Clinical applications of robotic technology in vascular and endovascular surgery

BackgroundEmerging robotic technologies are increasingly being used by surgical disciplines to facilitate and improve performance of minimally invasive surgery. Robot-assisted intervention has recently been introduced into the field of vascular surgery to potentially enhance laparoscopic vascular and endovascular capabilities. The objective of this study was to review the current status of clinical robotic applications in vascular surgery.MethodsA systematic literature search was performed in order to identify all published clinical studies related to robotic implementation in vascular intervention. Web-based search engines were searched using the keywords “surgical robotics,” “robotic surgery,” “robotics,” “computer assisted surgery,” and “vascular surgery” or “endovascular” for articles published between January 1990 and November 2009. An evaluation and critical overview of these studies is reported. In addition, an analysis and discussion of supporting evidence for robotic computer-enhanced telemanipulation systems in relation to their applications in laparoscopic vascular and endovascular surgery was undertaken.ResultsSeventeen articles reporting on clinical applications of robotics in laparoscopic vascular and endovascular surgery were detected. They were either case reports or retrospective patient series and prospective studies reporting laparoscopic vascular and endovascular treatments for patients using robotic technology. Minimal comparative clinical evidence to evaluate the advantages of robot-assisted vascular procedures was identified. Robot-assisted laparoscopic aortic procedures have been reported by several studies with satisfactory results. Furthermore, the use of robotic technology as a sole modality for abdominal aortic aneurysm repair and expansion of its applications to splenic and renal artery aneurysm reconstruction have been described. Robotically steerable endovascular catheter systems have potential advantages over conventional catheterization systems. Promising results from applications in cardiac interventions and preclinical studies have urged their use in vascular surgery. Although successful applications in endovascular repair of abdominal aortic aneurysm and lower extremity arterial disease have been reported, published clinical experience with the endovascular robot is limited.ConclusionsRobotic technology may enhance vascular surgical techniques given preclinical evidence and early clinical reports. Further clinical studies are required to quantify its advantages over conventional treatments and define its role in vascular and endovascular surgery

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

Current Trends and Future Developments in Robotic Cardiac Surgery

Robotic Cardiac Surgery has revolutionised operating for surgeons to provide less operative pain, shorter hospital stays and improved quality of life. As surgeons are constantly trying new techniques, Robotic Cardiac Surgery now encompasses mitral valve surgery, coronary revascularisation, atrial fibrillation surgery, pacing lead implantation, congenital cardiac operations, cardiac tumours resection and diaphragmatic pacing. Robotic technology is gradually becoming more affordable and so more centres are investing in training surgeons in these techniques. As a result, robotic cardiac surgery has developed into a rapidly evolving speciality with exciting new possibilities... (excerpt

