Robots in the operating theatre—chances and challenges

Intraoperative Surgical Navigation Is as Effective as Conventional Surgery for Zygomaticomaxillary Complex Fracture Reduction

Background/Objectives: Zygomaticomaxillary complex (ZMC) fractures are the second most common of all facial bone fractures, and conventional treatment represents a challenge even for experienced surgeons. The aim of this systematic review and meta-analysis was to compare Intraoperative Surgical Navigation (ISN) with conventional surgery in the treatment of ZMC fractures. Methods: We reported our systematic review and meta-analysis based on the recommendation of the PRISMA 2020 guideline. The electronic search was conducted on 9 February 2025 in two search engines (PubMed and Web of Science) and two databases (Embase and the Cochrane Library). Randomized controlled trials and observational studies were included. The outcome variables were accuracy, operative time, maximum mouth opening, postoperative stay, amount of bleeding, and cheek numbness. The random-effects model was used for the analysis, and the results were given as mean differences and odds ratios with 95% confidence intervals (CI). After duplicate removal, 1961 articles were found. After the selection procedure, five studies were found to be eligible for qualitative and quantitative analysis. Results: There were no statistically significant differences between ISN and conventional surgery regarding the outcomes investigated, except in postoperative average deviation of the zygomatic bone. Our results showed an improvement of 0.64 mm [CI: 0.32, 0.92] zygomatic bone deviation when ISN was used. Conclusions: The results suggest that ISN is as effective as the conventional technique in the treatment of ZMC fractures. However, because of the low number of eligible studies, further randomized controlled trials are necessary to strengthen the level of evidence on this matter.

Robotic technology in surgery; a classification system of soft tissue surgical robotic devices

BACKGROUND

The field of robotic-assisted surgery is rapidly growing as many robotic surgical devices are in development and about to enter the market. Currently, there is no universally accepted language for labeling the different robotic systems. To facilitate this communication, we created what is, to our knowledge, the first classification of surgical robotic technologies that organizes and classifies surgical robots used for endoscopy, laparoscopy and thoracoscopy.

METHODS

We compiled a list of surgical robots intended to be used for endoscopy, laparoscopy, and/or thoracoscopy by searching United States, European, Hong Kong, Japan, and Korean databases for approved devices. Devices showcased at the 2023 Annual Meeting for the Society of Robotic Surgery were added. We also systematically reviewed the literature for any existing surgical robotic classifications or categorizations. We then created a multidisciplinary committee of 8 surgeons and 2 engineers to construct a proposed classification of the devices included in our search.

RESULTS

We identified 40 robotic surgery systems intended to be used for endoscopy, laparoscopy and/or thoracoscopy. The proposed classification organizes robotic devices with regard to architecture, port design, and configuration (modular carts, multi-arm integrated cart, table-attachable or arm-table integration).

CONCLUSION

This 3-level classification of robotic surgical devices used for endoscopy, laparoscopy and/or thoracoscopy describes important characteristics of robotic devices systematically.

Navigating the future of guided dental implantology: A scoping review

BACKGROUND

The aim of this scoping review was to understand the development of robotics and its accuracy in placing dental implants when compared to other forms of guided surgery.

METHODS

An electronic search was conducted on the electronic databases of PubMed, Cochrane, and Science direct with the following queries: ((robotics) AND (dental implant)) AND (accuracy). The search timeline was between 2017 and 2022.

RESULTS

A total of 54 articles were screened for title and abstract, of which 16 were deemed eligible for inclusion. Thirty-one articles were excluded mainly because they were out of topic (not relevant) or not in English. In total, 16 articles were included for analysis.

CONCLUSIONS

This review thoroughly analyses 5 years of literature concerning the evolution of robotics in dental implant surgery, underscoring the necessity for additional research on nascent technologies reported and a comparative study with static and dynamic systems for clinical efficacy evaluation.

