Robot assisted stapedotomy ex vivo with an active handheld instrument

Micron is a fully handheld active micromanipulator that helps to improve position accuracy and precision in microsurgery by cancelling hand tremor. This work describes adaptation, tuning, and testing of the Micron system for stapedotomy, a microsurgical procedure performed in the middle ear to restore hearing that requires accurate manipulation in narrow spaces. Two end-effectors, a handle, and a brace (or rest) were designed and prototyped. The control system was adapted for the new hardware. The system was tested ex vivo in stapedotomy procedure comparing manually-performed and Micron-assisted surgical tasks. Tremor amplitude was found to be reduced significantly. Further testing is needed in order to obtain statistically significant results regarding other parameters dealing with regularity of the fenestra shap

Endoscopic and Robotic Stapes Surgery: Review with Emphasis on Recent Surgical Refinements

Purpose of Review Stapes surgery has been established as the gold standard for surgical treatment of conductive hearing loss in otosclerosis. Excellent outcomes with very low complication rate are reported for this surgery. Recent advances to improve surgical outcome have modified the surgical technique with endoscopes, and recent studies report development of robotical assistance. This article reviews the use of endoscopes and robotical assistance for stapes surgery. Recent Findings While different robotic models have been developed, 2 models for stapes surgery have been used in the clinical setting. These can be used concomitant to an endoscope or microscope. Endoscopes are used on a regular base regarding stapes surgery with similar outcomes as microscopes. Endoscopic stapes surgery shows similar audiological results to microscopic technique with an advantage of less postoperative dysgeusia and pain. Its utility in cases of revision surgery or malformation is emphasized. Summary Endoscopic stapes surgery is used on a regular basis with excellent outcomes similar to the microscopic approach, while reducing surgical morbidity. Robotic technology is increasingly being developed in the experimental setting, and first applications are reported in its clinical use

From teleoperation to autonomous robot-assisted microsurgery: A survey

Robot-assisted microsurgery (RAMS) has many benefits compared to traditional microsurgery. Microsurgical platforms with advanced control strategies, high-quality micro-imaging modalities and micro-sensing systems are worth developing to further enhance the clinical outcomes of RAMS. Within only a few decades, microsurgical robotics has evolved into a rapidly developing research field with increasing attention all over the world. Despite the appreciated benefits, significant challenges remain to be solved. In this review paper, the emerging concepts and achievements of RAMS will be presented. We introduce the development tendency of RAMS from teleoperation to autonomous systems. We highlight the upcoming new research opportunities that require joint efforts from both clinicians and engineers to pursue further outcomes for RAMS in years to come

Robotic Assistant Systems for Otolaryngology-Head and Neck Surgery

Recently, there has been a significant movement in otolaryngology-head and neck surgery (OHNS) toward minimally invasive techniques, particularly those utilizing natural orifices. However, while these techniques can reduce the risk of complications encountered with classic open approaches such as scarring, infection, and damage to healthy tissue in order to access the surgical site, there remain significant challenges in both visualization and manipulation, including poor sensory feedback, reduced visibility, limited working area, and decreased precision due to long instruments. This work presents two robotic assistance systems which help to overcome different aspects of these challenges. The first is the Robotic Endo-Laryngeal Flexible (Robo-ELF) Scope, which assists surgeons in manipulating flexible endoscopes. Flexible endoscopes can provide superior visualization compared to microscopes or rigid endoscopes by allowing views not constrained by line-of-sight. However, they are seldom used in the operating room due to the difficulty in precisely manually manipulating and stabilizing them for long periods of time. The Robo-ELF Scope enables stable, precise robotic manipulation for flexible scopes and frees the surgeon’s hands to operate bimanually. The Robo-ELF Scope has been demonstrated and evaluated in human cadavers and is moving toward a human subjects study. The second is the Robotic Ear Nose and Throat Microsurgery System (REMS), which assists surgeons in manipulating rigid instruments and endoscopes. There are two main types of challenges involved in manipulating rigid instruments: reduced precision from hand tremor amplified by long instruments, and difficulty navigating through complex anatomy surrounded by sensitive structures. The REMS enables precise manipulation by allowing the surgeon to hold the surgical instrument while filtering unwanted movement such as hand tremor. The REMS also enables augmented navigation by calculating the position of the instrument with high accuracy, and combining this information with registered preoperative imaging data to enforce virtual safety barriers around sensitive anatomy. The REMS has been demonstrated and evaluated in user studies with synthetic phantoms and human cadavers

