Modeling, Analysis, Force Sensing and Control of Continuum Robots for Minimally Invasive Surgery

This dissertation describes design, modeling and application of continuum robotics for surgical applications, specifically parallel continuum robots (PCRs) and concentric tube manipulators (CTMs). The introduction of robotics into surgical applications has allowed for a greater degree of precision, less invasive access to more remote surgical sites, and user-intuitive interfaces with enhanced vision systems. The most recent developments have been in the space of continuum robots, whose exible structure create an inherent safety factor when in contact with fragile tissues. The design challenges that exist involve balancing size and strength of the manipulators, controlling the manipulators over long transmission pathways, and incorporating force sensing and feedback from the manipulators to the user. Contributions presented in this work include: (1) prototyping, design, force sensing, and force control investigations of PCRs, and (2) prototyping of a concentric tube manipulator for use in a standard colonoscope. A general kinetostatic model is presented for PCRs along with identification of multiple physical constraints encountered in design and construction. Design considerations and manipulator capabilities are examined in the form of matrix metrics and ellipsoid representations. Finally, force sensing and control are explored and experimental results are provided showing the accuracy of force estimates based on actuation force measurements and control capabilities. An overview of the design requirements, manipulator construction, analysis and experimental results are provided for a CTM used as a tool manipulator in a traditional colonoscope. Currently, tools used in colonoscopic procedures are straight and exit the front of the scope with 1 DOF of operation (jaws of a grasper, tightening of a loop, etc.). This research shows that with a CTM deployed, the dexterity of these tools can be increased dramatically, increasing accuracy of tool operation, ease of use and safety of the overall procedure. The prototype investigated in this work allows for multiple tools to be used during a single procedure. Experimental results show the feasibility and advantages of the newly-designed manipulators

Cable-driven parallel mechanisms for minimally invasive robotic surgery

Minimally invasive surgery (MIS) has revolutionised surgery by providing faster recovery times, less post-operative complications, improved cosmesis and reduced pain for the patient. Surgical robotics are used to further decrease the invasiveness of procedures, by using yet smaller and fewer incisions or using natural orifices as entry point. However, many robotic systems still suffer from technical challenges such as sufficient instrument dexterity and payloads, leading to limited adoption in clinical practice. Cable-driven parallel mechanisms (CDPMs) have unique properties, which can be used to overcome existing challenges in surgical robotics. These beneficial properties include high end-effector payloads, efficient force transmission and a large configurable instrument workspace. However, the use of CDPMs in MIS is largely unexplored. This research presents the first structured exploration of CDPMs for MIS and demonstrates the potential of this type of mechanism through the development of multiple prototypes: the ESD CYCLOPS, CDAQS, SIMPLE, neuroCYCLOPS and microCYCLOPS. One key challenge for MIS is the access method used to introduce CDPMs into the body. Three different access methods are presented by the prototypes. By focusing on the minimally invasive access method in which CDPMs are introduced into the body, the thesis provides a framework, which can be used by researchers, engineers and clinicians to identify future opportunities of CDPMs in MIS. Additionally, through user studies and pre-clinical studies, these prototypes demonstrate that this type of mechanism has several key advantages for surgical applications in which haptic feedback, safe automation or a high payload are required. These advantages, combined with the different access methods, demonstrate that CDPMs can have a key role in the advancement of MIS technology.Open Acces

The Role of Visualization, Force Feedback, and Augmented Reality in Minimally Invasive Heart Valve Repair

