Computer- and robot-assisted Medical Intervention

Medical robotics includes assistive devices used by the physician in order to make his/her diagnostic or therapeutic practices easier and more efficient. This chapter focuses on such systems. It introduces the general field of Computer-Assisted Medical Interventions, its aims, its different components and describes the place of robots in that context. The evolutions in terms of general design and control paradigms in the development of medical robots are presented and issues specific to that application domain are discussed. A view of existing systems, on-going developments and future trends is given. A case-study is detailed. Other types of robotic help in the medical environment (such as for assisting a handicapped person, for rehabilitation of a patient or for replacement of some damaged/suppressed limbs or organs) are out of the scope of this chapter.Comment: Handbook of Automation, Shimon Nof (Ed.) (2009) 000-00

Robotic-assisted internal fixation of femoral fractures

Closed surgical techniques for the internal fixation of femoral fractures require orthopaedic surgeons to work in close proximity to X-rays. In addition to the occupational health risk this imposes, inexperienced surgeons often encounter great difficulty in achieving optimal positioning of fracture repair fixtures. A vision-guided robotic system has been proposed as a possible solution to these problems and an initial investigation involving two exemplar orthopaedic procedures has been undertaken. Robotic surgery assistance imposes rigorous safety-related design constraints, since the orthopaedic robot must operate in close proximity to the patient and operating staff. The design and implementation of a purpose-built robotic system for orthopaedic surgery assistance is described in this paper

Robots and tools for remodeling bone

The field of robotic surgery has progressed from small teams of researchers repurposing industrial robots, to a competitive and highly innovative subsection of the medical device industry. Surgical robots allow surgeons to perform tasks with greater ease, accuracy, or safety, and fall under one of four levels of autonomy; active, semi-active, passive, and remote manipulator. The increased accuracy afforded by surgical robots has allowed for cementless hip arthroplasty, improved postoperative alignment following knee arthroplasty, and reduced duration of intraoperative fluoroscopy among other benefits. Cutting of bone has historically used tools such as hand saws and drills, with other elaborate cutting tools now used routinely to remodel bone. Improvements in cutting accuracy and additional options for safety and monitoring during surgery give robotic surgeries some advantages over conventional techniques. This article aims to provide an overview of current robots and tools with a common target tissue of bone, proposes a new process for defining the level of autonomy for a surgical robot, and examines future directions in robotic surgery

Image-Guided Robotic Dental Implantation With Natural-Root-Formed Implants

Dental implantation is now recognized as the standard of the care for tooth replacement. Although many studies show high short term survival rates greater than 95%, long term studies (\u3e 5 years) have shown success rates as low as 41.9%. Reasons affecting the long term success rates might include surgical factors such as limited accuracy of implant placement, lack of spacing controls, and overheating during the placement. In this dissertation, a comprehensive solution for improving the outcome of current dental implantation is presented, which includes computer-aided preoperative planning for better visualization of patient-specific information and automated robotic site-preparation for superior placement and orientation accuracy. Surgical planning is generated using patient-specific three-dimensional (3D) models which are reconstructed from Cone-beam CT images. An innovative image-guided robotic site-preparation system for implants insertion is designed and implemented. The preoperative plan of the implant insertion is transferred into intra-operative operations of the robot using a two-step registration procedure with the help of a Coordinate Measurement Machine (CMM). The natural-root implants mimic the root structure of natural teeth and were proved by Finite Element Method (FEM) to provide superior stress distribution than current cylinder-shape implants. However, due to their complicated geometry, manual site-preparation for these implants cannot be accomplished. Our innovative image-guided robotic implantation system provides the possibility of using this advanced type of implant. Phantom experiments with patient-specific jaw models were performed to evaluate the accuracy of positioning and orientation. Fiducial Registration Error (FRE) values less than 0.20 mm and final Target Registration Error (TRE) values after the two-step registration of 0.36±0.13 mm (N=5) were achieved. Orientation error was 1.99±1.27° (N=14). Robotic milling of the natural-root implant shape with single- and double-root was also tested, and the results proved that their complicated volumes can be removed as designed by the robot. The milling time for single- and double-root shape was 177 s and 1522 s, respectively

