The benefits of haptic feedback in robot assisted surgery and their moderators: a metaanalysis

Robot assisted surgery (RAS) provides medical practitioners with valuable tools, decreasing strain during surgery and leading to better patient outcomes. While the loss of haptic sensation is a commonly cited disadvantage of RAS, new systems aim to address this problem by providing artificial haptic feedback. N = 56 papers that compared robotic surgery systems with and without haptic feedback were analyzed to quantify the performance benefits of restoring the haptic modality. Additionally, this study identifies factors moderating the effect of restoring haptic sensation. Overall results showed haptic feedback was effective in reducing average forces (Hedges' g = 0.83) and peak forces (Hedges' g = 0.69) applied during surgery, as well as reducing the completion time (Hedges' g = 0.83). Haptic feedback has also been found to lead to higher accuracy (Hedges' g = 1.50) and success rates (Hedges' g = 0.80) during surgical tasks. Effect sizes on several measures varied between tasks, the type of provided feedback, and the subjects' levels of surgical expertise, with higher levels of expertise generally associated with smaller effect sizes. No significant differences were found between virtual fixtures and rendering contact forces. Implications for future research are discussed

Haptics-Enabled Teleoperation for Robotics-Assisted Minimally Invasive Surgery

The lack of force feedback (haptics) in robotic surgery can be considered to be a safety risk leading to accidental tissue damage and puncturing of blood vessels due to excessive forces being applied to tissue and vessels or causing inefficient control over the instruments because of insufficient applied force. This project focuses on providing a satisfactory solution for introducing haptic feedback in robotics-assisted minimally invasive surgical (RAMIS) systems. The research addresses several key issues associated with the incorporation of haptics in a master-slave (teleoperated) robotic environment for minimally invasive surgery (MIS). In this project, we designed a haptics-enabled dual-arm (two masters - two slaves) robotic MIS testbed to investigate and validate various single-arm as well as dual-arm teleoperation scenarios. The most important feature of this setup is the capability of providing haptic feedback in all 7 degrees of freedom (DOF) required for RAMIS (3 translations, 3 rotations and pinch motion of the laparoscopic tool). The setup also enables the evaluation of the effect of replacing haptic feedback by other sensory cues such as visual representation of haptic information (sensory substitution) and the hypothesis that surgical outcomes may be improved by substituting or augmenting haptic feedback by such sensory cues

Measuring the impact of haptic feedback in collaborative robotic scenarios

[EN] In recent years, the interaction of a human operator with teleoperated robotic systems has been much improved. One of the factors influencing this improvement is the addition of force feedback to complement the visual feedback provided by traditional graphical user interfaces. However, the users of these systems performing tasks in isolated and safe environments are often inexperienced and occasional users. In addition, there is no common framework to assess the usability of these systems, due to the heterogeneity of applications and tasks, and therefore, there is a need for new usability assessment methods that are not domain specific. This study addresses this issue by proposing a measure of usability that includes five variables: user efficiency, user effectiveness, mental workload, perceived usefulness, and perceived ease of use. The empirical analysis shows that the integration of haptic feedback improves the usability of these systems for non-expert users, even though the differences are not statistically significant; further, the results suggest that mental workload is higher when haptic feedback is added. The analysis also reveals significant differences between participants depending on gender.SIPublicación en abierto financiada por el Consorcio de Bibliotecas Universitarias de Castilla y León (BUCLE), con cargo al Programa Operativo 2014ES16RFOP009 FEDER 2014-2020 DE CASTILLA Y LEÓN, Actuación:20007-CL - Apoyo Consorcio BUCL

Design of a wearable fingertip haptic device for remote palpation: Characterisation and interface with a virtual environment

