Keywords robotic surgical procedures - microsurgery - minimally-invasive surgical procedures
Introduction
The concept of robot-assisted surgery was proposed by military doctors during World
War II, aiming to create a system to remotely control surgeries. However, it was not
until 1994 that Phil Green designed a remote surgery operating system, which consisted
of a console and a wireless control arm.[1 ] The last decade has seen robotic surgery become the standard in some specialties
to perform minimally-invasive procedures.[2 ]
Robotic surgery has opened a new era of minimally-invasive procedures, with its improved
precision, greater degrees of freedom (DOFs), superior three-dimensional (3D) vision,
improved resolution, and elimination of tremors.[3 ] Urological, gastrointestinal, endocrine, cardiac and plastic surgeries are some
of the examples of fields in which robotic surgery is more established.[4 ]
The most widely used robotic system is the Da Vinci Surgical System (Intuitive Surgical,
Inc., Sunnyvale, CA, United States), which currently uses high-definition (HD) 3D
magnification with seven DOFs.[4 ] The Da Vinci robot consists of three elements: the surgeon's console, the patient-side
cart with its articulated or swiveling arms, and the vision cart.[5 ] Thus, this system has the advantages of 3D stereoscopic vision, greater dexterity,
in which the movements of the instruments are facilitated by articulated wrists enabling
seven DOFs, greater accuracy, and faster mastery of endoscopy.[6 ] However, there are limitations to the system, such as size, as the robot components
occupy considerable space, installation time, and high cost.[7 ]
One of the most common applications of robotics is in microsurgery, a unique field
which requires the highest levels of precision for optimal results and high success
rates.[3 ] There are initial applications such as transoral robotic reconstructive surgery,[8 ]
[9 ] nipple-sparing mastectomy (NSM) with immediate breast reconstruction (IBR) using
prosthesis,[10 ]
[11 ] minimally-invasive harvest of pedicled or microsurgical muscle flaps,[12 ]
[13 ]
[14 ] and robot-assisted microsurgery.[3 ]
[15 ]
Recently, the first clinically available surgical robot for microsurgery was developed,
called MUSA (MicroSure, Eindhoven, The Netherlands). Acting on the stabilization of
movements, the MUSA robot filters out tremors and is easily maneuverable, and the
preclinical tests confirmed the safety and feasibility of this robot in performing
microsurgical anastomoses.[16 ]
[17 ]
It is undeniable that robotic surgery has a leading role today, with perspectives
of its use in plastic surgery, for example, in which robots have a 3D reading system
that can scan human faces and other parts of the body, quickly generating accurate
models.[18 ] It has also been shown[19 ] that, in a center in which the learning curve has already been overcome, robotic
surgery becomes cheaper than the equivalent open surgery for the treatment of endometrial
cancer.
The biggest disadvantage is the high cost of purchasing and maintaining the equipment,
a fact that may change in the future, with the increase in the number of procedures
performed using the robot and the consequent reduction in the unit cost per operation.[20 ]
The need to accelerate the understanding of robotic surgery and microsurgery is currently
extremely important.
The present study will analyze the literature on this topic in order to contribute
to the choice of microsurgery in appropriate procedures. Furthermore, our conclusions
can contribute to the new era of Medicine, in which robotic devices are considered
great allies, with the objective of verifying the effectiveness of the results of
the use of the robot in microsurgeries, to support the investment in it on the part
of the hospitals, as well as evaluating minimally-invasive procedures in different
reconstructive surgical fields.
In the present article, we conduct a systematic review and evaluate the benefits of
robotic surgery and its contribution to microsurgery, comparing it with other surgical
techniques used in patients of all age groups.
