A novel miniature robotic guidance device for stereotactic neurosurgical interventions: preliminary experience with the iSYS1 robot

Launching Stealth AutoGuideTM robot for stereotactic biopsy procedures in a neurosurgical centre: learning curve and workflow optimization

Background

Accurate histological analysis is crucial for confirming intracerebral neoplasia due to the diverse array of potential diagnoses presented by imaging. In the realm of biopsy techniques, the use of robot-based systems is on the rise, primarily owing to their heightened targeting accuracy. The objective of this study was to elucidate the practicality, learning curve and workflow associated with robot-guided biopsies upon their introduction to a neurosurgical centre.

Materials and methods

In March 2022, the neurosurgical department at our institution adopted the Medtronic Stealth AutoGuide™ cranial robotic guidance platform, a miniaturized robotic guidance device designed for stereotactic procedures. Four experienced neurosurgeons underwent training with the Stealth AutoGuide™ system, after which 51 consecutive biopsies were performed. The evaluation encompassed entry and target accuracy, preoperative setup time, time required for the biopsy procedure, and overall operating time. Statistical analysis was conducted to identify any differences between the initial 26 and subsequent sets of 25 patients, with the aim of identifying changes in workflow.

Results

The study included all patients necessitating a diagnostic biopsy for intracerebral tumours, with only one patient excluded due to the inaccessibility of the intended target point caused by tumour calcification. Notably, there were no significant differences between the first 25 and last 26 patients in the median time from incision to the first biopsy (overall: 11.5 min, IQR 9.03-15.0), the procedure time (overall: 30.0 min, IQR 23.5-46.5), median accuracy at entry (overall: 2.05 mm, IQR 0.8-3.8), or target point (overall: 2.2 mm (IQR 1.6-3.7). However, a significant reduction in robot setup time was observed between the two groups, median 2.69 min versus 1.17 min, respectively (p ≤ 0.001).

Conclusion

The deployment of the robotic biopsy system, Stealth AutoGuide™, showed high feasibility, steep learning curve due to uncomplicated technical handling using our standardized operative workflow. Therefore, even in prone position a high diagnostic yield was achieved. Overall, the Stealth AutoGuide™ system facilitated biopsies in traditionally challenging regions with concise procedure time and surgeon-independent high accuracy.

Accuracy of frameless robot-assisted stereoelectroencephalography depth electrode implantation using the neurolocate registration system in paediatric patients

BACKGROUND

We assessed the accuracy and performed a directional analysis of robot-assisted implantation of stereoelectroencephalography (SEEG) depth electrodes in children using the frameless neurolocate 3D registration module.

METHODS

Thirteen children with epilepsy undergoing stereotactic robot-assisted insertion of SEEG electrodes were included. Six children were operated on with standard frame-based registration while 7 with the use of the frameless neurolocate registration module. Accuracy and directional analysis of orthogonal and oblique electrodes were assessed by calculating the absolute error, the radial error, the angle error, and the Euclidean distance.

RESULTS

Of 172 electrodes 89 were implanted in the 6 standard frame-based mode patients and 83 in the 7 neurolocate patients. The overall mean age was 12.2 ± 4.4 years (range 2-17). The mean number of electrodes in each patient was 13.2 ± 2.04 (range 9-17). The median radial error of electrode placement in the neurolocate patients (1.08 mm, [IQR: 1.26]) was significantly less when compared with standard frame-based mode patients (1.49 mm, [IQR 1.25)]; p = 0.04). The same applies to the median angle error which was in the neurolocate group 1.61° [IQR: 1.46] and in the standard frame-based group 2.16° [IQR: 2.09]; p = 0.019. Directional analysis of electrode trajectories in the neurolocate group showed that in the x-axis the median absolute error of orthogonal electrodes (0.4 mm, [IQR: 0.475]) was less when compared with oblique electrodes (0.7 mm, [IQR: 1.2]; p = 0.007). In the standard frame-based mode group in the y-axis, the median absolute error of orthogonal electrodes (0.7 mm, [IQR: 1.3]) was less compared with oblique electrodes (1.25 mm, [IQR: 1.6]; p = 0.03).

CONCLUSION

In paediatric patients, robot-assisted SEEG depth electrode implantation with the non-invasive and easy-to-use frameless neurolocate registration module is a consistent and accurate procedure.

Robot-assisted stereotactic brain biopsy: A systematic review and meta-analysis

INTRODUCTION

Intracranial lesions often require tissue diagnosis through stereotactic biopsies. Originating in the 1970s, this technique has progressed, but limitations and risks persist. Recently, robot-assisted techniques have made strides, providing the potential for safer and more precise procedures. This study assesses the effectiveness and safety of robot-assisted brain biopsies.

METHODS

Following Cochrane and PRISMA guidelines, PubMed, Embase, and Web of Science were searched for publications up to July 2024. Outcomes assessed included neurological deficits, hemorrhage, mortality, target point error, operative time, and length of stay. Data extraction and bias assessment were conducted using standardized methods, and statistical analysis was performed using R software.

RESULTS

In this meta-analysis, 27 papers were included, involving 2605 patients. The gender distribution was 1448 males to 1141 females. The mean error in millimeters for the entry point error was 1.04 (95%CI: 0.72-1.37), while the target point error was 1.08 (95%CI: 0.49-1.66). The mean operative time was 52.45 min (95%CI: 37.83-67.07). Diagnostic yield had an estimated rate of 98% (95%CI: 97-98%; I²=31%). The length of hospital stay was 4.64 days (95%CI: 3.13, 6.14), from admission to discharge. The postoperative hemorrhage had an estimated risk of 6% (95%CI: 4-9%; I²=71%), while for transient neurological deficits, it was 4% (95%CI: 2-6%; I²=60%). Finally, the death related to the procedure was found to have an estimated risk of 0% (95%CI: 0-0%; I²=0%).

CONCLUSION

Our study found that the diagnostic yield of stereotactic brain biopsy, especially with robotic assistance, has proven to be highly effective. Robot-assisted biopsies also seems to reduce operative times and demonstrate high precision with low entry point error and target point error. Additionally, complication rates appear to be relatively low, and the average hospital stay is favorably short, underscoring the advantages of robotic assistance in stereotactic brain biopsy procedures.

Components of Robotic Systems in Image-Guided Percutaneous Interventions

The field of interventional radiology is facing a growing demand for percutaneous procedures targeting smaller and more complex lesions. Percutaneous medical robots have proven to increase efficiency and accuracy and can address these issues. This review is intended to provide an overview of the functionality and components of these robotic systems for operators learning to use them. We begin by discussing the functions of robots in percutaneous interventions and how they operate. After this discussion, greater focus is then placed on the technical components of robots which help achieve these functions.