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

Augmentation Of Human Skill In Microsurgery

Surgeons performing highly skilled microsurgery tasks can benefit from information and manual assistance to overcome technological and physiological limitations to make surgery safer, efficient, and more successful. Vitreoretinal surgery is particularly difficult due to inherent micro-scale and fragility of human eye anatomy. Additionally, surgeons are challenged by physiological hand tremor, poor visualization, lack of force sensing, and significant cognitive load while executing high-risk procedures inside the eye, such as epiretinal membrane peeling. This dissertation presents the architecture and the design principles for a surgical augmentation environment which is used to develop innovative functionality to address the fundamental limitations in vitreoretinal surgery. It is an inherently information driven modular system incorporating robotics, sensors, and multimedia components. The integrated nature of the system is leveraged to create intuitive and relevant human-machine interfaces and generate a particular system behavior to provide active physical assistance and present relevant sensory information to the surgeon. These include basic manipulation assistance, audio-visual and haptic feedback, intraoperative imaging and force sensing. The resulting functionality, and the proposed architecture and design methods generalize to other microsurgical procedures. The system's performance is demonstrated and evaluated using phantoms and in vivo experiments

Endoscopy

Endoscopy is a fast moving field, and new techniques are continuously emerging. In recent decades, endoscopy has evolved and branched out from a diagnostic modality to enhanced video and computer assisting imaging with impressive interventional capabilities. The modern endoscopy has seen advances not only in types of endoscopes available, but also in types of interventions amenable to the endoscopic approach. To date, there are a lot more developments that are being trialed. Modern endoscopic equipment provides physicians with the benefit of many technical advances. Endoscopy is an effective and safe procedure even in special populations including pediatric patients and renal transplant patients. It serves as the tool for diagnosis and therapeutic interventions of many organs including gastrointestinal tract, head and neck, urinary tract and others

OPTICAL NAVIGATION TECHNIQUES FOR MINIMALLY INVASIVE ROBOTIC SURGERIES

Minimally invasive surgery (MIS) involves small incisions in a patient's body, leading to reduced medical risk and shorter hospital stays compared to open surgeries. For these reasons, MIS has experienced increased demand across different types of surgery. MIS sometimes utilizes robotic instruments to complement human surgical manipulation to achieve higher precision than can be obtained with traditional surgeries. Modern surgical robots perform within a master-slave paradigm, in which a robotic slave replicates the control gestures emanating from a master tool manipulated by a human surgeon. Presently, certain human errors due to hand tremors or unintended acts are moderately compensated at the tool manipulation console. However, errors due to robotic vision and display to the surgeon are not equivalently addressed. Current vision capabilities within the master-slave robotic paradigm are supported by perceptual vision through a limited binocular view, which considerably impacts the hand-eye coordination of the surgeon and provides no quantitative geometric localization for robot targeting. These limitations lead to unexpected surgical outcomes, and longer operating times compared to open surgery. To improve vision capabilities within an endoscopic setting, we designed and built several image guided robotic systems, which obtained sub-millimeter accuracy. With this improved accuracy, we developed a corresponding surgical planning method for robotic automation. As a demonstration, we prototyped an autonomous electro-surgical robot that employed quantitative 3D structural reconstruction with near infrared registering and tissue classification methods to localize optimal targeting and suturing points for minimally invasive surgery. Results from validation of the cooperative control and registration between the vision system in a series of in vivo and in vitro experiments are presented and the potential enhancement to autonomous robotic minimally invasive surgery by utilizing our technique will be discussed