Robot-assisted techniques in vascular and endovascular surgery

Robotic-Assisted Endovascular Treatment for Transplant Renal Artery Stenosis: A Feasibility Study

PURPOSE

To describe a single-center experience with robotic-assisted endovascular treatment for transplant renal artery stenosis.

MATERIALS AND METHODS

This is a single-center, retrospective, feasibility study of 4 consecutive cases of robotic-assisted endovascular surgery for transplant renal artery stenosis from October 2021 to August 2022.

RESULTS

All lesions were identified, and stenting was performed with no complications. Conversion to manual control was not necessary. The mean fluoroscopy time was 25.25 min (range 12-60.9). A control Doppler ultrasound was routinely performed, demonstrating no residual lesions in all cases. There was no reintervention during the follow-up period. The operator learning curve was felt to be acceptable.

CONCLUSION

Robotic-assisted endovascular treatment is a feasible technique for transplant renal artery stenosis.

A zero-shot reinforcement learning strategy for autonomous guidewire navigation

PURPOSE

The treatment of cardiovascular diseases requires complex and challenging navigation of a guidewire and catheter. This often leads to lengthy interventions during which the patient and clinician are exposed to X-ray radiation. Deep reinforcement learning approaches have shown promise in learning this task and may be the key to automating catheter navigation during robotized interventions. Yet, existing training methods show limited capabilities at generalizing to unseen vascular anatomies, requiring to be retrained each time the geometry changes.

METHODS

In this paper, we propose a zero-shot learning strategy for three-dimensional autonomous endovascular navigation. Using a very small training set of branching patterns, our reinforcement learning algorithm is able to learn a control that can then be applied to unseen vascular anatomies without retraining.

RESULTS

We demonstrate our method on 4 different vascular systems, with an average success rate of 95% at reaching random targets on these anatomies. Our strategy is also computationally efficient, allowing the training of our controller to be performed in only 2 h.

CONCLUSION

Our training method proved its ability to navigate unseen geometries with different characteristics, thanks to a nearly shape-invariant observation space.

Performance Evaluation of a Miniature and Disposable Endovascular Robotic Device

PURPOSE

The LIBERTY® Robotic System is a miniature, single-use device designed to facilitate remote-controlled navigation to intravascular targets. We aim to evaluate the robot's performance to manipulate a range of microguidewires and microcatheters during percutaneous endovascular procedures.

MATERIALS AND METHODS

Six interventional radiologists performed selective robotic-assisted catheterization of eight pre-determined vascular targets in a pig model. The navigation time from the guiding catheter tip to the target vessel was recorded. Each physician with a clinical experience of 20 years completed a questionnaire to evaluate the ease of use, accuracy, and safety of the robotic operation.

RESULTS

Most of the physicians reached the vascular targets in less than one minute. There was no angiographic evidence of vascular injury such as artery laceration or contusion. All physicians reported consensus about the high performance of the robot.

CONCLUSION

The miniature disposable robot is effective at reaching a range of vessels in a porcine model. Physicians found the device intuitive and easy to operate remotely.

The impact of the first and the second wave of the COVID-19 pandemic on vascular surgery practice in the leading regional center: a comparative, retrospective study

BACKGROUND

We conducted an analysis of the vascular surgery regional center reorganization in response to the first and the second wave of the coronavirus disease-2019 (COVID-19) pandemic to see what lessons we learned from the first wave.

METHODS

The study included a total of 632 patients admitted to the vascular surgery department in three periods: March-May 2020, October-December 2020, and October-December 2019 as a control period.

RESULTS

In the pandemic periods the number of admitted patients decreased in relation to the control period. There was a reduction in performed procedures. We observed an increase in the ratio of less invasive procedures. There was a significant decline in hospitalization time in comparison to the control period.

CONCLUSIONS

The reduction of scheduled admissions and procedures affected vascular centers all over the world. Minimally invasive procedures were more willingly performed to shorten the hospitalization time and reduce the patient's exposure to hospital infection. It allowed us to treat more patients during the second wave. Nevertheless, an increased number of vascular patients should be expected in the future, which will result from the failure to perform elective procedures during the pandemic.

