Miniature robots can assist in Laparoscopic cholecystectomy

A multi-camera, multi-view system for training and skill assessment for robot-assisted surgery

PURPOSE

This paper introduces the concept of using an additional intracorporeal camera for the specific goal of training and skill assessment and explores the benefits of such an approach. This additional camera can provide an additional view of the surgical scene, and we hypothesize that this additional view would improve surgical training and skill assessment in robot-assisted surgery.

METHODS

We developed a multi-camera, multi-view system, and we conducted two user studies ([Formula: see text]) to evaluate its effectiveness for training and skill assessment. In the training user study, subjects were divided into two groups: a single-view group and a dual-view group. The skill assessment study was a within-subject study, in which every subject was shown single- and dual view recorded videos of a surgical training task, and the goal was to count the number of errors committed in each video.

RESULTS

The results show the effectiveness of using an additional intracorporeal camera view for training and skill assessment. The benefits of this view are modest for skill assessment as it improves the assessment accuracy by approximately 9%. For training, the additional camera view is clearly more effective. Indeed, the dual-view group is 57% more accurate than the single-view group in a retention test. In addition, the dual-view group is 35% more accurate and 25% faster than the single-view group in a transfer test.

CONCLUSION

A multi-camera, multi-view system has the potential to significantly improve training and moderately improve skill assessment in robot-assisted surgery. One application of our work is to include an additional camera view in existing virtual reality surgical training simulators to realize its benefits in training. The views from the additional intracorporeal camera can also be used to improve on existing surgical skill assessment criteria used in training systems for robot-assisted surgery.

Development of an in vivo visual robot system with a magnetic anchoring mechanism and a lens cleaning mechanism for laparoendoscopic single-site surgery (LESS)

BACKGROUND

Surgical robot systems which can significantly improve surgical procedures have been widely used in laparoendoscopic single-site surgery (LESS). For a relative complex surgical procedure, the development of an in vivo visual robot system for LESS can effectively improve the visualization for surgical robot systems.

METHODS

In this work, an in vivo visual robot system with a new mechanism for LESS was investigated. A finite element method (FEM) analysis was carried out to ensure the safety of the in vivo visual robot during the movement, which was the most important concern for surgical purposes. A master-slave control strategy was adopted, in which the control model was established by off-line experiments.

RESULTS

The in vivo visual robot system was verified by using a phantom box. The experiment results show that the robot system can successfully realize the expected functionalities and meet the demands of LESS.

CONCLUSION

The experiment results indicate that the in vivo visual robot with high manipulability has great potential in clinical application.

In Vivo Robotic Laparoscopy

Laparoscopy reduces patient trauma but limits the surgeon's ability to view or touch the surgical environment directly. The surgeon's ability to visualize and manipulate target organs can be improved using currently available external robotic systems. However, tool tip orientation and optimal camera placement remain limited because the robot instruments and cameras are still constrained by the entry incisions. Placing a robot completely within the abdominal cavity would provide an unconstrained platform that could provide an enhanced field of view from arbitrary angles and dexterous manipulators not constrained by the abdominal wall fulcrum effect. Several in vivo robots have been developed and successfully tested in a porcine model. These in vivo robots have been used to observe trocar and tool insertions and placement, and to provide additional camera angles that improved surgical visualization. Equipped with a grasper, such robots will provide task assistance. These in vivo robots will be much less expensive than the current generation of large external robotic surgical systems and will ultimately allow a surgeon to be a remote first responder irrespective of the location of the patient.

Preliminary design of an actuated imaging probe for generation of additional visual cues in a robotic surgery

BACKGROUND

The aim of this study was to enhance the visual feedback of surgeons, during robotic surgeries, by designing and developing an actuated 2D imaging probe, which is used in conjunction with the traditional stereoscopic camera of the da Vinci surgical system. The probe provides the surgeon with additional visual cues, overcoming visualization constraints encountered during certain scenarios of robot-assisted minimally invasive surgery.

METHODS

The actuated imaging probe is implemented as a master-slave tele-manipulated system, and it is designed to be compatible with the da Vinci surgical system. The detachable probe design enables it to be mounted on any of the EndoWrist(®) instruments of the robot and is controlled by the surgeon using a custom-made pedal system. The image from the 2D probe is rendered along with the stereoscopic view on the surgeon's console.

RESULTS

The experimental results demonstrate the effectiveness of the proposed actuated imaging probe when used as an additional visualization channel and in surgical scenarios presenting visual problems due to tissue occlusion.

CONCLUSION

The study shows the potential benefits of an additional actuated imaging probe when used in conjunction with traditional surgical instruments to perform surgical tasks requiring visualization from multiple orientations and workspaces.

