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Page 2 of 8 Jonis et al. Plast Aesthet Res 2023;10:29 https://dx.doi.org/10.20517/2347-9264.2023.06

INTRODUCTION
The development of surgical treatment of lymphedema has been challenging. The first attempt was
described in the early 20th century when ablative procedures such as Charles and Homans were
introduced . Since then, a variety of surgical modalities have been proposed, but often with unsatisfactory
[1]
[4]
[1-3]
results . The first lymphaticovenous anastomosis (LVA) was described in 1960 . But it was not until the
1990s, when Koshima revolutionized the technique by introducing the concept of super microsurgery, that
[5,6]
the LVA gained traction for the surgical management of lymphedema . Since then, the success of the LVA
increased with the introduction of designated microsurgical instruments and novel diagnostic imaging
techniques such as Near Infrared Lymphography (NIRF) and high-frequency ultrasound .
[7,8]
Super microsurgery typically demands exceptional hand-eye coordination, meticulous tissue handling,
dexterity, and operative flow . These qualities can be influenced by various internal and external factors,
[9]
such as the surgeons’ capabilities, tremors, fatigue, and/or aging. Furthermore, super microsurgery can have
a detrimental effect on the surgeon due to prolonged static, awkward positioning, repetitive motions, and
overall generalized muscular fatigue . To ameliorate these factors, the logical next step in advancing super
[10]
microsurgery is the development of robotic assistance.

Robotic-assisted microsurgery (RAMS) has the potential to enhance safety for clinicians and patients by
improving super microsurgical procedures, providing ergonomic designs and enhancing instrument
handling. In turn, it can provide physical relief, and standardize the quality of therapy, notwithstanding the
surgeons’ capabilities, ultimately leading to improved patient outcomes .
[11]

The MUSA is a robotic platform designed specifically for (super)microsurgery, capable of overcoming
human limitations and seamlessly integrating into the existing infrastructure of the operating theatre. This
review aims to provide an overview of the development of the MUSA and its role in lymphatic surgery.

HISTORY OF ROBOT ASSISTANCE IN MICROSURGERY
The exact origin of robot assistance in surgery is difficult to trace. In the 1970s, the National Aeronautics
and Space Administration started developing telerobotic systems to facilitate surgery in space and sparked a
[12]
new interest in utilizing robotics for surgical purposes . Since then, the development of systems to aid
microsurgeons has become a growing field in research, facilitating effective cooperation among surgeons,
[13]
IT experts, engineers, and scientists from diverse fields .

The first master-slave system for microsurgery was developed by Jet Propulsion Laboratories in
collaboration with MicroDexterity Systems and Dr. Steve Charles, a vitreo-retinal surgeon . Ultimately, it
[14]
was tested in a clinical setting and was successful in completing an end-to-end anastomosis on a rat’s
carotid artery .
[15]

The Da Vinci Surgical System (Intuitive Surgical, Inc.) was designed and is mainly used for endoscopic
surgery. However, its use in reconstructive microsurgery has been widely documented. While the feasibility
of the Da Vinci robot has been evidenced and surgeon users report a steep learning curve, no large-scale
data have been published proving its efficacy in microsurgery [16-18] . Furthermore, multiple studies indicate
that the Da Vinci robot disrupts operative workflow, has limited optic magnification for microsurgery, and
lacks suitable instruments for (super)microsurgery [16,18-20] .