Robotic DIEP Flap Harvest through a Totally Extraperitoneal Approach Using a Single-Port Surgical Robotic System

A New Era in Perforator Flap Surgery for Breast Reconstruction: A Comparative Study of Robotic versus Standard Harvest of Bilateral Deep Inferior Epigastric Artery Perforator Flaps

BACKGROUND

 Traditional deep inferior epigastric artery perforator (DIEP) flap harvest splits the anterior sheath, weakening the abdominal wall and predisposing patients to bulge or hernia. Abdominal wall morbidity may be decreased using minimally invasive techniques. We refined a transabdominal approach to the robotic harvest of bilateral DIEP flaps.

METHODS

 A retrospective medical record study involving all patients who underwent bilateral or bipedicled robotic DIEP (rDIEP) or standard DIEP (sDIEP) flap harvest between July 2021 and September 2022. Outcomes included abdominal wall morbidity, total operative time, length of stay (LOS), and complications.

RESULTS

 Forty-seven patients were included (48 sDIEP flaps, 46 rDIEP flaps) with no significant difference in patient characteristics. Fascial incision length in the rDIEP group was shorter (4.1 vs. 11.7 cm, p < 0.001). Mesh reinforcement of the abdominal wall was used in 13/24 sDIEP and none in rDIEP patients (p < 0.001). Operative time was longer in the rDIEP cohort (739 vs. 630 minutes, p = 0.013), although subanalysis showed no difference in the second half of the cohort. The average robotic dissection time was 135 minutes, which decreased significantly with the surgeon's experience. There were no intraoperative complications from using the robot. LOS was shorter with rDIEP but not statistically significant (3.9 vs. 4.3 days, p = 0.157).

CONCLUSION

 This study represents the most extensive cohort analysis of bilateral rDIEP flap harvest, offering a comprehensive comparison to traditional sDIEP. The initial results underscore the viability of robotic techniques for flap harvesting, highlighting potential advantages including reduced fascial incision length and decreased abdominal disruption. Furthermore, using robotics may obviate the necessity for fascial reinforcement with mesh.

Clinical experience in open robotic-assisted microsurgery: user consensus of the European Federation of Societies for Microsurgery

This study provides a comprehensive guide to robotic-assisted microsurgery. Following more than 900 clinical cases in 13 centers, this joint project was initiated to summarize and consent to the user experience. Two robotic systems specifically designed for the needs of open microsurgery received the first certification for clinical application (CE mark) in 2019 and 2020. Since their introduction into clinical application, several European microsurgical centers have implemented these systems, generating user experiences in multiple microsurgical subspecialties. All institutions using the MUSA-2 microsurgical robot (Microsure B.V., Eindhoven, Netherlands) or Symani Surgical System (Medical Microinstruments, Inc., Wilmington, Delaware, US) were invited to join the multicenter project. A modified nominal group technique was applied to answer five major questions regarding current and future indications and developments in open robotic-assisted microsurgery. Steep preclinical and clinical learning curves were characterized. General considerations concerning the two different systems are presented. Specifics for each microsurgical subspecialty are reported. Following two voting rounds, a consensus was reached in three of the five major questions with "lymphatics" being the top indication, "higher precision" being the top benefit, and "automation" being the top long-term goal of robotic-assisted microsurgery. This joint project of all Symani and MUSA-2 users presents clinical cases and the subsequent initial knowledge and experience. Lymphatics as a top indicator and a higher precision as the top benefit point toward the capabilities of robotic-assisted microsurgery in manipulation of smallest structures. Automation may further enhance and simplify robotic procedures in future. This project also provides a comprehensive guide to any institution aiming to introduce such a system for open robotic-assisted microsurgery in future.

The Present and Future of Robotic Surgery in Breast Cancer and Breast Reconstruction

Background: Breast cancer is the second most common cancer in women with an improving mortality rate and a growing need for reconstruction following oncologic resection. Advancements in robotic surgery and minimally invasive techniques have offered refinement to traditional open techniques of flap harvest for reconstruction, particularly regarding improved donor site morbidity. Methods: The literature review was based on a PubMed database search using the keyword "Robotic breast reconstruction" in conjunction with the Boolean operators "Flap", "Latissimus", and "DIEP" to specify the search. In total, 106 results were generated, which were then manually reviewed and condensed for a comprehensive stance on the current status, technique, variations, and outcomes for robotic breast reconstruction. Results: Robotic technique has been described for the latissimus dorsi (LD) and deep inferior epigastric perforator (DIEP) flaps for breast reconstruction. For LD, robotic flap harvest reduces donor site morbidity, incisional length, and hospital length of stay, with similar complication rates for seroma/hematoma/infection, and longer operative times. Robotic LD procedures have been described in conjunction with single-site nipple-sparing mastectomy and flap elevation leading to a full minimally invasive resection and reconstruction from one lateral incision. Robotic DIEP harvest offers a considerably smaller fascial incision/rectus muscle dissection and has a comparable complication rate to traditional techniques with shorter hospital length of stay, and improved pain, at the expense of longer operating times. Data on hernia/bulge reduction from robotic techniques is limited and not yet available. Conclusions: Robotic breast reconstruction offers great potential for improving breast reconstruction in terms of donor site morbidity, length of incision, hospital length of stay at the cost of longer operating times, and increased technical skill/specialization, but it has yet to be proven on a large scale with long-term outcome data. Multi-center, prospective clinical data and trials are needed to help elucidate the potential for equivalence and superiority of the minimally invasive approach compared to standard open techniques, but the future is promising for robotic surgery in breast cancer and breast reconstruction.

