There has been a continuing push to reduce the invasiveness of surgery by accessing the abdominal cavity through a single incision, such as with laparoendoscopic single-site (LESS) surgery. Although LESS procedures offer significant benefits, added complexities still inhibit the procedures. Robotic surgery is proving to be an excellent option to overcome these limitations. This paper presents the experimental results of the single-incision in vivo surgical robot (SISR), a multifunctional, dexterous, twoarmed robot capable of performing surgical tasks while overcoming the issues associated with manual LESS operations. In vivo surgical procedures have been used to demonstrate the efficacy of using a robotic platform over traditional laparoscopic tools. The most recent experimental test resulted in the first successful in vivo robotic LESS colectomy utilizing a robot completely contained within the abdominal cavity. In this test, SISR showed significant benefits including access to all quadrants in the peritoneal cavity and improved dexterity

Farritor, Shane M.

Mondry, Jack M.

Oleynikov, Dmitry

Wortman, Tyler D.

English

DigitalCommons@University of Nebraska

University of Nebraska - Lincoln DigitalCommons@University of Nebraska - Lincoln Mechanical & Materials Engineering Faculty Publications Mechanical & Materials Engineering, Department of 2013 Single-Site Colectomy With Miniature In Vivo Robotic Platform Tyler D. Wortman University of Nebraska–Lincoln, tylerwortman@gmail.com Jack M. Mondry University of Nebraska–Lincoln, jack.mondry@gmail.com Shane M. Farritor University of Nebraska–Lincoln, sfarritor@unl.edu Dmitry Oleynikov University of Nebraska Medical Center, Omaha, NE, doleynik@unmc.edu Follow this and additional works at: https://digitalcommons.unl.edu/mechengfacpub Wortman, Tyler D.; Mondry, Jack M.; Farritor, Shane M.; and Oleynikov, Dmitry, "Single-Site Colectomy With Miniature In Vivo Robotic Platform" (2013). Mechanical & Materials Engineering Faculty Publications. 137. https://digitalcommons.unl.edu/mechengfacpub/137 This Article is brought to you for free and open access by the Mechanical & Materials Engineering, Department of at DigitalCommons@University of Nebraska - Lincoln. It has been accepted for inclusion in Mechanical & Materials Engineering Faculty Publications by an authorized administrator of DigitalCommons@University of Nebraska - Lincoln. 926 IEEE TRANSACTIONS ON BIOMEDICAL ENGINEERING, VOL. 60, NO. 4, APRIL 2013Single-Site Colectomy With Miniature In VivoRobotic PlatformTyler D. Wortman∗, Jack M. Mondry, Shane M. Farritor, and Dmitry OleynikovAbstract—There has been a continuing push to reduce the in-vasiveness of surgery by accessing the abdominal cavity through asingle incision, such as with laparoendoscopic single-site (LESS)surgery. Although LESS procedures offer significant benefits,added complexities still inhibit the procedures. Robotic surgeryis proving to be an excellent option to overcome these limitations.This paper presents the experimental results of the single-incisionin vivo surgical robot (SISR), a multifunctional, dexterous, two-armed robot capable of performing surgical tasks while overcom-ing the issues associated with manual LESS operations. In vivosurgical procedures have been used to demonstrate the efficacy ofusing a robotic platform over traditional laparoscopic tools. Themost recent experimental test resulted in the first successful in vivorobotic LESS colectomy utilizing a robot completely containedwithin the abdominal cavity. In this test, SISR showed significantbenefits including access to all quadrants in the peritoneal cavityand improved dexterity.Index Terms—Laparoendoscopic single-site surgery (LESS),miniature robot, minimally invasive surgery, robotic surgery.I. INTRODUCTIONLAPAROENDOSCOPIC single-site surgery (LESS) hasbeen viewed as an important step for reducing the in-vasiveness of surgical procedures. LESS surgery is performedby utilizing multiple articulating, bent, or flexible laparoscopictools inserted through a single specialized port, typically placedin the abdominal wall [1]. Although LESS procedures are the-oretically better for the patient, inherent drawbacks