Methodology
On the PubMed and Cochrane databases, we performed a systematic review of the literature
on robotic surgery and microsurgery based on the Preferred Reporting Items for Systematic
Reviews and Meta-Analyses (PRISMA) statement. The search terms used were robotic surgery AND microsurgery , and we applied a filter to studies published in the last 5 years (from 2015 to 2020)
in English or Portuguese, and studies performed in humans. Furthermore, we included
literature reviews, systematic reviews, meta-analyses, clinical studies, clinical
trials, comparative studies, controlled or randomized clinical trials, multicenter
studies, observational studies, case reports, and case series studies. Preclinical
and unfinished studies were excluded from the review.
The research question was based on the Patient, Intervention, Comparison, Outcome
(PICO) model. We included patients of all age groups. The intervention analyzed was
the use of robotics to perform microsurgery, comparing this technique with other methods.
Finally, the outcome of interest was the benefits of robotic surgery and its contribution
to microsurgery.
The analysis of the databases was performed independently and in pairs, as well as
the selection of articles by title, abstract, and full-text reading. All decisions
were compared, and differences that emerged were resolved by a third author. The results
were recorded in a shared Excel (Microsoft Corp., Redmond, WA, United States) spreadsheet,
and all duplicates were excluded.
The search, completed in January 2021, resulted in 90 articles found on the selected
databases, and 2 of these were excluded because they were duplicates. After analyzing
titles, abstracts and reading the full text, 25 articles were selected for the present
review. A flowchart of the selection of articles is presented in [Figure 1 ].
Fig. 1 Flowchart of the selection of articles.
Results
Goto et al.[21 ] conducted an observational study to evaluate the benefits of iArmS, a system used
in neurological microsurgery that supports the surgeon's arm weight. The evaluation
parameters were the surgeon's level of fatigue, degree of tremor, and ease in performing
the procedure. The authors[21 ] approved the system in all three assessments, stating that it enables the performance
of an accurate and quality technique for microneurosurgery. Ibrahim et al.[3 ] also highlighted the applicability of robotics in neurosurgery, drawing attention
to the Canadian NeuroArm robot, which assists in the performance of standardized techniques
such as biopsy and microdissection.
Smith et al.,[22 ] in their review of the evolution and application of robotics in neurosurgery, concluded
that this technology has brought several benefits. According to the authors,[22 ] robotics can be used for the treatment of brain tumors, spinal cord injuries, brain
stimulation, and biopsies. In addition, the associated use of the robot and imaging
methods resulted in higher levels of surgical precision. The authors[22 ] suggest that this technology tends to develop more and more, which will enable the
performance of procedures not feasible through conventional surgery, as suggested
by Roizenblatt et al.[23 ]
Kavoussi[24 ] compared vasectomy reversal performed through robotic surgery and microsurgery.
The study did not demonstrate a statistically significant difference between the two
methods regarding the effectiveness of the procedure. However, the author[24 ] suggests that robotic surgery is promising, being an extremely effective method
in vasectomy reversal, as stated by Ibrahim et al.[3 ] Darves-Bornoz et al.[25 ] reviewed the application of robotics to each of the four primary male infertility
procedures: vasectomy reversal, varicocelectomy, testicular sperm extraction, and
spermatic cord denervation. For the authors,[25 ] although the robotic platform has been quickly adopted by other urological subspecialties,
it is still not common among reproductive urologists, as the data examining the approach
are sparse, and no studies have tried to rigorously check the results. While the use
of robots offers potential benefits to treat male infertility, rigorous clinical trials
are still needed.
Edwards et al.[26 ] performed a randomized clinical trial with the aim of comparing intraocular surgery
to remove the retinal membrane through a robot-assisted technique and through manual
surgery. The study[26 ] demonstrated that robotic-assisted surgery resulted in longer operative times, but
fewer iatrogenic injuries and greater anatomical accuracy. Therefore, the authors[26 ] suggested that robotics is promising technology for ophthalmic surgery, as did Ibrahim
et al.[3 ]. In their studies, Bourcier et al.[27 ] and Roizenblatt et al.[23 ] also came to this conclusion, emphasizing that robotic surgery manages to circumvent
one of the main limitations of manual surgery: the surgeon's hand tremor. Roizenblatt
et al.[23 ] stated that the guarantee of precision is of extreme importance in eye surgery,
since minimal erroneous movements can result in permanent sequelae, such as blindness
when injuring the retina.
