Symani-Assisted Microsurgery in Head and Neck Reconstruction: A Systematic Review of Indications, Techniques, and Pooled Analysis of Clinical Outcomes.

Robot-assisted microsurgery with the Symani surgical system has emerged as a potential adjunct in complex reconstructive procedures. Its application in head and neck reconstruction remains early and incompletely characterized. We performed a systematic review to evaluate indications, technical utilization, and reported clinical outcomes of Symani-assisted microsurgery in head and neck reconstruction. A systematic review was conducted in accordance with PRISMA guidelines. PubMed (MEDLINE), Embase, Scopus, and the Cochrane Library were searched for studies reporting Symani-assisted microsurgery in head and neck reconstruction. Primary outcomes were flap success and anastomotic complications. Secondary outcomes included operative time, conversion to conventional technique, ischemia time, reported learning curve metrics, and risk of bias. A total of eight studies encompassing 157 patients with 157 flaps were included. Study designs consisted primarily of case reports and retrospective case series. The Symani was used for arterial and/or venous anastomosis in free flap reconstruction, most commonly in radial forearm flaps and most commonly to the facial vessels. Flap success rates were high (> 95%) with only five requiring return to operating room and two flap losses; random-effects meta-analysis demonstrated a pooled flap loss rate of 3.3% (95% CI, 1.1%-9.1%; I2 = 0%). Anastomotic complication rates were reported to be low with conversion to conventional technique occurring in one case due to technical malfunction. Anastomosis times were poorly reported across studies. Early clinical experience suggests that robot-assisted microsurgery with the Symani surgical system in head and neck reconstruction is technically feasible with acceptable short-term outcomes in selected cases. However, evidence remains limited to small, heterogeneous series. Prospective comparative studies are required to determine whether robotic assistance confers meaningful clinical or efficiency advantages over conventional microsurgery and determine optimal operative indications.