The role of robotic surgery in neurological cases: A systematic review on brain and spine applications

The application of robotic surgery technologies in neurological surgeries resulted in some advantages compared to traditional surgeries, including higher accuracy and dexterity enhancement. Its success in various surgical fields, especially in urology, cardiology, and gynecology surgeries was reported in previous studies, and similar advantages in neurological surgeries are expected. Surgeries in the central nervous system with the pathology of millimeters through small working channels around vital tissue need especially high precision. Applying robotic surgery is therefore an interesting dilemma for these situations. This article reviews various studies published on the application of brain and spine robotic surgery and discusses the current application of robotic technology in neurological cases.

Robotic and robot-assisted skull base neurosurgery: systematic review of current applications and future directions

OBJECTIVE

The utility of robotic instrumentation is expanding in neurosurgery. Despite this, successful examples of robotic implementation for endoscopic endonasal or skull base neurosurgery remain limited. Therefore, the authors performed a systematic review of the literature to identify all articles that used robotic systems to access the sella or anterior, middle, or posterior cranial fossae.

METHODS

A systematic review of MEDLINE and PubMed in accordance with PRISMA guidelines performed for articles published between January 1, 1990, and August 1, 2021, was conducted to identify all robotic systems (autonomous, semiautonomous, or surgeon-controlled) used for skull base neurosurgical procedures. Cadaveric and human clinical studies were included. Studies with exclusively otorhinolaryngological applications or using robotic microscopes were excluded.

RESULTS

A total of 561 studies were identified from the initial search, of which 22 were included following full-text review. Transoral robotic surgery (TORS) using the da Vinci Surgical System was the most widely reported system (4 studies) utilized for skull base and pituitary fossa procedures; additionally, it has been reported for resection of sellar masses in 4 patients. Seven cadaveric studies used the da Vinci Surgical System to access the skull base using alternative, non-TORS approaches (e.g., transnasal, transmaxillary, and supraorbital). Five cadaveric studies investigated alternative systems to access the skull base. Six studies investigated the use of robotic endoscope holders. Advantages to robotic applications in skull base neurosurgery included improved lighting and 3D visualization, replication of more traditional gesture-based movements, and the ability for dexterous movements ordinarily constrained by small operative corridors. Limitations included the size and angulation capacity of the robot, lack of drilling components preventing fully robotic procedures, and cost. Robotic endoscope holders may have been particularly advantageous when the use of a surgical assistant or second surgeon was limited.

CONCLUSIONS

Robotic skull base neurosurgery has been growing in popularity and feasibility, but significant limitations remain. While robotic systems seem to have allowed for greater maneuverability and 3D visualization, their size and lack of neurosurgery-specific tools have continued to prevent widespread adoption into current practice. The next generation of robotic technologies should prioritize overcoming these limitations.

How close are we to anterior robotic skull base surgery?

PURPOSE OF REVIEW

The application of robotic surgery to anterior skull base disease has yet to be defined despite the potential for improved tumour resection with less morbidity in this region. Complex anatomy and restricted access have limited the development of robotic anterior skull base surgery.

RECENT FINDINGS

A limited number of transoral robotic surgical anterior skull base procedures have been undertaken; however, there are significant limitations to the utilization of this technology in the anterior skull base. In this article, the advantages, disadvantages and limitations of robotic anterior skull base surgery are discussed. Currently, the major limitation is the size of the robotic endoscope and of the available instrumentation. Technological advancements that provide promise for the future development of robotic anterior skull base surgery are in development, such as single-port robots, flexible instrument systems and miniaturization and growth of minimally invasive platforms.

SUMMARY

Although transnasal access to the skull base is not possible with the currently available robotic systems, promising technology does exist and is in development. Robotic anterior skull base surgery promises to provide greater access to skull base disease, improve oncologic results, reduce morbidity and to reduce the ergonomic burden on the surgeon.

Robotic Skull Base Surgery

Robotic surgery has become more common in otolaryngologic surgery since the introduction of the da Vinci robotic system, but has played a limited role in anterior and central skull base surgery, largely because of technical limitations of existing robots. Current robotic technology has been used in creative ways to access the skull base, but was not designed to navigate these complex anatomic constraints. Novel robots should target many of the limitations of current robotic technology, such as maneuverability, inability to suture, lack of haptic feedback, and absent integration with image guidance.

