An Introduction to Robotically Assisted Surgical Systems: Current Developments and Focus Areas of Research

Robotic assistance systems for diagnosis and therapy have become technically mature and widely available. Thus, they play an increasingly important role in patient care. This paper provides an overview of the general concepts of robotically assisted surgical systems, briefly revisiting historical and current developments in the surgical robotics market and discussing current focus areas of research. Comprehensiveness cannot be achieved in this format, but besides the general overview, references to further readings and more comprehensive reviews with regard to particular aspects are given. Therefore, the work at hand is considered as an introductory paper into the topic and especially addresses investigators, researchers, medical device manufacturers, and clinicians, who are new to this field

A Robotic System for Solo Surgery in Flexible Ureterorenoscopy

Urolithiasis is a common disease with increasing prevalence across all ages. A common treatment option for smaller kidney stones is flexible ureterorenoscopy (fURS), where a flexible ureteroscope (FU) is used for stone removal and to inspect the renal collecting system. The handling of the flexible ureteroscope and end effectors (EEs), however, is challenging and requires two surgeons. In this article, we introduce a modular robotic system for endoscope manipulation, which enables solo surgery (SSU) and is adaptable to various hand-held FUs. Both the developed hardware components and the proposed workflow and its representation in software are described. We then present and discuss the results of an initial user study. Finally, we describe subsequent developmental steps towards more extensive testing by clinical staff

Dietary Sargassum fusiforme improves memory and reduces amyloid plaque load in an Alzheimer's disease mouse model

Activation of liver X receptors (LXRs) by synthetic agonists was found to improve cognition in Alzheimer's disease (AD) mice. However, these LXR agonists induce hypertriglyceridemia and hepatic steatosis, hampering their use in the clinic. We hypothesized that phytosterols as LXR agonists enhance cognition in AD without affecting plasma and hepatic triglycerides. Phytosterols previously reported to activate LXRs were tested in a luciferase-based LXR reporter assay. Using this assay, we found that phytosterols commonly present in a Western type diet in physiological concentrations do not activate LXRs. However, a lipid extract of the 24(S)-Saringosterol-containing seaweed Sargassum fusiforme did potently activate LXR beta. Dietary supplementation of crude Sargassum fusiforme or a Sargassum fusiforme-derived lipid extract to AD mice significantly improved short-term memory and reduced hippocampal A beta plaque load by 81%. Notably, none of the side effects typically induced by full synthetic LXR agonists were observed. In contrast, administration of the synthetic LXRa activator, AZ876, did not improve cognition and resulted in the accumulation of lipid droplets in the liver. Administration of Sargassum fusiforme-derived 24(S)-Saringosterol to cultured neurons reduced the secretion of A beta 42. Moreover, conditioned medium from 24(S)-Saringosterol-treated astrocytes added to microglia increased phagocytosis of A beta. Our data show that Sargassum fusiforme improves cognition and alleviates AD pathology. This may be explained at least partly by 24(S)-Saringosterol-mediated LXR beta activation.</p

Model-Augmented Haptic Telemanipulation: Concept, Retrospective Overview, and Current Use Cases

Certain telerobotic applications, including telerobotics in space, pose particularly demanding challenges to both technology and humans. Traditional bilateral telemanipulation approaches often cannot be used in such applications due to technical and physical limitations such as long and varying delays, packet loss, and limited bandwidth, as well as high reliability, precision, and task duration requirements. In order to close this gap, we research model-augmented haptic telemanipulation (MATM) that uses two kinds of models: a remote model that enables shared autonomous functionality of the teleoperated robot, and a local model that aims to generate assistive augmented haptic feedback for the human operator. Several technological methods that form the backbone of the MATM approach have already been successfully demonstrated in accomplished telerobotic space missions. On this basis, we have applied our approach in more recent research to applications in the fields of orbital robotics, telesurgery, caregiving, and telenavigation. In the course of this work, we have advanced specific aspects of the approach that were of particular importance for each respective application, especially shared autonomy, and haptic augmentation. This overview paper discusses the MATM approach in detail, presents the latest research results of the various technologies encompassed within this approach, provides a retrospective of DLR's telerobotic space missions, demonstrates the broad application potential of MATM based on the aforementioned use cases, and outlines lessons learned and open challenges

A workspace analysis method to support intraoperative trocar placement in minimally invasive robotic surgery (MIRS)

This paper presents a new method to calculate and display an approximated workspace of a surgical robot in nearly realtime. Displaying this information on a screen in the operation room could support the surgeon during intraoperative trocar placement for teleoperated minimally invasive robotic surgery (MIRS). We give a short overview on existing trocar placement procedures in teleoperated MIRS and describe the possibilities and limitations of workspace analysis methods to support the surgeon during trocar placement. Our new method uses MIRS-specific simplifications to reduce the search space and enable the creation of a reduced workspace map. It was implemented for the DLR MiroSurge system. The implementation can create a reduced workspace map and display a mesh representation of the map in less than 2 seconds. We give a short outlook on how this method could be embedded in trocar placement procedures in the operation theater and what our future plans are with this method

