Recent Advancements in Robotic-assisted Plastic Surgery Procedures: A Systematic Review

Abstract

Background:

There has been a delayed, yet steady uptake of robotic-assisted surgery over the past decade within the field of plastic surgery. In an era of rapidly evolving scientific and technological development, there is a need for an update on the current literature for robotic-assisted plastic surgery procedures.

Methods:

Searches were conducted across major databases, including MEDLINE, Embase, and Central for published literature from March 2023 to December 2024. Only published articles written in English with full texts were considered for the final narrative synthesis.

Results:

Initially, we identified 1200 articles in the database search. Subsequently, 46 articles were included in our final narrative synthesis. Among the selected studies, 4 focused on reconstruction in transoral robotic surgery, 14 on breast surgery, 10 on robotic microsurgery, 5 on abdominal wall reconstruction, 6 on vaginoplasty, and 5 on flap harvest.

Conclusions:

The evidence to support the advantage of robotic plastic surgery procedures over traditional methods is relatively weak. However, there have been some advancements, specifically in transoral robotic surgery, robotic mastectomy, and breast reconstruction. Nevertheless, comprehensive exploration and prospective randomized trials are essential across all procedures to define the role of surgical robots in plastic surgery. The impediments to wider adoption include high costs, disruption to operative flow, and the absence of haptic feedback in robotic-assisted procedures within the specialty.

Takeaways

Question: What are the recent advancements and evidence of robotic-assisted plastic surgery procedures?

Findings: Among the selected studies, 4 focused on reconstruction in transoral robotic surgery, 14 on breast surgery, 10 on robotic microsurgery, 5 on abdominal wall reconstruction, 6 on vaginoplasty, and 5 on flap harvest.

Meaning: The evidence to support the advantage of robotic plastic surgery procedures over traditional methods is relatively weak. However, there have been some advancements specifically in transoral robotic surgery, robotic mastectomy, and breast reconstruction. Nevertheless, comprehensive exploration and prospective randomized trials are essential across all procedures to define the role of surgical robots in plastic surgery.

INTRODUCTION

Robotic surgery has revolutionized various surgical specialties by offering superior ergonomics, enhanced visualization, and increased dexterity compared with traditional laparoscopic procedures.¹ (See Video [online], which displays the overview of systematic review.)

The minimal incisions, comparable complication rates to conventional surgery, and shorter recovery times underscore its potential patient benefits. The trajectory of robotics research in medicine is on a continual upward trend.² In a keyword search spanning the past decade, urology, general surgery, and surgical oncology emerged as the leading surgical specialties in the number of publications on robotics. Notably, urology has outpaced other fields, publishing nearly 3 times the number of other specialties. Within urology, procedures such as prostatectomy, cystectomy, and radical nephrectomies have exhibited significant benefits over conventional methods.³

Video 1. displays the overview of systematic review.

Download video file ^{(62.2MB, mp4)}

In contrast, as is evident from Figure 1, the field of plastic surgery is still in its infancy in terms of incorporating robotic-assisted surgery into common practice. However, since the introduction of multiple robotic-assisted plastic surgery procedures (RPSP) by pioneers over a decade ago, there has been a steady uptake and innovation in this area.⁴ Several systematic reviews preceding this study have highlighted research on RPSP.^5–7 Dobbs et al⁵ and Nehme et al⁷ laid the foundation for the identification of robotic-assisted plastic surgery, whereas in 2023, Henn et al⁶ highlighted the use of artificial intelligence integration and semiautonomous robots in the field. However, these studies have not looked beyond procedures conducted by plastic surgeons. This review aimed to not only build upon this foundation of knowledge by identifying the most recent RPSP but also further investigate possible avenues of research in RPSP.

Fig. 1.

Publications on EMBASE regarding robotic surgery from each surgical specialty over the last decade.

METHODOLOGY

Our review was conducted by consulting the Cochrane Handbook of Systematic Review of Interventions, and the review was written according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guideline.^8,9 The protocol for this review was registered on PROSPERO before conducting the research.

