Steerable catheters for minimally invasive surgery: a review and future directions

A Minimally Invasive Robotic Tissue Palpation Device

OBJECTIVE

Robot-assisted minimally invasive surgery remains limited by the absence of haptic feedback, which surgeons routinely rely on to assess tissue stiffness. This limitation hinders surgeons' ability to identify and treat abnormal tissues, such as tumors, during robotic surgery.

METHODS

To address this challenge, we developed a robotic tissue palpation device capable of rapidly and non-invasively quantifying the stiffness of soft tissues, allowing surgeons to make objective and data-driven decisions during minimally invasive procedures. We evaluated the effectiveness of our device by measuring the stiffness of phantoms as well as lung, heart, liver, and skin tissues obtained from both rats and swine.

RESULTS

Results demonstrated that our device can accurately determine tissue stiffness and identify tumor mimics. Specifically, in swine lung, we determined elastic modulus (E) values of 9.1 ± 2.3, 16.8 ± 1.8, and 26.0 ± 3.6 kPa under different internal pressure of the lungs (PIP) of 2, 25, and 45 cmH2O, respectively. Using our device, we successfully located a 2-cm tumor mimic embedded at a depth of 5 mm in the lung subpleural region. Additionally, we measured E values of 33.0 ± 5.4, 19.2 ± 2.2, 33.5 ± 8.2, and 22.6 ± 6.0 kPa for swine heart, liver, abdominal skin, and muscle, respectively, which closely matched existing literature data.

CONCLUSION/SIGNIFICANCE

Results suggest that our robotic palpation device can be utilized during surgery, either as a stand-alone or additional tool integrated into existing robotic surgical systems, to enhance treatment outcomes by enabling accurate intraoperative identification of abnormal tissue.

Design Optimization of a Hybrid-Driven Soft Surgical Robot with Biomimetic Constraints

The current study investigated the geometry optimization of a hybrid-driven (based on the combination of air pressure and tendon tension) soft robot for use in robot-assisted intra-bronchial intervention. Soft robots, made from compliant materials, have gained popularity for use in surgical interventions due to their dexterity and safety. The current study aimed to design a catheter-like soft robot with an improved performance by minimizing radial expansion during inflation and increasing the force exerted on targeted tissues through geometry optimization. To do so, a finite element analysis (FEA) was employed to optimize the soft robot's geometry, considering a multi-objective goal function that incorporated factors such as chamber pressures, tendon tensions, and the cross-sectional area. To accomplish this, a cylindrical soft robot with three air chambers, three tendons, and a central working channel was considered. Then, the dimensions of the soft robot, including the length of the air chambers, the diameter of the air chambers, and the offsets of the air chambers and tendon routes, were optimized to minimize the goal function in an in-plane bending scenario. To accurately simulate the behavior of the soft robot, Ecoflex 00-50 samples were tested based on ISO 7743, and a hyperplastic model was fitted on the compression test data. The FEA simulations were performed using the response surface optimization (RSO) module in ANSYS software, which iteratively explored the design space based on defined objectives and constraints. Using RSO, 45 points of experiments were generated based on the geometrical and loading constraints. During the simulations, tendon force was applied to the tip of the soft robot, while simultaneously, air pressure was applied inside the chamber. Following the optimization of the geometry, a prototype of the soft robot with the optimized values was fabricated and tested in a phantom model, mimicking simulated surgical conditions. The decreased actuation effort and radial expansion of the soft robot resulting from the optimization process have the potential to increase the performance of the manipulator. This advancement led to improved control over the soft robot while additionally minimizing unnecessary cross-sectional expansion. The study demonstrates the effectiveness of the optimization methodology for refining the soft robot's design and highlights its potential for enhancing surgical interventions.

The State-of-the-Art and Perspectives of Laser Ablation for Tumor Treatment

Tumors significantly impact individuals' physical well-being and quality of life. With the ongoing advancements in optical technology, information technology, robotic technology, etc., laser technology is being increasingly utilized in the field of tumor treatment, and laser ablation (LA) of tumors remains a prominent area of research interest. This paper presents an overview of the recent progress in tumor LA therapy, with a focus on the mechanisms and biological effects of LA, commonly used ablation lasers, image-guided LA, and robotic-assisted LA. Further insights and future prospects are discussed in relation to these aspects, and the paper proposed potential future directions for the development of tumor LA techniques.

