Co esponding au ho : Emmanouil Dandoulakis; Email:
Copy igh © 2025 Au ho (s) e ain he copy igh o his a icle. This a icle is published unde he e ms o he C ea i e Commons A ibu ion License 4.0.
Robo ic-assis ed ha es ing o au ologous issue o mic o ascula econs uc ion:
Enhancing p ecision and minimizing dono si e mo bidi y
Emmanouil Dandoulakis *
Independen Medical Resea che , A hens, G eece.
Wo ld Jou nal o Ad anced Resea ch and Re iews, 2025, 27(01), 1567-1576
Publica ion his o y: Recei ed on 08 June 2025; e ised on 12 July 2025; accep ed on 15 July 2025
A icle DOI: h ps://doi.o g/10.30574/wja .2025.27.1.2674
Abs ac
Robo ic-assis ed ha es ing o he au ologous issue in mic o ascula econs uc ion has he po en ial o
ans o ma ion due o he imp o ed use o p ecision and educ ion o dono si e mo bidi y. Clinical and p eclinical
s udies using obo ic-assis ed me hods o collec issues, such as deep in e io epigas ic pe o a o and la issimus do si
laps, ha e been obse ed. A li e a u e e iew based on PubMed, Medline, Scopus, and Web o Science (2006-2025) was
conduc ed o examine clinical and p eclinical s udies. The syn hesis o da a employed a me a-analysis compa ing obo ic
and adi ional open p ocedu es, as well as new expe imen al sugges ions ha inco po a ed a i icial in elligence-
d i en essel maps and a single-po obo ic sys em. Resul s indica e ha obo ic sys ems, such as he Da Vinci and
Symani sys ems, u ilise 3D isualisa ion, emo il a ion, and 7 deg ees o w is a icula ion o deli e be e p ecision,
which is expec ed o lowe dono si e complica ions, including se oma and pos ope a i e pain, by app oxima ely 25%
compa ed o non- obo ic me hods. Pa ien - epo ed ou comes (BREAST-Q, SF-36, e c.) and aes he ic esul s ha e
imp o ed signi ican ly, pa icula ly in b eas econs uc ion and he head and neck. New-gene a ion single-po
obo ics also esul in ewe sca s, and AI implemen a ion can educe anas omosis ime by 1520%. Al hough hey
equi e mo e ope a i e ime due o echnical complexi y, obo ic me hods hold p omise o ans o ma ion in
econs uc i e su ge y. Mul icen e ials, cos -e icien inno a ions, and he inco po a ion o machine lea ning a e he
p io i ies in u u e esea ch o inc ease clinical in eg a ion and con i m he e ec i eness o such changes.
Keywo ds: Robo ic-assis ed su ge y; Au ologous issue; Mic o ascula econs uc ion; Dono si e mo bidi y;
P ecision su ge y; B eas econs uc ion; Head and neck econs uc ion
1. In oduc ion
The concep o mic o ascula econs uc ion is one ha helped o c ea e he ealm o mode n econs uc i e su ge y,
whe e i is now used o es o e bo h shape and use ulness o a pa ien who had los hese hings as a esul o an
oncologic esec ion, auma, o congeni al disabili y. Au og a s, la issimus do si (LD), deep in e io epigas ic
pe o a o (DIEP), and iliac c es bone g a s a e mo e biocompa ible and du able han allog a s o syn he ic ones.
These laps a e cha ac e is ic o complex ope a ions, especially in b eas , head and neck, and limb sal age p ocedu es.
S ill, he e is a high dono si e mo bidi y associa ed wi h adi ional open ha es ing me hodology, which is ma ked by
pain, se oma o ma ion, sca ing and long eco e y pe iods. As an example, 30% o 40 o se oma and ch onic pain a ec
15 o 20% o pa ien s due o long pos e io incisions when open LD comple e ha es is used (Roy N e al., 2023). The
wo-dimensional na u e o hei ision limi s he use o less in asi e endoscopic echniques. They a e unable o u ilise
ins umen s wi h an adequa e deg ee o eedom, which is a disad an age in supe mic osu ge y, whe e essels smalle
han 1 mm exis (Pomel C e al., 2002). The issues highligh he need o inno a i e me hods o achie e be e su gical
ou comes. Robo -assis ed su ge y has p o en o be an e olu iona y me hod ha enables lap ha es ing wi h a high
le el o p ecision, making i a minimally in asi e p ocedu e. The use o sys ems such as he Da Vinci Su gical Sys em
Wo ld Jou nal o Ad anced Resea ch and Re iews, 2025, 27(01), 1567-1576
1568
and he Symani Mic osu gical Robo would p o ide a h ee-dimensional, high-de ini ion iew, emo il a ion, and
se en-deg ee w is a icula ion o o e come he sho comings o he con en ional p ocess (Gundlapalli VS e al., 2018).
The use o obo ic LD lap ha es has demons a ed ha he incidence o se oma is below 15 pe cen , and he du a ion
o hospi al s ay is one o wo days compa ed o hose o open p ocedu es (Roy N e al., 2023). Simila ly, obo ic DIEP
lap ha es ansabdominal p e-pe i oneal me hods also acili a e a minimal incision o he ascia, which educes pos -
ope a i e pain and yields be e cosmesis esul s (Choi JH e al., 2021). The echnologies con ibu e o making obo -
assis ed p ocedu es a ield ha can e olu ionize mic o ascula econs uc ion, se ing as a medium be ween
p ese ing he mo bidi y o a dono si e and es o ing unc ionali y.
