The Current Landscape of Robotics in Lymphatic Supermicrosurgery: A Systematic Review

Abstract Lymphedema affects over 250 million people worldwide and is increasingly managed with physiologic procedures such as lymphovenous bypass (LVB) and vascularized lymph node transfer (VLNT). These supermicrosurgical techniques require advanced training, are ergonomically demanding, and can be limited in anatomically constrained regions. Robotic surgical systems offer high-resolution visualization, motion scaling, tremor reduction, and improved ergonomics, making them promising adjuncts for lymphatic supermicrosurgery. However, evidence on safety, feasibility, and outcomes remains limited. A systematic review was conducted in accordance with PRISMA guidelines using PubMed, Cochrane Library, and Embase from inception through December 2024. Eligible studies included human clinical reports of robotic-assisted peripheral lymphatic reconstruction. Extracted data included demographics, operative details, outcomes, and study quality. Seven studies involving 134 patients and 221 anastomoses were included, of which 78% (172) were performed robotically. The Symani system was most frequently used. Robotic procedures comprised 59.9% LVBs and 32% VLNTs or other free flaps. Across studies, mean anastomotic time was longer with robotic assistance (25.7 minutes) compared with manual techniques (11 minutes); however, three studies demonstrated significant time reduction with experience, ultimately approaching manual times. When reported, clinical outcomes, including limb volume reduction and quality-of-life measures, were comparable between robotic and manual groups. Advantages included tremor elimination and improved ergonomics, while challenges included cost, setup time, and lack of haptic feedback. Robotic-assisted lymphatic supermicrosurgery is safe and feasible, with outcomes comparable to conventional surgery. Continued refinement, cost reduction, and standardized outcome reporting will determine its role in expanding therapeutic and preventive lymphatic reconstruction.