Injectable hydrogels for personalized cancer immunotherapies

The field of cancer immunotherapy has shown significant growth, and researchers are now focusing on effective strategies to enhance and prolong local immunomodulation. Injectable hydrogels (IHs) have emerged as versatile platforms for encapsulating and controlling the release of small molecules and cells, drawing significant attention for their potential to enhance antitumor immune responses while inhibiting metastasis and recurrence. IHs delivering natural killer (NK) cells, T cells, and antigen-presenting cells (APCs) offer a viable method for treating cancer. Indeed, it can bypass the extracellular matrix and gradually release small molecules or cells into the tumor microenvironment, thereby boosting immune responses against cancer cells. This review provides an overview of the recent advancements in cancer immunotherapy using IHs for delivering NK cells, T cells, APCs, chemoimmunotherapy, radio-immunotherapy, and photothermal-immunotherapy. First, we introduce IHs as a delivery matrix, then summarize their applications for the local delivery of small molecules and immune cells to elicit robust anticancer immune responses. Additionally, we discuss recent progress in IHs systems used for local combination therapy, including chemoimmunotherapy, radio-immunotherapy, photothermal-immunotherapy, photodynamic-immunotherapy, and gene-immunotherapy. By comprehensively examining the utilization of IHs in cancer immunotherapy, this review aims to highlight the potential of IHs as effective carriers for immunotherapy delivery, facilitating the development of innovative strategies for cancer treatment. In addition, we demonstrate that using hydrogel-based platforms for the targeted delivery of immune cells, such as NK cells, T cells, and dendritic cells (DCs), has remarkable potential in cancer therapy. These innovative approaches have yielded substantial reductions in tumor growth, showcasing the ability of hydrogels to enhance the efficacy of immune-based treatments. STATEMENT OF SIGNIFICANCE: As cancer immunotherapy continues to expand, the mode of therapeutic agent delivery becomes increasingly critical. This review spotlights the forward-looking progress of IHs, emphasizing their potential to revolutionize localized immunotherapy delivery. By efficiently encapsulating and controlling the release of essential immune components such as T cells, NK cells, APCs, and various therapeutic agents, IHs offer a pioneering pathway to amplify immune reactions, moderate metastasis, and reduce recurrence. Their adaptability further shines when considering their role in emerging combination therapies, including chemoimmunotherapy, radio-immunotherapy, and photothermal-immunotherapy. Understanding IHs' significance in cancer therapy is essential, suggesting a shift in cancer treatment dynamics and heralding a novel period of focused, enduring, and powerful therapeutic strategies.

Compact Design and Task Space Control of a Robotic Transcatheter Delivery System for Mitral Valve Implant

Mitral regurgitation (MR) is one of the most common valvular abnormalities, and the gold-standard for treatment is surgical mitral valve repair/replacement. Most patients with severe MR are over the age of 75, which makes open-heart surgery challenging. Thus, minimally invasive surgeries using transcatheter approaches are gaining popularity. This paper proposes the next generation of a robotic transcatheter delivery system for the mitral valve implant that focuses on the design of the actuation system, modeling, and task space control. The proposed actuation system is compact while still enabling bidirectional torsion, bending, and prismatic joint motion. A pulley structure is employed to actuate the torsion and bending joints using only one motor per joint in conjunction with an antagonistic passive spring to reduce tendon slack. The robotic transcatheter is also optimized to increase its stability and reduce bending deflection. An inverse kinematics model (with an optimization algorithm), singularity analysis method, and joint hysteresis and compensation model are developed and verified. Finally, a task space controller is also proposed. Experiments, including trajectory tracking and demonstrations of the robot motion in an ex vivo porcine heart and a phantom heart through a tortuous path are presented.

A novel polarity configuration for enhancing ablation depth of pulsed field ablation: Design, modeling, and in vivo validation

BACKGROUND

Pulsed field ablation (PFA) has been increasingly used to cut off the delivery of abnormal electrical signals in the treatment of cardiac arrhythmias. A successful cut off requires forming a layer of transmural damage on the heart wall, and this layer depends on the depth of ablation by PFA.

PURPOSE

This study aims to propose a novel polarity configuration of PFA to increase the ablation depth in the treatment of cardiac arrhythmias.

METHOD

A novel polarity configuration was designed for a multi-electrode system, where the number of electrodes is greater than two. The polarity configuration in such multi-electrode system is called the paired-electrode interlaced configuration (PIC). The existing configuration called the single-electrode interlaced configuration (SIC) was used to compare with the PIC. To both the SIC and PIC, a full-SIC or a full-PIC is called when all electrodes (anode, cathode) in a catheter is used otherwise partial-SIC or partial-PIC is called. By the comparison between the full-SIC and full-PIC, the benefit of the PIC was exhibited as opposed to the SIC, but an extra ablation step was added in the PIC in order to form a continuous ablation zone. The other comparative study was taken between a partial-PIC and a partial-SIC with the same number of ablation step. In this study, a rabbit model was built by infusing 0.4% saline solution (at 37°C) into the rabbit's abdominal cavity which surrounds the liver. This model was considered as a biometric environment of the heart, namely cardiac-mimetic model (CMM).