ARViS: a bleed-free multi-site automated injection robot for accurate, fast, and dense delivery of virus to mouse and marmoset cerebral cortex

Genetically encoded fluorescent sensors continue to be developed and improved. If they could be expressed across multiple cortical areas in non-human primates, it would be possible to measure a variety of spatiotemporal dynamics of primate-specific cortical activity. Here, we develop an Automated Robotic Virus injection System (ARViS) for broad expression of a biosensor. ARViS consists of two technologies: image recognition of vasculature structures on the cortical surface to determine multiple injection sites without hitting them, and robotic control of micropipette insertion perpendicular to the cortical surface with 50 μm precision. In mouse cortex, ARViS sequentially injected virus solution into 100 sites over a duration of 100 min with a bleeding probability of only 0.1% per site. Furthermore, ARViS successfully achieved 266-site injections over the frontoparietal cortex of a female common marmoset. We demonstrate one-photon and two-photon calcium imaging in the marmoset frontoparietal cortex, illustrating the effective expression of biosensors delivered by ARViS.

Image-guided biopsy of intracranial lesions in children, with a small robotic device: a case series

BACKGROUND AND OBJECTIVES

Robot-assisted biopsies have gained popularity in the last years. Most robotic procedures are performed with a floor-based robotic arm. Recently, Medtronic Stealth Autoguide, a miniaturized robotic arm that work together with an optical neuronavigation system, was launched. Its application in pediatric cases is relatively unexplored. In this study, we retrospectively report our experience using the Stealth Autoguide, for frameless stereotactic biopsies in pediatric patients.

METHODS

Pediatric patients who underwent stereotactic biopsy using the Stealth Autoguide cranial robotic platform from July 2020 to May 2023 were included in this study. Clinical, neuroradiological, surgical, and histological data were collected and analyzed.

RESULTS

Nineteen patients underwent 20 procedures (mean age was 9-year-old, range 1-17). In four patients, biopsy was part of a more complex surgical procedure (laser interstitial thermal therapy - LITT). The most common indication was diffuse intrinsic brain stem tumor, followed by diffuse supratentorial tumor. Nine procedures were performed in prone position, eight in supine position, and three in lateral position. Facial surface registration was adopted in six procedures, skull-fixed fiducials in 14. The biopsy diagnostic tissue acquisition rate was 100% in the patients who underwent only biopsy, while in the biopsy/LITT group, one case was not diagnostic. No patients developed clinically relevant postoperative complications.

CONCLUSION

The Stealth Autoguide system has proven to be safe, diagnostic, and highly accurate in performing stereotactic biopsies for both supratentorial and infratentorial lesions in the pediatric population.

Current State of Robotics in Interventional Radiology

As a relatively new specialty with a minimally invasive nature, the field of interventional radiology is rapidly growing. Although the application of robotic systems in this field shows great promise, such as with increased precision, accuracy, and safety, as well as reduced radiation dose and potential for teleoperated procedures, the progression of these technologies has been slow. This is partly due to the complex equipment with complicated setup procedures, the disruption to theatre flow, the high costs, as well as some device limitations, such as lack of haptic feedback. To further assess these robotic technologies, more evidence of their performance and cost-effectiveness is needed before their widespread adoption within the field. In this review, we summarise the current progress of robotic systems that have been investigated for use in vascular and non-vascular interventions.

Robotics in Interventional Radiology: Review of Current and Future Applications

This review is a brief overview of the current status and the potential role of robotics in interventional radiology. Literature published in the last decades, with an emphasis on the last 5 years, was reviewed and the technical developments in robotics and navigational systems using CT-, MR- and US-image guidance were analyzed. Potential benefits and disadvantages of their current and future use were evaluated. The role of fusion imaging modalities and artificial intelligence was analyzed in both percutaneous and endovascular procedures. A few hundred articles describing results of single or several systems were included in our analysis.

Frameless robot-assisted stereotactic biopsy: an effective and minimally invasive technique for pediatric diffuse intrinsic pontine gliomas

PURPOSE

Diffuse intrinsic pontine gliomas (DIPGs) are prone to high surgical risks, and they could even lead to death due to their specific sites. To determine the value of frameless robot-assisted stereotactic biopsies of DIPGs, when compared it with microsurgical biopsies.

METHODS

We conducted a retrospective study of 71 pediatric patients who underwent biopsies from January 2016 to January 2021. (i) group 1: microsurgical biopsies, and (ii) group 2: frameless robot-assisted stereotactic biopsies. Demographic information, neuroimaging characteristics, pathological diagnoses, operation time, postoperative intensive care unit (ICU) stay time, postoperative hospitalization time, complications, cost, and perioperative mortality rate (POMR) were collected for analyses.

RESULTS

32 Cases underwent microsurgical biopsies (group 1) and 39 cases underwent frameless robot-assisted stereotactic biopsies (group 2). All cases were accurately diagnosed after surgery. There was no significant difference in gender, age, symptom times and tumor volumes between the two groups (p > 0.05); operation time, postoperative ICU, stay time and postoperative hospitalization time were longer in group 1 than in group 2 (p < 0.001); the intraoperative bleeding volumes and cost were higher in group 1 than in group 2 (p < 0.001). Group 1 patients required more perioperative blood transfusion than group 2 (p = 0.001), and the new neurological impairments were more frequent in group 1 than in group 2 (p = 0.003). The POMR was 9.38% (3/32) in group 1 and 0 in group 2 (p = 0.087).

CONCLUSIONS

Frameless robot-assisted stereotactic biopsy was an effective and minimally invasive technique for pediatric DIPGs.

Development of a miniaturized robotic guidance device for stereotactic neurosurgery

OBJECTIVE

Consistently high accuracy and a straightforward use of stereotactic guidance systems are crucial for precise stereotactic targeting and a short procedural duration. Although robotic guidance systems are widely used, currently available systems do not fully meet the requirements for a stereotactic guidance system that combines the advantages of frameless surgery and robotic technology. The authors developed and optimized a small-scale yet highly accurate guidance system that can be seamlessly integrated into an existing operating room (OR) setup due to its design. The aim of this clinical study is to outline the development of this miniature robotic guidance system and present the authors' clinical experience.

METHODS

After extensive preclinical testing of the robotic stereotactic guidance system, adaptations were implemented for robot fixation, software usability, navigation integration, and end-effector application. Development of the robotic system was then advanced in a clinical series of 150 patients between 2013 and 2019, including 111 needle biopsies, 13 catheter placements, and 26 stereoelectroencephalography (SEEG) electrode placements. During the clinical trial, constant modifications were implemented to meet the setup requirements, technical specifications, and workflow for each indication. For each application, specific setup, workflow, and median procedural accuracy were evaluated.