The Current State of the Art in Autologous Breast Reconstruction: A Review and Modern/Future Approaches

Background/Objectives: Modern breast reconstruction has undergone substantial evolution, with implant-based, pedicled autologous, and free autologous techniques. The purpose of this study is to review the current state of the art in free autologous breast reconstruction, highlighting advancements in the types of flaps, donor site selection, techniques, and functional restoration. Methods: A literature review was conducted using PubMed to capture studies related to well-known free flaps that are used for breast reconstruction. Studies for each flap type were reviewed and sorted for inclusion into one of six categories: (1) clinical outcomes, (2) comparison studies of alternative flaps, (3) preoperative planning, (4) flap classifications and perfusion zones, (5) technique descriptions, and (6) time and cost analyses. Results: The majority (77%) of articles included were written on various types of abdominally based free flaps, including TRAM, DIEP, and SIEA flaps. These studies indicated an evolution in technique over time to minimize donor site morbidity, improve patient-reported and functional outcomes, improve efficiency, and expand clinical indications. The remaining 23% of articles discussed alternative flap choices, including PAP, TUG, S/IGAP, and LAP flaps. Studies highlighted technical challenges and the evolution of techniques to make these flaps more accessible, as well as how to combine flaps to expand clinical indications. Conclusions: Autologous breast reconstruction has evolved significantly, with advancements in techniques such as robotic-assisted surgery, multi-flap reconstruction, bipedicled flaps, and neurotization. This review highlights the current best practices while acknowledging ongoing challenges and the potential for future innovations in microsurgery, nerve regeneration, and personalized medicine, which hold promise for further refining outcomes.

Not All Deep Inferior Epigastric Artery Perforator Flaps Are Created Equal: A Review of Donor-site Morbidity in Abdominally Based Autologous Breast Reconstruction

Background

Breast reconstruction after mastectomy is one of the most common procedures performed in plastic surgery. Autologous reconstruction is associated with better long-term patient satisfaction than implant-based reconstruction but with the requisite donor site and potential for associated morbidity.

Methods

The authors review the literature regarding the technical evolution of abdominally based autologous breast reconstruction and the effect of these changes as well as patient morbidities on bulge, hernia, and all-cause donor-site morbidity.

Results

The impact of patient risk factors on surgical outcomes is evaluated in the context of constantly improving technical surgical innovation. Patients' premorbid abdominal condition and prior abdominal procedures along with traditional complicating factors such as age, obesity, and smoking are associated with increased rates of donor-site complications. Conversely, shorter fascial incisions with or without robotic and laparoscopic assistance are associated with lower rates of abdominal weakness and healing complications than traditional abdominal free flap harvest. Perforator selection and abdominal closure techniques also play a key role.

Conclusions

There are contributions of both patient factors and technical aspects that when optimized can help minimize the risk of donor-site morbidity in deep inferior epigastric artery perforator flap breast reconstruction.

Evolution and Adaptations of Robotic DIEP Flap Surgery: A Systematic Review

BACKGROUND

The integration of robotic technology into surgical procedures has gained considerable attention for its promise to enhance a variety of clinical outcomes. Robotic deep inferior epigastric perforator (DIEP) flap harvest has emerged as a novel approach for autologous breast reconstruction. This systematic review aims to provide a comprehensive overview of the current techniques, outcomes, and complications of robotic DIEP flap surgery.

METHODS

A systematic literature search was conducted after PRISMA 2020 guidelines across databases including PubMed, Embase, Google Scholar, and Web of Science from 2000 to 2023. Articles exploring robotic DIEP flap harvest for breast reconstruction were assessed to compare operative techniques, clinical outcomes, and complications. The risk of bias was evaluated using ROBINS-I and the Newcastle-Ottawa scale.

RESULTS

Fourteen studies involving 108 patients were included. Three studies used a totally extraperitoneal (TEP) technique, whereas 11 studies used a transabdominal preperitoneal (TAPP) approach. Preoperative planning utilized computed tomography angiography and magnetic resonance angiography imaging. The mean robotic operative time was 64 minutes, with total operative times averaging 574 minutes for TAPP and 497 minutes for TEP. The mean length of stay was 5 days, and the mean fascial incision length was 3 cm. Overall complication rate was 14.9%, with no significant difference compared with conventional DIEP flap procedures.

CONCLUSION

Robotic DIEP flap harvest is a promising technique that may reduce postoperative pain and limiting abdominal donor site morbidity. Potential limitations include longer operative times, variable hospital stays, and increased costs.

The Donut DIEP Flap: A Novel Scarless Technique

SUMMARY

Deep inferior epigastric perforator (DIEP) flap surgery is a common technique for breast reconstruction. However, the long and noticeable abdominal scar is one of its greatest disadvantages. Here, the authors suggest a minimal scarring DIEP flap harvest with a novel abdominal design. The key to this method is to preserve more skin tissue with a circular design centered around the navel. Three circular incisions are made: (1) the smallest circle represents an incision around the umbilicus; (2) the middle circle with a radius of less than 3.5 cm indicates another skin incision because the donut-like skin paddle between the small and middle circles is included in the flap; and (3) the largest circle with a radius of greater than 10 cm represents the extent of flap dissection that was performed diagonally from the skin toward the Scarpa fascia. Pedicle dissection proceeds with the conventional method. For closure, a purse-string suture is performed with the umbilicus at its center, leaving only a single small circular scar around the umbilicus as the final scar. Closure of the donor-site is possible with the patient in a supine or slightly flexed position because of less skin excision.