RESULT

The experimental results have shown that the full-PIC is superior to the full-SIC in the ablation depth, specifically in both the maximum (4.14 ± 0.55 mm vs. 3.35 ± 0.26 mm, p < 0.01) and the minimum (3.18 ± 0.29 mm vs. 2.76 ± 0.28 mm, p < 0.05), and in the ablation width, specifically only in the maximum (8.27 ± 0.76 mm vs. 7.09 ± 0.51 mm, p = 0.019) under an identical ablation time (i.e., 5 s). It is noted that the minimum ablation width did not show a significant difference between the full-PIC and full-SIC (specifically, 5.61 ± 0.86 mm vs. 4.67 ± 0.73 mm, p = 0.069). Considering the lethal electric field threshold (LEFT) to be 600 V/cm for liver tissues, the maximum and minimum ablation depth generated by the full-PIC was found larger than that by the full-SIC (3.90 vs. 3.52 mm, and 3.03 vs. 2.48 mm, respectively) in the simulation. Meanwhile, similar experiment results by comparing the partial-PIC and partial-SIC have been obtained, which shows a significant increase in both the maximum ablation depth (4.81 ± 0.87 mm vs. 3.30 ± 0.73 mm, p < 0.001) and the maximum ablation width (8.19 ± 0.85 mm vs. 6.47 ± 1.13 mm, p = 0.001).

CONCLUSIONS

(1) The electric field in the PIC is concentrated around the pair of electrodes, and the pattern of the field is a significant factor in the energy delivery along the direction of the depth. (2) The increase of the ablation depth can significantly expand the range of the tissue on the heart, where the PFA can apply, and can therefore readily form a layer of transmural damage on the heart wall at positions at which the wall is thicker.

Toward a novel soft robotic system for minimally invasive interventions

PURPOSE

During minimally invasive surgery, surgeons maneuver tools through complex anatomies, which is difficult without the ability to control the position of the tools inside the body. A potential solution for a substantial portion of these procedures is the efficient design and control of a pneumatically actuated soft robot system.

METHODS

We designed and evaluated a system to control a steerable catheter tip. A macroscale 3D printed catheter tip was designed to have two separately pressurized channels to induce bending in two directions. A motorized hand controller was developed to allow users to control the bending angle while manually inserting the steerable tip. Preliminary characterization of two catheter tip prototypes was performed and used to map desired angle inputs into pressure commands.

RESULTS

The integrated robotic system allowed both a novice and a skilled surgeon to position the steerable catheter tip at the location of cylindrical targets with sub-millimeter accuracy. The novice was able to reach each target within ten seconds and the skilled surgeon within five seconds on average.

CONCLUSION

This soft robotic system enables its user to simultaneously insert and bend the pneumatically actuated catheter tip with high accuracy and in a short amount of time. These results show promise concerning the development of a soft robotic system that can improve outcomes in minimally invasive interventions.

MRI-Conditional Eccentric-Tube Injection Needle: Design, Fabrication, and Animal Trial

Effective radiation therapy aims to maximize the radiation dose delivered to the tumor while minimizing damage to the surrounding healthy tissues, which can be a challenging task when the tissue-tumor space is small. To eliminate the damage to healthy tissue, it is now possible to inject biocompatible hydrogels between cancerous targets and surrounding tissues to create a spacer pocket. Conventional methods have limitations in poor target visualization and device tracking. In this paper, we leverage our MR-tracking technique to develop a novel injection needle for hydrogel spacer deployment. Herein, we present the working principle and fabrication method, followed by benchtop validation in an agar phantom, and MRI-guided validation in tissue-mimic prostate phantom and sexually mature female swine. Animal trials indicated that the spacer pockets in the rectovaginal septum can be accurately visualized on T2-weighted MRI. The experimental results showed that the vaginal-rectal spacing was successfully increased by 12 ± 2 mm anterior-posterior.