New cardiovascular techniques have been developed to address the unique requirements of high risk, elderly, surgical patients with heart valve disease by avoiding both sternotomy and cardiopulmonary bypass. However, these technologies pose new challenges in visualization, force application, and intracardiac navigation. Force feedback and augmented reality (AR) can be applied to minimally invasive mitral valve repair and transcatheter aortic valve implantation (TAVI) techniques to potentially surmount these challenges. Our study demonstrated shorter operative times with three dimensional (3D) visualization compared to two dimensional (2D) visualization; however, both experts and novices applied significantly more force to cardiac tissue during 3D robotics-assisted mitral valve annuloplasty than during conventional open mitral valve annuloplasty. This finding suggests that 3D visualization does not fully compensate for the absence of haptic feedback in robotics-assisted cardiac surgery. Subsequently, using an innovative robotics-assisted surgical system design, we determined that direct haptic feedback may improve both expert and trainee performance using robotics-assisted techniques. We determined that during robotics-assisted mitral valve annuloplasty the use of either visual or direct force feedback resulted in a significant decrease in forces applied to cardiac tissue when compared to robotics-assisted mitral valve annuloplasty without force feedback. We presented NeoNav, an AR-enhanced echocardiograpy intracardiac guidance system for NeoChord off-pump mitral valve repair. Our study demonstrated superior tool navigation accuracy, significantly shorter navigation times, and reduced potential for injury with AR enhanced intracardiac navigation for off-pump transapical mitral valve repair with neochordae implantation. In addition, we applied the NeoNav system as a safe and inexpensive alternative imaging modality for TAVI guidance. We found that our proposed AR guidance system may achieve similar or better results than the current standard of care, contrast enhanced fluoroscopy, while eliminating the use of nephrotoxic contrast and ionizing radiation. These results suggest that the addition of both force feedback and augmented reality image guidance can improve both surgical performance and safety during minimally invasive robotics assisted and beating heart valve surgery, respectively

A gaze-contingent framework for perceptually-enabled applications in healthcare

Patient safety and quality of care remain the focus of the smart operating room of the future. Some of the most influential factors with a detrimental effect are related to suboptimal communication among the staff, poor flow of information, staff workload and fatigue, ergonomics and sterility in the operating room. While technological developments constantly transform the operating room layout and the interaction between surgical staff and machinery, a vast array of opportunities arise for the design of systems and approaches, that can enhance patient safety and improve workflow and efficiency. The aim of this research is to develop a real-time gaze-contingent framework towards a "smart" operating suite, that will enhance operator's ergonomics by allowing perceptually-enabled, touchless and natural interaction with the environment. The main feature of the proposed framework is the ability to acquire and utilise the plethora of information provided by the human visual system to allow touchless interaction with medical devices in the operating room. In this thesis, a gaze-guided robotic scrub nurse, a gaze-controlled robotised flexible endoscope and a gaze-guided assistive robotic system are proposed. Firstly, the gaze-guided robotic scrub nurse is presented; surgical teams performed a simulated surgical task with the assistance of a robot scrub nurse, which complements the human scrub nurse in delivery of surgical instruments, following gaze selection by the surgeon. Then, the gaze-controlled robotised flexible endoscope is introduced; experienced endoscopists and novice users performed a simulated examination of the upper gastrointestinal tract using predominately their natural gaze. Finally, a gaze-guided assistive robotic system is presented, which aims to facilitate activities of daily living. The results of this work provide valuable insights into the feasibility of integrating the developed gaze-contingent framework into clinical practice without significant workflow disruptions.Open Acces

Medical Robotics

The first generation of surgical robots are already being installed in a number of operating rooms around the world. Robotics is being introduced to medicine because it allows for unprecedented control and precision of surgical instruments in minimally invasive procedures. So far, robots have been used to position an endoscope, perform gallbladder surgery and correct gastroesophogeal reflux and heartburn. The ultimate goal of the robotic surgery field is to design a robot that can be used to perform closed-chest, beating-heart surgery. The use of robotics in surgery will expand over the next decades without any doubt. Minimally Invasive Surgery (MIS) is a revolutionary approach in surgery. In MIS, the operation is performed with instruments and viewing equipment inserted into the body through small incisions created by the surgeon, in contrast to open surgery with large incisions. This minimizes surgical trauma and damage to healthy tissue, resulting in shorter patient recovery time. The aim of this book is to provide an overview of the state-of-art, to present new ideas, original results and practical experiences in this expanding area. Nevertheless, many chapters in the book concern advanced research on this growing area. The book provides critical analysis of clinical trials, assessment of the benefits and risks of the application of these technologies. This book is certainly a small sample of the research activity on Medical Robotics going on around the globe as you read it, but it surely covers a good deal of what has been done in the field recently, and as such it works as a valuable source for researchers interested in the involved subjects, whether they are currently “medical roboticists” or not