© 2018 Tzemanaki, Al, Melhuish and Dogramadzi. This paper presents the development of a wearable Fingertip Haptic Device (FHD) that can provide cutaneous feedback via a Variable Compliance Platform (VCP). The FHD includes an inertial measurement unit, which tracks the motion of the user's finger while its haptic functionality relies on two parameters: pressure in the VCP and its linear displacement towards the fingertip. The combination of these two features results in various conditions of the FHD, which emulate the remote object or surface stiffness properties. Such a device can be used in tele-operation, including virtual reality applications, where rendering the level of stiffness of different physical or virtual materials could provide a more realistic haptic perception to the user. The FHD stiffness representation is characterised in terms of resulting pressure and force applied to the fingertip created through the relationship of the two functional parameters - pressure and displacement of the VCP. The FHD was tested in a series of user studies to assess its potential to create a user perception of the object's variable stiffness. The viability of the FHD as a haptic device has been further confirmed by interfacing the users with a virtual environment. The developed virtual environment task required the users to follow a virtual path, identify objects of different hardness on the path and navigate away from "no-go" zones. The task was performed with and without the use of the variable compliance on the FHD. The results showed improved performance with the presence of the variable compliance provided by the FHD in all assessed categories and particularly in the ability to identify correctly between objects of different hardness

Increasing Transparency and Presence of Teleoperation Systems Through Human-Centered Design

Teleoperation allows a human to control a robot to perform dexterous tasks in remote, dangerous, or unreachable environments. A perfect teleoperation system would enable the operator to complete such tasks at least as easily as if he or she was to complete them by hand. This ideal teleoperator must be perceptually transparent, meaning that the interface appears to be nearly nonexistent to the operator, allowing him or her to focus solely on the task environment, rather than on the teleoperation system itself. Furthermore, the ideal teleoperation system must give the operator a high sense of presence, meaning that the operator feels as though he or she is physically immersed in the remote task environment. This dissertation seeks to improve the transparency and presence of robot-arm-based teleoperation systems through a human-centered design approach, specifically by leveraging scientific knowledge about the human motor and sensory systems. First, this dissertation aims to improve the forward (efferent) teleoperation control channel, which carries information from the human operator to the robot. The traditional method of calculating the desired position of the robot\u27s hand simply scales the measured position of the human\u27s hand. This commonly used motion mapping erroneously assumes that the human\u27s produced motion identically matches his or her intended movement. Given that humans make systematic directional errors when moving the hand under conditions similar to those imposed by teleoperation, I propose a new paradigm of data-driven human-robot motion mappings for teleoperation. The mappings are determined by having the human operator mimic the target robot as it autonomously moves its arm through a variety of trajectories in the horizontal plane. Three data-driven motion mapping models are described and evaluated for their ability to correct for the systematic motion errors made in the mimicking task. Individually-fit and population-fit versions of the most promising motion mapping model are then tested in a teleoperation system that allows the operator to control a virtual robot. Results of a user study involving nine subjects indicate that the newly developed motion mapping model significantly increases the transparency of the teleoperation system. Second, this dissertation seeks to improve the feedback (afferent) teleoperation control channel, which carries information from the robot to the human operator. We aim to improve a teleoperation system a teleoperation system by providing the operator with multiple novel modalities of haptic (touch-based) feedback. We describe the design and control of a wearable haptic device that provides kinesthetic grip-force feedback through a geared DC motor and tactile fingertip-contact-and-pressure and high-frequency acceleration feedback through a pair of voice-coil actuators mounted at the tips of the thumb and index finger. Each included haptic feedback modality is known to be fundamental to direct task completion and can be implemented without great cost or complexity. A user study involving thirty subjects investigated how these three modalities of haptic feedback affect an operator\u27s ability to control a real remote robot in a teleoperated pick-and-place task. This study\u27s results strongly support the utility of grip-force and high-frequency acceleration feedback in teleoperation systems and show more mixed effects of fingertip-contact-and-pressure feedback