Identification of the Position of a Tethered Delivery Catheter to Retrieve an Untethered Magnetic Robot in a Vascular Environment

In this paper, we propose a method of identifying the position of a tethered delivery catheter in a vascular environment, recombining an untethered magnetic robot (UMR) to the tethered delivery catheter, and safely retrieving them from the vascular environment in an endovascular intervention by utilizing a separable and recombinable magnetic robot (SRMR) and a magnetic navigation system (MNS). From images of a blood vessel and a tethered delivery catheter taken from two different angles, we developed a method of extracting the position of the delivery catheter in the blood vessel by introducing dimensionless cross-sectional coordinates. Then, we propose a retrieval method for the UMR by using the magnetic force considering the delivery catheter's position, suction force, and rotating magnetic field. We used thane MNS and feeding robot to simultaneously apply magnetic force and suction force to the UMR. In this process, we determined a current solution for generating magnetic force by using a linear optimization method. Finally, we conducted in vitro and in vivo experiments to verify the proposed method. In the in vitro experiment, which was in a glass tube environment, by using an RGB camera, we confirmed that the location of the delivery catheter in the glass tube could be recognized within an average error of 0.05 mm in each of the X- and Z-coordinates and that the retrieval success rate was greatly improved in comparison with that in the case without the use of magnetic force. In an in vivo experiment, we successfully retrieved the UMR in the femoral arteries of pigs.

Flexible Needle Steering with Tethered and Untethered Actuation: Current States, Targeting Errors, Challenges and Opportunities

Accurate needle targeting is critical for many clinical procedures, such as transcutaneous biopsy or radiofrequency ablation of tumors. However, targeting errors may arise, limiting the widespread adoption of these procedures. Advances in flexible needle (FN) steering are emerging to mitigate these errors. This review summarizes the state-of-the-art developments of FNs and addresses possible targeting errors that can be overcome with steering actuation techniques. FN steering techniques can be classified as passive and active. Passive steering directly results from the needle-tissue interaction forces, whereas active steering requires additional forces to be applied at the needle tip, which enhances needle steerability. Therefore, the corresponding targeting errors of most passive FNs and active FNs are between 1 and 2 mm, and less than 1 mm, respectively. However, the diameters of active FNs range from 1.42 to 12 mm, which is larger than the passive steering needle varying from 0.5 to 1.4 mm. Therefore, the development of active FNs is an area of active research. These active FNs can be steered using tethered internal direct actuation or untethered external actuation. Examples of tethered internal direct actuation include tendon-driven, longitudinal segment transmission and concentric tube transmission. Tendon-driven FNs have various structures, and longitudinal segment transmission needles could be adapted to reduce tissue damage. Additionally, concentric tube needles have immediate advantages and clinical applications in natural orifice surgery. Magnetic actuation enables active FN steering with untethered external actuation and facilitates miniaturization. The challenges faced in the fabrication, sensing, and actuation methods of FN are analyzed. Finally, bio-inspired FNs may offer solutions to address the challenges faced in FN active steering mechanisms.

Self-folding soft-robotic chains with reconfigurable shapes and functionalities

Magnetic continuum soft robots can actively steer their tip under an external magnetic field, enabling them to effectively navigate in complex in vivo environments and perform minimally invasive interventions. However, the geometries and functionalities of these robotic tools are limited by the inner diameter of the supporting catheter as well as the natural orifices and access ports of the human body. Here, we present a class of magnetic soft-robotic chains (MaSoChains) that can self-fold into large assemblies with stable configurations using a combination of elastic and magnetic energies. By pushing and pulling the MaSoChain relative to its catheter sheath, repeated assembly and disassembly with programmable shapes and functions are achieved. MaSoChains are compatible with state-of-the-art magnetic navigation technologies and provide many desirable features and functions that are difficult to realize through existing surgical tools. This strategy can be further customized and implemented for a wide spectrum of tools for minimally invasive interventions.

Experimental Protocol and Phantom Design and Development for Performance Characterization of Conventional Devices for Peripheral Vascular Interventions

Conventional catheter-based interventions for treating peripheral artery disease suffer high failure and complication rates. The mechanical interactions with the anatomy constrain catheter controllability, while their length and flexibility limit their pushability. Also, the 2D X-ray fluoroscopy guiding these procedures fails to provide sufficient feedback about the device location relative to the anatomy. Our study aims to quantify the performance of conventional non-steerable (NS) and steerable (S) catheters in phantom and ex vivo experiments. In a 10 mm diameter, 30 cm long artery phantom model, with four operators, we evaluated the success rate and crossing time in accessing 1.25 mm target channels, the accessible workspace, and the force delivered through each catheter. For clinical relevance, we evaluated the success rate and crossing time in crossing ex vivo chronic total occlusions. For the S and NS catheters, respectively, users successfully accessed 69 and 31% of the targets, 68 and 45% of the cross-sectional area, and could deliver 14.2 and 10.2 g of mean force. Using a NS catheter, users crossed 0.0 and 9.5% of the fixed and fresh lesions, respectively. Overall, we quantified the limitations of conventional catheters (navigation, reachable workspace, and pushability) for peripheral interventions; this can serve as a basis for comparison with other devices.

