Download PDF
CC BY 4.0 · J Reconstr Microsurg
DOI: 10.1055/a-2460-4940
Original Article

Further Validating the Robotic Microsurgery Platform through Preclinical Studies on Rat Femoral Artery and Vein

Jeongmok Cho
1   Department of Plastic and Reconstructive Surgery, University of Ulsan, College of Medicine, Seoul Asan Medical Center, Seoul, Korea
,
Donggeon Kim
1   Department of Plastic and Reconstructive Surgery, University of Ulsan, College of Medicine, Seoul Asan Medical Center, Seoul, Korea
,
Taehyun Kim
1   Department of Plastic and Reconstructive Surgery, University of Ulsan, College of Medicine, Seoul Asan Medical Center, Seoul, Korea
,
Changsik John Pak
1   Department of Plastic and Reconstructive Surgery, University of Ulsan, College of Medicine, Seoul Asan Medical Center, Seoul, Korea
,
Hyunsuk Peter Suh
1   Department of Plastic and Reconstructive Surgery, University of Ulsan, College of Medicine, Seoul Asan Medical Center, Seoul, Korea
,
Joon Pio Hong 
1   Department of Plastic and Reconstructive Surgery, University of Ulsan, College of Medicine, Seoul Asan Medical Center, Seoul, Korea
› Author Affiliations Funding This research was funded in part by MMI. Symani robotic platform and necessary robotic instrumentation was provided by MMI as part of the research funding agreement between MMI and Asan Medical Center. The senior author J.P.H. is a consultant for MMI.
› Further Information
Also available at
   Permissions and Reprints

Abstract

Background This research aims to validate the proficiency and accuracy of the robotic microsurgery platform using rat femoral vessel model.

Methods A total of 256 rat femoral vessels were performed, half using robotic and the other by manual microanastomosis by eight microsurgeons with less than 5 years of experience given eight trials (rats) each. Vessel demographics, proficiency (duration of suture and Structured Assessment of Robotic Microsurgical Skills [SARMS]), and accuracy (patency and scanning electron microscopic [SEM]) were analyzed between the two groups.

Results Using the robot, an average of four trials was needed to reach a plateau in total anastomosis time and patency. Significant more time was required for each vessel anastomosis (34.33 vs. 21.63 minutes on the eighth trial, p < 0.001) one factor being a higher number of sutures compared with the handsewn group (artery: 7.86 ± 0.51 vs. 5.86 ± 0.67, p = 0.035, vein: 12.63 ± 0.49 vs. 9.57 ± 0.99, p = 0.055). The SARMS scores became nonsignificant between the two groups on the fourth trial. The SEM showed a higher tendency of unevenly spaced sutures, infolding, and tears in the vessel wall for the handsewn group.

Conclusion Using the robot, similar patency, accuracy, and proficiency can be reached through a fast but steep learning process within four trials (anastomosis of eight vessels) as the handsewn group. The robotic anastomosis may take longer time, but this is due to the increased number of sutures reflecting higher precision and accuracy. Further insight of precision and accuracy was found through the SEM demonstrating the possibility of the robot to prevent unexpected and unwanted complications.

