Intra-operative robotics: NeuroArm

Evolution of Neurosurgical Robots: Historical Progress and Future Direction

In 1985, Professor KWOH first introduced robots into neurosurgery. Since then, advancements of stereotactic frames, radiographic imaging, and neuronavigation have led to the dominance of classic stereotactic robots. A comprehensive retrieval was performed using academic databases and search agents to acquire professional information, with a cutoff date of June, 2024. This reveals a multitude of emerging technologies are coming to the forefront, including tremor filtering, motion scaling, obstacle avoidance, force sensing, which have made significant contributions to the high efficiency, high precision, minimally invasive, and exact efficacy of robot-assisted neurosurgery. Those technologies have been applied in innovative magnetic resonance-compatible neurosurgical robots, such as Neuroarm and Neurobot, with real-time image-guided surgery. Despite these advancements, the major challenge is considered as magnetic resonance compatibility in terms of space, materials, driving, and imaging. Future research directions are anticipated to focus on 1) robotic precise perception; 2) artificial intelligence; and 3) the advancement of telesurgery.

A deep unrolled neural network for real-time MRI-guided brain intervention

Accurate navigation and targeting are critical for neurological interventions including biopsy and deep brain stimulation. Real-time image guidance further improves surgical planning and MRI is ideally suited for both pre- and intra-operative imaging. However, balancing spatial and temporal resolution is a major challenge for real-time interventional MRI (i-MRI). Here, we proposed a deep unrolled neural network, dubbed as LSFP-Net, for real-time i-MRI reconstruction. By integrating LSFP-Net and a custom-designed, MR-compatible interventional device into a 3 T MRI scanner, a real-time MRI-guided brain intervention system is proposed. The performance of the system was evaluated using phantom and cadaver studies. 2D/3D real-time i-MRI was achieved with temporal resolutions of 80/732.8 ms, latencies of 0.4/3.66 s including data communication, processing and reconstruction time, and in-plane spatial resolution of 1 × 1 mm2. The results demonstrated that the proposed method enables real-time monitoring of the remote-controlled brain intervention, and showed the potential to be readily integrated into diagnostic scanners for image-guided neurosurgery.

Microsurgery Robots: Applications, Design, and Development

Microsurgical techniques have been widely utilized in various surgical specialties, such as ophthalmology, neurosurgery, and otolaryngology, which require intricate and precise surgical tool manipulation on a small scale. In microsurgery, operations on delicate vessels or tissues require high standards in surgeons' skills. This exceptionally high requirement in skills leads to a steep learning curve and lengthy training before the surgeons can perform microsurgical procedures with quality outcomes. The microsurgery robot (MSR), which can improve surgeons' operation skills through various functions, has received extensive research attention in the past three decades. There have been many review papers summarizing the research on MSR for specific surgical specialties. However, an in-depth review of the relevant technologies used in MSR systems is limited in the literature. This review details the technical challenges in microsurgery, and systematically summarizes the key technologies in MSR with a developmental perspective from the basic structural mechanism design, to the perception and human-machine interaction methods, and further to the ability in achieving a certain level of autonomy. By presenting and comparing the methods and technologies in this cutting-edge research, this paper aims to provide readers with a comprehensive understanding of the current state of MSR research and identify potential directions for future development in MSR.

Robotic Instruments Inside the MRI Bore: Key Concepts and Evolving Paradigms in Imaging-enhanced Cranial Neurosurgery

