Surgical Robotics
Systems, Applications, and Visions
Jacob Rosen, Blake Hannaford, Richard M. Satava (Editors)
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Publisher: Springer; 1st Edition. (December 1, 2010) Hardcover: 889 pages Language: English ISBN-10: 1441911251 ISBN-13: 978-1441911254 Publisher Web Site  |
Surgical robotics is a rapidly evolving field. With roots in academic research, surgical robotic systems are now clinically used across a wide spectrum of surgical procedures. Surgical Robotics: Systems Applications and Visions provides a comprehensive view of the field both from the research and clinical perspectives. This volume takes a look at surgical robotics from four different perspectives, addressing vision, systems, engineering development and clinical a pplications of these technologies.
The book also:
• Discusses specific surgical applications of robotics that have already been deployed in operating rooms
• Covers specific engineering breakthroughs that have occurred in surgical robotics
• Details surgical robotic applications in specific disciplines of surgery including orthopedics, urology, cardiac surgery, neurosurgery, ophthalmology, pediatric surgery and general surgery
Surgical Robotics: Systems Applications and Visions is an ideal volume for researchers and engineers working in biomedical engineering.
Table of Contents
Preface
Part 1 - Visions and Overviews
Chapter 01 - Future Directions in Robotic Surgery
Richard M. Satava
Chapter 02 -
Military Robotic Combat Casualty Extraction and Care
Andrew C. Yoo, Gary R. Gilbert,, and Timothy J. Broderick
Chapter 03 - Telemedicine for the Battlefield: Present and Future Technologies
Pablo Garcia
Chapter 04 -
Overcoming Barriers to Wider Adoption of Mobile Telerobotic Surgery: Engineering, Clinical and Business Challenges
Charles R. Doarn and Gerald R. Moses
Part 2 - Systems
Chapter 05 - Accurate Positioning for Intervention on the Beating Heart Using a Crawling Robot
Nicholas A. Patronik, Takeyoshi Ota, Marco A. Zenati, and Cameron N. Riviere
Chapter 06 - Miniature In Vivo Robots for NOTES
Shane M. Farritor, Amy C. Lehman,, and Dmitry Oleynikov
Chapter 07 - A Compact, Simple, and Robust Teleoperated Robotic
Surgery System
Ji Ma and Peter Berkelman
Chapter 08
- Raven: Developing a Surgical Robot from a Concept to a Transatlantic Teleoperation Experiment
Jacob Rosen, Mitchell Lum, Mika Sinanan,, and Blake Hannaford
Chapter 09 - The da Vinci Surgical System
Simon DiMaio, Mike Hanuschik,, and Usha Kreaden
Chapter 10 - RIO: Robotic-Arm Interactive Orthopedic System MAKOplasty: User Interactive Haptic Orthopedic Robotics.
Benny Hagag, Rony Abovitz, Hyosig Kang, Brian Schmitz, and Michael Conditt
Chapter 11 - Robotic Surgery: Enabling Technology?
Moshe Shoham
Chapter 12 - Enabling Medical Robotics for the Next Generation of Minimally Invasive Procedures: Minimally Invasive Cardiac Surgery with Single Port Access
Howie Choset, Marco Zenati, Takeyoshi Ota, Amir Degani, David Schwartzman, Brett Zubiate,, and Cornell Wright
Chapter 13 - Wireless Intraocular Microrobots: Opportunities and Challenges
Olgac¸ Ergeneman, Christos Bergeles, Michael P. Kummer, Jake J. Abbott,, and Bradley J. Nelson
Chapter 14 - Single and Multiple Robotic Capsules for Endoluminal Diagnosis and Surgery
Arianna Menciassi, Pietro Valdastri, Kanako Harada, and Paolo Dario
Chapter 15 - Visual Guidance of an Active Handheld Microsurgical Tool
Brian C. Becker, Sandrine Voros, Robert A. MacLachlan, Gregory D. Hager, and Cameron N. Riviere
Chapter 16 - Swimming Micro Robots for Medical Applications
Gbor Kosa and Gbor SzOkely
Chapter 17 - Flagellated Bacterial Nanorobots for Medical Interventions in the Human Body
Sylvain Martel
Part 3 - Engineering Developments
Chapter 18 - Force Feedback and Sensory Substitution for Robot-Assisted Surgery
Allison M. Okamura, Lawton N. Verner, Tomonori Yamamoto James C. Gwilliam, and Paul G. Griffiths
Chapter 19 - Tactile Feedback in Surgical Robotics
Martin O. Culjat, James W. Bisley, Chih-Hung King
Christopher Wottawa, Richard E. Fan, Erik P. Dutson,
Warren S. Grundfest
Chapter 20 - Robotic Techniques for Minimally Invasive Tumor Localization
Michael D. Naish, Rajni V. Patel, Ana Luisa Trejos
Melissa T. Perri,, and Richard A. Malthaner
Chapter 21 - Motion Tracking for Beating Heart Surgery
Rogerio Richa, Antonio P. L. Bo, and Philippe Poignet
Chapter 22 - Towards the Development of a Robotic System for Beating Heart Surgery
øzkan Bebek and M. Cenk Cavusoglu
Chapter 23 - Robotic Needle Steering: Design, Modeling, Planning,
and Image Guidance
Noah J. Cowan, Ken Goldberg, Gregory S. Chirikjian,
Gabor Fichtinger, Ron Alterovitz, Kyle B. Reed,
Vinutha Kallem, Wooram Park, Sarthak Misra,
Allison M. Okamura
Chapter 24 - Macro and Micro Soft-Tissue Biomechanics and
Tissue Damage: Application in Surgical Robotics
Jacob Rosen, Jeff Brown, Smita De, and Blake Hannaford
Chapter 25 - Objective Assessment of Surgical Skills
Jacob Rosen, Mika Sinanan, and Blake Hannaford
Part 4 - Clinical Applications/Overviews
Chapter 26 - Telesurgery: Translation Technology to Clinical Practice
Mehran Anvari
Chapter 27 - History of Robots in Orthopedics
Michael Conditt
Chapter 28 - Robotic-Assisted Urologic Applications
Thomas S. Lendvay and Ryan S. Hsi
Chapter 29 - Applications of Surgical Robotics in Cardiac Surgery
E.J. Lehr, E. Rodriguez,, and W.R. Chitwood