Robot-Assisted Microsurgery-what does the learning curve look like?

Background

The introduction of robotic assistance in surgical practice has led to advancements such as the MUSA-2 robotic system that was designed for microsurgical procedures. Advantages of this system include tremor filtration and motion scaling. Initial studies showed promising results in skill acquisition for robot-assisted microsurgery. This study evaluated the learning curve for microsurgical anastomosis with and without robotic assistance among surgeons of varying experience levels.

Methods

Fifteen surgeons were divided into 3 groups (novice, intermediate, and expert) based on their microsurgical experience. They performed 10 anastomoses by hand and 10 with robotic assistance on synthetic polyvinyl alcohol vessels (diameter of 2 mm) in a laboratory setting. Participants were timed and mistakes such as backwall and leakage were assessed and recorded. Demographic information was collected.

Results

Statistical differences were found in manual anastomosis times between the intermediate and novice groups compared to the experts (p < 0.01). However, no statistical difference was found in the mean time between groups for the robot-assisted anastomoses. Novice doctors had the steepest learning curve for hand-sewn anastomosis. Experts had the fastest completion time at the end of the 10th robotic session, finishing at 14 min, compared to 33 min at the 2nd session. All groups reduced their mean time in half through their 10 robotic sessions.

Conclusion

This study indicated similarities in the learning curves for robot-assisted anastomosis among surgeons with varied experience levels. Experts excelled technically in manual anastomoses, but robot-assistance enabled novice and intermediate surgeons to perform comparably to the experts. Robotic assistance may aid more novice learners in performing microsurgical anastomosis safely at earlier points in their education.

Clinical, Preclinical, and Educational Applications of Robotic-Assisted Flap Reconstruction and Microsurgery: A Systematic Review

INTRODUCTION

Microsurgery and super-microsurgery allow for highly technical reconstructive surgeries to be performed, with repairs of anatomical areas of less than 1 mm. Robotic-assisted surgery might allow for further advances within microsurgery, providing higher precision, accuracy, and scope to operate in previously inaccessible anatomical areas. However, robotics is not well-established within this field. We provide a summary of the clinical and preclinical uses of robotics within flap reconstruction and microsurgery, educational models, and the barriers to widespread implementation.

METHODS

A systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses was conducted of PubMed, Medline, and Embase. Preclinical, educational, and clinical articles were included.

RESULTS

One thousand five hundred and forty-two articles were screened; 87 articles met the inclusion criteria across flap harvest, flap/vessel pedicle dissection, vascular anastomosis, and nerve repair. The literature presents several potential benefits to the surgeon and patient such as high cosmetic satisfaction, minimally invasive access with reduced scarring (flap harvest), and low complication rates. Lack of haptic feedback was reported by authors to not impede the ability to perform vessel anastomosis; however, this required further investigation. A steep learning curve was identified, particularly for microsurgeons embarking upon robotic-assisted surgery.

CONCLUSION

Robotic-assisted surgery can potentially enhance microsurgery and flap reconstruction, with feasibility demonstrated within this review, up to anastomosis of 0.4 mm in diameter. However, there is a lack of sufficiently powered comparative studies, required to strengthen this statement. To increase accessibility to robotic surgery for plastic and reconstructive surgeons, educational opportunities must be developed with standardized assessment of skill acquisition.

Learning curve of robotic assisted microsurgery in surgeons with different skill levels: a prospective preclinical study

Achieving precision in microsurgery requires skill, adequate instruments and magnification, as well as extensive training. Dedicated surgical robotic systems have enhanced and expanded the application of (super-)microsurgical techniques by introducing motion scaling and providing improved surgeon ergonomics. In this prospective preclinical trial, we analyzed the learning curve in robotic assisted microsurgery in 13 participants including medical students, residents, and attending physicians. Data on demographics as well as prior experience in surgery, microsurgery, and gaming were collected. In three study sessions, the participants performed nine microsurgical anastomoses each on 2 mm vessel models using the Symani® Surgical System in combination the VITOM 3D exoscope. A senior expert microsurgeon reviewed the de-identified and blinded videos and scored all anastomoses using a modified "Structured Assessment of Microsurgical Skills" (SARMS) score. All participants significantly reduced their time needed per anastomosis and their overall SARMS score, as well as individual scores for motion and speed throughout the trial. We saw a significant correlation of prior years of practice in surgery with the overall mean time and mean SARMS score. In a separate analysis of the three sessions, this influence could no longer be seen in the last session. Furthermore, we found no significant effect of gender, age, hand dominance, or gaming experience on speed and quality of the anastomoses. In this study of 117 robotic assisted anastomoses, a rapid improvement of performance of all participants with different surgical skills levels could be shown, serving as encouraging evidence for further research in the implementation of microsurgical robotic systems.

Fully Telemetric Robotic Microsurgery: Clinical Experience With 23 Cases

BACKGROUND

Recently, there is an ongoing trend in plastic surgery with robotic-assisted microsurgery and supermicrosurgery devices being developed. Combining a telemetrically controlled robotic microscope with an also telemetrically controlled microsurgery robot unlocks synergistic effects with complete disconnection of the operating surgeon from the operating field. Here, we report the first clinical free flap reconstructions using this setup.

