Clinical experience in open robotic-assisted microsurgery: user consensus of the European Federation of Societies for Microsurgery

This study provides a comprehensive guide to robotic-assisted microsurgery. Following more than 900 clinical cases in 13 centers, this joint project was initiated to summarize and consent to the user experience. Two robotic systems specifically designed for the needs of open microsurgery received the first certification for clinical application (CE mark) in 2019 and 2020. Since their introduction into clinical application, several European microsurgical centers have implemented these systems, generating user experiences in multiple microsurgical subspecialties. All institutions using the MUSA-2 microsurgical robot (Microsure B.V., Eindhoven, Netherlands) or Symani Surgical System (Medical Microinstruments, Inc., Wilmington, Delaware, US) were invited to join the multicenter project. A modified nominal group technique was applied to answer five major questions regarding current and future indications and developments in open robotic-assisted microsurgery. Steep preclinical and clinical learning curves were characterized. General considerations concerning the two different systems are presented. Specifics for each microsurgical subspecialty are reported. Following two voting rounds, a consensus was reached in three of the five major questions with "lymphatics" being the top indication, "higher precision" being the top benefit, and "automation" being the top long-term goal of robotic-assisted microsurgery. This joint project of all Symani and MUSA-2 users presents clinical cases and the subsequent initial knowledge and experience. Lymphatics as a top indicator and a higher precision as the top benefit point toward the capabilities of robotic-assisted microsurgery in manipulation of smallest structures. Automation may further enhance and simplify robotic procedures in future. This project also provides a comprehensive guide to any institution aiming to introduce such a system for open robotic-assisted microsurgery in future.