Chapter 30 - Robotics in Neurosurgery
L.N. Sekhar, D. Ramanathan, J. Rosen, L.J. Kim, D. Friedman, D. Glozman, K. Moe, T. Lendvay, and B. Hannaford
Chapter 31 - Applications of Surgical Robotics in Pediatric General Surgery
John Meehan
Chapter 32 - Applications of Surgical Robotics in Gynecologic Surgery
Rabbie K. Hanna and John F. Boggess
Chapter 33 - Applications of Surgical Robotics in General Surgery
Ozanan Meireles and Santiago Horgan
Preface
The dictum Primum non nocere (First, do no harm) and the dictum “Primum
Succurrere” (First, hasten to help) as the prime directives of ethics in medicine
may dictate two orthogonal approaches of practicing medicine, both of which are
aimed to provide the best health care to the patient. The conservative approach
relies on decades of evidence-based practice and clinical experience with a specific
medical or surgical approach. However, every now and then, a scientific, technological, or clinical breakthrough occurs (alone or in combination) which leads to a
paradigm shift along with disruptive new approach to health care. To some extent,
this progressive approach is regulated by rigorous clinical trials as dictated by the
Federal and Drug Administration (FDA) aimed at demonstration of safety and
effectiveness. Although the progressive treatment approach results in a relativity
high risk, there is a concomitant high reward in terms of healing and regaining a
high quality of life.
Surgical robotics is a recent and very significant breakthrough in surgery. The
introduction of a surgical robot into the operating room (OR) combines a technological breakthrough with a clinical breakthrough in developing new surgical
techniques and approaches to improve the quality and outcome of surgery. As
significant as these breakthroughs are, it is not surprising that they occurred because
they are based on more than a decade of innovation in field of robotics in both
academia and industry. The promise of surgical robotics is to deliver high levels of
dexterity and vision to anatomical structures that cannot be approached by the
surgeon’s fingers and viewed directly by the surgeon’s eyes. Making this technolo-
gy available to surgeons has led to new surgical techniques that could not be
accomplished previously. It is likely that clinical knowledge accumulated using
these new systems or even by simply realizing their capabilities will lead to the
development of new surgical robotic systems in the future. The surgical robot and
various imaging modalities may be viewed as mediators between the surgeon’s
hands and eyes and the surgical site, respectively; however, these two elements are
part of a larger information system that will continue to evolve and affect every
aspect of surgery and healthcare in general. Archived medical history, preoperative scans, preplanning, quantitative recording of the surgical execution, follow-up and outcome assessment are all part of feed forward and feedback mechanisms that will improve the quality of healthcare.
As product of a rapidly evolving research field, this assembly of monographs aimed to capture a wide spectrum of topics spanning from ambitious visions for the future down to today’s clinical practice. The book is divided into four sections:
1. The vision and overviews section reviews the field from the civilian and military perspectives. It includes chapters discussing the Trauma Pod concept – a vision of an OR without humans. The importance of the trauma pod project was that it demonstrated the capability of automating all the services in the OR – services that are currently provided today by a scrub nurse and a circulation nurse that have been demonstrated to be translates to services by a robotic cell – robotic arms and information systems. Whether this concept of automation will be extended into clinical practice and thereby emphasizing even more the role of a surgeon as a decision maker while the operation is executed by the surgical robot automatically is yet to be seen.
2. The systems section is divided into two subsections including chapters describ ing key efforts in systems development and integration of macro- (first section) and micro (second section) surgical robots in both academia and industry. Developing a macro-surgical robotic system is challenging in part due to the difficulties in translating qualitative clinical requirements into quantitative engineering specifications. Moreover, a successful system development as a whole is often a result of multidisciplinary and interdisciplinary efforts including all the subdisciplines of engineering and surgery – efforts that should not be taken lightly. In addition to challenges of macro-systems development, developing surgical robotics on a micro-system level introduces a significant reduction in scale. Forces, torques, pressures, and stresses do not scale down linearly with the geometrical dimensions. These interesting scaling properties challenge many engineering and surgical concepts. Inspired by the film “Fantastic Voyage,” the promise of a micro-robotic system is the capability to travel in the human body and provide local treatment. This concept is still in its infancy, and the academic research currently conducted in this field is focused on fundamental aspects of the system such as propulsion, navigation, energy source, manipulation, and control.
