The Effect of Haptic Feedback on Efficiency and Safety During Preretinal Membrane Peeling Simulation.

PurposeWe determine whether haptic feedback improves surgical performance and outcome during simulated a preretinal membrane peeling procedure.MethodsA haptic-enabled virtual reality preretinal membrane peeling simulator was developed using a surgical cockpit with two multifinger haptic devices. Six subjects (three trained retina surgeons and three nonsurgeons) performed the preretinal membrane peeling surgical procedure using two modes of operation: visual and haptic feedback, and visual feedback only.ResultsTask completion time, tool tip path trajectory, tool-retina collision force, and retinal damage were all reduced with haptic feedback used and compared to modes where haptic feedback was disabled.ConclusionsHaptic feedback improves efficiency and safety during preretinal membrane peeling simulation.Translational relevanceThese findings highlight the potential benefit of haptic feedback for improving performance and safety of vitreoretinal surgery

A 5-DOFs Robot for Posterior Segment Eye Microsurgery

In retinal surgery clinicians access the internal volume of the eyeball through small scale trocar ports, typically 0.65 mm in diameter, to treat vitreoretinal disorders like idiopathic epiretinal membrane and age-related macular holes. The treatment of these conditions involves the removal of thin layers of diseased tissue, namely the epiretinal membrane and the internal limiting membrane. These membranes have an average thickness of only 60 μm and 2 μm respectively making extremely challenging even for expert clinicians to peel without damaging the surrounding tissue. In this work we present a novel Ophthalmic microsurgery Robot (OmSR) designed to operate a standard surgical forceps used in these procedures with micrometric precision, overcoming the limitations of current robotic systems associated with the offsetting of the remote centre of motion of the end effector when accessing the sclera. The design of the proposed system is presented, and its performance evaluated. The results show that the end effector can be controlled with an accuracy of less than 30 μm and the surgical forceps opening and closing positional error is less than 4.3 μm. Trajectory-following experiments and membrane peeling experiments are also presented, showing promising results in both scenarios

Force-Sensing-Based Multi-Platform Robotic Assistance for Vitreoretinal Surgery

Vitreoretinal surgery aims to treat disorders of the retina, vitreous body, and macula, such as retinal detachment, diabetic retinopathy, macular hole, epiretinal membrane and retinal vein occlusion. Challenged by several technical and human limitations, vitreoretinal practice currently ranks amongst the most demanding fields in ophthalmic surgery. Of vitreoretinal procedures, membrane peeling is the most common to be performed, over 0.5 million times annually, and among the most prone to complications. It requires an extremely delicate tissue manipulation by various micron scale maneuvers near the retina despite the physiological hand tremor of the operator. In addition, to avoid injuries, the applied forces on the retina need to be kept at a very fine level, which is often well below the tactile sensory threshold of the surgeon. Retinal vein cannulation is another demanding procedure where therapeutic agents are injected into occluded retinal veins. The feasibility of this treatment is limited due to challenges in identifying the moment of venous puncture, achieving cannulation and maintaining it throughout the drug delivery period. Recent advancements in medical robotics have significant potential to address most of the challenges in vitreoretinal practice, and therefore to prevent traumas, lessen complications, minimize intra-operative surgeon effort, maximize surgeon comfort, and promote patient safety. This dissertation presents the development of novel force-sensing tools that can easily be used on various robotic platforms, and robot control methods to produce integrated assistive surgical systems that work in partnership with surgeons against the current limitations in vitreoretinal surgery, specifically focusing on membrane peeling and vein cannulation procedures. Integrating high sensitivity force sensing into the ophthalmic instruments enables precise quantitative monitoring of applied forces. Auditory feedback based upon the measured forces can inform (and warn) the surgeon quickly during the surgery and help prevent injury due to excessive forces. Using these tools on a robotic platform can attenuate hand tremor of the surgeon, which effectively promotes tool manipulation accuracy. In addition, based upon certain force signatures, the robotic system can precisely identify critical instants, such as the venous puncture in retinal vein cannulation, and actively guide the tool towards clinical targets, compensate any involuntary motion of the surgeon, or generate additional motion that will make the surgical task easier. The experimental results using two distinct robotic platforms, the Steady-Hand Eye Robot and Micron, in combination with the force-sensing ophthalmic instruments, show significant performance improvement in artificial dry phantoms and ex vivo biological tissues

State of the art of robotic surgery related to vision: Brain and eye applications of newly available devices