Miniature Surgical Robots in the Era of NOTES and LESS

Laparoscopy is an established method for the treatment of numerous surgical conditions. Natural orifice transluminal endoscopic surgery (NOTES) is a novel surgical technique that uses the natural orifices of the human body as entrances to the abdominal cavity. An alternative concept of minimally invasive approach to the abdominal cavity is to insert all the laparoscopic instruments through ports using a single small incision on the abdominal wall. A suggested name for this technique is laparoendoscopic single-site surgery (LESS). Considering the technical difficulties in NOTES and LESS and the progress in informatics and robotics, the use of robots seems ideal. The aim of this study is to investigate if there is at present, a realistic possibility of using miniature robots in NOTES or LESS in daily clinical practice. An up-to-date review on in vivo surgical miniature robots is made. A Web-based research of the English literature up to March 2013 using PubMed, Scopus, and Google Scholar as search engines was performed. The development of in vivo miniature robots for use in NOTES or LESS is a reality with great advancements, potential advantages, and possible application in minimally invasive surgery in the future. However, true totally NOTES or LESS procedures on humans using miniature robots either solely or as assistance, remain a dream at present.

Miniature Surgical Robots in the Era of NOTES and LESS

Laparoscopy is an established method for the treatment of numerous surgical conditions. Natural orifice transluminal endoscopic surgery (NOTES) is a novel surgical technique that uses the natural orifices of the human body as entrances to the abdominal cavity. An alternative concept of minimally invasive approach to the abdominal cavity is to insert all the laparoscopic instruments through ports using a single small incision on the abdominal wall. A suggested name for this technique is laparoendoscopic single-site surgery (LESS). Considering the technical difficulties in NOTES and LESS and the progress in informatics and robotics, the use of robots seems ideal. The aim of this study is to investigate if there is at present, a realistic possibility of using miniature robots in NOTES or LESS in daily clinical practice. An up-to-date review on in vivo surgical miniature robots is made. A Web-based research of the English literature up to March 2013 using PubMed, Scopus, and Google Scholar as search engines was performed. The development of in vivo miniature robots for use in NOTES or LESS is a reality with great advancements, potential advantages, and possible application in minimally invasive surgery in the future. However, true totally NOTES or LESS procedures on humans using miniature robots either solely or as assistance, remain a dream at present.

Modular Assembly Micro-Robots for Natural Orifice Transluminal Endoscopic Surgery

Surgical operations are progressively being performed using minimally invasive techniques. Natural Orifice Transluminal Endoscopic Surgery (NOTES) is a novel surgical technique that uses the natural orifices of the human body in order to approach the peritoneal cavity. There are two basic types of robotics for NOTES; the external robots that stay outside the patient but act inside the abdominal cavity, and the internal robots that stay and act in the abdomen. The internal robots could only be mini-robots. The development of modular assembling reconfigurable micro-robots is a revolutionary idea for the NOTES. Modular micro-robots consist of small subunits which could be assembled and construct a functional miniature robot. These surgical micro-robots may increase the possibility for true scarless tele-surgery. Although specific applications of intrabdominal surgical micro-robots are still in an early concept stage, the field is rapidly evolving. In the future, patients may be operated by specialized micro-robotic intrabdominal surgeons.

3-D operation situs reconstruction with time-of-flight satellite cameras using photogeometric data fusion

Minimally invasive procedures are of growing importance in modern surgery. Navigation and orientation are major issues during these interventions as conventional endoscopes only cover a limited field of view. We propose the application of a Time-of-Flight (ToF) satellite camera at the zenith of the pneumoperitoneum to survey the operation situs. Due to its limited field of view we propose a fusion of different 3-D views to reconstruct the situs using photometric and geometric information provided by the ToF sensor. We were able to reconstruct the entire abdomen with a mean absolute mesh-to-mesh error of less than 5 mm compared to CT ground truth data, at a frame rate of 3 Hz. The framework was evaluated on real data from a miniature ToF camera in an open surgery pig study and for quantitative evaluation with a realistic human phantom. With the proposed approach to operation situs reconstruction we improve the surgeons' orientation and navigation and therefore increase safety and speed up surgical interventions.

