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Geiger L, Zuniga MG, Lenarz T, Majdani O, Rau TS. Drilling accuracy evaluation of a mouldable surgical targeting system for minimally invasive access to anatomic targets in the temporal bone. Eur Arch Otorhinolaryngol 2023; 280:4371-4379. [PMID: 37010602 PMCID: PMC10477231 DOI: 10.1007/s00405-023-07925-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 03/13/2023] [Indexed: 04/04/2023]
Abstract
PURPOSE Minimally invasive cochlear implant surgery using a micro-stereotactic surgical targeting system with on-site moulding of the template aims for a reliable, less experience-dependent access to the inner ear under maximal reduction of trauma to anatomic structures. We present an accuracy evaluation of our system in ex-vivo testing. METHODS Eleven drilling experiments were performed on four cadaveric temporal bone specimens. The process involved preoperative imaging after affixing the reference frame to the skull, planning of a safe trajectory preserving relevant anatomical structures, customization of the surgical template, execution of the guided drilling and postoperative imaging for determination of the drilling accuracy. Deviation between the drilled and desired trajectories was measured at different depths. RESULTS All drilling experiments were successfully performed. Other than purposely sacrificing the chorda tympani in one experiment, no other relevant anatomy, such as facial nerve, chorda tympani, ossicles or external auditory canal were harmed. Deviation between the desired and achieved path was found to be 0.25 ± 0.16 mm at skulls' surface and 0.51 ± 0.35 mm at the target level. The closest distance of the drilled trajectories' outer circumference to the facial nerve was 0.44 mm. CONCLUSIONS We demonstrated the usability for drilling to the middle ear on human cadaveric specimen in a pre-clinical setting. Accuracy proved to be suitable for many applications such as procedures within the field of image-guided neurosurgery. Promising approaches to reach sufficient submillimetre accuracy for CI surgery have been outlined.
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Affiliation(s)
- Lena Geiger
- Department of Otolaryngology and Cluster of Excellence EXC 2177/1 "Hearing4all", Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - M Geraldine Zuniga
- Department of Otolaryngology and Cluster of Excellence EXC 2177/1 "Hearing4all", Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
- Ear Medical Group, San Antonio, TX, USA
- Tecnologico de Monterrey, Instituto de Otorrinolaringologia, Hospital Zambrano Hellion, TecSalud, San Pedro Garza Garcia, Mexico
| | - Thomas Lenarz
- Department of Otolaryngology and Cluster of Excellence EXC 2177/1 "Hearing4all", Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Omid Majdani
- Department of Otolaryngology and Cluster of Excellence EXC 2177/1 "Hearing4all", Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Thomas S Rau
- Department of Otolaryngology and Cluster of Excellence EXC 2177/1 "Hearing4all", Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
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Topsakal V, Heuninck E, Matulic M, Tekin AM, Mertens G, Van Rompaey V, Galeazzi P, Zoka-Assadi M, van de Heyning P. First Study in Men Evaluating a Surgical Robotic Tool Providing Autonomous Inner Ear Access for Cochlear Implantation. Front Neurol 2022; 13:804507. [PMID: 35386404 PMCID: PMC8979022 DOI: 10.3389/fneur.2022.804507] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 02/10/2022] [Indexed: 11/17/2022] Open
Abstract
Image-guided and robot-assisted surgeries have found their applications in skullbase surgery. Technological improvements in terms of accuracy also opened new opportunities for robotically-assisted cochlear implantation surgery (RACIS). The HEARO® robotic system is an otological next-generation surgical robot to assist the surgeon. It first provides software-defined spatial boundaries for orientation and reference information to anatomical structures during otological and neurosurgical procedures. Second, it executes a preplanned drill trajectory through the temporal bone. Here, we report how safe the HEARO procedure can provide an autonomous minimally invasive inner ear access and the efficiency of this access to subsequently insert the electrode array during cochlear implantation. In 22 out of 25 included patients, the surgeon was able to complete the HEARO® procedure. The dedicated planning software (OTOPLAN®) allowed the surgeon to reconstruct a three-dimensional representation of all the relevant anatomical structures, designate the target on the cochlea, i.e., the round window, and plan the safest trajectory to reach it. This trajectory accommodated the safety distance to the critical structures while minimizing the insertion angles. A minimal distance of 0.4 and 0.3 mm was planned to facial nerve and chorda tympani, respectively. Intraoperative cone-beam CT supported safe passage for the 22 HEARO® procedures. The intraoperative accuracy analysis reported the following mean errors: 0.182 mm to target, 0.117 mm to facial nerve, and 0.107 mm to chorda tympani. This study demonstrates that microsurgical robotic technology can be used in different anatomical variations, even including a case of inner ear anomalies, with the geometrically correct keyhole to access to the inner ear. Future perspectives in RACIS may focus on improving intraoperative imaging, automated segmentation and trajectory, robotic insertion with controlled speed, and haptic feedback. This study [Experimental Antwerp robotic research otological surgery (EAR2OS) and Antwerp Robotic cochlear implantation (25 refers to 25 cases) (ARCI25)] was registered at clinicalTrials.gov under identifier NCT03746613 and NCT04102215.
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Affiliation(s)
- Vedat Topsakal
- Department of Otorhinolaryngology Head and Neck Surgery, University Hospital UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium
- *Correspondence: Vedat Topsakal
| | - Emilie Heuninck
- Department of Otorhinolaryngology Head and Neck Surgery, University Hospital UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | | | - Ahmet M. Tekin
- Department of Otorhinolaryngology Head and Neck Surgery, University Hospital UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium
- Department of Otorhinolaryngology, Klinikum Bad Salzungen, Bad Salzungen, Germany
| | - Griet Mertens
- Department of Otorhinolaryngology, Head and Neck Surgery, Department of Translational Neurosciences, Faculty of Medicine and Health Sciences, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
| | - Vincent Van Rompaey
- Department of Otorhinolaryngology, Head and Neck Surgery, Department of Translational Neurosciences, Faculty of Medicine and Health Sciences, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
| | | | | | - Paul van de Heyning
- Department of Otorhinolaryngology, Head and Neck Surgery, Department of Translational Neurosciences, Faculty of Medicine and Health Sciences, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
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Robotics, automation, active electrode arrays, and new devices for cochlear implantation: A contemporary review. Hear Res 2022; 414:108425. [PMID: 34979455 DOI: 10.1016/j.heares.2021.108425] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 12/16/2021] [Accepted: 12/23/2021] [Indexed: 01/14/2023]
Abstract
In the last two decades, cochlear implant surgery has evolved into a minimally invasive, hearing preservation surgical technique. The devices used during surgery have benefited from technological advances that have allowed modification and possible improvement of the surgical technique. Robotics has recently gained popularity in otology as an effective tool to overcome the surgeon's limitations such as tremor, drift and accurate force control feedback in laboratory testing. Cochlear implantation benefits from robotic assistance in several steps during the surgical procedure: (i) during the approach to the middle ear by automated mastoidectomy and posterior tympanotomy or through a tunnel from the postauricular skin to the middle ear (i.e. direct cochlear access); (ii) a minimally invasive cochleostomy by a robot-assisted drilling tool; (iii) alignment of the correct insertion axis on the basal cochlear turn; (iv) insertion of the electrode array with a motorized insertion tool. In recent years, the development of bone-attached parallel robots and image-guided surgical robotic systems has allowed the first successful cochlear implantation procedures in patients via a single hole drilled tunnel. Several other robotic systems, new materials, sensing technologies applied to the electrodes, and smart devices have been developed, tested in experimental models and finally some have been used in patients with the aim of reducing trauma in cochleostomy, and permitting slow and more accurate insertion of the electrodes. Despite the promising results in laboratory tests in terms of minimal invasiveness, reduced trauma and better hearing preservation, so far, no clinical benefits on residual hearing preservation or better speech performance have been demonstrated. Before these devices can become the standard approach for cochlear implantation, several points still need to be addressed, primarily cost and duration of the procedure. One can hope that improvement in the cost/benefit ratio will expand the technology to every cochlear implantation procedure. Laboratory research and clinical studies on patients should continue with the aim of making intracochlear implant insertion an atraumatic and reversible gesture for total preservation of the inner ear structure and physiology.