Robotic Surgical Approach to the Mesial Temporal Region: A Preliminary Three-Dimensional Cadaveric Study of Technical Feasibility

OBJECTIVE

Robotic surgical systems are used worldwide in various fields. In this study, we present the advantages and disadvantages of the most common robotic surgical system, the da Vinci Xi system, in the supracerebellar transtentorial approach to the mesial temporal region and discuss options for its integration into neurosurgery.

METHODS

Our study was conducted at the Advanced Simulation and Applied Endoscopic Surgery Training and Research Center and Anatomy Laboratory. Four formalin-fixed human cadaveric head specimens with red silicone dye injected into their arterial structures and blue silicone dye injected into their venous structures were used in the study. Dissections were performed in microscopic and robotic stages. All phases were photographed using a three-dimensional photographic technique.

RESULTS

The mesial temporal lobe could be accessed via the supracerebellar transtentorial route with the use of the robotic system. We show that the robotic system can be used in difficult approaches and narrow regions with a wider exposure and superior image quality than with the microscopic approach, improving the ergonomics for the surgeon. The shortcomings of robotic systems are examined and innovative solutions are offered.

CONCLUSIONS

This study shows the advantages and disadvantages of the robotic surgical approach to the mesial temporal region via the supracerebellar transtentorial route. Robotic surgical systems can play a major role in neurosurgical practices with the tools designed and the innovative solutions determined in this study. Nevertheless, further research and development of these systems and related instruments are necessary to ensure their wider implementation in neurosurgery.

Robot-Assisted Simulated Strabismus Surgery

Purpose

This study aims to investigate the feasibility of robot-assisted simulated strabismus surgery using the new da Vinci Xi Surgical System and to report what we believe is the first use of a surgical robot in experimental eye muscle surgery.

Methods

Robot-assisted strabismus surgeries were performed on a strabismus eye model using the robotic da Vinci Xi Surgical System. On the lateral rectus of each eye, we performed a procedure including, successively, a 4-mm plication followed by a 4-mm recession of the muscle to end with a 4-mm resection. Operative time from conjunctival opening to closing and successful completion of the different steps with or without complications or unexpected events were assessed.

Results

Robot-assisted strabismus procedures were successfully performed on six eyes. The feasibility of robot-assisted simulated strabismus surgery is confirmed. The da Vinci Xi system provided the appropriate dexterity and operative field visualization necessary to perform conjunctival and Tenon's capsule opening and closing, muscle identification, suturing, desinsertion, sectioning, and resuturing. The mean duration to complete the whole procedure was 27 minutes (range, 22–35). There were no complications or unexpected intraoperative events.

Conclusions

Experimental robot-assisted strabismus surgery is technically feasible using the new robotic da Vinci Xi Surgical System. This is, to our knowledge, the first use of a surgical robot in ocular muscle surgery.

Translational Relevance

Further experimentation will allow the advantages of robot-assisted microsurgery to be identified while underlining the improvements and innovations necessary for clinical use.

Transoral robotic surgery for sellar tumors: first clinical study

OBJECTIVE

The aim of this study was to confirm the feasibility of an innovative transoral robotic surgery (TORS), using the da Vinci Surgical System, for patients with sellar tumors. This technique was designed to offer a new minimally invasive approach, without soft-palate splitting, that avoids the rhinological side effects of classic endonasal approaches.

METHODS

The authors performed a prospective study of TORS in patients with symptomatic sellar tumors. Specific anatomical features were required for inclusion in the study and were determined on the basis of preoperative open-mouth CT scans of the brain. The main outcome measure was sellar accessibility using the robot. Resection quality, mean operative time, postoperative changes in patients' vision, side effects, and complications were additionally reported.

RESULTS

Between February and May 2016, 4 patients (all female, mean age 49.5 years) underwent TORS for resection of sellar tumors as participants in this study. All patients presented with symptomatic visual deficits confirmed as bitemporal hemianopsia. All tumors had a suprasellar portion and a cystic part. In all 4 cases, the operation was performed via TORS, without the need for a second surgery. Sella turcica accessibility was satisfactory in all cases. In 3 cases, tumor resection was complete. The mean operative time was 2 hours 43 minutes. Three patients had a significant visual improvement at Day 1. No rhinological side effects or complications in patients occurred. No pathological examination was performed regarding the fluid component of the tumors. There was 1 postoperative delayed CSF leak and 1 case of transient diabetes insipidus. Side effects specific to TORS included minor sore throat, transient hypernasal speech, and 1 case of delayed otitis media. The mean length of hospital stay and mean follow up were 8.25 days and 82 days, respectively.

