New remote centre of motion mechanism for robot-assisted minimally invasive surgery

Safety Issues in the Development of an Innovative Medical Parallel Robot Used in Renal Single-Incision Laparoscopic Surgery

Robotic-assisted single-incision laparoscopic surgery (SILS) is becoming an increasingly widespread field worldwide due to the benefits it brings to both the patient and the surgeon. The goal of this study is to develop a secure robotic solution for SILS, focusing specifically on urology, by identifying and addressing various safety concerns from an early design stage. Starting with the medical tasks and protocols, the technical specifications of the robotic system as well as potential; hazards have been identified. By employing competitive engineering design methods such as Analytic Hierarchy Process (AHP), Risk assessment, and Failure Mode and Effects Analysis (FMEA), a safe design solution is proposed. A set of experiments is conducted to validate the proposed concept, and the results strongly support the development of the experimental model. The Finite Element Analysis (FEA) method is applied to validate the mechanical architecture within a set of simulations, demonstrating the compliance of the robotic system with the proposed technical specifications and its capability to safely perform SILS procedures.

Artificial Intelligence-Based Hazard Detection in Robotic-Assisted Single-Incision Oncologic Surgery

THE PROBLEM

Single-incision surgery is a complex procedure in which any additional information automatically collected from the operating field can be of significance. While the use of robotic devices has greatly improved surgical outcomes, there are still many unresolved issues. One of the major surgical complications, with higher occurrence in cancer patients, is intraoperative hemorrhages, which if detected early, can be more efficiently controlled.

AIM

This paper proposes a hazard detection system which incorporates the advantages of both Artificial Intelligence (AI) and Augmented Reality (AR) agents, capable of identifying, in real-time, intraoperative bleedings, which are subsequently displayed on a Hololens 2 device.

METHODS

The authors explored the different techniques for real-time processing and determined, based on a critical analysis, that YOLOv5 is one of the most promising solutions. An innovative, real-time, bleeding detection system, developed using the YOLOv5 algorithm and the Hololens 2 device, was evaluated on different surgical procedures and tested in multiple configurations to obtain the optimal prediction time and accuracy.

RESULTS

The detection system was able to identify the bleeding occurrence in multiple surgical procedures with a high rate of accuracy. Once detected, the area of interest was marked with a bounding box and displayed on the Hololens 2 device. During the tests, the system was able to differentiate between bleeding occurrence and intraoperative irrigation; thus, reducing the risk of false-negative and false-positive results.

CONCLUSION

The current level of AI and AR technologies enables the development of real-time hazard detection systems as efficient assistance tools for surgeons, especially in high-risk interventions.

Force-based control strategy for a collaborative robotic camera holder in laparoscopic surgery using pivoting motion

Introduction: Laparoscopic surgery often relies on a fixed Remote Center of Motion (RCM) for robot mobility control, which assumes that the patient's abdominal walls are immobile. However, this assumption is inaccurate, especially in collaborative surgical environments. In this paper, we present a force-based strategy for the mobility of a robotic camera-holder system for laparoscopic surgery based on a pivoting motion. This strategy re-conceptualizes the conventional mobility control paradigm of surgical robotics. Methods: The proposed strategy involves direct control of the Tool Center Point's (TCP) position and orientation without any constraints associated with the spatial position of the incision. It is based on pivoting motions to minimize contact forces between the abdominal walls and the laparoscope. The control directly relates the measured force and angular velocity of the laparoscope, resulting in the reallocation of the trocar, whose position becomes a consequence of the natural accommodation allowed by this pivoting. Results: The effectiveness and safety of the proposed control were evaluated through a series of experiments. The experiments showed that the control was able to minimize an external force of 9 N to ±0.2 N in 0.7 s and reduce it to 2 N in just 0.3 s. Furthermore, the camera was able to track a region of interest by displacing the TCP as desired, leveraging the strategy's property that dynamically constrains its orientation. Discussion: The proposed control strategy has proven to be effective minimizing the risk caused by sudden high forces resulting from accidents and maintaining the field of view despite any movements in the surgical environment, such as physiological movements of the patient or undesired movements of other surgical instruments. This control strategy can be implemented for laparoscopic robots without mechanical RCMs, as well as commercial collaborative robots, thereby improving the safety of surgical interventions in collaborative environments.

