Robotically assisted laparoscopic surgery. From concept to development

Robotic Surgery in Urology: History from PROBOT® to HUGOTM

The advent of robotic surgical systems had a significant impact on every surgical area, especially urology, gynecology, and general and cardiac surgery. The aim of this article is to delineate robotic surgery, particularly focusing on its historical background, its evolution, its present status, and its future perspectives. A comprehensive literature review was conducted upon PubMed/MEDLINE, using the keywords "robotic surgical system", "robotic surgical device", "robotics AND urology". Additionally, the retrieved articles' reference lists were investigated. Analysis concentrated on urological surgical systems for laparoscopic surgery that have been given regulatory approval for use on humans. From the late 1980s, before daVinci® Era in 2000s, ancestor platform as Probot® and PUMA 560 were described to outline historical perspective. Thus, new robotic competitors of Intuitive Surgical such as Senhance®, Revo-I®, Versius®, Avatera®, Hinotori®, and HugoTM RAS were illustrated. Although daVinci® had high level competitiveness, and for many years represented the most plausible option for robotic procedures, several modern platforms are emerging in the surgical market. Growing competition through unique features of the new robotic technologies might extend applications fields, improve diffusion, and increase cost-effectiveness procedures. More experiences are needed to identify the role of these new advancements in surgical branches and in healthcare systems.

A review on tele-manipulators for remote diagnostic procedures and surgery

With modern medicine and healthcare services improving in leaps and bounds, the integration of telemedicine has helped in expanding these specialised healthcare services to remote locations. Healthcare telerobotic systems form a component of telemedicine, which allows medical intervention from a distance. It has been nearly 40 years since a robotic technology, PUMA 560, was introduced to perform a stereotaxic biopsy in the brain. The use of telemanipulators for remote surgical procedures began around 1995, with the Aesop, the Zeus, and the da Vinci robotic surgery systems. Since then, the utilisation of robots has steadily increased in diverse healthcare disciplines, from clinical diagnosis to telesurgery. The telemanipulator system functions in a master–slave protocol mode, with the doctor operating the master system, aided by audio-visual and haptic feedback. Based on the control commands from the master, the slave system, a remote manipulator, interacts directly with the patient. It eliminates the requirement for the doctor to be physically present in the spatial vicinity of the patient by virtually bringing expert-guided medical services to them. Post the Covid-19 pandemic, an exponential surge in the utilisation of telerobotic systems has been observed. This study aims to present an organised review of the state-of-the-art telemanipulators used for remote diagnostic procedures and surgeries, highlighting their challenges and scope for future research and development.

Real Time Estimator to Perform Targeted Biopsies With a Free-Wrist Robot Despite Large Deformations of the Insertion Orifice

In the context of keyhole surgery, and more particularly of uterine biopsy, the fine automatic movements of a surgical instrument held by a robot with 3 active DOF’s require an exact knowledge of the point of rotation of the instrument. However, this center of rotation is not fixed and moves during an examination. This paper deals with a new method of detecting and updating the interaction matrix linking the movements of the robot with the surgical instrument. This is based on the method of updating the Jacobian matrix which is named the “Broyden method”. It is able to take into account body tissue deformations in real time in order to improve the pointing task for automatic movements of a surgical instrument in an unknown environment.

Future Platforms of Robotic Surgery

Among the various robotic devices that exist for urologic surgery, the most common are synergistic telemanipulator systems. Several have achieved clinical feasibility and have been licensed for use in humans: the standard da Vinci, Avatera, Hinotori, Revo-i, Senhance, Versius, and Surgenius. Handheld and hands-on synergistic systems are also clinically relevant for use in urologic surgeries, including minimally invasive and endoscopic approaches. Future trends of robotic innovation include an exploration of more robust haptic systems that offer kinesthetic and tactile feedback; miniaturization and microrobotics; enhanced visual feedback with greater magnification and higher fidelity detail; and autonomous robots.

Robotic Surgery: At the Crossroads of a Data Explosion

BACKGROUND

For the last 20 years, controversies in robotic surgery focused on cost reduction, development of new platforms and technologies, creation and validation of curriculum and virtual simulators, and conduction of randomized clinical trials to determine the best applications of robotics [Leal Ghezzi and Campos in World J Surg 40:2550-2557, 2016].