CONCLUSIONS

To our knowledge, this is the first report of the surgical treatment of sellar tumors by means of a minimally invasive TORS. This approach using the da Vinci Surgical System seems feasible and constitutes an innovative neurosurgical technique that may avoid the adverse side effects and technical disadvantages of the classic transsphenoidal route. Moreover, TORS allows an inferosuperior approach to the sella turcica, which is a key point, as the tumor is approached in the direction of its growth.

Augmented-reality integrated robotics in neurosurgery: are we there yet?

Surgical robots have captured the interest—if not the widespread acceptance—of spinal neurosurgeons. But successful innovation, scientific or commercial, requires the majority to adopt a new practice. “Faster, better, cheaper” products should in theory conquer the market, but often fail. The psychology of change is complex, and the “follow the leader” mentality, common in the field today, lends little trust to the process of disseminating new technology. Beyond product quality, timing has proven to be a key factor in the inception, design, and execution of new technologies. Although the first robotic surgery was performed in 1985, scant progress was seen until the era of minimally invasive surgery. This movement increased neurosurgeons’ dependence on navigation and fluoroscopy, intensifying the drive for enhanced precision. Outside the field of medicine, various technology companies have made great progress in popularizing co-robots (“cobots”), augmented reality, and processor chips. This has helped to ease practicing surgeons into familiarity with and acceptance of these technologies. The adoption among neurosurgeons in training is a “follow the leader” phenomenon, wherein new surgeons tend to adopt the technology used during residency. In neurosurgery today, robots are limited to computers functioning between the surgeon and patient. Their functions are confined to establishing a trajectory for navigation, with task execution solely in the surgeon’s hands. In this review, the authors discuss significant untapped technologies waiting to be used for more meaningful applications. They explore the history and current manifestations of various modern technologies, and project what innovations may lie ahead.

Visual-perceptual mismatch in robotic surgery

BACKGROUND

The principal objective of the experiment was to analyze the effects of the clutch operation of robotic surgical systems on the performance of the operator. The relative coordinate system introduced by the clutch operation can introduce a visual-perceptual mismatch which can potentially have negative impact on a surgeon's performance. We also assess the impact of the introduction of additional tactile sensory information on reducing the impact of visual-perceptual mismatch on the performance of the operator.

METHODS

We asked 45 novice subjects to complete peg transfers using the da Vinci IS 1200 system with grasper-mounted, normal force sensors. The task involves picking up a peg with one of the robotic arms, passing it to the other arm, and then placing it on the opposite side of the view. Subjects were divided into three groups: aligned group (no mismatch), the misaligned group (10 cm z axis mismatch), and the haptics-misaligned group (haptic feedback and z axis mismatch). Each subject performed the task five times, during which the grip force, time of completion, and number of faults were recorded.

RESULTS

Compared to the subjects that performed the tasks using a properly aligned controller/arm configuration, subjects with a single-axis misalignment showed significantly more peg drops (p = 0.011) and longer time to completion (p < 0.001). Additionally, it was observed that addition of tactile feedback helps reduce the negative effects of visual-perceptual mismatch in some cases. Grip force data recorded from grasper-mounted sensors showed no difference between the different groups.

CONCLUSIONS

The visual-perceptual mismatch created by the misalignment of the robotic controls relative to the robotic arms has a negative impact on the operator of a robotic surgical system. Introduction of other sensory information and haptic feedback systems can help in potentially reducing this effect.

Robotics in Neurosurgery: Evolution, Current Challenges, and Compromises

BACKGROUND

Advances in technology have pushed the boundaries of neurosurgery. Surgeons play a major role in the neurosurgical field, but robotic systems challenge the current status quo. Robotic-assisted surgery has revolutionized several surgical fields, yet robotic-assisted neurosurgery is limited by available technology.

METHODS

The literature on the current robotic systems in neurosurgery and the challenges and compromises of robotic design are reviewed and discussed.

RESULTS

Several robotic systems are currently in use, but the application of these systems is limited in the field of neurosurgery. Most robotic systems are suited to assist in stereotactic procedures. Current research and development teams focus on robotic-assisted microsurgery and minimally invasive surgery. The tasks of miniaturizing the current tools and maximizing control challenge manufacturers and hinder progress. Furthermore, loss of haptic feedback, proprioception, and visualization increase the time it takes for users to master robotic systems.

