Prevalence of haptic feedback in robot-mediated surgery : a systematic review of literature

© 2017 Springer-Verlag. This is a post-peer-review, pre-copyedit version of an article published in Journal of Robotic Surgery. The final authenticated version is available online at: https://doi.org/10.1007/s11701-017-0763-4With the successful uptake and inclusion of robotic systems in minimally invasive surgery and with the increasing application of robotic surgery (RS) in numerous surgical specialities worldwide, there is now a need to develop and enhance the technology further. One such improvement is the implementation and amalgamation of haptic feedback technology into RS which will permit the operating surgeon on the console to receive haptic information on the type of tissue being operated on. The main advantage of using this is to allow the operating surgeon to feel and control the amount of force applied to different tissues during surgery thus minimising the risk of tissue damage due to both the direct and indirect effects of excessive tissue force or tension being applied during RS. We performed a two-rater systematic review to identify the latest developments and potential avenues of improving technology in the application and implementation of haptic feedback technology to the operating surgeon on the console during RS. This review provides a summary of technological enhancements in RS, considering different stages of work, from proof of concept to cadaver tissue testing, surgery in animals, and finally real implementation in surgical practice. We identify that at the time of this review, while there is a unanimous agreement regarding need for haptic and tactile feedback, there are no solutions or products available that address this need. There is a scope and need for new developments in haptic augmentation for robot-mediated surgery with the aim of improving patient care and robotic surgical technology further.Peer reviewe

Robotic manipulators for single access surgery

This thesis explores the development of cooperative robotic manipulators for enhancing surgical precision and patient outcomes in single-access surgery and, specifically, Transanal Endoscopic Microsurgery (TEM). During these procedures, surgeons manipulate a heavy set of instruments via a mechanical clamp inserted in the patient’s body through a surgical port, resulting in imprecise movements, increased patient risks, and increased operating time. Therefore, an articulated robotic manipulator with passive joints is initially introduced, featuring built-in position and force sensors in each joint and electronic joint brakes for instant lock/release capability. The articulated manipulator concept is further improved with motorised joints, evolving into an active tool holder. The joints allow the incorporation of advanced robotic capabilities such as ultra-lightweight gravity compensation and hands-on kinematic reconfiguration, which can optimise the placement of the tool holder in the operating theatre. Due to the enhanced sensing capabilities, the application of the active robotic manipulator was further explored in conjunction with advanced image guidance approaches such as endomicroscopy. Recent advances in probe-based optical imaging such as confocal endomicroscopy is making inroads in clinical uses. However, the challenging manipulation of imaging probes hinders their practical adoption. Therefore, a combination of the fully cooperative robotic manipulator with a high-speed scanning endomicroscopy instrument is presented, simplifying the incorporation of optical biopsy techniques in routine surgical workflows. Finally, another embodiment of a cooperative robotic manipulator is presented as an input interface to control a highly-articulated robotic instrument for TEM. This master-slave interface alleviates the drawbacks of traditional master-slave devices, e.g., using clutching mechanics to compensate for the mismatch between slave and master workspaces, and the lack of intuitive manipulation feedback, e.g. joint limits, to the user. To address those drawbacks a joint-space robotic manipulator is proposed emulating the kinematic structure of the flexible robotic instrument under control.Open Acces

Context-aware learning for robot-assisted endovascular catheterization

Endovascular intervention has become a mainstream treatment of cardiovascular diseases. However, multiple challenges remain such as unwanted radiation exposures, limited two-dimensional image guidance, insufficient force perception and haptic cues. Fast evolving robot-assisted platforms improve the stability and accuracy of instrument manipulation. The master-slave system also removes radiation to the operator. However, the integration of robotic systems into the current surgical workflow is still debatable since repetitive, easy tasks have little value to be executed by the robotic teleoperation. Current systems offer very low autonomy, potential autonomous features could bring more benefits such as reduced cognitive workloads and human error, safer and more consistent instrument manipulation, ability to incorporate various medical imaging and sensing modalities. This research proposes frameworks for automated catheterisation with different machine learning-based algorithms, includes Learning-from-Demonstration, Reinforcement Learning, and Imitation Learning. Those frameworks focused on integrating context for tasks in the process of skill learning, hence achieving better adaptation to different situations and safer tool-tissue interactions. Furthermore, the autonomous feature was applied to next-generation, MR-safe robotic catheterisation platform. The results provide important insights into improving catheter navigation in the form of autonomous task planning, self-optimization with clinical relevant factors, and motivate the design of intelligent, intuitive, and collaborative robots under non-ionizing image modalities.Open Acces

