机器人辅助神经介入手术研究进展

神经介入手术是神经功能障碍性疾病诊断与治疗及相关脑科学研究的重要方法。机器人辅助神经介入手术可以提高介入操作的微创性和精准性,是目前重要研究方向。神经介入手术的导航技术逐渐从传统的光学导航向MRI导航发展,介入材料从刚性针向主动式柔性针发展,手术路径规划与导航技术及手术机器人控制技术也不断发展。本文总结上述四方面关键技术,综述机器人辅助神经介入手术研究进展,以促进其临床应用。     

单孔腹腔镜手术器械研究的最新进展**★

背景：单孔腹腔镜外科手术因其创伤小、术后疼痛轻、住院时间短、美容效果好等特点，成为当今医学科技最前沿的发展方向。但是目前单孔腹腔镜手术器械较少且存在不足，不能满足微创外科的要求。 目的：确认单孔腹腔镜手术的可行性，总结分析现存的几种单孔腹腔镜手术操作平台及多自由度器械，以期对单孔腹腔镜手术器械进行优化、改进，提高其应用能力。 方法：利用计算机检索万方数据库、清华同方数据库、维普数据库、Springer Link全文电子期刊、IEEE数据库、Elsevier数据库、国家知识产权局专利、美国专利、欧洲专利，检索英文关键词为“single-port access，laparoscopic surgery，minimally invasive surgery，ports，multi-degree-of-freedom instruments”，中文关键词为“单孔入路，腹腔镜外科，微创外科，平台，多自由度器械”，主要筛选出近10年内最具代表性的文献资料。经查阅、整理出35篇可支持本综述的文献。 结果与结论：单孔腹腔镜技术已成为现在微创外科的主流；现存的平台都已将多孔集中为单孔，达到对患者创伤更小的目的，但仍需在放置稳定性、经济性、功能整合等方面改进；现存的多自由度器械已通过增加关节的方式实现了多自由度运动，但过于复杂的传动机构、不甚便捷的控制系统以及过高的经济成本仍阻碍微创外科技术进一步的发展。     

五维力反馈虚拟手术装置的优化设计

虚拟手术是虚拟现实技术在医学领域的重要应用,医生借助虚拟手术系统与虚拟环境进行交互,可以进行手术规划、手术培训和远程手术。虚拟手术系统中的力反馈设备是其重要组成部分,也是制约当前虚拟手术发展的瓶颈问题之一。力反馈技术可以使医生获得与虚拟对象交互产生的力觉,如同进行真实手术操作一样,可以使训练更真实、准确、可靠。虚拟手术系统的开发和利用可以节约培训医务人员的成本和时间。文章主要介绍了一套用于虚拟手术系统的五自由度力反馈装置,该装置不仅能跟踪人手的五维运动而且能输出五维的触觉力。以自行设计的装置为研究对象,分析其设计不完善的方面,重点分析了减速比对装置响应速度滞后的影响,并在分析的基础上对该装置进行了设计优化。     

阅读辅助机器人取书装置设计

背景：康复辅具是利用辅助技术将辅助器具产品配置于残障者,最大限度实现生活自理和参与社会活动。 目的：分析了国内外阅读辅助机器人的研究现状,并对该领域的一些关键技术进行探讨,并设计出了一种新型取书装置。 方法：依据阅读辅助机器人的发展特点和应用背景,设计一种阅读辅助机器人的取书装置,帮助肢体残疾者从书架上获取书籍。 结果与结论：基于三维设计软件UG设计了阅读辅助机器人的取书装置。通过运动仿真,功能满足拟人化,能够完成取书的动作。仿真表明该装置可靠安全,有效可行。     

向显微神经外科新高度--"锁孔"技术迈进

Keyhole技术是近年发展起来的一种外科手术操作技术，1995年最先由郎文当代英语辞典（英文版）正式收录。该辞典对这一词条的解释是：经体表小切口处置体内病变的一种手术方法，称之为“锁孔”切口手术。该技术源于普通外科、胸科和骨科，即在体表行微切口或利用体表孔道将光导纤维、内窥镜等小型器械置于体腔深部，进行病变的活检、切除、止血、引流等操作。在神经外科领域Keyhole技术促使显微神经外科水平又有新的突破。近20余年，整个临床医学外科手术操作趋向智能化、小型化和闭合化。又以手术操作的小型化为中心环节，诞生了微侵袭神…     