still causeproblems for the surgeons. Current LESS techniques involvecrossing the bent tools, resulting in collateral hand movementsin which the surgeon’s right hand controls the left end effectorand vice versa. For these reasons, there has been an increasedinterest in the use of robotics to improve the outcomes of surgeryManuscript received June 14, 2012; revised August 31, 2012; acceptedOctober 18, 2012. Date of current version March 15, 2013. This work wassupported in part by the National Science Foundation, NASA EPSCoR,Nebraska Research Initiative, Telemedicine and Advanced Technology Re-search Center, and the Nebraska Space Grant Consortium. Asterisk indicatescorresponding author.∗T. D. Wortman was with the Department of Mechanical and Materials Engi-neering, University of Nebraska–Lincoln, Lincoln, NE 68588 USA. He is nowwith the Department of Mechanical Engineering, Massachusetts Institute ofTechnology, Cambridge, MA 02139 USA (e-mail: tylerwortman@gmail.com).J. M. Mondry and S. M. Farritor are with the Department of Mechanical andMaterials Engineering, University of Nebraska–Lincoln, Lincoln, NE 68588USA (e-mail: jack.mondry@gmail.com; sfarritor@unl.edu).D. Oleynikov is with the University of Nebraska Medical Center, Omaha, NE68198 USA (e-mail: doleynik@unmc.edu).Color versions of one or more of the figures in this paper are available onlineat http://ieeexplore.ieee.org.Digital Object Identifier 10.1109/TBME.2012.2226884and to make procedures more precise [2], [3]. Robotic surgeryis quickly becoming a viable platform for overcoming the limi-tations associated with LESS.Currently, the da Vinci Surgical System (Intuitive Surgical)is the most advanced commercially available robotic system forseveral types of surgery. Surgical dexterity and visualizationare improved by the use of articulating Endo-wrists and 3-Dimaging. Recent advancements in the system have allowed forthe successful completion of LESS procedures [4], [5]. How-ever, limitations remain including difficulties in repositioningthe patient, arm collisions, size, and high cost [6].Several small laparoscopic tools with externally actuated,robotic end effectors have also been developed. Some notableexamples are the COLOBOT, Hyper-Finger, and IREP. TheCOLOBOT is a pneumatic bendable robotic tip for semiau-tonomous colonoscopy procedures [7]. Hyper-Finger is a smalland highly dexterous active forceps tool that enables more ad-vanced laparoscopic surgery [8]. IREP is an insertable roboticend effector platform with two snake-like arms and a stereo-scopic camera designed specifically for LESS procedures [9].Researchers have also developed completely insertable in vivosurgical robots capable of performing complete surgical proce-dures while addressing the limitations associated with LESSprocedures [10], [11]. These two-armed surgical robots can beinserted through a single incision one arm at a time. The robotsare then assembled inside the abdominal cavity and remotelyoperated by a trained surgeon to perform surgical tasks. Thisrobotic approach has advantages for LESS colectomies becausethis system offers access to all quadrants in the peritoneal cav-ity, improved visualization and dexterity, and intuitive controlswhen compared to traditional laparoscopic methods.Recently, other research performed by the European ARAK-NES project has resulted in the development of similar in vivosurgical robots, such as SPRINT [12]. SPRINT is similar in ar-chitecture to the previous work discussed above and the robotthat will be discussed in this paper, single-incision in vivo sur-gical robot (SISR). Both are composed of two arms, each witha single end effector, haptic user interfaces, illuminated stereo-scopic vision, as well as teleoperational capabilities. Both robotswere designed to have the arms individually inserted througha single small incision. The research presented in this paperhas important differences in comparison to the SPRINT robot.SISR is a completely in vivo robot, composed of two 4-DOFarms, specifically designed for colectomy procedures. The de-sign approach differs in that all of the SISR actuating motorsare contained within the abdominal cavity. The SPRINT robothas 6 DOF on each