Pilot study on robot-assisted microsurgical lymphatico-venular anastomosis

Microsurgery facilitates procedures such as transplantation of tissue as well
as lymph oedema treatment. Currently the surgeon*s hands are the limiting
factor in microsurgical performance. Robot-assistance increases the movement
precision and might therefore be of great importance for the advancement of
microsurgery in the world.

This pilot study assesses the performance of a robot-assisted microsurgery.
Lympho-venular anastomosis(LVA) is the most difficult procedure in microsurgery
at this moment. This LVA technique is applied to treat for example breast
cancer related lymph oedema. Therefore, this LVA procedure is compared using a
manual expert and the same expert applying robot assisted LVA.

A prospective pilot study in Maastircht University Medical Center assesses
twenty patients to undergo either robot assisted (n=30) or manual LVA (n=30) to
treat the BRCLA. Primary outcome parameter is LVA anastomosis technique.
Secondary outcome measures include duration of surgery, technical errors during
surgery & complications peri-operatively, surgeon*s satisfaction with the LVA
procedure, the patients* convenience during surgery, arm volume over time and
patient*s symptom development over time.

LVA is a minimally invasive procedure, which can be performed under local
anaesthesia. The indocyanine green (ICG) is injected into the second and fourth
finger webspace of the lymphedematous limb. Next, ICG lymphangiography is
performed. Using the photographs as a guide and the ICG angiography, the
injection sites fluorescent stains are identified. The patient*s limb is then
prepared for surgery.
Before making the incision, a mix of lidocaine and epinephrine is injected at
the site of incision to achieve local anaesthesia and optimal haemostasis.

Based on the ICG lymphangiography mapping incisions of 1.5 to 2 cm are made at
the predetermined sites. Lymphatic vessels are identified.
When a viable lymphatic vessel is identified it is end-toend anastomosed to a
similarly sized adjacent recipient venule in the subdermal plane.

Generally 1 to 3 anastomoses are made in a lymphedematous arm. The surgery
takes approximately two hours.

The robot assists the surgery implying that the movements of the surgeon are
delayed. The same instruments are used and surgery steps are identical to the
manual technique.

The robot holds the microsurgical instruments and is extensively tested in the
laboratory and on animals. It has not shown any negative side effect compared
to the experienced manual LVA techniques.