Review of robotic technology for keyhole transcranial stereotactic neurosurgery

The research of stereotactic apparatus to guide surgical devices began in 1908, yet a major part of today's stereotactic neurosurgeries still rely on stereotactic frames developed almost half a century ago. Robots excel at handling spatial information, and are, thus, obvious candidates in the guidance of instrumentation along precisely planned trajectories. In this review, we introduce the concept of stereotaxy and describe a standard stereotactic neurosurgery. Neurosurgeons' expectations and demands regarding the role of robots as assistive tools are also addressed. We list the most successful robotic systems developed specifically for or capable of executing stereotactic neurosurgery. A critical review is presented for each robotic system, emphasizing the differences between them and detailing positive features and drawbacks. An analysis of the listed robotic system features is also undertaken, in the context of robotic application in stereotactic neurosurgery. Finally, we discuss the current perspective, and future directions of a robotic technology in this field. All robotic systems follow a very similar and structured workflow despite the technical differences that set them apart. No system unequivocally stands out as an absolute best. The trend of technological progress is pointing toward the development of miniaturized cost-effective solutions with more intuitive interfaces.This work has been partially financed by the NETT Project (FP7-PEOPLE-2011-ITN-289146), ACTIVE Project (FP7-ICT-2009-6-270460), and FCT PhD grant (ref. SFRH/BD/86499/2012)

Image-guided surgery and medical robotics in the cranial area

Surgery in the cranial area includes complex anatomic situations with high-risk structures and high demands for functional and aesthetic results. Conventional surgery requires that the surgeon transfers complex anatomic and surgical planning information, using spatial sense and experience. The surgical procedure depends entirely on the manual skills of the operator. The development of image-guided surgery provides new revolutionary opportunities by integrating presurgical 3D imaging and intraoperative manipulation. Augmented reality, mechatronic surgical tools, and medical robotics may continue to progress in surgical instrumentation, and ultimately, surgical care. The aim of this article is to review and discuss state-of-the-art surgical navigation and medical robotics, image-to-patient registration, aspects of accuracy, and clinical applications for surgery in the cranial area

Recent trends, technical concepts and components of computer-assisted orthopedic surgery systems: A comprehensive review

Computer-assisted orthopedic surgery (CAOS) systems have become one of the most important and challenging types of system in clinical orthopedics, as they enable precise treatment of musculoskeletal diseases, employing modern clinical navigation systems and surgical tools. This paper brings a comprehensive review of recent trends and possibilities of CAOS systems. There are three types of the surgical planning systems, including: systems based on the volumetric images (computer tomography (CT), magnetic resonance imaging (MRI) or ultrasound images), further systems utilize either 2D or 3D fluoroscopic images, and the last one utilizes the kinetic information about the joints and morphological information about the target bones. This complex review is focused on three fundamental aspects of CAOS systems: their essential components, types of CAOS systems, and mechanical tools used in CAOS systems. In this review, we also outline the possibilities for using ultrasound computer-assisted orthopedic surgery (UCAOS) systems as an alternative to conventionally used CAOS systems.Web of Science1923art. no. 519

Evaluation of Autonomous Robotic Milling Methodology for Natural Tooth-Shaped Implants Based on SKO Optimization