3. The engineering developments section covers technologies, algorithms, and experimental data to enhance and improve the current capabilities of surgical robotics. Topics of chapters in this section include tactile and force feedback, motion tracking, needle steering, soft tissue biomechanics of internal organs, and objective assessment of surgical skill. All of these will be incorporated into different layers of the surgical robotic systems in the future and will eventually put a superior robotic system in the hands of the surgeon for improving the outcome.
4. The clinical applications section includes chapters authored by surgeons who use surgical robotic systems clinically and describe the current clinical
applications of surgical robotics in several subdisciplines of surgery including
urology, cardiology, neurosurgery, pediatric surgery gynecology, and general
surgery as well as telesurgery. Most of these chapters also provide some
thoughts about future applications of surgical robots in surgery. The generic
nature of the surgical robotic system allows the surgeon to explore many
surgical procedures that were not targeted by the robot’s original developers.
Moreover, today’s growing vast array of clinical applications of surgical robotics demonstrates that the clinical community can adopt new surgical approaches
once a capable tool such as a robot is made available.
Jacob Rosen
Blake Hannaford
Richard Satava
Part 1 - Visions and Overviews
Chapter 01 - Future Directions in Robotic Surgery
Richard M. Satava
Abstract - Robotic surgery has become an established part of clinical surgery.
The advantages of using a robot have been enumerated by many clinicians, however
the true potential has yet to be realized. In addition, the systems available today are
extraordinarily simple and cumbersome relative to the more sophisticated robotic
systems used in other industries. However more important is the fact that
the fundamental principles underlying robotics have yet to be exploited, such as
systems integration, feedback control, automatic performance, simulation and
rehearsal and integration into healthcare enterprise. By looking at robotic imple
mentation in other industries, and exploring the new robotic technologies in the
laboratories, it is possible to speculate on the future directions which would be
possible in surgical robotics.
Chapter 02 -
Military Robotic Combat Casualty Extraction and CareAndrew C. Yoo, Gary R. Gilbert,, and Timothy J. Broderick
Abstract - Buddy treatment, first responder combat casualty care, and patient
evacuation under hostile fire have compounded combat losses throughout history.
Force protection of military first responders is complicated by current international
and coalition troop deployments for peacekeeping operations, counter terrorism, and
humanitarian assistance missions that involve highly visible, politically sensitive,
low intensity combat in urban terrain. The United States Department of Defense
(DoD) has significantly invested in autonomous vehicles, and other robots to support
its Future Force. The US Army Telemedicine and Advanced Technology Research
Center (TATRC) has leveraged this DoD investment with augmented funding to
broadly focus on implementing technology in each phase of combat casualty care.
This ranges from casualty extraction, physiologic real-time monitoring, and life
saving interventions during the “golden hour” while greatly reducing the risk to first
responders.
The TATRC portfolio of projects aims to develop, integrate, and adapt robotic
technology for unmanned ground and air battlefield casualty extraction systems that
operate in hostile environments that include enemy fire. Work continues on multiple
ground extraction systems including a prototype dynamically balanced bipedal
Battlefield Extraction Assist Robot (BEAR) capable of extracting a 300–500
pound casualty from a variety of rugged terrains that include urban areas and
traversing stairs. The TATRC and the Defense Advanced Research Projects Agency
(DARPA) are collaborating to investigate the use of Unmanned Aircraft Systems
(UAS) to conduct casualty evacuation (CASEVAC) missions. TATRC has
also sponsored research in robotic implementation of Raman and Laser-Induced
Breakdown Spectroscopy (LIBS) to detect and identify potential chemical and
biological warfare agents and explosive hazards to casualties and first responders during the extraction process, and patient monitoring equipment with sophisticated telemedicine and patient monitoring equipment such as “smart stretchers” that allow for real-time physiologic monitoring throughout the combat casualty care process, from extraction to definitive care. Other projects are intended to build upon these monitoring systems and incorporate telerobotic and near autonomous casualty assessment and life saving treatment to the battlefield. These have included the DARPA Trauma Pod and several TATRC efforts to integrate robotic arms with the Life Support for Trauma and Transport (LSTAT) litter for robotic implementation of non-invasive technologies such as acoustic cauterization of hemorrhage via High Intensity Focused Ultrasound (HIFU). Several projects have explored the essential telecommunication link needed to implement telesurgery and telemedicine in extreme environments. UAS were leveraged to establish a telecommunication network link for telemedicine and telesurgery applications in extreme situations. Another collaborative telesurgery research project at the NASA Extreme Environ- ment Mission Operations (NEEMO) included performing telesurgery in an undersea location.
Research into identification and solutions of the limitations of telecommunica tion and robotics that prevent robust casualty interventions will allow future medical robots to provide robust casualty extraction and care that will save the lives and limbs of our deployed warfighters.
Chapter 03 - Telemedicine for the Battlefield: Present and Future Technologies
Pablo Garcia
Abstract - Providing medical care in the field is very challenging because of the limited availability of medical resources. The current practice in military operations is to
stabilize patients far forward and evacuate them to better equipped medical facil
ities, such as combat field hospitals. This strategy has proven very successful in
recent conflicts. However, it is possible to save more lives and ameliorate the
consequences of long term injuries by providing an accurate diagnosis earlier,
specialized surgical care faster and more sophisticated intensive care during trans
port. This chapter focuses on technologies that allow augmenting the diagnostics
and treatment capabilities of medical teams in the field.