METHODS

Twenty-three surgeries were performed with the combined remote approach using the Symani Surgical System and the RoboticScope in open microsurgery procedures. Anastomosis time and ischemia time were recorded. The surgical performance for anastomoses was assessed using the modified Structured Assessment of Microsurgical Skills (SAMS) score. Subjective satisfaction was evaluated by the surgeons in comparison with conventional microsurgery. To evaluate the learning curve, the senior authors first four (first group) and last four (last group) procedures were compared.

RESULTS

Overall, flap survival was 95.7%. The average arterial anastomosis time was 36.7 ± 10.9 min. Total time of surgery was 277.7 ± 63.8 min, and ischemia time was 100.6 ± 24.9 min. Most SAMS score parameters were significantly higher in the last group of surgical procedures compared with the first operations. Subjective satisfaction was equal or better with the combined robotic-assisted approach in most categories.

CONCLUSIONS

Our data demonstrates safety and feasibility of the use of a combined remote approach. Robotic systems for microsurgical procedures may hold promising potential for improvement of surgical quality and open up new frontiers in microsurgery.

Transabdominal Robotic Harvest of Bilateral DIEP Pedicles in Breast Reconstruction: Technique and Interdisciplinary Approach

BACKGROUND

 The deep inferior epigastric artery perforator (DIEP) flap is the gold standard for autologous breast reconstruction. However, the conventional procedure's anterior sheath division, from perforating vessels to the pedicle origin, risks weakening the abdominal wall's primary strength layer. Employing the da Vinci Xi Surgical System with indocyanine green dye and near-infrared fluorescence imaging, we refined a robotic technique for bilateral DIEP flap harvest. This approach enhances safety during vessel dissection, utilizing smaller fascial incisions. This study will present this technique in detail to microsurgeons interested in robotic DIEP flaps.

METHODS

 In a retrospective cohort study spanning July 2021 to September 2022, female patients undergoing robotic bilateral DIEP flap reconstruction were analyzed. Following suprafascial flap dissection, the surgical robot was docked to target the pelvis, identifying and exposing deep inferior epigastric vessels intracorporeally. Mobilization and division occurred at their bases, with retrieval through a minimal anterior fascial incision, minimizing disruption to the abdominal wall and its motor innervation.

RESULTS

 The study comprised 23 patients (46 flaps), with a mean fascial length of 4.1 cm and mean pedicle length of 12.82 cm. Mesh usage was absent. Robotic time averaged 139 minutes, overall case length was 739 minutes, and the average length of stay was 3.9 days. Notably, no pedicle or intra-abdominal injuries were reported.

CONCLUSION

 This technique ensures safe and efficient pedicle dissection in robotic DIEP flap harvests. Given the limited number of plastic surgeons adept in minimally invasive abdominal surgeries, we recommend collaborative efforts, with general surgeons initially assisting microsurgeons in adopting the robotic approach. This strategy facilitates a smooth transition until plastic surgeons attain confidence and competence in independent robotic dissection.

The application of robotics in plastic and reconstructive surgery: A systematic review

BACKGROUND

Robotic assisted surgery (RAS) has seen significant advancement in many surgical specialties, although the application of robotics in plastic and reconstructive surgery remains to be widely established. This systematic review aims to assess the role of RAS in plastic and reconstructive surgery.

METHODS

The review protocol was published and registered a priori as CRD42024507420. A comprehensive electronic search for relevant studies was performed in MEDLINE, Embase and Google scholar databases.

RESULTS

Overall, 132 studies were initially identified, of which, 44 studies satisfied the eligibility criteria with a cumulative total of 239 patients. RAS demonstrated a high degree of procedural success and anastomotic patency in microvascular procedures. There was no significant difference in periprocedural adverse events between robotic and manual procedures.

CONCLUSION

RAS can be feasibly implemented in plastic and reconstructive surgery with a good efficacy and safety profile, particularly for microsurgical anastomosis and trans-oral surgery.

Contemporary Microsurgical Breast Reconstruction: Abdominally Based Flaps

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Understand the types of abdominally based flaps, their anatomy, and their drawbacks. 2. Understand important aspects of the history and physical examination of patients wishing to undergo these procedures. 3. Understand the benefits of preoperative planning and its role in avoiding complication. 4. Understand the operative steps of the procedures and tips to increase efficiency. 5. Understand the postoperative care of these patients and the role of enhanced recovery pathways.

SUMMARY

In this article, the authors review the history, current state, and future directions related to abdominally based microsurgical breast reconstruction. This article covers preoperative, intraoperative, and postoperative considerations intended to improve patient outcomes and prevent complications. Evidence-based findings are reported when available to comprehensively review important aspects of these procedures.

The emerging role of robotics in plastic and reconstructive surgery: a systematic review and meta-analysis

The role of robotics has grown exponentially. There is an active interest amongst practitioners in the transferability of the potential benefits into plastic and reconstructive surgery; however, many plastic surgeons report lack of widespread implementation, training, or clinical exposure. We report the current evidence base, and surgical opportunities, alongside key barriers, and limitations to overcome, to develop the use of robotics within the field. This systematic review of PubMed, Medline, and Embase has been conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PROSPERO (ID: CRD42024524237). Preclinical, educational, and clinical articles were included, within the scope of plastic and reconstructive surgery. 2, 181, articles were screened; 176 articles met the inclusion criteria across lymph node dissection, flap and microsurgery, vaginoplasty, craniofacial reconstruction, abdominal wall reconstruction and transoral robotic surgery (TOR). A number of benefits have been reported including technical advantages such as better visualisation, improved precision and accuracy, and tremor reduction. Patient benefits include lower rate of complications and quicker recovery; however, there is a longer operative duration in some categories. Cost presents a significant barrier to implementation. Robotic surgery presents an exciting opportunity to improve patient outcomes and surgical ease of use, with feasibility for many subspecialities demonstrated in this review. However, further higher quality comparative research with careful case selection, which is adequately powered, as well as the inclusion of cost-analysis, is necessary to fully understand the true benefit for patient care, and justification for resource utilisation.