Modular Assembly Micro-Robots for Natural Orifice Transluminal Endoscopic Surgery, the Future of Minimal Invasive Surgery

Surgical operations are progressively being performed using minimally invasive techniques. Natural Orifice Transluminal Endoscopic Surgery (NOTES) is a novel surgical technique that uses the natural orifices of the human body in order to approach the peritoneal cavity. There are two basic types of robotics for NOTES; the external robots that stay outside the patient but act inside the abdominal cavity, and the internal robots that stay and act in the abdomen. The internal robots could only be mini-robots. The development of modular assembling reconfigurable micro-robots is a revolutionary idea for the NOTES. Modular micro-robots consist of small subunits which could be assembled and construct a functional miniature robot. These surgical micro-robots may increase the possibility for true scarless tele-surgery. Although specific applications of intrabdominal surgical micro-robots are still in an early concept stage, the field is rapidly evolving. In the future, patients may be operated by specialized micro-robotic intrabdominal surgeons.

Robotic platforms for general and colorectal surgery

Surgeons are increasingly turning to new technologies to help them overcome the barriers imposed by minimally invasive surgery (MIS). Robotics is an enabling technology with obvious applications to MIS. This manuscript looks at robotic platforms for general surgical application and explores the advantages, limitations and possible future roles.

A new, safer, controllable field-of-view endoscope avoiding movement inside body cavities

One of the greatest difficulties in endoscopic surgery is the limited field-of-view (FOV) of endoscopes. During endoscopic manipulation in body cavities to expand the FOV, there is the risk of inadvertent damage to body tissues, nerves, and internal organs. The risk increases especially in surgery that is performed inside a very small cavity, or in which body tissues are very fragile. To overcome these issues, we developed a novel endoscope that can provide various FOVs without moving or bending the endoscope itself inside the body cavity and investigated the feasibility of using the new endoscope in vivo. A beam splitter was used to visualize both forward and side views, and two polarization plates and observation windows were used to avoid overlap of the two views. An endoscope having a 7-mm diameter was fabricated through which both views were clearly visualized in vivo. It took only 0.7s to change the FOV with high repeatability, with a maximum distance error of 2.8%. The new endoscope can provide forward and panoramic views without moving the endoscope; therefore, the risk of inadvertent damage to fragile body tissues can be significantly decreased.

In vivo miniature robots for natural orifice surgery: State of the art and future perspectives

Natural orifice translumenal endoscopic surgery (NOTES) is the integration of laparoscopic minimally invasive surgery techniques with endoscopic technology. Despite the advances in NOTES technology, the approach presents several unique instrumentation and technique-specific challenges. Current flexible endoscopy platforms for NOTES have several drawbacks including limited stability, triangulation and dexterity, and lack of adequate visualization, suggesting the need for new and improved instrumentation for this approach. Much of the current focus is on the development of flexible endoscopy platforms that incorporate robotic technology. An alternative approach to access the abdominal viscera for either a laparoscopic or NOTES procedure is the use of small robotic devices that can be implanted in an intracorporeal manner. Multiple, independent, miniature robots can be simultaneously inserted into the abdominal cavity to provide a robotic platform for NOTES surgery. The capabilities of the robots include imaging, retraction, tissue and organ manipulation, and precise maneuverability in the abdominal cavity. Such a platform affords several advantages including enhanced visualization, better surgical dexterity and improved triangulation for NOTES. This review discusses the current status and future perspectives of this novel miniature robotics platform for the NOTES approach. Although these technologies are still in pre-clinical development, a miniature robotics platform provides a unique method for addressing the limitations of minimally invasive surgery, and NOTES in particular.

Insertable Surgical Imaging Device with Pan, Tilt, Zoom, and Lighting

In this paper we describe work we have done in developing an insertable surgical imaging device with multiple degrees of freedom for minimally invasive surgery. The device is fully insertable into the abdomen using standard 12 mm trocars. It consists of a modular camera and lens system which has pan and tilt capability provided by two small DC servo motors. It also has its own integrated lighting system that is part of the camera assembly. Once the camera is inserted into the abdomen, the insertion port is available for additional tooling, motivating the idea of single-port surgery. A third zoom axis has been designed for the camera as well, allowing close-up and far-away imaging of surgical sites with a single camera unit. In animal tests with the device we have performed surgical procedures including cholecystectomy, appendectomy, running (measuring) the bowel, suturing, and nephrectomy. Preliminary tests suggest that the new device may have advantages over a standard laparoscope including the following.

• Low-cost and simple design.

• Easier and more intuitive to use than a standard laparoscope.

• Joystick operation requires no specialized operator training.

• Pan/tilt functions provide a large imaging volume not restricted by the fulcrum point of standard laparoscope.

• Time to perform procedures was better than or equivalent to a standard laparoscope.

We believe these insertable platforms will be an integral part of future surgical systems. The platforms can be used with tooling as well as imaging devices, allowing many surgical procedures to be performed using such a system.