The decisions made by the first responders are critical for the patient chances of
survival and they are done with very little information on the real status of the
patient. For example, recognizing an internal head injury or abdominal bleeding
is critical to determine where the patient should be evacuated but this information
is currently not available. Once a patient is evacuated to a medical facility it is
impossible to provide all specialties required to treat complex injuries (it is not
uncommon for general trauma surgeons to conduct head procedures because they
do not have a neurosurgeon in the staff). Finally, once patients are stable enough to
transport them outside the country they are taken on long transcontinental flights
with a small team of nurses and doctors who have limited means to react to adverse
conditions in patients.
Technology can be used to force multiply the capabilities of the medical
personnel in the field by allowing them to perform more sophisticated diagnosis
and treatments closed to the point of injury. Figure 3.1 illustrates the different layers
of technology which can be used to treat patients in the field. Each additional layer
adds a level of sophistication to the one below but is applicable to a smaller pool of
patients.
Chapter 04 -
Overcoming Barriers to Wider Adoption of Mobile Telerobotic Surgery: Engineering, Clinical and Business Challenges
Charles R. Doarn and Gerald R. Moses
Abstract - Advances in technology yield many benefits to our daily lives. Our ability
to integrate robotics, telecommunications, information systems and surgical tools into
a common platform has created new approaches in utilizing less invasive means to
treat both common and more complex disease states. A significant amount of invest
ment has been made both from government funding and private sector or commercial
funding in the research and development of systems in the area of robotic surgery and
the application of telesurgery; and this has led to the development of clinically-
relevant distribution of surgical expertise using a surgical robot and telecommunication link. This has predominately been in support of government-funded activities.
While early work by Jacques Marescaux in Operation Lindberg and the extensive
research performed using Intuitive Surgical’s da Vinci, SRI’s M7 and the University
of Washington’s Raven has shown tremendous promise in surgical care, there remains
a variety of barriers to wider adoption of telerobotic surgery. These barriers are
multidisciplinary and often interdisciplinary. Widespread application of telesurgery
as a medical force multiplier depends upon resolution of these barriers, which include
bandwidth, latency, quality of service (QoS), research, and reimbursement. The
following summarizes how telesurgery has developed, what the challenges are and
how they are being ameliorated for wider adoption.
Part 2 - Systems
Chapter 05 - Accurate Positioning for Intervention on the Beating Heart Using a Crawling Robot
Nicholas A. Patronik, Takeyoshi Ota, Marco A. Zenati, and Cameron N. Riviere
Abstract - Heart failure resulting from myocardial infarct, oxygen-deprived tissue
death, is a serious disease that affects over 20 million patients in the world. The
precise injection of tissue-engineered materials into the infarct site is emerging as a
treatment strategy to improve cardiac function for patients with heart failure.
We have developed a novel miniature robotic device (HeartLander) that can act
as a manipulator for precise and stable interaction with the epicardial surface of the
beating heart by mounting directly to the organ. The robot can be delivered to and
operate within the intrapericardial space with the chest closed, through a single
small incision below the sternum. The tethered crawling device uses vacuum
pressure to maintain prehension of the epicardium, and a drive wire transmission
motors for actuation. An onboard electromagnetic tracking sensor enables the
display of the robot location on the heart surface to the surgeon, and closed-loop
control of the robot positioning to targets. In a closed-chest animal study with the
pericardium intact, HeartLander demonstrated the ability to acquire a pattern of
targets located on the posterior surface of the beating heart within an average of
1.7 1.0 mm. Dye injections were performed following the target acquisitions to
simulate injection therapy for heart failure. HeartLander may prove useful in the
delivery of intrapericardial treatments, like myocardial injection therapy, in a
precise and stable manner, which could be performed on an outpatient basis.
Chapter 06 - Miniature In Vivo Robots for NOTES
Shane M. Farritor, Amy C. Lehman,, and Dmitry Oleynikov
Abstract - Eliminating all external incisions would be a significant step in reducing
the invasiveness of surgical procedures. Accessing the peritoneal cavity through a
natural orifice, as in Natural Orifice Translumenal Endoscopic Surgery (NOTES),
promises distinct patient advantages, but is surgically challenging. Performing
laparoscopic surgeries through a single transumbilical incision is also gaining
renewed interest as a potential bridge to enabling NOTES. Both of these types of
surgical procedures are inherently limited by working with multiple instruments
through a constrained insertion point. New technologies are necessary to overcome
these limitations and provide the surgeon with adequate visual feedback and
triangulation. Miniature in vivo robots provide a unique approach by providing a
platform that is completely inserted into the peritoneal cavity to enable minimally
invasive surgery. This chapter describes the design and feasibility testing of miniature in vivo robots that can provide stable visualization and manipulation platforms
for NOTES and single incision surgery.
Chapter 07 - A Compact, Simple, and Robust Teleoperated Robotic
Surgery System
Ji Ma and Peter Berkelman
Abstract - The utility of current commercial teleoperated robotic surgery systems is
limited by their high cost, large size, and time-consuming setup procedures.
We have developed a prototype system which aims to overcome these obstacles
by being much smaller, simpler, and easier to set up and operate, while providing
equivalent functionality and performance for executing surgical procedures.
The prototype system is modular and each component manipulator is approxi
mately 2.5 kg or less, so that they system is easily portable and each manipulator
can be individually positioned and fixed in place by hand to a rigid frame above
the operating table. All system components and materials are autoclaveable and
immersible in fluids, so that each manipulator can be sterilized and stored by the
standard operating procedures used for any other surgical instrument, and no sterile
draping is required. The system is described and results of untrained user trials
performing standard laparoscopic surgery skill tasks are given.
