Prevalence of haptic feedback in robot-mediated surgery: a systematic review of literature

Recommendations on Robotic Hepato-Pancreato-Biliary Surgery. The Paris Jury-Based Consensus Conference

OBJECTIVE

To establish the first consensus guidelines on the safety and indications of robotics in Hepato-Pancreatic-Biliary (HPB) surgery. The secondary aim was to identify priorities for future research.

BACKGROUND

HPB robotic surgery is reaching the IDEAL 2b exploration phase for innovative technology. An objective assessment endorsed by the HPB community is timely and needed.

METHODS

The ROBOT4HPB conference developed consensus guidelines using the Zurich-Danish model. An impartial and multidisciplinary jury produced unbiased guidelines based on the work of 10 expert panels answering predefined key questions and considering the best-quality evidence retrieved after a systematic review. The recommendations conformed with the GRADE and SIGN50 methodologies.

RESULTS

Sixty-four experts from 20 countries considered 285 studies, and the conference included an audience of 220 attendees. The jury (n=10) produced recommendations or statements covering 5 sections of robotic HPB surgery: technology, training and expertise, outcome assessment, and liver and pancreatic procedures. The recommendations supported the feasibility of robotics for most HPB procedures and its potential value in extending minimally invasive indications, emphasizing, however, the importance of expertise to ensure safety. The concept of expertise was defined broadly, encompassing requirements for credentialing HPB robotics at a given center. The jury prioritized relevant questions for future trials and emphasized the need for prospective registries, including validated outcome metrics for the forthcoming assessment of HPB robotics.

CONCLUSIONS

The ROBOT4HPB consensus represents a collaborative and multidisciplinary initiative, defining state-of-the-art expertise in HPB robotics procedures. It produced the first guidelines to encourage their safe use and promotion.

Novel force feedback technology improves suturing in robotic-assisted surgery: a pre-clinical study

INTRODUCTION

The inability to sense force applied to tissue is suggested as a limitation to robotic-assisted surgery (RAS). This pre-clinical study evaluated the impact of a novel force feedback (FFB) technology, integrated on a next-generation robotic system that allows surgeons to sense forces exerted at the instrument tips, on suturing performance by novice surgeons during RAS.

METHODS

Twenty-nine novice surgeons (< 50 RAS cases in the last 5 years) were randomized into two groups with (n = 15) or without (n = 14) FFB sensing. Participants performed interrupted stitches on ex vivo porcine bladder and running stitches on porcine aorta (Fig. 1A) over four runs. Average forces applied, number of errors, time for exercise completion, and Robotic Anastomosis Competence Evaluation (RACE) technical skill ratings were compared using a three-way mixed-model ANOVA and applicable post hoc tests. Fig. 1 A View from surgeon console of participant performing suturing tasks using Kotobuki dry model (Exercise 1 to 3), Foam dry model (Exercise 4 and 5), Urinary Bladder ex vivo tissue (Exercise 6), and Aorta ex vivo tissue (Exercise 7). B Description of 7 suturing exercises and anatomical models used for each exercise RESULTS: FFB sensing significantly lowered the mean force applied (bladder, 1.71 N vs 2.40 N, p < 0.006; aorta, 1.80 N vs 2.53 N, p < 0.006), average number of errors (bladder, 0.59 vs 1.76, p < 0.001; aorta, 0.38 vs 1.14, p < 0.001), and the time to completion (bladder, 659 s vs 781 s, p = 0.002; aorta, 460 s vs 570 s, p = 0.001) (Fig. 1C). The FFB group applied less tissue trauma with a higher RACE skill score (3.75 vs 3.03, p = 0.012).

CONCLUSION

This study showed that novice surgeons using FFB-enabled instruments completed suturing tasks using less force, with fewer errors, taking less time, and less tissue trauma during RAS. Future studies are required to better understand the impact of FFB technology on surgical performance and potential patient benefits.

A piezoresistive-based 3-axial MEMS tactile sensor and integrated surgical forceps for gastrointestinal endoscopic minimally invasive surgery

In robotic-assisted surgery (RAS), traditional surgical instruments without sensing capability cannot perceive accurate operational forces during the task, and such drawbacks can be largely intensified when sophisticated tasks involving flexible and slender arms with small end-effectors, such as in gastrointestinal endoscopic surgery (GES). In this study, we propose a microelectromechanical system (MEMS) piezoresistive 3-axial tactile sensor for GES forceps, which can intuitively provide surgeons with online force feedback during robotic surgery. The MEMS fabrication process facilitates sensor chips with miniaturized dimensions. The fully encapsulated tactile sensors can be effortlessly integrated into miniature GES forceps, which feature a slender diameter of just 3.5 mm and undergo meticulous calibration procedures via the least squares method. Through experiments, the sensor's ability to accurately measure directional forces up to 1.2 N in the Z axis was validated, demonstrating an average relative error of only 1.18% compared with the full-scale output. The results indicate that this tactile sensor can provide effective 3-axial force sensing during surgical operations, such as grasping and pulling, and in ex vivo testing with a porcine stomach. The compact size, high precision, and integrability of the sensor establish solid foundations for clinical application in the operating theater.