arm with 4 DOF being actuated by on-boardmotors and the remaining 2 DOF being externally actuated.0018-9294/$31.00 © 2013 IEEEIEEE TRANSACTIONS ON BIOMEDICAL ENGINEERING, VOL. 60, NO. 4, APRIL 2013 927Fig. 1. SISR prototype.Having all the actuators within the robot results in the robotnot constrained by the entry incision. This has important clin-ical relevance for colectomy and other procedures because thecompletely in vivo robot can be easily repositioned during thesurgery, allowing it to operate on large organs. SISR can be eas-ily repositioned in a matter of seconds by rotating or translatingthe rod that supports it.In this paper, a surgical robot designed for LESS is presented.Section II includes a brief explanation of the surgical robot plat-form design. Section III details the in vivo results, specifically,the first successful in vivo robotic LESS colectomy utilizing arobot completely contained within the abdominal cavity. SectionIV analyzes the data that were collected during the experimentalsurgeries. The conclusions of the paper along with future goalsare given in Section V.II. METHODSThe basic robot design of SISR, shown in Fig. 1, consistsof two 4-DOF arms that can be individually inserted into asingle 30-mm incision and completely contained within the ab-dominal cavity. This robot was developed for all LESS pro-cedures, specifically targeting colon resections. A 30-mm in-cision, although larger than traditional laparoscopic incisionsof 5–12 mm, will be placed at or near the umbilicus and stillmaintain cosmetically pleasing results.Each arm of the robot comprises of a torso, upper arm, andforearm. The dimensions of these links are 61.9, 50.8, and81.4 mm, respectively. The overall diameter of the links variesbut never exceeds 28 mm. The corresponding joint links weredesigned to maximize joint range of motion. This yields an in-dividual arm workspace volume of 1856 cm3 and a bimanualintersecting workspace volume of 776 cm3 . A 2-DOF shoulderFig. 2. SISR colon resection screen shots.joint, located between the torso and upper arm, provides yawand pitch. A 1-DOF elbow joint also provides yaw. Each end ef-fector has a rotational degree of freedom, along with open/closeactuation, if necessary.To insert the robot, the straight arms are separated and insertedindividually through the single incision. Army-Navy retractorsare used to lift the abdominal wall to create enough space toinsert the robot without disturbing the internal tissue. After therobot is completely inserted within the abdominal cavity, con-trol rods attached to the torso segments are positioned to alignthe robot arms. An additional support rod is then attached tothe control rods to mate the robot arms. Once assembled, aGelPort (Applied Medical) is placed over the support rod andthe abdominal cavity is insufflated with CO2 . The support rodprotrudes out through the incision and allows the robot to berigidly supported by the operating table and grossly positioned,if needed.Extensive details on the robot and user interface design aswell as a full kinematic analysis of SISR including theoreticalforces, velocities, workspace, and manipulability can be foundin [13].III. EXPERIMENTAL RESULTSSISR has been tested in multiple nonsurvival surgical pro-cedures in live porcine models at the University of NebraskaMedical Center. All surgical protocol was approved by the Insti-tutional Animal Care and Use Committee (IACUC). Throughoutthe procedures, specially trained laparoscopic surgeons were onhand to control the robot and assess its efficacy. During these928 IEEE TRANSACTIONS ON BIOMEDICAL ENGINEERING, VOL. 60, NO. 4, APRIL 2013Fig. 3. SISR left and right arm endpoint velocity.Fig. 4. SISR left and right arm endpoint position.procedures, a simple insertion procedure was used, the robotoperated, and then the robot and specimen were extracted allthrough the single incision. For each procedure, the left arm ofthe robot was outfitted with a grasping end effector, while theright arm utilized monopolar cautery. The following details themost recent surgical procedure, a complete robotic cecectomy,and a colectomy procedure specifically targeting the cecum.A. InsertionSISR was inserted into