New FDA-approved robot opens doors for microsurgery in L.A.
ASPS members at Cedars-Sinai in Los Angeles successfully completed the first robot-assisted microsurgical head and neck cancer reconstructive surgery in the United States earlier this year. The procedure, performed by Victor Chien, MD, used the Symani Surgical System, which uses wristed robotic arms with 7 degrees of flexibility and received FDA approval for microsurgery last year.
"The benefits of this microsurgical platform is in providing greater precision and care when handling tissue in small and diseased vessels," says Dr. Chien, a plastic surgeon in the Jim and Eleanor Randall Department of Surgery at Cedars-Sinai. "By removing the limitations that come with natural tremors in a human hand, the robot helped us execute this procedure in an efficient manner."
The Symani Surgical System is remote-controlled, allowing the operating surgeons to sit in a unique chair with hand controllers and use a 3D screen to guide the procedure. In addition to reducing – if not entirely eliminating – the natural tremors typically associated with the human hand under a standard microscope, Dr. Chien says the system's magnification capabilities allow for decreased trauma to vessel walls and reduce donor site morbidity, which potentially result in decreased lengths of hospital stays for patients.
The system is also notable in that the FDA approval allows it to be used by plastic surgeons – and not in an "off-label" manner like other systems – such as the Da Vinci surgical system, developed by Sunnyvale, Calif.-based Intuitive Surgical, Inc., which, as PSN reported in its March 2024 cover story ("Options on the table") require plastic surgeons to use the system in collaboration with non-plastic surgeons who are credentialed to use the devices.
"This is going to raise the bar for the entire specialty," Dr. Chien says. "I think it's going to democratize microsurgery and allow those 'at the sharpest end of the spear' to go even further."
Curtis Cetrulo Jr., MD, director of the Division of Plastic Surgery at Cedars-Sinai, tells PSN that besides head and neck reconstruction surgery, the robot can be employed for other complex procedures such as breast reconstruction, lower-extremity microsurgical reconstruction and lymphovenous bypass procedure for lymphedema. Dr. Cetrulo adds that the department has also used the device for intracranial and intraoral cases, including jaw reconstruction.
"I think we're still defining the indications – where it works best and how it can be most efficient," Dr. Cetrulo notes. "Theoretically, all microsurgeries should be more precise and accurate. There are studies that show the inside of the vessel walls are cleaner and less damaged when the robot is used."
In addition to the demonstrable improvements to patient care, the device is also helping plastic surgeons ergonomically. Instead of being hunched over a microscope working with a limited range of motion, the surgical robot allows plastic surgeons to work through a 3D scope, sitting up straight in a comfortable position.
"In the talk I'm composing, the first slide is a copy of my own cervical MRI," Dr. Chien says. "In our field, there are high rates of cervical injury – and surgeons needing physical therapy or operations leads to issues at institutional levels with lost productivity or an earlier exit from the field. This device is something that could improve the longevity of a surgeon's career."
Democratizing surgery
While some robotic systems still necessitate collaboration between departments, some plastic surgeons have wondered about what effects robotic surgery might have on scope creep and other specialties being able to perform work that plastic surgeons spend years in training to master. From a "democratizing" standpoint, Drs. Cetrulo and Chien agree that if doctors from other specialties can be trained to do various procedures on the robot, the focus should fall more on patient benefit than a specific specialty "owning" a procedure.
"We're talking about patients around the world who don't have access to care but who now could," Dr. Cetrulo says. "This device allowed that to happen. You put one of these devices in a hospital in an underserved area, and they could run it 24/7, 365 days a year to perform cases that people couldn't otherwise access. Part of our mission is to train as many people as we can on this technology so they can go back home and put this to work improving patient care."
Dr. Chien says he's not concerned that the training to use a surgical robot will replace the years of training he and other plastic surgeons require to become a microsurgeon.
"I think because plastic and reconstructive surgery is a principles-based discipline and really a special way of thinking about a problem, its practice can only be elevated by technical advancements – not replaced," he says. "I'd like to think it's in our DNA. From Shushruta to Harold Gilles, MD, to the modern era of plastic surgery as a defined discipline, to Joseph Murray, MD, performing the first renal transplant and being recognized with the Nobel Prize, through today, our discipline employs a philosophical approach to reconstructive surgery that permeates every aspect of our training. Microsurgery is a cornerstone of plastic surgery training from the start of residency to the end of fellowship, exemplifying this as the singular focus and goal rather than one of multiple competing training priorities that may include ablative head and neck procedures or hand and upper-extremity reconstruction.
"As Dr. Cetrulo pointed out, this device will allow more surgeons to perform basic, rudimentary limb salvage or life-saving or life-changing primary microsurgical interventions," Dr. Chien continues. "It doesn't address the more complex questions of: 'Is this the right patient?' or 'What kind of flap do they need?' or 'How complex will this procedure be?' I don't think we're going to see an encroachment on the scope of plastic surgery. In fact, I think plastic surgery will expand because of this."
Both doctors agree the potential the robot provides for the specialty is limitless.
"Once you think about using dissection tools at this level – intra-abdominal, intrapelvic, intracranial, intrathoracic – it's very exciting," Dr. Chien says. "We have an opportunity to accomplish things that we would never have been able to before."