RESULTS

Application of the miniature robotic system was feasible in 149 of 150 cases. The setup in each procedure was successfully implemented without adding significant OR time. The workflow was seamlessly integrated into the preexisting procedure. In the course of the study, procedural accuracy was improved. For the biopsy procedure, the real target error (RTE) was reduced from a mean of 1.8 ± 1.03 mm to 1.6 ± 0.82 mm at entry (p = 0.05), and from 1.7 ± 1.12 mm to 1.6 ± 0.72 mm at target (p = 0.04). For the SEEG procedures, the RTE was reduced from a mean of 1.43 ± 0.78 mm in the first half of the procedures to 1.12 ± 0.52 mm (p = 0.002) at entry in the second half, and from 1.82 ± 1.13 mm to 1.57 ± 0.98 mm (p = 0.069) at target, respectively. No healing complications or infections were observed in any case.

CONCLUSIONS

The miniature robotic guidance device was able to prove its versatility and seamless integration into preexisting workflow by successful application in 149 stereotactic procedures. According to these data, the robot could significantly improve accuracy without adding time expenditure.

A Comparation Between Frame-Based and Robot-Assisted in Stereotactic Biopsy

Introduction

Frame-based stereotactic biopsy is well-established to play an essential role in neurosurgery. In recent years, different robotic devices have been introduced in neurosurgery centers. This study aimed to compare the SINO surgical robot-assisted frameless brain biopsy with standard frame-based stereotactic biopsy in terms of efficacy, accuracy and complications.

Methods

A retrospective analysis was performed on 151 consecutive patients who underwent stereotactic biopsy at Chongqing Sanbo Jiangling Hospital between August 2017 and December 2021. All patients were divided into the frame-based group (n = 47) and the SINO surgical robot-assisted group (n = 104). The data collected included clinical characteristics, diagnostic yield, operation times, accuracy, and postoperative complications.

Results

There was no significant difference in diagnostic yield between the frame-based group and the SINO surgical robot-assisted group (95.74 vs. 98.08%, p > 0.05). The mean operation time in the SINO surgical robot-assisted group was significantly shorter than in the frame-based group (29.36 ± 13.64 vs. 50.57 ± 41.08 min). The entry point error in the frame-based group was significantly higher than in the robot-assisted group [1.33 ± 0.40 mm (0.47–2.30) vs. 0.92 ± 0.27 mm (0.35–1.65), P < 0.001]. The target point error in the frame-based group was also significantly higher than in the robot-assisted group [1.63 ± 0.41 mm (0.74–2.65) vs. 1.10 ± 0.30 mm (0.69–2.03), P < 0.001]. Finally, there was no significant difference in postoperative complications between the two groups.

Conclusion

Robot-assisted brain biopsy becomes an increasingly mainstream tool in the neurosurgical procedure. The SINO surgical robot-assisted platform is as efficient, accurate and safe as standard frame-based stereotactic biopsy and provides a reasonable alternative to stereotactic biopsy in neurosurgery.

Frameless stereotactic brain biopsy and external ventricular drainage placement using the RONNA G4 system

Robot-assisted stereotactic procedures are among the latest technological improvements in neurosurgery. Herein, to the best of our knowledge, we report a first external ventricular drainage (EVD) placement using the RONNA G4 robotic system preformed together with brain biopsy, all in one procedure. A patient was presented with progressive drowsiness, cognitive slowing, poor mobility and incontinent. Magnetic resonance imaging brain scans revealed multicentric process located in the basal ganglia right with extensive vasogenic edema and dilatated ventricular system. Using the RONNAplan software two trajectories were planned: one for brain biopsy on the left side and one for EVD implantation on the right side; the procedures went without complications. The RONNA G4 robotic system is an accurate neurosurgical tool for performing frameless brain biopsies and EVD placement. Further studies are needed in order to enroll a larger patient sample and to calculate the possible placement deviation, and to perform the comparison with other robotic systems.

Primary Experiences with Robot-assisted Navigation-based Frameless Stereo-electroencephalography: Higher Accuracy than Neuronavigation-guided Manual Adjustment

The use of robot-assisted frameless stereotactic electroencephalography (SEEG) is becoming more common. Among available robotic arms, Stealth Autoguide (SA) (Medtronic, Minneapolis, MN, USA) functions as an optional instrument of the neuronavigation system. The aims of this study were to present our primary experiences with SEEG using SA and to compare the accuracy of implantation between SA and navigation-guided manual adjustment (MA). Seventeen electrodes from two patients who underwent SEEG with SA and 18 electrodes from four patients with MA were retrospectively reviewed. We measured the distance between the planned location and the actual location at entry (De) and the target (Dt) in each electrode. The length of the trajectory did not show a strong correlation with Dt in SA (Pearson's correlation coefficient [r] = 0.099, p = 0.706) or MA (r = 0.233, p = 0.351). De and Dt in SA were shorter than those in MA (1.99 ± 0.90 vs 4.29 ± 1.92 mm, p = 0.0002; 3.59 ± 2.22 vs 5.12 ± 1.40 mm, p = 0.0065, respectively). SA offered higher accuracy than MA both at entry and target. Surgical times per electrode were 38.9 and 32 min in the two patients with SA and ranged from 51.6 to 88.5 min in the four patients with MA. During the implantation period of 10.3 ± 3.6 days, no patients experienced any complications.

A novel technique for fence-post tube placement in glioma using the robot-guided frameless neuronavigation technique under exoscope surgery: patient series

BACKGROUND

Robotic technology is increasingly used in neurosurgery. The authors reported a new technique for fence-post tube placement using robot-guided frameless stereotaxic technology with neuronavigation in patients with glioma.

OBSERVATIONS

Surgery was performed using the StealthStation S8 linked to the Stealth Autoguide cranial robotic guidance platform and a high-resolution three-dimensional (3D) surgical microscope. A surgical plan was created to determine the removal area using fence-post tube placement at the tumor and normal brain tissue boundary. Using this surgical plan, the robotic system allowed quick and accurate fence-post tube positioning, automatic alignment of the needle insertion and measurement positions in the brain, and quick and accurate puncture needle insertion into the brain tumor. Use of a ventricular drainage tube for the outer needle cylinder allowed placement of the puncture needle in a single operation. Furthermore, use of a high-resolution 3D exoscope allowed the surgeon to simultaneously view the surgical field image and the navigation screen with minimal line-of-sight movement, which improved operative safety. The position memory function of the 3D exoscope allowed easy switching between the exoscope and the microscope and optimal field of view adjustment.

LESSONS

Fence-post tube placement using robot-guided frameless stereotaxic technology, neuronavigation, and an exoscope allows precise glioma resection.