Robotic calvarial bone sampling

The aim of this study was to assess the feasibility of complex unicortical calvarial harvesting by using the Cold Ablation Robot-Guided Laser Osteotome (CARLO® primo+). A cadaveric study was performed with a progressive complexity of the bone harvesting. This preliminary study on the cadaveric cranial vault area examined the tracking precision, the strategies, settings and durations of harvesting, the accuracy of the unicortical bone cutting, and the risk of dura exposition. All sampling was realised with no more difficulty than that experienced during the standard procedure. No bicortical cutting occurred during CARLO® primo + robot-guided laser cutting. During the second sampling, dura was partially exposed due to improper angulation of the curved osteotome during harvesting. Complex unicortical calvarial harvesting using robot-guided laser appears to be feasible and safe. In the future, robotic approaches will probably replace current surgical techniques using cutting guides and help reduce intraoperative inaccuracies due to the human factor.

A Novel Precise Optical Navigation System for Craniomaxillofacial Surgery Registered With an Occlusal Splint

BACKGROUND

An augmented reality tool allows visual tracking of real anatomical structures and superimposing virtual images, so it can be used for navigation of important structures during surgery.

OBJECTIVES

The authors have developed a new occlusal splint-based optical navigation system for craniomaxillofacial surgery. In this study, the authors aim to measure the accuracy of the system and further analyze the main factors influencing precision.

METHODS

Ten beagle dogs were selected and a three-dimensional model was established through computed tomography scanning, dental model making, and laser scanning, and then registration was performed according to the tooth marking points. The bilateral mandibular osteotomy was performed on Beagle dogs under navigation system based on the occlusal splint. The left side was taken to compare the deviation between the preoperative plan and the surgical results, and the accuracy of distance and angle and the stability of the system were analyzed.

RESULTS

The average position deviation between the preoperative design and intraoperative navigation was: 0.01 ± 0.73 mm on the lateral height of the mandibular ramus, 0.26 ± 0.57 mm on the inner height of the mandibular ramus, and 0.20 ± 0.51 mm on the osteotomy length. The average angle deviation is 0.94° ± 1.38° on the angle between the mandibular osteotomy plane and ramus plane and 0.66° ± 0.97° on the angle of the retained mandibular angle. And most of the data showed good consistency.

CONCLUSIONS

In summary, the accuracy of the system can meet clinical requirements and can be used as a useful tool to improve the accuracy of craniomaxillofacial surgery.

Application research of master-slave cranio-maxillofacial surgical robot based on force feedback

BACKGROUND

The complex anatomical structure, limited field of vision, and easily damaged nerves, blood vessels, and other anatomical structures are the main challenges of a cranio-maxillofacial (CMF) plastic surgical robot. Bearing these characteristics and challenges in mind, this paper presents the design of a master-slave surgical robot system with a force feedback function to improve the accuracy and safety of CMF surgery.

METHODS

A master-slave CMF surgical robot system based on force feedback is built with the master tactile robot and compact slave robot developed in the laboratory. Model-based master robot gravity compensation and force feedback mechanism is used for the surgical robot. Control strategies based on position increment control and ratio control are adopted. Aiming at the typical mandibular osteotomy in CMF surgery, a scheme suitable for robot-assisted mandibular osteotomy is proposed. The accuracy and force feedback function of the robot system under direct control and master-slave motion modes are verified by experiments.

RESULTS

The drilling experiment of the mandible model in direct control mode shows that the average entrance point error is 1.37 ± 0.30 mm, the average exit point error is 1.30 ± 0.25 mm, and the average posture error is 2.27° ± 0.69°. The trajectory tracking and in vitro experiment in the master-slave motion mode show that the average position following error is 0.68 mm, and the maximum force following error is 0.586 N, achieving a good tracking and force feedback function.

CONCLUSION

The experimental results show that the designed master-slave CMF robot can assist the surgeon in completing accurate mandibular osteotomy surgery. Through force feedback mechanism, it can improve the interaction between the surgeon and the robot, and complete tactile trajectory movements.