The study by Roizenblatt et al.[23 ] also highlighted other possibilities of application of robotics in eye surgery,
such as in the treatment of macular injury, diabetic retinopathy, and canalization
of retinal veins. Furthermore, Bourcier et al.[27 ] reported the first case of pterygium removal with the DaVinci Si HD robotic system.
The procedure was performed in an elderly patient, who did not present any peri- or
postoperative complications and obtained a satisfactory result, proving that it is
an effective and safe technique to perform eye surgery. These procedures require dexterity
and high sharpness of vision, which can be improved by robotics.[27 ] Roizenblatt et al.[23 ] claim that, in addition to canceling the tremor, the robot is able to scale the
surgeon's movement, ensuring even more precision.
Gonzalez-Ciccarelli et al.[28 ] discussed the robotic approach to hepatobiliary surgery, whose advantage is its
potential to overcome the technical limitations of laparoscopy. The robot enables
the performance of complex hilum preparations and hepatocaval dissections as well
as parenchymal transections with minimal blood loss. Robot-assisted liver resections
enable the performance of complex reconstructions of vascular and biliary anastomoses,
preserving the liver parenchyma in lesions located in the upper posterior segments,
avoiding large hepatectomies. In experienced hands, larger and extensive hepatectomies
can also be performed with excellent results. The limitations include large lesions,
resections of posterosuperior segments, and results that are not generalizable in
inexperienced hands. However, it is promising technology that could expand the indications
for minimally-invasive hepatobiliary surgery.[28 ]
Gundlapalli et al.[29 ] reported a case of a patient who underwent right mastectomy, and the Da Vinci robot
was used for breast reconstruction, more precisely for intra-abdominal dissection
of the deep inferior epigastric vessels. This technique provided considerable precision
to the surgical procedure, in addition to not leading to postoperative complications.
However, further comparative studies are needed to assess the long-term outcomes and
its cost-effectiveness.
Fiorelli et al.[30 ] compared the use of traditional endoscopic CO2 laser in the treatment of subglottic
stenosis with the AcuBlade laser system, performed through robotic microsurgery. The
latter proved to be superior in reducing the chances of edema and the risk of recurrence,
since it avoids injuring nearby tissues through laser dissipation, which is common
in other techniques, and it can perform a more precise incision.[30 ]
Fu et al.[31 ] reviewed the role of transoral robotic surgery (TORS), transoral laser microsurgery
(TLM), and lingual tonsillectomy in the identification of squamous cell carcinoma
of the neck and head. The study[31 ] supported the use of TORS and TLM to assist in the identification of this tumor,
with higher detection rates compared to the traditional diagnosis. The authors[31 ] also demonstrated that the addition of formal lingual tonsillectomy using TORS/TLM
is a safe and effective option that can increase the yield of locating a primary occult
tumor.[31 ] Kwong et al.[32 ] and Lörincz et al.[33 ] also wrote about the use of TORS in head and neck cancer, stating that it guarantees
improved visualization, instrumentation, and ergonomics in transoral resections, with
good results, in addition to playing the role of a multidisciplinary team in this
field.
Additionally, Castellano and Sharma[34 ] performed a systematic review on the effects of TORS on the patient's quality of
life after treatment and on the swallowing function of the patient with head and neck
cancer. They[34 ] concluded that, when comparing patients who underwent TORS with those submitted
to open surgery, the former had a higher score on the quality-of-life questionnaires
and also showed an improvement in their swallowing function. However, the authors[34 ] note that the results depend on a few factors, such as baseline, T stage, and the
status of the adjuvant treatment.[34 ] Another important point about TORS was highlighted by Chalmers et al.[35 ] in their study on the role of reconstruction in post-TORS defects, in addition to
the role of robotic reconstruction in the medical practice.