Future Directions in the Treatment of Thyroid and Parathyroid Disease

The surgical management of thyroid and parathyroid disease has evolved considerably since the era of Theodor Kocher. We review the current trends in thyroid and parathyroid surgery concerning robotic surgery for remote access, the use of parathyroid autofluorescence detection technology to aid in the prevention of hypocalcemia as well as the use of thermal ablation to target thyroid nodules in a minimally invasive way. We also discuss how artificial intelligence is being used to improve the workflow and diagnostics preoperatively as well as for intraoperative decision-making. We also discuss potential areas where future research may enhance outcomes.

Multi-silicone bilateral soft physical twin as an alternative to traditional user interfaces for remote palpation: a comparative study

Teleoperated medical technologies are a fundamental part of the healthcare system. From telemedicine to remote surgery, they allow remote diagnosis and treatment. However, the absence of any interface able to effectively reproduce the sense of touch and interaction with the patient prevents the implementation of teleoperated systems for primary care examinations, such as palpation. In this paper, we propose the first reported case of a soft robotic bilateral physical twin for remote palpation. By creating an entirely soft interface that can be used both to control the robot and receive feedback, the proposed device allows the user to achieve remote palpation by simply palpating the soft physical twin. This is achieved through a compact design showcasing 9 pneumatic chambers and exploiting multi-silicone casting to minimize cross-noise and allow teleoperation. A comparative study has been run against a traditional setup, and both the control and feedback of the physical twin are carefully analyzed. Despite distributed tactile feedback not achieving the same performance as the visual map, the soft control and visual feedback combination showcases a 5.1% higher accuracy. Moreover, the bilateral soft physical twin results always in a less invasive procedure, with 41% lower mechanical work exchanged with the remote phantom.

The benefits of haptic feedback in robot assisted surgery and their moderators: a meta-analysis

Robot assisted surgery (RAS) provides medical practitioners with valuable tools, decreasing strain during surgery and leading to better patient outcomes. While the loss of haptic sensation is a commonly cited disadvantage of RAS, new systems aim to address this problem by providing artificial haptic feedback. N = 56 papers that compared robotic surgery systems with and without haptic feedback were analyzed to quantify the performance benefits of restoring the haptic modality. Additionally, this study identifies factors moderating the effect of restoring haptic sensation. Overall results showed haptic feedback was effective in reducing average forces (Hedges' g = 0.83) and peak forces (Hedges' g = 0.69) applied during surgery, as well as reducing the completion time (Hedges' g = 0.83). Haptic feedback has also been found to lead to higher accuracy (Hedges' g = 1.50) and success rates (Hedges' g = 0.80) during surgical tasks. Effect sizes on several measures varied between tasks, the type of provided feedback, and the subjects' levels of surgical expertise, with higher levels of expertise generally associated with smaller effect sizes. No significant differences were found between virtual fixtures and rendering contact forces. Implications for future research are discussed.

A Survey on Force Sensing Techniques in Robot-Assisted Minimally Invasive Surgery

Minimally invasive surgery (MIS) is commonly used in some robotic-assisted surgery (RAS) systems. However, many RAS lack the strength and tactile sensation of surgical tools. Therefore, researchers have developed various force sensing techniques in robot-assisted minimally invasive surgery (RMIS). This paper provides a systematic classification and review of force sensing approaches in the field of RMIS, with a particular focus on direct and indirect force sensing. In this survey, the relevant literature on various sensing principles, haptic sensor design standards, and sensing technologies between 2000 and 2022 is reviewed. This survey can also serve as a roadmap for future developments by identifying the shortcomings of the field and discussing the emerging trends in force sensing methods.

Successful all robotic-assisted excision of highly malignant mediastinal neuroblastoma in a toddler: A case report

An otherwise well 28-month-old girl presented with fever/left thigh pain. Computed tomography identified a 7 cm right posterior mediastinal tumor extending to the paravertebral and intercostal spaces with multiple bone and bone marrow metastases on bone scintigraphy. Thoracoscopic biopsy diagnosed MYCN non-amplified neuroblastoma. Chemotherapy shrank the tumor to 5 cm by 35 months of age. Robotic-assisted resection was chosen because the patient was large enough and public health insurance coverage was available. At surgery, the tumor was well-demarcated by chemotherapy and dissection posteriorly from the ribs/intercostal spaces and medially from the paravertebral space and azygos vein was facilitated by superior visualization/instrument articulation. The capsule of the resected specimen was intact on histopathology, confirming complete tumor resection. Despite minimum distance specifications between arms, trocars, and target sites with robotic assistance, excision was safe without instrument collisions. Robotic assistance should be actively considered for pediatric malignant mediastinal tumor provided the thorax is of adequate size.