Present and Future Trends in Transoral Surgical Intervention: Maximal Surgery, Minimally Invasive Surgery, and Transoral Robotic Surgery

Oral and maxillofacial surgery (OMFS) has undergone a renaissance/metamorphosis as a specialty and in the technologic innovations that have enhanced the surgical care of patients. This article reviews traditional maximal transoral approaches in the management of common pathologic lesions seen by OMFS, and compares these techniques with a literature review that applies minimally invasive technology and innovative robotic surgery (transoral robotic surgery) to treat similar lesions. The traditional approaches described in this article have transcended generations and future trends are suggested that will improve the training of the OMFS legacy as clinicians move forward in the care of patients.

Accuracy of dental implant surgery with robotic position feedback and registration algorithm: An in-vitro study

BACKGROUND

The purpose of this study was to develop and validate a positioning method with hand-guiding and contact position feedback of robot based on a human-robot collaborative dental implant system (HRCDIS) for robotic guided dental implant surgery.

METHODS

An HRCDIS was developed based on a light-weight cooperative robot arm, UR5. A three-dimensional (3D) virtual partially edentulous mandibular bone was reconstructed using the cone bone computed tomography images. After designing the preoperative virtual implant planning using the computer software, a fixation guide worn on teeth for linking and fixing positioning marker was fabricated by 3D printing. The fixation guide with the positioning marker and a resin model mimicking the oral tissues were assembled on a head phantom. The planned implant positions were derived by the coordinate information of the positioning marker. The drilling process using the HRCDIS was conducted after mimicking the experimental set-up and planning the drilling trajectory. Deviations between actual and planned implant positions were measured and analyzed.

RESULTS

The head phantom experiments results showed that the error value of the central deviation at hex (refers to the center of the platform level of the implant) was 0.79 ± 0.17 mm, central deviation at the apex was 1.26 ± 0.27 mm, horizontal deviation at the hex was 0.61 ± 0.19 mm, horizontal deviation at the apex was 0.91 ± 0.55 mm, vertical deviation at the hex was 0.38 ± 0.17 mm, vertical deviation at the apex was 0.37 ± 0.20 mm, and angular deviation was 3.77 ± 1.57°.

CONCLUSIONS

The results from this study preliminarily validate the feasibility of the accurate navigation method of the HRCDIS.

A Compact Surgical Robot System for Craniomaxillofacial Surgery and its Preliminary Study

ABSTRACT

Craniomaxillofacial surgery has the characteristics of complex anatomical structure, narrow surgical field, and easy damage to nerves, blood vessels, and other structures. Compared with the traditional bare-hand operation, robot-assisted craniofacial surgery is expected to achieve a more stable and accurate surgical operation. So we have developed a robot-assisted craniofacial surgery system. A compact mechanism design was adopted for the robot system, integrates with visual and force perception modules. The motion analysis and working space analysis are carried out on the mechanical structure. The binocular vision module is integrated and the robot hand-eye calibration process was completed. The target tracking method based on staple is used to achieve tracking and monitoring of the target area. A distributed robot control system based on CAN bus technology is designed, and a position-based visual servo control method is adopted. Then the precision test of the robot system prototype and the drilling experiment of the 3D printed mandible model were carried out. The average pixel error of the vision module is 0.15 pixels. Based on the staple tracking method, the average center error rate of the image is 0.3175 mm, and the overlap rate is 88.76%. The drilling experiment of the mandible model showed that the average entrance position error is 1.76 ± 0.36 mm, the average target position error is 1.62 ± 0.27 mm, and the angle error is 5.36 ± 0.31 degrees. The designed craniofacial robot system can better assist surgeons to complete the mandibular osteotomy.

