Robot-assisted tremor control for performance enhancement of retinal microsurgeons

Bibliometric analysis of research trends and hotspots on robot-assisted thyroid surgery

BACKGROUND

Thyroid surgery involves the partial or complete removal of the thyroid gland and is a frequently performed surgical procedure. The adoption of robots, equipped with flexible and stable operating systems, has garnered acceptance among numerous surgeons for their capability to enable precise anatomical dissection in thyroid surgery. To gain a comprehensive insight into the present research landscape of robot-assisted thyroid surgery, this paper endeavored to conduct a thorough analysis of the field through bibliometric analysis.

METHODS

Relevant literature pertaining to robot-assisted thyroid surgery was retrieved from the Web of Science Core Collection (WOSCC) database, spanning from the inception of WOSCC to October 17, 2022. Visual analyses of publication quantity, distribution across countries/regions, institutions/organizations, authorship, journals, references, and keywords were conducted using Microsoft Excel, the bibliometrix package in R, Citescape, and VOSviewer software.

RESULTS

A total of 505 articles from 406 institutions in 36 countries/regions were included. South Korea emerged with highest number of publications. Notably, Professor CHUNG WY from Yonsei University in South Korea and the journal "Surg Endosc" stood out with the most publications. The current research landscape indicated significant interest in endoscopic thyroidectomy, surgical procedures, and the axillary approach. In addition, transoral robotic thyroidectomy (TROT), and learning curve (LC) were recognized as research frontiers, representing potential future hotspots in this field.

CONCLUSION

This study marks the first bibliometric analysis of the literature on robot-assisted thyroid surgery. The results highlight endoscopic thyroidectomy, surgical procedures, and the axillary approach as current research hotspots, with TROT and LC identified as potential future research hotspots.

Numerical simulation of mechanical properties of epiretinal membrane peeling

An epiretinal membrane (ERM) is a fibrocellular proliferation on the inner surface of the retina causing blurred and distorted central vision. Surgery is the only effective method for ERM removal. This paper investigated the mechanical properties of ERM peeling using the finite element (FE) method. A FE model of ERM formation on the retina surface was constructed. The failure criterion was applied to the attachment pegs to represent the adhesive force between the ERM and retina. The simulation results were consistent with the experimental data in published research. The maximum peeling force was 4.1 mN at a peeling velocity of 2 mm/s and an angle of 30°. The peeling force was minimum at the peeling angle of 45° and increased with the increase in peeling velocity and Young's modulus of the membrane. The outcome of this paper can improve the safety and efficiency of ERM removal.

A Polysomnographic Study of Effects of Sleep Deprivation on Novice and Senior Surgeons during Simulated Vitreoretinal Surgery

PURPOSE

To assess the impact of a 3-hour polysomnography (PSG)-recorded night of sleep deprivation on next-morning simulated microsurgical skills among vitreoretinal (VR) surgeons with different levels of surgical experience and associate the sleep parameters obtained by PSG with Eyesi-generated performance.

DESIGN

Self-controlled cohort study.

PARTICIPANTS

Eleven junior VR surgery fellows with < 2 years of surgical experience and 11 senior surgeons with > 10 years of surgical practice.

METHODS

Surgical performance was assessed at 7am after a 3-hour sleep-deprived night using the Eyesi simulator and compared with each subject's baseline performance.

MAIN OUTCOME MEASURES

Changes in Eyesi-generated score (0-700, worst to best), time for task completion (minutes), tremor-specific score (0-100, worst to best), and out-of-tolerance tremor percentage. Polysomnography was recorded during sleep deprivation.

RESULTS

Novice surgeons had worse simulated surgical performance after sleep deprivation compared with self-controlled baseline dexterity in the total score (559.1 ± 39.3 vs. 593.8 ± 31.7; P = 0.041), time for task completion (13.59 ± 3.87 minutes vs. 10.96 ± 1.95 minutes; P = 0.027), tremor-specific score (53.8 ± 19.7 vs. 70.0 ± 15.3; P = 0.031), and out-of-tolerance tremor (37.7% ± 11.9% vs. 28.0% ± 9.2%; P = 0.031), whereas no performance differences were detected in those parameters among the senior surgeons before and after sleep deprivation (P ≥ 0.05). Time for task completion increased by 26% (P = 0.048) in the post-sleep deprivation simulation sessions for all participants with a high apnea-hypopnea index (AHI) and by 37% (P = 0.008) among surgeons with fragmented sleep compared with those with normal AHI and < 10 arousals per hour, respectively. Fragmented sleep was the only polysomnographic parameter associated with a worse Eyesi-generated score, with a 10% (P = 0.005) decrease the following morning.