Search Methods

A comprehensive search was performed by combining keywords and Medical Subject Heading terms through Boolean operators. (See figure, Supplemental Digital Content 1, which displays the sample search strategy, http://links.lww.com/PRSGO/D805.) Searches were conducted across major databases, including MEDLINE, Embase, and Central for exploration of published literature.

Inclusion for Review

Once identified, articles were organized in Endnote 20, where duplicates were eliminated. The refined set of articles was then uploaded to Rayyan for screening overseen by K.K. and A.E. This involved the assessment of titles and abstracts against predetermined criteria according to the protocol. Following the initial title and abstract screening phase, full-text articles of each publication underwent further independent review for final inclusion in our study. Any discrepancies in the inclusion process between the reviewers were resolved by consulting D.N. and S.G.

Inclusion and Exclusion Criteria

Articles included in this study had to be written in English, present either prospective or retrospective studies (including case reports, case-cohort, case-control, and randomized control trials), involve preclinical or clinical studies with direct/translational applications in RPSP, and have been published between March 2022 and December 2024. The publication date restriction was set based on a past systematic review.⁶

Common reasons for exclusion included robotic surgery that had no connection to RPSP, transoral robotic surgery (TORS) with no mention of reconstruction, and nonsurgically related applications of robots such as telemedicine. Moreover, they were not considered for inclusion if the technology did not directly involve the use of surgical robots such as virtual surgical planning, computer-assisted bone contouring and resection, or the creation of 3-dimensional patient-specific implants.

Bias Assessment

The included articles were then assessed for their bias and quality based on a validated method introduced by Hawker et al.¹⁰ This involves critiquing 9 aspects of an article and rating them as “good,” “fair,” “poor,” or “very poor.” (See table, Supplemental Digital Content 2, which displays the results of quality assessment, http://links.lww.com/PRSGO/D806.)

Data Extraction and Synthesis

Each article’s primary outcome as well as the robotic surgery procedure and study design were then recorded on an Excel spreadsheet. (See table, Supplemental Digital Content 3, which displays the results of data extraction, http://links.lww.com/PRSGO/D807.) A narrative synthesis was then carried out by exploring the theory behind each intervention, the relationships between similar studies, and the advantages and barriers to their implementation.¹¹ The weight of each article for outcome reporting was matched based on the bias and quality assessment. The process of article search, screening, and inclusion are outlined in Figure 2.

Fig. 2.

PRISMA flow diagram.

RESULTS

Description of Results

Our initial search yielded 1200 articles from Central (184), Embase (488), and MEDLINE (528). After deduplication, 1007 articles went under the title and abstract screening. Subsequently, 102 articles were eligible for full article review. A total of 46 articles were included in our final narrative synthesis.

Transoral Robotic Surgery

TORS is a method that allows surgeons access to the base of the tongue down to the hypopharynx, with excellent visualization and dexterity in a confined space, without having to conduct lip-splitting mandibulotomies.^12,13 With such benefits, it is clear as to why publications have moved beyond basic studies, to now investigating larger cohorts and with analysis and comparison to traditional methods.^14,15

Four studies were identified in this review which mention the use of reconstruction following tumor resection using TORS. Insights from these studies provide further perspectives on the evolving landscape of robotic-assisted surgery in the oropharynx. In the setting of cancer treatments, studies have shown that patients undergoing TORS for tumor resection have a well-preserved quality of life and functional outcome as well as oncological outcomes comparable to open methods.¹⁴ Other articles, like the investigation of alternative flaps (nasoseptal flaps for lateral oropharynx defect), signify the promising future for the exploration of novel techniques within TORS.¹⁶ However, in the context of RPSP, there are only a few studies that explore reconstructive options.¹⁷

Several limitations to transoral robotic reconstructive surgery have been proposed, including lack of cost performance and evidence of improved outcome when 2 teams use robotic-assisted surgery.¹⁸ Although efforts have been made to create reconstructive algorithms for TORS reconstruction, further studies of transoral robotic reconstructive surgery are needed to validate its safety and efficacy.^19,20

Breast Reconstruction

Robotic Mastectomy

In light of increasing efforts to conduct nipple-preserving mastectomy in certain cases of breast cancer, robotic-assisted techniques have emerged as a potential alternative to conventional methods.^21,22 Commonly carried out via a small vertical axillary incision, the collective findings from robotic mastectomies included in the review evaluate different facets of this surgical approach.