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Riojas KE, Tran ET, Freeman MH, Noble JH, Webster RJ, Labadie RF. Clinical Translation of an Insertion Tool for Minimally Invasive Cochlear Implant Surgery. J Med Device 2021; 15:031001. [PMID: 33995757 PMCID: PMC8086187 DOI: 10.1115/1.4050203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 01/22/2021] [Indexed: 11/08/2022] Open
Abstract
The objective of this paper is to describe the development of a minimally invasive cochlear implant surgery (MICIS) electrode array insertion tool concept to enable clinical translation. First, analysis of the geometric parameters of potential MICIS patients (N = 97) was performed to inform tool design, inform MICIS phantom model design, and provide further insight into MICIS candidacy. Design changes were made to the insertion tool based on clinical requirements and parameter analysis results. A MICIS phantom testing model was built to evaluate insertion force profiles in a clinically realistic manner, and the new tool design was evaluated in the model and in cadavers to test clinical viability. Finally, after regulatory approval, the tool was used for the first time in a clinical case. Results of this work included first, in the parameter analysis, approximately 20% of the population was not considered viable MICIS candidates. Additionally, one 3D printed tool could accommodate all viable candidates with polyimide sheath length adjustments accounting for interpatient variation. The insertion tool design was miniaturized out of clinical necessity and a disassembly method, necessary for removal around the cochlear implant, was developed and tested. Phantom model testing revealed that the force profile of the insertion tool was similar to that of traditional forceps insertion. Cadaver testing demonstrated that all clinical requirements (including complete disassembly) were achieved with the tool, and the new tool enabled 15% deeper insertions compared to the forceps approach. Finally, and most importantly, the tool helped achieve a full insertion in its first MICIS clinical case. In conclusion, the new insertion tool provides a clinically viable solution to one of the most difficult aspects of MICIS.
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Affiliation(s)
- Katherine E. Riojas
- Department of Mechanical Engineering, Vanderbilt University, Nashville, TN 37212
| | - Emily T. Tran
- Department of Mechanical Engineering, The University of Tulsa, Tulsa, OK 74104
| | - Michael H. Freeman
- Department of Otolaryngology–Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN 37232
| | - Jack H. Noble
- Department of Electrical Engineering and Computer Science, Vanderbilt University, Nashville, TN 37212
| | - Robert J. Webster
- Department of Mechanical Engineering, Vanderbilt University, Nashville, TN 37212
| | - Robert F. Labadie
- Department of Otolaryngology–Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN 37232
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Rau TS, Witte S, Uhlenbusch L, Kahrs LA, Lenarz T, Majdani O. Concept description and accuracy evaluation of a moldable surgical targeting system. J Med Imaging (Bellingham) 2021; 8:015003. [PMID: 33634206 PMCID: PMC7893323 DOI: 10.1117/1.jmi.8.1.015003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 01/19/2021] [Indexed: 11/14/2022] Open
Abstract
Purpose: We explain our concept for customization of a guidance instrument, present a prototype, and describe a set of experiments to evaluate its positioning and drilling accuracy. Methods: Our concept is characterized by the use of bone cement, which enables fixation of a specific configuration for each individual surgical template. This well-established medical product was selected to ensure future intraoperative fabrication of the template under sterile conditions. For customization, a manually operated alignment device is proposed that temporary defines the planned trajectory until the bone cement is hardened. Experiments (n=10) with half-skull phantoms were performed. Analysis of accuracy comprises targeting validations and experiments including drilling in bone substitutes. Results: The resulting mean positioning error was found to be 0.41±0.30 mm at the level of the target point whereas drilling was possible with a mean accuracy of 0.35±0.30 mm. Conclusion: We proposed a cost-effective, easy-to-use approach for accurate instrument guidance that enables template fabrication under sterile conditions. The utilization of bone cement was proven to fulfill the demands of an easy, quick, and prospectively intraoperatively doable customization. We could demonstrate sufficient accuracy for many surgical applications, e.g., in neurosurgery. The system in this early development stage already outperforms conventional stereotactic frames and image-guided surgery systems in terms of targeting accuracy.
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Affiliation(s)
- Thomas S Rau
- Hannover Medical School, Department of Otolaryngology, Cluster of Excellence EXC 2177/1 "Hearing4all", Hannover, Germany
| | - Sina Witte
- Hannover Medical School, Department of Otolaryngology, Cluster of Excellence EXC 2177/1 "Hearing4all", Hannover, Germany
| | - Lea Uhlenbusch
- Hannover Medical School, Department of Otolaryngology, Cluster of Excellence EXC 2177/1 "Hearing4all", Hannover, Germany
| | - Lüder A Kahrs
- University of Toronto Mississauga, Department of Mathematical and Computational Sciences, Mississauga, Ontario, Canada.,Hospital for Sick Children (SickKids), Centre for Image Guided Innovation and Therapeutic Intervention, Toronto, Ontario, Canada
| | - Thomas Lenarz
- Hannover Medical School, Department of Otolaryngology, Cluster of Excellence EXC 2177/1 "Hearing4all", Hannover, Germany
| | - Omid Majdani
- Hannover Medical School, Department of Otolaryngology, Cluster of Excellence EXC 2177/1 "Hearing4all", Hannover, Germany
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Cömert E, Cömert A. Surgical anatomy of the transcanal infracochlear approach. Eur Arch Otorhinolaryngol 2021; 279:159-168. [PMID: 33532901 DOI: 10.1007/s00405-021-06635-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 01/20/2021] [Indexed: 01/29/2023]
Abstract
PURPOSE The objective of this study is to describe the detailed surgical anatomy of the infracochlear approach to prevent complications and to compare the postauricular transcanal microscopic and endoscopic approaches to reach the petrous apex. METHODS Cadaver heads were dissected using a binocular surgical microscope, endoscopes, and an electric drill. The dimensions of the access field that could be reached and manipulated with surgical instruments and straight drill via postauricular transcanal microscopic and endoscopic approaches were evaluated. RESULTS Both postauricular microscopic and transcanal endoscopic approaches were considered to be inapplicable in cases with a tympanic cavity located jugular bulb closer than 3 mm to the cochlea. This relationship was seen in 3 (9%) sides of the cadavers. In 4 specimens (12%), a cochlear aqueduct with an open lumen was detected. Both postauricular microscopic and transcanal endoscopic approaches reached a nearly identic dissection area. Detailed anatomy of the approach and measurements about the topography of the third portion of the facial nerve from the tympanic cavity were presented. CONCLUSION Both traditional microscopic postauricular and endoscopic transcanal approaches provided comparable access areas to the inferior petrous apex with wide exposure, and radiologic measurements were compatible. A tympanic cavity located jugular bulb in close relation with cochlea was the only instance that restricted the applicability of this technique.
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Affiliation(s)
- Ela Cömert
- Department of Otolaryngology, Kırıkkale University School of Medicine, Ankara Yolu 7. Km, 71450, Yahşihan, Kırıkkale, Turkey.
| | - Ayhan Cömert
- Department of Anatomy, Ankara University School of Medicine, Ankara, Turkey
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8
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Švaco M, Stiperski I, Dlaka D, Šuligoj F, Jerbić B, Chudy D, Raguž M. Stereotactic Neuro-Navigation Phantom Designs: A Systematic Review. Front Neurorobot 2020; 14:549603. [PMID: 33192433 PMCID: PMC7644893 DOI: 10.3389/fnbot.2020.549603] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 09/16/2020] [Indexed: 11/28/2022] Open
Abstract
Diverse stereotactic neuro-navigation systems are used daily in neurosurgery and novel systems are continuously being developed. Prior to clinical implementation of new surgical tools, methods or instruments, in vitro experiments on phantoms should be conducted. A stereotactic neuro-navigation phantom denotes a rigid or deformable structure resembling the cranium with the intracranial area. The use of phantoms is essential for the testing of complete procedures and their workflows, as well as for the final validation of the application accuracy. The aim of this study is to provide a systematic review of stereotactic neuro-navigation phantom designs, to identify their most relevant features, and to identify methodologies for measuring the target point error, the entry point error, and the angular error (α). The literature on phantom designs used for evaluating the accuracy of stereotactic neuro-navigation systems, i.e., robotic navigation systems, stereotactic frames, frameless navigation systems, and aiming devices, was searched. Eligible articles among the articles written in English in the period 2000–2020 were identified through the electronic databases PubMed, IEEE, Web of Science, and Scopus. The majority of phantom designs presented in those articles provide a suitable methodology for measuring the target point error, while there is a lack of objective measurements of the entry point error and angular error. We identified the need for a universal phantom design, which would be compatible with most common imaging techniques (e.g., computed tomography and magnetic resonance imaging) and suitable for simultaneous measurement of the target point, entry point, and angular errors.