METHODS

This review explores the robotic systems which are currently indicated for use or development in gastrointestinal/abdominal surgery. These systems are reviewed and analyzed for clinical impact in these areas. In a MEDLINE search of articles with the search terms abdominal, gastrointestinal, review and robotic surgery, a total of 4306 total articles as of 2021 were assessed. Publicly available information, highest cited articles and reviews were assessed by the authors to determine the most significant regarding clinical outcomes.

RESULTS

Despite this increased number of articles related to robotic surgery, ongoing controversies have led to limitation in the use of current and future robotic surgery platforms [Connelly et al. in J Robotic Surg 14:155-165, 2020]. Newer robotic platforms have limited studies or analysis that would allow meaningful definite conclusions. A multitude of new scenarios are possible due to this limited information.

CONCLUSION

Robotic surgery is in evolution to a larger conceptual field of computationally enhanced surgery (CES). Various terms have been used in the literature including computer-assisted surgery or digital Surgery [Ranev and Teixeira in Surg Clin North Am 100:209-218, 2020]. With the growth of technological changes inherent in CES, the ability to validate these improvements in outcomes will require new metrics and analytic tools. This learning feedback and metric analysis will generate the new opportunities in simulation, training and application [Julian and Smith in Int J Med Robot 15:e2037, 2019].

Safety with Innovation in Colon and Rectal Robotic Surgery

Robotic colorectal surgery has been touted as a possible way to overcome the limitations of laparoscopic surgery and has shown promise in rectal resections, thus shifting traditional open surgeons to a minimally invasive approach. The safety, efficacy, and learning curve have been established for most colorectal applications. With this and a robust sales and marketing model, utilization of the robot for colorectal surgery continues to grow steadily. However, this disruptive technology still requires standards for training, privileging and credentialing, and safe implementation into clinical practice.

An eye-tracking based robotic scrub nurse: proof of concept

BACKGROUND

Within surgery, assistive robotic devices (ARD) have reported improved patient outcomes. ARD can offer the surgical team a "third hand" to perform wider tasks and more degrees of motion in comparison with conventional laparoscopy. We test an eye-tracking based robotic scrub nurse (RSN) in a simulated operating room based on a novel real-time framework for theatre-wide 3D gaze localization in a mobile fashion.

METHODS

Surgeons performed segmental resection of pig colon and handsewn end-to-end anastomosis while wearing eye-tracking glasses (ETG) assisted by distributed RGB-D motion sensors. To select instruments, surgeons (ST) fixed their gaze on a screen, initiating the RSN to pick up and transfer the item. Comparison was made between the task with the assistance of a human scrub nurse (HSNt) versus the task with the assistance of robotic and human scrub nurse (R&HSNt). Task load (NASA-TLX), technology acceptance (Van der Laan's), metric data on performance and team communication were measured.

RESULTS

Overall, 10 ST participated. NASA-TLX feedback for ST on HSNt vs R&HSNt usage revealed no significant difference in mental, physical or temporal demands and no change in task performance. ST reported significantly higher frustration score with R&HSNt. Van der Laan's scores showed positive usefulness and satisfaction scores in using the RSN. No significant difference in operating time was observed.

CONCLUSIONS

We report initial findings of our eye-tracking based RSN. This enables mobile, unrestricted hands-free human-robot interaction intra-operatively. Importantly, this platform is deemed non-inferior to HSNt and accepted by ST and HSN test users.

A National Survey of Robotic Surgery Training Among Otolaryngology-Head and Neck Surgery Residents

OBJECTIVE

The aim of this study is to describe the current state of robotic surgery training among Otolaryngology-Head and Neck Surgery (OHNS) residency programs in the United States.

METHODS

This is a national survey study among OHNS residents. All OHNS residency programs were identified via the Accreditation Council for Graduate Medical Education website. A total of 64/127 (50.3%) of OHNS programs were selected based on a random number generator. The main outcome measure was the number of OHNS residents with access to robotic surgery training and assessment of operative experience in robotic surgery among those residents.