New concept in neurovascular navigation: technical description and preclinical experience with the Bendit 17 and Bendit 21 microcatheters in a rabbit aneurysm model

BACKGROUND

Endovascular treatment of intracranial vascular diseases, such as aneurysms, is often challenged by unfavorable vascular anatomy. The Bendit Steerable Microcatheter (Bendit Technologies, Tel Aviv, Israel) has bending and torqueing capabilities designed to improve navigation and stability during device delivery, with or without a guidewire. We describe our preclinical experience with the Bendit 17 and Bendit 21 microcatheters in a rabbit aneurysm model.

METHODS

Bifurcation and side wall aneurysms were created surgically in six New Zealand rabbits. We attempted to navigate Bendit devices through the vasculature and enter the aneurysms without a guidewire. Various positions within the aneurysm were selectively explored. Angiographic imaging was used to visualize catheterization, navigation, vascular manipulations, and placement of coils, stents, and intrasaccular devices.

RESULTS

We successfully navigated the Bendit microcatheters to all aneurysms without a guidewire. We successfully recanalized a nearly occluded carotid artery and navigated the Bendit through a braided stent. In contrast, we were unable to navigate a comparator device with a guidewire as effectively as the Bendit. Coils were introduced at different locations within the aneurysm and could be pushed, pulled, and repositioned with the Bendit tip. Finally, we used the Bendit to deliver intrasaccular devices designed for terminal aneurysms to treat side wall aneurysms.

CONCLUSIONS

Bendit's bending and torqueing abilities, combined with its stability in the bent position, enable quick navigation and optimal deployment of devices. Clinical studies are necessary to determine whether these navigation advantages lead to more efficient treatment of intracranial and peripheral aneurysms.

Magnetically steerable catheters: State of the art review

Magnetically steerable catheters (MSCs) have caught the interest of researchers due to their various potential uses in clinical applications, for example, minimally invasive surgery. Many significant advances in the design, implementation and analysis of MSCs have been accomplished in the last decade. This review concentrates on the configurations of current MSCs with an in depth look at control of the device and the specific workspace. This review also evaluates MSCs and references possible future system designs and difficulties. The concept of magnetic manipulation is briefly presented. Then, by category, the MSC is introduced. Following that, a discussion of future works and challenges of the review systems is provided. The conclusions are finally addressed.

Highly Integrated Multi-Material Fibers for Soft Robotics

Soft robots are envisioned as the next generation of safe biomedical devices in minimally invasive procedures. Yet, the difficulty of processing soft materials currently limits the size, aspect-ratio, manufacturing throughput, as well as, the design complexity and hence capabilities of soft robots. Multi-material thermal drawing is introduced as a material and processing platform to create soft robotic fibers imparted with multiple actuations and sensing modalities. Several thermoplastic and elastomeric material options for the fibers are presented, which all exhibit the rheological processing attributes for thermal drawing but varying mechanical properties, resulting in adaptable actuation performance. Moreover, numerous different fiber designs with intricate internal architectures, outer diameters of 700 µm, aspect ratios of 10³ , and a fabrication at a scale of 10s of meters of length are demonstrated. A modular tendon-driven mechanism enables 3-dimensional (3D) motion, and embedded optical guides, electrical wires, and microfluidic channels give rise to multifunctionality. The fibers can perceive and autonomously adapt to their environments, as well as, probe electrical properties, and deliver fluids and mechanical tools to spatially distributed targets.

Effects of a Fluoroscopy Agent on Radio Opacity and Steering Performance of Pressure-Driven Steerable Micro Guidewire

This paper presents experimental results of effects of a fluoroscopy agent on the radio opacity and steering performance of the steerable micro guidewire. The guidewire is driven by internal pressure, and made of the silicone polymer mixed with the barium sulfate, BaSO₄, masterbatch. Steerable distal tips with different BaSO₄ densities up to 30 % are fabricated. The radio opacity is measured by comparing CT (computed tomography) numbers of the steerable distal tips. The steering performance is measured by the bending angle at particular internal pressures while being bent up to 180 0. Experiment results show that the radio opacity improves while the bending stiffness decreases as the concentration of the barium sulfate increases.

Visual servoing of continuum robots: Methods, challenges, and prospects

BACKGROUND

Recent advancements in continuum robotics have accentuated developing efficient and stable controllers to handle shape deformation and compliance. The control of continuum robots (CRs) using physical sensors attached to the robot, particularly in confined spaces, is difficult due to their limited accuracy in three-dimensional deflections and challenging localisation. Therefore, using non-contact imaging sensors finds noticeable importance, particularly in medical scenarios. Accordingly, given the need for direct control of the robot tip and notable uncertainties in the kinematics and dynamics of CRs, many papers have focussed on the visual servoing (VS) of CRs in recent years.

