Robotic-assisted simulation of eyelid laceration repair: A proof-of-concept study

Robotic surgical systems have revolutionized surgical precision across multiple surgical disciplines by offering enhanced dexterity, tremor elimination, motion scaling, and high-definition 3 D visualization.[1] The Da Vinci robotic surgical system, in particular, has achieved widespread adoption in urology, gynecology, cardiothoracic surgery, and general surgery, where it has demonstrated significant improvements in surgeon ergonomics and procedural accuracy, especially in anatomically confined spaces.[2,3,4,5] Despite these advances, the integration of robotic platforms into ophthalmic surgery has remained limited, largely due to the extreme microsurgical precision required, the small operative field, and the proximity of critical visual structures.[6]

Ophthalmic procedures, especially those involving the eyelids and periocular region, require extreme meticulous tissue handling, precise suture placement, and constant awareness of the underlying globe. Eyelid laceration repair represents one of the most fundamental yet delicate oculoplastic procedures as improper alignment or inadvertent globe injury can result in functional, cosmetic, or vision-threatening complications.[7,8] Traditional manual techniques rely heavily on surgeon experience and fine motor control, making them an ideal benchmark for evaluating emerging surgical technologies aimed at enhancing precision and safety.

Recent interest has emerged in exploring robotic assistance for ophthalmic and oculoplastic procedures, particularly in simulation and preclinical models.[9] Potential advantages of robotic systems in periocular surgery include motion scaling for fine suturing, tremor filtration, and ambidextrous instrument control.[10] However, the lack of ophthalmology-specific robotic instruments, high costs, and limited evidence supporting feasibility have hindered clinical translation. Consequently, early-phase feasibility and proof-of-concept studies are essential to determine whether existing robotic platforms can be adapted for ophthalmic applications.

Simulation-based evaluation plays a critical role in assessing novel surgical techniques before progression to animal or human studies. Synthetic tissue models, mannequin-based setups, and hybrid simulation incorporating biological tissues allow reproducible assessment of technical feasibility, procedural safety, and surgeon learning curves without ethical or patient-related risks. Furthermore, the use of simulator-trained surgeons enables evaluation of whether structured robotic training can translate into safe and effective task performance in ophthalmic scenarios.[11]

Eyelid wound repair is particularly well suited for such exploratory investigations as it involves superficial tissue planes, well-defined anatomical landmarks, and standardized suturing techniques. Demonstrating safe robotic suturing in close proximity to a simulated globe is a critical step in validating the potential role of robotic systems in oculoplastic trauma surgery.

The present proof-of-concept study was designed to evaluate the technical feasibility and safety of robot-assisted various types of eyelid laceration repair using the Da Vinci surgical system in a simulated periocular environment. By employing a surgical glove stuffed with cut sponge with a goat’s eye, this study aims to establish foundational evidence supporting further preclinical exploration of robotic platforms in ophthalmic and oculoplastic surgery.

Methods

This was an experimental proof-of-concept simulation study conducted in a controlled laboratory setting.

The procedure was performed by a trained ophthalmologist who had completed a cumulative total of 12 hours of robotic surgical training using a virtual robotic surgical simulator prior to the study [Fig. 1]. The modules involved picking up rings using forceps and transferring the rings from one hand to other, placing the rings in a moving target, placement of needles through desired points, and pulling threads bimanually.

Commercially available latex gloves were taken, and two fingers were cut at the level of palm; sponges were cut in rectangular shapes and inserted into the lumen of the cut gloves. This was done to mimic the eyelid skin and architecture [Fig. 2]. A goat’s eye was first placed over a Thermocol block and fixed to it with the help of pins [Fig. 3a]. The fingers of the gloves were fashioned in a manner to imitate the upper and lower eyelids and were also pinned [Fig. 3b and c]. A black ink pen was used to draw eyelid fold 8 mm from the upper eyelid margin and 6 mm from the lower eyelid margin. Lashes were also drawn at the margin [Fig. 3d].

Curvilinear incisions measuring 20 mm were manually created on both the simulated upper and lower eyelids using surgical blades to mimic eyelid anterior lamellar lacerations. Another margin involving eyelid full thickness wound was created by cutting the full thickness of the glove.

The Da Vinci robotic surgical system was used for repair of both the wounds. Using robotic needle drivers, the surgeon performed interrupted suturing with 6-0 silk sutures for anterior lamellar wounds [Figs. 4 and 5]. The full thickness wound was repaired by using 4-0 silk for the eyelid margin, 6-0 Vicryl for the tarsus (simulated by sponge), and 6-0 silk for the skin [Fig. 6]. The total time taken to complete suturing was recorded.

Primary outcomes included: Feasibility of robotic suturing, total suturing time, accuracy of wound edge approximation, and safety, assessed by the absence of corneal or globe contact.

Results

Robot-assisted repair of simulated eyelid lacerations was successfully completed in all attempts. Four interrupted sutures were placed in each of the upper and lower eyelid anterior lamellar wounds with satisfactory alignment and wound edge approximation [Fig. 7].

