The Encyclopedia of Medical Robotics

The following sections are included:

• PREFACE
• ABOUT THE EDITOR
• CONTENTS

The da Vinci^® Surgical System is a platform for robot-assisted minimally invasive surgery (RAMIS). This chapter provides an overview of the design of the da Vinci System, as well as several of its key subsystems for vision, tissue manipulation, anatomical access, and operator technology training. Clinical adoption of the system to date is described briefly, and we leave the reader with some thoughts on possible future development directions.

The most common application of surgical robotics worldwide is for radical prostatectomy in the treatment of prostate cancer. This operation is very well suited for a minimally invasive robot-assisted surgery due to the location of the prostate within the male pelvis. Additionally, this is a technically challenging operation and surgical technique matters for cancer control, as well as functional outcomes including the return of continence and erection function for patients. The da Vinci robot has been utilized over the last 15 years with good results. Cost remains a challenging issue for wide spread application of robot-assisted radical prostatectomy. Future improvements with image integration will improve surgeons’ ability to perform this procedure.

Ever since the 1980s when the minimal access approach through a mini-anterior thoracotomy was introduced for the bypass of the left anterior descending (LAD) coronary artery, minimally invasive cardiac surgery has continued to develop. Endoscopic surgery was introduced in the 1990s and it became apparent that the available endoscopic instruments had limitations in performing the tasks required in cardiac surgical procedures. The conventional instruments were rigid tools with only 4 degrees of freedom that moved and rotated along 2 axes only. Hence, they were mainly used for excisional procedures and not appropriate to enable microscopic reconstructive procedures required in cardiac surgery. In addition, the available endoscopic cameras transmitted a two-dimensional image. In cardiac surgery, it was essential to have the binocular vision and depth perception to accomplish the required tasks safely. Therefore, there was a demand for innovation in cardiac surgery to perform minimally invasive cardiac surgery and satisfy the demand of the consumer-minded patients seeking more minimally invasive cardiac surgery. The development of robotic surgical systems or computer-assisted surgery allowed the surgeon to overcome the limitations in minimally invasive cardiac surgery. The digital interface between the surgeons’ hands and the robotic instruments enhanced the surgical technical ability and enabled endoscopic microsurgery that is required in cardiac surgery. In this chapter, we illustrate two robotic-assisted cardiac surgical procedures: coronary artery bypass surgery and valvular surgery.

Minimally invasive surgery represents a revolution in the care of the surgical patient. The perceived benefits of smaller scars, less pain, shorter hospital stay and faster recovery led surgeons to continually push the envelope of what could be accomplished with the laparoscope. While patient benefits accrued, the challenge of increasing complex procedures and the clear ergonomic disadvantages of laparoscopic surgery have taken their toll on clinical penetration and surgeon well-being. The advent of surgical robotics addresses many, but not all, of the shortcomings presented by laparoscopy as a result of improved dexterity and visualization. This chapter reviews the background and clinical applications for robotic-assisted minimally invasive gastrointestinal surgery, including foregut, hindgut and hepatopancreaticobiliary surgery. The available evidence is short on superior clinical effectiveness, however, there are clear areas of perceived advantages and areas for further innovation.

This chapter gives a brief overview of the DLR MiroSurge versatile surgical robotic demonstrator, its major components, mechatronic design and control paradigms. Central component is the robot arm Miro based on intelligent mechatronic technology developed at DLR. The system is adapted to various medical applications by attaching various instruments, e.g., the dedicated instrument MICA, and a surgeon workstation providing HD 3D vision and haptic feedback. Furthermore, a selection of current research topics concerning novel MIRS applications and system components are introduced.

Single-port surgery offers a number of advantages over the traditional multiport approaches to minimally invasive surgery (MIS), particularly in terms of less incision related trauma and better cosmetic results. With the use of robotic assistance, some of the detrimental factors associated with single-port surgery can be avoided, resulting in higher precision, enhanced instrument dexterity, improved patient safety and ergonomic control. This chapter presents an overview of commercial and emerging robotic platforms for single-port interventions. It outlines recent technical achievements as well as open challenges to practical clinical translation of robot-assisted single-port surgery. Future research in terms of improved instrumentation, visualization and control are also discussed. The increasing number of robotic platforms for single-port surgery currently under development accelerates the potential clinical uptake of this technology.

Concentric tube robots consist of nested sets of pre-curved elastic tubes that bend and deform one another when they are translated and rotated with respect to each other, resulting in tentacle-like motion. Concentric tube robots are needle-sized devices, which makes them promising instruments for minimally invasive surgical tasks. Their potential has motivated a significant amount of research focused on modeling their behavior, designing their actuation systems and shape to meet application requirements, controlling them in surgical environments, planning their motions in constrained anatomy, and sensing their shape in space for real-time feedback. In this chapter, we present an overview of concentric tube robots’ development for use as both steerable needles and robotic manipulators.

