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J Reconstr Microsurg
DOI: 10.1055/a-2596-5437
Original Article

Comparison of Biomechanical and Histopathological Properties of Robot-Assisted Anastomoses Using the Symani Surgical System® versus Conventional Anastomoses in a Preclinical Microsurgical Model

Vincent G.J. Guillaume 
1   Department of Plastic Surgery, Hand and Reconstructive Surgery, University Hospital RWTH Aachen, Aachen, Germany
,
Tekoshin Ammo
1   Department of Plastic Surgery, Hand and Reconstructive Surgery, University Hospital RWTH Aachen, Aachen, Germany
,
Sophie Leypold
2   Institute for Pathology, University Hospital RWTH Aachen, Aachen, Germany
,
Maximilian Praster
3   Department of Orthopedic Surgery, Trauma and Reconstructive Surgery, University Hospital RWTH Aachen, Aachen, Germany
,
Danny Jonigk
2   Institute for Pathology, University Hospital RWTH Aachen, Aachen, Germany
4   German Center for Lung Research (DZL), BREATH Hannover, Hanover, Germany
,
Justus P. Beier
1   Department of Plastic Surgery, Hand and Reconstructive Surgery, University Hospital RWTH Aachen, Aachen, Germany
,
Tim Leypold
1   Department of Plastic Surgery, Hand and Reconstructive Surgery, University Hospital RWTH Aachen, Aachen, Germany
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Funding None.
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Abstract

Background

The Symani surgical system (Symani) is the first robotic system specifically designed for microsurgical purposes and attracted substantial interest in recent times. Despite some initial investigations, no independent analysis of the histopathological/biomechanical properties and anastomoses quality of Symani-sutured anastomoses have been conducted so far. This study aims to compare in-depth robotic-assisted microsurgical anastomoses using the Symani versus conventional anastomoses regarding anastomosis quality, biomechanical, and histopathological properties.

Methods

We compared 12 microsurgical end-to-end anastomoses sewn by the Symani versus 12 by the conventional technique in a preclinical artery chicken-thigh-model regarding time until completion of the anastomosis, anastomosis quality (modified MARS10-rating and anastamosis lapse index (ALI)) and diameter. Additionally, histopathological analysis of the thread hole diameter, and knot firmness as well as biomechanical tests for intraluminal resistance and tensile strength of the anastomoses were conducted.

Results

Anastomosis quality was comparable between both techniques. The Symani-assisted anastomosis took a significantly longer time to perform than conventional anastomosis. Histopathological analysis revealed similar vessel wall damage while showing greater variability in knot spacing and bite width in the robotic anastomoses. No significant differences were observed in the tensile strength test or intraluminal resistance. However, the knot firmness of Symani-assisted anastomosis was significantly less than conventionally performed knots.

Conclusion

This study demonstrates that the Symani performs on par with conventional anastomosis techniques regarding anastomosis quality, vessel wall damage, intraluminal resistance, and tensile strength. Long-term continuous training and/or further innovations of the Symani system may lower the time required to perform the anastomosis and improve knot firmness.

Keywords

microsurgery - robotics - robotic-assisted microsurgery - anastomosis - super microsurgery

Presented at: nowhere.