RESULTS

A total of 140 OHNS residents participated in the survey, of which 59.3% (n = 83) were male. Response rate was 40.2%. Respondents came from middle 50.0% (n = 70), southern 17.8% (n = 25), western 17.8% (n = 25), and eastern sections 14.3% (n = 20). Most respondents (94.3%, n = 132) reported that their institution utilized a robot for head and neck surgery. Resident experience at the bedside increased in the junior years of training and console experience increased across the years particularly for more senior residents. However, 63.4% of residents reported no operative experience at the console. Only 11.4% of programs have a structured robotics training program.

CONCLUSION

This survey indicated that nearly all OHNS residencies utilize robotic surgery in their clinical practice with residents receiving little formal education in robotics or experience at the console. OHNS residencies should aim to increase access to training opportunities in order to increase resident competency.

LEVEL OF EVIDENCE

IV.

Sensor-based indicators of performance changes between sessions during robotic surgery training

Training of surgeons is essential for safe and effective use of robotic surgery, yet current assessment tools for learning progression are limited. The objective of this study was to measure changes in trainees' cognitive and behavioral states as they progressed in a robotic surgeon training curriculum at a medical institution. Seven surgical trainees in urology who had no formal robotic training experience participated in the simulation curriculum. They performed 12 robotic skills exercises with varying levels of difficulty repetitively in separate sessions. EEG (electroencephalogram) activity and eye movements were measured throughout to calculate three metrics: engagement index (indicator of task engagement), pupil diameter (indicator of mental workload) and gaze entropy (indicator of randomness in gaze pattern). Performance scores (completion of task goals) and mental workload ratings (NASA-Task Load Index) were collected after each exercise. Changes in performance scores between training sessions were calculated. Analysis of variance, repeated measures correlation, and machine learning classification were used to diagnose how cognitive and behavioral states associate with performance increases or decreases between sessions. The changes in performance were correlated with changes in engagement index (rrm=-.25,p<.001) and gaze entropy (rrm=-.37,p<.001). Changes in cognitive and behavioral states were able to predict training outcomes with 72.5% accuracy. Findings suggest that cognitive and behavioral metrics correlate with changes in performance between sessions. These measures can complement current feedback tools used by medical educators and learners for skills assessment in robotic surgery training.

Review of Advanced Medical Telerobots

The advent of telerobotic systems has revolutionized various aspects of the industry and human life. This technology is designed to augment human sensorimotor capabilities to extend them beyond natural competence. Classic examples are space and underwater applications when distance and access are the two major physical barriers to be combated with this technology. In modern examples, telerobotic systems have been used in several clinical applications, including teleoperated surgery and telerehabilitation. In this regard, there has been a significant amount of research and development due to the major benefits in terms of medical outcomes. Recently telerobotic systems are combined with advanced artificial intelligence modules to better share the agency with the operator and open new doors of medical automation. In this review paper, we have provided a comprehensive analysis of the literature considering various topologies of telerobotic systems in the medical domain while shedding light on different levels of autonomy for this technology, starting from direct control, going up to command-tracking autonomous telerobots. Existing challenges, including instrumentation, transparency, autonomy, stochastic communication delays, and stability, in addition to the current direction of research related to benefit in telemedicine and medical automation, and future vision of this technology, are discussed in this review paper.

Load Reduction Control on Tool-Insertion Port for Laparoscopic Surgical Robot Using Semi-Active Joints

In robotic surgery, the load exerted on the insertion port in the patient’s abdominal wall due to misalignment of the robot’s remote center of motion and the insertion port or external forces acting on the tip of the forceps during surgery, can not only stress the patient’s body but also increase the friction between the robotic forceps and the trocar, and adversely affect fine surgical manipulations or the accuracy of force estimation. To reduce such loads on the insertion port in robotic surgery, this study proposes a control method for a surgical assist robotic arm with semi-active joints. The control method was implemented on a six-degree-of-freedom pneumatically driven vertical multi-joint robotic arm with a two-axis gimbal joint (two semi-active joints) that only executes torque control, which was previously developed by the authors, and verified through an experiment. The load on the insertion port is reduced by applying torque control on the semi-active joints to compensate for the external forces on the forceps. We constructed a control system that includes a disturbance compensator and conducted a velocity-control experiment by subjecting the forceps constrained by the insertion port to an external force. The results showed that when the torque was compensated for by the semi-active joints, the load on the insertion port was reduced by 65% and 52% when the external force on the tip of the forceps was 0 N and 3 N, respectively.