The surgical paradigm of minimally invasive surgery (MIS) has been a key driver to the adoption of robotic surgical assistance. Progress in the last three decades has led to a gradual transition from manual laparoscopic surgery with rigid instruments to robot-assisted surgery. In the last decade, the increasing demand for new surgical paradigms to enable access into the anatomy without skin incision (intraluminal surgery) or with a single skin incision (single-port access SPA surgery) has led researchers to investigate snake-like flexible surgical devices. In this chapter, we first present an overview of the background, motivation, and taxonomy of MIS and its newer derivatives. Challenges of MIS and its newer derivatives (SPA and intraluminal surgery) are outlined along with the architectures of new snake-like robots meeting these challenges. We also examine the commercial and research surgical platforms developed over the years to address the specific functional requirements and constraints imposed by operations in confined spaces. The chapter concludes with an evaluation of open problems in surgical robotics for intraluminal and SPA, and a look at future trends in surgical robot design that could potentially address these unmet needs.

Traditionally, straight and rigid surgical tools have been developed to interface with surgical sites, since they are reliable in their tasks, allow efficient force transmission over a significant length, and are easier to manipulate with less potential for errors and malfunction. However, flexible robots would be instrumental in extending the benefits of minimally invasive surgery, especially in single-port surgery (SPS) and natural orifice transluminal endoscopic surgery (NOTES). Flexible robotic systems offer more dexterity in constrained environment as well as visualization for structures outside the line of sight, and more compliant interaction with the surrounding tissues. State-of-the-art flexible robotic systems have been proposed, developed, and tested in laboratory and clinical settings in both industry and academia. These systems showed promising results in the areas of ear, nose, and throat (ENT), neuro, cardiac, vascular, and gastrointestinal surgery. The chapter also presents research in flexible surgical robots, including robot design and miniaturization, appropriate actuators to control multiple degrees of freedom (DoFs), ability to implement stiffness modulation to enable both soft and rigid modes in the flexible robots, and compatibility with different imaging modalities.

Autonomous surgery involves having surgical tasks performed by a robot operating under its own will, with partial or no human involvement. There are several important advantages of automation in surgery, which include increasing precision of care due to submillimeter robot control, real-time utilization of biosignals for interventional care, improvements to surgical efficiency and execution, and computer-aided guidance under various medical imaging and sensing modalities. While these methods may displace some tasks of surgical teams and individual surgeons, they also present new capabilities in interventions that are too difficult or go beyond the skills of a human. In this chapter, we provide an overview of robot autonomy in commercial use and in research, and present some of the challenges faced in developing autonomous surgical robots.

Haptics, the sense of touch, enables humans to perform a wide variety of exploration and manipulation tasks, including those performed during surgical procedures. In teleoperated robot-assisted surgery, haptic feedback to the surgeon is limited due to challenges in sensing, control, and mechanism design. In addition, the optimal form of haptic feedback is unknown because how the human brain processes and uses the sense of touch is not completely understood. Thus, engineers seeking to add haptic feedback to robot-assisted minimally invasive surgical (RAMIS) systems must develop an understanding of haptics in both engineering and human contexts. This chapter reviews the role of haptics in clinical applications, practical challenges of clinical implementation of haptic feedback, and engineered systems that have been designed to provide direct or substituted kinesthetic (force) and cutaneous (tactile) haptic feedback in research and commercial RAMIS systems.

Teleoperated robotic systems extend human capabilities beyond natural and physical boundaries. As a result, they can be used to perform minimally invasive surgery inside a patient’s body. This is called telerobotics-assisted surgery or telerobotic surgery. The primary goal of this technology is to use position commands at the surgeon’s console (called the “master” robot in teleoperation terminology) to control the patient-side surgical robot (termed the “slave” robot). Currently, surgeons performing telerobotic surgery can monitor the surgery through 3D visual observation. The component that is missing in the telerobotic surgical systems currently approved for patient use is the feel of contact forces generated during surgery. In general, force sensation provides information regarding the nature of physical interactions and tissue characteristics. In conventional manual surgery, the surgeon uses force sensations to (a) find pathological tissue (e.g., tumors) inside organs, (b) monitor the safety of tool-tissue interactions to avoid excessive forces that can cause damage, and (c) ensure surgical control especially in places outside the field of view of the endoscopic camera. The need for force feedback in telerobotic surgery has been studied by several researchers; however, the problem is not fully resolved yet. In this chapter, we review these and other challenges in telerobotic surgery, investigate relevant ongoing research, and discuss possible future directions.

Over the past decade, Robotic Minimally Invasive Surgeries (RMIS) devices have made their presence increasingly felt in operating rooms (ORs) in terms of numbers of deployed systems, diversity of surgical devices and variety of certified procedures. As such RMIS systems proliferate, the need to develop, validate and deploy surgical skill assessment frameworks to facilitate effective training and certification becomes increasingly critical. Hence, in our work, we begin with an overview of the historical perspective on surgical skill assessment before focusing our attention to surgeon-assessment with RMIS systems available on the marketplace. We outline some of the advances and major research challenges in this field, discuss the ongoing advances and quality-improvement efforts prior to discussion of the “as-yet unsolved” problems in skill assessment.

This chapter presents an overview of the current status of training and skills assessment in robotics-assisted minimally invasive surgery (RAMIS). Although significant advances have been achieved in assessing surgical skill in general, only a subset of existing techniques has been applied to RAMIS training. The loss of haptic information that results from the reduced access conditions present in RAMIS compromises the safety of the procedure. This limitation must be overcome through training, however, current methods for determining the skill level of trainees are still lacking. This chapter presents an overview of the current state of the art for the development of techniques and instruments that contribute toward better training methods for surgeons learning RAMIS.

The following section is included:

• INDEX