METHODS

The significance of this research towards safe human-robot interaction has fuelled our survey on the previous methods, current challenges, and future opportunities.

RESULTS

Beginning with actuation modalities and modelling approaches, the paper investigates VS methods in medical and non-medical scenarios.

CONCLUSIONS

Finally, challenges and prospects of VS for CRs are discussed, followed by concluding remarks.

Current Advances and Future Perspectives of Advanced Polymer Processing for Bone and Tissue Engineering: Morphological Control and Applications

Advanced polymer processing has received extensive attention due to its unique control of complex force fields and customizability, and has been widely applied in various fields, especially in preparation of functional devices for bioengineering and biotechnology. This review aims to provide an overview of various advanced polymer processing techniques including rotation extrusion, electrospinning, micro injection molding, 3D printing and their recent progresses in the field of cell proliferation, bone repair, and artificial blood vessels. This review dose not only attempts to provide a comprehensive understanding of advanced polymer processing, but also aims to guide for design and fabrication of next-generation device for biomedical engineering.

Reprogrammable Soft Swimmers for Minimally Invasive Thrombus Extraction

Thrombosis-related diseases are the primary cause of death in the world. Despite recent advances in thrombosis treatment methods, their invasive nature remains a crucial factor, which leads to considerable deadly consequences. Soft magnetic robots are attracting widespread interest due to their fast response, remote actuation, and shape reprogrammability and can potentially avoid the side effects of conventional approaches. This paper outlines a new approach to the thrombosis treatment via reprogrammable magnetic soft robots that penetrate, hook, and extract the plasma clots in a vein-mimicking system under applied rotating magnetic fields. We present shape-switching bioinspired soft swimmers, capable of locomotion by different mechanisms in vein-mimicking flow conditions and whose swimming efficiency is similar to animals. Further, we demonstrate the potential of a developed robot for minimally invasive thromboextraction with and without fibrinolytic usage, including hooking the plasma clot for 3.1 ± 1.1 min and extracting it from the vein-mimicking system under the applied magnetic fields. We consider an interesting solution for thrombosis treatment to avoid substantial drawbacks of the existing methods.

Physics-Informed Modeling and Control of Multi-Actuator Soft Catheter Robots

Catheter-based endovascular interventional procedures have become increasingly popular in recent years as they are less invasive and patients spend less time in the hospital with less recovery time and less pain. These advantages have led to a significant growth in the number of procedures that are performed annually. However, it is still challenging to position a catheter in a target vessel branch within the highly complicated and delicate vascular structure. In fact, vessel tortuosity and angulation, which cause difficulties in catheterization and reaching the target site, have been reported as the main causes of failure in endovascular procedures. Maneuverability of a catheter for intravascular navigation is a key to reaching the target area; ability of a catheter to move within the target vessel during trajectory tracking thus affects to a great extent the length and success of the procedure. To address this issue, this paper models soft catheter robots with multiple actuators and provides a time-dependent model for characterizing the dynamics of multi-actuator soft catheter robots. Built on this model, an efficient and scalable optimization-based framework is developed for guiding the catheter to pass through arteries and reach the target where an aneurysm is located. The proposed framework models the deflection of the multi-actuator soft catheter robot and develops a control strategy for movement of catheter along a desired trajectory. This provides a simulation-based framework for selection of catheters prior to endovascular catheterization procedures, assuring that given a fixed design, the catheter is able to reach the target location. The results demonstrate the benefits that can be achieved by design and control of catheters with multiple number of actuators for navigation into small vessels.

Hyper-Redundant Manipulator Capable of Adjusting Its Non-Uniform Curvature with Discrete Stiffness Distribution

Hyper-redundant manipulators are widely used in minimally invasive surgery because they can navigate through narrow passages in passive compliance with the human body. Although their stability and dexterity have been significantly improved over the years, we need manipulators that can bend with appropriate curvatures and adapt to complex environments. This paper proposes a design principle for a manipulator capable of adjusting its non-uniform curvature and predicting the bending shape. Rigid segments were serially stacked, and elastic fixtures in the form of flat springs were arranged between hinged-slide joint segments. A manipulator with a diameter of 4.5 mm and a length of 28 mm had been fabricated. A model was established to predict the bending shape through minimum potential energy theory, kinematics, and measured stiffnesses of the flat springs. A comparison of the simulation and experimental results indicated an average position error of 3.82% of the endpoints when compared to the total length. With this modification, the manipulator is expected to be widely used in various fields such as small endoscope systems and single-port robot systems.