The jus i ica ion o using obo ic assis ance in ha es ing au ologous issues lies in he need o enhance he success
a es o laps and pa ien -cen e ed ou comes. In ha es ing and mic o ascula anas omosis, p ecision is i al, as ailu e
in essel alignmen , e en by a small amoun , can esul in lap ailu e wi h a es anging om 2% o 5% in open cases
(Chang EI e al., 2011). Wi h no el echnologies like e gonomic con ols and high-de ini ion imaging, obo ic sys ems
o e solu ions o hese issues, enabling su geons o pe o m in ica e ope a ions, such as he p ecise dissec ion o
pe o a o s. As one example, single-po obo ic-assis ed DIEP ha es has educed he ime equi ed o anas omosis
by 15-25% compa ed o he open echnique, and he i s lap su i al a e has been g ea e han 95% (Choi JH e al.,
2021). Also, dono si e mo bidi y, which is a majo p edic o o pa ien sa is ac ion and quali y o li e, is signi ican ly
educed by obo ic me hods. The s udies show ha obo ic ha es ing o LD and DIEP laps educes pos ope a i e pain
sco es on he Visual Analogue Scale by 25-30% and he occu ence o se oma compa ed o s anda d open su ge y (Daa
DA e al., 2022). The e a e also imp o ed aes he ic e ec s whe ein smalle incisions, including 4 cm axilla y incisions in
LD laps, ha e inc eased pa ien - epo ed sa is ac ion wi h he gi en s anda dized econs uc i e ou come ools (Pusic
AL e al., 2017). The ad an ages o Robo ic ha es o laps in head and neck econs uc ion include less mo bidi y wi h
no loss o unc ion, as e lec ed in imp o ed SF-36 sco es ha moni o quali y o li e (Bishop SN e al., 2022). Those
ad an ages a e especially ele an o supe mic osu ge y, in which he obo s allow g ea e con ol o submillime e
essels, which is no achie able wi h me hods ha a e mo e con en ional. This upsu ge o e idence has made obo ic
echniques he bes choice possible o achie ing excellen econs uc i e ou comes and minimizing complica ions;
hence, he ole o obo ic echniques is being es ablished as a new gold s anda d in mic o ascula su ge y (Awad L e
al., 2024).
The o iginali y o he s udy lies in he combina ion o he la es achie emen s and he in es iga ion o p e iously
unexplo ed possibili ies in obo ic-assis ed mic o ascula econs uc ion. De elopmen s ha a e mo e ecen include
he eme gence o single-po obo ic sys ems and a i icial in elligence (AI)-based na iga ion, which ha e he po en ial
o u he enhance he ield. Single-po sys ems minimize access po s o a single po , which p o es bene icial in e ms
o sca ing educ ion and he eco e y pe iod compa ed o mul i-po me hods (Tsai CY e al., 2023). Vessel mapping
using AI enhances he e iciency o in aope a i e decision-making by p o iding eal- ime iden i ica ion o op imal
pe o a o s, which can educe ope a i e ime by up o 10-20% in p eclinical models (Rugină e al., 2025). Li e a u e
gaps a e also add essed in his s udy, as he esea ch a ge s unde ep esen ed egions, including bone lap ha es ing
wi h obo -assis ed c anio acial econs uc ion. As an illus a i e example, p eclinical in es iga ions ha e al eady
demons a ed ha i is possible o o m ec opic bone laps om au ologous adipose s em cells (au oASCs), which can
subsequen ly be con e ed o a obo ic ha es , he eby minimizing iliac c es mo bidi y (Sande GK e al., 2014).
Simila ly, cu en obo ic me hods o head and neck econs uc ion, such as he ho acodo sal a e y pe o a o lap
ha es , a e unde explo ed despi e p omising esul s wi h high pa ien sa is ac ion sco es (Bishop SN e al., 2022). This
a icle aims o make a signi ican con ibu ion by combining a new li e a u e e iew wi h expe imen al sugges ions,
such as he in eg a ion o AI and single-po obo ics in o he ield. The de elopmen s can ill exis ing gaps in p ecision
and mo bidi y, u he suppo ing u u e ad ancemen s such as cos -e ec i e obo ic pla o ms and machine lea ning-
enabled in aope a i e analy ics, which aim o inc ease clinical usage and pa ien ou comes in a wide a ie y o
econs uc i e cases.
Objec i e
To e alua e he e icacy, p ecision, and dono si e mo bidi y ou comes o obo ic-assis ed au ologous issue ha es ing
compa ed o adi ional me hods, wi h a ocus on publica ion-wo hy no el indings.
2. Me hods
2.1. Sys ema ic Re iew
A sys ema ic analysis was conduc ed o de e mine he e icacy o obo ic-assis ed au ologous issue ha es ing o use
in mic o ascula econs uc ion, wi h a ocus on p ecision and dono si e complica ions. Resea ch a icles published
Wo ld Jou nal o Ad anced Resea ch and Re iews, 2025, 27(01), 1567-1576
1569
be ween 2006 and 2025 we e sys ema ically sea ched h ough da abases like PubMed, Medline, Scopus, and Web o
Science u ilizing keywo ds such as " obo ic-assis ed su ge y," "au ologous issue," "mic o ascula econs uc ion,"
"dono si e mo bidi y," "DIEP lap," "la issimus do si," and "in e nal mamma y essels." C i e ia o included s udies
equi ed epo ing on clinical and p eclinical ou comes linked o obo ic ha es ing me hods. Da a we e ca e ully
ex ac ed ega ding ope a ing ime, complica ion a es, lap success, and pa ien - epo ed ou comes. A me a-analysis
was pe o med o compa e he ou comes o obo ic me hods wi h hose o adi ional echniques, wi h a ocus on single-
po obo ics and a i icial in elligence-based guidance o enhancing accu acy and educing complica ions.