Notably, high-quality prospective trials, including a randomized control trial, have underscored the safety of robotic mastectomies, with no significant differences in major complications compared with conventional procedures.^22–24 Although patient satisfaction can be similar between open and minimally invasive techniques, robotic surgery consistently excels in scar appearance and length and wound location satisfaction.^22,24,25 Pain assessments reveal comparable outcomes in the long term, though a study has reported significance for improved pain control in minimal access techniques in early postoperative settings.^22,24 Although oncological outcomes are generally comparable to open methods, the necessity for longer follow-ups for definitive conclusions has been emphasized.^22–24

However, a cost-effectiveness analysis suggests that endoscopic nipple-sparing mastectomy may be more pragmatic than robotic mastectomy at this point, considering similar clinical outcomes and patient-reported measures.²² In terms of complications, nipple-areola complex necrosis remains a concern. However, insights are emerging regarding the influence of incision site and patient selection in reducing this complication.^22,26,27 Data on postoperative nipple sensation show conflicting results.^22,24,28

Deep Inferior Epigastric Perforator Harvest

The traditional anterior approach to harvesting the deep inferior epigastric perforator (DIEP) flap often results in large fascial incisions and muscle disruption due to the posterior course of the DIEP pedicle.^29,30 However, robotic-assisted DIEP (RoboDIEP) flap harvest offers potential patient benefits by minimizing abdominal morbidity by dissecting the pedicle from the posterior aspect.⁴ Selber⁴ has previously described how the length of fascial incision spared (B) via the robotic approach can be calculated by subtracting the length of the intramuscular course (A) from the entire length of the pedicle (C), quantified by the equation B = C − A.^4,30 In other words, patients with shorter intramuscular courses benefit more by maximizing the robot’s ability to access the posterior pedicle while reducing fascial incision length.

Most importantly, studies in the review showed that RoboDIEP harvest is a safe and effective method for autologous breast reconstruction.^30–33 Additionally, Bishop et al³⁰ have reported a shortened fascia incision length by almost 10 cm (mean reduction of 13.4–3.6 cm) in their patient cohort compared with the conventional method. Moreover, RoboDIEP potentially reduces pain and shortens hospital stays compared with conventional DIEP breast reconstruction.^30,31 Furthermore, the feasibility of bilateral pedicle dissection using a modified port docking location emphasizes the versatility and advantages of this evolving robotic approach.³³ However promising, further prospective randomized studies with larger sample sizes are warranted to validate its benefits over conventional methods, especially regarding donor site complications, and to validate claims regarding hospital stay duration and pain scores. Limitations of RoboDIEP such as the possible loss of pneumoperitoneum during pedicle dissection and subsequent loss of visual fields need to be addressed.³²

Latissimus Dorsi Harvest

Robotic-assisted latissimus dorsi harvest in the context of breast reconstruction presents several advantages. These include the absence of donor site incisions, the ability to preserve pedicles, and the provision of a reliable flap, particularly for delayed reconstruction postirradiation.^4,34

Studies have demonstrated its safety, high patient satisfaction, convenience over endoscopic methods, and the added benefit of reduced scarring when using single-port robotic systems.^35,36 A single incision as small as 5 cm along the axillary line has been reported for the harvest and inset the latissimus dorsi flap for breast reconstruction.³⁴ Further research of different aspects of robotic-assisted latissimus dorsi harvest and the substantiation of current claims can be anticipated as its indications expand.