Research progress and development trend of surgical robot and surgical instrument arm

BACKGROUND

In recent years, surgical robots have become an indispensable part of the medical field. Surgical robots are increasingly being used in the areas of gynaecological surgery, urological surgery, orthopaedic surgery, general surgery and so forth. In this paper, the development of surgical robots in different operations is reviewed and analysed. In the type of master-slave surgical robotic system, the robotic surgical instrument arms were located in the execution terminal of a surgical robot system, as one of the core components, and directly contact with the patient during the operation, which plays an important role in the efficiency and safety of the operation. In clinical, the arm function and design in different systems varies. Furtherly, the current research progress of robotic surgical instrument arms used in different operations is analysed and summarised. Finally, the challenge and trend are concluded.

METHODS

According to the classification of surgical types, the development of surgical robots for laparoscopic surgery, neurosurgery, orthopaedics and microsurgery are analysed and summarised. Then, focusing on the research of robotic surgical instrument arms, according to structure type, the research and application of straight-rod surgical instrument arm, joint surgical instrument arm and continuous surgical instrument arm are analysed respectively.

RESULTS

According to the discussion and summary of the characteristics of the existing surgical robots and instrument arms, it is concluded that they still have a lot of room for development in the future. Therefore, the development trends of the surgical robot and instrument arm are discussed and analysed in the five aspects of structural materials, modularisation, telemedicine, intelligence and human-machine collaboration.

CONCLUSION

Surgical robots have shown the development trend of miniaturisation, intelligence, autonomy and dexterity. Thereby, in the field of science and technology, the research on the next generation of minimally invasive surgical robots will usher in a peak period of development.

Comparison of robotic and manual implantation of intracerebral electrodes: a single-centre, single-blinded, randomised controlled trial

There has been a significant rise in robotic trajectory guidance devices that have been utilised for stereotactic neurosurgical procedures. These devices have significant costs and associated learning curves. Previous studies reporting devices usage have not undertaken prospective parallel-group comparisons before their introduction, so the comparative differences are unknown. We study the difference in stereoelectroencephalography electrode implantation time between a robotic trajectory guidance device (iSYS1) and manual frameless implantation (PAD) in patients with drug-refractory focal epilepsy through a single-blinded randomised control parallel-group investigation of SEEG electrode implantation, concordant with CONSORT statement. Thirty-two patients (18 male) completed the trial. The iSYS1 returned significantly shorter median operative time for intracranial bolt insertion, 6.36 min (95% CI 5.72–7.07) versus 9.06 min (95% CI 8.16–10.06), p = 0.0001. The PAD group had a better median target point accuracy 1.58 mm (95% CI 1.38–1.82) versus 1.16 mm (95% CI 1.01–1.33), p = 0.004. The mean electrode implantation angle error was 2.13° for the iSYS1 group and 1.71° for the PAD groups (p = 0.023). There was no statistically significant difference for any other outcome. Health policy and hospital commissioners should consider these differences in the context of the opportunity cost of introducing robotic devices.

Trial registration: ISRCTN17209025 (https://doi.org/10.1186/ISRCTN17209025).

A Bulk Retrospective Study of Robot-Assisted Stereotactic Biopsies of Intracranial Lesions Guided by Videometric Tracker

Background: Biopsies play an important role in the diagnosis of intracranial lesions, and robot-assisted procedures are increasingly common in neurosurgery centers. This research investigates the diagnoses, complications, and technology yield of 700 robotic frameless intracranial stereotactic biopsies conducted with the Remebot system. Method: This research considered 700 robotic biopsies performed between 2016 and 2020 by surgeons from the Department of Functional Neurosurgery in Beijing's Tiantan Hospital. The data collected included histological diagnoses, postoperative complications, operation times, and the accuracy of robotic manipulation. Results: Among the 700 surgeries, the positive rate of the biopsies was 98.2%. The most common histological diagnoses were gliomas, which accounted for 62.7% of cases (439/700), followed by lymphoma and germinoma, which accounted for 18.7% (131/700) and 7.6% (53/700). Bleeding was found in 14 patients (2%) by post-operation computed tomography scans. A total of 29 (4.14%) patients had clinical impairments after the operation, and 9 (1.29%) experienced epilepsy during the operation. The post-biopsy mortality rate was 0.43%. Operation time-from marking the cranial point to suturing the skin-was 16.78 ± 3.31 min (range 12-26 min). The target error was 1.13 ± 0.30 mm, and the entry point error was 0.99 ± 0.24 mm. Conclusion: A robot-assisted frameless intracranial stereotactic biopsy guided by a videometric tracker is an efficient, safe, and accurate method for biopsies.

Cranial neurosurgical robotics

OBJECT

The purpose of this review is to highlight the major factors limiting the progress of robotics development in the field of cranial neurosurgery.

METHODS

A literature search was performed focused on published reports of any Neurosurgical technology developed for use in cranial neurosurgery. Technology was reviewed and assessed for strengths and weaknesses, use in patients and whether or not the project was active or closed.

RESULTS

Published reports of 24 robots are discussed going back to 1985. In total, there were 9 robots used in patients (PUMA, Robot Hand, EXPERT, Neuromate, Evolution 1, ROSA, iSYS1, NeuroArm and NeuRobot) and only 2 active today (ROSA, NeuroArm). Of all clinically active systems, only three were used in more than 30 patients (ROSA, iSYS1 & NeuroArm). Projects were limited by cost, technology adoption, and clinical utility to actually improve workflow. The most common use of developed robots is for Stereotaxis.

CONCLUSIONS

There is a clear void in the area of cranial neurosurgery regarding robotics technology despite success in other fields of surgery. Significant factors such as cost, technology limitations, market size and regulatory pathway all contribute to a steep gradient for success.

Robotic guidance platform for laser interstitial thermal ablation and stereotactic needle biopsies: a single center experience

While laser ablation has become an increasingly important tool in the neurosurgical oncologist's armamentarium, deep seated lesions, and those located near critical structures require utmost accuracy during stereotactic laser catheter placement. Robotic devices have evolved significantly over the past two decades becoming an accurate and safe tool for stereotactic neurosurgery. Here, we present our single center experience with the MedTech ROSA ONE Brain robot for robotic guidance in laser interstitial thermal therapy (LITT) and stereotactic biopsies. We retrospectively analyzed the first 70 consecutive patients treated with ROSA device at a single academic medical center. Forty-three patients received needle biopsy immediately followed by LITT with the catheter placed with robotic guidance and 27 received stereotactic needle biopsy alone. All the procedures were performed frameless with skull bone fiducials for registration. We report data regarding intraoperative details, mortality and morbidity, diagnostic yield and lesion characteristics on MRI. Also, we describe the surgical workflow for both procedures. The mean age was 60.3 ± 15 years. The diagnostic yield was positive in 98.5% (n = 69). Sixty-three biopsies (90%) were supratentorial and seven (10%) were infratentorial. Gliomas represented 54.3% of the patients (n = 38). There were two postoperative deaths (2.8%). No permanent morbidity related to surgery were observed. We did not find intraoperative technical problems with the device. There was no need to reposition the needle after the initial placement. Stereotactic robotic guided placement of laser ablation catheters and biopsy needles is safe, accurate, and can be implemented into a neurosurgical workflow.