Use of Robotic Technology in the Management of Complex Colorectal Pathology

Use of robotic surgery is increasing in multiple surgical specialties including colorectal. We argue that the improved visualization and better instrumentation outweigh the increased cost and operating room time. However, the indications for its use are not clearly defined. This is especially true in complex pathologies such as rectal cancer and complicated diverticulitis. We explore the limited clinical data on the subject to support or dismiss the use of this currently developing technology.

A novel hybrid 3D endoscope zooming and repositioning system: Design and feasibility study

BACKGROUND

Manipulation of the endoscope during minimally invasive surgery is a major source of inconvenience and discomfort. This report elucidates the architecture of a novel one-hand controlled endoscope positioning device and presents a practicability evaluation.

METHODS AND MATERIALS

Setup time and total surgery time, number and duration of the manipulations, side effects of three-dimensional (3D) imaging, and ergonomic complaints were assessed by three surgeons during cadaveric and in vivo porcine trials.

RESULTS

Setup was accomplished in an average (SD) of 230 (120) seconds. The manipulation time was 3.87 (1.77) seconds for angular movements and 0.83 (0.24) seconds for zooming, with an average (SD) of 30.5 (16.3) manipulations per procedure. No side effects of 3D imaging or ergonomic complaints were reported.

CONCLUSIONS

The integration of an active zoom into a passive endoscope holder delivers a convenient synergy between a human and a machine-controlled holding device. It is shown to be safe, simple, and intuitive to use and allows unrestrained autonomic control of the endoscope by the surgeon.

Design and Prototyping of Miniaturized Straight Bevel Gears for Biomedical Applications

This paper presents a semi-automated design algorithm for computing straight bevel gear involute profiles. The proposed formulation is based on the Tredgold approximation method. It allows the design of a pair of bevel gears with any desired number of teeth and relative axes inclination angles by implementing additive manufacturing technology. A specific case study is discussed to calculate the profiles of two straight bevel gears of a biomedical application. Namely, this paper illustrates the design of the bevel gears for a new laparoscopic robotic system, EasyLap, under development with a grant from POR Calabria 2014–2020 Fesr-Fse. A meshing analysis is carried out to identify potential design errors. Moreover, finite element-based tooth contact analysis is fulfilled for determining the vibrational performances of the conjugate tooth profiles throughout a whole meshing cycle. Simulation results and a built prototype are reported to show the engineering feasibility and effectiveness of the proposed design approach.

The 100 most influential manuscripts in robotic surgery: a bibliometric analysis

Since the first robotic assisted surgery in 1985, the number of procedures performed annually has steadily increased. Bibliometric analysis highlights the key studies that have influenced current practice in a field of interest. We use bibliometric analysis to evaluate the 100 most cited manuscripts on robotic surgery and discuss their content and influence on the evolution of the platform. The terms 'robotic surgery,' 'robot assisted surgery' and 'robot-assisted surgery' were used to search Thomson Reuters Web of Science database for full length, English language manuscripts. The top 100 cited manuscripts were analyzed by manuscript type, surgical specialty, first and last author, institution, year and journal of publication. 14,980 manuscripts were returned. Within the top 100 cited manuscripts, the majority featured urological surgery (n = 28), followed by combined results from multiple surgical subspecialties (n = 15) and colorectal surgery (n = 13). The majority of manuscripts featured case series/reports (n = 42), followed by comparative studies (n = 24). The most cited paper authored by Nelson et al. (432 citations) reviewed technological advances in the field. The year and country with the greatest number of publications were 2009 (n = 15) and the USA (n = 68). The Johns Hopkins University published the most top 100 manuscripts (n = 18). The 100 most cited manuscripts reflect the progression of robotic surgery from a basic instrument-holding platform to today's articulated instruments with 3D technology. From feasibility studies to multicenter trials, this analysis demonstrates how robotic assisted surgery has gained acceptance in urological, colorectal, general, cardiothoracic, orthopedic, maxillofacial and neuro surgery.

