Current and emerging robotic assisted intervention for Notes

Progress in Control-Actuation Robotic System for Gastrointestinal NOTES Development

Purpose

Natural orifice transluminal endoscopic surgery (NOTES) is a minimally invasive surgical procedure that reduces patient trauma, infection probability, and rehabilitation time. This paper reviews the progress made in the control-actuation robotic systems for gastrointestinal NOTES development. Material and Methods. A survey on both existing and state-of-the-art control-actuation robotic systems for gastrointestinal NOTES was conducted in December 2021.

Results

Nine control-actuation robotic systems for gastrointestinal NOTES were identified. The structures and specifications of these robotic systems were reported. The technical parameters were also discussed. Special attention was directed to systems using a control-actuation structure and tendon-driven mechanism. The control-actuation robotic systems typically deploy a control-actuation structure and tendon-driven mechanism. Control-actuation robotic systems for gastrointestinal NOTES show great ability to improve operational accuracy and flexibility and flatten the learning curve of procedures. These characteristics suggest that the use of control-actuation robotic systems is worth exploring in future development.

Robotics in therapeutic endoscopy (with video)

Since its inception, endoscopy has evolved from a solely diagnostic procedure to an expanding therapeutic field within gastroenterology. The incorporation of robotics in gastroenterology initially addressed shortcomings of flexible endoscopes in natural orifice transluminal endoscopy. Developing therapeutic endoscopic robotic platforms now offer operators improved ergonomics, visualization, dexterity, precision, and control and the possibility of increasing proficiency and standardization of complex endoscopic procedures including endoscopic submucosal dissection, endoscopic full-thickness resection, and endoscopic suturing. The following review discusses the history, potential applications, and tools currently available and in development for robotics in therapeutic endoscopy.

Clinical adoption of robotics in endoscopy: Challenges and solutions

The endoscope was traditionally used as a diagnostic instrument. In past decades, it has increasingly been adapted for therapeutic intents. Subsequently, the master–slave robotic concept was introduced into the field of endoscopy to potentially reduce the difficulty and complication rates of endoscopic therapeutic procedures. As interest in robotic endoscopy intensified, progressively more robotic endoscopic platforms were developed, tested, and introduced. Nevertheless, the future of robotic endoscopy hinges on the ability to meet specific clinical needs of procedurists. Three aspects are vital in ensuring continued success and clinical adoption of the robotic endoscope—demonstration of clinical safety and cost‐efficacy of the device, widespread availability of directed training opportunities to enhance technical skills and clinical decision‐making capabilities of the procedurist, and continued identification of new clinical applications beyond the current uses of the device. This review provides a brief discussion of the historical development of robotic endoscopy, current robotic endoscopic platforms, use of robotic endoscopy in conventional therapeutic endoscopic procedures, and the future of robotic endoscopy.

Overcoming Abdominal and Pelvic Cavity Workspace Constraints in Robotic-Assisted NOTES

Despite early enthusiasm in robotic-assisted NOTES, several technical challenges exist. Various spinopelvic anatomical constraints can significantly act as obstacles and affect entry and space availability for the deployment of straight and rigid transvaginal/transanal NOTES instruments. Anatomical constraints such as the sacral slope, position, and distance to the target organs are defined. Transvaginal access to the surgical site required a high insertion angle between 20° and 30° to overcome the pronounced sacral slope resulting in dexterity and reachability limitations. A new set of robotic parameters was generated to introduce a 7 degrees of freedom robotic arm. Workspace simulation and phantom precision measurements have shown a significant improvement in the reachability and maneuverability of the robotic platform. While the robotic arms provided stable dexterity, it is constrained when reaching target sites in larger patients. This study has provided an insight and a solution in rigid instrument design, paving a safe route for transvaginal/transanal access for abdominal surgeries towards robotic-assisted NOTES.