CONCLUSIONS

This study detected impaired simulated surgical dexterity among novice surgeons after acute sleep deprivation, whereas senior surgeons maintained their surgical performance, suggesting that the impact of poor sleep quality on surgical skills is offset by increased experience. When considering the 2 study groups together, sleep fragmentation and AHI were associated with jeopardized surgical performance after sleep deprivation.

FINANCIAL DISCLOSURE(S)

The authors have no proprietary or commercial interest in any materials discussed in this article.

Weight-adjusted caffeine and β-blocker use in novice versus senior retina surgeons: a self-controlled study of simulated performance

BACKGROUND/OBJECTIVES

Tremor and expertise are potentially influenced variables in vitreoretinal surgery. We investigated whether surgeon experience impacts the association of microsurgical performance with caffeine and β-blockers weight-adjusted intake.

SUBJECTS/METHODS

Novice and senior surgeons (<2 and >10 practice years, respectively) were recruited in this self-controlled, cross-sectional study. A simulator's task sequence was repeated over 2 days, 30 min after the following exposures: day 1, placebo, 2.5 mg/kg caffeine, 5.0 mg/kg caffeine, and 0.6 mg/kg propranolol; and day 2, placebo, 0.2 mg/kg propranolol, 0.6 mg/kg propranolol, and 5.0 mg/kg caffeine. Outcomes were total score (0-700, worst-best), simulation time (minutes), intraocular trajectory (centimeters), and tremor-specific score (0-100, worst-best).

RESULTS

We recruited 15 novices (9 men [60%], 1.33 ± 0.49 practice years) and 11 seniors (8 men [72.7%], 16.00 ± 4.24 practice years). Novices performed worse after 2.5 mg/kg caffeine and improved following 0.2 mg/kg propranolol in total score (557 vs. 617, p = 0.009), trajectory (229.86 vs. 208.07, p = 0.048), time (14.9 vs. 12.7, p = 0.048), and tremor-score (55 vs. 75, p = 0.009). Surgical performance improved with propranolol post-caffeine but remained worse than 0.2 mg/kg propranolol in total score (570 vs. 617, p = 0.014), trajectory (226.59 vs. 208.07, p = 0.033), and tremor-score (50 vs. 75, p = 0.029). Seniors' tremor-score was lower after 2.5 mg/kg caffeine compared to 0.2 mg/kg propranolol (8 vs. 37, p = 0.015). Tremor-score following propranolol post-caffeine remained inferior to 0.6 mg/kg propranolol alone (17 vs. 38, p = 0.012).

CONCLUSION

While caffeine and propranolol were associated with performance changes among novices, only tremor was affected in seniors, without dexterity changes. The pharmacologic exposure impact on surgical dexterity seems to be offset by increased experience.

Validation of collaborative cyberspace virtual reality oculometry enhanced with near real-time spatial audio

Currently, most medical image data, such as optical coherence tomography (OCT) images, are displayed in two dimensions on a computer screen. Advances in computer information technology have contributed to the growing storage of these data in electronic form. However, the data are usually processed only locally on site. To overcome such hurdles, a cyberspace virtual reality (csVR) application was validated, in which interactive OCT data were presented simultaneously to geographically distant sites (Lucerne, London, and Barcelona) where three graders independently measured the ocular csVR OCT diameters. A total of 109 objects were measured, each three times, resulting in a total of 327 csVR measurements. A minor mean absolute difference of 5.3 µm was found among the 3 measurements of an object (standard deviation 4.2 µm, coefficient of variation 0.3% with respect to the mean object size). Despite the 5 h of online work, csVR was well tolerated and safe. Digital high-resolution OCT data can be remotely and collaboratively processed in csVR. With csVR, measurements and actions enhanced with spatial audio communication can be made consistently in near real time, even if the users are situated geographically far apart. The proposed visuo-auditory framework has the potential to further boost the convenience of digital medicine toward csVR precision and collaborative medicine.