Microsurgery

The field of robotic microsurgery now has dedicated microsurgery robots such as Symani (MMI, Italy) and MUSA (Microsure, the Netherlands), which have both been approved for use in Europe. The key difference between the 2 systems is that MUSA 2 uses manual instruments, whereas Symani uses miniaturized wristed microinstruments controlled by a “master-slave” robotic system.³⁷ With MUSA 3 on its way, further dissemination of robotic microsurgery can be anticipated. These robots can be further complemented with RoboticScope from BHS Technologies, a microscope headset equipped with a high-definition camera and augmented reality.^38–41

Studies found in this review regarding microsurgery robots demonstrated the feasibility and safety of these systems. For vascular anastomosis, studies reported successful robotic anastomosis for various indications.^37,42 Interestingly, 1 case of perforator-to-perforator anastomosis of a 0.6-mm artery has been recorded.³⁷ In the case of lymphovenous anastomosis, patency was similar between robotic and manual methods.^43,44 Robotic methods were also found to be noninferior to manual methods in the improvement of quality of life while providing superior ergonomics, especially in deep planes.^41,44

Limitations of this method include the absence of haptic feedback, leading to complications like thrombosis, and the need to switch between robotic and manual for artery and vein anastomosis.^42,43 Further prospective studies with larger patient cohorts are essential to fully evaluate the benefits of robotic microsurgery over manual techniques.

Vaginoplasty

One complication arising from penile inversion vaginoplasty is inadequate vaginal depth (reported in up to 12% of cases).⁴⁵ It stems from factors such as insufficient dilation, scarring, and limited genital skin availability.^46–48 To address this issue without resorting to colon usage, robotic-assisted peritoneal vaginoplasty has emerged as a potential solution in recent years.⁴⁹ Initial studies suggest its feasibility and potential improvement of safety compared with alternatives such as colovaginoplasty.⁴⁷ However, further research in the setting of gender-affirming surgery is required to assess long-term risks and complications such as hematoma, abscess, and internal hernia.⁵⁰

Others

Robotic abdominal wall reconstruction has emerged as a noteworthy domain worthy of further exploration for application in RPSP. Robotic abdominal wall reconstruction has been utilized from simple hernia mesh onlay repairs to more complex abdominal reconstructions involving myofascial release.⁵¹ These procedures have been validated by high-quality articles that have reported data that suggest durable repairs with reduced wound complications, shorter hospital stays, and lower overall costs compared with open surgery.^51–53

In the context of flap harvests, the exploration of diverse procedures shed light on possible applications for RPSP. For instance, a robotic omentum flap harvest, used in thoracic surgery, highlights the feasibility of raising an omentum flap within a closed chest cavity.⁵⁴ This method may be further adapted for posterior approaches to chest wall reconstructions, such as for radiation necrosis and infections. Although not included in this study, applications of omentum flaps for anterior chest wall reconstruction have been previously demonstrated for their feasibility.⁵⁵ Furthermore, robotic-assisted intercostal muscle flaps for a bronchopleural fistula closure showed improved pain scores with the surgeons benefiting from robotic maneuverability and advanced imaging capabilities.⁵⁶ Classical flaps such as the rectus abdominis have also been raised robotically. A study has shown its reconstructive flexibility with a posterior approach to its resection, and an algorithm for its indication has been suggested.⁵⁷ Finally, a study of robotic-assisted raising of the radial free forearm flap has also reported improved aesthetic outcomes by avoiding linear scars during pedicle dissection.⁵⁸

DISCUSSION

The innovation of technology, fueled by visionaries of the past, present, and future, will continue to make an exponential impact on healthcare as we know it. Since the first development of a forward-viewing laparoscope by a gastroenterologist in 1929, we have witnessed the development of minimally invasive surgery become commonplace.⁵⁹ On the same continuum, robotic surgery has made leaps from the first robotic cholecystectomy in 1997 and the first trans-Atlantic remote operation in 2001 to now dominating minimally invasive surgery in certain surgical subspecialties.⁴ However, as with any innovative technique, criticism and rigorous evaluation of evidence are paramount for its improvement. Therefore, through this review, we set out to recognize the current state of robotics in plastic surgery to evaluate its benefits and limitations and to look for possible avenues of exploration. This attempt has yielded 46 studies that have been published regarding RPSP in a span of 15 months. We believe this speaks volumes to the accelerated interest surrounding the topic.

