As surgical techniques take ever-greater strides forward, medical professionals are requesting cutting-edge technologies to help them master the smallest of procedures. While microsurgery focuses on connecting tiny structures, such as veins, arteries, nerves and lymph vessels of less than 2mm in diameter, supermicrosurgery gets in even closer.
To carry out such precise procedures at sub-millimeter levels, however, requires technological assistance—and a helping hand from a robot. According to Sjaak Deckers, CEO and co-founder of microsurgical robot developer Microsure, supermicrosurgery is usually defined as working with anatomical structures of 0.5mm or less. He said:
“For example, for lymphovenous anastomosis, the structures are 0.5mm or less and to connect them you might have to put five or six sutures on each circumference.”
But not only does the Netherlands-based company expect its MUSA-3 robot to support existing microsurgeons in their complex work, but it also aims to “help them go where no human has ever gone before.”
“Supermicrosurgery is the next frontier.
With our robots, we can help microsurgeons remain at their high-performance level—and enable them to carry out surgical procedures in the future that can’t actually be done today.”
As Small as Humanly Possible
Microsure’s founding in 2016 was as a direct result of calls from surgeons for a technological solution to the challenges of microsurgery and supermicrosurgery. Sjaak Deckers explained:
“Microsurgeons from Maastricht University Medical Center asked the Robotics Department at Eindhoven University of Technology whether they could create a device for them.
They were operating at a scale that is as small as humanly possible and wanted a micromanipulator to shrink down their movements and remove their tremors.
Beyond the age of 50, surgeons can develop a tremor and so after years of training they can end up with just a short time to operate at a high level before their performance deteriorates.
They also wanted to be able to work in a more ergonomic position.”
An initial prototype was created; then a clinical version, MUSA-2, was built. This was the world’s first CE-certified microsurgical robot. Sjaak Deckers explained:
“Microsurgeons carried out over 50 procedures with MUSA-2, including breast reconstructions, lymphovenous anastomosis and nerve repairs.
We demonstrated the feasibility of the technology and the capability of the robot, then used the feedback to develop the MUSA-3.”
Retaining Control
MUSA-3 consists of two robotic arms, each with six joints and suspended from a cart, which are controlled by joysticks that mimic the shape of surgical instruments. The encoders in the joysticks measure the movements of the surgeon, which are then translated into the movements of the robot arms.
On the end of each robot arm, there is a disposal adaptor into which the surgeon fits his own micro forceps, scissors and needle-holder, etc. He said:
“The surgeon is in control—when he or she looks through the digital or hybrid microscope, what they see on the 3D screen are just the tips of the two instruments. They don’t even notice their hands are no longer directly involved.
The system is very intuitive and easy to use—within less than three days of training all the surgeons who have worked with the robot feel very comfortable using it for their patients.”
Improved Clinical Outcomes
Because clinicians can use their own instruments, the MUSA-3 has low operating costs. Clinical trials begin next year with the hope of launching the system on the European market in 2025. Sjaak Deckers suggested:
“A typical hospital might have 10 microsurgeons, but only one or two can carry out supermicrosurgery. We want to make every microsurgeon into a top supermicrosurgeon—someone who can consistently and reliably complete sutures on very small structures.”
Microsurgeons currently work in various fields including reconstructive, hand and lymphatic surgery. In the future, it is also hoped they might operate within urology, neurosurgery and ophthalmology. He added:
“There is a general thought now that using smaller free flap structures is much better for the patient, with better clinical outcomes. And the hope is that with robots and supermicrosurgery we might also be able to carry out surgical procedures that are currently impossible.
For example, it was recently discovered that the brain may contain lymph vessels to clear fluids and there are some theories that these might have some impact on diseases like Alzheimer’s or Parkinson’s.
But brain lymphatic structures are 0.1mm to 0.2mm and it is impossible to work manually with them, so a robot is mandatory.
Right now, however, there are no robots on the market with that kind of precision.”
An Exciting Future
The other leading player in the field is Italy-based MMI, with its Symani System. Created to perform microsurgical anastomosis, suturing and ligation, on blood vessels, lymphatic ducts and nerves, it has also been used in a broad range of procedures.
Mark Toland, CEO, said:
“People with hard-to-treat conditions deserve options that can give them a better quality of life and we hope that by expanding access to microsurgical and supermicrosurgical procedures, we are able to drive that initiative forward.”
Microsure recently asked 100 microsurgeons across Europe, the USA and Asia about the use of microsurgery in their hospitals. The survey revealed that a typical hospital currently sees almost 400 procedures per year, but surgeons expect to see this figure increase by at least 70% in the next five years.
Sjaak Deckers said:
“We see an exciting future for microsurgery and supermicrosurgery. We already have more than 1,000 microsurgeons who have expressed interest in using MUSA-3. They realize like us that when their eyes need a microscope to see what they are doing, then their hands need a robot arm to perform.”