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Affiliation(s)
- Marko Švaco
- Faculty of Mechanical Engineering and Naval Architecture, University of Zagreb, Zagreb, Croatia.,Department of Neurosurgery, University Hospital Dubrava, Zagreb, Croatia
| | - Ivan Stiperski
- Faculty of Mechanical Engineering and Naval Architecture, University of Zagreb, Zagreb, Croatia
| | - Domagoj Dlaka
- Department of Neurosurgery, University Hospital Dubrava, Zagreb, Croatia
| | - Filip Šuligoj
- Faculty of Mechanical Engineering and Naval Architecture, University of Zagreb, Zagreb, Croatia.,Department of Neurosurgery, University Hospital Dubrava, Zagreb, Croatia
| | - Bojan Jerbić
- Faculty of Mechanical Engineering and Naval Architecture, University of Zagreb, Zagreb, Croatia.,Department of Neurosurgery, University Hospital Dubrava, Zagreb, Croatia
| | - Darko Chudy
- Department of Neurosurgery, University Hospital Dubrava, Zagreb, Croatia.,Croatian Institute for Brain Research, School of Medicine University of Zagreb, Zagreb, Croatia.,Department of Surgery, School of Medicine University of Zagreb, Zagreb, Croatia
| | - Marina Raguž
- Department of Neurosurgery, University Hospital Dubrava, Zagreb, Croatia.,Croatian Institute for Brain Research, School of Medicine University of Zagreb, Zagreb, Croatia.,Department of Anatomy and Clinical Anatomy, School of Medicine University of Zagreb, Zagreb, Croatia
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Ye M, Li W, Chan DTM, Chiu PWY, Li Z. A Semi-Autonomous Stereotactic Brain Biopsy Robot With Enhanced Safety. IEEE Robot Autom Lett 2020. [DOI: 10.1109/lra.2020.2967732] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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10
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Rau TS, Kreul D, Lexow J, Hügl S, Zuniga MG, Lenarz T, Majdani O. Characterizing the size of the target region for atraumatic opening of the cochlea through the facial recess. Comput Med Imaging Graph 2019; 77:101655. [DOI: 10.1016/j.compmedimag.2019.101655] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 07/05/2019] [Accepted: 08/19/2019] [Indexed: 11/26/2022]
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Abstract
The advances in technology leading to rapid developments in implantable auditory devices are constantly evolving. Devices are becoming smaller, less visible, and more efficient. The ability to preserve hearing outcomes with cochlear implantation will continue to evolve as surgical techniques improve with the use of continuous feedback during the procedure as well as with intraoperative delivery of drugs and robot assistance. As engineering methods improve, there may one day be a totally implantable aid that is self-sustaining in hearing-impaired patients making them indistinguishable from patients without hearing loss.
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Affiliation(s)
- Robert M Rhodes
- The Department of Otolaryngology Head and Neck Surgery, The University of Oklahoma Health Sciences Center, 800 Stanton L Young Boulevard, Suite 1400, Oklahoma City, OK 73104, USA
| | - Betty S Tsai Do
- The Department of Otolaryngology Head and Neck Surgery, The University of Oklahoma Health Sciences Center, 800 Stanton L Young Boulevard, Suite 1400, Oklahoma City, OK 73104, USA.
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Dahroug B, Tamadazte B, Weber S, Tavernier L, Andreff N. Review on Otological Robotic Systems: Toward Microrobot-Assisted Cholesteatoma Surgery. IEEE Rev Biomed Eng 2018; 11:125-142. [PMID: 29994589 DOI: 10.1109/rbme.2018.2810605] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Otologic surgical procedures over time have become minimally invasive due to the development of medicine, microtechniques, and robotics. This trend then provides an expected reduction in the patient's recovery time and improvement in the accuracy of diagnosis and treatment. One of the most challenging difficulties that such techniques face are precise control of the instrument and supply of an ergonomic system to the surgeon. The objective of this literature review is to present requirements and guidelines for a surgical robotic system dedicated to middle ear surgery. This review is particularly focused on cholesteatoma surgery (diagnosis and surgical tools), which is one of the most frequent pathologies that urge for an enhanced treatment. This review also presents the current robotic systems that are implemented for otologic applications.
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Pre-operative Screening and Manual Drilling Strategies to Reduce the Risk of Thermal Injury During Minimally Invasive Cochlear Implantation Surgery. Ann Biomed Eng 2017; 45:2184-2195. [PMID: 28523516 DOI: 10.1007/s10439-017-1854-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 05/11/2017] [Indexed: 10/19/2022]
Abstract
This article presents the development and experimental validation of a methodology to reduce the risk of thermal injury to the facial nerve during minimally invasive cochlear implantation surgery. The first step in this methodology is a pre-operative screening process, in which medical imaging is used to identify those patients that present a significant risk of developing high temperatures at the facial nerve during the drilling phase of the procedure. Such a risk is calculated based on the density of the bone along the drilling path and the thermal conductance between the drilling path and the nerve, and provides a criterion to exclude high-risk patients from receiving the minimally invasive procedure. The second component of the methodology is a drilling strategy for manually-guided drilling near the facial nerve. The strategy utilizes interval drilling and mechanical constraints to enable better control over the procedure and the resulting generation of heat. The approach is tested in fresh cadaver temporal bones using a thermal camera to monitor temperature near the facial nerve. Results indicate that pre-operative screening may successfully exclude high-risk patients and that the proposed drilling strategy enables safe drilling for low-to-moderate risk patients.
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Caversaccio M, Gavaghan K, Wimmer W, Williamson T, Ansò J, Mantokoudis G, Gerber N, Rathgeb C, Feldmann A, Wagner F, Scheidegger O, Kompis M, Weisstanner C, Zoka-Assadi M, Roesler K, Anschuetz L, Huth M, Weber S. Robotic cochlear implantation: surgical procedure and first clinical experience. Acta Otolaryngol 2017; 137:447-454. [PMID: 28145157 DOI: 10.1080/00016489.2017.1278573] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
CONCLUSION A system for robotic cochlear implantation (rCI) has been developed and a corresponding surgical workflow has been described. The clinical feasibility was demonstrated through the conduction of a safe and effective rCI procedure. OBJECTIVES To define a clinical workflow for rCI and demonstrate its feasibility, safety, and effectiveness within a clinical setting. METHOD A clinical workflow for use of a previously described image guided surgical robot system for rCI was developed. Based on pre-operative images, a safe drilling tunnel targeting the round window was planned and drilled by the robotic system. Intra-operatively the drill path was assessed using imaging and sensor-based data to confirm the proximity of the facial nerve. Electrode array insertion was manually achieved under microscope visualization. Electrode array placement, structure preservation, and the accuracy of the drilling and of the safety mechanisms were assessed on post-operative CT images. RESULTS Robotic drilling was conducted with an accuracy of 0.2 mm and safety mechanisms predicted proximity of the nerves to within 0.1 mm. The approach resulted in a minimal mastoidectomy and minimal incisions. Manual electrode array insertion was successfully performed through the robotically drilled tunnel. The procedure was performed without complications, and all surrounding structures were preserved.