Pilot study of a surgical robot system for zygomatic implant placement

Zygomatic implant technology has been regarded as an alternative treatment to massive grafting surgery in the severe atrophic maxillary. Nowadays, the assistant method with a real-time surgical navigation has been applied to reduce the risks of zygomatic implant placement. However, the accuracy of the complex operation is highly dependent on the experience of the surgeon. In order to avoid disadvantages of traditional surgical navigation systems, a novel surgical robot system for the zygomatic implant placement has been designed and developed. Firstly, the drilling trajectory of the zygomatic implant placement is designed through the pre-operative planning system. Secondly, the real-time positions of the surgical instruments are constantly updated with the guidance of the optical tracker. Finally, through a coordinate transformation algorithm, the drilling performance can be conducted with the control of a six degree of freedom robot. In order to evaluate the accuracy of the robot, phantom experiments had been carried out. The angle, entry point and exit point deviation of the robotic system are 1.52 ± 0.58°, 0.79 ± 0.19 mm, and 1.49 ± 0.48 mm, respectively. Meanwhile, a comparison between the robotic and manual operation demonstrates that the use of the surgical robot system for the zygomatic implant placement can improve the accuracy of the operation.

[Application of artificial intelligence in stomatology treatment and nursing]

Currently, artificial intelligence technology is being developed rapidly and is used in many clinical areas, especially in stomatology. The application of artificial intelligence technology in stomatology is a new technological revolution. This study focuses on artificial intelligence and its application status. The advantages, current situation, and development prospect of the application of artificial intelligence technology in stomatology treatment and nursing, such as oral and maxillofacial surgery, implant, prosthetics, orthodontics, oral medicine therapy, guidance, and teaching, are provided.

Surgical Navigation: A Systematic Review of Indications, Treatments, and Outcomes in Oral and Maxillofacial Surgery

PURPOSE

This systematic review investigates the most common indications, treatments, and outcomes of surgical navigation (SN) published from 2010 to 2015. The evolution of SN and its application in oral and maxillofacial surgery have rapidly developed over recent years, and therapeutic indications are discussed.

MATERIALS AND METHODS

A systematic search in relevant electronic databases, journals, and bibliographies of the included articles was carried out. Clinical studies with 5 or more patients published between 2010 and 2015 were included. Traumatology, orthognathic surgery, cancer and reconstruction surgery, skull-base surgery, and foreign body removal were the areas of interests.

RESULTS

The search generated 13 articles dealing with traumatology; 5, 6, 2, and 0 studies were found that dealt with the topics of orthognathic surgery, cancer and reconstruction surgery, skull-base surgery, and foreign body removal, respectively. The average technical system accuracy and intraoperative precision reported were less than 1 mm and 1 to 2 mm, respectively. In general, SN is reported to be a useful tool for surgical planning, execution, evaluation, and research. The largest numbers of studies and patients were identified in the field of traumatology. Treatment of complex orbital fractures was considerably improved by the use of SN compared with traditionally treated control groups.

CONCLUSIONS

SN seems to be a very promising addition to the surgical toolkit. Planning details of the surgical procedure in a 3-dimensional virtual environment and execution with real-time guidance can significantly improve precision. Among factors to be considered are the financial investments necessary and the learning curve.

[Application and development of surgical robot systems in craniomaxillofacial surgery]

Traditional craniomaxillofacial surgery significantly affects aesthetic appreciation. In contrast to traditional methods, robot-assisted surgery has been extensively investigated because it is microinvasive, precise, and safe. With robot-assisted surgery, operational vision and manipulation space become extended. As a result, operational quality and patient's postoperative life are improved. This article reviewed the development of surgical robot systems and their applications in craniomaxillofacial surgery.

Solving challenges in inter- and trans-disciplinary working teams: Lessons from the surgical technology field

INTRODUCTION

Engineering a medical technology is a complex process, therefore it is important to include experts from different scientific fields. This is particularly true for the development of surgical technology, where the relevant scientific fields are surgery (medicine) and engineering (electrical engineering, mechanical engineering, computer science, etc.). Furthermore, the scientific field of human factors is important to ensure that a surgical technology is indeed functional, process-oriented, effective, efficient as well as user- and patient-oriented. Working in such trans- and inter-disciplinary teams can be challenging due to different working cultures. The intention of this paper is to propose an innovative cooperative working culture for the interdisciplinary field of computer-assisted surgery (CAS) based on more than ten years of research on the one hand and the interdisciplinary literature on working cultures and various organizational theories on the other hand.