Optical force estimation for interactions between tool and soft tissues

Robotic assistance in minimally invasive surgery offers numerous advantages for both patient and surgeon. However, the lack of force feedback in robotic surgery is a major limitation, and accurately estimating tool-tissue interaction forces remains a challenge. Image-based force estimation offers a promising solution without the need to integrate sensors into surgical tools. In this indirect approach, interaction forces are derived from the observed deformation, with learning-based methods improving accuracy and real-time capability. However, the relationship between deformation and force is determined by the stiffness of the tissue. Consequently, both deformation and local tissue properties must be observed for an approach applicable to heterogeneous tissue. In this work, we use optical coherence tomography, which can combine the detection of tissue deformation with shear wave elastography in a single modality. We present a multi-input deep learning network for processing of local elasticity estimates and volumetric image data. Our results demonstrate that accounting for elastic properties is critical for accurate image-based force estimation across different tissue types and properties. Joint processing of local elasticity information yields the best performance throughout our phantom study. Furthermore, we test our approach on soft tissue samples that were not present during training and show that generalization to other tissue properties is possible.

A Review on Tactile Displays for Conventional Laparoscopic Surgery

Laparoscopic surgery (LS) is a minimally invasive technique that offers many advantages over traditional open surgery: it reduces trauma, scarring, and shortens recovery time. However, an important limitation is the loss of tactile sensations. Although some progress has been made in robotic-assisted minimally invasive surgery (RMIS) setups, RMIS is still not widely accessible. This review aims to identify which tactile display technologies have been proposed and experimentally validated for the restoration of tactile sensations during conventional laparoscopic surgical tasks. We conducted a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We identified relevant articles published over the past 10 years through a search on Web of science, Scopus, IEEE Xplore Digital, and PubMed repositories. A total of 143 articles met the inclusion criteria and 24 were included in the final review. From the reviewed articles, we classified the proposed tactile displays into two categories based on the use of skin contact: (i) skin tactile displays, which include vibrotactile, skin-indentation, and grip-feedback devices, and (ii) non-contact tactile displays based on visualization tools. This survey aims to contribute to further research in the area of tactile displays for laparoscopic surgery by providing a better understanding of the current state of the art and identifying the remaining challenges.

How does the modality of delivering force feedback influence the performance and learning of surgical suturing skills? We don’t know, but we better find out! A review

Background

Force feedback is a critical element for performing and learning surgical suturing skill. Force feedback is impoverished or not present at all in non-open surgery (i.e., in simulation, laparoscopic, and robotic-assisted surgery), but it can be augmented using different modalities. This rapid, systematic review examines how the modality of delivering force feedback influences the performance and learning of surgical suturing skills.

Methods

An electronic search was performed on PubMed/MEDLINE, Web of Science, and Embase databases to identify relevant articles. The results were synthesized using vote counting based on direction of effect.

Results

A total of nine studies of medium-to-low quality were included. The synthesis of results suggests that the visual modality could be more beneficial than the tactile and auditory modalities in improving force control and that auditory and tactile modalities could be more beneficial than the visual modality in improving suturing performance. Results are mixed and unclear with regards to how modality affects the reduction of force magnitude and unclear when unimodal was compared to multimodal feedback. The studies have a general low level of evidence.

Conclusion

The low number of studies with low methodological quality and low level of evidence (most were proof of concept) prevents us from drawing any meaningful conclusion and as such it is currently unknown whether and how force feedback modality influences surgical suturing skill. Speculatively, the visual modality may be more beneficial for improving the control of exerted force, while auditory and tactile modalities may be more effective in improving the overall suturing performance. We consider the issue of feedback modality to be highly relevant in this field, and we encourage future research to conduct further investigation integrating principles from learning psychology and neuroscience: identify feedback goal, context, and skill level and then design and compare feedback modalities accordingly.

Understanding the adoption of digital workflows in orthotic & prosthetic practice from practitioner perspectives: a qualitative descriptive study

BACKGROUND

The implementation of digital technology (DT) in orthotics and prosthetics (O&P) has been slow despite recent research suggesting that the use of DT will continue to grow and become more prevalent within the industry. There is a need to further investigate DT in O&P practice and the current state of its use in the field.

OBJECTIVE

This study aimed to explore the views and experiences of practitioners using DT workflows in their O&P practice.

METHODS

In this qualitative descriptive study, 10 in-depth, semistructured interviews with O&P practitioners were conducted. A content analysis was performed to analyze the transcripts and identify key themes from the data.

RESULTS

The study examined the experiences of practitioners using or trying to use DT in their practices, and three key themes were identified on the implementation of digital practice: 1) technological advancement and scientific evidence; 2) marketplace, economic, and operational factors; and 3) industry mindset shift in embracing DT practice.