In vivo microrobots for natural orifice transluminal surgery. Current status and future perspectives

The possibility to operate inside the peritoneal cavity through small holes performed in hollow organs that is presented by Natural Orifice Transluminal Endoscopic Surgery (NOTES) represents a major paradigm shift in general surgery. While this new approach seems very appealing from patients' perspectives because it eliminates completely abdominal wall aggression and promises to reduce postoperative pain, it is very challenging for surgeons because of the major constraints imposed by both the mode of access and the limited technology currently available. For this reason NOTES applications at the present time are performed by only a few surgeons and mainly to perform non-complex procedures. While new devices are under development, many of them are trying mainly to simply improve current endoscopic platforms and seem not to offer breakthrough solutions. The numerous challenges introduced by natural orifice approaches require a radical shift in the conception of new technologies in order to make this emerging operative access safe and reproducible. The convergence of several enabling technologies in the field of miniaturization, communication and micro-mechatronics brings the possibility to realize on a large scale the revolutionary concept of miniature in vivo co-operative robots. These robots provide vision and task assistance without the constraints of the entry incision and have been shown in experimental settings to possess many qualities that could be ideal to partner with Natural Orifice Surgery. This article explores the current status of microrobotics as well as presents potential future scenarios of their applications in NOTES.

Robotic Oncological Surgery: Technology That's Here to Stay?

A robot functioning in an environment may exhibit various forms of behavior emerge from the interaction with its environment through sense, control and plan activities. Hence, this paper introduces a behaviour selection based navigation and obstacle avoidance algorithm with effective method for adapting robotic behavior according to the environment conditions and the navigated terrain. The developed algorithm enable the robot to select the suitable behavior in real-time to avoid obstacles based on sensory information through visual and ultrasonic sensors utilizing the robot's ability to step over obstacles, and move between surfaces of different heights. In addition, it allows the robot to react in appropriate manner to the changing conditions either by fine-tuning of behaviors or by selecting different set of behaviors to increase the efficiency of the robot over time. The presented approach has been demonstrated on quadruped robot in several different experimental environments and the paper provides an analysis of its performance.

Visual exposure using single-handed magnet-driven intra-abdominal wireless camera in minimal access surgery: is better than 30 degrees endoscope

BACKGROUND

The operative field of view in minimal access surgery is constrained by the location of the optical port, the direction of view of the endoscope, and the limited degrees of freedom of movement of rigid endoscopes through the access port. The aim of this study was to examine the feasibility of employing a special magnetic setup with a single external handle to fixate, drive, and orientate intra-abdominal wireless camera, and compare its visual exposure with that of a 30 degrees endoscope.

METHODS

A wireless magnet-driven camera setup was developed comprising a mini wireless camera with integrated white light-emitting diodes, a specially constructed base unit for orientation control and smooth sliding motion, and an external magnetic handle to fixate and drive the camera from the outer surface of the abdominal wall. In a laboratory-based experiment, ten subjects with no laparoscopic surgical experience were asked to identify 160 randomly distributed labels in a trainer box using both a 30 degrees endoscope and the wireless camera magnetic setup in a random order. Data were analyzed using Student's t-test.

RESULTS

The mean (standard deviation) of the number of identified labels was higher using the wireless camera magnetic setup 74.8 (16.96) compared with 30 degrees endoscope 54.7 (12.18); p \ 0.001. However, the mean execution time was longer with the camera magnetic system 34.9 (4.4) min compared with the 30 degrees endoscope 24.1 (2.8) min; p \ 0.001.

CONCLUSION

The use of the magnetic wireless camera setup with a single external handle is feasible and has demonstrated a wider visual exposure than the 30 degrees endoscope.

The current state of miniature in vivo laparoscopic robotics

Minimally invasive surgery (MIS) reduces patient trauma and shortens recovery time, but also limits the dexterity of the surgeon because degrees of freedom are lost due to the fulcrum effect of the entry incisions. Visual feedback is also limited by the laparoscope, which typically provides two-dimensional feedback and is constrained by the entry incision. Developments within surgical robotics aim to mitigate these constraints. However, these developments have primarily included large external machines that augment vision and improve dexterity, but are still fundamentally constrained by the use of long tools through small incisions. An alternative concept is the use of miniature in vivo surgical robots that can be placed entirely into the peritoneal cavity through either an abdominal incision, or, after insertion into the stomach through the esophagus, can enter through a gastrotomy. This paper reviews the development of fixed-base camera robots for providing auxiliary views of the surgical field and of mobile robots with a movable platform for vision and task assistance in laparoscopic procedures. Moreover, the progress towards the application of similar robots for natural orifice transluminal endoscopic surgery (NOTES) and forward environments is discussed.

