead of fixed
handling joysticks [Figure 1]. In the system, the specialized microsurgical instruments are connected to
flexible robotic arms, which are guided through freely movable forceps-like joysticks. The system also allows
teleoperation, and the forceps-like joystick’s similarity to conventional micro-instruments has been reported
to enhance the robot-assisted experience .
[15]

The available but limited literature reporting the first experiences of the robotic system application in
lymphatic reconstructive procedures [15,25] , including the personal experience of the senior author of this
manuscript, suggests the technical feasibility of the technique, with clinical outcomes comparable between
robotic-assisted and conventional lymphatic surgery [26,27] [Table 1]. However, potential drawbacks of these
initial applications of the new technology definitely exist and are analyzed below.

THE CHALLENGES OF ROBOTIC-ASSISTED (SUPER)MICROSURGERY
Despite the obvious advantages of using robotic-assisted supermicrosurgery, a number of limiting factors
have to be acknowledged as well. The major obstacle in the broad integration of robotic technology in the
surgical routine is the learning curve and the initially increased operating times. The published literature
indicates increased anastomosis times using the robot versus the manual technique, even for very
experienced microsurgeons. However, the learning curve was found to be steep, with the quick
improvement in the operating times. The frequency of practice and level of microsurgical experience were
found to support faster improvement and significantly decrease anastomosis time [27,28] .

Furthermore, the absence of haptic feedback and the need for the performing surgeon to develop a “see-
feel” concept during the performance of the anastomosis is a relative limiting factor. The use of adequate
imaging support and training has been reported to significantly and rapidly improve the absence of
sensorial feedback, especially among already experienced surgeons [15,29] .

Lastly, the increased costs to purchase and maintain the robot, the expensive robotic consumables and
instruments, as well as the need to have an appropriately educated operating room team to maintain time
efficiency have to be taken into consideration and may limit the accessibility and adoption of the
technology.