Robot Autonomy for Surgery

Autonomous surgery involves having surgical tasks performed by a robot operating under its own will, with partial or no human involvement. There are several important advantages of automation in surgery, which include increasing precision of care due to sub-millimeter robot control, real-time utilization of biosignals for interventional care, improvements to surgical efficiency and execution, and computer-aided guidance under various medical imaging and sensing modalities. While these methods may displace some tasks of surgical teams and individual surgeons, they also present new capabilities in interventions that are too difficult or go beyond the skills of a human. In this chapter, we provide an overview of robot autonomy in commercial use and in research, and present some of the challenges faced in developing autonomous surgical robots

Prevalence of haptic feedback in robot-mediated surgery : a systematic review of literature

© 2017 Springer-Verlag. This is a post-peer-review, pre-copyedit version of an article published in Journal of Robotic Surgery. The final authenticated version is available online at: https://doi.org/10.1007/s11701-017-0763-4With the successful uptake and inclusion of robotic systems in minimally invasive surgery and with the increasing application of robotic surgery (RS) in numerous surgical specialities worldwide, there is now a need to develop and enhance the technology further. One such improvement is the implementation and amalgamation of haptic feedback technology into RS which will permit the operating surgeon on the console to receive haptic information on the type of tissue being operated on. The main advantage of using this is to allow the operating surgeon to feel and control the amount of force applied to different tissues during surgery thus minimising the risk of tissue damage due to both the direct and indirect effects of excessive tissue force or tension being applied during RS. We performed a two-rater systematic review to identify the latest developments and potential avenues of improving technology in the application and implementation of haptic feedback technology to the operating surgeon on the console during RS. This review provides a summary of technological enhancements in RS, considering different stages of work, from proof of concept to cadaver tissue testing, surgery in animals, and finally real implementation in surgical practice. We identify that at the time of this review, while there is a unanimous agreement regarding need for haptic and tactile feedback, there are no solutions or products available that address this need. There is a scope and need for new developments in haptic augmentation for robot-mediated surgery with the aim of improving patient care and robotic surgical technology further.Peer reviewe

Multimodality with Eye tracking and Haptics: A New Horizon for Serious Games?

The goal of this review is to illustrate the emerging use of multimodal virtual reality that can benefit learning-based games. The review begins with an introduction to multimodal virtual reality in serious games and we provide a brief discussion of why cognitive processes involved in learning and training are enhanced under immersive virtual environments. We initially outline studies that have used eye tracking and haptic feedback independently in serious games, and then review some innovative applications that have already combined eye tracking and haptic devices in order to provide applicable multimodal frameworks for learning-based games. Finally, some general conclusions are identified and clarified in order to advance current understanding in multimodal serious game production as well as exploring possible areas for new applications

A flexible access platform for robot-assisted minimally invasive surgery

Advances in Minimally Invasive Surgery (MIS) are driven by the clinical demand to reduce the invasiveness of surgical procedures so patients undergo less trauma and experience faster recoveries. These well documented benefits of MIS have been achieved through parallel advances in the technology and instrumentation used during procedures. The new and evolving field of Flexible Access Surgery (FAS), where surgeons access the operative site through a single incision or a natural orifice incision, is being promoted as the next potential step in the evolution of surgery. In order to achieve similar levels of success and adoption as MIS, technology again has its role to play in developing new instruments to solve the unmet clinical challenges of FAS. As procedures become less invasive, these instruments should not just address the challenges presented by the complex access routes of FAS, but should also build on the recent advances in pre- and intraoperative imaging techniques to provide surgeons with new diagnostic and interventional decision making capabilities. The main focus of this thesis is the development and applications of a flexible robotic device that is capable of providing controlled flexibility along curved pathways inside the body. The principal component of the device is its modular mechatronic joint design which utilises an embedded micromotor-tendon actuation scheme to provide independently addressable degrees of freedom and three internal working channels. Connecting multiple modules together allows a seven degree-of-freedom (DoF) flexible access platform to be constructed. The platform is intended for use as a research test-bed to explore engineering and surgical challenges of FAS. Navigation of the platform is realised using a handheld controller optimised for functionality and ergonomics, or in a "hands-free" manner via a gaze contingent control framework. Under this framework, the operator's gaze fixation point is used as feedback to close the servo control loop. The feasibility and potential of integrating multi-spectral imaging capabilities into flexible robotic devices is also demonstrated. A force adaptive servoing mechanism is developed to simplify the deployment, and improve the consistency of probe-based optical imaging techniques by automatically controlling the contact force between the probe tip and target tissue. The thesis concludes with the description of two FAS case studies performed with the platform during in-vivo porcine experiments. These studies demonstrate the ability of the platform to perform large area explorations within the peritoneal cavity and to provide a stable base for the deployment of interventional instruments and imaging probes