Surgical outcomes of robotic versus conventional autologous breast reconstruction: a systematic review and meta-analysis

Breast reconstruction is an integral part of breast cancer management. Conventional techniques of flap harvesting for autologous breast reconstruction are associated with considerable complications. Robotic surgery has enabled a new spectrum of minimally invasive breast surgeries. The current systematic review and meta-analysis study was designed to retrieve the surgical and clinical outcomes of robotic versus conventional techniques for autologous breast reconstruction. An extensive systematic literature review was performed from inception to 25 April 2023. All clinical studies comparing the outcomes of robotic and conventional autologous breast reconstruction were included for meta-analysis. The present meta-analysis included seven articles consisting of 783 patients. Of them, 263 patients received robotic breast reconstruction, while 520 patients received conventional technique. Of note, 477 patients received latissimus dorsi flap (LDF) and 306 were subjected to deep inferior epigastric artery perforator (DIEP) flap. There was a significantly prolonged duration of surgery (MD 58.36;95% CI 32.05,84.67;P < 0.001) and duration of anaesthesia (MD 47;95% CI 16.23,77.77;P = 0.003) among patients who underwent robotic surgery. There was a similar risk of complications between robotic and conventional surgeries. The mean level of pain intensity was significantly lower among patients who received robotic breast surgery (MD- 0.28;95% CI - 0.73,0.17; P = 0.22). There was prolonged length of hospitalization among patients with conventional DIEP flap surgery (MD- 0.59;95% CI - 1.13,- 0.05;P = 0.03). The present meta-analysis highlighted the feasibility, safety, and effectiveness of robotic autologous breast reconstruction. This included the successful harvesting of LDF and DIEP flap with acceptable surgical and functional outcomes.

[Robotic-Assisted DIEP Flap Harvest for Autologous Breast Reconstruction: Case Report, Technical Aspects and Identification of Suitable Patients]

BACKGROUND

Robotic-assisted harvest of the deep inferior epigastric perforator (DIEP) flap is an innovative modification of the traditional open preparation for autologous breast reconstruction. It is assumed that donor-site morbidity (herniae, bulging) is reduced by minimising the fascial incision length in robotic-assisted DIEP flap harvest.

MATERIAL & METHODS

This is the first report of a robotic-assisted DIEP harvest in Germany, which was performed in April 2023 at the University Hospital of Freiburg in an interdisciplinary approach of the Departments of Plastic Surgery, Urology and Gynaecology. To determine the value of this novel technique, we assessed the demand by retrospectively performing an analysis of potential patients and conducted a cost analysis based on the breast reconstructions with DIEP flap harvest performed between April 2021 and May 2023 at the Department of Plastic Surgery at Freiburg University Hospital. To this end, we carried out a retrospective analysis of preoperative CT angiographies to determine the proportion of patients suitable for a robotic-assisted procedure in a post-hoc analysis. Furthermore, we describe the basic robotic-assisted techniques and discuss the TEP and TAPP laparoscopic approaches.

RESULTS

In line with the previously published literature, a short intramuscular course (≤25 mm) and a perforator diameter of≥1.5 mm and≥2.7 mm (subgroup) were defined as a crucial condition for the robotic-assisted procedure. We analysed 65 DIEP flaps harvested in 51 patients, of which 26 DIEP flaps in 22 patients met both criteria, i. e.≤25 mm intramuscular course and≥1.5 mm diameter of the perforator, while 10 DIEP flaps in 10 patients additionally met the criteria of the subgroup (≥2.7 mm diameter). Based on the intramuscular course of the perforators in the CT angiographies of those 26 DIEP flaps, a potential reduction of the fascial incision of 96.8±25.21 mm (mean±standard deviation) compared with the conventional surgical approach was calculated. The additional material costs in our case were EUR 986.01. However, ischaemia time was 33,5 minutes longer than the median of the comparative cohort.

CONCLUSION

The robotic-assisted procedure has already proven to be a feasible alternative in a suitable patient population. However, further studies are needed to confirm that robotic-assisted DIEP flap harvest actually reduces harvest site morbidity and thereby justifies the additional costs and complexity.

Robot-Assisted Capsulectomy with Immediate Reimplantation in Breast Reconstruction

SUMMARY

Recent reports have introduced robotic breast surgery for immediate breast reconstruction with an implant. However, relevant reports of robot-assisted breast reconstruction including capsulectomy are limited. Although capsulectomy lowers risk of capsular contracture and thus contributes to better aesthetic outcomes, total capsulectomy may have complications, such as injury to axillary structures or chest wall and overlying skin devascularization. To minimize the risk of injury, the authors used a robotic system with Da Vinci SP, which has freely movable arms and clear, magnified three-dimensional vision, for total capsulectomy. Compared with conventional procedures, robotic surgery has the critical advantage of minimal incision and concealed scars, contributing to positive aesthetic outcomes. This study suggests that robot-assisted capsulectomy is technically feasible and safe for patients undergoing breast reconstruction with immediate reimplantation.