the abdominal cavity for the surgicalprocedure through an incision of 40-mm length on the um-bilicus. This incision was purposefully oversized to allow easyinsertion for feasibility tests. In the future, the incision could bereduced to the stated goal of 30 mm. As described previously,each arm was individually inserted and then mated to the as-sembly rod. The entire insertion process took an average of 5 m.B. Surgical ProcedureDuring the procedure, a complete cecectomy was performed.As the cecum is located at the end of the colon, only one tran-section was needed.At the time of the surgery, the on-board camera was not yetoperational so a traditional laparoscope was used to visualizethe operation. The video feedback from the laparoscope wasrecorded and selected screenshots of critical tasks being com-pleted during the cecectomy are shown in Fig. 2. Frame (A)is identification of the colon mesentery; Frame (B) is dissec-tion of the colon mesentery; Frame (C) is mobilization of thecolon mesentery; Frame (D) is transection of the colon usinga supplementary Endo GIH stapling device; Frame (E) showsthe robot assisting with further transection; and Frame (F) isremoval of the specimen and completion of the cecectomy pro-cedure. Robotic operating time, defined as the time from thesurgeon’s first use of the robot until the robot was removed,was approximately 30 min. Typical robotic operating times forcolectomies on humans are around 120 min [14].IV. DISCUSSIONMotor encoder positional data were recorded using LabVIEWduring the successful procedure. These data can be transformedinto the X,Y , and Z positions of each arm’s end effector asIEEE TRANSACTIONS ON BIOMEDICAL ENGINEERING, VOL. 60, NO. 4, APRIL 2013 929functions of time throughout the surgery. The data were filteredand various plots were produced to better visually analyze andto note any observable trends.The path distance traveled over the duration of the colectomyprocedure was calculated for the left and right end effectors. Theleft arm travels about 12 m, while the right arm travels about20 m. Analysis reveals that the right arm is much more activethan the left arm. Colectomies use the graspers on the left armto grab tissue and position it, while the cautery on the right armis used in much more fine repetitive movements as it cuts thetissue. This stretch-and-dissect process is iteratively repeateduntil the surgery is complete. Because the right arm is muchmore active, it travels almost twice the overall distance.Fig. 3 shows the time history plots of the left and right armendpoint velocities. The peak velocity for left arm is around550 mm/s and the right arm’s peak velocity is close to 250 mm/s.The maximum velocity for the left arm is only reached twicewith most of the other peaks topping out at approximately200 mm/s. The average velocities are 10.8 and 22.7 mm/s for theleft and right arms, respectively. Again, the right arm appearsmuch more active. The left arm has several periods of little to novelocity where it would have been holding tissue in a specifiedposition.Fig. 4 show 3-D plots of each individual arms endpoint po-sition. It is much easier to discern the boundaries of the roboticworkspace in these plots even without viewing them as a 3-Dobject. The plots further verify that the right arm is used morethan the left. These plots also show that both arms used up themajority of the workspace volume. Although the robot did notneed to be repositioned during the surgery, it appears that theend effectors for both arms were occasionally limited by theinner boundary of the workspace. Improved initial positioningof the current robot or expanded inner workspace of a modifiedrobot could mitigate this problem in the future.Both plots verify that the right and left arms are used forsignificantly different surgical tasks. This suggests that non-symmetric arms could be a desirable design change. Becausethe right arm is used in slow, fine, articulated movements, itcould be designed to be more dexterous and precise. This couldinclude the addition of a compact spherical wrist joint. Con-versely, because the left arm is used in quick, coarse, manipu-lating movements, it would be advantageous to strengthen