Real-Time Visual Tracking of Dynamic Surgical Suture Threads

In order to realize many of the potential benefits associated with robotically assisted minimally invasive surgery, the robot must be more than a remote controlled device. Currently, using a surgical robot can be challenging, fatiguing, and time consuming. Teaching the robot to actively assist surgical tasks, such as suturing, has the potential to vastly improve both patient outlook and the surgeon's efficiency. One obstacle to completing surgical sutures autonomously is the difficulty in tracking surgical suture threads. This paper presents novel stereo image processing algorithms for the detection, initialization, and tracking of a surgical suture thread. A Non Uniform Rational B-Spline (NURBS) curve is used to model a thin, deformable, and dynamic length thread. The NURBS model is initialized and grown from a single selected point located on the thread. The NURBS curve is optimized by minimizing the image matching energy between the projected stereo NURBS image and the segmented thread image. The algorithms are evaluated using suture threads, a calibrated test pattern, and a simulated thread image. Additionally, the accuracy of the algorithms presented are validated as they track a suture thread undergoing translation, deformation, and apparent length changes. All of the tracking is in real-time. Note to Practioners: Abstract-The problem of tracking a surgical suture thread was addressed in this work. Since the suture thread is highly deformable, any tracking algorithm must be robust to intersections, occlusions, knot tying, and length changes. The detection algorithm introduced in this paper is capable of distinguishing different threads when they intersect. The tracking algorithm presented here demonstrate that it is possible, using polynomial curves, to track a suture thread as it deforms, becomes occluded, changes length, and even ties a knot in real time. The detection algorithm can enhance directional thin features while the polynomial curve modeling can track any string like structure. Further integration of the polynomial curve with a feed-forward thread model could improve the stability and robustness of the thread tracking.

Review of Kinematics for Minimally Invasive Surgery and Tele-Echography Robots

This paper deals with the survey of kinematic structures adapted to specific medical robots: minimally invasive surgery (MIS) and tele-echography. The large diversity of kinematic architectures that can be found in medical robotics leads us to perform a statistical analysis to inform and guide design of medical robots. Safety constraints and some considerations in design evolution of medical robots are presented in this paper. First, we describe the spectrum of medical robots in minimally invasive surgery and tele-echography applications and particularly the variety of kinematic architectures used. We present the robots and their kinematic architectures and highlight differences that occur in each medical application. We perform a statistical analysis which can serve as a resource in topological synthesis for each specific medical application. Safety is an important specification in medical robotics, and for that reason we show the means used to take into account this constraint. This study demonstrates that the nature of medical robots implies specific requirements leading to different kinematic structures. The statistical analysis gives information on choice of kinematic structures for medical applications (minimally invasive surgery and echography). The safety constraint as well as the interaction between doctor and robot leads to investigate new mechanical solutions to enhance medical robot safety and compliance. We expect that this paper will serve as a significant resource and help the design of future medical robots.

Kinematic Design of a Generalized Double Parallelogram Based Remote Center-of-Motion Mechanism for Minimally Invasive Surgical Robot

Robot-assisted minimally invasive surgery (MIS) has shown tremendous advances over the traditional techniques. To improve dexterity and back-drivability of the existing planar remote center-of-motion (RCM) mechanism, on which an active prismatic joint is required to drive the surgical tool move in–out of the patient's body, a two degrees-of-freedom (DOFs) planar RCM mechanism is proposed by constructing virtual parallelograms in this paper. The mechanism can be considered as a generalized double parallelogram; both of the actuated joints are revolute joints. This feature enhances the intrinsic back-drivability of the mechanism. The mathematical framework is introduced first to prove that the mechanism could execute RCM. Then, the inverse kinematics of the planar mechanism is solved, and the Jacobian matrix is derived in this paper. Further, the singularity and the kinematic performance based on the kinematic equations are investigated, and the workspace of the mechanism is verified. Finally, a prototype was built to test the function of the proposed RCM mechanism. The results show that the mechanism can fulfill the constraint of MIS, and it can be used as the basic element of the active manipulator in an MIS robot.