Intraoperative MRI has been increasingly used to robotically deliver electrodes and catheters into the human brain using a linear trajectory with great clinical success. Current cranial MR guided robotics do not allow for continuous real-time imaging during the procedure because most surgical instruments are not MR-conditional. MRI guided robotic cranial surgery can achieve its full potential if all the traditional advantages of robotics (such as tremor-filtering, precision motion scaling, etc.) can be incorporated with the neurosurgeon physically present in the MRI bore or working remotely through controlled robotic arms. The technological limitations of design optimization, choice of sensing, kinematic modeling, physical constraints, and real-time control had hampered early developments in this emerging field, but continued research and development in these areas over time has granted neurosurgeons far greater confidence in using cranial robotic techniques. This article elucidates the role of MR-guided robotic procedures using clinical devices like NeuroBlate and Clearpoint that have several thousands of cases operated in a "linear cranial trajectory" and planned clinical trials, such as LAANTERN for MR guided robotics in cranial neurosurgery using LITT and MR-guided putaminal delivery of AAV2 GDNF in Parkinson's disease. The next logical improvisation would be a steerable curvilinear trajectory in cranial robotics with added DOFs and distal tip dexterity to the neurosurgical tools. Similarly, the novel concept of robotic actuators that are powered, imaged, and controlled by the MRI itself is discussed in this article, with its potential for seamless cranial neurosurgery.

State of the Art and Future Opportunities in MRI-Guided Robot-Assisted Surgery and Interventions

Magnetic resonance imaging (MRI) can provide high-quality 3-D visualization of target anatomy, surrounding tissue, and instrumentation, but there are significant challenges in harnessing it for effectively guiding interventional procedures. Challenges include the strong static magnetic field, rapidly switching magnetic field gradients, high-power radio frequency pulses, sensitivity to electrical noise, and constrained space to operate within the bore of the scanner. MRI has a number of advantages over other medical imaging modalities, including no ionizing radiation, excellent soft-tissue contrast that allows for visualization of tumors and other features that are not readily visible by other modalities, true 3-D imaging capabilities, including the ability to image arbitrary scan plane geometry or perform volumetric imaging, and capability for multimodality sensing, including diffusion, dynamic contrast, blood flow, blood oxygenation, temperature, and tracking of biomarkers. The use of robotic assistants within the MRI bore, alongside the patient during imaging, enables intraoperative MR imaging (iMRI) to guide a surgical intervention in a closed-loop fashion that can include tracking of tissue deformation and target motion, localization of instrumentation, and monitoring of therapy delivery. With the ever-expanding clinical use of MRI, MRI-compatible robotic systems have been heralded as a new approach to assist interventional procedures to allow physicians to treat patients more accurately and effectively. Deploying robotic systems inside the bore synergizes the visual capability of MRI and the manipulation capability of robotic assistance, resulting in a closed-loop surgery architecture. This article details the challenges and history of robotic systems intended to operate in an MRI environment and outlines promising clinical applications and associated state-of-the-art MRI-compatible robotic systems and technology for making this possible.

A novel 3D-vision-based collaborative robot as a scope holding system for port surgery: a technical feasibility study

OBJECTIVE

A clear, stable, suitably located vision field is essential for port surgery. A scope is usually held by hand or a fixing device. The former yields fatigue and requires lengthy training, while the latter increases inconvenience because of needing to adjust the scope. Thus, the authors innovated a novel robotic system that can recognize the port and automatically place the scope in an optimized position. In this study, the authors executed a preliminary experiment to test this system's technical feasibility and accuracy in vitro.

METHODS

A collaborative robotic (CoBot) system consisting of a mechatronic arm and a 3D camera was developed. With the 3D camera and programmed machine vision, CoBot can search a marker attached to the opening of the surgical port, followed by automatic alignment of the scope's axis with the port's longitudinal axis so that optimal illumination and visual observation can be achieved. Three tests were conducted. In test 1, the robot positioned a laser range finder attached to the robot's arm to align the sheath's center axis. The laser successfully passing through two holes in the port sheath's central axis defined successful positioning. Researchers recorded the finder's readings, demonstrating the actual distance between the finder and the sheath. In test 2, the robot held a high-definition exoscope and relocated it to the setting position. Test 3 was similar to test 2, but a metal holder substituted the robot. Trained neurosurgeons manually adjusted the holder. The manipulation time was recorded. Additionally, a grading system was designed to score each image captured by the exoscope at the setting position, and the scores in the two tests were compared using the rank-sum test.

RESULTS

The CoBot system positioned the finder successfully in all rounds in test 1; the mean height errors ± SD were 1.14 mm ± 0.38 mm (downward) and 1.60 mm ± 0.89 mm (upward). The grading scores of images in tests 2 and 3 were significantly different. Regarding the total score and four subgroups, test 2 showed a more precise, better-positioned, and more stable vision field. The total manipulation time in test 2 was 20 minutes, and for test 3 it was 52 minutes.