Monitoring companion for industrial robotic processes

For system integrators, optimizing complex industrial robotic applications (e.g. robotised welding) is a difficult and time-consuming task. This procedure is rendered tedious and often very hard to achieve when the operator cannot access the robotic system once in operation, perhaps because the installation is far away or because of the operational environment. In these circumstances, as an alternative to physically visiting the installation site, the system integrator may rely on additional nearby sensors to remotely acquire the necessary process information. While it is hard to completely replace this trial and error approach, it is possible to provide a way to gather process information more effectively that can be used in several robotic installations.This thesis investigates the use of a "monitoring robot" in addition to the task robot(s) that belong to the industrial process to be optimized. The monitoring robot can be equipped with several different sensors and can be moved into close proximity of any installed task robot so that it can be used to collect information from that process during and/or after the operation without interfering. The thesis reviews related work in the industry and in the field of teleoperation to identify the most important challenges in remote monitoring and teleoperation. From the background investigation it is clear that two very important issues are: i) the nature of the teleoperator’s interface and; ii) the efficiency of the shared control between the human operator and the monitoring system. In order to investigate these two issues efficiently it was necessary to create experimental scenarios that operate independently from any application scenario, so an abstract problem domain is created. This way the monitoring system's control and interface can be evaluated in a context that presents challenges that are typical of a remote monitoring task but are not application domain specific. Therefore the validity of the proposed approach can be assessed from a generic and, therefore, more powerful and widely applicable perspective. The monitoring framework developed in this thesis is described, both in the shared control design choices based on virtual fixtures (VF) and the implementation in a 3D visualization environment. The monitoring system developed is evaluated with a usability study with user participants. The usability study aims at assessing the system's performance along with its acceptance and ease of use in a static monitoring task, accompanied by user\hyp{}filled TLX questionnaires. Since future work will apply this system in real robotic welding scenarios, this thesis finally reports some preliminary work in such an application