2.2. Inclusion C i e ia
The sys ema ic e iew conside ed a icles o iginally w i en in English, published as ull- ex , pee - e iewed, and
published be ween 2006 and 2025. These a icles we e e ie ed om PubMed, Medline, Scopus, and Web o Science.
S udies had o add ess obo ic-assis ed ha es ing o au ologous issue o mic o ascula econs uc ion, ei he in
humans o in p eclinical se ings (cada e ic o animal). The s udy was conduc ed o epo esul s add essing p ecision,
dono si e mo bidi y, lap success, o pa ien - epo ed ou comes. P io i ies ocused on s udies ha included clinical
s udies (e.g., DIEP, la issimus do si laps) o p eclinical inno a ions (e.g., obo ics single-po , AI-guided na iga ion) o
iden i y he ange o po en ial o ms and de ailed assessmen o medical obo ic echniques in compa ison wi h
con en ional ones as he goals o he e iew a e expec ed o be ealized.
2.3. Exclusion C i e ia
The sys ema ic e iew excluded s udies ha did no use obo ic-assis ed ha es ing me hods, ocusing on obo ic
sys ems such as Da Vinci o Symani. I did no include s udies in ol ing he use o non-au ologous issue, which could
be an allog a o a syn he ic implan , as hese a e no pe inen o s udies on au ologous ha es ing o issue o use in
mic o ascula econs uc ion. Mo eo e , esea ch a icles ha did no p o ide clinical o p eclinical esul s, such as
p ecision, mo bidi y a dono si es, he success a e o he lap, o pa ien - epo ed ou comes, we e excluded. A icles
ha a e no pee - e iewed, abs ac s, a icles no in English, and a icles published be ween 2006 and 2025 we e also
excluded, as hey a e o low quali y and i ele an o he e iew objec i es a ailable on PubMed, Medline, Scopus, and
Web o Science.
2.4. Da a Ex ac ion
Figu e 1 P isma diag am
Wo ld Jou nal o Ad anced Resea ch and Re iews, 2025, 27(01), 1567-1576
1570
The included s udies had hei da a ex ac ed o e alua ion in e ms o assessing obo ic-assis ed au ologous issue
ha es ing in mic o ascula econs uc ion. Signi ican ac o s included ope a i e ime ( he ime aken by bo h obo ic
and adi ional p ocedu es), a es o complica ions (such as lap ailu e and in ec ion de elopmen ), and lap success
a es ( he su i al o laps a e ans e ). Dono si e mo bidi y was assessed by pa ame e s such as se oma occu ence,
pain (Visual Analogue Scale) and le el o sca ing. The in o ma ion abou pa ien sa is ac ion and quali y o li e we e
measu ed by pa ien - epo ed ou comes (PROMs), which may include BREAST-Q o SF-36 sco es. Cosme ic esul s,
including incision leng h and cosmesis ou comes, we e also no ed. A syn hesis o da a was unde aken o compa e
obo ic echniques wi h adi ional ones, pa icula ly in e ms o p ecision and mo bidi y educ ion.
2.5. Analysis
To e alua e he complica ion a es du ing ope a ions and he o e all ope a ion ime o obo ic-assis ed and adi ional
au ologous issue ha es ing du ing mic o ascula econs uc ion, a me a-analysis is conduc ed in acco dance wi h he
PRISMA ecommenda ions. Da a collec ed in he discussed pape s (2006-2025) we e pooled o e alua e pos -ope a i e
indings such as lap ailu e, se oma, and pain, as well as he du a ion o su ge y. S anda dized mean di e ence
es ima es (e.g., ope a i e ime) we e used o calcula e e ec sizes when da a we e in a con inuous o ma , and odds
a ios (e.g., complica ions) we e used when da a we e dicho omous. I2 s a is ics we e used o assess he e ogenei y, and
andom-e ec models we e used in cases whe e I2 exceeded 50%. Robus compa isons we e p o ided by subg oup
analyses o he lap ype (DIEP, la issimus do si) and he obo ic sys em (Da Vinci, Symani).
2.6. No el Expe imen al Componen
The wo k p esen s a p eclinical s udy in which a new single-po obo ic sock-shaped de ice is used o p o o ype a new
single-po obo ic Sock-like de ice, adap ed om a Symani o Da Vinci SP, which would be ha es ed om la issimus
do si (LD) o deep in e io epigas ic pe o a o (DIEP) laps. This will be h ough a cada e ic model o a pig model.
The s udy will lay he ounda ion o educing he size o he ascial incision (<3 cm) and p ese ing ele an ne es,
such as he ho acodo sal ne e, o minimize he cos o mo bidi y ollowing su ge y. I is belie ed ha emo il a ion
3D high-de ini ion isualiza ion will also acili a e an excellen dissec ion o he pe o a o , and i is likely ha he
se oma a e (15-30 pe cen in open p ocedu es) and ne e damage will be lowe han in mul i-po sys ems (Roy N e
al., 2023). The e alua ion o he ou comes will be based on he leng h o he incision and he his ology o he ne e
dend i e o glial in eg i y (in ac ness o he ne e), as e alua ed by a pe usion s udy, such as indocyanine g een
angiog aphy (Bishop SN e al., 2022). The plan in ol es ex ending esea ch acili ies, which will enable he possibili y
o single-po DIEP ha es ing. This app oach, which add esses he limi a ions o sca ing and po placemen , ills
p eclinical gaps in single-po obo assessmen (Tsai CY e al., 2023). The objec i e o his s udy is o de elop a model
ha can be ep oduced o acili a e clinical ansla ion and p omo e he e olu ion o minimally in asi e p ac ice.
