Robot-Assisted Pterygium Surgery: Feasibility Study in a Nonliving Porcine Model

Controlling of Applied Force and Cornea Displacement Estimation in Robotic Corneal Surgery With a Gripper Surgical Instrument

BACKGROUND

The human eye consists of highly sensitive, hydrated, and relatively thin tissues, making precise control and accurate force estimation crucial in robotic eye surgery. This paper introduces a novel control method and state observer designed for a gripper surgical instrument used on the external ocular surface during robotic eye surgery.

METHODS

A novel state observer, operating in tandem with the controller, estimates the applied force. The proposed control approach, termed the Fixed-time Observer-based Sliding Mode Control (FOSMC), estimates the applied force by determining the gripper states and uses an eye model to calculate its displacement.

RESULTS

The performance of the proposed control method was compared with two other finite-time and asymptotic techniques across two scenarios. The results demonstrated excellent performance using the proposed method.

CONCLUSIONS

The FOSMC control technique effectively estimates the applied force during robotic eye surgery, making it a reliable solution for controlling the gripper surgical instrument.

Robotics and cybersurgery in ophthalmology: a current perspective

Ophthalmology is one of the most enriched fields, allowing the domain of artificial intelligence to be part of its point of interest in scientific research. The requirement of specialized microscopes and visualization systems presents a challenge to adapting robotics in ocular surgery. Cyber-surgery has been used in other surgical specialties aided by Da Vinci robotic system. This study focuses on the current perspective of using robotics and cyber-surgery in ophthalmology and highlights factors limiting their progression. A review of literature was performed with the aid of Google Scholar, Pubmed, CINAHL, MEDLINE (N.H.S. Evidence), Cochrane, AMed, EMBASE, PsychINFO, SCOPUS, and Web of Science. Keywords: Cybersurgery, Telesurgery, ophthalmology robotics, Da Vinci robotic system, artificial intelligence in ophthalmology, training on robotic surgery, ethics of the use of robots in medicine, legal aspects, and economics of cybersurgery and robotics. 150 abstracts were reviewed for inclusion, and 68 articles focusing on ophthalmology were included for full-text review. Da Vinci Surgical System has been used to perform a pterygium repair in humans and was successful in ex vivo corneal, strabismus, amniotic membrane, and cataract surgery. Gamma Knife enabled effective treatment of uveal melanoma. Robotics used in ophthalmology were: Da Vinci Surgical System, Intraocular Robotic Interventional Surgical System (IRISS), Johns Hopkins Steady-Hand Eye Robot and smart instruments, and Preceyes' B.V. Cybersurgery is an alternative to overcome distance and the shortage of surgeons. However, cost, availability, legislation, and ethics are factors limiting the progression of these fields. Robotic and cybersurgery in ophthalmology are still in their niche. Cost-effective studies are needed to overcome the delay. Technologies, such as 5G and Tactile Internet, are required to help reduce resource scheduling problems in cybersurgery. In addition, prototype development and the integration of artificial intelligence applications could further enhance the safety and precision of ocular surgery.

Robot-Assisted Orbital Fat Decompression Surgery: First in Human

Purpose

To explore the safety and feasibility of robot-assisted orbital fat decompression surgery.

Methods

Ten prospectively enrolled patients (18 eyes) with Graves’ ophthalmopathy underwent robot-assisted orbital fat decompression surgery with the da Vinci Xi surgical system. Intraoperative blood loss, operative time, and complications were recorded. For every patient, the exophthalmos of the operated eyes and Graves’ orbitopathy quality of life (GO-QoL) were measured both preoperatively and 3 months postoperatively to assess the surgical effect.

Results

All surgical procedures were successfully performed. The mean duration to complete the whole procedure was 124.3 ± 33.2 minutes (range, 60–188). The mean intraoperative blood loss was 17.8 ± 6.2 mL (range, 7.5–28). There were neither complications nor unexpected events in terms of either orbital decompression surgery or robot-assisted procedures. The mean exophthalmos was 20.2 ± 1.8 mm before surgery and 17.9 ± 1.4 mm postoperatively (P < 0.0001). The preoperative and postoperative GO-QoL on the visual function arm was 84.38 ± 20.04 and 93.75 ± 9.32, respectively. The preoperative and postoperative GO-QoL on the appearance arm was 42.50 ± 14.97 and 64.38 ± 21.46, respectively (P = 0.027).

Conclusions

The da Vinci Xi surgical system provided the stability, dexterity, and good visualization necessary for orbital fat decompression surgery, indicating the safety and feasibility of robot-assisted orbital fat decompression surgery.

Translational Relevance

Based on a literature search using EMBASE and MEDLINE databases, we believe that this study reports the first in-human results of the safety and effectiveness of da Vinci robot-assisted orbital fat decompression surgery.

