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Robotic-assisted microsurgery has emerged as a growing subspecialty in plastic, reconstructive, and hand surgery for the past five years, following its first in-human application in 2021. Robotic systems, such as the Symani® Surgical System, can enhance precision and surgeon ergonomics in micro- and supermicrosurgery through motion scaling, ultra-fine instrumentation, and remote operation. Clinical benefits have been demonstrated in peripheral and central lymphatic reconstruction, as well as in other reconstructive microsurgical procedures.

We prospectively collected data on all patients at our institution who underwent surgery using the Symani® Surgical System and provided consent for data analysis. Data variables included epidemiological, intraoperative and postoperative parameters.

Between 2021 and 2026, the Symani® Surgical System was used in 160 cases involving 156 patients. Of these, 63% were female and the mean age was 50 years. The primary indication was lymphatic reconstruction (70%). Additional indications included free flap surgery and prophylactic lymphatic reconstruction in trauma (14.4%) and oncologic cases (14.4%). A total of 221 robotic-assisted anastomoses was performed, including 107 lymphovenous, 98 arterial or venous, 3 lympholymphatic, 2 lymphnode-to-vein anastomoses, and 11 epineural coaptations. Mean surgery time across all cases was 338 minutes. Notably, duration of surgery, especially in high-frequency procedures like lymph tissue transfer, decreased significantly over time, reflecting optimization of intraoperative workflow and robotic setup. Three cases of postoperative flap or amputate loss were recorded, none were attributable to robotic system use.

We report long-term outcomes from a large single-center experience with robotic-assisted micro- and supermicrosurgical anastomoses across multiple reconstructive. After more than four years of utilizing the Symani® Surgical System, no robot-associated complications were identified. Furthermore, operative times, including system setup and robotic anastomoses, decreased over time, addressing concerns regarding prolonged duration. These findings support the safe integration of robotic assistance in high-volume microsurgical centers and highlight its potential to add value in selected surgical contexts.

Lymphovenous anastomosis is an established treatment for peripheral lymphedema. To date, the use of microsurgical robotic platforms in lymphatic surgery has been limited to vascular anastomoses. This study reports the first fully robotic-assisted lymphovenous anastomosis and explores the potential implications for future robotic-assisted lymphatic surgery.

Two patients with lower limb lymphedema underwent fully robotic-assisted lymphovenous anastomosis using a microsurgical robotic platform (Symani® Surgical System). The procedure involved robotic-assisted microdissection of both lymphatic and venous vessels, followed by robotic-assisted lymphovenous anastomosis.

Four fully robotic-assisted lymphovenous anastomoses were successfully completed in the lower extremities of two patients. Intraoperative indocyanine green imaging confirmed patency in all cases, demonstrating the technical feasibility of a fully robotic-assisted approach.

Fully robotic-assisted lymphovenous anastomosis is a safe and feasible surgical technique. The use of a microsurgical robotic platform enhances surgical precision and improves ergonomics, thereby supporting operative endurance. Further research is required to compare this new approach with conventional manual techniques in terms of clinical outcomes and cost-effectiveness. Future technical advancements, such as a broader variety of microsurgical instrumentation and the integration of automated robotic surgery, may further expand the application of robotic assistance in lymphatic surgery.

Reconstructive microsurgery can restore central lymphatic flow in congenital or acquired lymphatic disorders. Robotic-assisted microsurgery has recently emerged as a promising technique to improve surgical access to the prevertebral axial lymphatic system. In this context, the deep cervical lymphatic network has become a target to enhance drainage of the meningeal lymphatic vessels and the brain’s glymphatic system. Emerging reports suggest that lymphatic reconstruction in the deep neck may influence neurological function.

We report our experience treating patients with central lymphatic obstruction using lympho-venous anastomosis (LVA) at different anatomical levels according to the underlying pathology and site of obstruction. In addition, previously treated cases of lymphatic reconstruction in the deep neck and facial region were retrospectively evaluated for potential effects on neurological and cognitive function.

In one patient with 13q deletion syndrome, LVA performed in the deep cervical lymphatic system resulted in sustained neurological and cognitive improvement over a two-year follow-up period. In another case, robotic-assisted LVA of 0.2-mm facial lymphatic vessels performed to treat severe eyelid edema was associated with improvements in memory and visual function one month postoperatively

These observations highlight the potential importance of meningeal lymphatic drainage for neurological function. Deep cervical lymphatic reconstruction, potentially facilitated by robotic-assisted micro- and supermicrosurgery, may represent a novel therapeutic approach for central lymphatic disorders and possibly neurodevelopmental or neurodegenerative conditions. However, robust preclinical and clinical evidence remains limited, and further mechanistic and translational studies are required to clarify the therapeutic role of cervical lymphatic surgery in neurological disease.