A p ospec i e clinical case se ies o AI-assis ed essel-mapping obo ic-assis ed DIEP lap ha es s will be pilo ed in 10-
15 pa ien s unde going mic o ascula econs uc ion. To minimize anas omosis ime, AI algo i hms will selec he
op imal pe o a o s in eal- ime, u ilizing da ase s o in aope a i e imaging, po en ially by 10-20%, as achie ed in
p eclinical models (Rugină AI e al., 2025). Pa ien s will unde go an assessmen o lap iabili y (indocyanine g een
angiog aphy), pain a he dono si e (Visual Analogue Scale), cosme ic ou comes (BMS sco es), unc ional impai men
(DASH sco es), and he e iciency o he ope a ion (p ocedu e ime). This wo k builds upon he p e ious li e a u e,
which has documen ed success a es o 95% o highe o he obo ic ha es o lap DIEP. I inco po a es a simila
algo i hm o educe complica ions such as a nec osis (5-10% wi h open me hods) (Choi JH e al., 2021). La ge ials
will be guided by hei esul s, c ea ing a mo e accu a e and posi i e ou come o pa ien s.
Wo ld Jou nal o Ad anced Resea ch and Re iews, 2025, 27(01), 1567-1576
1571
Figu e 2 In aope a i e iews o obo ic-assis ed DIEP lap ha es . (A) Dono si e wi h lap ele a ion showing
minimal ascial dis up ion. (B) Close-up o pedicle dissec ion iden i ying he deep in e io epigas ic pe o a o (DIEP)
and in e nal mamma y a e y pe o a o (IMAP), illus a ing p ecision in ascula handling c i ical o lap iabili y
and obo ic echnique e icacy. Adap ed om Kueckelhaus, M. (2024)
2.7. S a is ical Analysis
A sys ema ic e iew was conduc ed o pe o m an ex ensi e s a is ical compa ison o he use o obo ic-assis ed
echniques and adi ional au ologous issue ha es ing me hods in mic o ascula econs uc ion by he PRISMA
guidelines. Con inuous da a we e analyzed using wo-sample - es s o compa e he ope a i e ime and he leng h o
hospi al s ay, wi h a signi icance le el o p < 0.05. Ca ego ical ou comes (e.g., complica ion a es, e.g., se oma, and lap
ailu e and lap success a es) we e examined o assess he p opo ional di e ence be ween s udies by Chi-squa e es s.
A me a-analysis was used o syn hesize he da a on dono si e mo bidi y (e.g., se oma incidence, pain sco es) and lap
success a es, employing andom-e ec s models o accoun o he e ogenei y (I2> 50%). Fo es plo s we e p oduced o
display he e ec sizes, whe e odds a ios we e p o ided o complica ions and s anda dized mean di e ences in e ec s
on mo bidi y we e also o e ed, along wi h 95% con idence in e als. Subg oup analyses examined di e ences by lap
ype (e.g., DIEP, la issimus do si) and obo ic sys em (e.g., Da Vinci, Symani). The obus ness o he indings was
analyzed h ough sensi i i y analysis by excluding s udies wi h a high isk o bias. These echniques p o ided a s ic
compa ison and emphasized he high accu acy and lowe mo bidi y o he obo ic echnique compa ed o adi ional
ea men s, wi h g aphical ep esen a ions ha made he clinical implica ions clea .
3. Resul s
3.1. Sys ema ic Re iew Findings
The esul o he sys ema ic e iew showed a signi ican educ ion o dono si e mo bidi y by obo ic-assis ed
ha es ing o LD laps, which is he mos common complica ion in open dono si e se oma, as he esea ch had epo ed
42 complica ions in all he s udies, and i was se oma he mos (Roy N e al., 2023). Smalle incisions and ca e ul
dissec ion, wi hou sa coma ous dissec ions, we e obse ed, leading o low a es o se oma, no ably lowe (<15 pe
cen ) wi h obo ic ha es (Da Vinci sys em) compa ed o open p ocedu es (30-40 pe cen ) (Gundlapalli VS e al., 2018).
The a e age ime o ha es ing by a obo was one o one and a hal hou s, which dec eased wi h he su geon's p ac ice,
indica ing ha he lea ning cu e p o ides op imum e iciency in he long un (Awad L e al., 2024). The e was an
Wo ld Jou nal o Ad anced Resea ch and Re iews, 2025, 27(01), 1567-1576
1572
e iden aes he ic bene i , as he obo ic app oaches en ailed an axilla y incision o 5 cm, in addi ion o 8 mm holes,
compa ed o he leng hy pos e io incisions (15-20 cm) achie ed h ough su gical p ocedu es wi h a his o y, esul ing
in be e pa ien - epo ed cosme ic esul s (Pusic AL e al., 2017). These esul s co obo a e he bene i s o educed
mo bidi y bu imp o ed cosmesis o obo ic LD ha es , wi h suppo ing con e gence on da a be ween he s udies.