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Affiliation(s)
- Marco Caversaccio
- Department of ENT, Head and Neck Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Image-Guided Therapy and Artificial Hearing Research, ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - Kate Gavaghan
- Image-Guided Therapy and Artificial Hearing Research, ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - Wilhelm Wimmer
- Department of ENT, Head and Neck Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Image-Guided Therapy and Artificial Hearing Research, ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - Tom Williamson
- Image-Guided Therapy and Artificial Hearing Research, ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - Juan Ansò
- Image-Guided Therapy and Artificial Hearing Research, ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - Georgios Mantokoudis
- Department of ENT, Head and Neck Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nicolas Gerber
- Image-Guided Therapy and Artificial Hearing Research, ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - Christoph Rathgeb
- Image-Guided Therapy and Artificial Hearing Research, ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - Arne Feldmann
- Musculoskeletal Biomechanics, Institute for Surgical Technologies and Biomechanics, University of Bern, Bern, Switzerland
| | - Franca Wagner
- University Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | | | - Martin Kompis
- Department of ENT, Head and Neck Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christian Weisstanner
- University Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | | | - Kai Roesler
- Department of Neurology, Inselspital, University of Bern, Bern, Switzerland
| | - Lukas Anschuetz
- Department of ENT, Head and Neck Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Markus Huth
- Department of ENT, Head and Neck Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stefan Weber
- Image-Guided Therapy and Artificial Hearing Research, ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
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Ke J, Zhang SX, Hu L, Li CS, Zhu YF, Sun SL, Wang LF, Ma FR. Minimally Invasive Cochlear Implantation Assisted by Bi-planar Device: An Exploratory Feasibility Study in vitro. Chin Med J (Engl) 2017; 129:2476-2483. [PMID: 27748341 PMCID: PMC5072261 DOI: 10.4103/0366-6999.191787] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background: A single drilled tunnel from the lateral mastoid cortex to the cochlea via the facial recess is essential for minimally invasive cochlear implant surgery. This study aimed to explore the safety profile of this kind of new image-guided and bi-planar device-assisted surgery procedure in vitro. Methods: Image-guided minimally invasive cochlear implantations were performed on eight cadaveric temporal bone specimens. The main procedures were: (1) temporal bone specimens were prepared for surgery and fiducial markers were registered. (2) computed tomography (CT) scans were performed for future reference. (3) CT scan images were processed and drill path was planned to minimize cochlear damage. (4) bi-planar device-assisted drilling was performed on the specimens using the registration. (5) surgical safety was evaluated by calculating the deviation between the drill and the planned paths, and by measuring the closest distance between the drilled path and critical anatomic structures. Results: Eight cases were operated successfully to the basal turn of the cochlear with intact facial nerves (FNs). The deviations from target points and entrance points were 0.86 mm (0.68–1.00 mm) and 0.44 mm (0.30–0.96 mm), respectively. The angular error between the planned and the drilled trajectory was 1.74° (1.26–2.41°). The mean distance from the edge of the drilled path to the FN and to the external canal was 0.60 mm (0.35–0.83 mm) and 1.60 mm (1.30–2.05 mm), respectively. In five specimens, the chorda tympani nerves were well preserved. In all cases, no injury happened to auditory ossicles. Conclusions: This exploratory study demonstrated the safety of the newly developed image-guided minimally invasive cochlear implantation assisted by the bi-planar device and established the operational procedures. Further, more in vitro experiments are needed to improve the system operation and its safety.
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Affiliation(s)
- Jia Ke
- Department of Otorhinolarygology - Head and Neck Surgery, Peking University Third Hospital, Beijing 100191, China
| | - Shao-Xing Zhang
- Department of Otorhinolarygology - Head and Neck Surgery, Peking University Third Hospital, Beijing 100191, China
| | - Lei Hu
- Robotics Institute, School of Mechanical Engineering and Automation, Beihang University, Beijing 100191, China
| | - Chang-Sheng Li
- Robotics Institute, School of Mechanical Engineering and Automation, Beihang University, Beijing 100191, China
| | - Yun-Feng Zhu
- Robotics Institute, School of Mechanical Engineering and Automation, Beihang University, Beijing 100191, China
| | - Shi-Long Sun
- Department of Otorhinolarygology - Head and Neck Surgery, Peking University Third Hospital, Beijing 100191, China
| | - Li-Feng Wang
- Robotics Institute, School of Mechanical Engineering and Automation, Beihang University, Beijing 100191, China
| | - Fu-Rong Ma
- Department of Otorhinolarygology - Head and Neck Surgery, Peking University Third Hospital, Beijing 100191, China
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A Neuromonitoring Approach to Facial Nerve Preservation During Image-guided Robotic Cochlear Implantation. Otol Neurotol 2016; 37:89-98. [DOI: 10.1097/mao.0000000000000914] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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17
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Vision-based real-time position control of a semi-automated system for robot-assisted joint fracture surgery. Int J Comput Assist Radiol Surg 2015; 11:437-55. [PMID: 26429787 DOI: 10.1007/s11548-015-1296-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Accepted: 09/10/2015] [Indexed: 01/19/2023]
Abstract
PURPOSE Joint fracture surgery quality can be improved by robotic system with high-accuracy and high-repeatability fracture fragment manipulation. A new real-time vision-based system for fragment manipulation during robot-assisted fracture surgery was developed and tested. METHODS The control strategy was accomplished by merging fast open-loop control with vision-based control. This two-phase process is designed to eliminate the open-loop positioning errors by closing the control loop using visual feedback provided by an optical tracking system. Evaluation of the control system accuracy was performed using robot positioning trials, and fracture reduction accuracy was tested in trials on ex vivo porcine model. RESULTS The system resulted in high fracture reduction reliability with a reduction accuracy of 0.09 mm (translations) and of [Formula: see text] (rotations), maximum observed errors in the order of 0.12 mm (translations) and of [Formula: see text] (rotations), and a reduction repeatability of 0.02 mm and [Formula: see text]. CONCLUSIONS The proposed vision-based system was shown to be effective and suitable for real joint fracture surgical procedures, contributing a potential improvement of their quality.
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Kobler JP, Nuelle K, Lexow GJ, Rau TS, Majdani O, Kahrs LA, Kotlarski J, Ortmaier T. Configuration optimization and experimental accuracy evaluation of a bone-attached, parallel robot for skull surgery. Int J Comput Assist Radiol Surg 2015; 11:421-36. [PMID: 26410844 DOI: 10.1007/s11548-015-1300-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 09/10/2015] [Indexed: 11/25/2022]
Abstract
PURPOSE Minimally invasive cochlear implantation is a novel surgical technique which requires highly accurate guidance of a drilling tool along a trajectory from the mastoid surface toward the basal turn of the cochlea. The authors propose a passive, reconfigurable, parallel robot which can be directly attached to bone anchors implanted in a patient's skull, avoiding the need for surgical tracking systems. Prior to clinical trials, methods are necessary to patient specifically optimize the configuration of the mechanism with respect to accuracy and stability. Furthermore, the achievable accuracy has to be determined experimentally. METHODS A comprehensive error model of the proposed mechanism is established, taking into account all relevant error sources identified in previous studies. Two optimization criteria to exploit the given task redundancy and reconfigurability of the passive robot are derived from the model. The achievable accuracy of the optimized robot configurations is first estimated with the help of a Monte Carlo simulation approach and finally evaluated in drilling experiments using synthetic temporal bone specimen. RESULTS Experimental results demonstrate that the bone-attached mechanism exhibits a mean targeting accuracy of [Formula: see text] mm under realistic conditions. A systematic targeting error is observed, which indicates that accurate identification of the passive robot's kinematic parameters could further reduce deviations from planned drill trajectories. CONCLUSION The accuracy of the proposed mechanism demonstrates its suitability for minimally invasive cochlear implantation. Future work will focus on further evaluation experiments on temporal bone specimen.