Chapter 08
- Raven: Developing a Surgical Robot from a Concept to a Transatlantic Teleoperation Experiment
Jacob Rosen, Mitchell Lum, Mika Sinanan,, and Blake Hannaford
Abstract -
Chapter 09 - The da Vinci Surgical System
Simon DiMaio, Mike Hanuschik,, and Usha Kreaden
Abstract -
Chapter 10 - RIO: Robotic-Arm Interactive Orthopedic System MAKOplasty: User Interactive Haptic Orthopedic Robotics.
Benny Hagag, Rony Abovitz, Hyosig Kang, Brian Schmitz, and Michael Conditt
Abstract -
Chapter 11 - Robotic Surgery: Enabling Technology?
Moshe Shoham
Abstract - Since its emergence, modern robotics has empowered mankind to reach
goals ranging from the hazardous to unfeasible. In the medical field, robots have
ushered in an era of minimized invasiveness, improved accuracy, lessened patient
trauma and shortened recovery periods.
This chapter offers an overview of currently available medical robots and
especially evaluates their technology-enabling capacities. Combination of significantly higher accuracy than conventional free-hand techniques with minimally
invasive capability renders robotics an enabling technology. Obviously, dramatic
dimensional changes in robots, to levels allowing for their introduction to the body
for diagnostic and therapeutic purposes, also designates them to an enabling
technology. The few currently available surgical robots are categorized in this
chapter according to their enabling potential, along with a presentation of a future
micro-robot for in-body treatment.
Chapter 12 - Enabling Medical Robotics for the Next Generation of Minimally Invasive Procedures: Minimally Invasive Cardiac Surgery with Single Port Access
Howie Choset, Marco Zenati, Takeyoshi Ota, Amir Degani, David Schwartzman, Brett Zubiate,, and Cornell Wright
Abstract - Minimally invasive cardiac surgery (MICS) is an evolving strategy
aimed at delivering the desired form of cardiovascular therapy with the least change
in homeostasis, ideally matching the same degree of invasiveness of percutaneous
cardiac interventions. Cardiac surgery is different from other surgical procedures
because the large sternotomy incision required to access the heart requires general
endotracheal anesthesia (GETA) and the heart–lung machine that is required for
open-heart surgery (e.g. valve repair) adds further morbidity (Mack: JAMA 14 Au2
285:568–572, 2001; Borst and Grundeman: Circulation 99:1400–1403,1999). We
have developed a novel, highly articulated robotic surgical system (CardioARM) to
enable minimally invasive intrapericardial therapeutic delivery through a subxiphoid approach. The CardioARM is a robotic surgical system consisting of serially
connected rigid cylindrical links housing flexible working ports through which
catheter-based tools for therapy and imaging can be advanced. The CardioARM
is controlled via a computer-driven user interface which is operated outside of the
operative field. We believe single port access to be key to the success of the
CardioARM. We have performed preliminary proof of concept studies in a porcine
preparation by performing epicardial ablation.
Chapter 13 - Wireless Intraocular Microrobots: Opportunities and Challenges
Olgac¸ Ergeneman, Christos Bergeles, Michael P. Kummer, Jake J. Abbott,, and Bradley J. Nelson
Abstract - Many current and proposed retinal procedures are at the limits of human
performance and perception. Microrobots that can navigate the fluid in the interior
of the eye have the potential to revolutionize the way the most difficult retinal
procedures are conducted. Microrobots are typically envisioned as miniature
mechatronic systems that utilize MEMS technology to incorporate sensing and
actuation onboard. This chapter presents a simpler alternative approach for the
development of intraocular microrobots consisting of magnetic platforms and
functional coatings. Luminescence dyes immobilized in coatings can be excited
and read wirelessly to detect analytes or physical properties. Drug coatings can be
used for diffusion-based delivery, and may provide more efficient therapy than
microsystems containing pumps, as diffusion dominates over advection at the
microscale. Oxygen sensing for diagnosis and drug therapy for retinal vein occlusions are presented as example applications. Accurate sensing and therapy requires
precise control to guide the microrobot in the interior of the human eye. We require
an understanding of the possibilities and limitations in wireless magnetic control.
We also require the ability to visually track and localize the microrobot inside the
eye, while obtaining clinically useful retinal images. Each of these topics is
discussed.
Chapter 14 - Single and Multiple Robotic Capsules for Endoluminal Diagnosis and Surgery
Arianna Menciassi, Pietro Valdastri, Kanako Harada, and Paolo Dario
Abstract - The present chapter illustrates robotic approaches to endolomuninal
diagnosis and therapy of hollow organs of the human body, with a specific reference
to the gastrointestinal (GI) tract. It gives an overview of the main technological and
medical problems to be approached when dealing with miniaturized robots having a
pill-like size, which are intended to explore the GI tract teleoperated by clinicians
with high precision, flexibility, effectiveness and reliability. Considerations on
different specifications for diagnostic and surgical swallowable devices are presented, by highlighting problems of power supply, dynamics, kinematics and
working space. Two possible solutions are presented with details about design
issues, fabrication and testing: the first solution consists of the development of
active capsules, 2–3 cm 15 3 in volume, for teleoperated diagnosis in the GI tract; the
second solution illustrates a multiple capsule approach allowing to overcome power
supply and working space problems, that are typical in single capsule solutions.
