Over the past decade, robotic surgery has ushered a new era of minimally-invasive procedures. It has found multiple applications in a number of specialties. With superior 3-dimensional visualisation, more degrees of freedom, and tremor-filtered control of the operating arms, this medical innovation has slowly diffused into the field of plastic surgery. The aim of this review is to discuss the current application of the surgical robot in plastic surgery, highlighting the clinical advances it has provided to the challenging field of reconstructive surgery. The authors present the three most important robotical systems designed to date, and outline the major advantages of robotic surgery that have stimulated its adoption by plastic surgeons. This is followed by highlighting the range of applications in reconstructive surgery, specifically head and neck, breast reconstruction, muscle flap harvest, lymphoedema surgery, and brachial plexus/peripheral nerve surgery. The authors finish by presenting some of the shortcomings of the da Vinci® (Intuitive Surgical, Inc., Sunnyvale, CA) platform that preclude its broader application.
Over the past decade, robotic surgery has ushered a new era of minimally-invasive procedures. It has found multiple applications in a number of specialties, including urology, gynaecology, cardiothoracic surgery, and otorhinolaryngology. With superior 3-dimensional visualisation, more degrees of freedom, and tremor-filtered control of the operating arms, this medical innovation has slowly diffused into the field of plastic surgery. The aim of this review is to discuss the current application of the surgical robot in plastic surgery, highlighting the clinical advances it has provided to the challenging field of reconstructive surgery.
The AESOP® system
The AESOP® was designed by Computer Motion, Inc. (Santa Barbara, CA), a medical robotics company founded in 1989. The purpose of this platform was to manipulate a laparoscopic surgical camera. It received US Food and Drug Administration (FDA) approval in 19941. Later, this robotical system burgeoned forth to include additional technologies, namely voice control, network facilities, and optical arms with seven degrees of freedom2. These contributed to improving the surgeon’s dexterity, as they enhanced his/her ability to control a stable image and prevent unnecessary/inadvertent movements (streaking the lens); also, fewer staff were required in the operating room3.
The ZEUS® system
In 1995, Computer Motion added a number of surgical arms to AESOP® for holding and manipulating surgical instruments. This marked the birth of ZEUS® (FDA approved in 2001)1. The ZEUS robotic system comprises a control console in which the surgeon is comfortably seated outside the operating room, along with a minimum of three robotic arms attached to the operating table. These can accommodate no less than 28 different instruments2. The ZEUS® platform was used during the famous ‘Operation Lindbergh’, the first transcontinental robot-assisted laparoscopic cholecystectomy4. Images were, however, still in 2D.
The da Vinci® system
Intuitive Surgical, Inc. (Sunnyvale, CA), along with other institutions, such as Massachusetts Institute of Technology and International Business Machines Corporation, developed the da Vinci® system (FDA approved in 2000)2. This system is made of three components: the surgeon’s console, the patient trolley (holding articulated surgical arms), and an advanced imaging system1. The surgical arms allow very precise gestures in 7° movements, scaling down of movements up to 5 : 1, and give an instrument flexibility of 360°. These characteristics give the surgeon the illusion that the tips of the instruments are an extension of the control grips3.
Updated versions have followed: The da Vinci S® system had increased ease of handling and increased amplitude of arm and instrument movements, and the da Vinci Si® system afforded further improvements in manipulators and pedals with a high-definition vision5, 6.
The da Vinci® system is the most widely used and had successful applications in endocrine, gynaecologic, urologic, and cardiothoracic surgeries. Its application to the ranging fields of plastic and reconstructive surgery will be analysed in this article.