Likewise, Li et al.[36 ] performed an analysis of the United States National Cancer database to compare the
long-term outcomes of patients with oropharyngeal carcinoma treated with TORS, TLM,
and non-robotic surgery. The study[36 ] evaluated the potential decrease in the risk of positive margins and the need for
adjuvant chemoradiotherapy. However, the results showed that the survival rate was
equivalent among all patients. Because of this, he authors[36 ] concluded that the TORS can be considered the primary surgical modality for the
management of oropharyngeal carcinomas.
Moreover, Hanna et al.,[37 ] in their review, questioned whether robotic surgery is an option for early-T-stage
laryngeal cancer, and compared TORS to TLM and partial open surgery in achieving negative
margins, requiring adjuvant radiation. No difference was observed between the rates
of positive margins of TORS and TLM, which suggests that TORS is a cancer-specific
treatment option. Akst et al.[38 ] discussed robotic microlaryngeal phonosurgery, in which a new robotic ear, nose,
and throat (ENT) microsurgery system (REMS) was developed, emphasizing cooperative
control rather than remote control. This technology enables an improvement in surgical
precision, and is subjectively easy to use, but future tests are still needed for
its use in the clinical practice.
McGuire et al.[39 ] analyzed a series of cases, and concluded that there is potential for performing
robotic microlaryngeal surgery (RMLS) using the Modular Oral Retractor (MOR) device,
which reduces the need for lingual retraction suture, providing adequate exposure
of the anterior commissure, enabling 360° access to the lesion, and eliminating the
narrow view of the traditional laryngoscope. However, prospective research comparing
RMLS and traditional microlaryngeal surgery is needed to determine the comparative
results of each method.
Kim et al.[40 ] reported the cases of two patients diagnosed with tumors with mandibular invasion
in which a 3D simulation software was used. Virtual surgical planning (VSP) is emerging
as essential for mandibular reconstruction, due to the limited surgical field in the
modified face-lift incision used in robotic neck dissection for oral cavity cancer.
The authors[40 ] concluded that the VSP has an important role to play in the era of robotic surgery,
even if still limited.
Saleh et al.[2 ] addressed the issue of plastic and reconstructive robotic microsurgery and concluded
that robots will not replace surgeons; rather, they will only be sophisticated instruments
used by surgeons. The major focus within robotic plastic surgery has been microvascular
surgery; however, robotic surgery can be applied to all aspects of the reconstructive
practice. Neurorobotic surgery, the harvest and insertion of flaps, dissection of
donor and recipient vessels, and nerve or vascular graft harvesting can be performed
with significantly reduced morbidity, improving patient outcomes. However, the current
outcomes of robotic surgery are at least comparable to those of traditional methods
with limited accessible evidence.
Dahroug et al.[41 ] reviewed microrobot-assisted otologic cholesteatoma surgery, and they concluded
that there is still no robotic system capable of performing this surgery, but several
interdisciplinary fields aim at the efficient implementation of this robotic system
in the future. There are several obstacles, such as the engineering required to create
a device so small, ergonomic and with the necessary accuracy. Ibrahim et al.[3 ] also suggested the possibility of the future implementation of robotics in this
field.
Van Mulken et al.[42 ] performed a randomized pilot study comparing robotic and non-robotic supermicrosurgery
of lymphatic venous anastomosis (LVA) in the treatment of breast-cancer-related lymphedema.
Better results were observed in patients who underwent the robotic surgery, in addition
to a reduction in the time to perform the anastomosis. Ibrahim et al.[3 ] have also mentioned robotic lymphedema surgery, noting that it is a microsurgical
niche that requires a high degree of precision.
