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8 Robotic Microvascular and Free Flap Surgery: Overview of Current Robotic Applications and Introduction of a Dedicated Robot…
81
The operating microsurgeon controls two master manipulators that are activated by a foot pedal (Fig. 8.6a, b). The
robotic arms are attached to a suspension ring that is placed
above the operating eld and assist the microsurgeon by
tremor ltration and motion scaling. Consequently, hand-eye
coordination is improved and the precision of the surgeon is
enhanced. The system can be used in combination with genuine surgical microscopes or camera systems. The size and
weight of the system are small leaving the setup and workow of a microvascular operation intact and making hybrid
operations possible (quickly alternating conventional surgery and robot assistance).
8.3 Current Applications ofRobotics
inMicrovascular andFree Flap
Surgery
Robotic assistance with use of the Da Vinci Surgical System
is originally known for its benets in endoscopic procedures
providing small incision surgery and reducing donor site
morbidities. Compared with conventional surgery, the robotassisted surgery contains 3D vision and wristed instruments
which allow for increased accessibility and movement during endoscopic procedures. For robot-assisted microsurgery,
additional advantages are motion scaling and tremor ltration. The MUSA is designed for these matters using slave
arms that have the possibility to hold dedicated microsurgical instruments, downsize motions, and lter the physiological tremor to gain more precision during microsurgery.
8.3.1 Robotic Flap Harvesting
8.3.1.1 Deep Inferior Epigastric Perforator Flap
Several authors have described robot-assisted harvesting of a
deep inferior epigastric perforator (DIEP) ap using the Da
Vinci Surgical System. The use of this platform resulted in
an improved precision of the DIEP ap harvest and decrease
of the donor site morbidity by minimizing the incision length
of the anterior rectus sheath [10]. Postoperatively, donor site
pain was diminished, and hospital stay was shorter compared
with a conventional DIEP ap procedure. However, the risk
for posterior rectus sheath or bowel injury and the longer
operation time can’t be unnoticed.
When comparing the robot-assisted DIEP ap harvest in
a transabdominal pre-peritoneal (TAPP) fashion with a
totally extraperitoneal (TEP) approach, the duration of
robotic harvest and pedicle dissection was not signicantly
different. Both approaches were considered feasible; however, the TEP procedure was less invasive by preserving the
posterior rectus sheath, thereby decreasing the risk of complications such as bowel injury and pneumoperitoneum [15].
Selber etal. applied robot-assisted surgery on harvesting
the ap pedicle. A long pedicle of 10–15cm through a small
fascial incision of 1–3cm could be harvested, which is in
fact a step forward in minimal-invasive autologous breast
reconstruction [27].
8.3.1.2 Rectus Abdominis Muscle Flap
Robot assistance with the DaVinci system is also described
in harvesting the rectus abdominis muscle for use as a free
ap to cover defects on the extremity [18, 28]. One author
harvested several rectus abdominis muscles in a porcine
model where other authors described the robot-assisted harvest of this ap in patients [18, 28, 29]. A steep learning
curve in robot-assisted harvesting was seen as adequate muscle aps could be dissected. Furthermore, a decreased
surgical- site morbidity was found without hernias, bulges, or
conversions to the open technique.
8.3.1.3 Internal Mammary Vessels
The AESOP surgical system was used by Boyd et al. to
explore an alternative approach of harvesting the internal
mammary vessels in 20 breast reconstruction patients,
including a muscle-sparing transverse rectus abdominis
musculocutaneous (TRAM) ap, superior gluteal artery
(SGA) ap, supercial inferior epigastric artery (SIEA) ap,
and superior gluteal arterial perforator (SGAP) ap [4]. With
this approach, the pedicle could be brought out through the
second intercostal space without cartilage resection. This
procedure could have been an advantage in skin-sparing
mastectomies; however, in two patients ap loss was documented following venous congestion. The authors reported
that the tunnel through the intercostal space was too narrow
with constriction of the pedicle as a result. With these ap
losses and six take-backs for hematoma evacuations, the
complication rate was very high, suggesting this alternative
approach had to be adjusted. This could also be the reason
for the AESOP system not being described in further research
regarding free ap surgery.