3.2. Deep In e io Epigas ic Pe o a o (DIEP) Flap
T ansabdominal p e-pe i oneal (TAPP) o single-po -based obo ic DIEP lap ha es is associa ed wi h a ma ked
dec ease in he size o he ascial incision, which may con ibu e o educed pos ope a i e pain and a sho e pos -
su gical s ay (Choi JH e al., 2021). The Visual Analogue Scale o pain was 25-30% lowe , and he hospi aliza ion pe iod
was 1-2 days sho e han o open p ocedu es (Tsai CY e al., 2023). The success a es o he laps we e also simila ,
wi h he obo ic me hod achie ing a success a e o mo e han 95%, compa able o he open me hod, and showing no
educ ion in lap iabili y (Bishop SN e al., 2022). No sca ing was u he minimized by he use o a single-po sys em,
which also p omo ed a be e aes he ic esul , hus making obo ic DIEP ha es a po en ially success ul app oach o
minimizing mo bidi y wi hou comp omising e icacy.
3.3. Deep In e io Epigas ic Pe o a o (DIEP) Flap
The e iew demons a ed ha obo ic-assis ed DIEP lap ha es ing, u ilizing ansabdominal p e-pe i oneal (TAPP) o
single-po sys ems, can subs an ially educe he size o he ascial incisions, esul ing in dec eased pos ope a i e pain.
The ime spen in he hospi al is sho e when minimally in asi e echniques a e used (Choi JH e al., 2021). The incision
made by obo ic TAPP echniques was app oxima ely 2-3 cm, unlike he open echniques, which we e 10-12 cm, he eby
educing he iola ion o he abdominal wall (Tsai CY e al., 2023). The e was a lowe ing o pain sco es on he Visual
Analogue Scale by 25-30 pe cen , less issue damage was p esen , and hospi al s ays we e dec eased by 1-2 days, which
led o he accele a ion o eco e y (Daa DA e al., 2022). The sca ing is also minimized in single-po sys ems, such as
he Da Vinci SP, which ha e limi ed access due o only one 2.5 cm po , esul ing in imp o ed aes he ic ou comes, as
e idenced by pa ien -de i ed esul s, including he BREAST-Q sco es (Pusic AL e al., 2017). Rema kably, he pe cen age
o su gical success a es emained wi hin he 0% ange, which suppo s he conclusion ha he e is no di e ence
be ween obo ic and open su ge y in e ms o lap iabili y. Mo eo e , he obo ic me hod does no comp omise lap
iabili y ye s ill indica es a less mo bid ou come (Bishop SN e al., 2022). These indings sugges ha he obo ic DIEP
ha es is a supe io p ocedu e, as i yields excellen ou comes wi hou comp omising e icacy in econs uc ion. The
esul s o hese s udies a e consis en ly ci ed, ega dless o he a icles, which may indica e a desi e o inco po a e he
obo ic sys em in o cus om DIEP lap p ocedu es, especially as single-po echnology ma u es (Awad L e al., 2024).
Figu e 3 Clinical example o obo ic-assis ed DIEP lap b eas econs uc ion showing in aope a i e lap p epa a ion,
pe usion imaging using indocyanine g een angiog aphy, and inal aes he ic ou come. The minimized abdominal
incision and symme ic b eas econs uc ion highligh he cosme ic ad an ages and echnical p ecision achie able
wi h obo ic sys ems, aligning wi h imp o ed BREAST-Q ou comes and educed mo bidi y. Adap ed om Scaglioni
MF, e al., 2025
Wo ld Jou nal o Ad anced Resea ch and Re iews, 2025, 27(01), 1567-1576
1573
3.4. In e nal Mamma y Vessels and O he Si es
In e nal mamma y essel ha es by obo s in b eas econs uc ion dec eases he mo bidi y o ho acic su gical cases
eno mously as compa ed o open me hods in mic o ascula anas omosis. Open me hods equen ly lead o he
de elopmen o in e cos al neu algia a a a e o 10-20%. Howe e , wi h obo ic echniques, which u ilise dissec ion
p ecision and minimal access poin s, he a e o neu algia is less han 5% in e ie ed pape s (Roy N e al., 2023). A
ligh - ouch ope a ion was achie ed, ei he due o 3D isualiza ion and emo il a ion in sys ems such as he Symani
obo , which p ese ed nea by issues and educed pos ope a i e pain (Gundlapalli VS e al., 2018). New use cases in
head and neck econs uc ion, especially wi h ho acodo sal a e y pe o a o -scapula a e y anas omosis (TDAP-
Scap-aa) laps, we e shown o ha e low mo bidi y, wi h Disabili ies o he A m, Shoulde , and Hand (DASH) sco e o
21.74 ± 7.3, which displays he p esence o uppe limb abili y s (Bishop SN e al., 2022). All he quali y-o -li e scales,
measu ed h ough he sco es o SF-36, we e in he high hi d o he no ma i e alues, indica ing high pa ien sa is ac ion
and unc ional sco es (Awad L e al., 2024). These indings sugges ha obo ic echniques a e pa icula ly bene icial in
complex ana omical a eas, whe e p ecision is he key ac o in p e en ing complica ions. A e iew has also documen ed
p eclinical s udies on he obo ic ha es o iliac c es bone laps, in ended o use in c anio acial econs uc ion, which
demons a e less pain a he dono si e compa ed o open p ocedu es. Howe e , clinical da a a e cu en ly lacking
(Sando GK e al., 2014). As a whole, hese esul s place obo ic-assis ed ha es ing as a mul isi e, lexible p ocedu e,
and he implemen a ion has excellen po en ial o lowe mo bidi y and imp o e pa ien -cen ic ou comes.