R2 advances in robotic-assisted spine surgery: comparative analysis of options, future directions, and bibliometric analysis of the literature

Spine surgery has undergone rapid advancements over the past several decades with the emergence of robotic and minimally invasive surgery (MIS). While conventional MIS spine surgery has had relative success, its complication profile has warranted continued efforts to improve clinical outcomes. We discuss the functional, clinical, and financial aspects of four robotic options for spinal pathologies, namely ROSA, Mazor X, Da Vinci, and ExcelsiusGPS, and conduct a bibliometric analysis to better understand current trends and applications of these robots as the field of robotic spine surgery continues to grow. An extensive search of English-language published literature on robotic-assisted spinal surgery was performed in Elsevier's Scopus database. A bibliometric analysis was then performed on the top 100 most cited papers. The search yielded articles regarding robotic-assisted spine surgery application, limitations, and functional outcomes secondary to spine pathology. Accuracy analyses of 1733 screw placements were reviewed. The top 100 papers were published between 1992 and 2020, with a significant increase from 2015 onwards. The top publishing institution was John Hopkins University (n = 8). The top contributing author was Dr. Isador H. Lieberman (n = 6). The USA (n = 34) had the most articles on robotic spinal surgery, followed by Germany (n = 12). This review examines robotic applications in spine surgery, including four available options: ROSA, Mazor X, Da Vinci, and ExcelsiusGPS. Publication output over time, surgical outcomes, screw accuracy, and cost-effectiveness of these technologies have been investigated here. Certain robots have functional, clinical, and financial differences worth noting. Given the dearth of existing literature reporting postoperative complications and long-term comparative outcomes, there is a clear need for further studies on this matter.

Mobile internet-based mixed-reality interactive telecollaboration system for neurosurgical procedures: technical feasibility and clinical implementation

OBJECTIVE

To increase access to health interventions and healthcare services for patients in resource-constrained settings, strategies such as telemedicine must be implemented for the allocation of medical resources across geographic boundaries. Telecollaboration is the dominant form of surgical telemedicine. In this study, the authors report and evaluate a novel mobile internet-based mixed-reality interactive telecollaboration (MIMIT) system as a new paradigm for telemedicine and validate its clinical feasibility.

METHODS

The application of this system was demonstrated for long-distance, real-time collaboration of neuroendoscopic procedures. The system consists of a local video processing workstation, a head-mounted mixed-reality display device, and a mobile remote device, connected over mobile internet (4G or 5G), allowing global point-to-point communication. Using this system, 20 cases of neuroendoscopic surgery were performed and evaluated. The system setup, composite video latency, technical feasibility, clinical implementation, and future potential business model were analyzed and evaluated.

RESULTS

The MIMIT system allows two surgeons to perform complex visual and verbal communication during the operation. The average video delay time is 184.25 msec (range 160–230 msec) with 4G mobile internet, and 23.25 msec (range 20–26 msec) with 5G mobile internet. Excellent image resolution enabled remote neurosurgeons to visualize all critical anatomical structures intraoperatively. Remote instructors could easily make marks on the surgical view; then the composite image, as well as the audio conversation, was transferred to the local surgeon. In this way, a real-time, long-distance collaboration can occur. This system was used for 20 neuroendoscopic surgeries in various cities in China and even across countries (Boston, Massachusetts, to Jingzhou, China). Its simplicity and practicality have been recognized by both parties, and there were no technically related complications recorded.

CONCLUSIONS

The MIMIT system allows for real-time, long-distance telecollaborative neuroendoscopic procedures and surgical training through a commercially available and inexpensive system. It enables remote experts to implement real-time, long-distance intraoperative interaction to guide inexperienced local surgeons, thus integrating the best medical resources and possibly promoting both diagnosis and treatment. Moreover, it can popularize and improve neurosurgical endoscopy technology in more hospitals to benefit more patients, as well as more neurosurgeons.

Cardiac Patch Transplantation Instruments for Robotic Minimally Invasive Cardiac Surgery: Initial Proof-of-concept Designs and Surgery in a Porcine Cadaver

Background: Damaged cardiac tissues could potentially be regenerated by transplanting bioengineered cardiac patches to the heart surface. To be fully paradigm-shifting, such patches may need to be transplanted using minimally invasive robotic cardiac surgery (not only traditional open surgery). Here, we present novel robotic designs, initial prototyping and a new surgical operation for instruments to transplant patches via robotic minimally invasive heart surgery.