A foldable manipulator with tunable stiffness based on braided structure

Minimally invasive surgery (MIS) has recently seen a surge in clinical applications due to its potential benefits over open surgery. In MIS, a long manipulator is placed through a tortuous human orifice to create a channel for surgical tools and provide support when they are operated. Currently the relative large profile and low stiffness of the manipulators limit the effectiveness and accuracy of MIS. Here we propose a new foldable manipulator with tunable stiffness. The manipulator takes a braided skeleton to enable radial folding, whereas membrane is used to seal the skeleton so as to adjust stiffness through creating negative pressure. We demonstrated experimentally, numerically, and analytically that, a flexible and a rigid state were obtained, and the ratio of bending stiffness in the rigid state to that in the flexible state reached 6.85. In addition, the manipulator achieved a radial folding ratio of 1.95. The proposed manipulator shows great potential in the design of surgical robots for MIS. © 2019 Wiley Periodicals, Inc. J Biomed Mater Res Part B, 2019.

What robot for tomorrow and what improvement can we expect?

PURPOSE OF REVIEW

The purpose of this review is to summarize the status of robotic surgery currently, contextualizing the advances and improvements we can expect in the immediate future. Robotics continues to demonstrate increased utility and expansion in medicine, particularly surgery. When coupled with the imminent expiry of Intuitive patents in the next few years, it is timely to consider what we can expect to see from new platforms; what new features might we anticipate and what technology will be available to enhance and improve patient care.

RECENT FINDINGS

There really are no limits with the anticipated developments in the field of medical robotics. Multiple large companies and academic institutions continue to invest in design and production with the release of a number of platforms already having occurred, whereas others are to come in the near future. The main anticipated advances will be haptic feedback, decreased cost, improved theatre assimilation with open consoles permitting free communication and lower theatre footprint. The robot patient interface is to be enhanced with single port platforms in production with a better interface including haptic feedback. The addition of NOTES and smarter flexible robotics is the next key area of interest, whereas the introduction of technology with image guidance and networking where large data sets or connectivity permit increased clinical acumen to enhance decision making.

SUMMARY

We are at the cusp of a tipping point as the intellectual property for the first major robotic system in surgery comes to an end. It is likely to be a period of great opportunity with enhanced surgery and patient outcomes through significant innovation, multiple platforms nearing dissemination, with various technological advances. We anticipate this will yield a great period of innovation and diversity. Will we see a truly automated robot soon; the Smart Tissue Autonomous Robots are the limit.

Robotic-Assisted Transrectal Cholecystectomy in a Porcine Model

Background. With increasing experience and technological advancement in surgical instruments, surgeons have explored the feasibility of single-incision laparoscopic surgery and natural orifice transluminal endoscopic surgery (NOTES). These techniques aim to further reduce surgical trauma, but are not popular due to their inherent pitfalls including clashing of instruments, lack of counter traction, lengthy operating time, and so on. A novel surgical robotic system was designed to overcome the limitations of the existing technologies. Animal trials were conducted to demonstrate its feasibility in performing robotic-assisted transrectal cholecystectomy in a porcine model. Method. The Novel surgical robotic system is a high dexterity, single access port surgical robotic system that enables surgeons to carry out single-port surgical procedure or NOTES. The proposed system’s main features include the ability to perform intraabdominal and pelvic surgeries via natural orifices like the vagina or rectum. The system is equipped with multiple miniaturized (16 mm diameter) internally motorized robotic arms, each with a minimum of 7 degrees of freedom, a dual in vivo camera system, a cannula, and an external swivel system. Results. Robotic-assisted transrectal cholecystectomy was successfully performed in 3 adult male pigs. The estimated blood loss was <10 mL in all 3 cases. There were no intraoperative complications. The system provided good dexterity and clear vision. Conclusions. The trial demonstrated that the system can provide the surgeon a stable platform with adequate spacing for the transrectal insertion of robotic arms, 3-dimensional vision, and enhanced dexterity in performing NOTES cholecystectomy.

Endoscopic trans-esophageal submucosal tunneling surgery: A new therapeutic approach for diseases located around the aorta ventralis

AIM

To assess the efficiency of endoscopic trans-esophageal submucosal tunneling surgery (EESTS) technique for diseases located around the aorta ventralis.

METHODS

Nine pigs were assigned to EESTs. The procedures were as follows: First, a long esophageal submucosal tunnel was established. Second, full-thickness myotomy was created. Third, an endoscope was entered into the abdominal cavity through a muscle incision and the endoscope was around the aorta ventralis. Eventually, celiac trunk ganglion neurolysis, partial hepatectomy and splenectomy, partial tissue resection in the area of the posterior peritoneum, and endoscopic submucosal dissection (ESD) combined with lymph node dissection were performed. The animals were given antibiotics for 5 d and necropsied 7 d after surgery.