CONCLUSIONS

The CoBot system successfully acted as a robust scope holding system to provide a stable and optimized surgical view during simulated port surgery, providing further evidence for the substitution of human hands, and leading to a more efficient, user-friendly, and precise operation.

Contributions of Robotics to the Safety and Efficacy of Invasive Monitoring With Stereoelectroencephalography

The purpose of this review is to provide a discussion of the history and utility of robotics in invasive monitoring for epilepsy surgery using stereoelectroencephalography (sEEG). The authors conducted a literature review of available sources to describe how the advent of surgical robotics has improved the efficacy and ease of performing sEEG surgery. The sEEG method integrates anatomic, electrographic, and clinical information to test hypotheses regarding the localization of the epileptogenic zone (EZ) and has been used in Europe since the 1950s. One of the primary benefits of robot-assisted sEEG implantation techniques is the ability to seamlessly transition between both orthogonal and oblique trajectory types using a single technique. Based on available information, it is our view that, when applied appropriately, robotic sEEG can have a low rate of complications and many advantages over both non-robotic sEEG implantation and traditional craniotomy-based invasive monitoring methods.

MRI Robots for Needle-Based Interventions: Systems and Technology

Magnetic resonance imaging (MRI) provides high-quality soft-tissue images of anatomical structures and radiation free imaging. The research community has focused on establishing new workflows, developing new technology, and creating robotic devices to change an MRI room from a solely diagnostic room to an interventional suite, where diagnosis and intervention can both be done in the same room. Closed bore MRI scanners provide limited access for interventional procedures using intraoperative imaging. MRI robots could improve access and procedure accuracy. Different research groups have focused on different technology aspects and anatomical structures. This paper presents the results of a systematic search of MRI robots for needle-based interventions. We report the most recent advances in the field, present relevant technologies, and discuss possible future advances. This survey shows that robotic-assisted MRI-guided prostate biopsy has received the most interest from the research community to date. Multiple successful clinical experiments have been reported in recent years that show great promise. However, in general the field of MRI robotic systems is still in the early stage. The continued development of these systems, along with partnerships with commercial vendors to bring this technology to market, is encouraged to create new and improved treatment opportunities for future patients.

An ultra-high field strength MR image-guided robotic needle delivery system for in-bore small animal interventions

PURPOSE

The purpose of this study was to develop and validate an image-guided robotic needle delivery system for accurate and repeatable needle targeting procedures in mouse brains inside the 12 cm inner diameter gradient coil insert of a 9.4 T MR scanner. Many preclinical research techniques require the use of accurate needle deliveries to soft tissues, including brain tissue. Soft tissues are optimally visualized in MR images, which offer high-soft tissue contrast, as well as a range of unique imaging techniques, including functional, spectroscopy and thermal imaging, however, there are currently no solutions for delivering needles to small animal brains inside the bore of an ultra-high field MR scanner. This paper describes the mechatronic design, evaluation of MR compatibility, registration technique, mechanical calibration, the quantitative validation of the in-bore image-guided needle targeting accuracy and repeatability, and demonstrated the system's ability to deliver needles in situ.

METHODS

Our six degree-of-freedom, MR compatible, mechatronic system was designed to fit inside the bore of a 9.4 T MR scanner and is actuated using a combination of piezoelectric and hydraulic mechanisms. The MR compatibility and targeting accuracy of the needle delivery system are evaluated to ensure that the system is precisely calibrated to perform the needle targeting procedures. A semi-automated image registration is performed to link the robot coordinates to the MR coordinate system. Soft tissue targets can be accurately localized in MR images, followed by automatic alignment of the needle trajectory to the target. Intra-procedure visualization of the needle target location and the needle were confirmed through MR images after needle insertion.