Wireless capsule endoscope for targeted drug delivery

The diagnosis and treatment of pathologies of the gastrointestinal (GI) tract are performed routinely by gastroenterologists using endoscopes and colonoscopes, however the small intestinal tract is beyond the reach of these conventional systems. Attempts have been made to access the small intestines with wireless capsule endoscopes (WCE). These pill-sized cameras take pictures of the intestinal wall and then relay them back for evaluation. This practice enables the detection and diagnosis of pathologies of the GI tract such as Crohn's disease, small intestinal tumours such as lymphoma and small intestinal cancer. The problems with these systems are that they have limited diagnostic capabilities and they do not offer the ability to perform therapy to the affected areas leaving only the options of administering large quantities of drugs or surgical intervention. To address the issue of administering therapy in the small intestinal tract this thesis presents an active swallowable microrobotic platform which has novel functionality enabling the microrobot to treat pathologies through a targeted drug delivery system. This thesis first reviews the state-of-the-art in WCE through the evaluation of current and past literature. A review of current practises such as flexible sigmoidoscopy, virtual colonoscopy and wireless capsule endoscopy are presented. The following sections review the state-of-the-art in methods of resisting peristalsis, drug targeting systems and drug delivery. A review of actuators is presented, in the context of WCE, with a view to evaluate their acceptability in adding functionality to current WCEs. The thesis presents a novel biologically-inspired holding mechanism which overcomes the issue of resisting natural peristalsis in the GI tract. An analysis of the two components of peristaltic force, circumferential and longitudinal peristaltic contractions, are presented to ensure correct functionality of the holding mechanism. A detailed analysis of the motorised method employed to deploy the expanding mechanism is described and a 5:1 scale prototype is presented which characterises the gearbox and validates the holding mechanism. The functionality of WCE is further extended by the inclusion of a novel targeting mechanism capable of delivering a metered dose of medication to a target site of interest in the GI tract. A solution to the problem of positioning a needle within a 360 degree envelope, operating the needle and safely retracting the needle in the GI tract is discussed. A comprehensive analysis of the mechanism to manoeuvre the needle is presented and validation of the mechanism is demonstrated through the evaluation of scale prototypes. Finally a drug delivery system is presented which can expel a 1 ml dose of medication, stored onboard the capsule, into the subcutaneous tissue of the GI tract wall. An analysis of the force required to expel the medication in a set period of time is presented and the design and analysis of a variable pitch conical compression spring which will be used to deliver the medication is discussed. A thermo mechanical trigger mechanism is presented which will be employed to release the compressed conical spring. Experimental results using 1:1 scale prototype parts validate the performance of the mechanisms.Open Acces

An investigation into perioperative outcome following gastrointestinal resection in England

This thesis represents research from Hospital Episode Statistics data and provides an insight into gastrointestinal resectional surgery in England. It examines national outcomes following major colorectal resection, oesophagectomy and gastrectomy. Having established these outcomes, I ventured to investigate the commonly used mortality measures in the literature. I also studied the timing and causes of deaths following colorectal resection in English NHS Trust hospital. I was able to demonstrate that a significant number of adverse outcomes occur beyond the initial hospital stay. I evaluated the role of two key factors - minimally invasive surgery and surgeon volume in trying to mitigate these adverse outcomes. I found that national outcome following elective or planned colorectal resection are comparable with other published cancer registry reports in England. For upper gastrointestinal resection for cancer, however, outcome are significantly worse than those from Far East, but superior to studies from the States. I derived 'medical morbidity' by studying secondary codes for medical complications. Surgical complications were quantified by using surrogates such as unplanned re-operation and re-intervention following the initial procedure. I undertook a review of the literature for published outcomes following planned colorectal resection in the elderly. This demonstrated heterogeneity in studies with regards to sample size and type of study. The most commonly used measure of post-operative risk was in-hospital or 30-day mortality. In the elderly population, we demonstrated high mortality up to one year following emergency colorectal resection. To understand this excess mortality that is not taken into account by short term metrics, we studied the causes of deaths in these patients. Significant deaths occur in the young and elderly due to cardiac causes, up to one year following major colorectal resection. This calls for further research to define a new intermediate term metric that accurately quantifies the mortality risk. The uptake of minimally invasive gastrointestinal resection in England has been promising. During the study period there has been a steady rise in number of resections undertaken laparoscopically. In colorectal surgery, laparoscopic resection has been associated with shorter length of stay, reduced morbidity and mortality. Outcome following minimally invasive oesophagectomy and gastrectomy have shown this technique to be safe and potentially beneficial in reducing pulmonary complications and length of stay. However further research is needed into this. Oesophagectomy, gastrectomy and pancreatectomy for cancer have all demonstrated a positive volume-outcome relationship. With increasing surgeon caseload, risk of 30-day mortality is lower. These structure and process measures may be utilised by policy makers to improve outcome following gastrointestinal resection in England.Open Acces