CONCLUSION

A collaborative effort involving academia, healthcare institutions, vendors, and individual practitioners will be required to facilitate the widespread adoption of DT in O&P. More work is required to overcome challenges from the technical, logistical, and cultural aspects.

Visual Haptic Feedback for Training of Robotic Suturing

Current surgical robotic systems are teleoperated and do not have force feedback. Considerable practice is required to learn how to use visual input such as tissue deformation upon contact as a substitute for tactile sense. Thus, unnecessarily high forces are observed in novices, prior to specific robotic training, and visual force feedback studies demonstrated reduction of applied forces. Simulation exercises with realistic suturing tasks can provide training outside the operating room. This paper presents contributions to realistic interactive suture simulation for training of suturing and knot-tying tasks commonly used in robotically-assisted surgery. To improve the realism of the simulation, we developed a global coordinate wire model with a new constraint development for the elongation. We demonstrated that a continuous modeling of the contacts avoids instabilities during knot tightening. Visual cues are additionally provided, based on the computation of mechanical forces or constraints, to support learning how to dose the forces. The results are integrated into a powerful system-agnostic simulator, and the comparison with equivalent tasks performed with the da Vinci Xi system confirms its realism.

Factors affecting the learning curve in robotic colorectal surgery

Learning related to robotic colorectal surgery can be measured by surgical process (such as time or adequacy of resection) or patient outcome (such as morbidity or quality of life). Time based metrics are the most commonly used variables to assess the learning curve because of ease of analysis. With analysis of the learning curve, there are factors which need to be considered because they may have a direct impact on operative times or may be surrogate markers of clinical effectiveness (unrelated to times). Variables which may impact on operation time include surgery case mix, hybrid technique, laparoscopic and open colorectal surgery experience, robotic surgical simulator training, technology, operating room team, and case complexity. Multidimensional analysis can address multiple indicators of surgical performance and include variables such as conversion rate, complications, oncological outcome and functional outcome. Analysis of patient outcome and/or global assessment of robotic skills may be the most reliable methods to assess the learning curve.

A Cylindrical Grip Type of Tactile Device Using Magneto-Responsive Materials Integrated with Surgical Robot Console: Design and Analysis

This paper proposes a cylindrical grip type of tactile device that is effectively integrated to a surgical robot console so that a surgeon can easily touch and feel the same stiffness as the operating organs. This is possible since the yield stress (or stiffness) of magnetic-responsive materials can be tuned or controlled by the magnetic field intensity. The proposed tactile device consists of two main parts: a magnetorheological elastomer (MRE) layer and a magnetorheological fluid (MRF) core. The grip shape of the device to be positioned on the handle part of the master of the surgical robot is configured and its operating principle is discussed. Then, a couple of equations to calculate the stiffness from the gripping force and the field-dependent yield stress of MRF are derived and integrated using the finite element analysis (FEA) model. After simulating the stiffness of the proposed tactile device as a function of the magnetic field intensity (or current), the stiffnesses of various human organs, including the liver and heart, are calculated from known data of an elastic modulus. It is demonstrated from comparative data between calculated stiffness from human tissues and simulated stiffness from FEA that the proposed tactile device can generate sufficient stiffness with a low current level to recognize various human organs which are significantly required in the surgical robot system.

INFLUENCE OF MINIMALLY INVASIVE LAPAROSCOPIC EXPERIENCE SKILLS ON ROBOTIC SURGERY DEXTERITY

Background:

It is unclear if there is a natural transition from laparoscopic to robotic surgery with transfer of abilities.

Aim:

To measure the performance and learning of basic robotic tasks in a simulator of individuals with different surgical background.

Methods:

Three groups were tested for robotic dexterity: a) experts in laparoscopic surgery (n=6); b) experts in open surgery (n=6); and c) non-medical subjects (n=4). All individuals were aged between 40-50 years. Five repetitions of four different simulated tasks were performed: spatial vision, bimanual coordination, hand-foot-eye coordination and motor skill.

Results:

Experts in laparoscopic surgery performed similar to non-medical individuals and better than experts in open surgery in three out of four tasks. All groups improved performance with repetition.

Conclusion:

Experts in laparoscopic surgery performed better than other groups but almost equally to non-medical individuals. Experts in open surgery had worst results. All groups improved performance with repetition.

Performance with robotic surgery versus 3D- and 2D-laparoscopy during pancreatic and biliary anastomoses in a biotissue model: pooled analysis of two randomized trials

BACKGROUND

Robotic surgery may improve surgical performance during minimally invasive pancreatoduodenectomy as compared to 3D- and 2D-laparoscopy but comparative studies are lacking. This study assessed the impact of robotic surgery versus 3D- and 2D-laparoscopy on surgical performance and operative time using a standardized biotissue model for pancreatico- and hepatico-jejunostomy using pooled data from two randomized controlled crossover trials (RCTs).