Chapter 15 - Visual Guidance of an Active Handheld Microsurgical Tool
Brian C. Becker, Sandrine Voros, Robert A. MacLachlan, Gregory D. Hager, and Cameron N. Riviere
Abstract - In microsurgery, a surgeon often deals with anatomical structures of sizes
that are close to the limit of the human hand accuracy. Robotic assistants can help to
push beyond the current state of practice by integrating imaging and robot-assisted
tools. This paper demonstrates control of a handheld tremor reduction micromanipulator with visual servo techniques, aiding the operator by providing three behaviors: “snap-to”, motion scaling, and standoff regulation. A stereo camera setup
viewing the workspace under high magnification tracks the tip of the micromanipulator and the object being manipulated. Individual behaviors are activated in task
specific situations when the micromanipulator tip is in the vicinity of the target. We
show that the snap-to behavior can reach and maintain a position at a target with
Root Mean Squared Error (RMSE) of 17.5 - 0.4 mm between the tip and target.
Scaling the operator’s motions and preventing unwanted contact with non-target
objects also provides a larger margin of safety.
Chapter 16 - Swimming Micro Robots for Medical Applications
Gbor Kosa and Gbor SzOkely
Abstract - We review micro-systems with robotic aspects that are used in medical diagnosis and intervention. We describe the necessary components for a micro-
robot and present the state of the art and gaps of knowledge. One of the great
challenges in micro robots is the propulsion. Different propulsive strategies and
specifically flagellar propulsion is evaluated in this chapter. We analyze the influence of the miniaturization on the micro-robot and try to estimate the future
developments in the field.
Chapter 17 - Flagellated Bacterial Nanorobots for Medical Interventions in the Human Body
Sylvain Martel
for such applications. In this chapter, we introduce the concept and show the advantages of integrating biological components and more specifically Magneto tactic Bacteria (MTB) for the development of hybrid nanorobots, i.e., nanorobots made of synthetic and biological nanoscale components, designed to operate efficiently in the human microvascular network. Similarly, the chapter shows the advantage of using Magnetic Resonance Imaging (MRI) as an imaging modality to control and track such medical nanorobots when operating inside the complex human vascular network. The chapter also presents preliminary experimental results suggesting the feasibility of guiding and controlling these nanorobots directly towards specific locations deep inside the human body.
Part 3 - Engineering Developments
Chapter 18 - Force Feedback and Sensory Substitution for Robot-Assisted Surgery
Allison M. Okamura, Lawton N. Verner, Tomonori Yamamoto James C. Gwilliam,, and Paul G. Griffiths
Abstract - It is hypothesized that the lack of haptic (force and tactile) feedback
presented to the surgeon is a limiting factor in the performance of teleoperated
robot-assisted minimally invasive surgery. This chapter reviews the technical challenges of creating force feedback in robot-assisted surgical systems and describes
recent results in creating and evaluating the effectiveness of this feedback in mock
surgical tasks. In the design of a force-feedback teleoperator, the importance of
hardware design choices and their relationship to controller design are emphasized.
In addition, the practicality and necessity of force feedback in all degrees of freedom
of the teleoperator are considered in the context of surgical tasks and the operating
room environment. An alternative to direct force feedback to the surgeon’s hands is
sensory substitution/augmented reality, in which graphical displays are used to
convey information about the forces between the surgical instrument and the patient,
or about the mechanical properties of the patient’s tissue. Experimental results
demonstrate that the effectiveness of direct and graphical force feedback depend
on the nature of the surgical task and the experience level of the surgeon.
Chapter 19 - Tactile Feedback in Surgical Robotics
Martin O. Culjat, James W. Bisley, Chih-Hung King
Christopher Wottawa, Richard E. Fan, Erik P. Dutson,
Warren S. Grundfest
Abstract - While commercial surgical robotic systems have provided improvements
to minimally invasive surgery, such as 3D stereoscopic visualization, improved
range of motion, and increased precision, they have been designed with only limited
haptic feedback. A number of robotic surgery systems are currently under develop
ment with integrated kinesthetic feedback systems, providing a sense of resistance
to the hands or arms of the user. However, the application of tactile feedback
systems has been limited to date. The challenges and potential benefits associated
with the development of tactile feedback systems to surgical robotics are discussed.
A tactile feedback system, featuring piezoresistive force sensors and pneumatic
silicone-based balloon actuators, is presented. Initial tests with the system mounted
on a commercial robotic surgical system have indicated that tactile feedback may
potentially reduce grip forces applied to tissues and sutures during robotic surgery,
while also providing high spatial and tactile resolution.
Chapter 20 - Robotic Techniques for Minimally Invasive Tumor Localization
Michael D. Naish, Rajni V. Patel, Ana Luisa Trejos
Melissa T. Perri,, and Richard A. Malthaner
Abstract - The challenges imposed by Minimally Invasive Surgery (MIS) have
been the subject of significant research in the last decade. In the case of cancer
surgery, a significant limitation is the inability to effectively palpate the target
tissue to localize tumor nodules for treatment or removal. Current clinical
technologies are still limited and tumor localization efforts often result in the
need to increase the size of the incision to allow finger access for direct palpation.
New methods of MIS tumor localization under investigation involve restoring the
sense of touch, or haptic feedback. The two most commonly investigated modes of
haptic perception include kinesthetic and tactile sensing, each with its own
advantages and disadvantages. Work in this area includes the development of
customized instruments with embedded sensors that aim to solve the problem
of limited haptic feedback in MIS. This chapter provides a review of the work to
date in the use of kinesthetic and tactile sensing information in MIS for tissue
palpation, with the goal of highlighting the benefits and limitations of each mode
when used to locate hidden tumors during MIS.
