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Page 6 of 8 Gousopoulos et al. Plast Aesthet Res 2023;10:7 https://dx.doi.org/10.20517/2347-9264.2022.101

development of new robots for specific indications. This progress is expected to enhance surgical precision
and enable the expansion of surgical procedures.

The expansion of microsurgical instruments to improve the degree of articulation and meet different size
demands will decisively influence the increase of robotic deployment. Additionally, the development of new
instruments or miniaturized versions of existing ones will augment the surgeon’s capabilities. Instruments
to dissect vessels and tissue will be introduced. The inclusion of biosensors and improvement in the haptic
feedback may restore one of the main drawbacks of robotic surgery, even if visual cues can mimic the
perception of tactile feedback. This is particularly crucial in supermicrosurgery, as the surgeon is unable to
sense the forces applied to the fragile lymphatic capillaries. Thus, the inclusion of haptic feedback could
further improve surgical precision and atraumatic handling [26,29] .

The optimal visualization of the operating field presents another topic of intense research that decisively
influences supermicrosurgery. The development, refinement or integration of imaging modalities such as
three-dimensional imaging, high-spectral imaging or near-infrared fluorescence imaging could facilitate the
intraoperative anatomical navigation, support the functional assessment of anastomosis patency and
partially compensate for the absence of haptic feedback [29,30] .

Last but not least, the inclusion of artificial intelligence systems in robot-assisted systems promises to bring
surgical techniques to a new level. The recording and analyzing of the surgical movements used in
intelligent robots will result in the development of cognitive skills and a process of “self-learning”, thus
leading to semi-automated surgical applications. The possibilities for improving surgical techniques and
[31]
training can be breathtaking .
CONCLUSION
Following the establishment of lymphatic reconstructive surgery as the only means currently available to at
least partially restore lymphatic integrity, the effort is now placed on refining the techniques used,
improving surgical outcomes and minimizing potential side effects.

Due to the extreme nature of lymphatic surgery, surgeons face technical and physical limitations. However,
robotic-assisted supermicrosurgery enables the performance of this delicate surgery beyond the physical
capabilities of the human hands, offering unprecedented dexterity, accuracy and endurance. In addition
robotic systems will make access to the central part of the lymphatic sytsem, e.g., the thoracic duct more
accessible .
[32]
The literature available so far demonstrates the feasibility of the technology and favorable clinical outcome,
with a considerable but steep learning curve effect. Undoubtedly tremendous potential is available,
empowering the growth and hopefully the accessibility of robotic-assisted supermicrosurgery, identifying
novel applications for the patient`s needs and optimizing surgical outcomes.

DECLARATIONS
Authors’ contributions
Review conception and design: Gousopoulos E, Grünherz L, Lindenblatt N
Manuscript preparation: Lindenblatt N
Critical revisions: Gousopoulos E, Grünherz L, Giovanoli P, Lindenblatt N