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Affiliation(s)
- Jan-Philipp Kobler
- Institute of Mechatronic Systems, Leibniz Universität Hannover, 30167 , Hanover, Germany.
| | - Kathrin Nuelle
- Institute of Mechatronic Systems, Leibniz Universität Hannover, 30167 , Hanover, Germany
| | | | - Thomas S Rau
- Hannover Medical School, 30625 , Hanover, Germany
| | - Omid Majdani
- Hannover Medical School, 30625 , Hanover, Germany
| | - Lueder A Kahrs
- Institute of Mechatronic Systems, Leibniz Universität Hannover, 30167 , Hanover, Germany
| | - Jens Kotlarski
- Institute of Mechatronic Systems, Leibniz Universität Hannover, 30167 , Hanover, Germany
| | - Tobias Ortmaier
- Institute of Mechatronic Systems, Leibniz Universität Hannover, 30167 , Hanover, Germany
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Individual Optimization of the Insertion of a Preformed Cochlear Implant Electrode Array. Int J Otolaryngol 2015; 2015:724703. [PMID: 26448764 PMCID: PMC4581552 DOI: 10.1155/2015/724703] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Accepted: 08/06/2015] [Indexed: 11/21/2022] Open
Abstract
Purpose. The aim of this study was to show that individual adjustment of the curling behaviour of a preformed cochlear implant (CI) electrode array to the patient-specific shape of the cochlea can improve the insertion process in terms of reduced risk of insertion trauma. Methods. Geometry and curling behaviour of preformed, commercially available electrode arrays were modelled. Additionally, the anatomy of each small, medium-sized, and large human cochlea was modelled to consider anatomical variations. Finally, using a custom-made simulation tool, three different insertion strategies (conventional Advanced Off-Stylet (AOS) insertion technique, an automated implementation of the AOS technique, and a manually optimized insertion process) were simulated and compared with respect to the risk of insertion-related trauma. The risk of trauma was evaluated using a newly developed “trauma risk” rating scale. Results. Using this simulation-based approach, it was shown that an individually optimized insertion procedure is advantageous compared with the AOS insertion technique. Conclusion. This finding leads to the conclusion that, in general, consideration of the specific curling behaviour of a CI electrode array is beneficial in terms of less traumatic insertion. Therefore, these results highlight an entirely novel aspect of clinical application of preformed perimodiolar electrode arrays in general.
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Accuracy of linear drilling in temporal bone using drill press system for minimally invasive cochlear implantation. Int J Comput Assist Radiol Surg 2015; 11:483-93. [PMID: 26183149 DOI: 10.1007/s11548-015-1261-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2015] [Accepted: 07/02/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE A minimally invasive approach for cochlear implantation involves drilling a narrow linear path through the temporal bone from the skull surface directly to the cochlea for insertion of the electrode array without the need for an invasive mastoidectomy. Potential drill positioning errors must be accounted for to predict the effectiveness and safety of the procedure. The drilling accuracy of a system used for this procedure was evaluated in bone surrogate material under a range of clinically relevant parameters. Additional experiments were performed to isolate the error at various points along the path to better understand why deflections occur. METHODS An experimental setup to precisely position the drill press over a target was used. Custom bone surrogate test blocks were manufactured to resemble the mastoid region of the temporal bone. The drilling error was measured by creating divots in plastic sheets before and after drilling and using a microscope to localize the divots. RESULTS The drilling error was within the tolerance needed to avoid vital structures and ensure accurate placement of the electrode; however, some parameter sets yielded errors that may impact the effectiveness of the procedure when combined with other error sources. The error increases when the lateral stage of the path terminates in an air cell and when the guide bushings are positioned further from the skull surface. At contact points due to air cells along the trajectory, higher errors were found for impact angles of [Formula: see text] and higher as well as longer cantilevered drill lengths. CONCLUSION The results of these experiments can be used to define more accurate and safe drill trajectories for this minimally invasive surgical procedure.
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Niccolini M, Castelli V, Diversi C, Kang B, Mussa F, Sinibaldi E. Development and preliminary assessment of a robotic platform for neuroendoscopy based on a lightweight robot. Int J Med Robot 2015; 12:4-17. [PMID: 25600885 DOI: 10.1002/rcs.1638] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Revised: 12/11/2014] [Accepted: 12/12/2014] [Indexed: 11/11/2022]
Abstract
BACKGROUND Ventriculostomy is a widely performed neurosurgical procedure; some risk factors can be mitigated by computer/robot-assisted approaches. Platforms fostering synergistic robot-surgeon integration are pursued, for which lightweight robots with compliant controlled joints must be assessed (because compliance hampers accuracy). METHODS We developed a platform encompassing, in particular, a lightweight robot and an optical tracker also used to enhance robot accuracy. Based on specifications by neurosurgeons, we designed a neuroendoscope-handling interface and assessed targeting accuracy in a model ventriculostomy where the robot was operated both autonomously and in hands-on (i.e. co-operative) mode. RESULTS Targeting errors were systematically below the procedure accuracy threshold (1 mm); the rms targeting errors were 0.51 and 0.54 mm for autonomous and hands-on control, respectively. No significant difference was observed between the considered control modes. Very positive feedback was gathered from neurosurgeons. CONCLUSIONS Accurate tool targeting under both autonomous and hands-on control was achieved.
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Affiliation(s)
- Marta Niccolini
- Center for Micro-BioRobotics@SSSA, Istituto Italiano di Tecnologia, Viale Rinaldo Piaggio 34, 56025, Pontedera, Italy
| | - Virginia Castelli
- Center for Micro-BioRobotics@SSSA, Istituto Italiano di Tecnologia, Viale Rinaldo Piaggio 34, 56025, Pontedera, Italy
| | - Costanza Diversi
- Center for Micro-BioRobotics@SSSA, Istituto Italiano di Tecnologia, Viale Rinaldo Piaggio 34, 56025, Pontedera, Italy
| | - Byungjeon Kang
- Center for Micro-BioRobotics@SSSA, Istituto Italiano di Tecnologia, Viale Rinaldo Piaggio 34, 56025, Pontedera, Italy.,The BioRobotics Institute, Scuola Superiore Sant'Anna, Viale Rinaldo Piaggio 34, 56025, Pontedera, Italy
| | - Federico Mussa
- Neurosurgery Department, Meyer Pediatric Hospital, Viale Pieraccini 24, 50139, Firenze, Italy
| | - Edoardo Sinibaldi
- Center for Micro-BioRobotics@SSSA, Istituto Italiano di Tecnologia, Viale Rinaldo Piaggio 34, 56025, Pontedera, Italy
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Feasibility of using EMG for early detection of the facial nerve during robotic direct cochlear access. Otol Neurotol 2014; 35:545-54. [PMID: 24492132 DOI: 10.1097/mao.0000000000000187] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
HYPOTHESIS Facial nerve monitoring can be used synchronous with a high-precision robotic tool as a functional warning to prevent of a collision of the drill bit with the facial nerve during direct cochlear access (DCA). BACKGROUND Minimally invasive direct cochlear access (DCA) aims to eliminate the need for a mastoidectomy by drilling a small tunnel through the facial recess to the cochlea with the aid of stereotactic tool guidance. Because the procedure is performed in a blind manner, structures such as the facial nerve are at risk. Neuromonitoring is a commonly used tool to help surgeons identify the facial nerve (FN) during routine surgical procedures in the mastoid. Recently, neuromonitoring technology was integrated into a commercially available drill system enabling real-time monitoring of the FN. The objective of this study was to determine if this drilling system could be used to warn of an impending collision with the FN during robot-assisted DCA. MATERIALS AND METHODS The sheep was chosen as a suitable model for this study because of its similarity to the human ear anatomy. The same surgical workflow applicable to human patients was performed in the animal model. Bone screws, serving as reference fiducials, were placed in the skull near the ear canal. The sheep head was imaged using a computed tomographic scanner and segmentation of FN, mastoid, and other relevant structures as well as planning of drilling trajectories was carried out using a dedicated software tool. During the actual procedure, a surgical drill system was connected to a nerve monitor and guided by a custom built robot system. As the planned trajectories were drilled, stimulation and EMG response signals were recorded. A postoperative analysis was achieved after each surgery to determine the actual drilled positions. RESULTS Using the calibrated pose synchronized with the EMG signals, the precise relationship between distance to FN and EMG with 3 different stimulation intensities could be determined for 11 different tunnels drilled in 3 different subjects. CONCLUSION From the results, it was determined that the current implementation of the neuromonitoring system lacks sensitivity and repeatability necessary to be used as a warning device in robotic DCA. We hypothesize that this is primarily because of the stimulation pattern achieved using a noninsulated drill as a stimulating probe. Further work is necessary to determine whether specific changes to the design can improve the sensitivity and specificity.