Adaptative damping assistance in bimanual laparoscopic surgery

PURPOSE

Laparoscopic surgery has demonstrated various advantages for the patients' care, but also presents some difficulties for the surgeons, such as kinematic restrictions. Robotic comanipulation, in which control of instruments is shared between the robot and the surgeon, can provide adaptative damping assistance which allows stabilisation of movements. The objective of the present study was to determine the contribution of this assistance on a bimanual laparoscopic task.

METHODS

Adaptative damping was studied on Peg Transfer task, performed by eighteen surgery-naive subjects. This exercise was repeated seven times without (Classic repetitions) and seven times with comanipulated robots (Robot repetitions), in a randomised order. We measured task performance, using Peg Transfer score; gesture performance, using hand oscillations and travelled distance; eye-tracking movements as an indicator of emergence of expertise. Participants' perceived workload was assessed by NASA TLX questionnaire, and difference in impression between the two conditions by UEQ questionnaire.

RESULTS

Adaptative damping improved gesture performance (oscillations F(1,17) = 23.473, p < 0.001, η² = 0.580), with a statistically significant simple effect on the tool oscillation for both non-dominant (p < 0.001) and dominant hands (p = 0.005), without influencing task performance (mean Peg Transfer score t(17) = 0.920, p = 0.382, d = 0.29), but deteriorating eye-tracking movements associated with emergence of expertise (mean fixation rate per second F(1,17) = 6.318, p = 0.022, η² = 0.271), at the cost of a high perceived workload (NASA TLX score 59.78/100).

CONCLUSION

Assistance by adaptative damping applied by comanipulated robots improved gesture performance during a laparoscopic bimanual task, without impacting task's performance without allowing the emergence of comportments associated with an expertise, and at the cost of a high perceived workload. Further research should investigate this assistance on more precise and clinical tasks performed by professionals.

Motion Smoothness-Based Assessment of Surgical Expertise: The Importance of Selecting Proper Metrics

The smooth movement of hand/surgical instruments is considered an indicator of skilled, coordinated surgical performance. Jerky surgical instrument movements or hand tremors can cause unwanted damages to the surgical site. Different methods have been used in previous studies for assessing motion smoothness, causing conflicting results regarding the comparison among surgical skill levels. We recruited four attending surgeons, five surgical residents, and nine novices. The participants conducted three simulated laparoscopic tasks, including peg transfer, bimanual peg transfer, and rubber band translocation. Tooltip motion smoothness was computed using the mean tooltip motion jerk, logarithmic dimensionless tooltip motion jerk, and 95% tooltip motion frequency (originally proposed in this study) to evaluate their capability of surgical skill level differentiation. The results revealed that logarithmic dimensionless motion jerk and 95% motion frequency were capable of distinguishing skill levels, indicated by smoother tooltip movements observed in high compared to low skill levels. Contrarily, mean motion jerk was not able to distinguish the skill levels. Additionally, 95% motion frequency was less affected by the measurement noise since it did not require the calculation of motion jerk, and 95% motion frequency and logarithmic dimensionless motion jerk yielded a better motion smoothness assessment outcome in distinguishing skill levels than mean motion jerk.

Robot-assisted subretinal injection system: development and preliminary verification

BACKGROUND

To design and develop a surgical robot capable of assisting subretinal injection.

METHODS

A remote center of motion (RCM) mechanical design and a master-slave teleoperation were used to develop and manufacture the assisted subretinal surgery robot (RASR). Ten fresh isolated porcine eyes were divided into the Robot Manipulation (RM) group and Manual Manipulation (MM) group (5 eyes for each group), and subretinal injections were performed by the robot and manual manipulation methods, respectively. A preliminary verification of the robot was performed by comparing the advantages and disadvantages of the robot manipulation and manual manipulation by using optical coherent tomography (OCT), fundus photography, and video motion capture analysis after the surgery.