Navigation system based in motion tracking sensor for percutaneous renal access

Tese de Doutoramento em Engenharia BiomédicaMinimally-invasive kidney interventions are daily performed to diagnose and treat several renal diseases. Percutaneous renal access (PRA) is an essential but challenging stage for most of these procedures, since its outcome is directly linked to the physician’s ability to precisely visualize and reach the anatomical target. Nowadays, PRA is always guided with medical imaging assistance, most frequently using X-ray based imaging (e.g. fluoroscopy). Thus, radiation on the surgical theater represents a major risk to the medical team, where its exclusion from PRA has a direct impact diminishing the dose exposure on both patients and physicians. To solve the referred problems this thesis aims to develop a new hardware/software framework to intuitively and safely guide the surgeon during PRA planning and puncturing. In terms of surgical planning, a set of methodologies were developed to increase the certainty of reaching a specific target inside the kidney. The most relevant abdominal structures for PRA were automatically clustered into different 3D volumes. For that, primitive volumes were merged as a local optimization problem using the minimum description length principle and image statistical properties. A multi-volume Ray Cast method was then used to highlight each segmented volume. Results show that it is possible to detect all abdominal structures surrounding the kidney, with the ability to correctly estimate a virtual trajectory. Concerning the percutaneous puncturing stage, either an electromagnetic or optical solution were developed and tested in multiple in vitro, in vivo and ex vivo trials. The optical tracking solution aids in establishing the desired puncture site and choosing the best virtual puncture trajectory. However, this system required a line of sight to different optical markers placed at the needle base, limiting the accuracy when tracking inside the human body. Results show that the needle tip can deflect from its initial straight line trajectory with an error higher than 3 mm. Moreover, a complex registration procedure and initial setup is needed. On the other hand, a real-time electromagnetic tracking was developed. Hereto, a catheter was inserted trans-urethrally towards the renal target. This catheter has a position and orientation electromagnetic sensor on its tip that function as a real-time target locator. Then, a needle integrating a similar sensor is used. From the data provided by both sensors, one computes a virtual puncture trajectory, which is displayed in a 3D visualization software. In vivo tests showed a median renal and ureteral puncture times of 19 and 51 seconds, respectively (range 14 to 45 and 45 to 67 seconds). Such results represent a puncture time improvement between 75% and 85% when comparing to state of the art methods. 3D sound and vibrotactile feedback were also developed to provide additional information about the needle orientation. By using these kind of feedback, it was verified that the surgeon tends to follow a virtual puncture trajectory with a reduced amount of deviations from the ideal trajectory, being able to anticipate any movement even without looking to a monitor. Best results show that 3D sound sources were correctly identified 79.2 ± 8.1% of times with an average angulation error of 10.4º degrees. Vibration sources were accurately identified 91.1 ± 3.6% of times with an average angulation error of 8.0º degrees. Additionally to the EMT framework, three circular ultrasound transducers were built with a needle working channel. One explored different manufacture fabrication setups in terms of the piezoelectric materials, transducer construction, single vs. multi array configurations, backing and matching material design. The A-scan signals retrieved from each transducer were filtered and processed to automatically detect reflected echoes and to alert the surgeon when undesirable anatomical structures are in between the puncture path. The transducers were mapped in a water tank and tested in a study involving 45 phantoms. Results showed that the beam cross-sectional area oscillates around the ceramics radius and it was possible to automatically detect echo signals in phantoms with length higher than 80 mm. Hereupon, it is expected that the introduction of the proposed system on the PRA procedure, will allow to guide the surgeon through the optimal path towards the precise kidney target, increasing surgeon’s confidence and reducing complications (e.g. organ perforation) during PRA. Moreover, the developed framework has the potential to make the PRA free of radiation for both patient and surgeon and to broad the use of PRA to less specialized surgeons.Intervenções renais minimamente invasivas são realizadas diariamente para o tratamento e diagnóstico de várias doenças renais. O acesso renal percutâneo (ARP) é uma etapa essencial e desafiante na maior parte destes procedimentos. O seu resultado encontra-se diretamente relacionado com a capacidade do cirurgião visualizar e atingir com precisão o alvo anatómico. Hoje em dia, o ARP é sempre guiado com recurso a sistemas imagiológicos, na maior parte das vezes baseados em raios-X (p.e. a fluoroscopia). A radiação destes sistemas nas salas cirúrgicas representa um grande risco para a equipa médica, aonde a sua remoção levará a um impacto direto na diminuição da dose exposta aos pacientes e cirurgiões. De modo a resolver os problemas existentes, esta tese tem como objetivo o desenvolvimento de uma framework de hardware/software que permita, de forma intuitiva e segura, guiar o cirurgião durante o planeamento e punção do ARP. Em termos de planeamento, foi desenvolvido um conjunto de metodologias de modo a aumentar a eficácia com que o alvo anatómico é alcançado. As estruturas abdominais mais relevantes para o procedimento de ARP, foram automaticamente agrupadas em volumes 3D, através de um problema de optimização global com base no princípio de “minimum description length” e propriedades estatísticas da imagem. Por fim, um procedimento de Ray Cast, com múltiplas funções de transferência, foi utilizado para enfatizar as estruturas segmentadas. Os resultados mostram que é possível detetar todas as estruturas abdominais envolventes ao rim, com a capacidade para estimar corretamente uma trajetória virtual. No que diz respeito à fase de punção percutânea, foram testadas duas soluções de deteção de movimento (ótica e eletromagnética) em múltiplos ensaios in vitro, in vivo e ex vivo. A solução baseada em sensores óticos ajudou no cálculo do melhor ponto de punção e na definição da melhor trajetória a seguir. Contudo, este sistema necessita de uma linha de visão com diferentes marcadores óticos acoplados à base da agulha, limitando a precisão com que a agulha é detetada no interior do corpo humano. Os resultados indicam que a agulha pode sofrer deflexões à medida que vai sendo inserida, com erros superiores a 3 mm. Por outro lado, foi desenvolvida e testada uma solução com base em sensores eletromagnéticos. Para tal, um cateter que integra um sensor de posição e orientação na sua ponta, foi colocado por via trans-uretral junto do alvo renal. De seguida, uma agulha, integrando um sensor semelhante, é utilizada para a punção percutânea. A partir da diferença espacial de ambos os sensores, é possível gerar uma trajetória de punção virtual. A mediana do tempo necessário para puncionar o rim e ureter, segundo esta trajetória, foi de 19 e 51 segundos, respetivamente (variações de 14 a 45 e 45 a 67 segundos). Estes resultados representam uma melhoria do tempo de punção entre 75% e 85%, quando comparados com o estado da arte dos métodos atuais. Além do feedback visual, som 3D e feedback vibratório foram explorados de modo a fornecer informações complementares da posição da agulha. Verificou-se que com este tipo de feedback, o cirurgião tende a seguir uma trajetória de punção com desvios mínimos, sendo igualmente capaz de antecipar qualquer movimento, mesmo sem olhar para o monitor. Fontes de som e vibração podem ser corretamente detetadas em 79,2 ± 8,1% e 91,1 ± 3,6%, com erros médios de angulação de 10.4º e 8.0 graus, respetivamente. Adicionalmente ao sistema de navegação, foram também produzidos três transdutores de ultrassom circulares com um canal de trabalho para a agulha. Para tal, foram exploradas diferentes configurações de fabricação em termos de materiais piezoelétricos, transdutores multi-array ou singulares e espessura/material de layers de suporte. Os sinais originados em cada transdutor foram filtrados e processados de modo a detetar de forma automática os ecos refletidos, e assim, alertar o cirurgião quando existem variações anatómicas ao longo do caminho de punção. Os transdutores foram mapeados num tanque de água e testados em 45 phantoms. Os resultados mostraram que o feixe de área em corte transversal oscila em torno do raio de cerâmica, e que os ecos refletidos são detetados em phantoms com comprimentos superiores a 80 mm. Desta forma, é expectável que a introdução deste novo sistema a nível do ARP permitirá conduzir o cirurgião ao longo do caminho de punção ideal, aumentado a confiança do cirurgião e reduzindo possíveis complicações (p.e. a perfuração dos órgãos). Além disso, de realçar que este sistema apresenta o potencial de tornar o ARP livre de radiação e alarga-lo a cirurgiões menos especializados.The present work was only possible thanks to the support by the Portuguese Science and Technology Foundation through the PhD grant with reference SFRH/BD/74276/2010 funded by FCT/MEC (PIDDAC) and by Fundo Europeu de Desenvolvimento Regional (FEDER), Programa COMPETE - Programa Operacional Factores de Competitividade (POFC) do QREN