RESULTS

The effects of geometric distortions and signal noise were found to be below threshold that would have an impact on the accuracy of the system. The system was found to have negligible effect on the MR image signal noise and geometric distortion. The system was mechanically calibrated and the mean image-guided needle targeting and needle trajectory accuracies were quantified in an image-guided tissue mimicking phantom experiment to be 178 ± 54 μm and 0.27 ± 0.65°, respectively.

CONCLUSIONS

An MR image-guided system for in-bore needle deliveries to soft tissue targets in small animal models has been developed. The results of the needle targeting accuracy experiments in phantoms indicate that this system has the potential to deliver needles to the smallest soft tissue structures relevant in preclinical studies, at a wide variety of needle trajectories. Future work in the form of a fully-automated needle driver with precise depth control would benefit this system in terms of its applicability to a wider range of animal models and organ targets.

Retrospective Review on Accuracy: A Pilot Study of Robotically Guided Thoracolumbar/Sacral Pedicle Screws Versus Fluoroscopy-Guided and Computerized Tomography Stealth-Guided Screws

Introduction Pedicle screw insertion is the mainstay of thora-cic and lumbosacral posterior spinal instrumentation. However, it may be associated with complications such as screw mal-positioning. The purpose of this study was to develop a pilot study to compare the accuracy of robot-guided screw insertion versus hand-guided screw placement for spinal instrumentation. The hand-guided screws were placed with assistance from computerized tomography (CT) stealth guidance or fluoroscopy. Materials and methods A retrospective analysis of medical records was done for all patients that had pedicle screw insertion for instrumentation between the dates of December 2013 and January 2016 with post-screw placement CT imaging. The analysis was conducted on screw accuracy between the two categories based on the Gertzbein-Robbins classification. Results A total of 49 screws were analyzed for accuracy in six patients. There was no statistically significant difference between the accuracy of hand-placed pedicle screws versus the robotically placed screws (p = 0.311). There was no statistically significant difference in blood loss (p = 0.616), length of procedure (p = 0.192), or post-operative length of stay (p = 0.587). Conclusion The findings of our pilot study agree with most prior studies that there was no statistically significant difference in the accuracy of pedicle screw placement between the two methods of screw placement. Therefore, the techniques are equivocal in accuracy. The new technology (robotic-guidance) is as safe as conventional techniques for screw placement. Just like in any surgery, the technique preference should remain surgeon dependent. The results are only from a small sample size in the development of a pilot study so a strong reliance on the data would not be suggested. The study was a preliminary study that will be used as a template and learning process to create a future prospective study to investigate CT stealth and robotically guided screw placement versus "free hand" guided screws.

Robotic versus fluoroscopy-guided pedicle screw insertion for metastatic spinal disease: a matched-cohort comparison

OBJECTIVE

Robot-guided pedicle screw placement is an established technique for the placement of pedicle screws. However, most studies have focused on degenerative disease. In this paper, the authors focus on metastatic spinal disease, which is associated with osteolysis. The associated lack of dense bone may potentially affect the automatic recognition accuracy of radiography-based surgical assistance systems. The aim of the present study is to compare the accuracy of the SpineAssist robot system with conventional fluoroscopy-guided pedicle screw placement for thoracolumbar metastatic spinal disease.

METHODS

Seventy patients with metastatic spinal disease who required instrumentation were included in this retrospective matched-cohort study. All 70 patients underwent surgery performed by the same team of experienced surgeons. The decision to use robot-assisted or fluoroscopy-guided pedicle screw placement was based the availability of the robot system. In patients who underwent surgery with robot guidance, pedicle screws were inserted after preoperative planning and intraoperative fluoroscopic matching. In the “conventional” group, anatomical landmarks and anteroposterior and lateral fluoroscopy guided placement of the pedicle screws. The primary outcome measure was the accuracy of screw placement on the Gertzbein-Robbins scale. Grades A and B (< 2-mm pedicle breach) were considered clinically acceptable, and all other grades indicated misplacement. Secondary outcome measures included an intergroup comparison of direction of screw misplacement, surgical site infection, and radiation exposure.