Robotic surgery is one of the most demanding and challenging applications in the field of automatic control. One of the conventional surgeries, the dental implantation, is the standard methodology to place the artificial tooth root composed of titanium material into the upper or lower jawbone. During the dental implant surgery, mechanical removal of the bone material is the most critical procedure because it may affect the patient\u27s safety including damage to the mandibular canal nerve and/or piercing the maxillary sinus. With this problem, even though short term survival rates are greater than 95%, long term success rate of the surgery is as low as 41.9% in 5 years. Since criteria of bone loss should be less than 0.2 mm per year, a high degree of anatomical accuracy is required. Considering the above issues leads to the employment of more precise surgery using computer assisted medical robots. In this dissertation, a computer-aided open-loop intra-operative robotic system with pre-operative planning is presented to improve the success rate of the dental implantation using different types of milling algorithms that also incorporate natural root-shaped implants. This dissertation also presents the refinement and optimization of three-dimensional (3D) dental implants with the complex root shapes of natural teeth. These root shapes are too complex to be drilled manually like current commercial implants and are designed to be conducive to robotic drilling utilizing milling algorithms. Due to the existence of sharp curvatures and undercuts, anatomically correct models must be refined for 3D robotic milling, and these refined shapes must be shown to be optimized for load bearing. Refinement of the anatomically correct natural tooth-shaped models for robotic milling was accomplished using Computer-Aided-Design (CAD) tools for smoothing the sham curvatures and undercuts. The load bearing optimization algorithm is based on the Soft-Kill Option (SKO) method, and the geometries are represented using non-uniform rational B-spline (NURBS) curves and surfaces. Based on these methods, we present optimized single and double root-shaped dental implants for use with robotic site preparation. Evaluation of phantom experiment has led us to investigate how the position, orientation, and depth of the robotic drilling defined with the dental tool exhibit accuracy and efficiency