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Mechatronic feasibility of minimally invasive, atraumatic cochleostomy. BIOMED RESEARCH INTERNATIONAL 2014; 2014:181624. [PMID: 25110661 PMCID: PMC4109217 DOI: 10.1155/2014/181624] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Accepted: 05/29/2014] [Indexed: 11/17/2022]
Abstract
Robotic assistance in the context of lateral skull base surgery, particularly during cochlear implantation procedures, has been the subject of considerable research over the last decade. The use of robotics during these procedures has the potential to provide significant benefits to the patient by reducing invasiveness when gaining access to the cochlea, as well as reducing intracochlear trauma when performing a cochleostomy. Presented herein is preliminary work on the combination of two robotic systems for reducing invasiveness and trauma in cochlear implantation procedures. A robotic system for minimally invasive inner ear access was combined with a smart drilling tool for robust and safe cochleostomy; evaluation was completed on a single human cadaver specimen. Access to the middle ear was successfully achieved through the facial recess without damage to surrounding anatomical structures; cochleostomy was completed at the planned position with the endosteum remaining intact after drilling as confirmed by microscope evaluation.
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Kobler JP, Schoppe M, Lexow GJ, Rau TS, Majdani O, Kahrs LA, Ortmaier T. Temporal bone borehole accuracy for cochlear implantation influenced by drilling strategy: an in vitro study. Int J Comput Assist Radiol Surg 2014; 9:1033-43. [PMID: 24728770 DOI: 10.1007/s11548-014-0997-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Accepted: 03/21/2014] [Indexed: 11/28/2022]
Abstract
PURPOSE Minimally invasive cochlear implantation is a surgical technique which requires drilling a canal from the mastoid surface toward the basal turn of the cochlea. The choice of an appropriate drilling strategy is hypothesized to have significant influence on the achievable targeting accuracy. Therefore, a method is presented to analyze the contribution of the drilling process and drilling tool to the targeting error isolated from other error sources. METHODS The experimental setup to evaluate the borehole accuracy comprises a drill handpiece attached to a linear slide as well as a highly accurate coordinate measuring machine (CMM). Based on the specific requirements of the minimally invasive cochlear access, three drilling strategies, mainly characterized by different drill tools, are derived. The strategies are evaluated by drilling into synthetic temporal bone substitutes containing air-filled cavities to simulate mastoid cells. Deviations from the desired drill trajectories are determined based on measurements using the CMM. RESULTS Using the experimental setup, a total of 144 holes were drilled for accuracy evaluation. Errors resulting from the drilling process depend on the specific geometry of the tool as well as the angle at which the drill contacts the bone surface. Furthermore, there is a risk of the drill bit deflecting due to synthetic mastoid cells. CONCLUSIONS A single-flute gun drill combined with a pilot drill of the same diameter provided the best results for simulated minimally invasive cochlear implantation, based on an experimental method that may be used for testing further drilling process improvements.
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Affiliation(s)
- Jan-Philipp Kobler
- Institute of Mechatronic Systems, Leibniz Universität Hannover, 30167 , Hannover, Germany.
| | - Michael Schoppe
- Institute of Mechatronic Systems, Leibniz Universität Hannover, 30167 , Hannover, Germany
| | | | - Thomas S Rau
- Hannover Medical School, 30625 , Hannover, Germany
| | - Omid Majdani
- Hannover Medical School, 30625 , Hannover, Germany
| | - Lüder A Kahrs
- Institute of Mechatronic Systems, Leibniz Universität Hannover, 30167 , Hannover, Germany
| | - Tobias Ortmaier
- Institute of Mechatronic Systems, Leibniz Universität Hannover, 30167 , Hannover, Germany
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Abstract
HYPOTHESIS A previously developed image-guided robot system can safely drill a tunnel from the lateral mastoid surface, through the facial recess, to the middle ear, as a viable alternative to conventional mastoidectomy for cochlear electrode insertion. BACKGROUND Direct cochlear access (DCA) provides a minimally invasive tunnel from the lateral surface of the mastoid through the facial recess to the middle ear for cochlear electrode insertion. A safe and effective tunnel drilled through the narrow facial recess requires a highly accurate image-guided surgical system. Previous attempts have relied on patient-specific templates and robotic systems to guide drilling tools. In this study, we report on improvements made to an image-guided surgical robot system developed specifically for this purpose and the resulting accuracy achieved in vitro. MATERIALS AND METHODS The proposed image-guided robotic DCA procedure was carried out bilaterally on 4 whole head cadaver specimens. Specimens were implanted with titanium fiducial markers and imaged with cone-beam CT. A preoperative plan was created using a custom software package wherein relevant anatomical structures of the facial recess were segmented, and a drill trajectory targeting the round window was defined. Patient-to-image registration was performed with the custom robot system to reference the preoperative plan, and the DCA tunnel was drilled in 3 stages with progressively longer drill bits. The position of the drilled tunnel was defined as a line fitted to a point cloud of the segmented tunnel using principle component analysis (PCA function in MatLab). The accuracy of the DCA was then assessed by coregistering preoperative and postoperative image data and measuring the deviation of the drilled tunnel from the plan. The final step of electrode insertion was also performed through the DCA tunnel after manual removal of the promontory through the external auditory canal. RESULTS Drilling error was defined as the lateral deviation of the tool in the plane perpendicular to the drill axis (excluding depth error). Errors of 0.08 ± 0.05 mm and 0.15 ± 0.08 mm were measured on the lateral mastoid surface and at the target on the round window, respectively (n =8). Full electrode insertion was possible for 7 cases. In 1 case, the electrode was partially inserted with 1 contact pair external to the cochlea. CONCLUSION The purpose-built robot system was able to perform a safe and reliable DCA for cochlear implantation. The workflow implemented in this study mimics the envisioned clinical procedure showing the feasibility of future clinical implementation.