METHODOLOGY

In this paper, a retrospective analysis of more than ten years of research work in inter- and trans-disciplinary teams in the field of CAS will be performed. This analysis is based on the documented observations of the authors, the study reports, protocols, lab reports and published publications. To additionally evaluate the scientific experience in an interdisciplinary research team, a literature analysis regarding scientific literature on trans- and inter-disciplinarity was performed. Own research and literature analyses were compared.

RESULTS

Both the literature and the scientific experience in an interdisciplinary research team show that consensus finding is not always easy. It is, however, important to start trans- and interdisciplinary projects with a shared mental model and common goals, which include communication and leadership issues within the project teams, i.e. clear and unambiguous information about the individual responsibilities and objectives to attain. This is made necessary due to differing leadership cultures within the cooperating disciplines. Another research outcome is the relevance of a cooperative learning culture throughout the complete duration of the project. Based on this cooperation, new ideas and projects were developed, i.e. a training concept for surgical trainers including technological competence for surgeons.

DISCUSSION

An adapted innovative paradigm for a cooperating working culture in CAS is based on a shared mental model and common goals from the very beginning of a project.

CONCLUSIONS

All actors in trans- and inter-disciplinary teams need to be interested in cooperation. This will lead to a common view on patients and technology models.

Automated image-guided surgery for common and complex dental implants

Dental implantation is now recognized as a standard of care for replacing missing teeth. Pre-operative planning with patient-specific images provides the basis for precise surgery, but such accuracy is hampered to some degree because of the manual drilling procedures performed by the surgeon. In this paper, a robotic system for automated site preparation for dental implants is presented in order to provide high accuracy drilling. The results of some experiments are given to validate the system. Additionally, results are shown for jaw surgery that utilize natural-root-formed implants which can contain multiple roots. This more complex type of implant is impossible to drill manually but can provide better long-term stability and success. With this robotic system, controlled and accurate drilling was achieved, which made more advanced implant designs possible.

Evolution and trends in reconstructive facial surgery: an update

Surgical correction of congenital and acquired facial deformities has transcended the primitive era of using non biologic materials to current attempts at own face growing through biotechnology. A summative account of this trend is still lacking in the literature. The objective of this article is to present an update on current knowledge in the strides to achieve functionally and aesthetically perfect facial reconstruction. It highlights the impact of advancements in 3D imaging, stereolithographic biomodelling, microvascular surgical tissue transplantation and tissue biotechnology in the surgical efforts to solve the problems of facial disfigurement whether congenital or acquired.

Medical Manipulators for Surgical Applications

Great advances have been made over the last decade with respect to medical manipulators for surgical robots. Although they cannot replace surgeons, they can increase surgeons’ abilities to perform surgeries with greater therapeutic effectiveness. These advanced surgical tools have been implemented in complex, precise, repetitive, and difficult surgeries. This chapter reviews medical manipulators used in surgical applications. At present, several kinds of medical manipulators have been developed to perform a variety of surgical procedures and can be classified into different categories. Here, the authors discuss general design principles and summarize and classify medical manipulators based on joint category and level of autonomy, with illustrations of applications. Finally, a brief synopsis is provided.

Telerobotic contact transscleral cyclophotocoagulation of the ciliary body with the diode laser

To assess the feasibility of using the Robotic Slave Micromanipulator Unit (RSMU) to remotely photocoagulate the ciliary body for the treatment of glaucoma with the diode laser. In fresh unoperated enucleated human eyes, the ciliary body was destroyed either with a standard contact transscleral cyclophotocoagulation 'by hand' diode laser technique, or remotely using the RSMU. The treated sections were fixed in formalin, paraffin-embedded, and stained with hematoxylin and eosin. Histological evaluation was performed by a masked observer using a standardized grading system based on the amount of damage to the ciliary body to evaluate effectiveness of treatment. Both methods of contact transscleral cyclophotocoagulation showed therapeutic tissue disruption of the ciliary processes and both the non-pigmented and pigmented ciliary epithelium. Histology examination of remote robotic contact transscleral cyclophotocoagulation and "by hand" technique produced similar degrees of ciliary body tissue disruption. Remote diode laser contact transscleral cyclophotocoagulation of the ciliary body in fresh enucleated human eyes is possible with the RSMU. Therapeutic tissue disruption of the ciliary body was achieved. Additional study is necessary to determine the safety and efficacy of robotically-delivered cyclophotocoagulation in live eyes.