로봇을 이용한 자율적 하악골채취 골절단술의 기초방법 개발과 그 정확도 평가

학위논문 (박사)-- 서울대학교 대학원 : 치의학대학원 치의과학과, 2019. 2. 김성민.Objectives: An autonomous robot osteotomy system using direct coordinate determination was developed in our study. The registration accuracy was evaluated by measuring the fiducial localization error (FLE) and target registration error (TRE) and the accuracy of the designed osteotomy method along a preprogrammed plan was evaluated. Furthermore, the accuracy of the robotic osteotomy and a manual osteotomy was compared in regard to cut position, length, angle and depth. Methods: A light-weight-robot was used in this study, with an electric gripper. A direct coordinate determination method, using three points on the teeth, was developed for registration and determination of FLE and TRE, as measured on a mandible model. Sixteen landmarks on the mandible were prepared with holes and zirconia beads and the TRE was computed in ten repeated measurements using the robot. A direct coordinate determination via three points was used for registering and a twenty stone model (7 cm x 7 cm x 3 cm). The osteotomy line was designed similar to the ramal bone graft (2 cm x 1 cm x 0.5 cm). To evaluate accuracy, we measured a position (how accurate the robot arm is located), length (how accurate the robot arm is moving while cutting), angle (the angle at which the robot arm is located), and depth (the depth of the disc cutting) error. Sixteen mandible phantoms were used to simulate the osteotomy for the ramus bone graft. An image of the phantom was obtained by three-dimensional camera scanning and a virtual ramal bone graft was designed with computer software. To evaluate an accuracy and precision, the mandible phantoms were scanned with cone beam computer tomography (CBCT). Cut position, length, angle and depth errors were measured and the results of the robotic surgery were compared with that of manual surgery. Results: The mean value of the FLE was 0.84 ± 0.38 mm and the third reference point which detected the lingual fossa of the right second molar had a larger error than the other reference points. The mean value of the TRE was 1.69 ± 0.82 mm and there were significant differences between the anterior body, posterior body, and coronoid/condyle groups. Landmarks at the anterior body had the lowest TRE (0.96 ± 0.47 mm) and landmarks on the coronoid and condyle had the highest TRE (2.12 ± 0.99 mm). An autonomous robot osteotomy with a direct coordinate determination using three points was successfully achieved. On the model RBG osteotomy, the posterior cut had 0.77±0.32 absolute mean value, the anterior cut had 0.82±0.43, the inferior cut had 0.76 ± 0.38 and the superior cut had 1.37 ± 0.83, respectively. The absolute mean values for osteotomy errors for position, length, angle, and depth were 0.93 ± 0.45 mm, 0.81 ± 0.34 mm, 1.26 ± 1.35°, and 1.19 ± 0.73 mm, respectively. The position and length errors were significantly lower than angle and depth errors. In the comparison between robotic surgery and manual surgery, there were significant differences of absolute mean value and variance in all categories. For the robotic surgery, the cut position, length, angle and depth errors were 0.70 ± 0.34 mm, 0.35 ± 0.19 mm, 1.32 ± 0.96° and 0.59 ± 0.46 mm, respectively. For the manual surgery, the cut position, length, angle and depth errors were 1.83 ± 0.65 mm, 0.62 ± 0.37 mm, 5.96 ± 3.47° and 0.40 ± 0.31 mm, respectively. The robotic surgery had significantly higher accuracy and lower variance for cut position, length and angle errors. On the other hand, the depth error had a significantly higher absolute mean value and variance than the robotic surgery. Conclusions: An autonomous robot osteotomy scheme was developed, using the direct coordinate determination by three points on the teeth, and proved an accurate method for registration. The incisal edge or buccal pit of the teeth were more proper reference points than the fossa of the teeth. The measured RMS of the TRE increased when the target moved away from the reference points. Robotic surgery showed high accuracy and precision in positioning and reduced accuracy in controlling the depth of disc sawing. The robotic surgery showed high accuracy and precision in positioning and somewhat low accuracy in controlling the depth of the disc sawing. Comparing robotic and manual surgeries, the robotic surgery was superior in accuracy and precision in position, length and angle. However, the manual surgery had higher accuracy and precision in depth.1. 