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Wimmer W, Bell B, Huth ME, Weisstanner C, Gerber N, Kompis M, Weber S, Caversaccio M. Cone Beam and Micro-Computed Tomography Validation of Manual Array Insertion for Minimally Invasive Cochlear Implantation. Audiol Neurootol 2013; 19:22-30. [DOI: 10.1159/000356165] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Accepted: 09/23/2013] [Indexed: 11/19/2022] Open
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An automated insertion tool for cochlear implants with integrated force sensing capability. Int J Comput Assist Radiol Surg 2013; 9:481-94. [DOI: 10.1007/s11548-013-0936-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Accepted: 08/01/2013] [Indexed: 11/26/2022]
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Coulson CJ, Assadi MZ, Taylor RP, Du X, Brett PN, Reid AP, Proops DW. A smart micro-drill for cochleostomy formation: A comparison of cochlear disturbances with manual drilling and a human trial. Cochlear Implants Int 2013; 14:98-106. [DOI: 10.1179/1754762811y.0000000018] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Gerber N, Bell B, Gavaghan K, Weisstanner C, Caversaccio M, Weber S. Surgical planning tool for robotically assisted hearing aid implantation. Int J Comput Assist Radiol Surg 2013; 9:11-20. [DOI: 10.1007/s11548-013-0908-5] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Accepted: 06/03/2013] [Indexed: 10/26/2022]
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Kral F, Gueler O, Perwoeg M, Bardosi Z, Puschban EJ, Riechelmann H, Freysinger W. Proof-of-concept of a laser mounted endoscope for touch-less navigated procedures. Lasers Surg Med 2013; 45:377-82. [PMID: 23737122 PMCID: PMC3791553 DOI: 10.1002/lsm.22148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2013] [Indexed: 11/08/2022]
Abstract
Background and Objectives During navigated procedures a tracked pointing device is used to define target structures in the patient to visualize its position in a registered radiologic data set. When working with endoscopes in minimal invasive procedures, the target region is often difficult to reach and changing instruments is disturbing in a challenging, crucial moment of the procedure. We developed a device for touch less navigation during navigated endoscopic procedures. Materials and Methods A laser beam is delivered to the tip of a tracked endoscope angled to its axis. Thereby the position of the laser spot in the video-endoscopic images changes according to the distance between the tip of the endoscope and the target structure. A mathematical function is defined by a calibration process and is used to calculate the distance between the tip of the endoscope and the target. The tracked tip of the endoscope and the calculated distance is used to visualize the laser spot in the registered radiologic data set. Results In comparison to the tracked instrument, the touch less target definition with the laser spot yielded in an over and above error of 0.12 mm. The overall application error in this experimental setup with a plastic head was 0.61 ± 0.97 mm (95% CI −1.3 to +2.5 mm). Conclusion Integrating a laser in an endoscope and then calculating the distance to a target structure by image processing of the video endoscopic images is accurate. This technology eliminates the need for tracked probes intraoperatively and therefore allows navigation to be integrated seamlessly in clinical routine. However, it is an additional chain link in the sequence of computer-assisted surgery thus influencing the application error. Lasers Surg. Med. 45:377–382, 2013. © 2013 Wiley Periodicals, Inc.
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Affiliation(s)
- Florian Kral
- Department of Otorhinolaryngology, Medical University Innsbruck, Innsbruck, Austria.
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Three-dimensional histological specimen preparation for accurate imaging and spatial reconstruction of the middle and inner ear. Int J Comput Assist Radiol Surg 2013; 8:481-509. [PMID: 23633112 PMCID: PMC3702969 DOI: 10.1007/s11548-013-0825-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2012] [Accepted: 02/27/2013] [Indexed: 11/02/2022]
Abstract
PURPOSE This paper presents a highly accurate cross-sectional preparation technique. The research aim was to develop an adequate imaging modality for both soft and bony tissue structures featuring high contrast and high resolution. Therefore, the advancement of an already existing micro-grinding procedure was pursued. The central objectives were to preserve spatial relations and to ensure the accurate three-dimensional reconstruction of histological sections. METHODS Twelve human temporal bone specimens including middle and inner ear structures were utilized. They were embedded in epoxy resin, then dissected by serial grinding and finally digitalized. The actual abrasion of each grinding slice was measured using a tactile length gauge with an accuracy of one micrometre. The cross-sectional images were aligned with the aid of artificial markers and by applying a feature-based, custom-made auto-registration algorithm. To determine the accuracy of the overall reconstruction procedure, a well-known reference object was used for comparison. To ensure the compatibility of the histological data with conventional clinical image data, the image stacks were finally converted into the DICOM standard. RESULTS The image fusion of data from temporal bone specimens' and from non-destructive flat-panel-based volume computed tomography confirmed the spatial accuracy achieved by the procedure, as did the evaluation using the reference object. CONCLUSION This systematic and easy-to-follow preparation technique enables the three-dimensional (3D) histological reconstruction of complex soft and bony tissue structures. It facilitates the creation of detailed and spatially correct 3D anatomical models. Such models are of great benefit for image-based segmentation and planning in the field of computer-assisted surgery as well as in finite element analysis. In the context of human inner ear surgery, three-dimensional histology will improve the experimental evaluation and determination of intra-cochlear trauma after the insertion of an electrode array of a cochlear implant system.
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Williamson TM, Bell BJ, Gerber N, Salas L, Zysset P, Caversaccio M, Weber S. Estimation of tool pose based on force-density correlation during robotic drilling. IEEE Trans Biomed Eng 2012; 60:969-76. [PMID: 23269744 DOI: 10.1109/tbme.2012.2235439] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The application of image-guided systems with or without support by surgical robots relies on the accuracy of the navigation process, including patient-to-image registration. The surgeon must carry out the procedure based on the information provided by the navigation system, usually without being able to verify its correctness beyond visual inspection. Misleading surrogate parameters such as the fiducial registration error are often used to describe the success of the registration process, while a lack of methods describing the effects of navigation errors, such as those caused by tracking or calibration, may prevent the application of image guidance in certain accuracy-critical interventions. During minimally invasive mastoidectomy for cochlear implantation, a direct tunnel is drilled from the outside of the mastoid to a target on the cochlea based on registration using landmarks solely on the surface of the skull. Using this methodology, it is impossible to detect if the drill is advancing in the correct direction and that injury of the facial nerve will be avoided. To overcome this problem, a tool localization method based on drilling process information is proposed. The algorithm estimates the pose of a robot-guided surgical tool during a drilling task based on the correlation of the observed axial drilling force and the heterogeneous bone density in the mastoid extracted from 3-D image data. We present here one possible implementation of this method tested on ten tunnels drilled into three human cadaver specimens where an average tool localization accuracy of 0.29 mm was observed.
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Affiliation(s)
- Tom M Williamson
- ARTORG Center for Computer Aided Surgery, University of Bern, Bern, Switzerland.
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Kratchman LB, Schurzig D, McRackan TR, Balachandran R, Noble JH, Webster RJ, Labadie RF. A manually operated, advance off-stylet insertion tool for minimally invasive cochlear implantation surgery. IEEE Trans Biomed Eng 2012; 59:2792-800. [PMID: 22851233 DOI: 10.1109/tbme.2012.2210220] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The current technique for cochlear implantation (CI) surgery requires a mastoidectomy to gain access to the cochlea for electrode array insertion. It has been shown that microstereotactic frames can enable an image-guided, minimally invasive approach to CI surgery called percutaneous cochlear implantation (PCI) that uses a single drill hole for electrode array insertion, avoiding a more invasive mastoidectomy. Current clinical methods for electrode array insertion are not compatible with PCI surgery because they require a mastoidectomy to access the cochlea; thus, we have developed a manually operated electrode array insertion tool that can be deployed through a PCI drill hole. The tool can be adjusted using a preoperative CT scan for accurate execution of the advance off-stylet (AOS) insertion technique and requires less skill to operate than is currently required to implant electrode arrays. We performed three cadaver insertion experiments using the AOS technique and determined that all insertions were successful using CT and microdissection.
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Affiliation(s)
- Louis B Kratchman
- Department of Mechanical Engineering, Vanderbilt University, Nashville, TN 37235, USA.
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A fully sensorized cooperative robotic system for surgical interventions. SENSORS 2012; 12:9423-47. [PMID: 23012551 PMCID: PMC3444109 DOI: 10.3390/s120709423] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/18/2012] [Revised: 07/03/2012] [Accepted: 07/03/2012] [Indexed: 11/24/2022]
Abstract
In this research a fully sensorized cooperative robot system for manipulation of needles is presented. The setup consists of a DLR/KUKA Light Weight Robot III especially designed for safe human/robot interaction, a FD-CT robot-driven angiographic C-arm system, and a navigation camera. Also, new control strategies for robot manipulation in the clinical environment are introduced. A method for fast calibration of the involved components and the preliminary accuracy tests of the whole possible errors chain are presented. Calibration of the robot with the navigation system has a residual error of 0.81 mm (rms) with a standard deviation of ±0.41 mm. The accuracy of the robotic system while targeting fixed points at different positions within the workspace is of 1.2 mm (rms) with a standard deviation of ±0.4 mm. After calibration, and due to close loop control, the absolute positioning accuracy was reduced to the navigation camera accuracy which is of 0.35 mm (rms). The implemented control allows the robot to compensate for small patient movements.