RESULTS

A total of 406 screws were placed at 206 levels. Sixty-one (29.6%) surgically treated levels were in the upper thoracic spine (T1–6), 74 (35.9%) were in the lower thoracic spine, and the remaining 71 (34.4%) were in the lumbosacral region. In the robot-assisted group (Group I; n = 35, 192 screws), trajectories were Grade A or B in 162 (84.4%) of screws. The misplacement rate was 15.6% (30 of 192 screws). In the conventional group (Group II; n = 35, 214 screws), 83.6% (179 of 214) of screw trajectories were acceptable, with a misplacement rate of 16.4% (35 of 214). There was no difference in screw accuracy between the groups (chi-square, 2-tailed Fisher’s exact, p = 0.89). One screw misplacement in the fluoroscopy group required a second surgery (0.5%), but no revisions were required in the robot group. There was no difference in surgical site infections between the 2 groups (Group I, 5 patients [14.3%]; Group II, 8 patients [22.9%]) or in the duration of surgery between the 2 groups (Group I, 226.1 ± 78.8 minutes; Group II, 264.1 ± 124.3 minutes; p = 0.13). There was also no difference in radiation time between the groups (Group I, 138.2 ± 73.0 seconds; Group II, 126.5 ± 95.6 seconds; p = 0.61), but the radiation intensity was higher in the robot group (Group I, 2.8 ± 0.2 mAs; Group II, 2.0 ± 0.6 mAs; p < 0.01).

CONCLUSIONS

Pedicle screw placement for metastatic disease in the thoracolumbar spine can be performed effectively and safely using robot-guided assistance. Based on this retrospective analysis, accuracy, radiation time, and postoperative infection rates are comparable to those of the conventional technique.

Virtual wall-based haptic-guided teleoperated surgical robotic system for single-port brain tumor removal surgery

This article presents a haptic-guided teleoperation for a tumor removal surgical robotic system, so-called a SIROMAN system. The system was developed in our previous work to make it possible to access tumor tissue, even those that seat deeply inside the brain, and to remove the tissue with full maneuverability. For a safe and accurate operation to remove only tumor tissue completely while minimizing damage to the normal tissue, a virtual wall-based haptic guidance together with a medical image-guided control is proposed and developed. The virtual wall is extracted from preoperative medical images, and the robot is controlled to restrict its motion within the virtual wall using haptic feedback. Coordinate transformation between sub-systems, a collision detection algorithm, and a haptic-guided teleoperation using a virtual wall are described in the context of using SIROMAN. A series of experiments using a simplified virtual wall are performed to evaluate the performance of virtual wall-based haptic-guided teleoperation. With haptic guidance, the accuracy of the robotic manipulator's trajectory is improved by 57% compared to one without. The tissue removal performance is also improved by 21% ( p < 0.05). The experiments show that virtual wall-based haptic guidance provides safer and more accurate tissue removal for single-port brain surgery.

Robotic-assisted real-time MRI-guided TAVR: from system deployment to in vivo experiment in swine model

PURPOSE

Real-time magnetic resonance imaging (rtMRI) guidance provides significant advantages during transcatheter aortic valve replacement (TAVR) as it provides superior real-time visualization and accurate device delivery tracking. However, performing a TAVR within an MRI scanner remains difficult due to a constrained procedural environment. To address these concerns, a magnetic resonance (MR)-compatible robotic system to assist in TAVR deployments was developed. This study evaluates the technical design and interface considerations of an MR-compatible robotic-assisted TAVR system with the purpose of demonstrating that such a system can be developed and executed safely and precisely in a preclinical model.

METHODS

An MR-compatible robotic surgical assistant system was built for TAVR deployment. This system integrates a 5-degrees of freedom (DoF) robotic arm with a 3-DoF robotic valve delivery module. A user interface system was designed for procedural planning and real-time intraoperative manipulation of the robot. The robotic device was constructed of plastic materials, pneumatic actuators, and fiber-optical encoders.

RESULTS

The mechanical profile and MR compatibility of the robotic system were evaluated. The system-level error based on a phantom model was 1.14 ± 0.33 mm. A self-expanding prosthesis was successfully deployed in eight Yorkshire swine under rtMRI guidance. Post-deployment imaging and necropsy confirmed placement of the stent within 3 mm of the aortic valve annulus.