8.3.1.4 Miscellaneous
Robotic assistance for latissimus dorsi ap harvesting is
described by different authors enabling an endoscopic approach
using the DaVinci system [30–34]. This technique is actually
associated with a lower complication rate at the expense of a
longer operative time compared with conventional surgery [34].
In primary nipple sparing mastectomy and immediate breast
reconstruction with robot-assisted harvesting of a latissimus
dorsi ap, only one small and inconspicuous axillary wound
was needed for reconstruction using the DaVinci system [33].
The prolonged surgical time and complexity of combining the
mastectomy and robot-assisted reconstruction were considered
as disadvantages. Additionally, the DaVinci system was used to
perform endoscopic harvest of free omental aps [17].
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J. A. G. N. Wolfs et al.
8.3.2 Robotic Microvascular Anastomosis
The RAMS, ZEUS, DaVinci, and MUSA systems have all
been used to perform microvascular anastomoses. These
anastomoses are performed in different surgical specialties
and at different acceptor sites.
8.3.2.1 Preclinical Studies
Various authors have reported robotic assistance during
microvascular anastomoses in animal models [6, 7, 12, 20,
35]. The DaVinci was used for dissection, tting of a vascular
clamp, section of the artery, and suturing of the anastomosis
[20]. Additionally, the system was applied for the anastomo-
sis for ureteral reconstruction using a long peritoneal ap [6].
The studies proved its feasibility as viable aps with patent
anastomoses were reported [12]. The time to perform the
robot-assisted anastomoses was analyzed concluding relatively short learning curves. Besides the DaVinci system,
robotic microvascular anastomoses on abdominal arteries and
femoral arteries were successfully carried out with use of the
MUSA robot in a rat model [36, 37]. All but one anastomosis
were patent and again a steep learning curve was seen.
8.3.2.2 Clinical Studies
Several clinical free aps have been described using robotassisted microvascular anastomosis. For example, the
DaVinci system was used to perform the microvascular anastomoses in oropharyngeal reconstruction using a free radial
forearm ap (FRFF) and anterolateral thigh (ALT) ap [13,
19, 38–40]. These microvascular anastomoses were carried
out without hand-sewn revisions or surgical complications
such as ap failures, take-backs, or stulas. All of these
microvascular anastomoses were considered feasible and
safe. When comparing conventional free ap reconstruction
with robot-assisted reconstruction with a FRFF, smaller donor
blood vessels could be selected when using the DaVinci system [13, 39]. Besides the aforementioned advantages, limitations of the DaVinci system were also reported. The longer
operating time, large and robust instruments, limited optics
and magnication, increased costs, and a complex operation
setup were considered the disadvantages after performing the
rst microvascular anastomosis using this platform [24].
8.3.3 Robotic Flap Inset
Robot-assisted ap inset using the DaVinci system has been
described during transoral free ap reconstructions. Robotic
assistance with this platform was used for inset of FRFF,
ALT aps, and FAMM aps [19, 38, 40]. The oropharynx is
not easily accessible which leads to less visual cues when
performing the inset of aps. Robot-assisted surgery leads to
more precision and, consequently, more chance of preserva-
tion of the mandible and lip without complications, such as
ap failures or stulas. The lack of visual cues to determine
whether sufcient tension has been applied for tying knots
for the anastomoses or ap inset raises the debate for incorporation of haptic feedback in robotic surgery.
8.3.4 Robotic Supermicrosurgery
Advancements in reconstructive microsurgery have evolved
into supermicrosurgery completing anastomoses between 0.3
and 0.8mm in diameter. Supermicrosurgery is limited by the
dexterity and the precision of the surgeon’s hand taking the
physiological tremor into account. The MUSA robot has been
designed for high surgical precision, safety, and userfriendliness. The system is compatible with standard (super)
microsurgical instruments and microscopes. To date, the
MUSA is used to perform lymphaticovenous anastomoses
(LVA) connecting vessels of approximately 0.3mm in patients
suffering from lymphedema in the arm after breast cancer
treatment (Fig.8.7a) [41]. Comparing robot-assisted with conventional LVA procedure, no signicant difference was found
on postoperative outcome in terms of improvement in quality
of life, arm circumference, and discontinuation of conservative treatment. Therefore, the MUSA was found to be feasible
for supermicrosurgical anastomosis, which concerns anastomoses signicantly smaller than standard free ap surgery.