Skill-based human-robot cooperation in tele-operated path tracking

This work proposes a shared-control tele-operation framework that adapts its cooperative properties to the estimated skill level of the operator. It is hypothesized that different aspects of an operatorâ\u80\u99s performance in executing a tele-operated path tracking task can be assessed through conventional machine learning methods using motion-based and task-related features. To identify performance measures that capture motor skills linked to the studied task, an experiment is conducted where users new to tele-operation, practice towards motor skill proficiency in 7 training sessions. A set of classifiers are then learned from the acquired data and selected features, which can generate a skill profile that comprises estimations of userâ\u80\u99s various competences. Skill profiles are exploited to modify the behavior of the assistive robotic system accordingly with the objective of enhancing user experience by preventing unnecessary restriction for skilled users. A second experiment is implemented in which novice and expert users execute the path tracking on different pathways while being assisted by the robot according to their estimated skill profiles. Results validate the skill estimation method and hint at feasibility of shared-control customization in tele-operated path tracking

Multi-robot cooperative platform : a task-oriented teleoperation paradigm

This thesis proposes the study and development of a teleoperation system based on multi-robot cooperation under the task oriented teleoperation paradigm: Multi-Robot Cooperative Paradigm, MRCP. In standard teleoperation, the operator uses the master devices to control the remote slave robot arms. These arms reproduce the desired movements and perform the task. With the developed work, the operator can virtually manipulate an object. MRCP automatically generates the arms orders to perform the task. The operator does not have to solve situations arising from possible restrictions that the slave arms may have. The research carried out is therefore aimed at improving the accuracy teleoperation tasks in complex environments, particularly in the field of robot assisted minimally invasive surgery. This field requires patient safety and the workspace entails many restrictions to teleoperation. MRCP can be defined as a platform composed of several robots that cooperate automatically to perform a teleoperated task, creating a robotic system with increased capacity (workspace volume, accessibility, dexterity ...). The cooperation is based on transferring the task between robots when necessary to enable a smooth task execution. The MRCP control evaluates the suitability of each robot to continue with the ongoing task and the optimal time to execute a task transfer between the current selected robot and the best candidate to continue with the task. From the operator¿s point of view, MRCP provides an interface that enables the teleoperation though the task-oriented paradigm: operator orders are translated into task actions instead of robot orders. This thesis is structured as follows: The first part is dedicated to review the current solutions in the teleoperation of complex tasks and compare them with those proposed in this research. The second part of the thesis presents and reviews in depth the different evaluation criteria to determine the suitability of each robot to continue with the execution of a task, considering the configuration of the robots and emphasizing the criterion of dexterity and manipulability. The study reviews the different required control algorithms to enable the task oriented telemanipulation. This proposed teleoperation paradigm is transparent to the operator. Then, the Thesis presents and analyses several experimental results using MRCP in the field of minimally invasive surgery. These experiments study the effectiveness of MRCP in various tasks requiring the cooperation of two hands. A type task is used: a suture using minimally invasive surgery technique. The analysis is done in terms of execution time, economy of movement, quality and patient safety (potential damage produced by undesired interaction between the tools and the vital tissues of the patient). The final part of the thesis proposes the implementation of different virtual aids and restrictions (guided teleoperation based on haptic visual