以成人体外下颌骨标本进行下颌管多断面数据观测

背景：近年牙种植以及正颌外科手术日益普及，下颌管及邻近组织的解剖结构越来越受到人们重视。但国内外实体标本测量数据报道相对较少。 目的：观察实体下颌骨标本，经过测量明确下颌管及邻近组织的解剖数据，为临床进行牙槽外科手术、牙种植以及正颌外科手术提供可靠的参考数据以及解剖学依据。 设计、时间及地点：对比观察，于2007-03/ 09在吉林医药学院解剖实验室完成。 材料：完整下颌骨标本20具。 方法：选取16具牙列完整的成人离体下颌骨标本和4具无牙下颌骨标本，测量下颌骨，在矢状剖面和颏孔后区每个牙位截面上有关磨牙、牙槽嵴以及下颌管的相关数据，然后进行统计学分析。 主要观察指标：颏孔的位置、颏孔前缘到颏管前缘水平距离、下颌孔的位置、下颌管与磨牙根尖及各方向上骨板的距离。 结果：下颌管位于下颌骨体内下方走行中偏舌侧，并近下颌骨下缘，与下颌第三磨牙根尖距离最近，在颏孔前方转向后外和颊侧出颏孔。下颌管在无牙下颌骨上与牙槽嵴顶距离明显缩小。 结论：通过对下颌骨离体标本做多断面的观察和测量，为口腔颌面外科手术前设计提供了准确可靠的依据，使得临床医师能更好的制定手术方案，预防术中大量出血、神经损伤以及下颌角骨折和颌骨的侧壁穿孔等并发症的发生。     

康复机器人系统结构及控制技术

康复机器人是近年来发展起来的一种新的运动神经康复治疗技术,作为医疗机器人的一个重要分支,它贯穿了康复医学、生物力学、机械学、电子学、材料学、计算机科学以及机器人学等诸多领域,已经成为了国际机器人领域的一个研究热点。根据康复机器人技术的发展特点和应用并结合该领域的研究背景，分别从康复机器人机械结构设计、系统架构和运动控制策略等方面详细分析和介绍了国内外近年来的主要研究成果，并对该领域的一些关键技术进行了探讨。     

微创脊柱外科技术的进展

微创手术是外科技术发展的方向,本文对脊柱外科手术中的显微外科技术、内镜技术、经皮穿刺椎体成形及后凸矫形技术等在椎间盘突出、椎管狭窄、椎体骨折及某些脊柱肿瘤手术中的应用及指征进行综述.     

神经外科手术协作机器人系统应用进展

目前常用的神经外科手术机器人系统的定位移动依靠传统光学导航,体积较大且价格昂贵,临床应用受到限制。近年来,神经外科手术机器人系统逐渐向协作机器人系统方向发展,协作机器人系统可配合术者操作,提高手术效率,确保手术操作更准确、更安全。相比监视控制系统和主从系统,协作机器人系统构造和操作更简单,成本更低,与人类感知觉的联合更紧密,可直接整合入手术场景。本文综述Evolution 1、ROVOT-m、RoboticScope、iArmS、Craniostar原型机和基于3D机器视觉的新型手术协作机器人共6种用于稳定操作和辅助术野观察的手术协作机器人系统的构成和工作原理,以促进其在神经外科的临床应用。     

微创治疗高血压性脑出血的临床分析

高血压脑出血目前已经成为常见病及多发病，且病人的年龄日趋年轻化。在临床的工作中，对于该病的治疗，根据病人的具体情况，采用内科保守治疗或外科手术治疗。而对于外科手术治疗的情况，采用尿激酶注射液、微创手术穿刺引流术，如操作得当，定位准确，具有操作简便、病人手术创伤小，病人恢复快等优点，消毒措施好，甚至可以在病房进行，大大降低手术的费用。     

Robot-Assisted Transoral Odontoidectomy : Experiment in New Minimally Invasive Technology, a Cadaveric Study

Objective

In the field of spinal surgery, a few laboratory results or clinical cases about robotic spinal surgery have been reported. In vivo trials and development of related surgical instruments for spinal surgery are required before its clinical application. We investigated the use of the da Vinci® Surgical System in spinal surgery at the craniovertebral junction in a human cadaver to demonstrate the efficacy and pitfalls of robotic surgery.