The total time required to complete suturing of both eyelids anterior lamellar wound was 12 minutes. Instrument handling was stable, and the robotic system allowed precise needle positioning despite the confined periocular workspace.

The full thickness wound was also successfully repaired by the robot-assisted system in a time period of 10 minutes.

Importantly, no inadvertent contact with the cornea or globe was observed throughout the procedure, indicating a decent safety profile in this simulated setting.

Discussion

Our proof-on-concept study demonstrates that robot-assisted eyelid laceration repair using the Da Vinci surgical system is technically feasible and can be performed safely in a simulated periocular model with satisfactory wound closure and no inadvertent corneal contact. However, ophthalmologists required at least 12 hours of virtual robotic surgery simulation training. We were able to place sutures in both the simulated upper and lower eyelid lamellar wounds, as well as the margin involving full thickness wound, and oppose the edges, showing that robotic manipulation was precise and efficient in the constrained periocular workspace. Our findings align with the broader trajectory of research investigating the application of robotic platforms in ophthalmic and periocular surgery, despite the challenges inherent in miniaturizing existing general surgical systems for ophthalmic use.

Robotic surgical systems, especially the Da Vinci platform, was originally developed for general and visceral surgeries, but its use in eye-related procedures has expanded over the past decade due to their advantages in motion scaling, tremor suppression, 3-dimensional visualization, and ergonomic control.[2,3,4] While dedicated ophthalmic robotics such as the Preceyes system are coming into clinical use for intraocular tasks, the Da Vinci platform remains a frequently studied telemanipulator for anterior surface and periocular procedures that benefit from its precision and reach.[12,13]

For ocular surface pathology, the first human case of robotic-assisted pterygium excision using the Da Vinci Si HD system has been reported, where pterygium excision with conjunctival autograft was completed uneventfully in a 73-year-old patient, with no need to convert to conventional surgery.[14] This early clinical success illustrates the system’s dexterity in delicate conjunctival and episcleral dissection, although the operative times were longer than conventional manual techniques, a common observation in early robotic applications that reflects both system constraints and the surgeon learning curve.

Beyond surface surgery, the Da Vinci robotic platform has been explored for penetrating keratoplasty (PK) in experimental settings. Chammas and colleagues reported on robot-assisted PK using the Da Vinci Xi system on human corneal tissue, successfully performing trephination and suturing for 12 corneas with appropriate suture depth confirmed by optical coherence tomography and no intraoperative complications.[15] These feasibility studies suggest that robotic articulation and visualization may be advantageous for circumferential suturing in corneal grafting, though limitations such as visualization and instrument size still challenge translation to routine clinical use.

Similarly, a number of preclinical and early clinical investigations have extended robotic systems to orbital and adnexal surgery, including globe-sparing resection of advanced periocular tumors. In a recent case series using the Da Vinci Xi, patients with basal cell carcinoma and squamous cell carcinoma underwent robotic-assisted orbital tumor resection with clear margins and preservation of ocular structures; the 3-dimensional optics and multidirectional instrumentation were highlighted as key factors enabling precise dissection in the confined orbital space. These reports, while limited and largely case-based, provide important proof points for applying robotic techniques to complex eyelid and orbital pathology where manual access and fine control are traditionally difficult.[16]

In addition to these specific applications, broader reviews of robotic assistance in eye care have confirmed that while robotics remains in an early stage within ophthalmology, there is a growing repertoire of investigative procedures demonstrating feasibility across corneal, ocular surface, and periocular tissues. A key theme across these studies is that the primary advantages, enhanced visualization, tremor-free motion, and motion scaling, help overcome some inherent limitations of manual microsurgery, particularly in narrow or deep anatomical corridors.

However, several challenges temper enthusiasm for widespread clinical adoption with current general-purpose systems. The Da Vinci system’s instrument size, endoscopic visualization (which is optimized for laparoscopic fields rather than microscopic ocular view), and the steep learning curve remain significant hurdles. Moreover, evidence is predominantly from case reports, small series, and experimental models, which limits robust conclusions about comparative efficacy, safety, or outcomes versus conventional techniques.

In this context, the present study contributes critical evidence for the feasibility and safety of robotic suturing in the periocular setting. Demonstrating successful eyelid wound repair without globe injury in simulation sets a foundation for further preclinical work including cadaveric models and instrument refinement that may eventually bridge robotic systems from ancillary exploratory roles toward practical adjuncts in ophthalmic trauma and reconstructive surgery.

Conclusion

Robot-assisted eyelid laceration repair using the Da Vinci surgical system is technically feasible and safe in a simulated environment. With prior virtual simulator training, ophthalmologists can perform precise periocular suturing without inadvertent globe injury in a controlled environment. Further preclinical and translational research is warranted to define the role of robotic platforms in oculoplastic and ophthalmic trauma surgery.

Funding Statement

Nil.