Human Performance and Workload Evaluation of Input Modalities for Telesurgery

In the last decade, surgical robots have been used routinely to assist surgeons e.g. during minimally-invasive surgery. Surgical instruments (e.g. needle drivers, scissors) are not directly manipulated by the surgeon, but by robotic arms located at the operation table. The surgeon controls the robotic system from a separated console with input devices. In contrast to conventional laparoscopy, a high degree of dexterity can be achieved by using such telerobotic systems despite the physical constraints of minimally-invasive surgery (also labeled as “keyhole technology”). In the current study, we empirically evaluated three different input modalities for telesurgery in a simulation environment. A sample of 18 individuals performed a pursuit tracking task using a mechanically coupled 6 DoF input interface (sigma.7) with vs. without friction/ inertia compensation or a freely moveable, optically tracked input interface. Besides input modality, movement scaling (high vs. moderate vs. low movement scaling), and arm stabilization (with vs. without armrest) were varied systematically. Results revealed positive effects of reducing friction/ inertia on manipulative precision and subjective workload, with the best results for the optically tracked device with minimal inertia and no friction. Yet, moving the device freely without any movement stabilization proved to be physically more demanding compared to the mechanically coupled interfaces

A wide diversity of bacteria from the human gut produces and degrades biogenic amines

Background: Biogenic amines (BAs) are metabolites produced by the decarboxylation of amino acids with significant physiological functions in eukaryotic and prokaryotic cells. BAs can be produced by bacteria in fermented foods, but little is known concerning the potential for microbes within the human gut microbiota to produce or degrade BAs. Objective: To isolate and identify BA-producing and BA-degrading microbes from the human gastrointestinal tract. Design: Fecal samples from human volunteers were screened on multiple growth media, under multiple growth conditions. Bacterial species were identified using 16S rRNA sequencing and BA production or degradation was assessed using ultra-performance liquid chromatography. Results: In total, 74 BA-producing or BA-degrading strains were isolated from the human gut. These isolates belong to the genera Bifidobacterium, Clostridium, Enterococcus, Lactobacillus, Pediococcus, Streptococcus, Enterobacter, Escherichia, Klebsiella, Morganella and Proteus. While differences in production or degradation of specific BAs were observed at the strain level, our results suggest that these metabolic activities are widely spread across different taxa present within the human gut microbiota. Conclusions: The isolation and identification of microbes from the human gut with BA-producing and BA-degrading metabolic activity is an important first step in developing a better understanding of how these metabolites influence health and disease. KEYWORDS: Biogenic amines, UPLC, gut ecology, bacterial metabolite

A Digital Twin Approach for Contextual Assistance for Surgeons During Surgical Robotics Training

Minimally invasive robotic surgery copes with some disadvantages for the surgeon of minimally invasive surgery while preserving the advantages for the patient. Most commercially available robotic systems are telemanipulated with haptic input devices. The exploitation of the haptics channel, e.g., by means of Virtual Fixtures, would allow for an individualized enhancement of surgical performance with contextual assistance. However, it remains an open field of research as it is non-trivial to estimate the task context itself during a surgery. In contrast, surgical training allows to abstract away from a real operation and thus makes it possible to model the task accurately. The presented approach exploits this fact to parameterize Virtual Fixtures during surgical training, proposing a Shared Control Parametrization Engine that retrieves procedural context information from a Digital Twin. This approach accelerates a proficient use of the robotic system for novice surgeons by augmenting the surgeon’s performance through haptic assistance. With this our aim is to reduce the required skill level and cognitive load of a surgeon performing minimally invasive robotic surgery. A pilot study is performed on the DLR MiroSurge system to evaluate the presented approach. The participants are tasked with two benchmark scenarios of surgical training. The execution of the benchmark scenarios requires basic skills as pick, place and path following. The evaluation of the pilot study shows the promising trend that novel users profit from the haptic augmentation during training of certain tasks

Adaption of the DLR MiroSurge System's Kinematics to Surgical Table Based Patient Repositioning in Minimally Invasive Surgery

In the context of minimally invasive surgery, an intraoperative repositioning of the patient may be required. Usually this is done by means of electrically actuated surgical tables. The well introduced DLR MIRO robots of the DLR MiroSurge system can be mounted to the side rails of surgical tables due to their light weight structure. In this case, however, the poses of the robot bases change with respect to each other depending on the table configuration. This paper addresses maintenance of fulcrum point, instrument tool center point (TCP), and hand-eye coordination despite variable robot bases to enhance the practical use of the MiroSurge system. Experimental results were verified with optical measuring methods, showing encouraging results

Extending the Capability of Using a Waterjet in Surgical Interventions by the Use of Robotics

In waterjet surgery a thin, high pressure jet is used for dissections and surface abrasion of soft tissue. This selective preparation method preserves nerves and vessels whereas the surrounding soft tissue is washed away. Objective: The aim of the presented work is to enhance the application field of this technique by resolving technological limitations. Methods: A technical task definition of handling a hand-guided waterjet applicator is derived from literature. All reported procedures require to follow a trajectory superimposed with an oscillating movement. By introducing a robotic system and a specialized kinematic approach the limited dexterity of the waterjet applicator is increased. Additionally, the system provides assistance by automatically performing parts of the task. Results: The method is applied to two different procedures: a minimally invasive dissection, as well as a surface abrasion for open medical treatments. On the basis of experiments with gelatine phantoms the performance of the method is shown for both procedures. Conclusion: In the minimally invasive use case the reachability limited by the conventional manual tools is extended by the capabilities of the robotic system. Simultaneously, the handling is simplified by automation of the superimposed oscillation. In the surface abrasion case a dense coverage of the treated area is achievable. The risk of cross infections could be reduced by spatial separation of patient and staff. Significance: Thus, the waterjet technology can be fully integrated into robotic surgery systems and benefit from their inherent abilities