Enhancing tele-operation - Investigating the effect of sensory feedback on performance

The decline in the number of healthcare service providers in comparison to the growing numbers of service users prompts the development of technologies to improve the efficiency of healthcare services. One such technology which could offer support are assistive robots, remotely tele-operated to provide assistive care and support for older adults with assistive care needs and people living with disabilities. Tele-operation makes it possible to provide human-in-the-loop robotic assistance while also addressing safety concerns in the use of autonomous robots around humans. Unlike many other applications of robot tele-operation, safety is particularly significant as the tele-operated assistive robots will be used in close proximity to vulnerable human users. It is therefore important to provide as much information about the robot (and the robot workspace) as possible to the tele-operators to ensure safety, as well as efficiency. Since robot tele-operation is relatively unexplored in the context of assisted living, this thesis explores different feedback modalities that may be employed to communicate sensor information to tele-operators. The thesis presents research as it transitioned from identifying and evaluating additional feedback modalities that may be used to supplement video feedback, to exploring different strategies for communicating the different feedback modalities. Due to the fact that some of the sensors and feedback needed are not readily available, different design iterations were carried out to develop the necessary hardware and software for the studies carried out. The first human study was carried out to investigate the effect of feedback on tele-operator performance. Performance was measured in terms of task completion time, ease of use of the system, number of robot joint movements, and success or failure of the task. The effect of verbal feedback between the tele-operator and service users was also investigated. Feedback modalities have differing effects on performance metrics and as a result, the choice of optimal feedback may vary from task to task. Results show that participants preferred scenarios with verbal feedback relative to scenarios without verbal feedback, which also reflects in their performance. Gaze metrics from the study also showed that it may be possible to understand how tele-operators interact with the system based on their areas of interest as they carry out tasks. This findings suggest that such studies can be used to improve the design of tele-operation systems.The need for social interaction between the tele-operator and service user suggests that visual and auditory feedback modalities will be engaged as tasks are carried out. This further reduces the number of available sensory modalities through which information can be communicated to tele-operators. A wrist-worn Wi-Fi enabled haptic feedback device was therefore developed and a study was carried out to investigate haptic sensitivities across the wrist. Results suggest that different locations on the wrist have varying sensitivities to haptic stimulation with and without video distraction, duration of haptic stimulation, and varying amplitudes of stimulation. This suggests that dynamic control of haptic feedback can be used to improve haptic perception across the wrist, and it may also be possible to display more than one type of sensor data to tele-operators during a task. The final study carried out was designed to investigate if participants can differentiate between different types of sensor data conveyed through different locations on the wrist via haptic feedback. The effect of increased number of attempts on performance was also investigated. Total task completion time decreased with task repetition. Participants with prior gaming and robot experience had a more significant reduction in total task completion time when compared to participants without prior gaming and robot experience. Reduction in task completion time was noticed for all stages of the task but participants with additional feedback had higher task completion time than participants without supplementary feedback. Reduction in task completion time varied for different stages of the task. Even though gripper trajectory reduced with task repetition, participants with supplementary feedback had longer gripper trajectories than participants without supplementary feedback, while participants with prior gaming experience had shorter gripper trajectories than participants without prior gaming experience. Perceived workload was also found to reduce with task repetition but perceived workload was higher for participants with feedback reported higher perceived workload than participants without feedback. However participants without feedback reported higher frustration than participants without feedback.Results show that the effect of feedback may not be significant where participants can get necessary information from video feedback. However, participants were fully dependent on feedback when video feedback could not provide requisite information needed.The findings presented in this thesis have potential applications in healthcare, and other applications of robot tele-operation and feedback. Findings can be used to improve feedback designs for tele-operation systems to ensure safe and efficient tele-operation. The thesis also provides ways visual feedback can be used with other feedback modalities. The haptic feedback designed in this research may also be used to provide situational awareness for the visually impaired