Robotic Applications in Cranial Neurosurgery: Current and Future

Robotics applied to cranial surgery is a fast-moving and fascinating field, which is transforming the practice of neurosurgery. With exponential increases in computing power, improvements in connectivity, artificial intelligence, and enhanced precision of accessing target structures, robots are likely to be incorporated into more areas of neurosurgery in the future-making procedures safer and more efficient. Overall, improved efficiency can offset upfront costs and potentially prove cost-effective. In this narrative review, we aim to translate a broad clinical experience into practical information for the incorporation of robotics into neurosurgical practice. We begin with procedures where robotics take the role of a stereotactic frame and guide instruments along a linear trajectory. Next, we discuss robotics in endoscopic surgery, where the robot functions similar to a surgical assistant by holding the endoscope and providing retraction, supplemental lighting, and correlation of the surgical field with navigation. Then, we look at early experience with endovascular robots, where robots carry out tasks of the primary surgeon while the surgeon directs these movements remotely. We briefly discuss a novel microsurgical robot that can perform many of the critical operative steps (with potential for fine motor augmentation) remotely. Finally, we highlight 2 innovative technologies that allow instruments to take nonlinear, predetermined paths to an intracranial destination and allow magnetic control of instruments for real-time adjustment of trajectories. We believe that robots will play an increasingly important role in the future of neurosurgery and aim to cover some of the aspects that this field holds for neurosurgical innovation.

THE SAFETY AND EFFICACY OF ROBOT-ASSISTED STEREOTACTIC BIOPSY FOR BRAIN GLIOMA: EARLIEST INSTITUTIONAL EXPERIENCES AND EVALUATION OF LITERATURE

Robot-assisted brain tumor biopsy is becoming one of the most important innovative technologies in neurosurgical practice. The idea behind its engagement is to advance the safety and efficacy of the biopsy procedure, which is much in demand when planning the management of endocranial tumor pathology. Herein, we provide our earliest institutional experiences in utilizing this mesmerizing technology. Cranial robotic device was employed for stereotactic robot-assisted brain glioma biopsy in three consecutive patients from our series: an anaplastic isocitrate dehydrogenase (IDH) negative astrocytoma (WHO grade III) located in the right trigone region of the periventricular white matter; a low grade diffuse astrocytoma (WHO grade II) of bilateral thalamic region spreading into the right mesencephalic area; and an IDH-wildtype glioblastoma (WHO grade IV) of the right frontal lobe producing a contralateral midline shifting. Robot-assisted tumor biopsy was successfully performed to get tissue samples for histopathologic and immunohistochemical analysis. The adjacent tissue iatrogenic damage of the eloquent cortical areas was minimal, while the immediate postoperative recovery was satisfactory in all patients. In conclusion, considering the preliminary results of our early experiences, robot-assisted tumor biopsy was proven to be a feasible and accurate procedure when surgery for brain glioma was not an option. It may increase safety and precision, without expanding surgical time, being similarly effective when compared to standard stereotactic and manual biopsy. Using this method to provide accurate sampling for histopathologic and immunohistochemical analysis is a safe and easy way to determine management strategies and outcome of different types of brain glioma.

Frameless stereotactic brain biopsy: A prospective study on robot-assisted brain biopsies performed on 32 patients by using the RONNA G4 system

BACKGROUND

We present a novel robotic neuronavigation system (RONNA G4), used for precise preoperative planning and frameless neuronavigation, developed by a research group from the University of Zagreb and neurosurgeons from the University Hospital Dubrava, Zagreb, Croatia. The aim of study is to provide comprehensive error measurement analysis of the system used for the brain biopsy.

METHODS

Frameless stereotactic robot-assisted biopsies were performed on 32 consecutive patients. Post-operative CT and MRI scans were assessed to precisely measure and calculate target point error (TPE) and entry point error (EPE).

RESULTS

The application accuracy of the RONNA system for TPE was 1.95 ± 1.11 mm, while for EPE was 1.42 ± 0.74 mm. The total diagnostic yield was 96.87%. Linear regression showed statistical significance between the TPE and EPE, and the angle of the trajectory on the bone.

CONCLUSION

The RONNA G4 robotic system is a precise and highly accurate autonomous neurosurgical assistant for performing frameless brain biopsies.

Preclinical Evaluation of the Stealth Autoguide Robotic Guidance Device for Stereotactic Cranial Surgery: A Human Cadaveric Study

INTRODUCTION

Stereotactic procedures are routinely performed for brain biopsies, deep brain stimulation, and placement of stereoelectroencephalography (SEEG) electrodes for epilepsy. The recently developed Stealth Autoguide (Medtronic, Minneapolis, MN, USA) device does not require patients to don a stereotactic frame. In this preclinical study, we sought to quantitatively compare the Stealth Autoguide robotic system to 2 devices commonly used in clinical practice: the Navigus biopsy system (Medtronic) and the Leksell stereotactic frame (Elekta Ltd., Stockholm, Sweden).

METHODS

In the first experimental setup, we compared target accuracy of the Stealth Autoguide to the Navigus system by using phantom heads filled with gelatin to simulate the brain tissue. In the second experimental setup, we inserted SEEG electrodes to targets within cadaveric heads in a simulated operating room environment.

RESULTS

Using a homogeneous gelatin-filled phantom 3D reconstruction of a human head, we found that using the Stealth Autoguide system, while maintaining accuracy, was faster to use than the Navigus system. In our simulated operating room environment using nonliving human cadaveric heads, we found the accuracy of the Stealth Autoguide robotic device to be comparable to that of the Leksell frame.

DISCUSSION/CONCLUSION

These results compare the use of the Stealth Autoguide robotic guidance system with commonly used stereotactic devices, and this is the first study to compare its use and accuracy with the Leksell frame. These findings provide mounting evidence that Stealth Autoguide will have potential clinical uses in various stereotactic neurosurgical procedures.

Frameless Stereotactic Brain Biopsies: Comparison of Minimally Invasive Robot-Guided and Manual Arm-Based Technique

BACKGROUND

Most brain biopsies are still performed with the aid of a navigation-guided mechanical arm. Due to the manual trajectory alignment without rigid skull contact, frameless aiming devices are prone to considerably lower accuracy.

OBJECTIVE

To compare a novel minimally invasive robot-guided biopsy technique with rigid skull fixation to a standard frameless manual arm biopsy procedure.

METHODS

Accuracy, procedural duration, diagnostic yield, complication rate, and cosmetic result were retrospectively assessed in 40 consecutive cases of frameless stereotactic biopsies and compared between a minimally invasive robotic technique using the iSYS1 guidance device (iSYS Medizintechnik GmbH) (robot-guided group [ROB], n = 20) and a manual arm-based technique (group MAN, n = 20).