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

DEVELOPMENT OF A KINETIC MODEL FOR STEERABLE CATHETERS FOR MINIMALLY INVASIVE SURGERY

The steerable catheters have demonstrated many advantages to overcome the limitations of the conventional catheters in the minimally invasive surgery. The motion and force transmission from the proximal end to distal tip of the catheter have significant effects to the efficiency and safety of surgery. While the force information between the catheter and the body (e.g., vessel) can be obtained by mounting sensors on the distal tip of the catheter, this would be more intrusive and less reliable than the one without the sensors, which is described in this disseration. In addition, the small diameters of the catheters may also restrict the idea of mounting sensors on the distal tip. The other approach to obtain the force information is to infer it from the information outside the body. This will demand an accurate mathematical model that describes the force and motion relation called kinetic model, and unfortunately, such a kinetic model is not available in the literature. In this dissertation, a kinetic model for steerable catheters is presented wich captures the following characteristics of the steerable catheter, namely (1) the geometrical non-linear behavior of the catheter in motion, (2) the deformable pathway, (3) the friction between the catheter and the pathyway, and (4) the contact between the catheter and pathway. A non-linear finite element system (SPACAR) was employed to capture these characteristics. A test-bed was built and an experiment was carried out to verify the developed kinetic model. The following conclusions can be drawn from this dissertation: (1) the developed kinetic model is accurte in comparison with those in literature; (2) the Dahl friction model, the LuGre friction model and the simplified LuGre friction model are able to capture the friction behavior between the catheter and the pathway but the Coulomb friction model fails (as it cannot capture the hysteresis property which has a significant influence on the behavior of the catheter); (3) the developed kinetic model has the potential of being used to optimize the design and operation of steerable catheters with several salient findings that (3a) the maximal contact force between the catheter and the pathway occurs on the tip of the distal part or the connecting part between the distal part and catheter body of the catheter and (3b) the rigidity and length of the distal part are crucial structural parameters that affect the motion and force transmission significantly. There are several contributions made by this dissertation. In the field of the steerable catheter, biomechanics and bio-instrumentation, the contributions are summarized in the following: (1) the approach to develop the kinetic model of the steerable catheter in a complex work environment is useful to model other similar compliant medical devices, such as endoscope; (2) the kinetic model of the steerable catheter can provide the force information to improve the efficiency and safety of MIS (minimally invastive surgery) and to realize the “doctor-assisted” catheter-based MIS procedure; (3) the kinetic model can provide accurate data for developing other simplified models for the steerable catheters in their corresponding work environments for realizing the robotic-based fully automated MIS procedure. (4) The kinetic model of the steerable catheter and the test-bed with the corresponding instruments and methods for the kinetic and kinematic measurements are a useful design validation in the steerable catheter technology as well as for the training of physicians to perform the catheter-based interventional procedure by adding more complex anatomic phantoms. In the field of continuum manipulator and continuum robots, the approach to develop the kinetic model is useful to model other manipulators and robots, such as snake-like robots

Challenges of continuum robots in clinical context: a review

With the maturity of surgical robotic systems based on traditional rigid-link principles, the rate of progress slowed as limits of size and controllable degrees of freedom were reached. Continuum robots came with the potential to deliver a step change in the next generation of medical devices, by providing better access, safer interactions and making new procedures possible. Over the last few years, several continuum robotic systems have been launched commercially and have been increasingly adopted in hospitals. Despite the clear progress achieved, continuum robots still suffer from design complexity hindering their dexterity and scalability. Recent advances in actuation methods have looked to address this issue, offering alternatives to commonly employed approaches. Additionally, continuum structures introduce significant complexity in modelling, sensing, control and fabrication; topics which are of particular focus in the robotics community. It is, therefore, the aim of the presented work to highlight the pertinent areas of active research and to discuss the challenges to be addressed before the potential of continuum robots as medical devices may be fully realised

Comparative Review of Endoscopic Devices Articulations Technologies Developed for Minimally Invasive Medical Procedures

This study introduces a comparative performance analysis of the technological solutions that have been used to build distal active articulations for minimally invasive medical procedures. The aim is to provide a practical and concise database and classification tool for anyone that wants to learn more about the technologies involved in minimally invasive medical devices, or for any designer interested in further improving these devices. A review of the different articulations developed in this field is therefore performed and organized by both actuation technology and structural architecture. Details are presented concerning the mechanical structures as well as the actuation and the mechanical transmission technologies available. The solutions are evaluated keeping as a reference some chosen required performances and characteristics for minimally invasive surgical procedures. Finally, a quantified comparison chart of these devices is given regarding selected criteria of interest for minimally invasive surgical application