Robotic applications in abdominal surgery: their limitations and future developments

BACKGROUND

In the past 20 years, the technical aspects of abdominal surgery have changed dramatically. Operations are now routinely performed by laparoscopic techniques utilizing small abdominal incisions, with less patient discomfort, earlier recovery, improved cosmesis, and in many cases reduced economic burden on the healthcare provider. These benefits have largely been seen in the application of laparoscopic techniques to relatively straightforward procedures. It is not clear whether the same benefits carry through to more complex abdominal operations, which are more technically demanding and for which current laparoscopic instrumentation is less well adapted. The aim of surgical robotics is to address these problems and allow the advantages of minimal access surgery to be seen in a greater range of operations.

METHODS

A literature search was performed to ascertain the current state of the art in surgical robotics for the abdomen, and the technologies emerging within this field. The reference lists of the sourced articles were also searched for further relevant papers.

RESULTS

Currently available robotic devices for abdominal surgery are limited to large, costly 'slave-master' or telemanipulator systems, such as the da Vinci (Intuitive Surgical, Sunny Vale, CA). In addition to their size and expense, these systems share the same limitation, by virtue of the fulcrum effect on instrument manipulation inherent in the use of ports by which external instruments gain access to the abdominal cavity. In order to overcome these limitations several smaller telemanipulator systems are being developed, and progress towards freely mobile intracorporeal devices is being made.

CONCLUSIONS

While current robotic systems have considerable advantages over conventional laparoscopic techniques, they are not without limitations. Miniaturisation of robotic components and systems is feasible and necessary to allow minimally invasive techniques to reach full potential. The ultimate extrapolation of this progress is the development of intracorporeal robotics, the feasibility of which has been demonstrated.

Education and research using experimental pigs in a medical school

Medium-sized animals such as miniature pigs are considered to be important for education and training in medical schools to master the skills required in surgical treatment. Much still remains to be done to establish total management for animal experiments using pigs. Improvement of the effective utilization of pigs is also required from the economical and ethical points of view. We have been providing a support system at a facility for experimental animals in a medical school for 3 years, and herein we introduce our personal experiments as an instructional lecture. Before starting surgical training using live pigs, sufficient education concerning animal ethics and dry laboratory training was completed. Four kinds of miniature pigs have been used as experimental animals; porcine rearing pens have been improved and a postoperative care system has been implemented. Moreover, staff at the center offer a preoperative service of anesthesia for surgical education, training, and research. Chronic experiments have increased to represent 35% and 48% of experiments using pigs in 2003 and 2004, respectively. Experimental pigs have undergone secondary use after being killed to reduce the number of animals used in experiments. Sharing and reuse have allowed effective use of miniature pig tissues and cells for research, and have reduced the number of animals used. We recommend that researchers consider use of our total systems because they can improve the quality of medical education and research and facilitate effective use of tissues and cells by sharing and reuse among different departments.

In vivo laparoscopic robotics

Robotic laparoscopic surgery is evolving to include in vivo robotic assistants. The impetus for the development of this technology is to provide surgeons with additional viewpoints and unconstrained manipulators that improve safety and reduce patient trauma. A family of these robots have been developed to provide vision and task assistance. Fixed-base and mobile robots have been designed and tested in animal models with much success. A cholecystectomy, prostatectomy, and nephrectomy have all been performed with the assistance of these robots. These early successful tests show how in vivo laparoscopic robotics may be part of the next advancement in surgical technology.

Mobile in vivo camera robots provide sole visual feedback for abdominal exploration and cholecystectomy

The use of small incisions in laparoscopy reduces patient trauma, but also limits the surgeon's ability to view and touch the surgical environment directly. These limitations generally restrict the application of laparoscopy to procedures less complex than those performed during open surgery. Although current robot-assisted laparoscopy improves the surgeon's ability to manipulate and visualize the target organs, the instruments and cameras remain fundamentally constrained by the entry incisions. This limits tool tip orientation and optimal camera placement. The current work focuses on developing a new miniature mobile in vivo adjustable-focus camera robot to provide sole visual feedback to surgeons during laparoscopic surgery. A miniature mobile camera robot was inserted through a trocar into the insufflated abdominal cavity of an anesthetized pig. The mobile robot allowed the surgeon to explore the abdominal cavity remotely and view trocar and tool insertion and placement without entry incision constraints. The surgeon then performed a cholecystectomy using the robot camera alone for visual feedback. This successful trial has demonstrated that miniature in vivo mobile robots can provide surgeons with sufficient visual feedback to perform common procedures while reducing patient trauma.