RESULTS

Both the robot and the manual manipulation were able to perform subretinal injections with a 100% success rate. The OCT results showed that the average subretinal area was 1.548 mm² and 1.461 mm² in the RM and MM groups, respectively (P > 0.05). Meanwhile the volume of subretinal fluid obtained using the retinal map mode built in OCT was not statistically different between the RM and MM groups (P > 0.05). By analyzing the surgical video using Kinovea, a motion capture and analysis software, the results suggest that the mean tremor amplitude of the RM group was 0.3681 pixels (x direction), which was significantly reduced compared to 18.8779 pixels (x direction) in the MM group (P < 0.0001).

CONCLUSION

Robot-assisted subretinal injection system (RASR) is able to finish subretinal injection surgery with better stability and less fatigue than manual manipulation.

Existe espaço para a microcirurgia na cirurgia robótica?

Robotic surgery opened a new era of minimally-invasive procedures, through its improved precision, elimination of tremors, greater degrees of freedom, and other facilitating aspects. The field of robotic microsurgery showed great growth in recent years in particular, since robotics offers a potentially-ideal configuration to perform the sensitive manipulations required in microsurgery. We conducted a systematic review to assess the benefits of robotic surgery and its contributions to microsurgery, comparing it with other surgical techniques used in patients of all age groups. We assessed 25 articles found in the PubMed and Cochrane databases using the terms ' robotic surgery ' AND microsurgery , with a filter for studies published in the last five years, and studies conducted in humans and published in English or Portuguese. We concluded that there is plenty of room for robotic surgery in microsurgery, such as in male infertility procedures, neurological microsurgery, ocular and otological surgeries, and transoral, hepatobiliary, microvascular, plastic and reconstructive surgeries.

A MULTIFACTORIAL APPROACH FOR IMPROVING THE SURGICAL PERFORMANCE OF NOVICE VITREORETINAL SURGEONS

PURPOSE

To quantitatively analyze and compare the novice vitreoretinal surgeons' performance after various types of external exposures.

METHODS

This prospective, self-controlled, cross-sectional study included 15 vitreoretinal fellows with less than 2 years of experience. Surgical performance was assessed using the Eyesi simulator after each exposure: Day 1, placebo, 2.5, and 5 mg/kg caffeine; Day 2, placebo, 0.2, and 0.6 mg/kg propranolol; Day 3, baseline simulation, breathalyzer reading of 0.06% to 0.10% and 0.11% to 0.15% blood alcohol concentration; Day 4, baseline simulation, push-up sets with 50% and 85% repetition maximum; Day 5, 3-hour sleep deprivation. Eyesi-generated total scores were the main outcome measured (0-700, worst to best).

RESULTS

Performances worsened after increasing alcohol exposure based on the total score (χ2 = 7; degrees of freedom = 2; P = 0.03). Blood alcohol concentration 0.06% to 0.10% and 0.11% to 0.15% was associated with diminished performance compared with improvements after propranolol 0.6 and 0.2 mg/kg, respectively (∆1 = -22 vs. ∆2 = +13; P = 0.02; ∆1 = -43 vs. ∆2 = +23; P = 0.01). Propranolol 0.6 mg/kg was positively associated with the total score, compared with deterioration after 2.5 mg/kg caffeine (∆1 = +7 vs. ∆2 = -13; P = 0.03).

CONCLUSION

Surgical performance diminished dose dependently after alcohol. Caffeine 2.5 mg/kg was negatively associated with dexterity, and performance improved after 0.2 mg/kg propranolol. No changes occurred after short-term exercise or acute 3-hour sleep deprivation.

Can robotics be the future of ophthalmic surgery?

The future of robotic ophthalmologic surgery looks promising. Innovations in robotic technology and artificial intelligence may provide an ideal machine-human interface with planned and precise movements minimizing unwanted tissue damage and improving clinical outcomes.