Raffaele Nuzzi, Luca Brusasco Department of Surgical Sciences, Eye Clinic, University of Torino, Turin, Italy Background: Robot-assisted surgery has revolutionized many surgical subspecialties, mainly where procedures have to be performed in confined, difficult to visualize spaces. Despite advances in general surgery and neurosurgery, in vivo application of robotics to ocular surgery is still in its infancy, owing to the particular complexities of microsurgery. The use of robotic assistance and feedback guidance on surgical maneuvers could improve the technical performance of expert surgeons during the initial phase of the learning curve. Evidence acquisition: We analyzed the advantages and disadvantages of surgical robots, as well as the present applications and future outlook of robotics in neurosurgery in brain areas related to vision and ophthalmology. Discussion: Limitations to robotic assistance remain, that need to be overcome before it can be more widely applied in ocular surgery. Conclusion: There is heightened interest in studies documenting computerized systems that filter out hand tremor and optimize speed of movement, control of force, and direction and range of movement. Further research is still needed to validate robot-assisted procedures. Keywords: robotic surgery related to vision, robots, ophthalmological applications of robotics, eye and brain robots, eye robot

Autonomous Needle Navigation in Retinal Microsurgery: Evaluation in ex vivo Porcine Eyes

Important challenges in retinal microsurgery include prolonged operating time, inadequate force feedback, and poor depth perception due to a constrained top-down view of the surgery. The introduction of robot-assisted technology could potentially deal with such challenges and improve the surgeon's performance. Motivated by such challenges, this work develops a strategy for autonomous needle navigation in retinal microsurgery aiming to achieve precise manipulation, reduced end-to-end surgery time, and enhanced safety. This is accomplished through real-time geometry estimation and chance-constrained Model Predictive Control (MPC) resulting in high positional accuracy while keeping scleral forces within a safe level. The robotic system is validated using both open-sky and intact (with lens and partial vitreous removal) ex vivo porcine eyes. The experimental results demonstrate that the generation of safe control trajectories is robust to small motions associated with head drift. The mean navigation time and scleral force for MPC navigation experiments are 7.208 s and 11.97 mN, which can be considered efficient and well within acceptable safe limits. The resulting mean errors along lateral directions of the retina are below 0.06 mm, which is below the typical hand tremor amplitude in retinal microsurgery

Doctor of Philosophy

dissertationIn this dissertation, we present methods for intuitive telemanipulation of manipulators that use piezoelectric stick-slip actuators (PSSAs). Commercial micro/nano-manipulators, which utilize PSSAs to achieve high precision over a large workspace, are typically controlled by a human operator at the joint level, leading to unintuitive and time-consuming telemanipulation. Prior work has considered the use of computer-vision-feedback to close a control loop for improved performance, but computer-vision-feedback is not a viable option for many end users. We discuss how open-loop models of the micro/nano-manipulator can be used to achieve desired end-effector movements, and we explain the process of obtaining open-loop models. We propose a rate-control telemanipulation method that utilizes the obtained model, and we experimentally quantify the effectiveness of the method using a common commercial manipulator (the Kleindiek MM3A). The utility of open-loop control methods for PSSAs with a human in the loop depends directly on the accuracy of the open-loop models of the manipulator. Prior research has shown that modeling of piezoelectric actuators is not a trivial task as they are known to suffer from nonlinearities that degrade their performance. We study the effect of static (non-inertial) loads on a prismatic and a rotary PSSA, and obtain a model relating the step size of the actuator to the load. The actuator-specific parameters of the model are calibrated by taking measurements in specific configurations of the manipulator. Results comparing the obtained model to experimental data are presented. PSSAs have properties that make them desirable over traditional DC-motor actuators for use in retinal surgery. We present a telemanipulation system for retinal surgery that uses a full range of existing disposable instruments. The system uses a PSSA-based manipulator that is compact and light enough that it could reasonably be made head-mounted to passively compensate for head movements. Two mechanisms are presented that enable the system to use existing disposable actuated instruments, and an instrument adapter enables quick-change of instruments during surgery. A custom stylus for a haptic interface enables intuitive and ergonomic telemanipulation of actuated instruments. Experimental results with a force-sensitive phantom eye show that telemanipulated surgery results in reduced forces on the retina compared to manual surgery, and training with the system results in improved performance. Finally, we evaluate operator efficiency with different haptic-interface kinematics for telemanipulated retinal surgery. Surgical procedures of the retina require precise manipulation of instruments inserted through trocars in the sclera. Telemanipulated robotic systems have been developed to improve retinal surgery, but there is not a unique mapping of the motions of the surgeon's hand to the lower-dimensional motions of the instrument through the trocar. We study operator performance during a precision positioning task on a force-sensing phantom retina, reminiscent of telemanipulated retinal surgery, with three common haptic-interface kinematics implemented in software on a PHANTOM Premium 6DOF haptic interface. Results from a study with 12 human subjects show that overall performance is best with the kinematics that represent a compact and inexpensive option, and that subjects' subjective preference agrees with the objective performance results