Methods: Robotic surgical instruments and automated control systems were designed, tested with simulation software and prototyped. Surgical proof-of-concept testing was performed on a pig cadaver.

Results: Three robotic instrument designs were developed. The first (called “Claw” for the claw-like patch holder at the tip) operates on a rack and pinion mechanism. The second design (“Shell-Beak”) uses adjustable folding plates and rods with a bevel gear mechanism. The third (“HeartStamp”) utilizes a stamp platform protruding through an adjustable ring. For the HeartStamp, rods run through a cylindrical structure designed to fit a uniportal Video-Assisted Thorascopic Surgery (VATS) surgical port. Designed to work with or without a sterile sheath, the patch is pushed out by the stamp platform as it protrudes. Two instrument robotic control systems were designed, simulated in silico and one of these underwent early ‘sizing and learning’ prototyping as a proof-of-concept. To reflect real surgical conditions, surgery was run “live” and reported exactly (as-it-happened). We successfully picked up, transferred and released a patch onto the heart using the HeartStamp in a pig cadaver model.

Conclusion: These world-first designs, early prototypes and a novel surgical operation pave the way for robotic instruments for automated keyhole patch transplantation to the heart. Our novel approach is presented for others to build upon free from restrictions or cost—potentially a significant moment in myocardial regeneration surgery which may open a therapeutic avenue for patients unfit for traditional open surgery.

A World-First Surgical Instrument for Minimally Invasive Robotically-Enabled Transplantation of Heart Patches for Myocardial Regeneration: A Brief Research Report

Background: Patch-based approaches to regenerating damaged myocardium include epicardial surgical transplantation of heart patches. By the time this therapy is ready for widespread clinical use, it may be important that patches can be delivered via minimally invasive and robotic surgical approaches. This brief research report describes a world-first minimally invasive patch transplantation surgical device design enabled for human operation, master-slave, and fully automated robotic control. Method: Over a 12-month period (2019-20) in our multidisciplinary team we designed a surgical instrument to transplant heart patches to the epicardial surface. The device was designed for use via uni-portal or multi-portal Video-Assisted Thorascopic Surgery (VATS). For preliminary feasibility and sizing, we used a 3D printer to produce parts of a flexible resin model from a computer-aided design (CAD) software platform in preparation for more robust high-resolution metal manufacturing. Results: The instrument was designed as a sheath containing foldable arms, <2 cm in diameter when infolded to fit minimally invasive thoracic ports. The total length was 35 cm. When the arms were projected from the sheath, three moveable mechanical arms at the distal end were designed to hold a patch. Features included: a rotational head allowing for the arms to be angled in real time, a surface with micro-attachment points for patches and a releasing mechanism to release the patch. Conclusion: This brief research report represents a first step on a potential pathway towards minimally invasive robotic epicardial patch transplantation. For full feasibility testing, future proof-of-concept studies, and efficacy trials will be needed.

Endonasal endoscopic transsphenoidal approach robot prototype: A cadaveric trial

BACKGROUND

The Endonasal Endoscopic Transsphenoidal Surgery (EETS) is a minimally invasive procedure to approach and remove pituitary tumors and other sellar lesions. The process causes less pain, faster recovery, and provides further minimal invasive access in critical cases. However, a slight deviation of tools from the target area can be fatal to the patients. The aim of this study is to design and develop a prototype robot to demonstrate neurosurgical robot-assisted EET approach.

METHODS

The effectiveness of a prototype robot in executing a minimally invasive EET surgery was studied in 6 cadavers. The robot was associated with a multi-information integrated technique for surgery including QR code tracking. The robot was controlled and driven by the neurosurgeon.

RESULTS

The standard procedure of EET was followed and the robot carried out the first stage of EET under the supervision of neurosurgeon. Finally, the sellar was reached by the neurosurgeon. The result was determined by qualitative analysis and was confirmed by the neurosurgeon. The time for the entire EET surgical procedure showed marked reduction compared to the traditional EET approach.