A hands-free region-of-interest selection interface for solo surgery with a wide-angle endoscope: preclinical proof of concept

BACKGROUND

A hands-free region-of-interest (ROI) selection interface is proposed for solo surgery using a wide-angle endoscope. A wide-angle endoscope provides images with a larger field of view than a conventional endoscope. With an appropriate selection interface for a ROI, surgeons can also obtain a detailed local view as if they moved a conventional endoscope in a specific position and direction.

METHODS

To manipulate the endoscope without releasing the surgical instrument in hand, a mini-camera is attached to the instrument, and the images taken by the attached camera are analyzed. When a surgeon moves the instrument, the instrument orientation is calculated by an image processing. Surgeons can select the ROI with this instrument movement after switching from 'task mode' to 'selection mode.' The accelerated KAZE algorithm is used to track the features of the camera images once the instrument is moved. Both the wide-angle and detailed local views are displayed simultaneously, and a surgeon can move the local view area by moving the mini-camera attached to the surgical instrument.

RESULTS

Local view selection for a solo surgery was performed without releasing the instrument. The accuracy of camera pose estimation was not significantly different between camera resolutions, but it was significantly different between background camera images with different numbers of features (P < 0.01). The success rate of ROI selection diminished as the number of separated regions increased. However, separated regions up to 12 with a region size of 160 × 160 pixels were selected with no failure. Surgical tasks on a phantom model and a cadaver were attempted to verify the feasibility in a clinical environment.

CONCLUSIONS

Hands-free endoscope manipulation without releasing the instruments in hand was achieved. The proposed method requires only a small, low-cost camera and an image processing. The technique enables surgeons to perform solo surgeries without a camera assistant.

Attention-Aware Robotic Laparoscope Based on Fuzzy Interpretation of Eye-Gaze Patterns

Laparoscopic robots have been widely adopted in modern medical practice. However, explicitly interacting with these robots may increase the physical and cognitive load on the surgeon. An attention-aware robotic laparoscope system has been developed to free the surgeon from the technical limitations of visualization through the laparoscope. This system can implicitly recognize the surgeon's visual attention by interpreting the surgeon's natural eye movements using fuzzy logic and then automatically steer the laparoscope to focus on that viewing target. Experimental results show that this system can make the surgeon–robot interaction more effective, intuitive, and has the potential to make the execution of the surgery smoother and faster.

Forward Kinematics Simulation for a Surgical Robot Using CATIA 5

Forward Kinematic simulation of a 6 DOF surgical robot tracking a path through the constraint of the Remote Center of Motion point (RCM) is developed in this paper. Theoretical calculations of the forward kinematics are analyzed by solving the configuration kinematic equations of the robot. CAD prototype of the surgical robot and the patient are created using CATIA5 part and assembly tools. The theoretical results are validated through a Kinematic simulation of CATIA kinematics. The simulation results confirm the usefulness of the six revolute joint robots in minimally invasive surgery (MIS) and the efficiency of using the power full CATIA5 software to simulate surgical robot, and checking the robot mechanism capability of doing surgical procedures.

A cost evaluation methodology for surgical technologies

OBJECTIVE

To create and validate a micro-costing methodology that surgeons and hospital administrators can use to evaluate the cost of implementing innovative surgical technologies.

METHODS

Our analysis is broken down into several elements of fixed and variable costs which are used to effectively and easily calculate the cost of surgical operations. As an example of application, we use data from 86 robot assisted gastric bypass operations made in our hospital. To validate our methodology, we discuss the cost reporting approaches used in 16 surgical publications with respect to 7 predefined criteria.

RESULTS

Four formulas are created which allow users to import data from their health system or particular situation and derive the total cost. We have established that the robotic surgical system represents 97.53 % of our operating room's medical device costs which amounts to $4320.11. With a mean surgery time of 303 min, personnel cost per operation amounts to $1244.73, whereas reusable instruments and disposable costs are, respectively, $1539.69 and $3629.55 per case. The literature survey demonstrates that the cost of surgery is rarely reported or emphasized, and authors who do cover this concept do so with variable methodologies which make their findings difficult to interpret.

CONCLUSION

Using a micro-costing methodology, it is possible to identify the cost of any new surgical procedure/technology using formulas that can be adapted to a variety of operations and healthcare systems. We hope that this paper will provide guidance for decision makers and a means for surgeons to harmonise cost reporting in the literature.