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Comparetti MD, Vaccarella A, Dyagilev I, Shoham M, Ferrigno G, De Momi E. Accurate multi-robot targeting for keyhole neurosurgery based on external sensor monitoring. Proc Inst Mech Eng H 2012; 226:347-59. [DOI: 10.1177/0954411912442120] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Robotics has recently been introduced in surgery to improve intervention accuracy, to reduce invasiveness and to allow new surgical procedures. In this framework, the ROBOCAST system is an optically surveyed multi-robot chain aimed at enhancing the accuracy of surgical probe insertion during keyhole neurosurgery procedures. The system encompasses three robots, connected as a multiple kinematic chain (serial and parallel), totalling 13 degrees of freedom, and it is used to automatically align the probe onto a desired planned trajectory. The probe is then inserted in the brain, towards the planned target, by means of a haptic interface. This paper presents a new iterative targeting approach to be used in surgical robotic navigation, where the multi-robot chain is used to align the surgical probe to the planned pose, and an external sensor is used to decrease the alignment errors. The iterative targeting was tested in an operating room environment using a skull phantom, and the targets were selected on magnetic resonance images. The proposed targeting procedure allows about 0.3 mm to be obtained as the residual median Euclidean distance between the planned and the desired targets, thus satisfying the surgical accuracy requirements (1 mm), due to the resolution of the diffused medical images. The performances proved to be independent of the robot optical sensor calibration accuracy.
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Affiliation(s)
- Mirko Daniele Comparetti
- Bioengineering Department, Neuroengineering and Medical Robotics Laboratory, Politecnico di Milano, Italy
| | - Alberto Vaccarella
- Bioengineering Department, Neuroengineering and Medical Robotics Laboratory, Politecnico di Milano, Italy
| | - Ilya Dyagilev
- Department of Mechanical Engineering, Technion - Israel Institute of Technology, Israel
| | - Moshe Shoham
- Department of Mechanical Engineering, Technion - Israel Institute of Technology, Israel
| | - Giancarlo Ferrigno
- Bioengineering Department, Neuroengineering and Medical Robotics Laboratory, Politecnico di Milano, Italy
| | - Elena De Momi
- Bioengineering Department, Neuroengineering and Medical Robotics Laboratory, Politecnico di Milano, Italy
- Istituto di Tecnologie Industriali ed Automazione, Consiglio Nazionale delle Ricerche, Italy
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Bell B, Stieger C, Gerber N, Arnold A, Nauer C, Hamacher V, Kompis M, Nolte L, Caversaccio M, Weber S. A self-developed and constructed robot for minimally invasive cochlear implantation. Acta Otolaryngol 2012; 132:355-60. [PMID: 22385333 DOI: 10.3109/00016489.2011.642813] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
CONCLUSION A robot built specifically for stereotactic cochlear implantation provides equal or better accuracy levels together with a better integration into a clinical environment, when compared with existing approaches based on industrial robots. OBJECTIVES To evaluate the technical accuracy of a robotic system developed specifically for lateral skull base surgery in an experimental set-up reflecting the intended clinical application. The invasiveness of cochlear electrode implantation procedures may be reduced by replacing the traditional mastoidectomy with a small tunnel slightly larger in diameter than the electrode itself. METHODS The end-to-end accuracy of the robot system and associated image-guided procedure was evaluated on 15 temporal bones of whole head cadaver specimens. The main components of the procedure were as follows: reference screw placement, cone beam CT scan, computer-aided planning, pair-point matching of the surgical plan, robotic drilling of the direct access tunnel, and postoperative cone beam CT scan for accuracy assessment. RESULTS The mean accuracy at the target point (round window) was 0.56 ± 0.41 mm with an angular misalignment of 0.88 ± 0.40°. The procedural time for the registration process through the completion of the drilling procedure was 25 ± 11 min. The robot was fully operational in a clinical environment.
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Affiliation(s)
- Brett Bell
- ARTORG Center, University of Bern, Switzerland
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Kratchman LB, Blachon GS, Withrow TJ, Balachandran R, Labadie RF, Webster RJ. Design of a bone-attached parallel robot for percutaneous cochlear implantation. IEEE Trans Biomed Eng 2011; 58:2904-10. [PMID: 21788181 DOI: 10.1109/tbme.2011.2162512] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Access to the cochlea requires drilling in close proximity to bone-embedded nerves, blood vessels, and other structures, the violation of which can result in complications for the patient. It has recently been shown that microstereotactic frames can enable an image-guided percutaneous approach, removing reliance on human experience and hand-eye coordination, and reducing trauma. However, constructing current microstereotactic frames disrupts the clinical workflow, requiring multiday intrasurgical manufacturing delays, or an on-call machine shop in or near the hospital. In this paper, we describe a new kind of microsterotactic frame that obviates these delay and infrastructure issues by being repositionable. Inspired by the prior success of bone-attached parallel robots in knee and spinal procedures, we present an automated image-guided microstereotactic frame. Experiments demonstrate a mean accuracy at the cochlea of 0.20 ± 0.07 mm in phantom testing with trajectories taken from a human clinical dataset. We also describe a cadaver experiment evaluating the entire image-guided surgery pipeline, where we achieved an accuracy of 0.38 mm at the cochlea.
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Affiliation(s)
- Louis B Kratchman
- Department of Mechanical Engineering, Vanderbilt University, Nashville, TN 37235, USA.
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Tovar-Arriaga S, Tita R, Pedraza-Ortega JC, Gorrostieta E, Kalender WA. Development of a robotic FD-CT-guided navigation system for needle placement-preliminary accuracy tests. Int J Med Robot 2011; 7:225-36. [PMID: 21538771 DOI: 10.1002/rcs.393] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2011] [Indexed: 11/09/2022]
Abstract
BACKGROUND A needle placement system using a serial robot arm for manipulation of biopsy and/or treatment needles is introduced. A method for fast calibration of the robot and the preliminary accuracy tests of the robotic system are presented. METHODS The setup consists of a DLR/KUKA Light Weight Robot III especially designed for safe human/robot interaction mounted on a mobile platform, a robot-driven angiographic C-arm system and a navigation system. RESULTS Calibration of the robot with the navigation system has a residual error of 0.23 mm (rms) with a standard deviation of ± 0.1 mm. Needle targeting accuracy with different trajectories was 1.2 mm (rms) with a standard deviation of ± 0.4 mm. CONCLUSIONS Robot absolute positioning accuracy was reduced to the navigation camera accuracy. The approach includes control strategies that may be very useful for interventional applications.
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Affiliation(s)
- Saúl Tovar-Arriaga
- Institute of Medical Physics, University of Erlangen-Nuremberg, Erlangen, Germany.
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Abstract
HYPOTHESIS Using image-guided surgical techniques, we propose that an industrial robot can be programmed to safely, effectively, and efficiently perform a mastoidectomy. BACKGROUND Whereas robotics is a mature field in many surgical applications, robots have yet to be clinically used in otologic surgery despite significant advantages including reliability and precision. METHODS We designed a robotic system that incorporates custom software with an industrial robot to manipulate a surgical drill through a complex milling profile. The software controls the movements of the robot based on real-time feedback from a commercially available optical tracking system. The desired path of the drill to remove the desired volume of mastoid bone was planned using computed tomographic scans of cadaveric specimens and then implemented using the robotic system. Bone-implanted fiducial markers were used to provide accurate registration between computed tomographic and physical space. RESULTS A mastoid cavity was milled on 3 cadaveric specimens with a 5-mm fluted ball bit. Postmilling computed tomographic scans showed that, for the 3 specimens, 97.70%, 99.99%, and 96.05% of the target region was ablated without violation of any critical feature. CONCLUSION To the best of our knowledge, this is the first time that a robot has been used to perform a mastoidectomy. Although significant hurdles remain to translate this technology to clinical use, we have shown that it is feasible. The prospect of reducing surgical time and enhancing patient safety by replacing human hand-eye coordination with machine precision motivates future work toward translating this technique to clinical use.
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