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

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

Accelerating Surgical Robotics Research: A Review of 10 Years With the da Vinci Research Kit

Robotic-assisted surgery is now well-established in clinical practice and has become the gold standard clinical treatment option for several clinical indications. The field of robotic-assisted surgery is expected to grow substantially in the next decade with a range of new robotic devices emerging to address unmet clinical needs across different specialities. A vibrant surgical robotics research community is pivotal for conceptualizing such new systems as well as for developing and training the engineers and scientists to translate them into practice. The da Vinci Research Kit (dVRK), an academic and industry collaborative effort to re-purpose decommissioned da Vinci surgical systems (Intuitive Surgical Inc, CA, USA) as a research platform for surgical robotics research, has been a key initiative for addressing a barrier to entry for new research groups in surgical robotics. In this paper, we present an extensive review of the publications that have been facilitated by the dVRK over the past decade. We classify research efforts into different categories and outline some of the major challenges and needs for the robotics community to maintain this initiative and build upon it

Cable-driven parallel mechanisms for minimally invasive robotic surgery

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

Hand eye coordination in surgery

The coordination of the hand in response to visual target selection has always been regarded as an essential quality in a range of professional activities. This quality has thus far been elusive to objective scientific measurements, and is usually engulfed in the overall performance of the individuals. Parallels can be drawn to surgery, especially Minimally Invasive Surgery (MIS), where the physical constraints imposed by the arrangements of the instruments and visualisation methods require certain coordination skills that are unprecedented. With the current paradigm shift towards early specialisation in surgical training and shortened focused training time, selection process should identify trainees with the highest potentials in certain specific skills. Although significant effort has been made in objective assessment of surgical skills, it is only currently possible to measure surgeons’ abilities at the time of assessment. It has been particularly difficult to quantify specific details of hand-eye coordination and assess innate ability of future skills development. The purpose of this thesis is to examine hand-eye coordination in laboratory-based simulations, with a particular emphasis on details that are important to MIS. In order to understand the challenges of visuomotor coordination, movement trajectory errors have been used to provide an insight into the innate coordinate mapping of the brain. In MIS, novel spatial transformations, due to a combination of distorted endoscopic image projections and the “fulcrum” effect of the instruments, accentuate movement generation errors. Obvious differences in the quality of movement trajectories have been observed between novices and experts in MIS, however, this is difficult to measure quantitatively. A Hidden Markov Model (HMM) is used in this thesis to reveal the underlying characteristic movement details of a particular MIS manoeuvre and how such features are exaggerated by the introduction of rotation in the endoscopic camera. The proposed method has demonstrated the feasibility of measuring movement trajectory quality by machine learning techniques without prior arbitrary classification of expertise. Experimental results have highlighted these changes in novice laparoscopic surgeons, even after a short period of training. The intricate relationship between the hands and the eyes changes when learning a skilled visuomotor task has been previously studied. Reactive eye movement, when visual input is used primarily as a feedback mechanism for error correction, implies difficulties in hand-eye coordination. As the brain learns to adapt to this new coordinate map, eye movements then become predictive of the action generated. The concept of measuring this spatiotemporal relationship is introduced as a measure of hand-eye coordination in MIS, by comparing the Target Distance Function (TDF) between the eye fixation and the instrument tip position on the laparoscopic screen. Further validation of this concept using high fidelity experimental tasks is presented, where higher cognitive influence and multiple target selection increase the complexity of the data analysis. To this end, Granger-causality is presented as a measure of the predictability of the instrument movement with the eye fixation pattern. Partial Directed Coherence (PDC), a frequency-domain variation of Granger-causality, is used for the first time to measure hand-eye coordination. Experimental results are used to establish the strengths and potential pitfalls of the technique. To further enhance the accuracy of this measurement, a modified Jensen-Shannon Divergence (JSD) measure has been developed for enhancing the signal matching algorithm and trajectory segmentations. The proposed framework incorporates high frequency noise filtering, which represents non-purposeful hand and eye movements. The accuracy of the technique has been demonstrated by quantitative measurement of multiple laparoscopic tasks by expert and novice surgeons. Experimental results supporting visual search behavioural theory are presented, as this underpins the target selection process immediately prior to visual motor action generation. The effects of specialisation and experience on visual search patterns are also examined. Finally, pilot results from functional brain imaging are presented, where the Posterior Parietal Cortical (PPC) activation is measured using optical spectroscopy techniques. PPC has been demonstrated to involve in the calculation of the coordinate transformations between the visual and motor systems, which establishes the possibilities of exciting future studies in hand-eye coordination

