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Jonis et al. Plast Aesthet Res 2023;10:29 https://dx.doi.org/10.20517/2347-9264.2023.06 Page 3 of 8

Development of a designated microsurgical robot
The aforementioned limitations and the increasing demand for super microsurgery resulted in a
collaboration between technicians of the Technical University of Eindhoven (TU/e, Eindhoven, Eindhoven)
and microsurgeons of the Maastricht University Medical Center to develop a surgical robot designated for
super microsurgery.

The MUSA is a lightweight, small-sized master-slave system that can be incorporated into any surgical
setting. It is compatible with existing surgical microscopes and exoscopes and uses conventional super
micro instruments. The robot consists of slave manipulators that can be mounted on the operating table
and can be adjusted in height according to the location of the operative field. The surgeon has a direct view
of the operation site and is able to perform surgery using joystick-like master manipulators. Through the
device software, the manipulators can filter out tremors and motion scaling is effectuated using the foot
pedals.

The efficacy of the MUSA Gen-1 was tested in a preclinical setting using 2 mm-silicone vessels and in vivo
rat models in previously reported studies [21,22] . In both studies, the time to perform an anastomosis was
logged and the quality of the anastomosis was measured using the modified version of the Structured
Assessment of Microsurgical Skills (SAMS) .
[23]
The SAMS score consists of four categories (dexterity, visuospatial ability, operative flow, and judgment),
and each category contains three items that can be scored from 1 (bad) to 5 (excellent). Overall performance
[23]
(1 bad-5 excellent) and indicative skill (1 novice-5 expert) were also evaluated .
During the preclinical studies with silicone vessels, conventional manual microsurgery had overall higher
SAMS scores compared to robot-assisted procedures. Overall, a learning curve was reported for indicative
[22]
skill and overall performance in both groups .
During the in vivo experiments with rat models, the abdominal aorta (1.8 to 2.4 mm) and femoral artery
(0.7 to 0.8 mm) were used. While manual surgery had shorter anastomosis times and higher SAMS scores,
the MUSA once more showed a steep learning curve, with surgery time gradually decreasing and overall
[21]
quality per anastomosis improving. Furthermore, patency was confirmed in all anastomoses but one .

Even though manual surgery reported higher SAMS scores, the results of the first designated microsurgical
robot were not disappointing. The steep learning curve in the robotic group indicates that with adequate
training, the MUSA robot has the potential to supersede manual surgery. Based on this newly gained
experience, a new generation MUSA was created with a more ergonomic design to improve manual
dexterity [21,22] .

FIRST-IN-HUMAN ROBOTIC LVA
In 2017 the first LVA using a designated microsurgical robot (MUSA) was performed, followed by the first-
in-human randomized pilot study to evaluate the feasibility of the MUSA in super microsurgery . The
[24]
study evaluated the efficacy of the MUSA in LVA surgery in patients suffering from breast cancer-related
lymphedema (BCRL). From 2017, twenty females suffering from unilateral BCRL of the arm, stage 1 or 2,
according to the International Society of Lymphology, with viable lymphatic vessels ICG stadium II-III
(Narushima) as determined with NIRF were randomized to undergo robot-assisted or manual LVA . In
[25]
the video Supplement Materials, an LVA is demonstrated with the use of the MUSA robot. A minimum of
30 h of robot microsurgical training was required before the surgeon can participate in the study.