목 적 본 연구에서는 세 점 접촉을 통한 좌표 결정 방식을 통해 실제 모델의 좌표와 로봇이 가지고 있는 좌표를 정합하는 방식을 이용하여 자율 로봇을 이용한 하악골채취 골절단술의 기초방법을 개발하고자 한다. 개발된 정합 방법의 위치 추적 오류 (fiducial localization error)와 목표 정합 오류 (target registration error)를 측정하여 정합의 정확성을 평가하고자 한다. 또한 사전에 프로그래밍된 골절단을 직육면체 모델에 시행하고 위치, 길이, 각도, 깊이의 오류를 측정하여 정확성을 알아보고자 한다. 추가적으로 3차원 가상수술을 통해 하악 상행지 골이식술(ramal bone graft)을 설계하고 하악 팬텀 모형에서 이에 맞게 자율 로봇이 골절단술을 수행하여 악골에서 있어서 로봇을 이용한 골절단술의 정확성을 평가해 보고 반대측은 대조군으로 외과의가 기존의 전통적인 방식으로 골절단술을 수행함으로써 양측을 비교하고자 한다. 2. 방 법 본 연구에서는 경량 로봇의 최종 작용체(end effector)에 전자 그리퍼(gripper)를 연결하고 이 그리퍼가 수술용 절삭기구나 디스크가 연결된 치과용 핸드피스를 잡고 골절단을 수행하도록 하였다. 실제 모델의 좌표와 로봇이 가지고 있는 좌표를 중첩하기 위해 세 점을 찍어 첫번째 점을 원점으로 하고, 두번째 점의 방향을 x축으로, 그리고 세 번째 점이 결정하는 평면을 xy 평면으로 인식하도록 하였다. 첫번째 실험에서는 위치 추적 오류와 목표 정합 오류의 평가를 위해 하악골 모델에 치아의 기준 세 점과 하악골의 총 16개의 목표 위치에 1mm 구멍을 뚫고 1mm 지름의 지르코니아 구를 적용하여 CBCT 상에서 잘 보일 수 있도록 하였다. 각 목표 위치에 10번씩 반복하여 위치를 인식하여 오류를 계산하고 목표 정합 오류의 위치별 차이를 분석하였다. 두번째 실험에서는 총 20 개의 직육면체 석고 모델 (7cm x 7cm x 3cm)을 제작하였고 석고의 절단 크기는 하악 상행지 골채취을 위한 골절단 크기 (2cm x 1cm x 0.5cm)와 동일하게 설계하였다. 로봇팔을 이용하여 3점 접촉을 하면 좌표값을 계산하여 미리 프로그래밍된 위치에서 골절단을 수행하였다. 로봇에 의해 수행된 석고 절단선은 위치, 길이 각도 및 깊이로 나누어 오류를 측정하였다. 세번째 실험에서는 하악 상행지 골채취를 위한 골절단 실험을 위해 총 16개의 하악 팬텀 모형을 사용하였다. 팬텀 모형을 삼차원 스캐닝으로 삼차원 영상을 얻고 가상 수술을 시행하여 골절단 크기와 형태 그리고 그 위치에 대한 계획을 세웠다. 이 가상 수술 계획에 따라 로봇이 팬텀 모델에 골절단 수술을 하였다. 반대 측은 대조군으로 기존의 전통적인 방식으로 외과의가 수행하여 양측의 오차를 비교하였다. 절단선의 위치, 길이, 각도 및 깊이를 측정하여 각각의 정확도를 비교하였다. 위치 오류는 x축으로는 로봇이 표면 접촉을 인식하고 골절단을 시행하기에 0의 값으로 측정되었고 y 축과 z 축으로 나누어 측정되었으며 평균값과 제곱평균제곱근를 계산하였다. 3. 결 과 위치 추적 오류와 목표 정합 오류는 각각 0.49±0.22 mm 와 0.98±0.47 mm로 측정되었으며 기준접에서 멀어질수록 목표 정합 오류는 더 큰 값을 보였다. 석고 모델 실험에서 절단선의 위치, 길이, 각도 및 깊이의 평균과 표준오차는 각각 0.93 ± 0.45 mm, 0.81 ± 0.34 mm, 1.26 ± 1.35°, 1.19 ± 0.73 mm 이었다. 위치가 가장 정확한 값을 보였으며 길이 그리고 깊이 순으로 오차가 증가하였으며, 각도와 절단 깊이 제어가 가장 오차가 많은 술식이었다. 하악 팬텀 수술에서 로봇을 이용한 골절단의 위치, 길이, 각도 및 깊이 오차 값은 각각 0.70 ± 0.34 mm, 0.35 ± 0.19 mm, 1.32 ± 0.96°, 0.59 ± 0.46 mm 였으며 외과의의 골절단에서는 값이 각각 1.83 ± 0.65 mm, 0.62 ± 0.37 mm, 5.96 ± 3.47°, 0.40 ± 0.31 mm 였다. 위치, 길이, 각도 오차는 로봇이 더 작은 값을 보였고 깊이 오차는 외과의의 수술에서 더 작은 값을 보였다. 4. 결 론 본 연구에서는 하악 상행지 골채취를 위한 자율 로봇을 이용한 골절단 시스템을 개발하였고 위치추적오류와 목표정합오류 모두 우수한 값을 보였다. 석고 모형과 하악 팬텀 모향을 이용한 두가지 실험 모두에서 유용성과 향상된 정확성을 확인할 수 있었다. 세점 접촉 좌표 결정 시스템은 실제 모델의 좌표를 로봇의 좌표로 등록하는 데 유용한 시스템이었으며, 하악 상행지 골절단술에 대한 자율로봇 시스템의 정확도는 기존의 외과의가 직접 수행하는 방식보다 우수하였다.Abstract (in English) 1. Introduction 1 2. Materials and Methods. 12 3. Results 26 4. Discussion 32 5. Conclusions 40 6. References 41 Tables and Figures 48 Abstract (in Korean) 74Docto

Robotic-assisted internal fixation of hip fractures: a fluoroscopy-based intraoperative registration technique

The internal fixation of proximal femoral (hip) fractures is the most frequently performed orthopaedic surgery procedure. When using a sliding compression hip screw, a commonly used fixation device, accurate positioning of the device within the femoral neck-head is achieved by initially drilling a pilot hole. A cannulated component of the hip screw is then inserted over the guide wire (surgical drill bit), which is used to drill the pilot hole. However, in practice, this fluoroscopically controlled drilling process is severely complicated by a depth perception problem and, as such, a surgeon can require several attempts to achieve a satisfactory guide wire placement. A prototype robotic-assisted orthopaedic surgery system has therefore been developed, with a view to achieving accurate right-first-time guide wire insertions. This paper describes the non-invasive digital X-ray photogrammetry-based registration technique which supports the proposed robotic-assisted drilling scenario. Results from preliminary laboratory (in vitro) trials employing this registration technique indicate that the cumulative error associated with the entire X-ray guided robotic system is within acceptable limits for the guide wire insertion process