CONCLUSION

The robot design was found to be technically feasible and hence can be used for assisting the EET procedure. The robot used was able to assist the neurosurgeon correctly to approach the sinus.

Removal of pediatric stage IV neuroblastoma by robot-assisted laparoscopy: A case report and literature review

BACKGROUND

Neuroblastoma (NB) is the most common extracranial solid tumor in children, with an incidence of approximately 1/10000. Surgical resection is an effective treatment for children with NB. Robot-assisted laparoscopic surgery is a new method and is superior to conventional laparoscopic surgery, since it has been preliminarily applied in clinical practice with a significant curative effect. This paper discusses significance and feasibility of complete resection of stage IV NB using robot-assisted laparoscopic surgery, while comparing its safety and effectiveness with conventional laparoscopic surgery.

CASE SUMMARY

In June 2018, a girl with stage IV retroperitoneal NB, aged 3 years and 5 mo, was admitted. Her weight was 15 kg, and her height was 100 cm. Robot-assisted, five-port laparoscopic resection of NB was performed. Starting from the middle point between the navel and the anterior superior iliac spine to the left lower abdomen, the pneumoperitoneum and observation hole (10 mm) were established using the Hasson technique. Operation arm #1 was located between the left anterior axillary line, the navel, and the costal margin (8 mm); operation arm #2 was located at the intersection of the right anterior axillary line and Pfannenstiel line (8 mm); one auxiliary hole was located between arm #2 (on the Pfannenstiel line) and the observation hole (12 mm); and another auxiliary hole (5 mm) was located slightly below the left side of the xiphoid. Along the right line of Toldt and the hepatic flexure of the transverse colon, the colon was turned to the left and below with a hook electrode. Through Kocher's incision, the duodenum and the pancreatic head were turned to the left to expose the inferior vena cava and the abdominal aorta. The vein was separated along the right external iliac, and the inferior vena cava was then lifted to expose the right renal vein from the bottom to the top. The tumor was transected horizontally below the renal vein, and it was first cut into pieces and then resected. The right renal artery and the left renal vein were also exposed, and the retrohepatic inferior vena cava was isolated. The tumor was resected along the surface of the psoas muscle, the back of the inferior vena cava, and the right side of the abdominal aorta. Finally, the lymph node metas-tases in front of the abdominal aorta and left renal vein were completely removed. The specimens were loaded into a disposable specimen retrieval bag and removed from the enlarged auxiliary hole. T-tube drainage was placed and brought out through a hole in the right lower quadrant of the abdomen. The operative time was 389 min, the time of pneumoperitoneum was 360 min, the intraoperative blood loss was approximately 200 mL, and the postoperative recovery was smooth. There were no complications, such as lymphatic fistula, diarrhea, bleeding, and paralytic ileus. Two months after discharge, there were no other complications. The literature on the application of robot-assisted laparoscopic surgery in the treatment of NB in children was reviewed

CONCLUSION

The robot has the advantages of a three-dimensional view and flexible operation, and it can operate finely along blood vessels. The successful experience of this case confirmed that robot-assisted laparoscopic surgery can skeletonize the abdominal blood vessels in the tumor and cut the tumor into pieces, indicating that robot-assisted laparoscopic surgery is feasible.

Solving the Time-Varying Inverse Kinematics Problem for the Da Vinci Surgical Robot

A dialytic-elimination and Newton-iteration based quasi-analytic inverse kinematics approach is proposed for the 6 degree of freedom (DOF) active slave manipulator in the Da Vinci surgical robot and other similar systems. First, the transformation matrix-based inverse kinematics model is derived; then, its high-dimensional nonlinear equations are transformed to a high-order nonlinear equation with only one unknown variable by using the dialytic elimination with a unitary matrix. Finally, the quasi-analytic solution is eventually obtained by the Newton iteration method. Simulations are conducted, and the result show that the proposed quasi-analytic approach has advantages in terms of accuracy (error < 0.00004 degree (or mm)), solution speed (< 20 ms) and is barely affected by the singularity during intermediate calculations, which proves that the approach meets the real-time and high-accuracy requirements of master‒slave mapping control for the Da Vinci surgical robots and other similar systems. In addition, the proposed approach can also serve as a design reference for other types of robotic arms that do not satisfy the Pieper principle.