Can the Shape of a Planar Pathway Be Estimated Using Proximal Forces of Inserting a Flexible Shaft?

The shape information of flexible endoscopes or other continuum structures, e.g., intro-vascular catheters, is needed for accurate navigation, motion compensation, and haptic feedback in robotic surgical systems. Existing methods rely on optical fiber sensors, electromagnetic sensors, or expensive medical imaging modalities such as X-ray fluoroscopy, magnetic resonance imaging, and ultrasound to obtain the shape information of these flexible medical devices. Here, we propose to estimate the shape/curvature of a continuum structure by measuring the force required to insert a flexible shaft into the internal channel/pathway of the continuum. We found that there is a consistent correlation between the measured insertion force and curvature of the planar continuum pathway. A testbed was built to insert a flexible shaft into a planar continuum pathway with adjustable shapes. The insertion forces, insertion displacement, and the shapes of the pathway were recorded. A neural network model was developed to model this correlation based on the training data collected on the testbed. The trained model, tested on the testing data, can accurately estimate the curvature magnitudes and the accumulated bending angles of the pathway simply based on the measured insertion force at the proximal end of the shaft. The approach may be used to estimate the curvature magnitudes and accumulated bending angles of flexible endoscopic surgical robots or catheters for accurate motion compensation, haptic force feedback, localization, or navigation. The advantage of this approach is that the employed proximal force can be easily obtained outside the pathway or continuum structure without any embedded sensor in the continuum structure. Future work is needed to further investigate the correlation between insertion forces and the pathway and enhance the capability of the model in estimating more complex shapes, e.g., spatial shapes with multiple bends.

Magnetically Guided Catheters, Micro- and Nanorobots for Spinal Cord Stimulation

Spinal cord stimulation (SCS) is an established treatment for refractory pain syndromes and has recently been applied to improve locomotion. Several technical challenges are faced by surgeons during SCS lead implantation, particularly in the confined dorsal epidural spaces in patients with spinal degenerative disease, scarring and while targeting challenging structures such as the dorsal root ganglion. Magnetic navigation systems (MNS) represent a novel technology that uses externally placed magnets to precisely steer tethered and untethered devices. This innovation offers several benefits for SCS electrode placement, including enhanced navigation control during tip placement, and the ability to position and reposition the lead in an outpatient setting. Here, we describe the challenges of SCS implant surgery and how MNS can be used to overcome these hurdles. In addition to tethered electrode steering, we discuss the navigation of untethered micro- and nanorobots for wireless and remote neuromodulation. The use of these small-scale devices can potentially change the current standard of practice by omitting the need for electrode and pulse generator implantation or replacement. Open questions include whether small-scale robots can generate an electrical field sufficient to activate neuronal tissue, as well as testing precise navigation, placement, anchoring, and biodegradation of micro- and nanorobots in the in vivo environment.

Physician-modified Steerable Endovascular Catheter

We demonstrate a simple, intraoperative modification to a 65 cm Beacon Tip Kumpe catheter (Cook Medical) using readily-available components in order to increase its functionality during endovascular procedures. The steerable endovascular catheter has near-spherical range, improving accessibility to challenging anatomy over conventional catheters as demonstrated by our qualitative modeling. In addition, the modification provides structural reinforcement at the catheter tip leading to precise wire advancement. Use of the steerable catheter was demonstrated in vivo during contralateral gate cannulation of an endovascular aneurysm repair, however it holds broad applications in visceral, branched and fenestrated cannulations. Physician-modified devices offer the potential to improve endovascular techniques and reduce additional procedure costs while avoiding regulatory board approval required of novel steerable endovascular devices.

In-vivo mechanical characterization of coronary atherosclerotic plaques in living swine using intravascular laser speckle imaging

The ability to evaluate the viscoelastic properties of coronary arteries is crucial for identifying mechanically unstable atherosclerotic plaques. Here, we demonstrate for the first time in living swine, the capability of intravascular laser speckle imaging (ILSI) to measure an index of coronary plaque viscoelasticity, τ, using a human coronary to swine xenograft model. Cardiac motion effects are evaluated by comparing the EKG-non-gated τ ¯ N G , and EKG-gated τ ¯ G among different plaque types. Results show that both τ ¯ N G and τ ¯ G are significantly lower in necrotic-core plaques compared with stable lesions. Discrete-point pullback measurements demonstrate the capability of ILSI for rapid mechanical characterization of coronary segments under physiological conditions, in-vivo.