Combined robot-assisted procedures : A review

Εισαγωγή Η λαπαροσκοπική χειρουργική διαδέχθηκε την ανοικτή χειρουργική, με αποτέλεσμα την ελαχιστοποίηση του χειρουργικού τραύματος και του χρόνου νοσηλείας και αποκατάστασης. Η ρομποτική χειρουργική αποτελεί τη νεότερη εξέλιξη στην ελάχιστα επεμβατική χειρουργική, προσφέροντας ανώτερη εικόνα, μεγαλύτερη ελευθερία κινήσεων και βελτίωση της εργονομίας της θέσης του χειρουργού σε σχέση με τη λαπαροσκοπική χειρουργική. Η διείσδυση της ρομποτικά υποβοηθούμενης χειρουργικής σε ένα ευρύ φάσμα χειρουργικών ειδικοτήτων, έχει φτάσει ακόμη και στην αντιμετώπιση σύγχρονων παθήσεων σε μία συνδυασμένη χειρουργική παρέμβαση. Σκοπός Σκοπός της παρούσας μελέτης είναι η συστηματική ανασκόπηση των διαθέσιμων αναφορών που αφορούν σε συνδυασμένες ρομποτικά υποβοηθούμενες επεμβάσεις, καταγράφοντας τα αποτελέσματα των μελετών, τις διαθέσιμες συγκρίσεις με αντίστοιχες συμβατικές μεθόδους, τα πλεονεκτήματα των προσεγγίσεων, αλλά και τους τυχόν περιορισμούς των υπό μελέτη μεθόδων. Μεθοδολογία Μετά από αναζήτηση σε μεγάλες διαδικτυακές ιατρικές βιβλιοθήκες, χρησιμοποιώντας κατάλληλες λέξεις ευρετηριασμού, έγινε συλλογή των διαθέσιμων βιβλιογραφικών αναφορών. Μετά από ανάλυση αυτών, επιλέχθηκαν συνολικά 54 άρθρα, συναφή προς το εξεταζόμενο θέμα, τα οποία αναλύθηκαν περαιτέρω. Αποτελέσματα Ένας μεγάλος αριθμός διαφορετικών συνδυασμένων επεμβάσεων έχει αναφερθεί, κυρίως στο πλαίσιο περιγραφής μεμονωμένων περιστατικών ή μικρών σειρών ασθενών. Τα αποτελέσματα των βιβλιογραφικών αναφορών αναλύθηκαν εκτενώς, ενώ παράλληλα δόθηκε βάση σε συγκριτικά δεδομένα και τυχόν μειονεκτήματα και περιορισμούς. Συμπέρασμα Οι συνδυασμένες ρομποτικά υποβοηθούμενες χειρουργικές επεμβάσεις αποτελούν μια νέα εξέλιξη στην ιστορία της χειρουργικής αντιμετώπισης. Περισσότερες δομημένες έρευνες και συγκριτικές αναλύσεις είναι απαραίτητες για την ασφαλή εξαγωγή συμπερασμάτων, την υποστήριξη των ενθαρρυντικών μηνυμάτων των πρώιμων διαθέσιμων δεδομένων και την αντιμετώπιση των καταγεγραμμένων περιορισμών.Background Open surgery has been succeeded by laparoscopic surgery, which allows for reduced surgical trauma and potentially shorter pain and recovery times. Robot-assisted surgery is the latest innovation in minimal invasive surgery, offering supreme visibility and dexterity in addition to a comfortable surgical posture, compared to conventional laparoscopy. Robotic techniques are continuously making inroads in most surgical specialties, causing a paradigm shift in therapy. Currently, the limits of robotics are pushed even further, treating multiple pathologies in a single setting. Purpose The purpose of the study is to provide a structured review of all reported cases on concomitant robot-assisted surgical procedures, focusing on the comparison to the respective alternative approaches, provided results, potential advantages and reported limitations and drawbacks. Methods A systematic search in major online medical libraries was conducted using the keywords "synchronous/ concomitant/ concurrent/ simultaneous" combined with "robotic/ robot-assisted/ da Vinci". The results were assessed and systematically analyzed, resulting in 54 articles which were thoroughly reviewed. Results A plethora of combined procedures have been described, mostly in form of case reports or case series. Concomitant robot-assisted operations are described as feasible and effective, especially in highly selected patients. Specific limitations and drawbacks were noted, and the findings were accordingly interpreted, in regards to the strengths and weaknesses of the available evidence. Conclusion Concomitant robot-assisted surgical procedures constitute a relatively new installment in the evolution of surgical therapy. Further well-structured studies and comparative analyses are needed, in order to further support the encouraging preliminary data, in terms of safety and efficacy and address the reported limitations