Robotic applications for intracardiac and endovascular procedures

The large incisions and long recovery periods that accompany traditional cardiac surgery procedures along with the constant patient demand for minimally invasive procedures have motivated cardiac surgeons to implement the robotic technologies in their armamentarium. The robotic systems have been utilized successfully in various cardiac procedures including atrial septal defect repair, left atrial myxoma resection, MAZE procedure and left ventricular lead placement, yet coronary artery bypass and mitral valve repair still comprise the vast majority of them. This review analyzes the development of the robot-assisted cardiac surgery in recent years, its outcomes, advantages, disadvantages, its patient selection criteria as well as its economic feasibility. Robotic endovascular surgery, albeit its limited applications, is presently considered an attractive alternative to conventional endovascular approaches. The increased flexibility and precision along with the wider range of accessible anatomy provided by the endovascular robotic systems, have increased the pool of patients that can be offered minimally invasive treatment options and have helped to overcome many limitations of the traditional endovascular procedures. With this review we aimed to summarize the applications of the commercially available endovascular robotic devices, as well as the limitations and the future perspectives in the field of endovascular robotic surgery.

Clinical applications of robotic surgery platforms: a comprehensive review

Robotic surgery has expanded globally across various medical specialties since its inception more than 20 years ago. Accompanying this expansion were significant technological improvements, providing tremendous benefits to patients and allowing the surgeon to perform with more precision and accuracy. This review lists some of the different types of platforms available for use in various clinical applications. We performed a literature review of PubMed and Web of Science databases in May 2023, searching for all available articles describing surgical robotic platforms from January 2000 (the year of the first approved surgical robot, da Vinci® System, by Intuitive Surgical) until May 1st, 2023. All retrieved robotic platforms were then divided according to their clinical application into four distinct groups: soft tissue robotic platforms, orthopedic robotic platforms, neurosurgery and spine platforms, and endoluminal robotic platforms. Robotic surgical technology has undergone a rapid expansion over the last few years. Currently, multiple robotic platforms with specialty-specific applications are entering the market. Many of the fields of surgery are now embracing robotic surgical technology. We review some of the most important systems in clinical practice at this time.

A multifunctional soft robot for cardiac interventions

In minimally invasive endovascular procedures, surgeons rely on catheters with low dexterity and high aspect ratios to reach an anatomical target. However, the environment inside the beating heart presents a combination of challenges unique to few anatomic locations, making it difficult for interventional tools to maneuver dexterously and apply substantial forces on an intracardiac target. We demonstrate a millimeter-scale soft robotic platform that can deploy and self-stabilize at the entrance to the heart, and guide existing interventional tools toward a target site. In two exemplar intracardiac procedures within the right atrium, the robotic platform provides enough dexterity to reach multiple anatomical targets, enough stability to maintain constant contact on motile targets, and enough mechanical leverage to generate newton-level forces. Because the device addresses ongoing challenges in minimally invasive intracardiac intervention, it may enable the further development of catheter-based interventions.

Overcoming Barriers and Advancements in Endovascular Robotics: A Review of Systems and Developments

Endovascular robots have the potential to revolutionize the field of vascular interventions by enhancing procedural efficiency, accuracy, and standardization. They aim to reduce radiation exposure, as well as physical strain on operators and medical staff, while enabling precise navigation of catheters through challenging anatomical structures. However, the widespread adoption of these robots faces barriers, such as real estate constraints, setup time, limited range of compatible tools, and high costs. This paper discusses these barriers and highlights Hansen Medical's Magellan and the Liberty robotic systems as notable examples. New developments will offer cost-effective, intuitive, and disposable approaches to endovascular procedures. Despite challenges, endovascular robots hold promise for improving access to endovascular therapy and transforming patient care in various healthcare settings.

Image-to-Patient Registration in Computer-Assisted Surgery of Head and Neck: State-of-the-Art, Perspectives, and Challenges

Today, image-guided systems play a significant role in improving the outcome of diagnostic and therapeutic interventions. They provide crucial anatomical information during the procedure to decrease the size and the extent of the approach, to reduce intraoperative complications, and to increase accuracy, repeatability, and safety. Image-to-patient registration is the first step in image-guided procedures. It establishes a correspondence between the patient's preoperative imaging and the intraoperative data. When it comes to the head-and-neck region, the presence of many sensitive structures such as the central nervous system or the neurosensory organs requires a millimetric precision. This review allows evaluating the characteristics and the performances of different registration methods in the head-and-neck region used in the operation room from the perspectives of accuracy, invasiveness, and processing times. Our work led to the conclusion that invasive marker-based methods are still considered as the gold standard of image-to-patient registration. The surface-based methods are recommended for faster procedures and applied on the surface tissues especially around the eyes. In the near future, computer vision technology is expected to enhance these systems by reducing human errors and cognitive load in the operating room.