thearm. This could be accomplished simply through the use ofmore powerful motors and varying gear ratios.V. CONCLUSION AND FUTURE WORKIn this paper, details on SISR, a dual-armed multifunctional invivo surgical robot designed specifically for LESS procedures,were presented. A brief overview of the robotic platform wasgiven. Experimental results are also presented. To the best ofthe authors’ knowledge, the robot completed the first successfulentirely in vivo robotic LESS colectomy.Future work includes continued in vivo surgical experimentsas well as an improvement on the reliability of the robot anddevelopment of safety protocol to prevent unintentional inter-actions or other complications. Improvements in the design arecontinually occurring to improve the robot with a goal to acquireFDA approval to perform a first-in-human procedure.REFERENCES[1] S. Can, A. Fiolka, D. Wilhelm, M. Burian, S. von Delius, A. Meining,A. Schneider, and H. Feussner, “Set of instruments for innovative, safeand sterile sigmoid access for natural-orifice transluminal endoscopicsurgery,” Biomed. Technol., vol. 53, no. 4, pp. 185–189, 2008.[2] D. B. Camarillo, T. M. Krummel, and J. K. Salisbury, “Robotic technol-ogy in surgery: past, present, and future,” Am. J. Surg., vol. 188, no. 4ASuppl, pp. 2S–15S, 2004.[3] R. H. Taylor, “A perspective on medical robots,” Proc. IEEE, vol. 94,no. 9, pp. 1652–1664, Sep. 2006.[4] M. Kroh, K. El-Hayek, S. Rosenblatt, B. Chand, P. Escobar, J. Kaouk, andS. Chalikonda, “First human surgery with a novel single-port robotic sys-tem: Cholecystectomy using the da Vinci single-site platform,” SurgicalEndoscopy, vol. 25, no. 11, pp. 3566–3573, 2011.[5] R. J. Stein, W. M. White, R. K. Goel, B. H. Irwin, G. P. Haber, andJ. H. Kaouk, “Robotic laparoendoscopic single-site surgery using Gel-port as the access platform,” Eur. Urology, vol. 57, no. 1, pp. 132–136,2010.[6] T. Falcone and J. Goldberg, “Robotic surgery,” Clin. Obstetrics Gynecol-ogy, vol. 46, no. 1, pp. 37–43, 2003.[7] G. Chen, T. Redarce, and M. T. Phan, “Development and kinematic anal-ysis of a silicone-rubber bending tip for colonoscopy,” in Proc. IEEE/RSJInt. Conf. Intell. Robots Syst., Oct. 2006, pp. 168–173.[8] K. Ikuta, T. Hasegawa, and S. Daifu, “Hyper redundant miniature manip-ulator “hyper finger” for remote minimally invasive surgery in deep area,”in Proc. IEEE Int. Conf. Rob. Autom., Sep. 2003, pp. 1098–1102.[9] J. Ding, K. Xu, R. Goldman, P. Allen, D. Fowler, and N. Simaan, “Design,simulation, and evaluation of kinematic alternatives for insertable roboticeffectors platforms in single port access surgery,” in Proc. IEEE Int. Conf.Rob. Autom., May 2010, pp. 1052–1058.[10] T. D. Wortman, K. W. Strabala, A. C. Lehman, S. M. Farritor, andD. Oleynikov, “Laparoendoscopic single-site surgery using a multi-functional miniature in vivo robot,” presented at the 5th Annu. Int. Conf.Minimally Invasive Rob. Assoc., San Diego, CA, 2010.[11] K. W. Strabala, T. D. Wortman, A. C. Lehman, S. M. Farritor, andD. Oleynikov, “Multi-functional robot for laparoendoscopic single-sitesurgery,” presented at the Annu. Meeting Soc. Am. Gastrointestinal En-doscopic Surgeons, Landover, MD, 2010.[12] M. Piccigallo, U. Scarfogliero, C. Quaglia, G. Petroni, P. Valdastri,A. Menciassi, and P. Dario, “Design of a novel bimanual robotic systemfor single-port laparoscopy,” IEEE/ASME Trans. Mechatronics, vol. 15,no. 6, pp. 871–878, Dec. 2010.[13] T. D. Wortman, R. L. McCormick, E. J. Markvicka, T. P. Frederick,S. M. Farritor, and D. Oleynikov, “Multi-functional surgical robot forlaparoendoscopic single-site colectomies,” presented at the ASME Int.Des. Eng. Tech. Conf., Washington, DC, 2011.[14] F. Huettner, P. E. Pacheco, J. L. Doubet, M. J. Ryan, D. I. Dynda, andD. L. Crawford, “One hundred and two consecutive robotic-assisted min-imally invasive colectomies—An outcome and technical update,” J. Gas-trointestinal Surgery, vol. 15, no. 7, pp. 1195–1204, 2011.

Single-Site Colectomy With Miniature \u3ci\u3eIn Vivo\u3c/i\u3e
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Single-Site Colectomy With Miniature \u3ci\u3eIn Vivo\u3c/i\u3e Robotic Platform

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