A pneumatic laparoscope holder controlled by head movement

BACKGROUND

In traditional laparoscopic surgery, the laparoscope is handled by a camera assistant according to verbal instructions from the surgeon. Thus there is a strong need for a laparoscope holder who intuitively provides the appropriate view with excellent stability.

METHODS

A pneumatically driven robotic arm was developed to hold and manipulate a laparoscope. The robotic arm is operated by the user's head movement, which is measured with gyroscopes attached to the operator's head and body.

RESULTS

We confirmed experimentally that head tracking can be performed accurately using the proposed method. The experimental results indicated that the robotic camera holder has sufficient dynamic characteristics to quickly follow the operator's head movement.

CONCLUSIONS

A laparoscope holder control system has been developed. In this system, a laparoscope is held by a pneumatically driven robotic arm that is controlled to follow the operator's head movement. The experimental results prove the effectiveness of the system. Copyright © 2014 John Wiley & Sons, Ltd.

[Robotic surgery]

Due to the fast spread of laparoscopic cholecystectomy, surgical procedures have been changed essentially. The new techniques applied for both abdominal and thoracic procedures provided the possibility for minimally invasive access with all its advantages. Robots - originally developed for industrial applications - were retrofitted for laparoscopic procedures. The currently prevailing robot-assisted surgery is ergonomically more advantageous for the surgeon, as well as for the patient through the more precise preparative activity thanks to the regained 3D vision. The gradual decrease of costs of robotic surgical systems and development of new generations of minimally invasive devices may lead to substantial changes in routine surgical procedures.

Medical Manipulators for Surgical Applications

Great advances have been made over the last decade with respect to medical manipulators for surgical robots. Although they cannot replace surgeons, they can increase surgeons’ abilities to perform surgeries with greater therapeutic effectiveness. These advanced surgical tools have been implemented in complex, precise, repetitive, and difficult surgeries. This chapter reviews medical manipulators used in surgical applications. At present, several kinds of medical manipulators have been developed to perform a variety of surgical procedures and can be classified into different categories. Here, the authors discuss general design principles and summarize and classify medical manipulators based on joint category and level of autonomy, with illustrations of applications. Finally, a brief synopsis is provided.

[Not Available]

The term “robot” was coined by the Czech playright Karel Capek in 1921 in his play Rossom's Universal Robots. The word “robot” is from the check word robota which means forced labor. The era of robots in surgery commenced in 1994 when the first AESOP (voice controlled camera holder) prototype robot was used clinically in 1993 and then marketed as the first surgical robot ever in 1994 by the US FDA. Since then many robot prototypes like the Endoassist (Armstrong Healthcare Ltd., High Wycombe, Buck, UK), FIPS endoarm (Karlsruhe Research Center, Karlsruhe, Germany) have been developed to add to the functions of the robot and try and increase its utility. Integrated Surgical Systems (now Intuitive Surgery, Inc.) redesigned the SRI Green Telepresence Surgery system and created the daVinci Surgical System^® classified as a master-slave surgical system. It uses true 3-D visualization and EndoWrist^®. It was approved by FDA in July 2000 for general laparoscopic surgery, in November 2002 for mitral valve repair surgery. The da Vinci robot is currently being used in various fields such as urology, general surgery, gynecology, cardio-thoracic, pediatric and ENT surgery. It provides several advantages to conventional laparoscopy such as 3D vision, motion scaling, intuitive movements, visual immersion and tremor filtration. The advent of robotics has increased the use of minimally invasive surgery among laparoscopically naïve surgeons and expanded the repertoire of experienced surgeons to include more advanced and complex reconstructions.

Present and future advanced laparoscopic surgery

Modern laparoscopy, starting with Kurt Semm's insufflators and the first successful appendectomies, has only been around for approximately 30 years. Since those early successes, the technology has grown from the inception of basic laparoscopy to endoscopic surgery through natural orifices, and it continues to evolve by leaps and bounds with computer-assisted surgery and improved robotics in surgery. Without question, laparoscopy has revolutionized the way we perform standard surgery, especially relative to the techniques that had been used for hundreds of years. Despite the development of multiple novel technologies since the 1980s, very little has changed with regard to basic conceptualizations and practice of laparoscopy. In this review article, we will describe the highlights of recent advanced laparoscopic surgery procedures, their potential applications within the field of surgery, and how these advances may impact and improve future quality and patient outcomes.