Robotics in Screening, Diagnosis and Treatment of Breast Cancer: A Perspective View

This perspective article aims to summarize and provide an outlook for developments around the use of robotics in the screening, diagnosis and treatment of breast cancer. We searched existing literature on the design and development of new systems and the current use of pre-existing surgical robotic systems. Robotic interventions for breast palpation and biopsy under ultrasound and MRI guidance are being developed and tested on simulated breast phantoms. Results are comparable to those achieved by clinicians; however, there are yet to be any human trials. Existing robotic surgical systems have been evaluated in human trials to perform nipple-sparing mastectomy and harvesting of autologous tissue for breast reconstruction. Results are comparable to traditional NSM and demonstrate positive short-term outcomes for patients. Robotic devices could revolutionize the clinical workflow around breast cancer through less invasive surgery, greater accuracy in biopsies and microsurgery and a potential reduction in clinicians' workload. However, more research into the practical deployment of these devices and concrete scientific evidence of better patient outcomes is needed.

Short Fasciotomy-Deep Inferior Epigastric Perforator Flap Harvest for Breast Reconstruction

BACKGROUND

Despite several technical modifications to further reduce donor invasiveness in harvesting deep inferior epigastric perforator (DIEP) flaps, techniques with general applicability and demonstrating clinical benefits are scarce. The present study aimed to introduce a short-fasciotomy technique and evaluate its reliability, efficacy, and applicability by comparison with those of conventional methods.

METHODS

A retrospective study was conducted with 304 consecutive patients who underwent DIEP flap-based breast reconstruction. A total of 180 patients underwent the conventional technique between October of 2015 and December of 2018 (cohort 1), and in 124 patients, the short-fasciotomy technique was implemented between January of 2019 and September of 2021 (cohort 2). In the short-fasciotomy technique, the rectus fascia was incised as much as overlies the intramuscular course of targeted perforators. After intramuscular dissection, pedicle dissection proceeded without additional fasciotomy. Postoperative complications and fasciotomy-saving benefits were compared.

RESULTS

The short-fasciotomy technique was successfully adapted for all patients in cohort 2, regardless of length of intramuscular course and number of harvested perforators, with no case requiring conversion to the conventional technique. The mean fasciotomy incision length in cohort 2 was 6.6 cm, which was significantly shorter than that in cohort 1 (11.1 cm). The mean length of the harvested pedicle in cohort 2 was 12.6 cm. No flap loss occurred in either group. The rate of other perfusion-related complications did not differ between the two groups. The rate of abdominal bulge/hernia was significantly lower in cohort 2.

CONCLUSIONS

The short-fasciotomy technique allows for less invasive DIEP flap harvest regardless of anatomical variability. It provides reliable outcomes with minimal functional donor-site morbidity.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Novel Port Placement in Robot-Assisted DIEP Flap Harvest Improves Visibility and Bilateral DIEP Access: Early Controlled Cohort Study

SUMMARY

To minimize donor-site damage, robot-assisted (RA) deep inferior epigastric perforator (DIEP) flap harvest has been suggested. Current robotic approaches favor port placement, which either does not allow a bilateral DIEP flap harvest through the same ports or necessitates additional scars. In this article, the authors propose a modification of port configuration. In a retrospective controlled cohort study, RA-DIEP and conventional DIEP surgery were compared. The perforator and pedicle were visualized conventionally until the level behind the rectus abdominis muscle. Next, the robotic system was installed to dissect the retromuscular pedicle. The authors assessed patient age; body mass index; history of smoking, diabetes mellitus, and hypertension; and additional surgical time. The length of the anterior rectus sheath (ARS) incision was measured. Pain was quantified using the visual analogue scale. Donor-site complications were assessed. Thirteen RA-DIEP flaps (11 unilateral and two bilateral) and 87 conventional DIEP flaps were harvested without flap loss. The bilateral DIEP flaps were raised without readjustments of the ports. The mean time for pedicle dissection was 53.2 ± 13.4 minutes. The length of the ARS incision was significantly shorter in the RA-DIEP group (2.67 ± 1.13 cm versus 8.14 ± 1.69 cm; 304.87% difference; P < 0.0001). There was no statistical difference in postoperative pain (day 1: 1.9 ± 0.9 versus 2.9 ± 1.6, P = 0.094; day 2: 1.8 ± 1.2 versus 2.3 ± 1.5, P = 0.319; day 3: 1.6 ± 0.9 versus 2.0 ± 1.3, P = 0.444). Preliminary results show that the authors' RA-DIEP approach is safe and allows dissection of bilateral RA-DIEP flaps with short ARS incision lengths.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Robot-assisted nipple-sparing mastectomy and immediate breast reconstruction with gel implant and latissimus dorsi muscle flap: Our initial experience

BACKGROUND

This study reports the preliminary results of da Vinci robot XI robot-assisted nipple-sparing mastectomy immediate breast reconstruction (R-NSMIBR) with gel implant and latissimus dorsi muscle flap.

METHODS

A total of 15 patients who underwent R-NSMIBR with gel implant and latissimus dorsi muscle flap surgery for breast cancer between September 2022 and November 2022 were evaluated.

RESULTS

Mean total operative time for R-NSMIBR was 361.9 ± 77.0 min. As the learning curve increased, the robot arm docking time decreased rapidly from the initial 25-10 min. Average total blood loss was 27.8 ± 10.7 mL and posterior surgical margin positivity rate was 0%. Perioperative complications and local recurrences or deaths were not observed at a mean follow-up of 3 ± 1 month 15 patients were satisfied with postoperative aesthetic results.

CONCLUSIONS

R-NSMIBR with a gel implant and latissimus dorsi muscle flap could be a new therapeutic option for breast reconstruction.