and audio feedback, protection of restricted workspace regions, etc.) using the task oriented teleoperation paradigm. A framework is defined for implementing and applying a basic set of virtual aids and constraints within the framework of a virtual simulator for laparoscopic abdominal surgery. The set of experiments have allowed to validate the developed work. The study revealed the influence of virtual aids in the learning process of laparoscopic techniques. It has also demonstrated the improvement of learning curves, which paves the way for its implementation as a methodology for training new surgeons.Aquesta tesi doctoral proposa l'estudi i desenvolupament d'un sistema de teleoperació basat en la cooperació multi-robot sota el paradigma de la teleoperació orientada a tasca: Multi-Robot Cooperative Paradigm, MRCP. En la teleoperació clàssica, l'operador utilitza els telecomandaments perquè els braços robots reprodueixin els seus moviments i es realitzi la tasca desitjada. Amb el treball realitzat, l'operador pot manipular virtualment un objecte i és mitjançant el MRCP que s'adjudica a cada braç les ordres necessàries per realitzar la tasca, sense que l'operador hagi de resoldre les situacions derivades de possibles restriccions que puguin tenir els braços executors. La recerca desenvolupada està doncs orientada a millorar la teleoperació en tasques de precisió en entorns complexos i, en particular, en el camp de la cirurgia mínimament invasiva assistida per robots. Aquest camp imposa condicions de seguretat del pacient i l'espai de treball comporta moltes restriccions a la teleoperació. MRCP es pot definir com a una plataforma formada per diversos robots que cooperen de forma automàtica per dur a terme una tasca teleoperada, generant un sistema robòtic amb capacitats augmentades (volums de treball, accessibilitat, destresa,...). La cooperació es basa en transferir la tasca entre robots a partir de determinar quin és aquell que és més adequat per continuar amb la seva execució i el moment òptim per realitzar la transferència de la tasca entre el robot actiu i el millor candidat a continuar-la. Des del punt de vista de l'operari, MRCP ofereix una interfície de teleoperació que permet la realització de la teleoperació mitjançant el paradigma d'ordres orientades a la tasca: les ordres es tradueixen en accions sobre la tasca en comptes d'estar dirigides als robots. Aquesta tesi està estructurada de la següent manera: Primerament es fa una revisió de l'estat actual de les diverses solucions desenvolupades actualment en el camp de la teleoperació de tasques complexes, comparant-les amb les proposades en aquest treball de recerca. En el segon bloc de la tesi es presenten i s'analitzen a fons els diversos criteris per determinar la capacitat de cada robot per continuar l'execució d'una tasca, segons la configuració del conjunt de robots i fent especial èmfasi en el criteri de destresa i manipulabilitat. Seguint aquest estudi, es presenten els diferents processos de control emprats per tal d'assolir la telemanipulació orientada a tasca de forma transparent a l'operari. Seguidament es presenten diversos resultats experimentals aplicant MRCP al camp de la cirurgia mínimament invasiva. En aquests experiments s'estudia l'eficàcia de MRCP en diverses tasques que requereixen de la cooperació de dues mans. S'ha escollit una tasca tipus: sutura amb tècnica de cirurgia mínimament invasiva. L'anàlisi es fa en termes de temps d'execució, economia de moviment, qualitat i seguretat del pacient (potencials danys causats per la interacció no desitjada entre les eines i els teixits vitals del pacient). Finalment s'ha estudiat l'ús de diferents ajudes i restriccions virtuals (guiat de la teleoperació via retorn hàptic, visual o auditiu, protecció de regions de l'espai de treball, etc) dins el paradigma de teleoperació orientada a tasca. S'ha definint un marc d'aplicació base i implementant un conjunt de restriccions virtuals dins el marc d'un simulador de cirurgia laparoscòpia abdominal. El conjunt d'experiments realitzats han permès validar el treball realitzat. Aquest estudi ha permès determinar la influencia de les ajudes virtuals en el procés d'aprenentatge de les tècniques laparoscòpiques. S'ha evidenciat una millora en les corbes d'aprenentatge i obre el camí a la seva implantació com a metodologia d'entrenament de nous cirurgians.Postprint (published version