Millimeter-Scale Soft Continuum Robots for Large-Angle and High-Precision Manipulation by Hybrid Actuation

Developing small-scale soft continuum robots with large-angle steering capacity and high-precision manipulation offers broad opportunities in various biomedical settings. However, existing continuum robots reach the bottleneck in actuation on account of the contradiction among small size, compliance actuation, large tender range, high precision, and small dynamic error. Herein, a 3D-printed millimeter-scale soft continuum robot with an ultrathin hollow skeleton wall (300 μm) and a large inner-to-outer ratio (0.8) is reported. After coating a thin ferromagnetic elastomer layer (≈100-150 μm), the proposed soft continuum robot equipped with hybrid actuation (tendon- and magnetic-driven mode) achieves large-angle (up to 100°) steering and high-precision (low to 2 μm for static positioning) micromanipulation simultaneously. Specifically, the robot implements an ultralow dynamic tracking error of ≈10 μm, which is ≈30-fold improved than the state of art. Combined with a microneedle/knife or nasopharyngeal swab, the robot reveals the potential for versatile biomedical applications, such as drug injection on the target tissue, diseased tissue ablation, and COVID-19 nasopharyngeal sampling. The proposed millimeter-scale soft continuum robot presents remarkable advances in large-range and high-precise actuation, which provides a new method for miniature continuum robot design and finds broad applications in biomedical engineering.

Recent Advances in Design and Actuation of Continuum Robots for Medical Applications

Traditional rigid robot application in the medical field is limited due to the limited degrees of freedom caused by their material and structure. Inspired by trunk, tentacles, and snakes, continuum robot (CR) could traverse confined space, manipulate objects in complex environment, and conform to curvilinear paths in space. The continuum robot has broad prospect in surgery due to its high dexterity, which can reach circuitous areas of the body and perform precision surgery. Recently, many efforts have been done by researchers to improve the design and actuation methods of continuum robots. Several continuum robots have been applied in clinic surgical interventions and demonstrated superiorities to conventional rigid-link robots. In this paper, we provide an overview of the current development of continuum robots, including the design principles, actuation methods, application prospect, limitations, and challenge. And we also provide perspective for the future development. We hope that with the development of material science, Engineering ethics, and manufacture technology, new methods can be applied to manufacture continuum robots for specific surgical procedures.

Protrusion mechanism study in sipunculid worms as model for developing bio-inspired linear actuators

The invertebrates ability to adapt to the environment during motion represents an intriguing feature to inspire robotic systems. We analysed the sipunculid speciesPhascolosoma stephensoni(Sipunculidae, Annelida), and quantitatively studied the motion behaviour of this unsegmented worm. The hydrostatic skeleton and the muscle activity make the infaunalP.stephensoniable to extrude part of its body (the introvert) from its burrow to explore the environment by remaining hidden within the rocky substrate where it settled. The introvert protrusion is associated with changes in the body shape while keeping the overall volume constant. In this study, we employed a marker-less optical tracking strategy to quantitatively study introvert protrusion (i.e. kinematics, elongation percentage and forces exerted) in different navigation media. WhenP.stephensonispecimens were free in sea water (outside from the burrow), the worms reached lengths up to three times their initial ones after protrusion. Moreover, they were able to elongate their introvert inside a viscous medium such as agar-based hydrogel. In this case, the organisms were able to break the hydrogel material, exerting forces up to 3 N and then to navigate easily inside it, producing stresses of some tens of kPa. Our measurements can be used as guidelines and specifications to design and develop novel smart robotic systems.

Electrothermally Driven Hydrogel-on-Flex-Circuit Actuator for Smart Steerable Catheters

This paper reports an active catheter-tip device functionalized by integrating a temperature-responsive smart polymer onto a microfabricated flexible heater strip, targeting at enabling the controlled steering of catheters through complex vascular networks. A bimorph-like strip structure is enabled by photo-polymerizing a layer of poly(N-isopropylacrylamide) hydrogel (PNIPAM), on top of a 20 × 3.5 mm² flexible polyimide film that embeds a micropatterned heater fabricated using a low-cost flex-circuit manufacturing process. The heater activation stimulates the PNIPAM layer to shrink and bend the tip structure. The bending angle is shown to be adjustable with the amount of power fed to the device, proving the device’s feasibility to provide the integrated catheter with a controlled steering ability for a wide range of navigation angles. The powered device exhibits uniform heat distribution across the entire PNIPAM layer, with a temperature variation of <2 °C. The operation of fabricated prototypes assembled on commercial catheter tubes demonstrates their bending angles of up to 200°, significantly larger than those reported with other smart-material-based steerable catheters. The temporal responses and bending forces of their actuations are also characterized to reveal consistent and reproducible behaviors. This proof-of-concept study verifies the promising features of the prototyped approach to the targeted application area.