Chapter 21 - Motion Tracking for Beating Heart Surgery
Rogerio Richa, Antonio P. L. Bo, and Philippe Poignet
Abstract -
Chapter 22 - Towards the Development of a Robotic System for Beating Heart Surgery
øzkan Bebek and M. Cenk Cavusoglu
Abstract - The use of intelligent robotic tools promises an alternative and superior
way of performing off-pump coronary artery bypass graft (CABG) surgery. In the
robotic-assisted surgical paradigm proposed, the conventional surgical tools are
replaced with robotic instruments, which are under direct control of the surgeon
through teleoperation. The robotic tools actively cancel the relative motion between
the surgical instruments and the point-of-interest on the beating heart, in contrast to
traditional off-pump CABG where the heart is passively constrained to dampen the
beating motion. As a result, the surgeon operates on the heart as if it were stationary.
We call the proposed algorithm “Active Relative Motion Cancelling” (ARMC) to
emphasize the active cancellation. This chapter will provide a review of our
research towards developing robotic tools for off-pump CABG surgery. First, we
will explain the algorithm we have developed to achieve effective motion cancellation. Second, we will explain the necessary sensory system for the beating heart
surgery and the developed whisker sensors to detect three-dimensional heart
motion. Third, we will explain the millirobotic gripper developed for minimal
invasive surgery. Finally, we will outlay the overall system design for robotic-
assisted beating heart surgery.
Chapter 23 - Robotic Needle Steering: Design, Modeling, Planning,
and Image Guidance
Noah J. Cowan, Ken Goldberg, Gregory S. Chirikjian,
Gabor Fichtinger, Ron Alterovitz, Kyle B. Reed,
Vinutha Kallem, Wooram Park, Sarthak Misra,
Allison M. Okamura
Abstract - This chapter describes how advances in needle design, modeling,
planning, and image guidance make it possible to steer flexible needles from
outside the body to reach specified anatomical targets not accessible using tradi
tional needle insertion methods. Steering can be achieved using a variety of
mechanisms, including tip-based steering, lateral manipulation, and applying forces
to the tissue as the needle is inserted. Models of these steering mechanisms can
predict needle trajectory based on steering commands, motivating new preoperative
path planning algorithms. These planning algorithms can be integrated with
emerging needle imaging technology to achieve intraoperative closed-loop guidance and control of steerable needles.
Chapter 24 - Macro and Micro Soft-Tissue Biomechanics and
Tissue Damage: Application in Surgical Robotics
Jacob Rosen, Jeff Brown, Smita De, and Blake Hannaford
Abstract - Accurate knowledge of biomechanical characteristics of tissues is essen
tial for developing realistic computer-based surgical simulators incorporating hap
tic feedback, as well as for the design of surgical robots and tools. Most past and
current biomechanical research is focused on soft and hard anatomical structures
that are subject to physiological loading while testing the organs in situ. Internal
organs are different in that respect since they are not subject to extensive loads as
part of their regular physiological function. However, during surgery, a different set
of loading conditions are imposed on these organs as a result of the interaction with
the surgical tools. The focus of the current study was to obtain the structural
biomechanical properties (engineering stress-strain and stress relaxation) of seven
abdominal organs, including bladder, gallbladder, large and small intestines, liver,
spleen, and stomach, using a porcine animal model. The organs were tested in vivo,
in situ, and ex corpus (the latter two conditions being postmortem) under cyclical
and step strain compressions using a motorized endoscopic grasper and a universal
testing machine. The tissues were tested with the same loading conditions commonly applied by surgeons during minimally invasive surgical procedures. Phenomenological models were developed for the various organs, testing conditions,
and experimental devices. A property database—unique to the literature—has been
created that contains the average elastic and relaxation model parameters measured
for these tissues in vivo and postmortem. The results quantitatively indicate the
significant differences between tissue properties measured in vivo and postmortem.
A quantitative understanding of how the unconditioned tissue properties and model
parameters are influenced by time postmortem and loading condition has been
obtained. The results provide the material property foundations for developing
science-based haptic surgical simulators, as well as surgical tools for manual and
robotic systems.