METHODS

Pooled analysis of data from two RCTs with 60 participants (36 surgeons, 24 residents) from 11 countries (December 2017-July 2019) was conducted. Each included participant completed two pancreatico- and two hepatico-jejunostomies in biotissue using 3D-robotic surgery, 3D-laparoscopy, or 2D-laparoscopy. Primary outcomes were the objective structured assessment of technical skills (OSATS: 12-60) rating, scored by observers blinded for 3D/2D and the operative time required to complete both anastomoses. Sensitivity analysis excluded participants with excess experience compared to others.

RESULTS

A total of 220 anastomoses were completed (robotic 80, 3D-laparoscopy 70, 2D-laparoscopy 70). Participants in the robotic group had less surgical experience [median 1 (0-2) versus 6 years (4-12), p < 0.001], as compared to the laparoscopic group. Robotic surgery resulted in higher OSATS ratings (50, 43, 39 points, p = .021 and p < .001) and shorter operative time (56.5, 65.0, 81.5 min, p = .055 and p < .001), as compared to 3D- and 2D-laparoscopy, respectively, which remained in the sensitivity analysis.

CONCLUSION

In a pooled analysis of two RCTs in a biotissue model, robotic surgery resulted in better surgical performance scores and shorter operative time for biotissue pancreatic and biliary anastomoses, as compared to 3D- and 2D-laparoscopy.

Reducing retraction forces with tactile feedback during robotic total mesorectal excision in a porcine model

Excessive tissue-instrument interaction forces during robotic surgery have the potential for causing iatrogenic tissue damages. The current in vivo study seeks to assess whether tactile feedback could reduce intraoperative tissue-instrument interaction forces during robotic-assisted total mesorectal excision. Five subjects, including three experts and two novices, used the da Vinci robot to perform total mesorectum excision in four pigs. The grip force in the left arm, used for retraction, and the pushing force in the right arm, used for blunt pelvic dissection around the rectum, were recorded. Tissue-instrument interaction forces were compared between trials done with and without tactile feedback. The mean force exerted on the tissue was consistently higher in the retracting arm than the dissecting arm (3.72 ± 1.19 vs 0.32 ± 0.36 N, p < 0.01). Tactile feedback brought about significant reductions in average retraction forces (3.69 ± 1.08 N vs 4.16 ± 1.12 N, p = 0.02), but dissection forces appeared unaffected (0.43 ± 0.42 vs 0.37 ± 0.28 N, p = 0.71). No significant differences were found between retraction and dissection forces exerted by novice and expert robotic surgeons. This in vivo animal study demonstrated the efficacy of tactile feedback in reducing retraction forces during total mesorectal excision. Further research is required to quantify the clinical impact of such force reduction.

Force sensing in robot-assisted keyhole endoscopy: A systematic survey

Instrument–tissue interaction forces in minimally invasive surgery (MIS) provide valuable information that can be used to provide haptic perception, monitor tissue trauma, develop training guidelines, and evaluate the skill level of novice and expert surgeons. Force and tactile sensing is lost in many robot-assisted surgery (RAS) systems. Therefore, many researchers have focused on recovering this information through sensing systems and estimation algorithms. This article provides a comprehensive systematic review of the current force sensing research aimed at RAS and, more generally, keyhole endoscopy, in which instruments enter the body through small incisions. Articles published between January 2011 and May 2020 are considered, following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. The literature search resulted in 110 papers on different force estimation algorithms and sensing technologies, sensor design specifications, and fabrication techniques.

The Challenges and Perspectives of the Integration Between Virtual and Augmented Reality and Manual Therapies

Virtual reality (VR) and augmented reality (AR) have been combined with physical rehabilitation and psychological treatments to improve patients' emotional reactions, body image, and physical function. Nonetheless, no detailed investigation assessed the relationship between VR or AR manual therapies (MTs), which are touch-based approaches that involve the manipulation of tissues for relieving pain and improving balance, postural stability and well-being in several pathological conditions. The present review attempts to explore whether and how VR and AR might be integrated with MTs to improve patient care, with particular attention to balance and to fields like chronic pain that need an approach that engages both mind and body. MTs rely essentially on touch to induce tactile, proprioceptive, and interoceptive stimulations, whereas VR and AR rely mainly on visual, auditory, and proprioceptive stimulations. MTs might increase patients' overall immersion in the virtual experience by inducing parasympathetic tone and relaxing the mind, thus enhancing VR and AR effects. VR and AR could help manual therapists overcome patients' negative beliefs about pain, address pain-related emotional issues, and educate them about functional posture and movements. VR and AR could also engage and change the sensorimotor neural maps that the brain uses to cope with environmental stressors. Hence, combining MTs with VR and AR could define a whole mind-body intervention that uses psychological, interoceptive, and exteroceptive stimulations for rebalancing sensorimotor integration, distorted perceptions, including visual, and body images. Regarding the technology needed to integrate VR and AR with MTs, head-mounted displays could be the most suitable devices due to being low-cost, also allowing patients to follow VR therapy at home. There is enough evidence to argue that integrating MTs with VR and AR could help manual therapists offer patients better and comprehensive treatments. However, therapists need valid tools to identify which patients would benefit from VR and AR to avoid potential adverse effects, and both therapists and patients have to be involved in the development of VR and AR applications to define truly patient-centered therapies. Furthermore, future studies should assess whether the integration between MTs and VR or AR is practically feasible, safe, and clinically useful.

