First-in-human robotic supermicrosurgery using a dedicated microsurgical robot for treating breast cancer-related lymphedema: a randomized pilot trial

Abstract

Advancements in reconstructive microsurgery have evolved into supermicrosurgery; connecting vessels with diameter between 0.3 and 0.8 mm for reconstruction of lymphatic flow and vascularized tissue transplantation. Supermicrosurgery is limited by the precision and dexterity of the surgeon's hands. Robot assistance can help overcome these human limitations, thereby enabling a breakthrough in supermicrosurgery. We report the first-in-human study of robot-assisted supermicrosurgery using a dedicated microsurgical robotic platform. A prospective randomized pilot study is conducted comparing robot-assisted and manual supermicrosurgical lymphatico-venous anastomosis (LVA) in treating breast cancer-related lymphedema. We evaluate patient outcome at 1 and 3 months post surgery, duration of the surgery, and quality of the anastomosis. At 3 months, patient outcome improves. Furthermore, a steep decline in duration of time required to complete the anastomosis is observed in the robot-assisted group (33-16 min). Here, we report the feasibility of robot-assisted supermicrosurgical anastomosis in LVA, indicating promising results for the future of reconstructive supermicrosurgery.

Fig. 1. The microsurgical robot.

a, b Setup of the robot in a laboratory setting. In general the system is composed of the following: (1) master manipulators that are forceps-like joysticks, mounted to the operating table. These master manipulators are controlled by the operating surgeon. (2) A suspension ring that is attached to the operating table. The ring is placed between the operating field and the surgical microscope. (3) Slave manipulators that are robotic arms, which are attached to the suspension ring. The robotic arms can be equipped with genuine (super)microsurgical instruments. (4) Foot pedals that activate the system. A digital interface converts the movements of the master manipulators onto movements of the robotic arms. Motion scaling and tremor filtration can be adjusted by the software and controlled by foot pedals. c The MUSA in a clinical setting (the authors have preoperatively obtained patient’s consent to publication of the image). The microsurgeon on the left controls the MUSA via two master manipulators, which are mounted to the operating table. Two slave manipulators, mounted to the suspension ring between the operating field and the surgical microscope, then mimic the surgeon’s hand movement. In this case the microsurgeon on the right provides manual assistance during the procedure in an identical way as would be in conventional microsurgery cases with two surgeons.

Fig. 2. Microscopic view of a lymphatico-venous anastomosis.

View through the microscope on a completed LVA.

Fig. 3. Preoperative NIRF lymphography and corresponding markings.

a An example of preoperative NIRF lymphography after intradermal ICG administration in the second and fourth finger web spaces of the right hand of a study subject, as performed in the lymphedema outpatient clinic. b Corresponding preoperative markings based on findings of NIRF lymphography in the same patient. Measuring tape is used to indicate the site for incision during the actual LVA procedure.