Currently other indications of robot-assisted microsurgery using the MUSA such as perforator-to-perforator aps
and conventional free aps are evaluated in clinical studies
(Fig.8.7b).
8.3.5 Robotic Microsurgical Training
In robot-assisted as well as conventional microsurgery, training is required to adequately perform microsurgical procedures. Microsurgical training is evaluated with use of
different surgical systems. Comparing the conventional
micro anastomosis with the robot-assisted procedure using
the ZEUS system, both fully trained surgeons and residents
showed longer anastomosis times and more errors of management during the robot-assisted procedure [5].
A steep learning curve in performing microvascular anastomoses with the DaVinci system was observed [42]. Robotic
microsurgery videos were evaluated to validate the Structured
Assessment of Robotic Microsurgical Skills (SARMS) as an
assessment instrument [43]. Prociency in robotic microsurgical skills could be achieved over a relatively limited number of practice sessions. A plateau following the steep
learning curve was seen after performing 22 trials which is
relatively short [41, 42, 44]. A side note is that the assessment instrument (SARMS) is specically designed for the
ab
8 Robotic Microvascular and Free Flap Surgery: Overview of Current Robotic Applications and Introduction of a Dedicated Robot…
83
Fig. 8.7 Clinical application of the MUSA robot. (a) Lymphaticovenous anastomoses and (b) free ap anastomosis for lower extremity
reconstruction
DaVinci system, as “camera movement” is part of the scoring items. Therefore, comparison to conventional microsurgery is not possible using this instrument.
To ensure user-friendly and quick-to-learn robotic microsurgery, the intention in developing the MUSA system was
to minimize the number of new skills that must be learned
and to maximize transfer of skills from the conventional
method to the robot-assisted method. As a result, after evaluation of the Structured Assessment of Microsurgical Skills
(SAMS), a comparable steep learning curve using the MUSA
robot was seen for microsurgical training of surgeons and
residents [37, 41]. Training in robot-assisted microsurgery
seems easy to facilitate for inexperienced surgeons.
tive pain and shorter length of hospital stay after robotic free
ap surgery in comparison with conventional surgery was
described keeping the risks of bowel injury during endoscopic
pedicle harvest in mind. A steep learning curve in performing
robot-assisted free ap surgery was reported by several
authors. Nevertheless, the best outcome after robot- assisted
free ap surgery was found in experienced robotic surgeons.
The main disadvantages reported are the setup time, operating time, costs, lack of haptic feedback, limited optics and
magnication, and large and robust instruments. Nowadays,
robot assistance is even possible in supermicrosurgery using
a newly developed dedicated microsurgical robot, the MUSA.
Clinically available robotic systems and novel robotic
platforms (i.e., still under development) should be further
improved. Current systems lack haptic feedback which
8.4 Future Perspectives
might be considered as a limitation compared with conventional surgery. However, in (super)microsurgery forces are
Robot assistance has great potential in the eld of microvascular and free ap surgery. To date, a few robotic platforms
have been described for this type of surgery. The DaVinci system was used in the majority of the studies. Robotic assistance has been applied for harvesting, microvascular
anastomosis, and inset of free aps. A reduction in postopera-
too low to rely on which also applies for conventional surgery. Hence, introduction of haptic feedback could be an
advantage as the incorporation in (super)microsurgery would
allow the surgeon to feel the small forces that occur. This
advancement might improve tissue handling and surgical
precision and, as a result, improve patient outcome. Another
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J. A. G. N. Wolfs et al.
way to compensate the lack of haptic feedback is to provide
intraoperative image guidance and add visual cues to improve
surgical efcacy. Optimal visualization is paramount during
microsurgery. The evolution of camera systems will enable
high magnication with 3D vision, replacing the current setting of the microscope in the operation eld. These camera
systems can be incorporated into robotic platforms or can be
used as external camera systems, such as exoscopes and
heads-up microscopes [45]. In addition to these new camera
systems, novel imaging techniques are promising areas in
the continued renement of microsurgery, such as HR stereotactic operation, spectral imaging, and real-time navigation systems. Near-infrared uorescence (NIRF) imaging
could contribute to critical decision-making by facilitating
real-time intraoperative anatomical navigation [46].
