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one eye and a fine forceps held in one hand. It differs Endoscopic telemicrosurgery and minimally invasive
by the use of binocular loupes and fine instruments held robotically‑assisted microsurgery, which is still in its
in both hands. The three‑dimensional (3D) vision is made infancy, could experience a significant development in the
possible by the treatment of a shifted image for each eye, 2020s, when a specialized robot will have been devised.
which is essential in microsurgery where the smallness The market potential is huge, especially if we think of the
of the depth of the operating field requires very precise replacement of all conventional surgical microscopes with
movements. robotically‑assisted microscopes.

FROM MICROSURGERY TO PROPERTIES OF ENDOSCOPIC
ENDOSCOPIC TELEMICROSURGERY TELEMICROSURGERY

Since its inception in the 1960s, microsurgery has Only robots will cross the limits of human capabilities.
experienced a paradoxical development. Countless surgical Some surgical robots have already disappeared from
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techniques have been described starting from digit the market (Aesope , Zeus ), and others are under
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replantation to hand transplant, through nerve repair by development (Amadeus , Newton , Gumby , etc.) including
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direct and indirect nerve grafts and neurotizations, free, some prototypes specific to microsurgery (MSR, RAMS ). In
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and pedicled flaps, and finally to the recent applications fact, only the DaVinci robot is currently available on the
of perforator flaps and the use of supermicrosurgery market.
applied to less than 0.5 mm diameter vessels. Meanwhile, The prospect of microsurgery is to develop systems
the technology itself (i.e. microscopes and instruments) in order to enhance human capabilities of vision and
has not changed in over fifty years. Microscopes have to enhance manipulation of tissue repair. Ultimately,
indeed evolved toward voice control screens with 3D conventional microsurgery only increases two human
glasses, digital image recording, and intraoperative videos, capabilities: the 3D optical magnification thanks to
but the optical magnification has not evolved since the binocular magnification glasses, and the manipulation
beginning of microsurgery. Microsurgical instruments are of inframillimetric tissue structures by fine instruments.
now made in titanium, but have remained exactly the Endoscopic telemicrosurgery enhances other visual and
same since their conception. Any technology experiences manual abilities that cannot be done by conventional
a revolution every half a century: it is an invariable law microsurgery [Figures 1 and 2].
of industry. Hence, why has microsurgery not registered
a technological leap since the 1960s? Is this due to its Magnified vision
compartmentalization, its ignorance on the progress of Optical magnification, a constitutive property of
other surgical disciplines? In other words, what is the microsurgery, is possible in both conventional
future of microsurgery? microsurgery and telemicrosurgery. Conventional
surgery allows magnification of vision in general up to
Surgery has undergone two major technological 25 times. Some supermicro surgical microscopes allow
advances since the second half of the twentieth century: magnification up to 50 times, but the handling of tissues
endoscopic surgery in the 1980s and telesurgery in the with ultra‑fine instruments and nylon up to 14/0, at the
2000s. Endoscopic surgery is the surgical technique extreme limit of human capabilities, represent a barrier
that uses both a miniature two‑dimensional (2D) camera to the common use of supermicrosurgery. The DaVinci
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and appropriate instruments to perform procedures by robot is the only surgical robot currently available, and
mini‑invasive approaches. The operator instinctively gets
an impression of 3D vision thanks to the micro motion
of the cameras, which allows the surgeon to scan the
operative field, but it is not a true 3D vision. Telesurgery
is a surgical technique that uses a robotic remote
manipulator to perform procedures without direct
contact between the operator and the patient. The term
robotic is an abuse of language, since the movements of
the remote manipulator are performed under the direct
control of the operator. Telesurgery, which suppresses
the physiological tremor of the operator can combine
the advantages of conventional open microsurgery with
a 10 times optical magnification (up to 25 times with
a digital zoom) and a 3D vision to those of endoscopic
surgery thanks to instrumental and optical arms whose
length allows to penetrate the surgical field by minimally
invasive incisions. Telesurgery, which has many other
properties, is most likely the next technological leap Figure 1: Installation of an endoscopic telemicrosurgical intervention
for the advancement of microsurgery, thanks to a new in pigs. In the foreground, the operator manipulates the instruments
remotely from the surgical field using the surgical console of the
concept: telemicrosurgery. DaVinci robot
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