CONCLUSIONS

These phantom and in vivo studies demonstrate the feasibility and advantages of robotic-assisted TAVR under rtMRI guidance. This robotic system increases the precision of valve deployments, diminishes environmental constraints, and improves the overall success of TAVR.

Robotic system for MRI-guided stereotactic neurosurgery

Stereotaxy is a neurosurgical technique that can take several hours to reach a specific target, typically utilizing a mechanical frame and guided by preoperative imaging. An error in any one of the numerous steps or deviations of the target anatomy from the preoperative plan such as brain shift (up to mm), may affect the targeting accuracy and thus the treatment effectiveness. Moreover, because the procedure is typically performed through a small burr hole opening in the skull that prevents tissue visualization, the intervention is basically “blind” for the operator with limited means of intraoperative confirmation that may result in reduced accuracy and safety. The presented system is intended to address the clinical needs for enhanced efficiency, accuracy, and safety of image-guided stereotactic neurosurgery for deep brain stimulation lead placement. The study describes a magnetic resonance imaging (MRI)-guided, robotically actuated stereotactic neural intervention system for deep brain stimulation procedure, which offers the potential of reducing procedure duration while improving targeting accuracy and enhancing safety. This is achieved through simultaneous robotic manipulation of the instrument and interactively updated in situ MRI guidance that enables visualization of the anatomy and interventional instrument. During simultaneous actuation and imaging, the system has demonstrated less than 15% signal-to-noise ratio variation and less than 0.20 geometric distortion artifact without affecting the imaging usability to visualize and guide the procedure. Optical tracking and MRI phantom experiments streamline the clinical workflow of the prototype system, corroborating targeting accuracy with three-ax- s root mean square error 1.38 ± 0.45 mm in tip position and 2.03 ± 0.58° in insertion angle.

Safety and accuracy of robot-assisted versus fluoroscopy-guided pedicle screw insertion for degenerative diseases of the lumbar spine: a matched cohort comparison

Object

Recent years have been marked by efforts to improve the quality and safety of pedicle screw placement in spinal instrumentation. The aim of the present study is to compare the accuracy of the SpineAssist robot system with conventional fluoroscopy-guided pedicle screw placement.

Methods

Ninety-five patients suffering from degenerative disease and requiring elective lumbar instrumentation were included in the study. The robot cohort (Group I; 55 patients, 244 screws) consisted of an initial open robot-assisted subgroup (Subgroup IA; 17 patients, 83 screws) and a percutaneous cohort (Subgroup IB, 38 patients, 161 screws). In these groups, pedicle screws were placed under robotic guidance and lateral fluoroscopic control. In the fluoroscopy-guided cohort (Group II; 40 patients, 163 screws) screws were inserted using anatomical landmarks and lateral fluoroscopic guidance. The primary outcome measure was accuracy of screw placement on the Gertzbein-Robbins scale (Grade A to E and R [revised]). Secondary parameters were duration of surgery, blood loss, cumulative morphine, and length of stay.

Results

In the robot group (Group I), a perfect trajectory (A) was observed in 204 screws (83.6%). The remaining screws were graded B (n = 19 [7.8%]), C (n = 9 [3.7%]), D (n = 4 [1.6%]), E (n = 2 [0.8%]), and R (n = 6 [2.5%]). In the fluoroscopy-guided group (Group II), a completely intrapedicular course graded A was found in 79.8% (n = 130). The remaining screws were graded B (n = 12 [7.4%]), C (n = 10 [6.1%]), D (n = 6 [3.7%]), and E (n = 5 [3.1%]). The comparison of “clinically acceptable” (that is, A and B screws) was neither different between groups (I vs II [p = 0.19]) nor subgroups (Subgroup IA vs IB [p = 0.81]; Subgroup IA vs Group II [p = 0.53]; Subgroup IB vs Group II [p = 0.20]). Blood loss was lower in the robot-assisted group than in the fluoroscopy-guided group, while duration of surgery, length of stay, and cumulative morphine dose were not statistically different.