RESULTS

Application of the robotic technique resulted in significantly higher accuracy at entry point (group ROB median 1.5 mm [0.4-3.2 mm] vs manual arm-based group (MAN) 2.2 mm [0.2-5.2 mm], P = .019) and at target point (group ROB 1.5 mm [0.4-2.8 mm] vs group MAN 2.8 mm [1.4-4.9 mm], P = .001), without increasing incision to suture time (group ROB 30.0 min [20-45 min vs group MAN 32.5 min [range 20-60 min], P = .09) and significantly shorter skin incision length (group ROB 16.3 mm [12.7-23.4 mm] vs group MAN 24.2 mm [18.0-37.0 mm], P = .008).

CONCLUSION

According to our data, the proposed technique of minimally invasive robot-guided brain biopsies can improve accuracy without increasing operating time while being equally safe and effective compared to a standard frameless arm-based manual biopsy technique.

A novel robot-guided minimally invasive technique for brain tumor biopsies

OBJECTIVE

As decisions regarding tumor diagnosis and subsequent treatment are increasingly based on molecular pathology, the frequency of brain biopsies is increasing. Robotic devices overcome limitations of frame-based and frameless techniques in terms of accuracy and usability. The aim of the present study was to present a novel, minimally invasive, robot-guided biopsy technique and compare the results with those of standard burr hole biopsy.

METHODS

A tubular minimally invasive instrument set was custom-designed for the iSYS-1 robot-guided biopsies. Feasibility, accuracy, duration, and outcome were compared in a consecutive series of 66 cases of robot-guided stereotactic biopsies between the minimally invasive (32 patients) and standard (34 patients) procedures.

RESULTS

Application of the minimally invasive instrument set was feasible in all patients. Compared with the standard burr hole technique, accuracy was significantly higher both at entry (median 1.5 mm [range 0.2-3.2 mm] vs 1.7 mm [range 0.8-5.1 mm], p = 0.008) and at target (median 1.5 mm [range 0.4-3.4 mm] vs 2.0 mm [range 0.8-3.9 mm], p = 0.019). The incision-to-suture time was significantly shorter (median 30 minutes [range 15-50 minutes] vs 37.5 minutes [range 25-105 minutes], p < 0.001). The skin incision was significantly shorter (median 16.3 mm [range 12.7-23.4 mm] vs 28.4 mm [range 20-42.2 mm], p = 0.002). A diagnostic tissue sample was obtained in all cases.

CONCLUSIONS

Application of the novel instrument set was feasible in all patients. According to the authors' data, the minimally invasive robot-guidance procedure can significantly improve accuracy, reduce operating time, and improve the cosmetic result of stereotactic biopsies.

Robotic Stereotaxy in Cranial Neurosurgery: A Qualitative Systematic Review

BACKGROUND

Modern-day stereotactic techniques have evolved to tackle the neurosurgical challenge of accurately and reproducibly accessing specific brain targets. Neurosurgical advances have been made in synergy with sophisticated technological developments and engineering innovations such as automated robotic platforms. Robotic systems offer a unique combination of dexterity, durability, indefatigability, and precision.

OBJECTIVE

To perform a systematic review of robotic integration for cranial stereotactic guidance in neurosurgery. Specifically, we comprehensively analyze the strengths and weaknesses of a spectrum of robotic technologies, past and present, including details pertaining to each system's kinematic specifications and targeting accuracy profiles.

METHODS

Eligible articles on human clinical applications of cranial robotic-guided stereotactic systems between 1985 and 2017 were extracted from several electronic databases, with a focus on stereotactic biopsy procedures, stereoelectroencephalography, and deep brain stimulation electrode insertion.

RESULTS

Cranial robotic stereotactic systems feature serial or parallel architectures with 4 to 7 degrees of freedom, and frame-based or frameless registration. Indications for robotic assistance are diversifying, and include stereotactic biopsy, deep brain stimulation and stereoelectroencephalography electrode placement, ventriculostomy, and ablation procedures. Complication rates are low, and mainly consist of hemorrhage. Newer systems benefit from increasing targeting accuracy, intraoperative imaging ability, improved safety profiles, and reduced operating times.

CONCLUSION

We highlight emerging future directions pertaining to the integration of robotic technologies into future neurosurgical procedures. Notably, a trend toward miniaturization, cost-effectiveness, frameless registration, and increasing safety and accuracy characterize successful stereotactic robotic technologies.

The Effect of Vascular Segmentation Methods on Stereotactic Trajectory Planning for Drug-Resistant Focal Epilepsy: A Retrospective Cohort Study

Background

Stereotactic neurosurgical procedures carry a risk of intracranial hemorrhage, which may result in significant morbidity and mortality. Vascular imaging is crucial for planning stereotactic procedures to prevent conflicts with intracranial vasculature. There is a wide range of vascular imaging methods used for stereoelectroencephalography (SEEG) trajectory planning. Computer-assisted planning (CAP) improves planning time and trajectory metrics. We aimed to quantify the effect of different vascular imaging protocols on CAP trajectories for SEEG.

Methods

Ten patients who had undergone SEEG (95 electrodes) following preoperative acquisition of gadolinium-enhanced magnetic resonance imaging (MR + Gad), magnetic resonance angiography and magnetic resonance angiography (MRV + MRA), and digital subtraction catheter angiography (DSA) were identified from a prospectively maintained database. SEEG implantations were planned using CAP using DSA segmentations as the gold standard. Strategies were then recreated using MRV + MRA and MR + Gad to define the “apparent” and “true” risk scores associated with each modality. Vessels of varying diameter were then iteratively removed from the DSA segmentation to identify the size at which all 3 vascular modalities returned the same safety metrics.

Results

CAP performed using DSA vessel segmentations resulted in significantly lower “true” risk scores and greater minimum distances from vasculature compared with the “true” risk associated with MR + Gad and MRV + MRA. MRV + MRA and MR + Gad returned similar risk scores to DSA when vessels <2 mm and <4 mm were not considered, respectively.

Conclusions

Significant variability in vascular imaging and trajectory planning practices exist for SEEG. CAP performed with MR + Gad or MRV + MRA alone returns “falsely” lower risk scores compared with DSA. It is unclear whether DSA is oversensitive and thus restricting potential trajectories.

Structural design of a positioning spherical parallel manipulator to be utilized in brain biopsy

BACKGROUND

During the last decades, there has been a great increase in the usage of robotic systems during surgeries in order to reach increased operational precision, reduced operation times, enhanced recovery periods, low infection risks, and limited scar formations for aesthetic reasons. In light of this, the current study focuses on the field of robotic surgery by introducing the kinematic structure of the precise robotic positioning manipulator for brain biopsy.