Robot-assisted endoscopic surgery

During the last three years, robot-assisted surgery systems are increasingly being applied in endoscopic surgery. They were introduced with the objective to overcome the challenges of standard endoscopic surgery. With the improvements in manipulation and visualisation that robotic-assistance offers, technologically complex procedures can be performed endoscopically and standard endoscopic procedures can be performed easier and with greater comfort to the surgeon. This serves the purpose of improvement of quality of care. The goal of this thesis was not only to assess the feasibility of various robot-assisted procedures both in experimental and clinical settings, but also to compare robot-assisted surgery to standard open and laparoscopic interventions. All studies aimed at assessing the benefits, challenges and potential pitfalls of using this new technology. In chapter 1 of this thesis, an introduction into robot-assisted surgery is provided. In chapters 2 to 5 of this thesis, the clinical experience with robot-assisted surgery at the University Medical Centre Utrecht is presented. This started with a series of 40 laparoscopic cholecystectomies as described in chapter 2. This relatively simple procedure was carried out repetitively in order to learn how to work with the, at that time, new technology of robotic assistance under accustomed circumstances. During these procedures only one conversion and no intra-operative complications occurred demonstrating it s safety. In our consecutive series of more complex procedures, as described in chapters 4 and 5, the number of conversions and complications was also low. Concerning the efficiency, operating times were comparable to times mentioned in literature and to times in our institute for procedures performed with standard endoscopic instrumentation. The critical remark that needs to be made, however, is the considerable set-up time we encountered in our series. The time needed to install and sterilely drape the equipment averaged 15 minutes. In chapter 3 we took a closer look at the time-loss and realised that robotic assistance in our institution will burden the operating schedules by approximately 20 minutes per procedure. This time-loss needs to be reduced in order to use robotic systems on a daily basis. In chapters 6 and 7 of this thesis, two challenging (robot-assisted) laparoscopic surgical procedures were compared to the standard open procedure in an experimental setting. It was noticed to be achievable to perform anastomoses with great ease and with a similar result as through the open approach, even though we had no previous experience with performing these procedures in a laparoscopic fashion. Furthermore, both robot-assisted retroperitoneal aortic replacements in pigs and ex-vivo intestinal anastomoses, as described in chapters 8 and 9, were compared to standard endoscopic surgery. For both procedures, clear advantages from robotic assistance were experienced. The vascular anastomoses were performed faster, with fewer errors and lower blood-loss with the use of the robot. A time/action analysis was performed for the intestinal anastomoses and it was demonstrated that even experienced laparoscopic surgeons performed better with use of the robot, even though they had no previous exposure to robot-assisted surgery. In conclusion, this thesis demonstrates that robot-assisted surgery is safe and efficient in both standard and complex endoscopic interventions. Robotic assistance was proven to offer distinct benefits over standard endoscopic surgery. To implement these systems in day-to-day surgery, the benefits will have to be demonstrated to outweigh the considerable investment of costs and time

Monolithic self-supportive bi-directional bending pneumatic bellows catheter

The minimally invasive surgery has proven to be advantageous over conventional open surgery in terms of reduction in recovery time, patient trauma, and overall cost of treatment. To perform a minimally invasive procedure, preliminary insertion of a flexible tube or catheter is crucial without sacrificing its ability to manoeuvre. Nevertheless, despite the vast amount of research reported on catheters, the ability to implement active catheters in the minimally invasive application is still limited. To date, active catheters are made of rigid structures constricted to the use of wires or on-board power supplies for actuation, which increases the risk of damaging the internal organs and tissues. To address this issue, an active catheter made of soft, flexible and biocompatible structure, driven via nonelectric stimulus is of utmost importance. This thesis presents the development of a novel monolithic self-supportive bi-directional bending pneumatic bellows catheter using a sacrificial molding technique. As a proof of concept, in order to understand the effects of structural parameters on the bending performance of a bellows-structured actuator, a single channel circular bellows pneumatic actuator was designed. The finite element analysis was performed in order to analyze the unidirectional bending performance, while the most optimal model was fabricated for experimental validation. Moreover, to attain biocompatibility and bidirectional bending, the novel monolithic polydimethylsiloxane (PDMS)-based dual-channel square bellows pneumatic actuator was proposed. The actuator was designed with an overall cross-sectional area of 5 x 5 mm2, while the input sequence and the number of bellows were characterized to identify their effects on the bending performance. A novel sacrificial molding technique was adopted for developing the monolithic-structured actuator, which enabled simple fabrication for complex designs. The experimental validation revealed that the actuator model with a size of5 x 5 x 68.4 mm3 i.e. having the highest number of bellows, attained optimal bi-directional bending with maximum angles of -65° and 75°, and force of 0.166 and 0.221 N under left and right channel actuation, respectively, at 100 kPa pressure. The bending performance characterization and thermal insusceptibility achieved by the developed pneumatic catheter presents a promising implementation of flexibility and thermal stability for various biomedical applications, such as dialysis and cardiac catheterization