Epiretinal membrane: A review

The prevalence of epiretinal membrane (ERM) is 7% to 11.8%, with increasing age being the most important risk factor. Although most ERM is idiopathic, common secondary causes include cataract surgery, retinal vascular disease, uveitis and retinal tears. The myofibroblastic pre-retinal cells are thought to transdifferentiate from glial and retinal pigment epithelial cells that reach the retinal surface via defects in the internal limiting membrane (ILM) or from the vitreous cavity. Grading schemes have evolved from clinical signs to ocular coherence tomography (OCT) based classification with associated features such as the cotton ball sign. Features predictive of better prognosis include absence of ectopic inner foveal layers, cystoid macular oedema, acquired vitelliform lesions and ellipsoid and cone outer segment termination defects. OCT-angiography shows reduced size of the foveal avascular zone. Vitrectomy with membrane peeling remains the mainstay of treatment for symptomatic ERMs. Additional ILM peeling reduces recurrence but is associated with anatomical changes including inner retinal dimpling.

Association of Weight-Adjusted Caffeine and β-Blocker Use With Ophthalmology Fellow Performance During Simulated Vitreoretinal Microsurgery

Importance

Vitreoretinal surgery can be technically challenging and is limited by physiologic characteristics of the surgeon. Factors that improve accuracy and precision of the vitreoretinal surgeon are invaluable to surgical performance.

Objectives

To establish weight-adjusted cutoffs for caffeine and β-blocker (propranolol) intake and to determine their interactions in association with the performance of novice vitreoretinal microsurgeons.

Design, Settings, and Participants

This single-blind cross-sectional study of 15 vitreoretinal surgeons who had less than 2 years of surgical experience was conducted from September 19, 2018, to September 25, 2019, at a dry-laboratory setting. Five simulations were performed daily for 2 days. On day 1, performance was assessed after sequential exposure to placebo, low-dose caffeine (2.5 mg/kg), high-dose caffeine (5.0 mg/kg), and high-dose propranolol (0.6 mg/kg). On day 2, performance was assessed after sequential exposure to placebo, low-dose propranolol (0.2 mg/kg), high-dose propranolol (0.6 mg/kg), and high-dose caffeine (5.0 mg/kg).

Interventions

Surgical simulation tasks were repeated 30 minutes after masked ingestion of placebo, caffeine, or propranolol pills during the 2 days.

Main Outcomes and Measures

An Eyesi surgical simulator was used to assess surgical performance, which included surgical score (range, 0 [worst] to 700 [best]), task completion time, intraocular trajectory, and tremor rate (range, 0 [worst] to 100 [best]). The nonparametric Friedman test followed by Dunn-Bonferroni post hoc test was applied for multiple comparisons.

Results

Of 15 vitreoretinal surgeons, 9 (60%) were male, with a mean (SD) age of 29.6 (1.4) years and mean (SD) body mass index (calculated as weight in kilograms divided by height in meters squared) of 23.15 (2.9). Compared with low-dose propranolol, low-dose caffeine was associated with a worse total surgical score (557.0 vs 617.0; difference, -53.0; 95% CI, -99.3 to -6.7; P = .009), a lower antitremor maneuver score (55.0 vs 75.0; difference, -12.0; 95% CI, -21.2 to -2.8; P = .009), longer intraocular trajectory (2298.6 vs 2080.7 mm; difference, 179.3 mm; 95% CI, 1.2-357.3 mm; P = .048), and increased task completion time (14.9 minutes vs 12.7 minutes; difference, 2.3 minutes; 95% CI, 0.8-3.8 minutes; P = .048). Postcaffeine treatment with propranolol was associated with performance improvement; however, surgical performance remained inferior compared with low-dose propranolol alone for total surgical score (570.0 vs 617.0; difference, -51.0; 95% CI, -77.6 to -24.4; P = .01), tremor-specific score (50.0 vs 75.0; difference, -16.0; 95% CI, -31.8 to -0.2; P = .03), and intraocular trajectory (2265.9 mm vs 2080.7 mm; difference, 166.8 mm; 95% CI, 64.1-269.6 mm; P = .03).

Conclusions and Relevance

The findings suggest that performance of novice vitreoretinal surgeons was worse after receiving low-dose caffeine alone but improved after receiving low-dose propranolol alone. Their performance after receiving propranolol alone was better than after the combination of propranolol and caffeine. These results may be helpful for novice vitreoretinal surgeons to improve microsurgical performance.