The DaVinci system consists of a console in the operation
room keeping the surgeon away from the surgical table. In
tele-surgery, the surgeon carries out the procedure while
located in a separate geographical location as the patient
which may become common practice in future microsurgery.
A reliable connection without any lag is mandatory to perform surgery safely.
Last but not least, a new trend that refers to intelligent
robotic systems and the ability of self-learning is cognitive
surgical robots which are supported by big data analytics.
Nowadays, assessment of microsurgical skills has been conducted by subjective observations of other trained surgeons.
The advantage of using robotic platforms for microsurgery is
that every movement and force can be registered. This data
can be used for the objective assessment using standardized
evaluation methods and, therefore, creating objective microsurgical training programs. The improved surgical data science could also be used to enable semi-automated surgery,
conducted by cognitive robots including articial intelligence to help improve surgical performance.
Robot assistance in microvascular and free ap surgery is
relatively underdeveloped compared to other surgical elds.
This is partially due to the fact that most operation robots are
not designed for microsurgery and therefore lack the delicate
instruments and precision that is needed for free aps and
microsurgical operations. The evolution of endoscopic harvest and inset of aps using current general robotic systems
and the availability of new dedicated microsurgical robots
such as the MUSA is propelling innovation and adoption of
robotic technology in our eld.
8.5 Selected Readings
• Dobbs TD, Cundy O, Samarendra H, Khan K, Whitaker
IS.A systematic review of the role of robotics in plastic
and reconstructive surgery-from inception to the future.
Front Surg. 2017;4:66.
A systematic literature search to identify all applications of robot assistance in plastic and reconstructive surgery. The feasibility of robotic plastic surgery has been
demonstrated in several specic indications. As technology, knowledge, and skills in this area improve, these
techniques have the potential to contribute positively to
patient and provider experience and outcomes.
• Ibrahim AE, Sarhane KA, Selber JC. New Frontiers in
robotic-assisted microsurgical reconstruction. Clin Plast
Surg. 2017;44(2):415–23.
The different clinical applications of robotic microsurgery are presented, highlighting its advantages over conventional microsurgery and outlining the main limitations
that might prevent its widespread use.
• Tan YPA, Liverneaux P, Wong JKF.Current limitations of
surgical robotics in reconstructive plastic microsurgery.
Front Surg. 2018;5:22.
Tan etal. performed a systematic review to evaluate
current state of surgical robotics within the eld of reconstructive microsurgery and their limitations. Despite the
theoretical potential of surgical robots, current commercially available robotic systems are suboptimal for plastic
or reconstructive microsurgery.
• van Mulken TJM, Boymans C, Schols RM, et al.
Preclinical experience using a new robotic system created
for microsurgery. Plast Reconstr Surg.
2018;142(5):1367–76.
A preclinical study concluded that it is feasible to complete anastomotic microsurgery on silicone vessels using
the newly developed Microsure robotic system.
• Selber JC.The robotic DIEP ap. Plast Reconstr Surg.
2020;145(2):340–3.
Selber describes the robotic DIEP ap procedure. The
robotic deep inferior epigastric artery perforator ap
permits the longest possible pedicle harvest through the
smallest possible fascial incision and, for this reason,
may be the next stage in the evolution of minimally invasive, autologous breast reconstruction.
• van Mulken TJM, Scharmga AMJ, Schols RM, etal. The
journey of creating the rst dedicated platform for robotassisted (super)microsurgery in reconstructive surgery.
Eur J Plast Surg. 2020;43(1):1–6.
This publication elaborates on the journey of creating
the rst dedicated microsurgical robot, currently known
as the MUSA robot.
• van Mulken TJM, Schols RM, Scharmga AMJ, et al.
First-in-human robotic supermicrosurgery using a dedicated microsurgical robot for treating breast cancerrelated lymphedema: a randomized pilot trial. Nat
Commun. 2020;11(1):757.