State of the Art in Robot-Assisted Eye Surgery

Despite the advantages that robot-assisted surgery can offer to patient care, its use in ophthalmic surgery has not yet progressed to the extent seen in other fields. As such, its use remains limited to research environments, both basic and clinical. The technical specifications for such ophthalmic surgical robots are highly challenging, but rapid progress has been made in recent years, and recent developments in this field ensure that the use of this technology in operating theatres will soon be a real possibility. Fully automated ocular microsurgery, carried out by a robot under the supervision of a surgeon, is likely to become our new reality. This review discusses the use of robot-assisted ophthalmic surgery, the recent progress in the field, and the necessary future developments which must occur before its use in operating theatres becomes routine.

Robotics and ophthalmology: Are we there yet?

Ophthalmology is a field that is now seeing the integration of robotics in its surgical procedures and interventions. Assistance facilitated by robots offers substantial improvements in terms of movement control, tremor cancellation, enhanced visualization, and distance sensing. Robotic technology has only recently been integrated into ophthalmology; hence, the progression is only in its initial stages. Robotic technologies such as da Vinci Surgical System are integrated into the field of ophthalmology and are assisting surgeons in complex eye surgeries. Ophthalmic surgeries require high accuracy and precision to execute tissue manipulation, and some complex ocular surgery may take few hours to complete the procedures that may predispose high-volume ophthalmic surgeons to work-related musculoskeletal disorders. A complete paradigm shift has been achieved in this particular field through the integration of advanced robotic technology, resulting in easier and more efficient procedures. Where robotic technology assists the surgeons and improves the overall quality of care, it also projects several challenges including limited availability, training, and the high cost of the robotic system. Although considerable studies and trials have been conducted for various robotic systems, only a few of them have made it to the commercial stage and ophthalmology, on its own, has a long way to go in robotics technology.

Robot-Assisted Simulated Strabismus Surgery

PURPOSE

This study aims to investigate the feasibility of robot-assisted simulated strabismus surgery using the new da Vinci Xi Surgical System and to report what we believe is the first use of a surgical robot in experimental eye muscle surgery.

METHODS

Robot-assisted strabismus surgeries were performed on a strabismus eye model using the robotic da Vinci Xi Surgical System. On the lateral rectus of each eye, we performed a procedure including, successively, a 4-mm plication followed by a 4-mm recession of the muscle to end with a 4-mm resection. Operative time from conjunctival opening to closing and successful completion of the different steps with or without complications or unexpected events were assessed.

RESULTS

Robot-assisted strabismus procedures were successfully performed on six eyes. The feasibility of robot-assisted simulated strabismus surgery is confirmed. The da Vinci Xi system provided the appropriate dexterity and operative field visualization necessary to perform conjunctival and Tenon's capsule opening and closing, muscle identification, suturing, desinsertion, sectioning, and resuturing. The mean duration to complete the whole procedure was 27 minutes (range, 22-35). There were no complications or unexpected intraoperative events.

CONCLUSIONS

Experimental robot-assisted strabismus surgery is technically feasible using the new robotic da Vinci Xi Surgical System. This is, to our knowledge, the first use of a surgical robot in ocular muscle surgery.

TRANSLATIONAL RELEVANCE

Further experimentation will allow the advantages of robot-assisted microsurgery to be identified while underlining the improvements and innovations necessary for clinical use.

Da Vinci Xi Robot-Assisted Penetrating Keratoplasty

PURPOSE

This study aims (1) to investigate the feasibility of robot-assisted penetrating keratoplasty (PK) using the new Da Vinci Xi Surgical System and (2) to report what we believe to be the first use of this system in experimental eye surgery.

METHODS

Robot-assisted PK procedures were performed on human corneal transplants using the Da Vinci Xi Surgical System. After an 8-mm corneal trephination, four interrupted sutures and one 10.0 monofilament running suture were made. For each procedure, duration and successful completion of the surgery as well as any unexpected events were assessed. The depth of the corneal sutures was checked postoperatively using spectral-domain optical coherence tomography (SD-OCT).

RESULTS

Robot-assisted PK was successfully performed on 12 corneas. The Da Vinci Xi Surgical System provided the necessary dexterity to perform the different steps of surgery. The mean duration of the procedures was 43.4 ± 8.9 minutes (range: 28.5-61.1 minutes). There were no unexpected intraoperative events. SD-OCT confirmed that the sutures were placed at the appropriate depth.

CONCLUSIONS

We confirm the feasibility of robot-assisted PK with the new Da Vinci Surgical System and report the first use of the Xi model in experimental eye surgery. Operative time of robot-assisted PK surgery is now close to that of conventional manual surgery due to both improvement of the optical system and the presence of microsurgical instruments.

TRANSLATIONAL RELEVANCE

Experimentations will allow the advantages of robot-assisted microsurgery to be identified while underlining the improvements and innovations necessary for clinical use.