Robotics in Implant-Based and Autologous Breast Reconstruction

Autologous and implant-based breast reconstruction continues to evolve as new technology and mastectomy techniques become available. Robotic-assisted breast reconstruction represents a growing field within plastic surgery, with the potential to improve aesthetic and functional outcomes, as well as patient satisfaction. This article provides a review of indications, techniques, and outcome data supporting the use of robotic assistance in both implant-based and autologous breast reconstruction from surgeons around the world.

Robotics in Microsurgery and Supermicrosurgery

Microsurgery has changed the ability to perform highly precise and technical surgeries through the utilization of high-powered microscopes and specialized instruments to manipulate and repair anatomical structures as small as a few millimeters. Since the first human trials of robotic-assisted microsurgery in 2006, the expansion of microsurgery to supermicrosurgery (luminal diameter less than 1 mm) has enabled successful repair of previously inaccessible structures. Surgical robotic systems can offer two distinct operative advantages: (1) minimal access surgery-by entering body cavities through ports, flap harvest can be redesigned to affect a minimally invasive approach for flaps such as the rectus abdominis muscle, the latissimus flap, and the deep inferior epigastric perforator flap; and (2) precision-by eliminating physiologic tremor, improving ergonomics, increasing accessibility to difficult spaces, and providing motion scaling, precision is significantly enhanced. Robotic-assisted microsurgery is a promising application of robotics for the plastic surgeon and has played an important role in flap harvest, head and neck reconstruction, nerve reconstruction, gender-affirming surgery, and lymphatic reconstruction-all the while minimizing surgical morbidity. This article aims to review the history, technology, and application of microsurgery and supermicrosurgery in plastic surgery.

The Expanding Utility of Robotic-Assisted Flap Harvest in Autologous Breast Reconstruction: A Systematic Review

The expansion of robotic surgery has led to developments in robotic-assisted breast reconstruction techniques. Specifically, robotic flap harvest is being evaluated to help maximize operative reliability and reduce donor site morbidity without compromising flap success. Many publications are feasibility studies or technical descriptions; few cohort analyses exist. This systematic review aims to characterize trends in robotic autologous breast reconstruction and provide a summative analysis of their results. A systematic review was conducted using PubMed, Medline, Scopus, and Web of Science to evaluate robot use in breast reconstruction. Studies dated from 2006 to 2022 were identified and analyzed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Full-text, peer-reviewed, English-language, and human subject studies were included. Non-breast reconstruction articles, commentary, expert opinion, editor's letter, and duplicate studies were excluded. A total of 17 full-text articles were analyzed. The two robotic breast procedures identified were the deep inferior epigastric perforator (DIEP) and the latissimus dorsi (LD) flap. Results showed comparable complication rates and increased operative times compared to NSQIP data on their corresponding open techniques. Additional findings reported in studies included patient reported outcomes, incision lengths, and downward trends in operative time with consecutive procedures. The available data in the literature confirms that robotic surgery is a promising alternative to traditional open methods of breast reconstruction following mastectomy.

Breast reconstruction: Review of current autologous and implant-based techniques and long-term oncologic outcome

Implant-based reconstruction is the most common method of breast reconstruction. Autologous breast reconstruction is an indispensable option for breast reconstruction demanding keen microsurgical skills and robust anatomical understanding. The reconstructive choice is made by the patient after a discussion with the plastic surgeon covering all the available options. Advantages and disadvantages of each technique along with long-term oncologic outcome are reviewed.

Modern Innovations in Breast Surgery: Robotic Breast Surgery and Robotic Breast Reconstruction

Robotic surgery has a history of applications in multiple surgical areas and has been applied in plastic surgery over the past decade. Robotic surgery allows for minimal access incisions and decreased donor site morbidity in breast extirpative surgery, breast reconstruction, and lymphedema surgery. Although a learning curve exists for the use of this technology, it can be safely applied with careful preoperative planning. Robotic nipple-sparing mastectomy may be combined with either robotic alloplastic or robotic autologous reconstruction in the appropriate patient.

[Robotics in plastic surgery]

In recent years surgical robotic systems which were specifically developed for microsurgery have expanded the application of robotic-assisted surgery to plastic reconstructive surgery. Currently, there are two microsurgical robotic systems available for reconstructive plastic surgery. Both systems feature tremor reduction and motion scaling technologies, which are intended to optimize the surgeon's precision and dexterity. In the Department of Plastic Surgery and Hand Surgery at the University Hospital Zurich, the Symani Surgical System® has already been used for many microsurgical and supermicrosurgical operations, including autologous breast reconstruction, nerve transfer and, in particular, reconstructive lymphatic surgery. Despite special technical challenges, such as a lack of haptic feedback, the advantages outweigh the disadvantages for an appropriately trained and skilled microsurgeon, including smaller surgical access incisions for anatomically deep structures and an improvement in surgical precision.

Minimally Invasive Approaches to DIEP flap Harvest: A review of current data

Breast cancer is the most prevalent cancer in the female population. Autologous tissue is often used for reconstruction after mastectomy. The deep inferior epigastric (DIEP) flap is a favorite for breast reconstruction because it entails careful perforator dissection with less muscle destruction. Recently, minimally invasive techniques in DIEP flap harvest have increased in popularity but their complication rate and security profile may vary from one technique to another. The purpose of this review study is to evaluate and compare two minimally invasive surgical approaches to abdominal based free flap harvest: the transabdominal pre-peritoneal robotic assisted DIEP flap harvest and total extra-peritoneal laparoscopic DIEP flap harvest.