Mixed reality applications in urology: Requirements and future potential

Background

Mixed reality (MR), the computer-supported augmentation of a real environment with virtual elements, becomes ever more relevant in the medical domain, especially in urology, ranging from education and training over surgeries. We aimed to review existing MR technologies and their applications in urology.

Methods

A non-systematic review of current literature was performed using the PubMed-Medline database using the medical subject headings (MeSH) term “mixed reality”, combined with one of the following terms: “virtual reality”, “augmented reality”, ‘’urology’’ and “augmented virtuality”. The relevant studies were utilized.

Results

MR applications such as MR guided systems, immersive VR headsets, AR models, MR-simulated ureteroscopy and smart glasses have enormous potential in education, training and surgical interventions of urology. Medical students, urology residents and inexperienced urologists can gain experience thanks to MR technologies. MR applications are also used in patient education before interventions.

Conclusions

For surgical support, the achievable accuracy is often not sufficient. The main challenges are the non-rigid nature of the genitourinary organs, intraoperative data acquisition, online and multimodal registration and calibration of devices. However, the progress made in recent years is tremendous in all respects and the gap is constantly shrinking.

∙

MR, including AV and AR, is an intriguing technology with tremendous potential in urology field.

∙The main challenges lie in intraoperative data acquisition, online and multimodal registration and calibration of devices and data, appropriate display hardware, as well as cooperative devices and tools in the operation theatres.

∙Medical experts should feel encouraged to experience MR solutions and to communicate their specific needs and effects they aim at.

Robotic colorectal surgery and ergonomics

Improved ergonomics for the operating surgeon may be an advantage of robotic colorectal surgery. Perceived robotic ergonomic advantages in visualisation include better exposure, three-dimensional vision, surgeon camera control, and line of sight screen location. Postural advantages include seated position and freedom from the constraints of the sterile operating field. Manipulation benefits include articulated instruments with seven degrees of freedom movement, elimination of fulcrum effect, tremor filtration, and scaling of movement. Potential ergonomic detriments of robotic surgery include lack of haptic feedback, visual, and mental strain from increased operating time and interruptions to workflow from crowding.

Haptic-Enabled Hand Rehabilitation in Stroke Patients: A Scoping Review

There is a plethora of technology-assisted interventions for hand therapy, however, less is known about the effectiveness of these interventions. This scoping review aims to explore studies about technology-assisted interventions targeting hand rehabilitation to identify the most effective interventions. It is expected that multifaceted interventions targeting hand rehabilitation are more efficient therapeutic approaches than mono-interventions. The scoping review will aim to map the existing haptic-enabled interventions for upper limb rehabilitation and investigates their effects on motor and functional recovery in patients with stroke. The methodology used in this review is based on the Arksey and O’Malley framework, which includes the following stages: identifying the research question, identifying relevant studies, study selection, charting the data, and collating, summarizing, and reporting the results. Results show that using three or four different technologies was more positive than using two technologies (one technology + haptics). In particular, when standardized as a percentage of outcomes, the combination of three technologies showed better results than the combination of haptics with one technology or with three other technologies. To conclude, this study portrayed haptic-enabled rehabilitation approaches that could help therapists decide which technology-enabled hand therapy approach is best suited to their needs. Those seeking to undertake research and development anticipate further opportunities to develop haptic-enabled hand telerehabilitation platforms.

Tool-tissue forces in surgery: A systematic review

Background

Excessive tool-tissue interaction forces often result in tissue damage and intraoperative complications, while insufficient forces prevent the completion of the task. This review sought to explore the tool-tissue interaction forces exerted by instruments during surgery across different specialities, tissues, manoeuvres and experience levels.

Materials & methods

A PRISMA-guided systematic review was carried out using Embase, Medline and Web of Science databases.