Since the previous systematic reviews, robot-assisted mastectomies have garnered attention through high-powered articles demonstrating the benefits of robotic-assisted surgery over open surgery regarding scar appearance, length, and wound location satisfaction.^22,24 Other methods of robotic breast reconstruction have also proven their feasibility, but in all cases, further randomized control trials and longer follow-ups will support its use in common practice. In the case of TORS, although it is an established method, further studies focusing on robotic reconstruction within the surgery can be conducted. Although robotic microsurgery has shown its feasibility through clinical research, it currently resides within a limited number of centers and practitioners and so further investigation is needed to better understand its role in RPSP. Noteworthy are the encouraging prospects of conducting perforator-to-perforator anastomosis and the possibilities of microsurgery within deeper planes.^37,41 Further research can be conducted for perforator to perforator in DIEP flaps and also for its application in small vessel surgery of the hand, head and neck, and the brain. Attempts to expand the indication of RPSP have also been appreciated in vaginoplasty and alternative methods of raising flaps and vessels.

Further inclusion of indications can also be investigated by looking beyond our surgical specialty. Abdominal and chest wall reconstruction are some of the few potential aspects that can benefit from methods such as the omentum flaps. Future research can consider broadening the scope of donor sites for reconstructive procedures, such as the robotic harvest of free jejunum through advanced robotic systems. Additionally, expanding the indications for robotic microsurgery, particularly within pediatric populations and other supermicrosurgery procedures, warrants further investigation. Attempting common procedures within plastic surgery may also prove to be useful in training plastic surgeons to be comfortable with robotics and understanding its benefits and limitations.

Despite their inherent benefits, RPSP in their current state have its limitations. Lack of haptics can be problematic in microsurgery, let alone supermicrosurgery, where surgeons must rely on subtle sensory feedback for anastomosis.⁴³ Furthermore, an inherent issue of RPSP is the lack of a single surgical system that allows the completion of a single procedure from start to finish. Besides the use of a pedicled latissimus dorsi flap in breast reconstruction, most procedures in this study only require robots for a single step of the surgery. For instance, in microsurgery, the machine must be docked for arterial anastomosis but undocked for venous coupling.⁴² In other cases, only certain aspects such as the pedicle dissection for flap harvest are conducted robotically, whereas the rest is done manually. This not only interrupts operative flow but also brings into question the cost-effectiveness which is already a well-cited issue.^22,30,33 Although system costs may be less of an issue in high-volume tertiary centers, research using affordable systems may be necessary to lower the barrier to entry. Therefore, further exploration of indications of RPSP, a robotic system that allows both flap raising, microsurgery, inset, and cost analysis, is crucial for further dissemination.

The current study’s strength lies in its comprehensive search using sensitive keywords allowing for the identification of pivotal studies with application to RPSP. However, the limitations of this study are the inclusion of low-quality studies, a short time frame, and nonstandardized outcome reporting. Though bias assessment was carried out, an objective quantitative evidence-based synthesis could not be conducted due to the wide scope and variability in outcome measurements.

In the future of surgery report published by the Royal College of Surgeons (United Kingdom), they anticipate minimally invasive surgery, virtual reality, augmented reality, artificial intelligence, big data, and personalized medicine to have a large impact on the healthcare system. Therefore, the field of plastic surgery must evolve with this rapidly changing scenery and continue to innovate and find creative solutions to complex surgical challenges. Although the application of RPSP is still limited to tertiary centers, future technological advancements will close this gap. Therefore, continued research and allowing future generations of plastic surgeons to be comfortable with using these technologies may help find RPSP, which may ultimately reduce wound complication rates, hospital stays, and overall cost savings compared with traditional open surgery and push the boundaries of achievable surgical feats.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.