Current State of Robotics in Interventional Radiology

As a relatively new specialty with a minimally invasive nature, the field of interventional radiology is rapidly growing. Although the application of robotic systems in this field shows great promise, such as with increased precision, accuracy, and safety, as well as reduced radiation dose and potential for teleoperated procedures, the progression of these technologies has been slow. This is partly due to the complex equipment with complicated setup procedures, the disruption to theatre flow, the high costs, as well as some device limitations, such as lack of haptic feedback. To further assess these robotic technologies, more evidence of their performance and cost-effectiveness is needed before their widespread adoption within the field. In this review, we summarise the current progress of robotic systems that have been investigated for use in vascular and non-vascular interventions.

Bioengineering, augmented reality, and robotic surgery in vascular surgery: A literature review

Biomedical engineering integrates a variety of applied sciences with life sciences to improve human health and reduce the invasiveness of surgical procedures. Technological advances, achieved through biomedical engineering, have contributed to significant improvements in the field of vascular and endovascular surgery. This paper aims to review the most cutting-edge technologies of the last decade involving the use of augmented reality devices and robotic systems in vascular surgery, highlighting benefits and limitations. Accordingly, two distinct literature surveys were conducted through the PubMed database: the first review provides a comprehensive assessment of augmented reality technologies, including the different techniques available for the visualization of virtual content (11 papers revised); the second review collects studies with bioengineering content that highlight the research trend in robotic vascular surgery, excluding works focused only on the clinical use of commercially available robotic systems (15 papers revised). Technological flow is constant and further advances in imaging techniques and hardware components will inevitably bring new tools for a clinical translation of innovative therapeutic strategies in vascular surgery.

Design and Modeling of a Bio-Inspired Compound Continuum Robot for Minimally Invasive Surgery

The continuum robot is a new type of bionic robot which is widely used in the medical field. However, the current structure of the continuum robot limits its application in the field of minimally invasive surgery. In this paper, a bio-inspired compound continuum robot (CCR) combining the concentric tube continuum robot (CTR) and the notched continuum robot is proposed to design a high-dexterity minimally invasive surgical instrument. Then, a kinematic model, considering the stability of the CTR part, was established. The unstable operation of the CCR is avoided. The simulation of the workspace shows that the introduction of the notched continuum robot expands the workspace of CTR. The dexterity indexes of the robots are proposed. The simulation shows that the dexterity of the CCR is 1.472 times that of the CTR. At last, the length distribution of the CCR is optimized based on the dexterity index by using a fruit fly optimization algorithm. The simulations show that the optimized CCR is more dexterous than before. The dexterity of the CCR is increased by 1.069 times. This paper is critical for the development of high-dexterity minimally invasive surgical instruments such as those for the brain, blood vessels, heart and lungs.

Quantifying and Statistically Modeling Residual Pneumoperitoneum after Robotic-Assisted Laparoscopic Prostatectomy: A Prospective, Single-Center, Observational Study

Background: Laparoscopic surgery (LS) requires CO₂ insufflation to establish the operative field. Patients with worsening pain post-operatively often undergo computed tomography (CT). CT is highly sensitive in detecting free air—the hallmark sign of a bowel injury. Yet, the clinical significance of free air is often confounded by residual CO₂ and is not usually due to a visceral injury. The aim of this study was to attempt to quantify the residual pneumoperitoneum (RPP) after a robotic-assisted laparoscopic prostatectomy (RALP). Methods: We prospectively enrolled patients who underwent RALP between August 2018 and January 2020. CT scans were performed on postoperative days (POD) 3, 5, and 7. To investigate potential factors influencing the quantity of RPP, correlation plots were made against common variables. Results: In total, 31 patients with a mean age of 66 years (median 67, IQR 62–70.5) and mean BMI 26.59 (median 25.99, IQR: 24.06–29.24) underwent RALP during the study period. All patients had a relatively unremarkable post-operative course (30/31 with Clavien–Dindo class 0; 1/31 with class 2). After 3, 5, and 7 days, 3.2%, 6.4%, and 32.3% were completely without RPP, respectively. The mean RPP at 3 days was 37.6 mL (median 9.58 mL, max 247 mL, IQR 3.92–31.82 mL), whereas the mean RPP at 5 days was 19.85 mL (median 1.36 mL, max 220.77 mL, IQR 0.19–5.61 mL), and 7 days was 10.08 mL (median 0.09 mL, max 112.42 mL, IQR 0–1.5 mL). There was a significant correlation between RPP and obesity (p = 0.04665), in which higher BMIs resulted in lower initial insufflation volumes and lower RPP. Conclusions: This is the first study to systematically assess RPP after a standardized laparoscopic procedure using CT. Larger patients tend to have smaller residuals. Our data may help surgeons interpreting post-operative CTs in similar patient populations.