Publication History

Received: 24 January 2025

Accepted: 17 April 2025

Article published online:
19 May 2025

© 2025. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Hong JPJ, Song S, Suh HSP. Supermicrosurgery: principles and applications. J Surg Oncol 2018; 118 (05) 832-839
    CrossrefPubMedSearch in Google Scholar
  • 2 Ballestín A, Malzone G, Menichini G, Lucattelli E, Innocenti M. New robotic system with wristed microinstruments allows precise reconstructive microsurgery: preclinical study. Ann Surg Oncol 2022; 29 (12) 7859-7867
    CrossrefPubMedSearch in Google Scholar
  • 3 Katz RD, Rosson GD, Taylor JA, Singh NK. Robotics in microsurgery: use of a surgical robot to perform a free flap in a pig. Microsurgery 2005; 25 (07) 566-569
    CrossrefPubMedSearch in Google Scholar
  • 4 Selber JC. Transoral robotic reconstruction of oropharyngeal defects: a case series. Plast Reconstr Surg 2010; 126 (06) 1978-1987
    CrossrefPubMedSearch in Google Scholar
  • 5 Selber JC, Baumann DP, Holsinger FC. Robotic latissimus dorsi muscle harvest: a case series. Plast Reconstr Surg 2012; 129 (06) 1305-1312
    CrossrefPubMedSearch in Google Scholar
  • 6 Pedersen J, Song DH, Selber JC. Robotic, intraperitoneal harvest of the rectus abdominis muscle. Plast Reconstr Surg 2014; 134 (05) 1057-1063
    CrossrefPubMedSearch in Google Scholar
  • 7 Malzone G, Menichini G, Innocenti M, Ballestín A. Microsurgical robotic system enables the performance of microvascular anastomoses: a randomized in vivo preclinical trial. Sci Rep 2023; 13 (01) 14003
    CrossrefPubMedSearch in Google Scholar
  • 8 Innocenti M, Malzone G, Menichini G. First-in-human free flap tissue reconstruction using a dedicated microsurgical robotic platform. Plast Reconstr Surg 2023; 151 (05) 1078-1082
    CrossrefPubMedSearch in Google Scholar
  • 9 Beier JP, Hackenberg S, Boos AM, Modabber A, Duong Dinh TA, Hölzle F. First series of free flap reconstruction using a dedicated robotic system in a multidisciplinary microsurgical center. Plast Reconstr Surg Glob Open 2023; 11 (09) e5240
    CrossrefPubMedSearch in Google Scholar
  • 10 Dastagir N, Obed D, Tamulevicius M, Dastagir K, Vogt PM. The use of the Symani surgical system in emergency hand trauma care. Surg Innov 2024; 31 (05) 460-465
    PubMedSearch in Google Scholar
  • 11 von Reibnitz D, Weinzierl A, Barbon C. et al. 100 anastomoses: a two-year single-center experience with robotic-assisted micro- and supermicrosurgery for lymphatic reconstruction. J Robot Surg 2024; 18 (01) 164
    PubMedSearch in Google Scholar
  • 12 Schäfer B, Bahm J, Beier JP. Nerve transfers using a dedicated microsurgical robotic system. Plast Reconstr Surg Glob Open 2023; 11 (08) e5192
    CrossrefPubMedSearch in Google Scholar
  • 13 Vollbach FH, Bigdeli AK, Struebing F, Weigel JL, Gazyakan E, Kneser U. Using a microsurgical robotic platform for in-flap anastomosis in autologous bipedicular breast reconstruction. Plast Reconstr Surg Glob Open 2024; 12 (01) e5511
    PubMedSearch in Google Scholar
  • 14 Schäfer B, Freund G, Bahm J, Beier JP. Robotic microsurgery for pediatric peripheral nerve surgery. J Robot Surg 2024; 18 (01) 388
    PubMedSearch in Google Scholar
  • 15 Wieker H, Hinrichs C, Retzlaff M. et al. A technical feasibility study on adaptation of a microsurgical robotic system to an intraoperative complication management in dental implantology: perforated Schneiderian membrane repair using Symani surgical system. J Robot Surg 2023; 17 (06) 2861-2867
    CrossrefPubMedSearch in Google Scholar
  • 16 Tolksdorf K, Hohberger FS, Ernst C, Tietz S, Schultze-Mosgau S, Tautenhahn F. First experience using a novel microsurgical robotic device for free flap surgery in cranio- and maxillofacial surgery. J Craniomaxillofac Surg 2024; 52 (06) 704-706
    PubMedSearch in Google Scholar
  • 17 Abla AA, Uschold T, Preul MC, Zabramski JM. Comparative use of turkey and chicken wing brachial artery models for microvascular anastomosis training. J Neurosurg 2011; 115 (06) 1231-1235
    PubMedSearch in Google Scholar
  • 18 Jeong HS, Moon MS, Kim HS, Lee HK, Yi SY. Microsurgical training with fresh chicken legs. Ann Plast Surg 2013; 70 (01) 57-61
    CrossrefPubMedSearch in Google Scholar
  • 19 Wessel KJ, Wendenburg I, Varnava C. et al. Ideal suturing technique for robot-assisted microsurgical anastomoses. J Robot Surg 2024; 18 (01) 272
    PubMedSearch in Google Scholar
  • 20 Stogowski P, Fliciński F, Białek J, Dąbrowski F, Piotrowski M, Mazurek T. Microsurgical anastomosis rating scale (MARS10): a final product scoring system for initial microsurgical training. Plast Surg (Oakv) 2021; 29 (04) 243-249
    CrossrefPubMedSearch in Google Scholar
  • 21 Ghanem AM, Al Omran Y, Shatta B, Kim E, Myers S. Anastomosis lapse index (ALI): a validated end product assessment tool for simulation microsurgery training. J Reconstr Microsurg 2016; 32 (03) 233-241
    PubMedSearch in Google Scholar
  • 22 Klein SL, Israel JE, Kronengold RT. New burst test method for comparing strengths of blood vessel repairs. Microsurgery 1995; 16 (02) 118-121
    PubMedSearch in Google Scholar
  • 23 Heitzer M, Brockhaus J, Kniha K. et al. Mechanical strength and hydrostatic testing of VIVO adhesive in sutureless microsurgical anastomoses: an ex vivo study. Sci Rep 2021; 11 (01) 13598
    PubMedSearch in Google Scholar
  • 24 Menichini G, Malzone G, Tamburello S. et al. Safety and efficacy of Symani robotic-assisted microsurgery: assessment of vascular anastomosis patency, thrombus, and stenosis in a randomized preclinical study. J Plast Reconstr Aesthet Surg 2024; 96: 1-10
    CrossrefPubMedSearch in Google Scholar
  • 25 Cho J, Kim D, Kim T, Pak CJ, Suh HP, Hong JP. Further validating the robotic microsurgery platform through preclinical studies on rat femoral artery and vein. J Reconstr Microsurg 2025
    PubMedSearch in Google Scholar
  • 26 Shimizu Y, Yasargil MG, Smith RD. Thrombogenesis in experimental microvascular anastomosis. J Microsurg 1979; 1 (01) 39-49
    PubMedSearch in Google Scholar