Ibrahim et al.[3 ] have also showed the clinical applications of robotic microsurgery. According to
their study,[3 ] the robot helps provide precision and better visualization of the facial artery
in microvascular surgery, and it is also able to perform peripheral nerve reconstruction
in microneural surgery, due to its accuracy and steadiness.
Most studies[2 ]
[3 ]
[21 ]
[22 ]
[23 ]
[24 ]
[25 ]
[26 ]
[27 ]
[30 ]
[38 ] have stated that robotic microsurgery can decrease tremor and improve the surgeon's
precision, resulting in a safe and promising technique. However, they have also agreed
that it is a high-cost method, which is one of its few disadvantages. According to
Fiorelli et al.,[30 ] the possibility of using robotics in other procedures, such as maxillofacial and
otorhinologic surgeries, justifies the high cost. Furthermore, Edwards et al.,[26 ] Bourcier et al.,[27 ] and Kavoussi[24 ] have reported a longer operative time with the robotic technique when compared to
conventional surgery, but the safety and efficacy of the method seemed to make up
for this point. According to Bourcier et al.,[27 ] the longer time can be explained by the surgeons' inexperience with the robotic
technique when compared to conventional surgery. On the other hand, Ibrahim et al.[3 ] have stated that another limitation of the technique is the small amount of tactile
feedback when the surgeon uses a robot, concluding that training in the complex techniques
of robotic microsurgery is essential for health professionals who are going to use
it, as concluded Doulgeris et al.[43 ] on robotics in neurosurgery.
[Table 1 ] summarizes the applications of robotic surgery studied.
Table 1
Article title
Author (year)
Study design
Application of robotic surgery
Intelligent Surgeon's Arm Supporting System iArmS in Microscopic Neurosurgery Utilizing
Robotic Technology
Goto et al.[21 ] (2018)
Prospective observational study
Microneurosurgery
30 Years of Neurosurgical Robots: Review and Trends for Manipulators and Associated
Navigational Systems
Smith et al.[22 ] (2016)
Literature review
Neurosurgery
Robotics in Neurosurgery: Evolution, Current Challenges, and Compromises
Doulgeris et al.[43 ] (2015)
Literature review
Neurosurgery
Validation of robot-assisted vasectomy reversal
Kavoussi[24 ] (2015)
Prospective interventional study
Vasectomy reversal
Robotic Surgery for Male Infertility
Darves-Bornoz et al.[25 ] (2021)
Literature review
Surgery for male infertility
First-in-human study of the safety and viability of intraocular robotic surgery
Edwards et al.[26 ] (2018)
Randomized clinical trial
Intraocular retinal membrane removal surgery
Robot-assisted tremor control for performance enhancement of retinal microsurgeons
Roizenblatt et al.[23 ] (2019)
Literature review
Eye surgery
Robotically Assisted Pterygium Surgery: First Human Case
Bourcier et al.[27 ] (2015)
Case report
Pterygium removal
Robotic approach to hepatobiliary surgery
Gonzalez-Ciccarelli et al.[28 ] (2017)
Systematic review
Hepatobiliary surgery
Endoscopic treatment of idiopathic subglottic stenosis with digital AcuBlade robotic
microsurgery system
Fiorelli et al.[30 ] (2018)
Case report and review
Subglottic stenosis treatment
Improved Glottic Exposure for Robotic Microlaryngeal Surgery: A Case Series
McGuire et al.[39 ] (2017)
Case series
Robotic microlaryngeal surgery
Robotic microlaryngeal phonosurgery: Testing of a “steady-hand” microsurgery platform
Akst et al.[38 ] (2018)
Randomized clinical trial
Microlaryngeal phonosurgery
The role of transoral robotic surgery,
transoral laser microsurgery, and lingual
tonsillectomy in the identification of head
and neck squamous cell carcinoma of
unknown primary origin: a systematic
review
Fu et al.[31 ] (2016)
Systematic review
Transoral robotic surgery
Is robotic surgery an option for early T-Stage laryngeal cancer? Early nationwide
results
Hanna et al.[37 ] (2020)
Retrospective observational study
Early T-stage laryngeal cancer
Transoral robotic surgery in head neck cancer management
Kwong et al.[32 ] (2015)
Review
Transoral robotic surgery
Systematic Review of Validated Quality of Life and Swallow Outcomes after Transoral