RESULTS

In all surgeries, one pig died from intraperitoneal hemorrhage after doing partial splenectomy, while the other pigs were alive after successfully operating other surgeries. For surgery of celiac trunk ganglion damage, at necropsy, there was no exudation in the abdominal cavity. Regarding surgery of partial hepatectomy, the wound with part healing was observed in the left hepatic lobe, and no bleeding or obvious exudation was seen. In surgery of partial splenectomy, massive hemorrhage was observed on the splenic wound surface, and the metal clips could not stop bleeding. After surgery of retroperitoneal tissue resection, mild tissue adhesion was observed in the abdominal cavity of one animal, and another one suffered from severe infection. For surgery of ESD and lymph node dissection, a moderate tissue adhesion was observed.

CONCLUSION

EESTS is a feasible and safe technique for diseases located around the aorta ventralis.

Water-jet outer sheath with braided shape memory polymer tubes for upper gastrointestinal tract screening

BACKGROUND

Flexible endoscopes have become an important tool for the diagnosis and treatment of gastric cancer. However, there are several limitations to the use of endoscopes in rural areas, including their high cost, poor portability, and unstable platform.

METHODS

This paper presents a novel low-cost outer sheath for stomach screening. The sheath uses braided shape memory polymer (SMP) tubes with a water-jet to control the stiffness and bending motion. The insertion part of the prototype is 250 mm long with a maximum outer diameter of 16 mm and incorporates an internal charge-coupled device camera.

RESULTS

We have tested the workspace and stiffness of the outer sheath. The prototype has also been validated with phantom and ex vivo porcine stomach experiments.

CONCLUSIONS

By controlling the water-jet and temperature of the braided SMP tubes, the outer sheath achieves a large workspace and a remarkable variability in stiffness, demonstrating the potential clinical value of the outer sheath system.

A Specimen Extraction Instrument Based on Braided Fiber Tube for Natural Orifice Translumenal Endoscopic Surgery

Natural orifice translumenal endoscopic surgery (NOTES) has offered significant advantages of less pain, reduced recovery time, and minimized scar after operation, demonstrating a promising development prospect. However, the large-size specimen extraction remains challenging for NOTES, due to the narrow space of the human natural orifices. To address such difficulties, a specimen extraction method that utilizes the braided fiber tube (BFT) structure with excellent retractility to accommodate and bind the bulky specimen has been proposed. Based on the theory of helical spring, the geometric model and the mechanical model of the BFT are established, and experiments have been performed to verify the accuracy of the derived mechanical model. In addition, a tensile test of using the BFT to extract large specimens via a small channel is carried out, which verifies the stable extraction performance of the proposed design. The BFT will not be damaged when extracting the specimen with a diameter less than 1.75 times of the channel diameter. A NOTES-specific specimen extraction instrument is designed according to the characteristics of NOTES, and it has three degrees-of-freedom and is able to actively capture different specimen by using a suction cup. Finally, specimen extraction experiments on NOTES multitasking platform phantom have been conducted using the prototyped instrument to validate its feasibility and effectiveness.

Nonparametric bootstrap technique for calibrating surgical SmartForceps: theory and application

Knowledge of forces, exerted on the brain tissue during the performance of neurosurgical tasks, is critical for quality assurance, case rehearsal, and training purposes. Quantifying the interaction forces has been made possible by developing SmartForceps, a bipolar forceps retrofitted by a set of strain gauges. The forces are estimated using voltages read from strain gauges. We therefore need to quantify the force-voltage relationship to estimate the interaction forces during microsurgery. This problem has been addressed in the literature by following the physical and deterministic properties of the force-sensing strain gauges without obtaining the precision associated with each estimate. In this paper, we employ a probabilistic methodology by using a nonparametric Bootstrap approach to obtain both point and interval estimates of the applied forces at the tool tips, while the precision associated with each estimate is provided. To show proof-of-concept, the Bootstrap technique is employed to estimate unknown forces, and construct necessary confidence intervals using observed voltages in data sets that are measured from the performance of surgical tasks on a cadaveric brain. Results indicate that the Bootstrap technique is capable of estimating tool-tissue interaction forces with acceptable level of accuracy compared to the linear regression technique under the normality assumption.