Methods

Dissection of pharyngeal wall to the exposure of C1 and odontoid process was performed with full robotic procedure. Although assistance of another surgeon was necessary for drilling and removal of odontoid process due to the lack of appropriate end-effectors, successful robotic procedures for dural sutures and exposing spinal cord proved its safety and dexterity.

Results

Robot-assisted odontoidectomy was successfully performed in a human cadaver using the da Vinci® Surgical System with few robotic arm collisions and minimal soft tissue damages. Da Vinci® Surgical System manifested more dexterous movement than human hands in the deep and narrow oral cavity. Furthermore, sutures with robotic procedure in the oral cavity demonstrated the advantage over conventional procedure.

Conclusion

Presenting cadaveric study proved the probability of robot-assisted transoral approach. However, the development of robotic instruments specific to spinal surgery must first precede its clinical application.     

Tele-robotics and artificial-intelligence in stroke care

In the last forty years, the field of medicine has experienced dramatic shifts in technology-enhanced surgical procedures – from its initial use in 1985 for neurosurgical biopsies to current implementation of systems such as magnetic-guided catheters for endovascular procedures. Systems such as the Niobe Magnetic Navigation system and CorPath GRX have allowed for utilization of a fully integrated surgical robotic systems for perioperative manipulation, as well as tele-controlled manipulation systems for telemedicine. These robotic systems hold tremendous potential for future implementation in cerebrovascular procedures, but lack of relevant clinical experience and uncharted ethical and legal territory for real-life tele-robotics have stalled their adoption for neurovascular surgery, and might present significant challenges for future development and widespread implementation. Yet, the promise that these technologies hold for dramatically improving the quality and accessibility of cerebrovascular procedures such as thrombectomy for acute stroke, drives the research and development of surgical robotics. These technologies, coupled with artificial intelligence (AI) capabilities such as machine learning, deep-learning, and outcome-based analyses and modifications, have the capability to uncover new dimensions within the realm of cerebrovascular surgery.     

Assessment of a disease-specific muscular impairment rating scale in myotonic dystrophy

OBJECTIVE: To document the intra/interrater reliability and the construct validity of the Muscular Impairment Rating Scale (MIRS) in assessing patients with myotonic dystrophy type 1 (DM1). The MIRS is a ordinal five-point rating scale, established in accordance with the clinically recognized distal to proximal progression of the muscular involvement in DM1, based partly on a manual muscle testing (MMT) of 11 muscle groups. METHODS: To assess the reliability of the MIRS, 55 patients with DM1 were examined by three different observers, one of them evaluating each patient twice. Intra- and interobserver reliability of the MIRS was measured using Cohen's weighted kappa. To assess the construct validity of the MIRS, correlations were made with the Functional Status Index (FSI) and eight timed functional tasks. RESULTS: The intraobserver reliability of the MIRS was excellent (weighted kappa = 0.84), and the interobserver reliability was interpreted as a substantial agreement (weighted kappa = 0.77 to 0.79). The correlation coefficients between MMT scores and MIRS grades were all highly significant (r(s) = -0.81 to -0.88, p < 0.001). The FSI showed a significant progressive increase of the total median dependence score in activities of daily living from 0 in MIRS grade 1 to 39 in MIRS grade 5 (p < 0.001). The time needed to perform the eight functional tasks was also found to significantly increase in relation with the progression of the MIRS grades. CONCLUSION: The MIRS is a quick, simple, and reliable measurement of muscular impairment in DM1. The FSI questionnaire and the timed motor activities supported its construct validity. The MIRS is useful to monitor major stages of DM1 progression, to study the natural history of the disease, and to identify homogeneous groups of patients for clinical trials.     

Robotic navigation in spine surgery: Where are we now and where are we going?