METHODOLOGY

Throughout the study, two degrees of freedom spherical parallel robot manipulator was proposed in order to position brain biopsy needle precisely during the brain biopsy operation on the target workspace.

RESULTS

Direct and inverse kinematics of the manipulator were carried out parametrically by using quaternion algebra. The prototype of the manipulator was manufactured by rapid prototyping for hardware verification.

CONCLUSIONS

Hardware verification of the manufactured prototype was completed distinctly by using motion capture cameras and manufactured mock-up setup that mimics tumour locations inside the brain. Successful verification results in terms of precision were achieved.

Image-Guided Biopsy of Intracranial Lesions with a Small Robotic Device (iSYS1): A Prospective, Exploratory Pilot Study

BACKGROUND

Robotic technologies have been used in the neurosurgical operating rooms for the last 30 yr. They have been adopted for several stereotactic applications and, particularly, image-guided biopsy of intracranial lesions which are not amenable for open surgical resection.

OBJECTIVE

To assess feasibility, safety, accuracy, and diagnostic yield of robot-assisted frameless stereotactic brain biopsy with a recently introduced miniaturized device (iSYS1; Interventional Systems Medizintechnik GmbH, Kitzbühel, Austria), fixed to the Mayfield headholder by a jointed arm.

METHODS

Clinical and surgical data of all patients undergoing frameless stereotactic biopsies using the iSYS1 robotized system from October 2016 to December 2017 have been prospectively collected and analyzed. Facial surface registration has been adopted for optical neuronavigation.

RESULTS

Thirty-nine patients were included in the study. Neither mortality nor morbidity related to the surgical procedure performed with the robot was recorded. Diagnostic tissue samples were obtained in 38 out of 39 procedures (diagnostic yield per procedure was 97.4%). All patients received a definitive histological diagnosis. Mean target error was 1.06 mm (median 1 mm, range 0.1-4 mm).

CONCLUSION

The frameless robotic iSYS1-assisted biopsy technique was determined to be feasible, safe, and accurate procedure; moreover, the diagnostic yield was high. The surface matching registration method with computed tomography as the reference image set did not negatively affect the accuracy of the procedure.

Improving patient safety during introduction of novel medical devices through cumulative summation analysis

OBJECTIVE The aim of this study was to implement cumulative summation (CUSUM) analysis as an early-warning detection and quality assurance system for preclinical testing of the iSYS1 novel robotic trajectory guidance system. METHODS Anatomically accurate 3D-printed skull phantoms were created for 3 patients who underwent implantation of 21 stereoelectroencephalography electrodes by surgeons using the current standard of care (frameless technique). Implantation schema were recreated using the iSYS1 system, and paired accuracy measures were compared with the previous frameless implantations. Entry point, target point, and implantation angle accuracy were measured on postimplantation CT scans. CUSUM analysis was undertaken prospectively. RESULTS The iSYS1 trajectory guidance system significantly improved electrode entry point accuracies from 1.90 ± 0.96 mm (mean ± SD) to 0.76 ± 0.57 mm (mean ± SD) without increasing implantation risk. CUSUM analysis was successful as a continuous measure of surgical performance and acted as an early-warning detection system. The surgical learning curve, although minimal, showed improvement after insertion of the eighth electrode. CONCLUSIONS The iSYS1 trajectory guidance system did not show any increased risk during phantom preclinical testing when used by neurosurgeons who had no experience with its use. CUSUM analysis is a simple technique that can be applied to all stages of the IDEAL (idea, development, exploration, assessment) framework as an extra patient safety mechanism. Further clinical trials are required to prove the efficacy of the device.

Navigation Systems for Treatment Planning and Execution of Percutaneous Irreversible Electroporation

The application of navigational systems has the potential to improve percutaneous interventions. The accuracy of ablation probe placement can be increased and radiation doses reduced. Two different types of systems can be distinguished, tracking systems and robotic systems. This review gives an overview of navigation devices for clinical application and summarizes first findings in the implementation of navigation in percutaneous interventions using irreversible electroporation. Because of the high number of navigation systems, this review focuses on commercially available ones.

Robot-assisted stereotactic brainstem biopsy in children: prospective cohort study

Tumours located within the brainstem comprise approximately a tenth of all paediatric brain tumours. Surgical biopsy of these tumours is technically challenging and has historically been associated with considerable risk. To this end, robot-assisted surgery theoretically allows for increased accuracy and precision. In this study we report our experience using the Neuromate robot (Renishaw, Gloucestershire, UK) to perform robot-assisted stereotactic biopsy in children with tumours located within the brainstem. An uncontrolled prospective cohort study was performed (phase II) according to the IDEAL model for safe surgical innovation. All cases were recorded on a prospectively maintained database. The database was searched over a 2-year period between the 1st December 2015 and the 31st November 2017 to identify all children with brainstem tumours that underwent robot-assisted stereotactic brain biopsy. When accessible, the post-operative MRI scans and pre-operative plans were compared to assess the target point localisation error (TPLE). Adverse events were recorded prospectively according to whether they resulted in increased hospital stay, caused neurological injury, or lead to death. In all, 11 consecutive children were identified with brain tumours located within the brainstem. In 10/11 cases specimens were diagnostic; in the remaining case a further biopsy was successful. The most frequent pathology was DIPG (7/15). Seven patients underwent an early post-operative volumetric MRI; the calculated median TPLE was 2.7 mm (range 0.5-4.2 mm). There were no surgical complications noted. Robot-assisted stereotactic biopsy in children appears to be feasible and safe. Research databases and comparative studies are warranted to further assess the technique.

5-ALA–induced fluorescence as a marker for diagnostic tissue in stereotactic biopsies of intracranial lymphomas: experience in 41 patients

OBJECTIVE

Stereotactic needle biopsies are usually performed for histopathological confirmation of intracranial lymphomas to guide adequate treatment. During biopsy, intraoperative histopathology is an effective tool to avoid acquisition of nondiagnostic samples. In the last years, 5-aminolevulinic acid (5-ALA)–induced fluorescence has been increasingly used for visualization of diagnostic brain tumor tissue during stereotactic biopsies. Recently, visible fluorescence was reported in the first cases of intracranial lymphomas as well. The aim of this study is thus to investigate the technical and clinical utility of 5-ALA–induced fluorescence in a large series of stereotactic biopsies for intracranial lymphoma.

METHODS

This prospective study recruited adult patients who underwent frameless stereotactic needle biopsy for a radiologically suspected intracranial lymphoma after oral 5-ALA administration. During biopsy, samples from the tumor region were collected for histopathological analysis, and presence of fluorescence (strong, vague, or no fluorescence) was assessed with a modified neurosurgical microscope. In tumors with available biopsy samples from at least 2 different regions the intratumoral fluorescence homogeneity was additionally investigated. Furthermore, the influence of potential preoperative corticosteroid treatment or immunosuppression on fluorescence was analyzed. Histopathological tumor diagnosis was established and all collected biopsy samples were screened for diagnostic lymphoma tissue.