Surgical Engineering in Cranio‐Maxillofacial Surgery: A Literature Review

A systematic review of the literature concerning surgical engineering in cranio‐maxillofacial surgery was performed. APubMed search yielded 1721 papers published between 1999 and 2011. Based on the inclusion/exclusion criteria, 1428 articles were excluded after review of titles and abstracts. Atotal of 292 articles were finally selected covering the following topics: finite element analysis (n = 18), computer‐assisted surgery (n = 111), rapid prototyping models (n = 41), preoperative training simulators (n = 4), surgical guides (n = 23), image‐guided navigation (n = 58), augmented reality (n = 2), video tracking (n = 1), distraction osteogenesis (n = 19), robotics (n = 8), and minimal invasive surgery (n = 7). The results show that surgical engineering plays a pivotal role in the development and improvement of cranio‐maxillofacial surgery. Some technologies, such as computer‐assisted surgery, image‐guided navigation, and three‐dimensional rapid prototyping models, have reached maturity and allow for multiple clinical applications, while augmented reality, robotics, and endoscopy still need to be improved.

Orthognathic model surgery by using of a passive Robot Arm

PURPOSE

The possibility of using a passive Robot Arm (3D method) in model surgery and comparing with manual technique model surgery.

PATIENTS AND METHODS

Seventeen patients undergoing orthognathic surgery gave consent for this study. Model surgery was performed by using a manual technique and using the Robot Arm. The model surgery that was performed by using the manual technique named group A and the one performed by the Robot Arm named group B. Patients' maxillary casts were measured before and after model surgery, and results were compared with those for the original treatment plan in the horizontal (X-axis), vertical (Y-axis), and transverse (Z-axis) planes.

RESULTS

Statistical analysis using Mann-Whitney U test for X- and Y-axis and independent sample t test for Z-axis have shown significant differences between both groups in X-axis (P = .026) and Y-axis (P = .021) but not in Z-axis (P = .762).

CONCLUSIONS

Model surgery performed with a Robot Arm is more accurate in all dimensions X, Y, and Z than the manual model surgery.

[The beginnings of robotic surgery--from the roots up to the da Vinci telemanipulator system]

The history of the robotic surgery is only 22 years old. The article gives a short overview regarding the history of robotics, the surgical robots, the da Vinci telemanipulator system and some further commercial and experimental surgical robotic surgical simulation is also emphasized. Robotic surgery has its own place within the following concepts: 1. computer assisted surgery (CAS), 2. computer integrated surgery (CIS), 3. surgical automation, 4. surgical system integration and 5. artificial intelligence (AI). At the end of the paper there are some important sources of informations regarding robotic surgery.

Image-guided surgery and medical robotics in the cranial area

Surgery in the cranial area includes complex anatomic situations with high-risk structures and high demands for functional and aesthetic results. Conventional surgery requires that the surgeon transfers complex anatomic and surgical planning information, using spatial sense and experience. The surgical procedure depends entirely on the manual skills of the operator. The development of image-guided surgery provides new revolutionary opportunities by integrating presurgical 3D imaging and intraoperative manipulation. Augmented reality, mechatronic surgical tools, and medical robotics may continue to progress in surgical instrumentation, and ultimately, surgical care. The aim of this article is to review and discuss state-of-the-art surgical navigation and medical robotics, image-to-patient registration, aspects of accuracy, and clinical applications for surgery in the cranial area.