The first UK report of robotic-assisted Lymphaticovenous anastomoses (LVA) for the management of lymphoedema

Summary

Lymphoedema remains a significant complication following axillary lymph node clearance, affecting at least 20% of breast cancer patients. One of the surgical approaches that has been shown to benefit such patients in a therapeutic setting is lymphaticovenous anastomosis surgery. Robotic-assisted microsurgery has emerged as a promising advancement in this domain, enhancing surgical precision through motion scaling and tremor elimination. We report the first UK case of a robot-assisted lymphaticovenous anastomoses (LVA) using the Symani Surgical System for the management of lymphoedema post axillary node clearance. This report showcases what can be achieved with the combination of the favourable ergonomics of a microsurgical robotic system and a high-quality 3D imaging system.

Dear Editor,

Lymphoedema represents a significant complication affecting at least one in five patients following axillary lymph node clearance for breast cancer.¹,² Robotic-assisted microsurgery has gained significant attraction in recent years following the introduction of dedicated microsurgical robotic systems.³

We report the first successful lymphaticovenous anastomosis (LVA) performed in the United Kingdom using the world’s first open robotic platform (Symani, Medical Microinstruments, Inc., USA).⁴

A 56-year–old woman had originally presented to a separate hospital with Grade 2 invasive ductal carcinoma of the left breast in August 2023, with extensive nodal disease in the left axilla, infraclavicular and internal mammary nodes. After completing neoadjuvant chemotherapy and radiotherapy, she proceeded to surgery in March 2024 which involved bilateral mastectomy, left axillary clearance, bilateral extended latissimus dorsi flaps and a LYMPHA (immediate lymphatic reconstruction) procedure in the left axilla. Unfortunately she developed a significant seroma in the post operative period which required antimicrobial therapy and a protracted inpatient stay.

In November of the same year she presented to our unit for management of lymphoedema of the ipsilateral upper limb. Conservative measures (manual lymphatic drainage and compression garments) had failed to provide relief. She had also developed recurrent cellulitis requiring PICC line insertion for intravenous antibiotic therapy.

Pre-operative assessment included near-infrared spectroscopy (NIR) imaging, which demonstrated suitable lymphatic channels for LVA at the level of the dorsal hand, dorsal forearm and anticubital fossa. A duplex ultrasound scan excluded recurrence and venous compromise. Nuclear medicine lymphoscintigraphic assessment excluded underlying primary lymphoedema. Pre-operative volumetric measurements using perometry showed a 26% percentage difference in total volume between her upper limbs.

Under general anaesthesia, three lymphaticovenous anastomoses were performed: two in the forearm and one on the dorsal aspect of the left hand. Standard LVA operative technique was used combining intraoperative patente blue dye and indocyanine green (ICG) lymphography for precise identification of three targeted lymphatic sites.

Two anastomoses were completed using the Symani Surgical System in an end-to-end configuration, while the third was hand-sewn. The robot is equipped with tremor reduction and motion scaling, providing enhanced dexterity for accurate manipulation of 11–0 Ethilon sutures. All anastomoses were successfully completed by the senior author (KWDR) without intraoperative complications [Fig. 1,Fig. 2].

Fig. 1.

Intraoperative image of a lymphatic vessel following completion of lymphaticovenous anastomosis (LVA) performed using Symani surgical robot. Indocyanine green (ICG) and patente bleu dye was used to confirm patency and flow through the anastomosis, demonstrating precise alignment enabled by robotic-assisted supermicrosurgery.

Fig. 2.

Setup of the surgeon controlling the robotic microsurgical instruments – two forceps-like wired hand controllers and a foot pedal; visualisation with 3D glasses and a remote screen using ORBEYE 4 K three-dimensional video exoscope.

To ensure ultra-high-definition visualisation we used the ORBEYE 4 K three dimensional video exoscope system that provides superior optical and magnification quality in comparison to the microscope.⁵ The surgical site is viewed on a 55- inch display equipped with 3D stereoscopic capabilities. This exoscope is also preferred as its compact design limits obstruction from robotic instruments and prevents the clashing, that we previously found occurs with the conventional microscope. The total operating time was 4 h and this demonstrates no appreciable difference compared to our hand sewn anastomoses [Fig. 2].

The patient was discharged on the same day and reported no immediate postoperative issues. Follow-up at five months showed a reduction in limb volume discrepancy from 26% to 18%, with further symptomatic improvement noted at eight months postoperatively. She remains under long term follow up.

Our case represents the first super-microsurgical application of a robot system for LVA in the United Kingdom and demonstrates the comparable operating timings, hospital stay and post operative outcomes to conventional hand sewn anastomosis.

Discussion

In the context of LVA, robotic assistance enhances the surgeon’s technical capacity by offering superior motion scaling, improved ergonomics, increased dexterity, and effective tremor filtration. These features collectively enable more precise manipulation of delicate structures, allowing surgeons to expand the boundaries of reconstructive microsurgery particularly in challenging cases involving anastomoses at submillimetric scales.

At the Royal Marsden Hospital, we have been performing LVA surgery manually since 2012 and it was interesting to note the significant benefits that the use of a microsurgical robotic platform brings to this operation. Even for the most skilled microsurgeon, the execution of a successful lymphaticovenous anastomosis when the vessels are <0.5 mm internal diameter can be challenging. However the Symani robotic system clearly facilitates more precise and stable suture placement. The Orbeye system (when optimally positioned and calibrated) offers the surgeon superior ergonomics, while maintaining excellent optical clarity and magnification.

The adoption of robotic systems is not without its drawbacks. Key limitations include high costs associated with the robotic system, consumables and the need for comprehensive training of the surgical team. Additionally, there is an initial learning curve, which may prolong operative times in early cases. Nonetheless, increasing surgical experience has been shown to reduce these times, as demonstrated in our case and further supported by the literature.

Supermicrosurgery has inherent limitations, as the caliber of target structure decreases, the demand for refined hand control, exceptional fine motor skills, and instrument stability intensifies. Procedures approaching vessels smaller than 0.5 mm in diameter often challenge the limits of human manual performance. Robotic platforms have the potential to overcome these barriers by enabling more stable and precise movements at the microscale.³

Funding

None.

Ethical approval

Not required.

Declaration of competing interest

None declared.