Robotic navigation is a new and rapidly emerging niche within minimally invasive spine surgery. The robotic arms-race began in 2004 and has resulted in no less than four major robotic surgical adjuncts. Current Food and Drug Administration (FDA)-approved applications of robotic navigation are limited to pedicle screw instrumentation, but new indications and experimental applications are rapidly emerging. As with any new technology, robotic navigation must be vetted for clinical efficacy, efficiency, safety, and cost-effectiveness. Given the rapid advancements made on a yearly basis, it is important to make frequent and objective assessments of the available technology. Thus, the authors seek to provide the most up-to-date review of the history, currently available technology, learning curve, novel applications, and cost effectiveness of today’s available robotic systems as it relates to spine surgery.     

Thoracic vertebra interbody fusion surgery with robotic assisted system in a swine model

Minimally invasive procedures have been increasing in spine surgery, and interest in robotic systems has inclined. In this study, we aimed to evaluate feasibility of a robotic-assisted thoracic spine interbody fusion in a swine model. Neurosurgeons performed the surgical procedures with robotic surgery certificates on the Da Vinci Xi Surgical System. Surgical approaches were applied using four ports while the swine was in the left lateral position. The surgical procedure was accomplished in 70 min including positioning and preparation of robotic system (20 min), placement of ports and thoracic dissection and confirmation of level with the C-arm system (10 min), discectomy and cage insertion (15 min), control of cage position via the C-arm system and closure (10 min). This study showed the anterior thoracic approach with robotic surgery is safe and feasible with providing a wide working area and high image quality.     

机器人辅助股骨干骨折复位

摘要： 背景：机器人辅助股骨骨折复位是研究股骨骨折治疗的一个方向。 目的：介绍一种机器人辅助股骨骨折复位系统以及初步的实验结果。 设计、时间及地点：股骨尸体标本的复位结果测量，2007年11月在德国汉诺威医学院创伤骨科的计算机辅助骨科实验室完成实验。 材料：14具不带软组织的成人正常股骨标本；工业机器人Stäubli RX 90CR (Stäubli Tec-Systems, Faverges, France)；三维C型臂(Iso C 3D C-arm)；导航系统（brainlab） 方法：骨折造成后，骨折区域3D透视成像，利用导航系统虚拟真实骨折断端的图象, 通过机械手带动骨折远端进行主-仆型的机械手骨折复位。一共实施了144次的机器人机械手骨折复位。 主要观察指标：骨折断端的侧方移位误差，外翻/内翻成角误差，旋转误差。 结果：对于简单骨折（AO分型 A型骨折），对比传统的骨折复位，复位效果满意（表1），平均复位时间4分34秒，侧方移位平均误差1.61mm，外翻/内翻成角平均误差1.09度，前/后成角平均误差1.42度，内/外旋转平均误差1.37度。随着骨折复杂(AO B型和C型)，由于主折块间不能直接对合，复位结果稍差，但是即便是非常复杂的骨折，旋转误差还是在4度以下。 结论：这个机器人辅助骨折复位系统运行良好，复位结果满意。一个标准的完整的机器人骨折复位解决平台有望形成。     

Geometrical accuracy evaluation of an affordable 3D printing technology for spine physical models

ObjectiveThe aim of the study is to develop a workflow to establish geometrical quality criteria for 3D printed anatomical models as a guidance for selecting the most suitable 3D printing technologies available in a clinical environment.MethodsWe defined the 3D geometry of a 25-year-old male patient’s L4 vertebra and the geometry was then printed using two technologies, which differ in printing resolution and affordability: Fused Deposition Modelling (FDM) and Digital Light Processing (DLP). In order to measure geometrical accuracy, the 3D scans of two physical models were compared to the virtual input model. To compare surface qualities of these printing technologies we determined surface roughness for two regions of interest. Finally, we present our experience in the clinical application of a physical model in a congenital deformity case.ResultsThe analysis of the distribution of the modified Hausdorff distance values along the vertebral surface meshes (99% of values <1 mm) of the 3D printed models provides evidence for high printing accuracy in both printing techniques. Our results demonstrate that the surface qualities, measured by roughness are adequate (~99% of values <0.1 mm) for both physical models. Finally, we implemented the FDM physical model for surgical planning.ConclusionWe present a workflow capable of determining the quality of 3D printed models and the application of a high quality and affordable 3D printed spine physical model in the pre operative planning. As a result of the visual guidance provided by the physical model, we were able to define the optimal trajectory of the screw insertion during surgery.     