Miniaturized robotic laparoscope-holder for rectopexy: first results of a prospective study

INTRODUCTION

Thanks to the technical progress in instrumentation, laparoscopic surgery has made considerable advances over the last decade. Various robotic systems have been introduced to assist laparoscopic procedures. A new prototype of miniaturized laparoscope-holder (called the Light Endoscope Robot [LER]) has been developed by the TIMC-IMAG-CNRS Laboratory in Grenoble, France and is now currently marketed by the French company Endocontrol™ (La Tronche, Grenoble). The aim of this pilot study was to assess the LER in clinical practice.

SUBJECTS AND METHODS

This was a prospective, single-center study. The LER had already been successfully validated on preclinical laboratory and cadaveric trials. The study was conducted at the Grenoble University Hospital during standardized laparoscopic rectopexies on adult patients. Demographic and operative data and qualitative results were collected prospectively and analyzed retrospectively. All patients provided written informed consent, and the study was approved by the Regional Committee for Medical and Health Research Ethics.

RESULTS

Between March 2008 and September 2010, 16 adult patients underwent laparoscopic rectopexy assisted by the LER. All the patients were women with an average age of 63.6 years and an average body mass index of 24 kg/m(2). The procedure was completed in 15 patients. No conversion to open surgery was required. The postoperative mortality rate was 0%, and a complication occurred in 1 patient. The surgeon graded ease of use as 7 ± 2, global comfort as 8 ± 2, and quality of vision as 8 ± 2.

CONCLUSIONS

This pilot study demonstrated the feasibility, safety, and comfort for the surgeon of the laparoscopic rectopexy assisted by the miniaturized light endoscope-holder LER.

Process of optimisation for a 4 DOF tele-echography robot

This paper deals with processes of optimisation for the design of a four degree-of-freedom robot dedicated to remote ultrasound tele-echography. This robot is designed to track the medical gestures of a remote expert moving an ultrasound probe. The goal is to optimise the kinematic structure by fixing the geometric parameters; these have a significant role in robot configuration singularities, with respect to current medical gestures and mechanism compactness. After choosing a dedicated kinematic structure, several optimisations are presented. Then an optimal choice of geometrical parameters of a global function in relation with kinematic performance indices and compactness is proposed. This robot is soon to be used in the experimental medical phase of the Prosit project.

Needlescopic surgery for liver, gallbladder and spleen diseases

BACKGROUND

We propose that needlescopic surgery (NS) should be considered as a way of improving the esthetic result and post-operative quality of life of patients and of reducing costs and stress on surgeons, and we have evaluated the results of NS.

METHODS

We used NS in 157 patients between May 1998 and December 2010: cholecystectomy in 150 patients, marsupialization of splenic and hepatic cysts in 4 and splenectomy in 3, respectively. Under general anesthesia, one 12-mm and two or three 2- or 3-mm ports were introduced into the operative field. The specimen was retrieved from the 12-mm wound using a plastic bag.

RESULTS

The procedures were successfully completed in all patients without conversion to an open procedure. In eight (5.3%) of 150 cholecystectomies a change to 5-mm instruments was required. The mean operation times and postoperative hospital stays for cholecystectomy, splenectomy, and marsupialization of splenic and hepatic cysts were 80.2 min and 3.2 days, 167 min and 5.6 days, 170 min and 7 days, and 120 min and 7 days, respectively. There were a few perioperative complications. The most important factor for reducing operation time and achieving a low conversion rate is the use of at least one 3- or 5-mm port for the grasping instruments in cholecystectomy. We recognized a residual cyst requiring splenectomy 62 months after marsupialization in one case. Technical points for performing safe procedures on solid organs were: no direct organ mobilization to avoid organ injuries, the rotation of the operating table and the utilization of organ gravity to create a better operative field, the minimum use of the needlescope to perform a safe maneuver and the improvement of bi-manual technique.

CONCLUSIONS

NS is a safe and feasible procedure for achieving minimal invasive surgery. We should consider NS as a first choice to treat operable diseases in this laparoscopic era.