RESULTS

The final study cohort included 41 patients with intracranial lymphoma. Stereotactic biopsies with assistance of 5-ALA were technically feasible in all cases. Strong fluorescence was found as maximum level in 30 patients (75%), vague fluorescence in 2 patients (4%), and no visible fluorescence in 9 patients (21%). In 28 cases, samples were obtained from at least 2 different tumor regions; homogenous intratumoral fluorescence was found in 16 of those cases (57%) and inhomogeneous intratumoral fluorescence in 12 (43%). According to histopathological analysis, all samples with strong or vague fluorescence contained diagnostic lymphoma tissue, resulting in a positive predictive value of 100%. Analysis showed no influence of preoperative corticosteroids or immunosuppression on fluorescence.

CONCLUSIONS

The data obtained in this study demonstrate the technical and clinical utility of 5-ALA–induced fluorescence in stereotactic biopsies of intracranial lymphomas. Thus, 5-ALA can serve as a useful tool to select patients not requiring intraoperative histopathology, and its application should markedly reduce operation time and related costs in the future.

5-ALA fluorescence and laser Doppler flowmetry for guidance in a stereotactic brain tumor biopsy

A fiber optic probe was developed for guidance during stereotactic brain biopsy procedures to target tumor tissue and reduce the risk of hemorrhage. The probe was connected to a setup for the measurement of 5-aminolevulinic acid (5-ALA) induced fluorescence and microvascular blood flow. Along three stereotactic trajectories, fluorescence (n = 109) and laser Doppler flowmetry (LDF) (n = 144) measurements were done in millimeter increments. The recorded signals were compared to histopathology and radiology images. The median ratio of protoporphyrin IX (PpIX) fluorescence and autofluorescence (AF) in the tumor was considerably higher than the marginal zone (17.3 vs 0.9). The blood flow showed two high spots (3%) in total. The proposed setup allows simultaneous and real-time detection of tumor tissue and microvascular blood flow for tracking the vessels.

A new tool for touch-free patient registration for robot-assisted intracranial surgery: application accuracy from a phantom study and a retrospective surgical series

OBJECTIVE The purpose of this study was to compare the accuracy of Neurolocate frameless registration system and frame-based registration for robotic stereoelectroencephalography (SEEG). METHODS The authors performed a 40-trajectory phantom laboratory study and a 127-trajectory retrospective analysis of a surgical series. The laboratory study was aimed at testing the noninferiority of the Neurolocate system. The analysis of the surgical series compared Neurolocate-based SEEG implantations with a frame-based historical control group. RESULTS The mean localization errors (LE) ± standard deviations (SD) for Neurolocate-based and frame-based trajectories were 0.67 ± 0.29 mm and 0.76 ± 0.34 mm, respectively, in the phantom study (p = 0.35). The median entry point LE was 0.59 mm (interquartile range [IQR] 0.25-0.88 mm) for Neurolocate-registration-based trajectories and 0.78 mm (IQR 0.49-1.08 mm) for frame-registration-based trajectories (p = 0.00002) in the clinical study. The median target point LE was 1.49 mm (IQR 1.06-2.4 mm) for Neurolocate-registration-based trajectories and 1.77 mm (IQR 1.25-2.5 mm) for frame-registration-based trajectories in the clinical study. All the surgical procedures were successful and uneventful. CONCLUSIONS The results of the phantom study demonstrate the noninferiority of Neurolocate frameless registration. The results of the retrospective surgical series analysis suggest that Neurolocate-based procedures can be more accurate than the frame-based ones. The safety profile of Neurolocate-based registration should be similar to that of frame-based registration. The Neurolocate system is comfortable, noninvasive, easy to use, and potentially faster than other registration devices.

Highlights from the First Annual Spinal Navigation, Emerging Technologies and Systems Integration Meeting

This paper provides a detailed report of the "First Annual Spinal Navigation, Emerging Technologies and Systems Integration" meeting held December 3, 2016 at the Seattle Science Foundation.

Robot-assisted stereotactic brain biopsy: systematic review and bibliometric analysis

INTRODUCTION

Stereotactic brain biopsy represents one of the earliest applications of surgical robotics. The aim of the present systematic review and bibliometric analysis was to evaluate the literature supporting robot-assisted brain biopsy and the extent to which the scientific community has accepted the technique.

METHODS

The Cochrane and PubMed databases were searched over a 30-year period between 1st of January 1988 and 31st of December 2017. Titles and abstracts were screened to identify publications that met the following criteria: (1) featured patients with brain pathology, (2) undergoing stereotactic brain biopsy, (3) reporting robot-assisted surgery, and (4) outcome data were provided. The reference lists of selected studies were also sought, and expert opinion sought to identify further eligible publications. Selected manuscripts were then reviewed, and data extracted on effectiveness and safety. The status of scientific community acceptance was determined using a progressive scholarly acceptance analysis.

RESULTS

All identified studies were non-randomised, including 1 retrospective cohort study and 14 case series or reports. The diagnostic biopsy rate varied from 75 to 100%, and the average target accuracy varied from 0.9 to 4.5 mm. Use of the robot was aborted in two operations owing to geometric inaccessibility and an error in image registration but no associated adverse events were reported. A compounding progressive scholarly acceptance analysis suggested a trend towards acceptance of the technique by the scientific community.

CONCLUSIONS

In conclusion, robot-assisted stereotactic brain biopsy is an increasingly mainstream tool in the neurosurgical armamentarium. Further evaluation should proceed along the IDEAL framework with research databases and comparative trials.

Brain biopsy performed with the RONNA G3 system: a case study on using a novel robotic navigation device for stereotactic neurosurgery

BACKGROUND

Robotic neuronavigation is becoming an important tool for neurosurgeons. We present a case study of a frameless stereotactic biopsy guided by the RONNA G3 robotic neuronavigation system.

METHODS

A 45 year-old patient with a history of vertigo, nausea and vomiting was diagnosed with multiple periventricular lesions. Neurological status was unremarkable. A frameless robotic biopsy of a brain lesion was performed.

RESULTS

Three tissue samples were obtained. There were no intraoperative or postoperative complications. Histological analysis showed a B-cell lymphoma. After merging the preoperative CT scan with the postoperative MRI and CT scans, the measured error between the planned and the postoperatively measured entry point was 2.24 mm and the measured error between the planned and postoperatively measured target point was 2.33 mm.

CONCLUSIONS

The RONNA G3 robotic system was used to navigate a Sedan brain biopsy needle to take tissue samples and could be a safe and precise tool for brain biopsy.