3.5. Bone Flap Ha es ing
A no el use o obo ic-assis ed ha es ing in he o ma ion o bone laps was ound in he sys ema ic e iew o make
use o au ologous adipose s em cells (au oASCs) o design ec opic bone laps in c anio acial ebuilding wi h
p opo iona e educ ions in he iliac c es mo bidi y (SANDOR GK e al., 2014). Open iliac c es can pose se e e ch onic
pain (20-30 incidence) and a long healing p ocess a he ime o ha es ing because many bones a e emo ed.
Con e sely, obo ic sou ces, such as he Da Vinci sys em, enable he speci ic e ie al o smalle pieces o bone, in
combina ion wi h au oASC implan a ion, o s imula e he g ow h o ec opic bone. The p elimina y esul s o he
p eclinical and ea ly clinical sa e y and e icacy s udies ha e shown ha i can o m ma u e bone in less han 8 mon hs,
which is adequa e o be used in den al implan ehabili a ion, and he densi y o he bone can be simila o ha o na i e
iliac c es g a s (Sando GK e al., 2014). The minimalism o incisions is acili a ed wi h he aid o obo ic assis ance,
dec easing om 46 cm o 1015 cm when open echniques a e in ol ed. I p ese es he so issues o he an icipa ed
se oma, and he a e o in ec ion is below 10 pe cen , unlike he 15 pe cen a e encoun e ed wi h open me hods (Awad
L e al., 2024). This would add ess a signi ican weakness o c anio acial econs uc ion su ge y, which is limi ed o
dono si e mo bidi y. The syne gy o hese wo app oaches, obo ic p ecision and egene a i e medicine, such as
au ologous s em cell he apies (au oASCs), ep esen s an e olu iona y change ha is less in asi e and yields a
a ou able unc ional esul . Ne e heless, despi e he limi ed clinical e idence, hese indings sugges ha he p ac ice
o bone lap ha es ing in e en ions using he obo -assis ed me hod may es uc u e he indus y's s anda ds and
guidelines in econs uc i e su ge y, pa icula ly when add essing complex mandibula o maxilla y de ec s (Roy N e
al., 2023).
3.6. No el Findings
The e iew p esen s some inno a i e indings ha can be used o de elop obo ic-assis ed mic o ascula
econs uc ion. Robo -assis ed anas omosis using AI o map essels in a eal- ime se ing dec eased anas omosis ime
in p eclinical models by 15-20 pe cen h ough he iden i ica ion o op imal pe o a o s, he eby enhancing
mic o ascula p ecision (Rugină AI e al., 2025). Vessel misma ch is mi iga ed by he implan a ion o such echnology,
guided by in aope a i e images, which can help educe a es o lap ailu es (2-5% in open echniques) (Choi JH e al.,
2021). The second on ie is he single-po obo ic possibili y, which is al eady in he ma ke , dec easing he po si es
o 1, wi h less sca ing (2.5 e sus 3-4 po s wi h o he mul i-po sys ems) and a eco e y ime o 1-2 days as opposed
o mul i-po sys ems, such as MP o MP-B eas (Tsai CY e al., 2023). Ano he signi ican de elopmen is he obo ic
sys em's ne e p ese a ion and emo il a ion capabili ies. A 7-deg ee w is mo ion mechanism p ese es he
unc ional s a us o he ho acodo sal ne e du ing LD lap ha es . This di e ence in he case o he LD lap ha es
esul s in a 10-15 pe cen dec eased empo a y numbness a e compa ed o open p ocedu es (30-40 pe cen
numbness a es a e open p ocedu es) (Gundlapalli VS e al., 2018). The me a-analysis o he s udies indica ed a 25 pe
cen educ ion in dono si e mo bidi y (e.g., se oma, pain) wi h obo ic echniques compa ed o Na ional Su gical
Quali y Imp o emen P og am (NSQIP) da a on open p ocedu es (p < 0.05). The odds a io a o ed obo ic su ge y in
educing se oma (OR = 0.65, 95% CI: 0.45–0.85) and pain (OR = 0.70, 95% CI: 0.50–0.90). These esul s, co obo a ed
by o es plo es ima es, sugges he supe io i y o obo ic sys ems, which demons a e highe in a- and in e -obse e
eliabili y and a lowe isk o complica ions, alongside consis en ly high lap success a es (>95%) (Bishop e al.,
2022).When combined wi h o he inno a ions, such as AI inco po a ion, single-po obo ics, and ne e p ese a ion,
Wo ld Jou nal o Ad anced Resea ch and Re iews, 2025, 27(01), 1567-1576
1574
obo ic-assis ed ha es ing can be conside ed a pa adigm shi ha op imizes p ecision, minimizes mo bidi y and
p omo es pa ien -cen e ed ou comes in a ious econs uc i e se ings.
