Robot-assisted Microsurgery: Lessons Learned from 50 Consecutive Cases.

Background: The potential of robot-assisted surgery in plastic and reconstructive surgery remains to be established, especially in free tissue transfer. This prospective study aimed to present our experience and findings from the first 50 consecutive cases of robot-assisted microsurgery using the Symani surgical system. Methods: A prospective database was maintained, recording patient demographics and surgical details for all cases of robot-assisted microsurgery in a large academic institution. All surgeons underwent an intensive training program with the Symani surgical system. Results: A total of 50 patients who underwent robot-assisted microsurgical reconstruction were identified. Free microsurgical tissue transfer was performed in 45 cases, targeted muscle reinnervation in four cases, and lymphovenous anastomoses in a single case. A total of 94 robot-assisted anastomoses and coaptations were performed, (46 venous and 30 arterial anastomoses, 16 nerve coaptations, two lymphovenous anastomoses). Six cases involved perforator-to-perforator anastomoses. Ninety-eight percent of attempted anastomoses were completed using the robot. Size-mismatch anastomoses, seen in 37.8% of cases, took significantly longer. Minor complications occurred in three cases and major in six cases. There were three cases of microvascular compromise requiring revision. One partial flap loss and no complete flap loss occurred. Conclusions: Our study highlights the immense potential of robot-assisted microsurgery, and a feasible and effective modality for various microsurgical procedures, with outcomes comparable to those of conventional microsurgery. Despite challenges, such as increased operating times and higher costs, the technology offers significant advantages, such as enhanced precision and motion scaling. We identify a slow learning curve and a necessity for higher caseloads.

[Robot-assisted Microsurgery in Lower Extremity Reconstruction]. / Roboter-assistierte Mikrochirurgie in der Rekonstruktion der unteren Extremität.

BACKGROUND: In recent years, various robotic systems specifically designed for microsurgical tasks have been developed and approved. There is not much evidence for these systems to date. In our study, we examined the use of robot-assisted microsurgery in the reconstruction of the lower extremity. PATIENTS/MATERIAL AND METHODS: Data was prospectively collected between February and November 2023. The Symani robotic system was used in 42 robot-assisted microsurgical procedures on the lower extremity, and the results were evaluated and documented. RESULTS: The average age of the patients was 57±18 years. A total of 39 free flap reconstructions (95%), one lymphatic surgical procedure (3%) and two nerve transfers (5%) were performed. In total, 46 anastomoses and coaptations were carried out. This included six arterial end-to-end anastomoses (11%), seven arterial end-to-side anastomoses (13%), 36 venous end-to-end anastomoses (65%), two lymphovenous anastomoses (4%), and five epineural coaptations in the context of nerve transfers (9%). Arterial end-to-end anastomoses took an average of 26±12 minutes, and arterial end-to-side anastomoses took 42±21 minutes. The venous anastomoses took an average of 33±12 minutes. Epineural coaptations took an average of 24±13 minutes. In no procedure was there a need for a conversion to conventional hand suturing. There were two arterial thromboses (5%), one of which was successfully revised to save the flap. One total flap loss occurred, but there were no partial flap losses. CONCLUSION: Using the Symani robotic system for microsurgical reconstruction of the lower extremity, we were able to demonstrate results that are comparable to conventional microsurgery.

Using a Microsurgical Robotic Platform for In-flap Anastomosis in Autologous Bipedicular Breast Reconstruction.

Autologous microsurgical breast reconstruction has become a standard of care. As techniques become more individualized and aim for less-invasive approaches, vessels ever smaller in diameter are considered for flap anastomosis. Robot-assisted surgery has great potential to reduce tremor and enhance precise motion. The Symani Surgical System (Medical Microinstruments, Inc., Wilmington, Del.) is a robotic platform designed for microsurgery. It was used for a microsurgical in-flap anastomosis of a bipedicular deep inferior epigastric artery flap for unilateral breast reconstruction. The procedure included fully robot-assisted anastomoses with significant size mismatches using a 3D-exoscope for magnification. Arterial and venous anastomoses were entirely robot-assisted completed in 23 minutes (seven stitches) and 28 minutes (eight stitches) using 9/0 nylon sutures. The intra- and postoperative course was uneventful. This robotic platform facilitates in-flap anastomoses of small vessels by increasing the precision of instrument handling and eliminating tremor. The combination of robotic platforms and exoscopes provides superior ergonomics in comparison with conventional (super)microsurgery. We expect robotic platforms to play a significant role in modern microsurgical breast reconstruction.

