New technology to facilitate microvascular anastomosis: the perspective of the aging microsurgeon

It has been 64 years since Julius Jacobsen reported on the use of the operating microscope in 1960[1]. The development of the microsurgical reconstructive ladder and the continued expansion of reconstructive microsurgery have benefitted countless patients by providing reconstructive solutions to complex problems resulting from trauma, tumors, and sepsis. The history of reconstructive microsurgery is based on advances in technology. Improved instruments and finer tools such as those that have been developed for supermicrosurgery is an example of this evolution. The ability to sew smaller and smaller vessels (arteries, veins, and lymphatics) has generated new fields in microsurgery such as perforator flaps, perforator-to-perforator anastomosis, and lympho-venous anastomosis to prevent lymphedema or treat long-standing cases of this condition. Microscopes have continually been updated with features that enhance our understanding of tissue perfusion (such as the use of fluorescent techniques, such as near-infrared imaging in combination with indocyanine green)[2]. Additional improvements include better illumination, three-dimensional visualization, and exoscope magnification of surgical fields that changes the ergonomics for the operating surgeon. With respect to vascular anastomosis, there have been relatively few advances in the way we connect vessels. The coupler device has been used for veins for more than four decades with excellent outcomes. Attempts have been made to use magnets for arterial anastomosis, but such methods have not been able to substitute for hand sewn arterial anastomosis which remains the gold standard for arterial repair. Robotic approaches have influenced virtually every surgical discipline. Reconstructive plastic surgery is no exception. The use of the DaVinci robot has facilitated pelvic exoneration reconstruction using the rectus abdominis muscle[3]. Advances in breast reconstruction are directly influenced by robotic harvest of DIEP flaps – decreasing morbidity and improving patient reported outcomes. In the last decade, there has been considerable emphasis on physician wellness, stress mitigation, burnout, and ergonomics of surgical practice[4]. The prolonged use of surgical loupes and headlights has led to cervical spine issues. Poor surgeon posture during procedures has led to lower back issues. The longevity of surgeons varies. There are several issues that confront the aging surgeon. These include changes in visual acuity, stamina, and musculoskeletal degenerative conditions such as osteoarthritis, cognitive skills, declination in hand-eye coordination, and the evolution of essential tremor. Although knowledge, experience and judgment may be extensive, the physical abilities of surgeons can decline with aging[5]. It has been said that “going out on top” with regard to skilled surgical execution of procedures is certainly better than the surgeon being asked to stop operating because of poor outcomes, increased incidence of serious complications, or errors in judgment that result in preventable morbidity. The practice of microsurgery is technically demanding, physically challenging, and requires endurance and the ability to concentrate on the sequence of steps that must be executed correctly to assure success. While many argue that the actual anastomosis of vessels is the most straightforward aspect of the operation, it remains the most critical determinant of free tissue transplantation success. There is a direct correlation with anastomotic technique and thrombosis. Intimal disruption, improper suture placement, and failure to capture the intima on both sides of the vessels result in failure. Modifying surgeon behavior such as avoiding caffeine, fasting before surgery, and selective use of beta blockers are factors that can reduce tremor. Regular exercise, adequate sleep, and avoiding alcohol the evening before surgery all help to reduce tremor[6]. Essential tremor increases with age. In fact, it is common in patients over 65 years of age. There are few microsurgeons practicing in their late 60s and 70s and yet these surgeons have the greatest experience in microsurgery. The use of technology to extend and perhaps improve the operative proficiency in the “aging surgeon” (defined as a surgeon older than 65 years of age) should be encouraged and fostered to maintain quality and assure patient safety. Many institutions require cognitive testing for physicians older than 65 years of age. Assuming cognitive ability is satisfactory, motor skills also should be evaluated. If motor performance is rendered unsatisfactory then surgical privileges may be limited or revoked. The Symani robot has several advantages that enhance a surgeon’s ability to perform microvascular anastomosis. Its dampening effect on hand motion at 7, 12, or 20 scaling eliminates tremor. It improves precision with regard to needle placement into the vessel wall, and as a result reduces tissue trauma during anastomosis. The robot, in concert with the Mitaka Hawksight exoscope, improves magnification and lighting and provides 3-dimensional imaging of the operative field. The ergonomics of the operative surgeon improve based on the fact that the surgeon is sitting upright in an ergonomically favorable position away from the operative field. the Symani robot (MMI Inc.) was recently approved by the FDA for use in free tissue transfer in adults. Early experience by middle-aged surgeons at the Cleveland Clinic and NYU-Langone has been favorable. There have been 10 free flap cases performed at the University of Pennsylvania – 8 by a senior surgeon aged 69½ years of age. All cases were successful. Feedback has been favorable with regard to enhanced precision and tremor dampening ability. The microsurgical armamentarium continues to evolve. New procedures centered around perforator to perforator anastomosis, lymphovenous bypass facilitated by the use of the robot[7]. Robotic technology will enhance all surgeons’ ability to perform these procedures reliably and safely but may be a critical factor in extending the life of the aging microsurgeons for the reasons that have been outlined.