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Jonis et al. Plast Aesthet Res 2023;10:29 https://dx.doi.org/10.20517/2347-9264.2023.06 Page 5 of 8

A total of 14 anastomoses were completed using robot assistance, with a mean number of 1.75 anastomoses
per patient; in the manual group, 26 anastomoses were performed with a mean number of 2 anastomoses
per patient. The mean duration per anastomoses was significantly higher in the robot-LVA group compared
to the manual-LVA group [respectively, 25 ± 6 min, range 16-33 min and 9 ± 6 min, range 4-36 min,
(P < 0.001)]. The mean surgical time in the robot-LVA group was 115 min (range 69 min to 185 min) vs.
81 min in the manual-LVA group (range 48 min to 140 min), but the difference was not significant.
Interestingly, the surgical time in the robot-LVA group decreased after every procedure, indicating a
[24]
reasonable learning curve .
Ultimately, the quality of the microsurgical techniques measured by the SAMS and UWOMSA was
significantly higher in the manual-LVA group compared to the robot-LVA groups (SAMS; 4.0 ± 0.3
[24]
and 3.2 ± 0.4, respectively (P < 0.001), (UWOMSA; 4.0 ± 0.5 and 3.4 ± 0.3, respectively (P < 0.001) .
This was the first clinical study using robotic assistance in LVA surgery. The prospects might be optimistic
due to favorable results when comparing manual vs. robot LVA. However, large-scale data are still needed
to corroborate these results. Momentarily, a continuation of the current study with a larger population is
being conducted.

VALUE OF THE ROBOTIC-ASSISTED MICROSURGERY
Developing the first robotic platform for microsurgery
Our Department of Plastic, Reconstructive and Hand Surgery in the Netherlands was honored to start and
pursue the endeavor of creating a robot for microsurgery in 2009. Through continuous collaboration with
the technicians of TU Eindhoven, the MUSA robot was created primarily for scientific purposes. Ultimately,
this collaboration resulted in the establishment of Microsure®.

Our first experience with robot assistance in microsurgery using the Da Vinci provided valuable insights
[20]
into the properties required for a designated microsurgical robot . Although the Da Vinci is able to
accommodate microsurgical instruments, its main focus is intra-abdominal procedures . Due to the
[30]
requisites of microsurgery, a custom platform with specific features was required.
Through the development of the MUSA, the preclinical and clinical trials by plastic surgeons using the
robotic platform continuously provide the engineers with valuable feedback and have been able to expand
the use of the MUSA [21,22,24,26] . Aside from LVA surgery, the MUSA is being used for digital nerve repairs and
free tissue transplantation. In 2019, MUSA got the Conformité Européenne certification, allowing its use
outside clinical trials.

Distinctive characteristics of MUSA robot
MUSA robot distinguishes itself from other RAMS due to its ability to integrate well into the conventional
surgical setting and, more importantly, to use current supermicrosurgical instruments. This enhances its
versatility to perform both microsurgical and super microsurgical procedures, limiting the introduction of
[26]
new disposable materials and thus reducing costs .
Meaningful technology development for patients
Nowadays, there has been a large influx of new medical gadgets and devices, with the intention (at least in
theory) to improve the quality of care and obtain better clinical outcomes. Skepticism and rejection are
sometimes warranted, as patients’ well-being and high-quality medical care should be the main goals of
clinicians and researchers. Clinicians should remain critical and continuously ask: what are the potential