Keywords

robotic microsurgery - supermicrosurgery - robotic-assisted surgery


Publication History

Received: 11 July 2024

Accepted: 16 October 2024

Accepted Manuscript online:
04 November 2024

Article published online:
17 January 2025

© 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Hong JPJ, Song S, Suh HSP. Supermicrosurgery: principles and applications. J Surg Oncol 2018; 118 (05) 832-839
    CrossrefPubMedSearch in Google Scholar
  • 2 Tamai S. History of microsurgery–from the beginning until the end of the 1970s. Microsurgery 1993; 14 (01) 6-13
    CrossrefPubMedSearch in Google Scholar
  • 3 Tamai S. History of microsurgery. Plast Reconstr Surg 2009; 124 (6, Suppl): e282-e294
    CrossrefPubMedSearch in Google Scholar
  • 4 Buncke HJ, Chang DW. History of microsurgery. Semin Plast Surg 2003; 17 (05) 5-16
    PubMedSearch in Google Scholar
  • 5 Gottlieb LJ, Krieger LM. From the reconstructive ladder to the reconstructive elevator. Plast Reconstr Surg 1994; 93 (07) 1503-1504
    CrossrefPubMedSearch in Google Scholar
  • 6 Hong JP. The use of supermicrosurgery in lower extremity reconstruction: the next step in evolution. Plast Reconstr Surg 2009; 123 (01) 230-235
    CrossrefPubMedSearch in Google Scholar
  • 7 Hong JP, Pak CJ, Suh HP. Supermicrosurgery in lower extremity reconstruction. Clin Plast Surg 2021; 48 (02) 299-306
    CrossrefPubMedSearch in Google Scholar
  • 8 Hong JP. and Editor-in-Chief Archives of Plastic Surgery. Failure is a failure if you learn nothing from it. Arch Plast Surg 2024; 51 (01) 1
    Thieme ConnectPubMedSearch in Google Scholar
  • 9 Hong JP, Koshima I. Using perforators as recipient vessels (supermicrosurgery) for free flap reconstruction of the knee region. Ann Plast Surg 2010; 64 (03) 291-293
    CrossrefPubMedSearch in Google Scholar
  • 10 Khajuria A, Kadhum M, Koshima I, Kannan R. Transitioning from microsurgery to supermicrosurgery: the recurrent ulnar artery model. Plast Reconstr Surg Glob Open 2022; 10 (10) e4589
    CrossrefPubMedSearch in Google Scholar
  • 11 Koshima I, Yamamoto T, Narushima M, Mihara M, Iida T. Perforator flaps and supermicrosurgery. Clin Plast Surg 2010; 37 (04) 683-689 , vii–iii
    CrossrefPubMedSearch in Google Scholar
  • 12 Mihara M, Hayashi Y, Iida T, Narushima M, Koshima I. Instruments for supermicrosurgery in Japan. Plast Reconstr Surg 2012; 129 (02) 404e-406e
    CrossrefPubMedSearch in Google Scholar
  • 13 Koshima I, Inagawa K, Yamamoto M, Moriguchi T. New microsurgical breast reconstruction using free paraumbilical perforator adiposal flaps. Plast Reconstr Surg 2000; 106 (01) 61-65
    CrossrefPubMedSearch in Google Scholar
  • 14 Iida T, Yoshimatsu H, Yamamoto T, Koshima I. A pilot study demonstrating the feasibility of supermicrosurgical end-to-side anastomosis onto large recipient vessels in head and neck reconstruction. J Plast Reconstr Aesthet Surg 2016; 69 (12) 1662-1668
    CrossrefPubMedSearch in Google Scholar
  • 15 Pereira N, Lee YH, Suh Y. et al. Cumulative experience in lymphovenous anastomosis for lymphedema treatment: the learning curve effect on the overall outcome. J Reconstr Microsurg 2018; 34 (09) 735-741
    Thieme ConnectPubMedSearch in Google Scholar
  • 16 Kim BS, Kuo WL, Cheong DC, Lindenblatt N, Huang JJ. Transcutaneous medial fixation sutures for free flap inset after robot-assisted nipple-sparing mastectomy. Arch Plast Surg 2022; 49 (01) 29-33
    Thieme ConnectPubMedSearch in Google Scholar
  • 17 Liverneaux PA, Hendriks S, Selber JC, Parekattil SJ. Robotically assisted microsurgery: development of basic skills course. Arch Plast Surg 2013; 40 (04) 320-326
    Thieme ConnectPubMedSearch in Google Scholar
  • 18 Smith KM, Shrivastava D, Ravish IR, Nerli RB, Shukla AR. Robot-assisted laparoscopic ureteroureterostomy for proximal ureteral obstructions in children. J Pediatr Urol 2009; 5 (06) 475-479
    CrossrefPubMedSearch in Google Scholar
  • 19 Innocenti M. Back to the future: robotic microsurgery. Arch Plast Surg 2022; 49 (03) 287-288
    Thieme ConnectPubMedSearch in Google Scholar
  • 20 Innocenti M, Malzone G, Menichini G. First-in-human free-flap tissue reconstruction using a dedicated microsurgical robotic platform. Plast Reconstr Surg 2023; 151 (05) 1078-1082