快速成型技术在仿生医学训练模型研发及临床中的应用

背景：快速成型术是一项新兴技术,它在医学教育及临床治疗中承担重要作用,研究运用快速成型术来研制医学训练模型,改变模型材料结构,探求制造新技术是一顶重要的任务。 目的：探讨快速成型制造形术的原理及方法,研究快速成型术在临床诊断、治疗及医学模拟教学中的运用前景。 方法：应用计算机检索PubMed 数据库、美国科技信息所的科学引文索引数据库及中国期刊全文数据库、中国科技期刊全文数据库,检索包括快速成形制造术、医学模拟教学、人体仿生材料、临床治疗方面最有代表性文献报道。 结果与结论：快速成型制造技术的出现和发展,为不能制作或难以用传统方法制作的人体器官模型提供了一种新的制造手段。采用 PRM 技术制作三维医学模型,不但可以使解剖特征具体化、医生之间以及医生与患者之间易于交流,使患者易于理解医生策划的手术,而且可用于模拟教学中,指导操作,进行手术过程操练。在临床诊断和外科手术策划中,可有效提高诊断和手术水平,缩短时间,节省费用。随着生物材料知识的发展,快速成型产品在医学领域的临床应用将不断增长,从仿生性医学训练模型研制到人体骨骼再生植入,再到器官置换,应用范围将会越来越广泛。     

How technology is driving the landscape of epilepsy surgery

This article emphasizes the role of the technological progress in changing the landscape of epilepsy surgery and provides a critical appraisal of robotic applications, laser interstitial thermal therapy, intraoperative imaging, wireless recording, new neuromodulation techniques, and high-intensity focused ultrasound. Specifically, (a) it relativizes the current hype in using robots for stereo-electroencephalography (SEEG) to increase the accuracy of depth electrode placement and save operating time; (b) discusses the drawback of laser interstitial thermal therapy (LITT) when it comes to the need for adequate histopathologic specimen and the fact that the concept of stereotactic disconnection is not new; (c) addresses the ratio between the benefits and expenditure of using intraoperative magnetic resonance imaging (MRI), that is, the high technical and personnel expertise needed that might restrict its use to centers with a high case load, including those unrelated to epilepsy; (d) soberly reviews the advantages, disadvantages, and future potentials of neuromodulation techniques with special emphasis on the differences between closed and open-loop systems; and (e) provides a critical outlook on the clinical implications of focused ultrasound, wireless recording, and multipurpose electrodes that are already on the horizon. This outlook shows that although current ultrasonic systems do have some limitations in delivering the acoustic energy, further advance of this technique may lead to novel treatment paradigms. Furthermore, it highlights that new data streams from multipurpose electrodes and wireless transmission of intracranial recordings will become available soon once some critical developments will be achieved such as electrode fidelity, data processing and storage, heat conduction as well as rechargeable technology. A better understanding of modern epilepsy surgery will help to demystify epilepsy surgery for the patients and the treating physicians and thereby reduce the surgical treatment gap.     

Use of neuronavigation and electrophysiology in surgery of subcortically located lesions in the sensorimotor strip

OBJECTIVES: Subcortical lesions in the sensorimotor strip are often considered to be inoperable. The purpose of this study was to evaluate the usefulness of a combined approach for surgery in this region, aided by a robotic neuronavigation system under electrophysiological control. METHODS: In a prospective study on 10 patients, space occupying lesions in the sensorimotor central area were removed using the Surgiscope robotic navigation system and the Nicolet Viking IV electrophysiological system. RESULTS: Precise tumour localisation with the neuronavigation system and the information on the patient's cortical motor distribution obtained by bipolar cortical stimulation led to postoperative improvement in motor function in all but one patient. Seven of the patients had focal, defined pathology (four metastases; two cavernoma; one aspergilloma). CONCLUSION: Due to the implementation of two recent technologies, surgery of lesions in the subcortical sensorimotor region can be performed with greater confidence.