Robotic Surgery
Castellano and Sharma[34 ] (2019)
Systematic review
Transoral robotic surgery
Clinical Value of transoral robotic surgery: Nationwide results from the first 5 years
of adoption
Li et al.[36 ] (2019)
Retrospective observational study
Transoral robotic surgery, transoral laser microsurgery
and non-robotic surgery
First-in-human robotic supermicrosurgery using a dedicated microsurgical robot for
treating breast cancer-related lymphedema: a randomized pilot trial
Van Mulken et al.[42 ] (2020)
Randomized pilot study
Robotic and non-robotic lymphatic venous anastomosis in lymphedema
Decision management in transoral robotic surgery: Indications, Individual patient
selection, and role in the multidisciplinary treatment for head and neck cancer from
a European perspective
Lörincz et al.[33 ] (2016)
Literature review
Transoral robotic surgery
Robot-Assisted Reconstruction in Head and Neck Surgical Oncology: The Evolving Role
of the Reconstructive Microsurgeon
Chalmers et al.[35 ] (2018)
Retrospective observational study
Transoral robotic surgery
The Role of Virtual Surgical Planning in the Era
of Robotic Surgery
Kim et al.[40 ] (2016)
Case report
Mandibulectomy and mandibular reconstruction
Plastic and reconstructive robotic microsurgery—a review of current practices
Saleh et al.[2 ] (2015)
Systematic review
Plastic and reconstructive surgery
Review on Otological Robotic Systems: Toward Micro-Robot Assisted Cholesteatoma Surgery
Dahroug et al.[41 ] (2018)
Literature review
Cholesteatoma surgery
New Frontiers in Robotic-Assisted Microsurgical Reconstruction
Ibrahim et al.[3 ] (2017)
Literature review
Clinical applications: neurosurgery, ophthalmic, otologic, microvascular, microneural,
and lymphedema surgeries, and vasectomy reversal
Robotic-assisted deep inferior epigastric artery perforator flap abdominal harvest
for breast reconstruction: A case report
Gundlapalli et al.[29 ] (2018)
Case report
Da Vinci robot in mastectomy
Discussion
It is well known that the advent of robotic surgery and its unique features have provided
microsurgeons with great levels of precision. In addition, with its high-definition,
3D optics and strong magnification, robotics offers a potentially ideal setup to perform
the sensitive manipulations required in microsurgery. These minimally-invasive possibilities
also enable microsurgeons to operate on in confined spaces, thus avoiding the need
for open approaches, which in turn can improve the functional outcomes.[3 ]
Regarding robotic microvascular surgery, the robot's improved precision enables an
easier performance of anastomoses in confined spaces, such as that of the facial artery,
which reduces the number of additional incisions. In addition, robotic plastic and
reconstructive microsurgery also seems to benefit from the new technology, with microvascular
surgery being the major focus in this field.[2 ]
[3 ] Based on these advantages, robotic microsurgery also seems to gain momentum in hepatobiliary
surgery, surpassing laparoscopic approaches.[28 ]
The unique features of robotic surgery are currently being expanded into the field
of supermicrosurgery, specifically for lymphedema surgery. These are extremely challenging
procedures from a technical point of view, and can exceed, in certain cases, the limits
of human precision, so the use of the robot in this scenario is beneficial. The studies
included in the present systematic review corroborate this statement, with reports
of the effectiveness of robotic surgery in the treatment of lymphedema.[3 ]
[42 ] Thus, with the use of robotic surgery, it is possible to better identify lymphatic
insufficiency and pressure gradients, which are fundamental for lymphedema surgery,
thus achieving promising results.[44 ]
In urology, robotic microsurgery has been used in vasoepididymostomy, subinguinal
varicocelectomy, spermatic cord denervation, vasovasostomy, testicular artery reanastomosis,
and vasectomy reversal. Studies[3 ]
[24 ]
[25 ] claim that robotics is a promising and effective technique in this filed, which
yields results that are satisfactory and superior to those of conventional surgery.