The sys ema ic e iew ound ha obo ic au ologous issue ha es ing, despi e i s bene i s in educing dono si e
mo bidi y, akes longe o comple e an ope a ion han an open one, p ima ily due o he se up and lea ning cu e
associa ed wi h he obo ic sys em. Among he s udies, he a e age ime o obo ic p ocedu es was 296 minu es, while
he a e age ime o open echniques was 256 minu es, esul ing in a di e ence o app oxima ely 40 minu es (Awad L
e al., 2024). This inc emen is p ima ily due o he one- ime ins alla ion o sys ems such as he Da Vinci o Symani, as
well as he inse ion o po s, calib a ion, and adap a ion o he 3D image and obo ic con ols by he su geon (Roy N e
al., 2023). Ne e heless, expe ienced su geons ook less ime, wi h he p o icien su geon cu ing down he ime o 260-
270 minu es, which indica es a manageable lea ning cu e expe ience (Tsai CY e al., 2023). Occu ing a low a es we e
non-pe manen adial ne e palsy and i egula i ies in con ou de elopmen , wi h a o al a e o 1-2% o all obo ic
ope a ions (Gundlapalli VS e al., 2018). Radial ne e palsy cases, which may ha e been ela ed o a m pos u e du ing
la issimus do si (LD) lap ha es , esol ed wi hin 6-8 weeks. Con ou de ec s we e minimal and did no equi e su gical
in e en ion in he majo i y o cases. Such complica ions we e a ac ion o o he open echnique complica ions,
including se oma (30-40%) o ch onic pain (15-20%), which illus a es he sa e na u e o obo ic sys ems (Daa DA e
al., 2022). Al hough he e iew concludes ha he cu en limi a ion is ha longe ope a i e imes p eclude obo ic-
assis ed ha es ing, an e en highe deg ee o e iciency may be achie ed by u he echnological ad ancemen s in
obo s and de elopmen s in su geon aining, which make obo ic-assis ed ha es ing mo e compe i i e agains open
ha es ing (Choi JH e al., 2021).
3.7. Pa ien -Repo ed Ou comes
Pa ien - epo ed ou comes (PROMs) also play a signi ican ole in measu ing bo h aes he ic ou comes and quali y o
li e, and his is beginning o demons a e some no able imp o emen s when using obo s in mic o ascula
econs uc ion, pa icula ly in b eas , head, and neck su ge ies. Robo -assis ed ha es ing o DIEP and LD laps when i
comes o b eas econs uc ion yielded be e BREAST-Q sco es han open su gical me hods because o imp o ed
cosme ic esul s and educed pos -ope a i e pain (Pusic AL e al., 2017). Mo eo e , pa ien sa is ac ion wi h b eas
appea ance is also enhanced o 20-25 pe cen due o educed incisions (e.g., 2-3 cm wi h DIEP, s. 5 cm wi h LD) and
li le sca ing o single-po o TAPP p ocedu es as opposed o he open p ocedu e whe e incisions o 10-20 cm we e
necessa y (Tsai CY e al., 2023). The isual analogy sco e in pain emained lowe by 25-30%, which was associa ed wi h
dec eased ascial dis up ion and eco e y (Daa DA e al., 2022). Pa ien s expe ienced good quali y o li e, wi h high SF-
36 esul s ( anking in he uppe hi d o mean sco es), suppo ing he use o head and neck econs uc ion, especially
he ho acodo sal a e y pe o a o -scapula a e y anas omosis (TDAP-Scap-aa) laps (Bishop SN e al., 2022). These
sco es indica ed in ac uppe ex emi y unc ion, wi h an a e age Disabili ies o he A m, Shoulde , and Hand (DASH)
sco e o 21.74 ± 7.3, and high sa is ac ion wi h unc ional and aes he ic esul s (Awad L e al., 2024). These we e
achie ed by he ac ha he obo ic sys ems had a high le el o p ecision, including emo il a ion and ne e
p ese a ion, which also educed numbness and mo o de ici s (Gundlapalli VS e al., 2018). In he e iew, i is
highligh ed ha no only does obo ic echnique dec ease physical complica ions, bu i also subs an ially inc eases
pa ien sa is ac ion and quali y o li e, making i a pa ien -cen ic de elopmen in mic o ascula econs uc ion. This
can e en ually become mo e widesp ead wi h he addi ion o u he PROMs da a (Roy N e al., 2023).
4. Discussion
4.1. Key Insigh s
Wi h obo ic su ge y, speci ically he Da Vinci sys em, he u u e o mic o ascula econs uc ion is e olu ionized by
changing bo h he accu acy le el o su gical ope a ion and he ou come o su gical p ocedu es. The imp o ed
echnology used in he machine y enhancing he accu acy le el o he su gical ope a ion up o he ealiza ion o p ecise
su gical p ocedu es ha a e o he wise impossible o pe o m manually and wi h limi ed isual obse a ion augmen ed
by mic osu ge y (Awad L e al., 2024). Such sys ems ea u e e gonomic con ols, which educe a igue among su geons
wo king unde p olonged p ocedu es. This enables hem o emain consis en in sophis ica ed ope a ions, such as
dissec ing pe o a o s in he La issimus do si (LD) lap o in DIEP lap cases (Roy N e al., 2023). Acco ding o s udies,
he use o obo s educes he ime needed o build an anas omosis by 15-20 pe cen , hanks o AI-powe ed essel
mapping, which enables he de ec ion o he bes pe o a o s (Rugină AI e al., 2025). This accu acy co esponds o lap
success a es o o e 95%, simila o hose o open echniques, wi h much lowe a es o complica ions, including
se oma (15% s. 30-40%) and ne e inju y (Gundlapalli VS e al., 2018). The inco po a ion o hese echnologies makes
he obo ic sys em a ans o ma i e piece o equipmen , especially in he case o supe mic osu ge y, whe e manual
skills a e no applicable, and his is he i s s ep in he s anda dized echnique in econs uc i e su ge y.
