Surgical treatments of lymphedema-a literature review on robot-assisted lymphovenous anastomosis (LVA).

[BACKGROUND AND OBJECTIVE] Lymphedema is a common issue after surgery and oncologic treatment, affecting millions of people worldwide. A better understanding of the condition has provided an increasing possibility of a tailormade treatment plan, and with improvement in surgical technique, we now have several surgical treatments to offer, including the lymphovenous anastomosis (LVA). Considering the size of lymph vessels used for LVA, sometimes as small as 0.3 mm, there is a need for improvement of the technical aspects of the procedures. This paper explores the potential of robotic assistance in LVA surgery as an innovative approach to overcome the limitations of human dexterity.

[METHODS] A literature review was performed on 2023-12-22 using PubMed, Cochrane, and Embase databases to identify all previous publications on robotic LVA surgery, resulting in a total of 65 publications. Original publications in English were considered and after selection, a total of 5 publications were included in the review.

[KEY CONTENT AND FINDINGS] Two surgical systems used in clinical practice were identified, the MUSA (Microsure) and the Symani Surgical System (Medical Microinstruments). Common topics for discussion include the increased precision the robot assistance provides, clinical outcomes, ergonomics, and the learning curve for aspiring robot surgeons. Anastomosis times were generally found to be longer initially, but several authors note that there is a steep learning curve with rapidly decreasing times with an increasing number of procedures. Overall clinical outcomes were comparable to those using manual anastomosis.

[CONCLUSIONS] The use of robotics in LVA surgery, has shown promising results through clinical studies. Robotic assistance can help augment the technical capacity of a surgeon through motion scaling and tremor filtration, facilitating the most delicate steps of the LVA. The learning curve is steep, and the technique can hopefully make microsurgical reconstructions available to a broader number of patients. Further development can include haptic feedback, structured training programs, and cost optimization through dissemination of the technology.