Conclusions

Robot-guided pedicle screw placement is a safe and useful tool for assisting spine surgeons in degenerative spine cases. Nonetheless, technical difficulties remain and fluoroscopy backup is advocated.

Current state-of-the-art and future perspectives of robotic technology in neurosurgery

Neurosurgery is one of the most demanding surgical specialties in terms of precision requirements and surgical field limitations. Recent advancements in robotic technology have generated the possibility of incorporating advanced technological tools to the neurosurgical operating room. Although previous studies have addressed the specific details of new robotic systems, there is very little literature on the strengths and drawbacks of past attempts, currently available platforms and prototypes in development. In this review, the authors present a critical historical analysis of the development of robotic technology in neurosurgery as well as a comprehensive summary of the currently available systems that can be expected to be incorporated to the neurosurgical armamentarium in the near future. Finally, the authors present a critical analysis of the main technical challenges in robotic technology development at the present time (such as the design of improved systems for haptic feedback and the necessity of incorporating intraoperative imaging data) as well as the benefits which robotic technology is expected to bring to specific neurosurgical subspecialties in the near future.

Introduction to haptics for neurosurgeons

Robots are becoming increasingly relevant to neurosurgeons, extending a neurosurgeon's physical capabilities, improving navigation within the surgical landscape when combined with advanced imaging, and propelling the movement toward minimally invasive surgery. Most surgical robots, however, isolate surgeons from the full range of human senses during a procedure. This forces surgeons to rely on vision alone for guidance through the surgical corridor, which limits the capabilities of the system, requires significant operator training, and increases the surgeon's workload. Incorporating haptics into these systems, ie, enabling the surgeon to "feel" forces experienced by the tool tip of the robot, could render these limitations obsolete by making the robot feel more like an extension of the surgeon's own body. Although the use of haptics in neurosurgical robots is still mostly the domain of research, neurosurgeons who keep abreast of this emerging field will be more prepared to take advantage of it as it becomes more prevalent in operating theaters. Thus, this article serves as an introduction to the field of haptics for neurosurgeons. We not only outline the current and future benefits of haptics but also introduce concepts in the fields of robotic technology and computer control. This knowledge will allow readers to be better aware of limitations in the technology that can affect performance and surgical outcomes, and "knowing the right questions to ask" will be invaluable for surgeons who have purchasing power within their departments.

Review of surgical robotics user interface: what is the best way to control robotic surgery?

BACKGROUND

As surgical robots begin to occupy a larger place in operating rooms around the world, continued innovation is necessary to improve our outcomes.

METHODS

A comprehensive review of current surgical robotic user interfaces was performed to describe the modern surgical platforms, identify the benefits, and address the issues of feedback and limitations of visualization.

RESULTS

Most robots currently used in surgery employ a master/slave relationship, with the surgeon seated at a work-console, manipulating the master system and visualizing the operation on a video screen. Although enormous strides have been made to advance current technology to the point of clinical use, limitations still exist. A lack of haptic feedback to the surgeon and the inability of the surgeon to be stationed at the operating table are the most notable examples. The future of robotic surgery sees a marked increase in the visualization technologies used in the operating room, as well as in the robots' abilities to convey haptic feedback to the surgeon. This will allow unparalleled sensation for the surgeon and almost eliminate inadvertent tissue contact and injury.

CONCLUSIONS

A novel design for a user interface will allow the surgeon to have access to the patient bedside, remaining sterile throughout the procedure, employ a head-mounted three-dimensional visualization system, and allow the most intuitive master manipulation of the slave robot to date.

Medical Robots: Current Systems and Research Directions

First used medically in 1985, robots now make an impact in laparoscopy, neurosurgery, orthopedic surgery, emergency response, and various other medical disciplines. This paper provides a review of medical robot history and surveys the capabilities of current medical robot systems, primarily focusing on commercially available systems while covering a few prominent research projects. By examining robotic systems across time and disciplines, trends are discernible that imply future capabilities of medical robots, for example, increased usage of intraoperative images, improved robot arm design, and haptic feedback to guide the surgeon.