Results

Of 462 articles screened, 45 studies discussing surgical tool-tissue forces were included. The studies were categorized into 9 different specialities with the mean of average forces lowest for ophthalmology (0.04N) and highest for orthopaedic surgery (210N). Nervous tissue required the least amount of force to manipulate (mean of average: 0.4N), whilst connective tissue (including bone) required the most (mean of average: 45.8). For manoeuvres, drilling recorded the highest forces (mean of average: 14N), whilst sharp dissection recorded the lowest (mean of average: 0.03N). When comparing differences in the mean of average forces between groups, novices exerted 22.7% more force than experts, and presence of a feedback mechanism (e.g. audio) reduced exerted forces by 47.9%.

Conclusions

The measurement of tool-tissue forces is a novel but rapidly expanding field. The range of forces applied varies according to surgical speciality, tissue, manoeuvre, operator experience and feedback provided. Knowledge of the safe range of surgical forces will improve surgical safety whilst maintaining effectiveness. Measuring forces during surgery may provide an objective metric for training and assessment. Development of smart instruments, robotics and integrated feedback systems will facilitate this.

•

This review explores tool-tissue forces during surgery, a new and expanding field.

•

Forces were lowest in ophthalmology (0.04N) and highest in orthopaedics (210N).

•

Forces were lowest during sharp dissection (0.03N) and highest when drilling (14N).

•

Being an expert (vs. novice) and having feedback mechanisms (e.g. haptic) reduced exerted forces.

•

Development of force metrics will facilitate training, assessment & novel technology.

Transoral robotic surgery in Ireland: the beginning

BACKGROUND

Transoral robotic surgery (TORS) has shown promising results in the treatment of myriad head and neck pathologies but is now most commonly used in the investigation and management of oropharyngeal squamous cell carcinoma.

AIMS

The aim of this study was to report our cases of the newly introduced TORS, particularly its role in identifying primary of unknown origin and the potential implications for patients. A literature review and our early experience should begin to debunk some of the criticisms of TORS including setup times and cost.

METHODS

Prospective data was collected from all patients undergoing transoral robotic surgery including demographics, indication, histology results in primary of unknown origin and complications.

RESULTS

We have performed 36 TORS procedures in total ranging from intermediate to major complex. Our complication rate is low, and this has improved with the passage of time. Haemorrhage rates remain at 5.6% (n = 2), and the average length of stay is 1 day. Successful identification of a primary tumour in cancer of unknown primary was 80% (n = 8).

CONCLUSIONS

We anticipate the integration of TORS into routine practice in the investigation and management of a number of ENT pathologies following robust clinical trials.

Robotic Surgery in Gastrointestinal Surgery

Robotic surgery is expanding in the minimally invasive treatment of gastrointestinal cancer. In the field of gastrointestinal cancer, robotic surgery is performed using a robot-assisted surgery system. In this system, the robot does not operate automatically but is controlled by the surgeon. The surgery assistant robot currently used in clinical practice worldwide is the leader-follower type, including the da Vinci® Surgical System (Intuitive Surgical). This review describes the current state of robotic surgery in the treatment of gastrointestinal cancer and discusses the future development of robotic systems in gastrointestinal surgery.

Is it possible to continue academic teaching in surgery during the COVID pandemic era?

In the era of the novel coronavirus (COVID-19) pandemic, we critically appraised the literature by means of a systematic review on surgical education and propose an educational curriculum with the aid of available technologies. We performed a literature search on 10 May 2020 of Medline/PubMed, Embase, Google Scholar and major journals with specific COVID-19 sections. Articles eligible for inclusion contained the topic of education in surgery in the context of COVID-19. Specific questions we aimed to answer were: Is there any difference in surgical education from pre-COVID-19 to now? How does technology assist us in teaching? Can we better harness technology to augment resident training? Two-hundred and twenty-six articles were identified, 21 relevant for our aim: 14 case studies, three survey analyses, three reviews and one commentary. The collapse of the traditional educational system due to social distancing caused a fragmentation of knowledge, a reduced acquisition of skills and a decreased employment of surgical trainees. These problems can be partially overcome by using new technologies and arranging 2-weeks rotation shifts, alternating clinical activities with learning. While medical care will remain largely based on the interaction with patients, students' adaptability to innovation will be a characteristic of post-COVID classes.

Analysis of performance factors in 240 consecutive cases of robot-assisted flexible ureteroscopic stone treatment

Flexible ureteroscopy is the keystone of modern kidney stone treatment. Although a simple surgical technique achieves good clinical results and a low complication rate, there are high demands on the surgeon's dexterity and ergonomic restrictions. Robotic-assisted flexible ureteroscopy (rfURS) could overcome these limitations. After 4 years of use of rfURS at a tertiary stone center, performance factors were analyzed to define the role of rfURS in kidney stone management. A rfURS system was installed in August 2014 at the SLK Kliniken (Heilbronn, Germany). Treatment data of N = 240 consecutive patients undergoing rfURS were prospectively collected and analyzed. The patient cohort represents typical stone formers. N = 240 renal units containing 443 stones with an average stone load of 1798 mm³ were treated. Surgical parameters as well as the peri- and postoperative complications were recorded, analyzed and compared to the current data in the literature. OR time 91 min, stone treatment time 55 min, stone treatment efficacy 33 mm³/min; perioperative complications 5.4%; robot times: preparation 5 min, docking 5 min, console time to stone contact 6 min, console time 75 min; postoperative complications 6.7%; postoperative length of stay 1.5 days; stone-free rate (residuals < 2 mm) 90% and re-treatment rate 8.75%. This consecutive series represents real-life data about the utilization of rfURS. The detailed analysis of performance factors revealed the successful utilization of the first generation of robotic systems in endourologic stone surgery, and indicates that the robot performs comparably to conventional flexible URS. Optimal ergonomics maintain the surgeon's endurance in long-lasting surgeries.