Non-Technical Skill Assessment and Mental Load Evaluation in Robot-Assisted Minimally Invasive Surgery

Background: Sensor technologies and data collection practices are changing and improving quality metrics across various domains. Surgical skill assessment in Robot-Assisted Minimally Invasive Surgery (RAMIS) is essential for training and quality assurance. The mental workload on the surgeon (such as time criticality, task complexity, distractions) and non-technical surgical skills (including situational awareness, decision making, stress resilience, communication, leadership) may directly influence the clinical outcome of the surgery. Methods: A literature search in PubMed, Scopus and PsycNet databases was conducted for relevant scientific publications. The standard PRISMA method was followed to filter the search results, including non-technical skill assessment and mental/cognitive load and workload estimation in RAMIS. Publications related to traditional manual Minimally Invasive Surgery were excluded, and also the usability studies on the surgical tools were not assessed. Results: 50 relevant publications were identified for non-technical skill assessment and mental load and workload estimation in the domain of RAMIS. The identified assessment techniques ranged from self-rating questionnaires and expert ratings to autonomous techniques, citing their most important benefits and disadvantages. Conclusions: Despite the systematic research, only a limited number of articles was found, indicating that non-technical skill and mental load assessment in RAMIS is not a well-studied area. Workload assessment and soft skill measurement do not constitute part of the regular clinical training and practice yet. Meanwhile, the importance of the research domain is clear based on the publicly available surgical error statistics. Questionnaires and expert-rating techniques are widely employed in traditional surgical skill assessment; nevertheless, recent technological development in sensors and Internet of Things-type devices show that skill assessment approaches in RAMIS can be much more profound employing automated solutions. Measurements and especially big data type analysis may introduce more objectivity and transparency to this critical domain as well. Significance: Non-technical skill assessment and mental load evaluation in Robot-Assisted Minimally Invasive Surgery is not a well-studied area yet; while the importance of this domain from the clinical outcome’s point of view is clearly indicated by the available surgical error statistics

Motor learning induced neuroplasticity in minimally invasive surgery

Technical skills in surgery have become more complex and challenging to acquire since the introduction of technological aids, particularly in the arena of Minimally Invasive Surgery. Additional challenges posed by reforms to surgical careers and increased public scrutiny, have propelled identification of methods to assess and acquire MIS technical skills. Although validated objective assessments have been developed to assess motor skills requisite for MIS, they poorly understand the development of expertise. Motor skills learning, is indirectly observable, an internal process leading to relative permanent changes in the central nervous system. Advances in functional neuroimaging permit direct interrogation of evolving patterns of brain function associated with motor learning due to the property of neuroplasticity and has been used on surgeons to identify the neural correlates for technical skills acquisition and the impact of new technology. However significant gaps exist in understanding neuroplasticity underlying learning complex bimanual MIS skills. In this thesis the available evidence on applying functional neuroimaging towards assessment and enhancing operative performance in the field of surgery has been synthesized. The purpose of this thesis was to evaluate frontal lobe neuroplasticity associated with learning a complex bimanual MIS skill using functional near-infrared spectroscopy an indirect neuroimaging technique. Laparoscopic suturing and knot-tying a technically challenging bimanual skill is selected to demonstrate learning related reorganisation of cortical behaviour within the frontal lobe by shifts in activation from the prefrontal cortex (PFC) subserving attention to primary and secondary motor centres (premotor cortex, supplementary motor area and primary motor cortex) in which motor sequences are encoded and executed. In the cross-sectional study, participants of varying expertise demonstrate frontal lobe neuroplasticity commensurate with motor learning. The longitudinal study involves tracking evolution in cortical behaviour of novices in response to receipt of eight hours distributed training over a fortnight. Despite novices achieving expert like performance and stabilisation on the technical task, this study demonstrates that novices displayed persistent PFC activity. This study establishes for complex bimanual tasks, that improvements in technical performance do not accompany a reduced reliance in attention to support performance. Finally, least-squares support vector machine is used to classify expertise based on frontal lobe functional connectivity. Findings of this thesis demonstrate the value of interrogating cortical behaviour towards assessing MIS skills development and credentialing.Open Acces