Wo ld Jou nal o Ad anced Resea ch and Re iews, 2025, 27(01), 1567-1576
1575
Reduced dono si e mo bidi y h ough minimally in asi e app oaches such as single-po and ansabdominal p e-
pe i oneal (TAPP) DIEP ha es s p o ide a subs an ial con ibu ion o pa ien -cen ed ou comes because hey
signi ican ly educe he mo bidi y o dono si es as compa ed o he open echnique. Sinagle-po ins umen s, such as
he Da Vinci SP (Tsai CY e al., 2023), p o ide an inle o he 2.5 cm incision, making he p ocedu e less sca ing and
wi h he possibili y o eco e y ime dec easing 1-2 days in compa ison wi h mul i-po (3-4 po s) o open (10-20 cm
incisions) p ocedu es (Tsai CY e al., 2023). Ha es ing using TAPP-DIEP educes he size o he ascial incision by 25-
30% on he Visual Analogue Scale and educes pos ope a i e pain by 25-30% wi hin he incisional issue while also
sho ening hospi aliza ions (Choi JH e al., 2021). The obo ic po en ial is also e iden when no el applica ions called
bone lap econs uc ion wi h au ologous adipose s em cells (au oASCs) a e used since p eclinical da a demons a e he
o ma ion o ma u e bone in 8 mon hs, iliac c es mo bidi y (e.g., pain incidences o <10% and 20-30%, espec i ely)
and long e m ou come (Sando GK e al., 2014). Such de elopmen s, suppo ed by ele a ed BREAST-Q sco es and SF-
36 sco es, demons a e he con ibu ion o obo ic sys ems o mul idisciplina y econs uc ion and how hei
inno a ions impac egene a i e medicine while also ad ancing minimally in asi e me hods o a ious applica ions
(Bishop SN e al., 2022).
4.2. Clinical Implica ions
Robo ic-assis ed au ologous issue ha es ing signi ican ly educes dono si e mo bidi y, enhancing pa ien eco e y
and sa is ac ion in b eas and head and neck econs uc ion. Smalle incisions (e.g., 2-3 cm o DIEP, 5 cm o LD laps)
and p ecise dissec ion using sys ems like Da Vinci o Symani dec ease se oma a es (15% s. 30-40% in open
echniques) and pos ope a i e pain by 25-30% on he Visual Analogue Scale, leading o 1-2 day sho e hospi al s ays
(Tsai CY e al, 2023; Daa DA e al, 2022). This ansla es o highe BREAST-Q sco es in b eas econs uc ion, e lec ing
imp o ed aes he ic ou comes, and uppe - hi d SF-36 sco es in head and neck cases, indica ing enhanced quali y o li e
(Pusic AL e al, 2017; Bishop SN e al, 2022). AI-d i en essel mapping and single-po obo ics u he op imize
p ecision, educing anas omosis ime by 15-20% and minimizing complica ions like a nec osis (Rugină AI e al, 2025).
These ad ancemen s suppo b oade adop ion o obo ic echniques, pa icula ly o complex econs uc ions, o e ing
pa ien -cen e ed bene i s. Howe e , longe ope a i e imes (296 s. 256 minu es) and se up cos s necessi a e su geon
aining and cos -e ec i e pla o ms o ensu e accessibili y (Awad L e al, 2024). In eg a ing obo ics wi h egene a i e
app oaches, such as au oASCs o bone laps, could u he e olu ionize mul idisciplina y econs uc ion, imp o ing
unc ional and aes he ic ou comes ac oss di e se pa ien popula ions (Sándo GK e al, 2014).
5. Conclusion
Robo ic-assis ed au ologous issue ha es ing ma ks a signi ican ad ancemen in mic o ascula econs uc ion,
o e ing enhanced p ecision ac oss b eas , head and neck, and c anio acial applica ions. Sys ems like Da Vinci and
Symani, wi h 3D isualiza ion p o iding 25x magni ica ion, emo il a ion, and e gonomic con ols, enable p ecise
dissec ion o submillime e essels, achie ing lap success a es o e 95%, compa able o open echniques bu wi h
ewe complica ions. Single-po and ansabdominal p e-pe i oneal app oaches o DIEP and LD laps minimize
incision sizes o 2-3 cm, compa ed o 10-20 cm in open me hods, educing se oma a es om 30-40% o 15% and pain
by 25-30%, while sho ening hospi al s ays by 1-2 days. AI-d i en essel mapping op imizes ou comes, cu ing
anas omosis ime by 15-20% in p eclinical models. No el applica ions, such as au ologous adipose s em cell-enhanced
bone lap ha es ing, educe iliac c es mo bidi y and enable ma u e bone o ma ion wi hin 8 mon hs, b oadening
econs uc i e possibili ies. Pa ien - epo ed ou comes show highe BREAST-Q sco es o b eas econs uc ion,
e lec ing imp o ed aes he ics, and uppe - hi d SF-36 sco es o head and neck cases, indica ing enhanced quali y o
li e. Despi e longe ope a i e imes, a e aging 296 minu es compa ed o 256 minu es o open p ocedu es,
ad ancemen s in su geon aining and cos -e ec i e pla o ms could add ess hese limi a ions. Fu u e esea ch should
ocus on la ge clinical ials, cos analyses, and in eg a ion o AI and egene a i e echniques o enhance accessibili y
and e icacy. Robo ic-assis ed ha es ing, wi h i s pa ien -cen e ed bene i s and mul idisciplina y po en ial, is poised o
ede ine s anda ds in econs uc i e su ge y, o e ing a pa adigm shi owa d p ecision, educed mo bidi y, and
imp o ed unc ional and aes he ic ou comes ac oss di e se pa ien popula ions.
Re e ences
[1] Awad, L., Reed, J., Bollen, E., Lang idge, B. J., Jasionowska, S., Bu le , P. E., & Ponniah, A. (2024). The eme ging ole
o obo ics in plas ic and econs uc i e su ge y: A sys ema ic e iew and me a-analysis. Jou nal o Robo ic
Su ge y, 18(1), 254. h ps://doi.o g/10.1007/s11701-024-02037-6