Laparoscopic Robotic Surgery: Current Perspective and Future Directions

Just as laparoscopic surgery provided a giant leap in safety and recovery for patients over open surgery methods, robotic-assisted surgery (RAS) is doing the same to laparoscopic surgery. The first laparoscopic-RAS systems to be commercialized were the Intuitive Surgical, Inc. (Sunnyvale, CA, USA) da Vinci and the Computer Motion Zeus. These systems were similar in many aspects, which led to a patent dispute between the two companies. Before the dispute was settled in court, Intuitive Surgical bought Computer Motion, and thus owned critical patents for laparoscopic-RAS. Recently, the patents held by Intuitive Surgical have begun to expire, leading to many new laparoscopic-RAS systems being developed and entering the market. In this study, we review the newly commercialized and prototype laparoscopic-RAS systems. We compare the features of the imaging and display technology, surgeons console and patient cart of the reviewed RAS systems. We also briefly discuss the future directions of laparoscopic-RAS surgery. With new laparoscopic-RAS systems now commercially available we should see RAS being adopted more widely in surgical interventions and costs of procedures using RAS to decrease in the near future.

Adaptive force and velocity control based on intrinsic contact sensing during surface exploration of dynamic objects

Haptic exploration is a process of using haptic feedback to interact and perceive an unknown object. It is an essential approach to understand the physical and geometrical properties of the object. While numerous research has been carried out for haptic exploration on static objects, haptic exploration on objects with dynamic movements has not been reported. It is due to the significant challenges to achieve robust force and velocity control when the object is nonstationary. In this work, a novel adaptive force and velocity control algorithm based on intrinsic contact sensing (ICS) for haptic surface exploration of dynamic objects is presented. A fuzzy-logic control framework making use of the information obtained from ICS has been developed. To validate the proposed control algorithm, extensive surface exploration experiments have been carried out on objects with different surface properties, geometries, stiffness, and concave or convex patterns. The validation results demonstrate the high accuracy and robustness of the proposed algorithm using different experimental platforms.

Haptics in Teleoperated Medical Interventions: Force Measurement, Haptic Interfaces and Their Influence on User's Performance

OBJECTIVES

Haptics in teleoperated medical interventions enables measurement and transfer of force information to the operator during robot-environment interaction. This paper provides an overview of the current research in this domain and guidelines for future investigations.

METHODS

We review current technologies in force measurement and haptic devices as well as their experimental evaluation and influence on user's performance.

RESULTS

Force sensing is moving away from the conventional proximal measurement methods to distal sensing and contact-less methods. Wearable devices that deliver haptic feedback on different body parts are increasingly playing an important role. Performance and accuracy improvement are the widely reported benefits of haptic feedback, while there is a debate on its effect on task completion time and exerted force.

CONCLUSION

With the surge of new ideas, there is a need for better and more systematic validation of the new sensing and feedback technology, through better user studies and novel methods like validated benchmarks and new taxonomies.

SIGNIFICANCE

This review investigates haptics from sensing to interfaces within the context of user's performance and the validation procedures to highlight salient advances. It provides guidelines to future developments and highlights the shortcomings in the field.

The Effect of Haptic Feedback on Efficiency and Safety During Preretinal Membrane Peeling Simulation

Purpose

We determine whether haptic feedback improves surgical performance and outcome during simulated a preretinal membrane peeling procedure.

Methods

A haptic-enabled virtual reality preretinal membrane peeling simulator was developed using a surgical cockpit with two multifinger haptic devices. Six subjects (three trained retina surgeons and three nonsurgeons) performed the preretinal membrane peeling surgical procedure using two modes of operation: visual and haptic feedback, and visual feedback only.

Results

Task completion time, tool tip path trajectory, tool–retina collision force, and retinal damage were all reduced with haptic feedback used and compared to modes where haptic feedback was disabled.

Conclusions

Haptic feedback improves efficiency and safety during preretinal membrane peeling simulation.

Translational Relevance

These findings highlight the potential benefit of haptic feedback for improving performance and safety of vitreoretinal surgery.

The future of robotic surgery

How robotics could help shape the future of surgical care.