This paper reports the rst-in-human study of robotassisted supermicrosurgery using a dedicated microsurgical robotic platform. A prospective randomized pilot
8 Robotic Microvascular and Free Flap Surgery: Overview of Current Robotic Applications and Introduction of a Dedicated Robot…
85
study was conducted comparing robot-assisted and manual supermicrosurgical lymphaticovenous anastomosis
(LVA) in treating breast cancer-related lymphedema.
• Murphy DC, Saleh DB.Articial Intelligence in plastic
surgery: what is it? Where are we now? What is on the
horizon? Ann R Coll Surg Engl. 2020;102(8):577–80.
Review article on articial intelligence (e.g., machine
learning, big data, etc.) in plastic surgery. Surgeons must
collaborate with computer scientists to ensure that AI
algorithms inform clinically relevant health objectives
and are interpretable. Ethical concerns are also
discussed.
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Technical Tips inMicrovascular Surgery
MariosNicolaides andGeorgiosPatanis
9
9.1 Introduction
Over the past two decades, microvascular anastomosis has
advanced remarkably, but there are still situations that challenge even the most experienced surgeons. Examples include
extremely small or short vessels, large discrepancies in vessel diameter, and difcult anatomy that limits the operative
eld. In such situations, excessive manipulation of the vessel
walls or substandard techniques can result in adverse effects.
This chapter outlines several tips that can be used to overcome these challenges and lessen the frustration associated
with the process. The suggested techniques have a steeper
learning curve and necessitate prociency in basic microsurgical skills, but once mastered they can lead to higher vessel
patency, increased ap survival rate, and reduced operative
time.
9.2 Modied Writing Position
andQuadropod Grip
Correct handling of surgical instruments is fundamental in
microsurgery to allow for minimal movements in the operative eld. Maintaining manual dexterity while avoiding body
fatigue is imperative given the long nature of most reconstructive operations. The microsurgeon should achieve a
well-supported hand position to avoid hand tremor and allow
for isolated nger movement. The hand is traditionally stabilized at the metacarpophalangeal joints by resting the lateral
aspect of the hand on any at surface in the operative eld.
M. Nicolaides (*)
Barts and The London School of Medicine and Dentistry, Queen
Mary University of London, London, UK
e-mail: marios.nicolaides@nhs.net
G. Patanis
London Reconstructive Microsurgery Unit (LRMU), Department
of Plastic Surgery, Emergency Care and Trauma Division, The
Royal London Hospital, Barts Health NHS Trust, London, UK
There are two commonly used handling methods for microsurgical instruments: the “writing” position and the “quadrupod” grip.
The “writing” position, also known as the three-digit tripod grip, is achieved by using the index and middle ngers
to manipulate the instrument against the thumb (Fig.9.1a).
Better stability and reduced resting tremor can be achieved
by gently exing the middle nger at the proximal and distal
interphalangeal joints while resting the index nger and
thumb on it (Fig.9.1b). This position can be used in most
cases of conventional microsurgery but is challenged in
supermicrosurgery (vessels with diameter of <0.8 mm),
where the resting motor tremor is exaggerated. The “quadrupod” grip can be used in such cases. This technique is
achieved by using the index, middle, and ring ngers to
manipulate the instrument against the thumb (Fig.9.1c). The
use of the ring nger decreases the distance from the tip of
the instrument and, thus, allows for more delicate and balanced movements. In this four-nger technique, microsurgical suturing can be performed by just moving the ring nger
and the other ngers follow.
9.3 Airborne Suture Tying
Suture tying in microvascular anastomoses is performed in a
timely manner, but usually not rushed, as most aps tolerate
long ischemia periods without signicant compromise to the
ap—the rst goal is an atraumatic anastomosis. However,
in cases of intestinal aps for pharyngoesophageal reconstruction, or compromised aps of any type, time is of
essence. The “airborne” suture tying technique aims to speed
up the knot tying process by maintaining the free suture end
always in the air.
• Step 1: First, the needle is passed through both vessels
keeping the end on the right (free end) short. The short
end is then grasped by the right forceps (two thirds of the
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M. Nicolaides and G. Patanis
Fig. 9.1 (a) The “writing” position, also known as the three-digit tri-
pod grip. (b) The “modied writing” position where the middle nger
is exed at the proximal and distal interphalangeal joints while the
index nger and thumb rest on it. (c) The “quadrupod” grip is achieved
by using the index, middle, and ring ngers to manipulate the instrument against the thumb
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Fig. 9.2 (a–f) Airborne suture step-by-step microvascular tying
distance from vessel to tip) with the instrument tip pointing up (Fig.9.2a).