Development and preliminary results of bimanual smart micro-surgical system using a ball-lens coupled OCT distance sensor

Bimanual surgery enhances surgical effectiveness and is required to successfully accomplish complex microsurgical tasks. The essential advantage is the ability to simultaneously grasp tissue with one hand to provide counter traction or exposure, while dissecting with the other. Towards enhancing the precision and safety of bimanual microsurgery we present a bimanual SMART micro-surgical system for a preliminary ex-vivo study. To the best of our knowledge, this is the first demonstration of a handheld bimanual microsurgical system. The essential components include a ball-lens coupled common-path swept source optical coherence tomography sensor. This system effectively suppresses asynchronous hand tremor using two PZT motors in feedback control loop and efficiently assists ambidextrous tasks. It allows precise bimanual dissection of biological tissues with a reduction in operating time as compared to the same tasks performed with conventional onehanded approaches. © 2016 Optical Society of America.1

Cable-driven parallel robot for transoral laser phonosurgery

Transoral laser phonosurgery (TLP) is a common surgical procedure in otolaryngology. Currently, two techniques are commonly used: free beam and fibre delivery. For free beam delivery, in combination with laser scanning techniques, accurate laser pattern scanning can be achieved. However, a line-of-sight to the target is required. A suspension laryngoscope is adopted to create a straight working channel for the scanning laser beam, which could introduce lesions to the patient, and the manipulability and ergonomics are poor. For the fibre delivery approach, a flexible fibre is used to transmit the laser beam, and the distal tip of the laser fibre can be manipulated by a flexible robotic tool. The issues related to the limitation of the line-of-sight can be avoided. However, the laser scanning function is currently lost in this approach, and the performance is inferior to that of the laser scanning technique in the free beam approach. A novel cable-driven parallel robot (CDPR), LaryngoTORS, has been developed for TLP. By using a curved laryngeal blade, a straight suspension laryngoscope will not be necessary to use, which is expected to be less traumatic to the patient. Semi-autonomous free path scanning can be executed, and high precision and high repeatability of the free path can be achieved. The performance has been verified in various bench and ex vivo tests. The technical feasibility of the LaryngoTORS robot for TLP was considered and evaluated in this thesis. The LaryngoTORS robot has demonstrated the potential to offer an acceptable and feasible solution to be used in real-world clinical applications of TLP. Furthermore, the LaryngoTORS robot can combine with fibre-based optical biopsy techniques. Experiments of probe-based confocal laser endomicroscopy (pCLE) and hyperspectral fibre-optic sensing were performed. The LaryngoTORS robot demonstrates the potential to be utilised to apply the fibre-based optical biopsy of the larynx.Open Acces

Autonomously Navigating a Surgical Tool Inside the Eye by Learning from Demonstration

A fundamental challenge in retinal surgery is safely navigating a surgical tool to a desired goal position on the retinal surface while avoiding damage to surrounding tissues, a procedure that typically requires tens-of-microns accuracy. In practice, the surgeon relies on depth-estimation skills to localize the tool-tip with respect to the retina in order to perform the tool-navigation task, which can be prone to human error. To alleviate such uncertainty, prior work has introduced ways to assist the surgeon by estimating the tool-tip distance to the retina and providing haptic or auditory feedback. However, automating the tool-navigation task itself remains unsolved and largely unexplored. Such a capability, if reliably automated, could serve as a building block to streamline complex procedures and reduce the chance for tissue damage. Towards this end, we propose to automate the tool-navigation task by learning to mimic expert demonstrations of the task. Specifically, a deep network is trained to imitate expert trajectories toward various locations on the retina based on recorded visual servoing to a given goal specified by the user. The proposed autonomous navigation system is evaluated in simulation and in physical experiments using a silicone eye phantom. We show that the network can reliably navigate a needle surgical tool to various desired locations within 137 microns accuracy in physical experiments and 94 microns in simulation on average, and generalizes well to unseen situations such as in the presence of auxiliary surgical tools, variable eye backgrounds, and brightness conditions.Comment: Accepted to ICRA 202