    CrossrefPubMedSearch in Google Scholar
  • 21 van Mulken TJM, Wolfs JAGN, Qiu SS. et al; MicroSurgical Robot Research Group. One-year outcomes of the first human trial on robot-assisted lymphaticovenous anastomosis for breast cancer-related lymphedema. Plast Reconstr Surg 2022; 149 (01) 151-161
    CrossrefPubMedSearch in Google Scholar
  • 22 Speck NE, Grufman V, Farhadi J. Trends and innovations in autologous breast reconstruction. Arch Plast Surg 2023; 50 (03) 240-247
    Thieme ConnectPubMedSearch in Google Scholar
  • 23 Lindenblatt N, Grünherz L, Wang A. et al. Early experience using a new robotic microsurgical system for lymphatic surgery. Plast Reconstr Surg Glob Open 2022; 10 (01) e4013
    CrossrefPubMedSearch in Google Scholar
  • 24 Beier JP, Hackenberg S, Boos AM, Modabber A, Duong Dinh TA, Hölzle F. First series of free flap reconstruction using a dedicated robotic system in a multidisciplinary microsurgical center. Plast Reconstr Surg Glob Open 2023; 11 (09) e5240
    CrossrefPubMedSearch in Google Scholar
  • 25 Weinzierl A, Barbon C, Gousopoulos E. et al. Benefits of robotic-assisted lymphatic microsurgery in deep anatomical planes. JPRAS Open 2023; 37: 145-154
    CrossrefPubMedSearch in Google Scholar
  • 26 Will PA, Hirche C, Berner JE, Kneser U, Gazyakan E. Lymphovenous anastomoses with three-dimensional digital hybrid visualization: improving ergonomics for supermicrosurgery in lymphedema. Arch Plast Surg 2021; 48 (04) 427-432
    Thieme ConnectPubMedSearch in Google Scholar
  • 27 Ballestín A, Malzone G, Menichini G, Lucattelli E, Innocenti M. New robotic system with wristed microinstruments allows precise reconstructive microsurgery: preclinical study. Ann Surg Oncol 2022; 29 (12) 7859-7867
    CrossrefPubMedSearch in Google Scholar
  • 28 Barbon C, Grünherz L, Uyulmaz S, Giovanoli P, Lindenblatt N. Exploring the learning curve of a new robotic microsurgical system for microsurgery. JPRAS Open 2022; 34: 126-133
    CrossrefPubMedSearch in Google Scholar
  • 29 Menichini G, Malzone G, Tamburello S. et al. Safety and efficacy of Symani robotic-assisted microsurgery: assessment of vascular anastomosis patency, thrombus, and stenosis in a randomized preclinical study. J Plast Reconstr Aesthet Surg 2024; 96: 1-10
    CrossrefPubMedSearch in Google Scholar
  • 30 Liverneaux P, Nectoux E, Taleb C. The future of robotics in hand surgery. Chir Main 2009; 28 (05) 278-285
    CrossrefPubMedSearch in Google Scholar
  • 31 Selber JC, Alrasheed T. Robotic microsurgical training and evaluation. Semin Plast Surg 2014; 28 (01) 5-10
    Thieme ConnectPubMedSearch in Google Scholar
  • 32 Adams Jr WP, Ansari MS, Hay MT. et al. Patency of different arterial and venous end-to-side microanastomosis techniques in a rat model. Plast Reconstr Surg 2000; 105 (01) 156-161
    CrossrefPubMedSearch in Google Scholar
  • 33 Chan-Park MB, Shen JY, Cao Y. et al. Biomimetic control of vascular smooth muscle cell morphology and phenotype for functional tissue-engineered small-diameter blood vessels. J Biomed Mater Res A 2009; 88 (04) 1104-1121
    CrossrefPubMedSearch in Google Scholar
  • 34 Malzone G, Menichini G, Innocenti M, Ballestín A. Microsurgical robotic system enables the performance of microvascular anastomoses: a randomized in vivo preclinical trial. Sci Rep 2023; 13 (01) 14003
    CrossrefPubMedSearch in Google Scholar
  • 35 Schäfer B, Bahm J, Beier JP. Nerve transfers using a dedicated microsurgical robotic system. Plast Reconstr Surg Glob Open 2023; 11 (08) e5192
    CrossrefPubMedSearch in Google Scholar
  • 36 Freschi C, Ferrari V, Melfi F, Ferrari M, Mosca F, Cuschieri A. Technical review of the da Vinci surgical telemanipulator. Int J Med Robot 2013; 9 (04) 396-406
    CrossrefPubMedSearch in Google Scholar
  • 37 Hanasono MM, Butler CE. Prevention and treatment of thrombosis in microvascular surgery. J Reconstr Microsurg 2008; 24 (05) 305-314
    Thieme ConnectPubMedSearch in Google Scholar
  • 38 Schuderer JG, Dinh HT, Spoerl S. et al. Risk factors for flap loss: analysis of donor and recipient vessel morphology in patients undergoing microvascular head and neck reconstructions. J Clin Med 2023; 12 (16) 5206
    CrossrefPubMedSearch in Google Scholar