Chapter 25 - Objective Assessment of Surgical Skills
Jacob Rosen, Mika Sinanan, and Blake Hannaford
Abstract - Minimally invasive surgery (MIS) involves a multi-dimensional series
of tasks requiring a synthesis between visual information and the kinematics and
dynamics of the surgical tools. Analysis of these sources of information is a key step
in mastering MIS but may also be used to define objective criteria for characterizing
surgical performance. The BlueDRAGON is a new system for acquiring the
kinematics and the dynamics of two endoscopic tools synchronized with the visual
view of the surgical scene. It includes passive mechanisms equipped with position
and force torque sensors for measuring the position and the orientation (P/O) of two endoscopic tools along with the force and torque (F/T) applied on them by the
surgeon’s hands. The analogy between Minimally Invasive Surgery (MIS) and
human language inspires the decomposition of a surgical task into its primary
elements in which tool/tissue interactions are considered as “words” that have
versions pronunciations defined by the F/T signatures applied on the tissues and
P/O of the surgical tools. The frequency of different elements or “words” and their
sequential associations or “grammar” both hold critical information about
the process of the procedure. Modeling these sequential element expressions
using a multi finite states model (Markov model – MM) reveals the structure of
the surgical task and is utilized as one of the key steps in objectively assessing
surgical performance. The surgical task is modeled by a fully connected, 30 state
Markov model representing the two surgical tools where each state corresponds to a
fundamental tool/tissue interaction based on the tool kinematics and associated with unique F/T signatures. In addition to the MM objective analysis, a scoring protocol
was used by an expert surgeon to subjectively assess the subjects’ technical
performance. The experimental protocol includes seven MIS tasks performed
on an animal model (pig) by 30 surgeons at different levels of training including
expert surgeons. Analysis of these data shows that the major differences between
trainees at different skill levels were: (a) the types of tool/tissue interactions being
used, (b) the transitions between tool/tissue interactions being applied by each hand, (c) time spent while performing each tool/tissue interaction, (d) the overall completion time, and (e) the variable F/T magnitudes being applied by the subjects through the endoscopic tools. An objective learning curve was defined based on measuring quantitative statistical distance (similarity) between MM of experts and MM of residents at different levels of training. The objective learning curve (e.g. statistical distance between MM) was similar to that of the subjective performance analysis. TheMMproved to be a powerful and compact mathematical model for decomposing a complex task such as laparoscopic suturing. Systems like surgical robots or virtual reality simulators in which the kinematics and the dynamics of the surgical tool are inherently measured may benefit from incorporation of the proposed methodology for
Part 4 - Clinical Applications/Overviews
Chapter 26 - Telesurgery: Translation Technology to Clinical Practice
Mehran Anvari
Abstract - The ability to extend the physical reach of a surgeon to treat a patient
urgically in another locality was one of the many promises which came with the
introduction of Robotic and Computer Assisted Technology into the field of surgery
in the late 1970s and early 1980s. In fact, it was the possibility of using a robot as
surgeons’ hands and eyes at a distance which led to some of the major grants from
DARPA, NASA and NIH for the development of the prototypes of the da Vinci and
the Zeus Systems which revolutionized the practice of Robotic and Computer
Assisted Surgery in the late 1990s.
The primary incentive of these agencies for making such investments was to
develop a system to allow them to provide emergency surgical care to the remote
operatives. Others saw parallel uses in enhancing quality of surgical care which can
be provided to settlements in remote parts of the world or at times of major
disasters. And yet another use of telesurgery was an application for practical
knowledge translation and a means for an expert surgeon to effectively achieve
tele-presence during telementoring of another surgeon with acquisition of new
surgical skills. The ability for two surgeons to collaborate across distances during
a surgical act was seen as the ultimate achievement in knowledge translation in
surgery.
It was these promises which sparked the efforts of many surgeons, engineers,
and inventors who dedicated a significant portion of their lives into enhancing the
field of Robotic Telesurgery.
Chapter 27 - History of Robots in Orthopedics
Michael Conditt
Abstract -
Chapter 28 - Robotic-Assisted Urologic Applications
Thomas S. Lendvay and Ryan S. Hsi
Abstract - The clinical use of robotic-assisted laparoscopic surgery has been most prevalent in urologic care. The robotic prostatectomy is the procedure that has
highlighted the potential of robotics. Because this procedure has become so rapidly
embraced, urologists have readily adapted the robotic platform to other procedures
such as radical cystectomy, partial nephrectomy, pediatric reconstructive proce
dures, and now female urologic and fertility procedures. Data on comparative
effectiveness between the robotic, laparoscopic, and open versions of urologic
procedures is still sparse, yet public pressure has forced a demand for access to
robotic urologic care. It remains to be seen if adequate robotic training can keep up
with the exploding need to provide robotic surgery options, but simulation training
is ideally situated to offer a solution to novice trainees and experienced surgeons
who wish to embark on robotic urologic surgery.
Chapter 29 - Applications of Surgical Robotics in Cardiac Surgery
E.J. Lehr, E. Rodriguez,, and W.R. Chitwood
Abstract - Minimally invasive surgery has revolutionized many fields of surgery over
the last two decades. Robotic assisted surgery is the latest iteration towards less
invasive techniques. Cardiac surgeons have slowly adapted minimally invasive and
robotic techniques into their armamentarium. In particular, minimally invasive mitral
valve surgery has evolved over the last decade and become the preferred method of
mitral valve repair and replacement at certain specialized centers worldwide because
of excellent results. We have developed a robotic mitral valve surgery program which
utilizes the da Vinci ® telemanipulation system allowing the surgeon to perform
complex mitral valve repairs through 5 mm port sites rather than a traditional median
sternotomy. In this rapidly evolving field, we review the evolution and clinical results
of robotically-assisted mitral valve surgery and review other cardiac surgical procedures for which da Vinci® is currently being used.
Chapter 30 - Robotics in Neurosurgery
L.N. Sekhar, D. Ramanathan, J. Rosen, L.J. Kim, D. Friedman, D. Glozman, K. Moe, T. Lendvay, and B. Hannaford
Abstract -
Chapter 31 - Applications of Surgical Robotics in Pediatric General Surgery
John Meehan
Abstract -
Chapter 32 - Applications of Surgical Robotics in Gynecologic Surgery
Rabbie K. Hanna and John F. Boggess
Abstract -
Chapter 33 - Applications of Surgical Robotics in General Surgery
Ozanan Meireles and Santiago Horgan
Abstract -