CONCLUSIONS

Robotic-assisted surgery is a promising field in neurosurgery, but improvements and breakthroughs in minimally invasive and endoscopic robotic-assisted surgical systems must occur before robotic assistance becomes commonplace in the neurosurgical field.

The evolving role of the oculoplastic surgeon in skull base surgery

PURPOSE OF REVIEW

Classical orbital approaches in skull base surgery have involved large incisions with extensive bone removal resulting in prolonged recovery with associated morbidity and mortality. The purpose of this review is to explore recent advances in skull base surgery that are applicable to the orbital surgeon.

RECENT FINDINGS

Transnasal endoscopic surgery provides access to the medial 180 degrees of the orbit. Access to the lateral 180 degrees may be obtained using transmaxillary and transcranial techniques. Transorbital approaches and multiport techniques further expand the reach of the skull base surgeon. These minimally invasive techniques are supplanting the classical pterional, frontotemporal, frontotemporal orbitozygomatic, frontal, and subfrontal approaches.

SUMMARY

The role of the orbital surgeon in skull base surgery is changing. Transnasal and transcranial approaches to orbital disorders using minimally invasive techniques are becoming more common. In addition, transorbital access to the skull base, paranasal sinuses, and anterior and middle cranial fossa is offering new opportunities for the orbital surgeon.

da Vinci robot-assisted keyhole neurosurgery: a cadaver study on feasibility and safety

The goal of this cadaver study was to evaluate the feasibility and safety of da Vinci robot-assisted keyhole neurosurgery. Several keyhole craniotomies were fashioned including supraorbital subfrontal, retrosigmoid and supracerebellar infratentorial. In each case, a simple durotomy was performed, and the flap was retracted. The da Vinci surgical system was then used to perform arachnoid dissection towards the deep-seated intracranial cisterns. It was not possible to simultaneously pass the 12-mm endoscope and instruments through the keyhole craniotomy in any of the approaches performed, limiting visualization. The articulated instruments provided greater dexterity than existing tools, but the instrument arms could not be placed in parallel through the keyhole craniotomy and, therefore, could not be advanced to the deep cisterns without significant clashing. The da Vinci console offered considerable ergonomic advantages over the existing operating room arrangement, allowing the operating surgeon to remain non-sterile and seated comfortably throughout the procedure. However, the lack of haptic feedback was a notable limitation. In conclusion, while robotic platforms have the potential to greatly enhance the performance of transcranial approaches, there is strong justification for research into next-generation robots, better suited to keyhole neurosurgery.

Robotics in keyhole transcranial endoscope-assisted microsurgery: a critical review of existing systems and proposed specifications for new robotic platforms

BACKGROUND

Over the past decade, advances in image guidance, endoscopy, and tube-shaft instruments have allowed for the further development of keyhole transcranial endoscope-assisted microsurgery, utilizing smaller craniotomies and minimizing exposure and manipulation of unaffected brain tissue. Although such approaches offer the possibility of shorter operating times, reduced morbidity and mortality, and improved long-term outcomes, the technical skills required to perform such surgery are inevitably greater than for traditional open surgical techniques, and they have not been widely adopted by neurosurgeons. Surgical robotics, which has the ability to improve visualization and increase dexterity, therefore has the potential to enhance surgical performance.

OBJECTIVE

To evaluate the role of surgical robots in keyhole transcranial endoscope-assisted microsurgery.

METHODS

The technical challenges faced by surgeons utilizing keyhole craniotomies were reviewed, and a thorough appraisal of presently available robotic systems was performed.

RESULTS

Surgical robotic systems have the potential to incorporate advances in augmented reality, stereoendoscopy, and jointed-wrist instruments, and therefore to significantly impact the field of keyhole neurosurgery. To date, over 30 robotic systems have been applied to neurosurgical procedures. The vast majority of these robots are best described as supervisory controlled, and are designed for stereotactic or image-guided surgery. Few telesurgical robots are suitable for keyhole neurosurgical approaches, and none are in widespread clinical use in the field.

CONCLUSION

New robotic platforms in minimally invasive neurosurgery must possess clear and unambiguous advantages over conventional approaches if they are to achieve significant clinical penetration.