[New Technologies in Microsurgery: Potential, Indications and Economical Aspects - Report of the Consensus Workshop of the German-Speaking Society for Microsurgery of Peripheral Nerves and Vessels (DAM)]

Recently, several new technologies to support microsurgeons have received European market approval. This article summarizes and discusses the impressions of an expert panel to classify the potential of new technologies in terms of benefits for the surgeon, specific indications and economic aspects during the 42nd Annual Meeting of the German-speaking Working Group for Microsurgery of Peripheral Nerves and Vessels (DAM) in Graz, Austria. In general, the expert panel addressed the principles and prerequisite for the successful establishment of new technologies and, in particular, novel optical and robotic systems. For this purpose, the current scientific literature was reviewed and initial clinical experience in the context of case series and retrospective studies was presented by the members of the expert panel. In the ensuing discussion, it was pointed out that it will first be necessary to identify patient subgroups in which the use of the new technologies is most likely to achieve a clinical benefit. Since clinical approval has already been granted for some systems, an approach can be developed for immediate clinical application from the simplest possible use to ever finer applications, i. e. from microsurgery to supermicrosurgery. Initially, funding for cost-intensive systems would presumably not be possible through revenue from standard care, but only through grants or subsidized clinical trials. In a final survey, the majority of meeting participants see the need for a price reduction of both visualization and surgical robotics technologies to enable widespread clinical establishment. Likewise, a majority of participants would prefer a combination of an exoscope or robotic microscope and a surgical robot for clinical use. The present consensus work addresses the development of a strategy for the effective establishment of new technologies, which should further increase the surgical quality of selected interventions.

Clinical outcomes following robotic versus conventional DIEP flap in breast reconstruction: A retrospective matched study

Background

A robotic deep inferior epigastric perforator (DIEP) flap created through a totally extraperitoneal approach minimizes violation of the donor site, which may lead to postoperative pain reduction and rapid recovery. The authors compared the clinical outcomes of robotic and conventional DIEP flap breast reconstructions.

Methods

Data from consecutive patients who underwent mastectomy with DIEP flaps for breast reconstruction between July 2017 and January 2021 were retrospectively reviewed. Patients were divided into robotic and conventional DIEP groups, and the two groups were matched using the inverse probability of treatment weighting method. They were compared based on the reconstruction time, drainage amount, postoperative pain, rescue analgesics, hospital stay, complications, and BREAST-Q scores.

Results

After matching, a dataset of 207 patients was formed, including 21 patients in the robotic DIEP group and 186 patients in the conventional DIEP group. The mean reconstruction time was longer in the robotic DIEP group than in the conventional DIEP group (P<0.001). In the robotic group, pain intensity during the postoperative 6–24 hours was significantly reduced (P=0.001) with less use of fentanyl (P=0.003) compared to the conventional DIEP group. The mean length of hospital stay for the robotic DIEP group was shorter than that for conventional DIEP (P=0.002). BREAST-Q scores indicated a higher level of the abdominal physical well-being domain in the robotic group (P=0.020). Complication rates were comparable between the two groups.

Conclusions

This study suggests that a robotic DIEP flap offers enhanced postoperative recovery, accompanied by a reduction in postoperative pain and hospital stay.

Robotic-Assisted Microsurgery and Its Future in Plastic Surgery

Within the last 20 years, robotic-assisted surgeries have been implemented as routine procedures in many surgical fields, except in plastic surgery. Although several case series report promising results, technical and economic aspects have prevented its translation into clinical routine. This review is based on a PubMed and Google Scholar database search, including case reports, case series, clinical and preclinical trials, as well as patents. Past, recent approaches, ongoing patents, as well as eight specific systems for robotic-assisted microsurgery and their potential to be translated into a clinical routine, are described. They may lay the ground for a novel field within plastic surgery. This review provides an overview of the emerging technologies and clinical and preclinical studies and discusses the potential of robotic assistance in the field of plastic surgery.

Does plastic surgery need a rewiring? A survey and systematic review on robotic-assisted surgery

Background

This is a paucity of data regarding plastic surgeons' opinions on robotic-assisted surgery (RAS). We developed a questionnaire aimed to survey plastic surgeons regarding training in robotics, concerns about widespread implementation, and new research directions.

Methods

A survey was created using Google Forms and sent to practicing plastic surgeons and trainees. Responses regarding desired conference proceedings about robotics, robotic residency training, and perceived barriers to implementation were elicited. Survey responses were utilized to direct a systematic review on RAS in plastic surgery.

Results

The survey received 184 responses (20.4%; 184/900). The majority (92.8%) of respondents were/are plastic surgery residents, with the most common fellowships being microsurgery (39.2%). Overall, 89.7% of respondents support some integration of robotics in the future of plastic surgery, particularly in pelvic/perineum reconstruction (56.4%), abdominal reconstruction (46.5%), microsurgery (43.6%), and supermicrosurgery (44.2%). Many respondents (66.1%) report never using a robot in their careers. Respondents expressed notable barriers to widespread robotic implementation, with cost (73.0%) serving as the greatest obstacle. A total of 10 studies (pelvic/perineum = 3; abdominal = 3; microsurgery = 4) were included after full-text review.

Conclusions

Evidence from our survey and review supports the growing interest and utility of RAS within the plastic and reconstructive surgery (PRS) and mirrors the established trend in other surgical subspecialties. Cost analyses will prove critical to implementing RAS within PRS. With validated benefits, plastic surgery programs can begin creating dedicated curricula for RAS.