Haptics in Robot-Assisted Surgery: Challenges and Benefits

Robotic surgery is transforming the current surgical practice, not only by improving the conventional surgical methods but also by introducing innovative robot-enhanced approaches that broaden the capabilities of clinicians. Being mainly of man-machine collaborative type, surgical robots are seen as media that transfer pre- and intra-operative information to the operator and reproduce his/her motion, with appropriate filtering, scaling, or limitation, to physically interact with the patient. The field, however, is far from maturity and, more critically, is still a subject of controversy in medical communities. Limited or absent haptic feedback is reputed to be among reasons that impede further spread of surgical robots. In this paper objectives and challenges of deploying haptic technologies in surgical robotics is discussed and a systematic review is performed on works that have studied the effects of providing haptic information to the users in major branches of robotic surgery. It has been tried to encompass both classical works and the state of the art approaches, aiming at delivering a comprehensive and balanced survey both for researchers starting their work in this field and for the experts

Expert-in-the-Loop Multilateral Telerobotics for Haptics-Enabled Motor Function and Skills Development

Among medical robotics applications are Robotics-Assisted Mirror Rehabilitation Therapy (RAMRT) and Minimally-Invasive Surgical Training (RAMIST) that extensively rely on motor function development. Haptics-enabled expert-in-the-loop motor function development for such applications is made possible through multilateral telerobotic frameworks. While several studies have validated the benefits of haptic interaction with an expert in motor learning, contradictory results have also been reported. This emphasizes the need for further in-depth studies on the nature of human motor learning through haptic guidance and interaction. The objective of this study was to design and evaluate expert-in-the-loop multilateral telerobotic frameworks with stable and human-safe control loops that enable adaptive “hand-over-hand” haptic guidance for RAMRT and RAMIST. The first prerequisite for such frameworks is active involvement of the patient or trainee, which requires the closed-loop system to remain stable in the presence of an adaptable time-varying dominance factor. To this end, a wave-variable controller is proposed in this study for conventional trilateral teleoperation systems such that system stability is guaranteed in the presence of a time-varying dominance factor and communication delay. Similar to other wave-variable approaches, the controller is initially developed for the Velocity-force Domain (VD) based on the well-known passivity assumption on the human arm in VD. The controller can be applied straightforwardly to the Position-force Domain (PD), eliminating position-error accumulation and position drift, provided that passivity of the human arm in PD is addressed. However, the latter has been ignored in the literature. Therefore, in this study, passivity of the human arm in PD is investigated using mathematical analysis, experimentation as well as user studies involving 12 participants and 48 trials. The results, in conjunction with the proposed wave-variables, can be used to guarantee closed-loop PD stability of the supervised trilateral teleoperation system in its classical format. The classic dual-user teleoperation architecture does not, however, fully satisfy the requirements for properly imparting motor function (skills) in RAMRT (RAMIST). Consequently, the next part of this study focuses on designing novel supervised trilateral frameworks for providing motor learning in RAMRT and RAMIST, each customized according to the requirements of the application. The framework proposed for RAMRT includes the following features: a) therapist-in-the-loop mirror therapy; b) haptic feedback to the therapist from the patient side; c) assist-as-needed therapy realized through an adaptive Guidance Virtual Fixture (GVF); and d) real-time task-independent and patient-specific motor-function assessment. Closed-loop stability of the proposed framework is investigated using a combination of the Circle Criterion and the Small-Gain Theorem. The stability analysis addresses the instabilities caused by: a) communication delays between the therapist and the patient, facilitating haptics-enabled tele- or in-home rehabilitation; and b) the integration of the time-varying nonlinear GVF element into the delayed system. The platform is experimentally evaluated on a trilateral rehabilitation setup consisting of two Quanser rehabilitation robots and one Quanser HD2 robot. The framework proposed for RAMIST includes the following features: a) haptics-enabled expert-in-the-loop surgical training; b) adaptive expertise-oriented training, realized through a Fuzzy Interface System, which actively engages the trainees while providing them with appropriate skills-oriented levels of training; and c) task-independent skills assessment. Closed-loop stability of the architecture is analyzed using the Circle Criterion in the presence and absence of haptic feedback of tool-tissue interactions. In addition to the time-varying elements of the system, the stability analysis approach also addresses communication delays, facilitating tele-surgical training. The platform is implemented on a dual-console surgical setup consisting of the classic da Vinci surgical system (Intuitive Surgical, Inc., Sunnyvale, CA), integrated with the da Vinci Research Kit (dVRK) motor controllers, and the dV-Trainer master console (Mimic Technology Inc., Seattle, WA). In order to save on the expert\u27s (therapist\u27s) time, dual-console architectures can also be expanded to accommodate simultaneous training (rehabilitation) for multiple trainees (patients). As the first step in doing this, the last part of this thesis focuses on the development of a multi-master/single-slave telerobotic framework, along with controller design and closed-loop stability analysis in the presence of communication delays. Various parts of this study are supported with a number of experimental implementations and evaluations. The outcomes of this research include multilateral telerobotic testbeds for further studies on the nature of human motor learning and retention through haptic guidance and interaction. They also enable investigation of the impact of communication time delays on supervised haptics-enabled motor function improvement through tele-rehabilitation and mentoring

Anthropomorphic surgical system for soft tissue robot-assisted surgery

Over the past century, abdominal surgery has seen a rapid transition from open procedures to less invasive methods such as laparoscopy and robot-assisted minimally invasive surgery (R-A MIS). These procedures have significantly decreased blood loss, postoperative morbidity and length of hospital stay in comparison with open surgery. R-A MIS has offered refined accuracy and more ergonomic instruments for surgeons, further minimising trauma to the patient.This thesis aims to investigate, design and prototype a novel system for R-A MIS that will provide more natural and intuitive manipulation of soft tissues and, at the same time, increase the surgeon's dexterity. The thesis reviews related work on surgical systems and discusses the requirements for designing surgical instrumentation. From the background research conducted in this thesis, it is clear that training surgeons in MIS procedures is becoming increasingly long and arduous. Furthermore, most available systems adopt a design similar to conventional laparoscopic instruments or focus on different techniques with debatable benefits. The system proposed in this thesis not only aims to reduce the training time for surgeons but also to improve the ergonomics of the procedure.In order to achieve this, a survey was conducted among surgeons, regarding their opinions on surgical training, surgical systems, how satisfied they are with them and how easy they are to use. A concept for MIS robotic instrumentation was then developed and a series of focus group meetings with surgeons were run to discuss it. The proposed system, named microAngelo, is an anthropomorphic master-slave system that comprises a three-digit miniature hand that can be controlled using the master, a three-digit sensory exoskeleton. While multi-fingered robotic hands have been developed for decades, none have been used for surgical operations. As the system has a human centred design, its relation to the human hand is discussed. Prototypes of both the master and the slave have been developed and their design and mechanisms is demonstrated. The accuracy and repeatability of the master as well as the accuracy and force capabilities of the slave are tested and discussed