Gods are watching and so what? Moralistic supernatural punishment across 15 cultures.

Psychological and cultural evolutionary accounts of human sociality propose that beliefs in punitive and monitoring gods that care about moral norms facilitate cooperation. While there is some evidence to suggest that belief in supernatural punishment and monitoring generally induce cooperative behaviour, the effect of a deity's explicitly postulated moral concerns on cooperation remains unclear. Here, we report a pre-registered set of analyses to assess whether perceiving a locally relevant deity as moralistic predicts cooperative play in two permutations of two economic games using data from up to 15 diverse field sites. Across games, results suggest that gods' moral concerns do not play a direct, cross-culturally reliable role in motivating cooperative behaviour. The study contributes substantially to the current literature by testing a central hypothesis in the evolutionary and cognitive science of religion with a large and culturally diverse dataset using behavioural and ethnographically rich methods.

Moralizing gods, impartiality and religious parochialism across 15 societies.

The emergence of large-scale cooperation during the Holocene remains a central problem in the evolutionary literature. One hypothesis points to culturally evolved beliefs in punishing, interventionist gods that facilitate the extension of cooperative behaviour toward geographically distant co-religionists. Furthermore, another hypothesis points to such mechanisms being constrained to the religious ingroup, possibly at the expense of religious outgroups. To test these hypotheses, we administered two behavioural experiments and a set of interviews to a sample of 2228 participants from 15 diverse populations. These populations included foragers, pastoralists, horticulturalists, and wage labourers, practicing Buddhism, Christianity, and Hinduism, but also forms of animism and ancestor worship. Using the Random Allocation Game (RAG) and the Dictator Game (DG) in which individuals allocated money between themselves, local and geographically distant co-religionists, and religious outgroups, we found that higher ratings of gods as monitoring and punishing predicted decreased local favouritism (RAGs) and increased resource-sharing with distant co-religionists (DGs). The effects of punishing and monitoring gods on outgroup allocations revealed between-site variability, suggesting that in the absence of intergroup hostility, moralizing gods may be implicated in cooperative behaviour toward outgroups. These results provide support for the hypothesis that beliefs in monitoring and punitive gods help expand the circle of sustainable social interaction, and open questions about the treatment of religious outgroups.

Genetic legacy of state centralization in the Kuba Kingdom of the Democratic Republic of the Congo.

Few phenomena have had as profound or long-lasting consequences in human history as the emergence of large-scale centralized states in the place of smaller scale and more local societies. This study examines a fundamental, and yet unexplored, consequence of state formation: its genetic legacy. We studied the genetic impact of state centralization during the formation of the eminent precolonial Kuba Kingdom of the Democratic Republic of the Congo (DRC) in the 17th century. We analyzed genome-wide data from over 690 individuals sampled from 27 different ethnic groups from the Kasai Central Province of the DRC. By comparing genetic patterns in the present-day Kuba, whose ancestors were part of the Kuba Kingdom, with those in neighboring non-Kuba groups, we show that the Kuba today are more genetically diverse and more similar to other groups in the region than expected, consistent with the historical unification of distinct subgroups during state centralization. We also found evidence of genetic mixing dating to the time of the Kingdom at its most prominent. Using this unique dataset, we characterize the genetic history of the Kasai Central Province and describe the historic late wave of migrations into the region that contributed to a Bantu-like ancestry component found across large parts of Africa today. Taken together, we show the power of genetics to evidence events of sociopolitical importance and highlight how DNA can be used to better understand the behaviors of both people and institutions in the past.

Use of oral cholera vaccine in Haiti: a rural demonstration project.

A cholera epidemic has claimed the lives of more than 8,000 Haitians and sickened 650,000 since the outbreak began in October 2010. Early intervention in the epidemic focused on case-finding, treatment, and water and sanitation interventions for prevention of transmission. Use of oral cholera vaccine (OCV) as part of a complementary set of control activities was considered but initially rejected by policymakers. In December 2011, the Minister of Health of Haiti called for a demonstration of the acceptability and feasibility of the use of OCV in urban and rural Haiti. This paper describes the collaborative activity that offered OCV to one region of the Artibonite Department of rural Haiti in addition to other ongoing treatment and control measures. Despite logistics and cold chain challenges, 45,417 persons were successfully vaccinated with OCV in the region, and 90.8% of these persons completed their second dose.