• Step 2: The left end (suture end) is grasped by the left
forceps (at a location so that it is double the size of the
free end) with the instrument tip pointing down (Fig.9.2b).
• Step 3: A C-loop (lasso loop) is created on the suture end
on top) which is wrapped under and around the tip of the
right instrument (Fig.9.2e).
• Step 6: The right instrument releases the short end
momentarily and moves up to regrasp it and bring it back
down through the loop to complete the second knot
(Fig.9.2f).
and encircles the tip of the right instrument (Fig.9.2c).
• Step 4: The right forceps releases the short end momentarily
and moves down with the loop, allowing the short end to fall
posterior to the C-loop, where it regrasps it (Fig.9.2d). The
rst knot is then secured to complete the rst throw. Both
the long and short ends of the suture point at each other.
• Step 5: The left forceps holding the suture end (long)
moves downward to form a vertical C-loop (concave side
This technique, besides being quicker than conventional
methods of knot tying, can also prevent damage caused to
surrounding structures when trying to pick up the free end
while also decrease the probability of lumen contamination
when the free end collects debris. The airborne suture tying
technique can be used in combination with the any suturing
method.
9 Technical Tips inMicrovascular Surgery
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9.4 One-Way-Up Technique
In situations where the operative eld is limited in space or
the vessel is short, the “one-way-up” technique for microvascular end-to-end anastomoses becomes useful. In this technique, anastomosis can be achieved without lifting the clamp
or maneuvering the vessel ends. The double clamp should be
placed with the tips facing the surgeon to allow for better
access and visualization.
• Step 1: The rst and only stay suture is placed as further
away from the surgeon as possible (at the back wall) outside in on the right side and inside out on the left side. The
knot is tied, and the long end secured on the clamp, while
the other end is cut short (Fig.9.3a).
• Step 2: The one-way-up technique is then started at the
most difcult point in the back wall by passing the needle
outside in on the left wall and inside out on the right wall
where the knot is tied (Fig.9.3b).
• Step 3: The next sutures are placed proximally to the pre-
vious one in a similar fashion. Suturing is continued until
the whole length of the inferior walls is sutured
(Fig.9.3c).
• Step 4: Then, the surgeon can change to their traditional
method of suturing for the anterior wall or apply
continuous- interrupted suturing (Fig.9.3d, e).
One end should be kept always long to assist in securing
the vessel ends while performing the one-way-up technique.
9.5 Continuous-Interrupted Suturing
Interrupted and continuous suturing are two widely accepted
and traditional suturing techniques for microvascular end-toend anastomoses. Interrupted suturing can be achieved by
placing three sutures at equal distance and then placing interrupted sutures in between (triangulation method). Continuous
suturing is faster but increases the risk of stricture.
Continuous-interrupted suturing is a new technique that
combines the advantages of both.
• Step 1: Two interrupted sutures are applied for the bi-
angulation technique or the back wall of the vessel is
already sutured as seen in Fig.9.4a.
• Step 2: A loose running suture is then applied on the ante-
rior wall next to the rst suture and continuing until three
or four consecutive loose loops are created—this step
mimics continuous suturing, but the suture is left loose
and untied instead (Fig.9.4b).
• Step 3: Starting from the rst, the loops are tied successively. The ends of each suture should be cut to avoid
multiple long ends in the anastomotic eld (Fig.9.4c).
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Fig. 9.3 (a–e) One-way-up microvascular anastomosis step-by-step technique
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Fig. 9.4 (a–e) Continuous-
interrupted suturing step-bystep technique
M. Nicolaides and G. Patanis
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• Step 4: Finally, the previous two steps are repeated until
all the anastomosis is completed (Fig.9.4d, e).
nosis of the anastomosis. Furthermore, the application of
the sutures can be done in a very precise manner as the
lumen and posterior wall of both vessels are visible
The continuous-interrupted suturing method is quicker
than the interrupted suturing method without risking ste-
throughout suturing without extensive manipulation of the
vessel walls.
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