The Hand-Held Force Magnifier: Surgical Tools to Augment the Sense of Touch

Modern surgeons routinely perform procedures with noisy, sub-threshold, or obscured visual and haptic feedback,either due to the necessary approach, or because the systems on which they are operating are exceeding delicate. For example, in cataract extraction, ophthalmic surgeons must peel away thin membranes in order to access and replace the lens of the eye. Elsewhere, dissection is now commonly performed with energy-delivering tools – rather than sharp blades – and damage to deep structures is possible if tissue contact is not well controlled. Surgeons compensate for their lack of tactile sensibility by relying solely on visual feedback, observing tissue deformation and other visual cues through surgical microscopes or cameras. Using visual information alone can make a procedure more difficult, because cognitive mediation is required to convert visual feedback into motor action. We call this the “haptic problem” in surgery because the human sensorimotor loop is deprived of critical tactile afferent information, increasing the chance for intraoperative injury and requiring extensive training before clinicians reach independent proficiency. Tools that enhance the surgeon’s direct perception of tool-tissue forces can therefore potentially reduce the risk of iatrogenic complications and improve patient outcomes. Towards this end, we have developed and characterized a new robotic surgical tool, the Hand-Held Force Magnifier (HHFM), which amplifies forces at the tool tip so they may be readily perceived by the user, a paradigm we call “in-situ” force feedback. In this dissertation, we describe the development of successive generations of HHFM prototypes, and the evaluation of a proposed human-in-the-loop control framework using the methods of psychophysics. Using these techniques, we have verified that our tool can reduce sensory perception thresholds, augmenting the user’s abilities beyond what is normally possible. Further, we have created models of human motor control in surgically relevant tasks such as membrane puncture, which have shown to be sensitive to push-pull direction and handedness effects. Force augmentation has also demonstrated improvements to force control in isometric force generation tasks. Finally, in support of future psychophysics work, we have developed an inexpensive, high-bandwidth, single axis haptic renderer using a commercial audio speaker

Cybersecurity and the Digital Health: An Investigation on the State of the Art and the Position of the Actors

Cybercrime is increasingly exposing the health domain to growing risk. The push towards a strong connection of citizens to health services, through digitalization, has undisputed advantages. Digital health allows remote care, the use of medical devices with a high mechatronic and IT content with strong automation, and a large interconnection of hospital networks with an increasingly effective exchange of data. However, all this requires a great cybersecurity commitment—a commitment that must start with scholars in research and then reach the stakeholders. New devices and technological solutions are increasingly breaking into healthcare, and are able to change the processes of interaction in the health domain. This requires cybersecurity to become a vital part of patient safety through changes in human behaviour, technology, and processes, as part of a complete solution. All professionals involved in cybersecurity in the health domain were invited to contribute with their experiences. This book contains contributions from various experts and different fields. Aspects of cybersecurity in healthcare relating to technological advance and emerging risks were addressed. The new boundaries of this field and the impact of COVID-19 on some sectors, such as mhealth, have also been addressed. We dedicate the book to all those with different roles involved in cybersecurity in the health domain