In the field of microneurosurgery, the University of Calgary, Canada, has built the
new and aforementioned NeuroArm, which provides visual, auditory and tactile feedback,
creating an immersive environment for the neurosurgeon. NeuroArm was developed to
perform standardized techniques (biopsy, microdissection, thermocoagulation, fine
sutures), thus enabling the performance of procedures such as lesionectomy and aneurysm
clipping,[45 ] with positive repercussions. In addition, studies[3 ]
[21 ]
[22 ]
[42 ] demonstrate that there is a possibility of using robotic microsurgery for the management
of brain tumors, spinal cord injuries, as well as in brain stimulation.
Ophthalmologic and otologic robotic microsurgery have great potential as well. Recently,
the Da Vinci Si HD robotic surgical system was tested and proved to be viable for
ocular surface microsurgery. Retinal membrane removal surgery, as well as the treatment
of pterygium, macular injury, diabetic retinopathy, and retinal vein canalization
have also been shown to benefit from robotic surgery.[3 ]
[23 ]
[26 ]
[27 ] As for ear surgery, it has been noted that robotic microsurgery appears to be a
promising method. However, technical developments are still needed to ensure the necessary
accuracy in these procedures.[3 ]
There has been a great increase in the use of robots in transoral reconstructive microsurgery,
reducing the morbidity associated with the excision of oropharyngeal tumors, which
were previously accessible only by aggressive approaches. The current possibilities
for TORS concern the reconstruction of postoperative defects, oropharyngeal carcinomas,
laryngeal cancer, in addition to the treatment of other types of head and neck cancer
and glottic stenosis. Therefore, there is a wide range of applications of TORS, as
well as of its benefits in relation to manual surgery. According to several authors,[30 ]
[31 ]
[32 ]
[34 ]
[36 ]
[37 ]
[38 ]
[39 ] robotics ensures better accuracy, precision and ergonomics in this field, enabling
the performance of innovative techniques.
Elimination of the hand tremors seems to be one of the main advantages of robotic
surgery over conventional techniques, and this is the biggest challenge for surgeons
in microsurgery. In addition, it has been recognized that the technique ensures greater
sharpness of vision and surgical precision, resulting in safer and often more effective
surgeries compared to manual surgery. Among the disadvantages of robotics, the studies[2 ]
[3 ]
[21 ]
[22 ]
[23 ]
[24 ]
[25 ]
[26 ]
[27 ]
[30 ]
[35 ]
[38 ]
[43 ] mainly emphasize the high cost and longer surgical time in many procedures. This
last disadvantage seems to be a consequence of the surgeons' lack of experience with
the new technology, which can be overcome in the future with adequate training and
practice on the part of the professionals.
Conclusion
From the present systematic review, we conclude that there is great room for robotics
in microsurgery. The selected studies point to a great perspective for the growth
of these practices, which are based on the use of robotics in the most varied fields,
such as microneurosurgery, biopsy and microdissection, primary procedures for male
infertility, and eye and ear surgeries. Another branch with exponential growth is
in transoral surgery, which is a safe and effective option for the identification
and treatment of various head and neck tumors. In addition, other approaches such
as hepatobiliary surgery and surgery for the treatment of lymphedema can be performed
using robots, and this new technology is therefore promising. The guarantee of dexterity,
sharpness of vision, and surgical precision translate into a safe and auspicious technique,
applicable in different fields of microsurgery.
