Robotic Surgery in Gynecologic Field

Operative laparoscopy was initially developed in the field of gynecology earlier on and the advent of laparoscopic surgery led to advances in general surgery as well. In the last few years, a number of articles have been published on the performance of surgical procedures using the robot-assisted laparoscopy. The shortcomings of conventional laparoscopy have led to the development of robotic surgical system and future of telerobotic surgery is not far away, enabling a surgeon to operate at a distance from the operating table. The complete loss of tactile sensation is often quoted as a big disadvantage of working with robotic systems. Although the first generation da Vinci robotic surgical system provides improved imaging and instrumentation, the absence of tactile feedback and the high cost of the technology remain as limitations. New generations of the robotic surgical systems have been developed, allowing visualization of preoperative imaging during the operation. Though the introduction of robotics is very recent, the potential for robotics in several specialties is significant. However, the benefit to patients must be carefully evaluated and proven before this technology can become widely accepted in the gynecologic surgery.     

Optimal tissue tension for secure laparoscopic knots

Security and strength of a knot are main concerns of the surgeon since last 4000 years. The advancement of endoscopic and minimally invasive surgery in last few decades had a significant influence on a knot tying. The most difficult methods of a knot tying are performed during endoscopic procedures, in which the surgeon execute instrumentation from outside the body without palpation of organs and three-dimensional vision. In addition, laparoscopic instruments due to friction in transmission mechanism have very poor force feedback. This results into difficulty in applying the appropriate grasping force to the tissue, resulting in slippage or damage to the tissue. Our hypothesis highlights the need of tissue approximation at the 'optimum tissue tension' sufficient to resist the slippage of suture/clip without strangulation. The purpose of suture is to maintain an approximation of the tissue until healing progresses to the point where artificial support is no longer necessary for the wound to resist normal stress. When the approximation is too tight, tension in tissue leads to diminished blood supply resulting into the necrosis. Various tissues need different blood supply and different tissue pressure for optimum healings. Proposed hypothesis helps to improve the feedback of current knot pushers or clip applicators used in laparoscopic surgery using optimum tissue tension. Tissue approximation at an optimal tissue tension translates into the secure laparoscopic knot/clip application resulting in prevention of wound dehiscence, anastomosis leak, and secondary haemorrhages.     

Perspectives in endoscopic cardiac surgery

Surgical telemanipulators are obviously used in cardiac surgery to provide the surgeon in a confined space the same stereoscopic vision, full dexterity, unimpaired hand-eye alignment and tactile feedback as in open surgery. This is the basic concept that enables the controlled fine soft tissue manipulation that is needed in bypass grafting and valve surgery. In 2005, a total of 2984 cardiac procedures were performed worldwide using the da Vinci system. This includes totally endoscopic coronary artery bypass grafting (TECAB), mitral valve repair (MVR) procedures, ASD closure and cardiac tissue ablation for atrial fibrillation.     

A novel safety mechanism to reduce the risk of inadvertent electrosurgical injury

Thousands of laparoscopic procedures requiring the use of electrosurgical devices are performed worldwide on a daily basis. The use of electrosurgery carries with it inherent risks related to the use of an energy source within the abdomen. Inadvertent tissue injury due to the use of electrosurgical devices is rare, but is associated with a high morbidity and mortality if undetected. This paper describes a novel, yet simple method using instrument markers and image processing algorithms to reduce the risk of unsafe activation of electrosurgical instruments during laparoscopy. The method was tested in a simulated environment and measured against the decision of an experienced laparoscopic surgeon. Results showed that the position of an instrument in a visual field could be accurately determined using an image processing algorithm to ascertain whether it was safe for activation in agreement with the decisions made by manual inspection.     

A review of haptic feedback in tele-operated robotic surgery

Abstract

During traditional surgery, the surgeons’ hands are in direct contact with organs, and surgeons rely on the sense of touch to perform surgery. In teleoperated robotic systems, all physical connections between the surgeon and both the robot and patient, are absent. The surgeon must estimate the force exerted on organs, based only on visual deformation of tissues he is pulling, pushing, gripping, or suturing. It is hard to imagine how to operate with no haptic sensations, and it is surprising that commercially available robots didn’t include until now any Haptic Feedback, despite reports about tissue injury, and inability to perform complex manipulation. The sense of touch must be created by stimuli sensed by the surgeon. Haptic sensors are required to collect and send haptic information, and display them on the operator’s side, creating telepresence, known as transparency. Multiple ways have been developed to improve transparency through force feedback and tactile feedback. However, this interferes with the stability of the closed-loop controlling interactions between master, robot and remote environment. Cutaneous feedback is more stable and less transparent; force feedback is more transparent and less stable. Thus, multimodal platforms of haptic feedback would try to find the best trade-off between both modalities.     

Application of artificial palpation in vascular surgeries for detection of peripheral arterial stenosis

Palpation is one of the applied methods that surgeons usually use during surgery in order to verify the health condition of a tissue/organ. In fact, most of surgical assessments are based on analysis of the force feedback received from tissue/organ via palpation. Although palpation has a key role in efficient progress of surgery operations, it depends very much on the experience and skill of the surgeons. This limits the application of this technique in some cases to a large extent. In this regard, an artificial tactile sensing approach is an innovative technology that tries to make tactile data more available for surgeons, especially in situations where doing the palpation is not possible or is too difficult. In this paper, having considered the present problems of artery bypass surgery in peripheral arterial occlusive disease (PAOD), applicability of a new tactile sensory system capable of detecting arterial stenosis during surgery was evaluated. Presenting the modelling and numerical solution of the problem, it was demonstrated that the artificial tactile sensing approach is not only capable of detecting the presence of an arterial stenosis in an artery, but also its type. Furthermore, it was shown that the new tactile sensory system (previously designed, fabricated and tested in laboratory) is efficiently capable of detecting the simulated artery in the simulated biological tissue as well as diagnosis of the stenosis occurred inside it.     

基于无网格的软组织切割模型的研究进展

具备支持实时交互能力的软组织切割模型对于虚拟手术仿真系统具有至关重要的意义。传统的软组织切割模型多基于网格建立,将软组织切割过程建模为手术刀具与软组织几何模型之间的网格切割计算,并在此基础上建立和求解生物力学方程以描述切割过程。由于网格切割计算代价高且软组织切割过程中涉及到复杂的生物力学问题,很难实现实时交互,严重影响了虚拟手术仿真效果。与此相反,基于无网格的软组织切割模型打破了网格限制,在触觉/视觉逼真度和实时性方面都具有很大优势。文中从力反馈和视觉反馈的渲染质量和速度等方面,就基于无网格的软组织切割模型的研究现状进行了概述,对存在的问题进行了分析和总结,并对未来的发展方向进行展望。     

Mirrored visual feedback limits distal effect anticipation

Modern tools in technological environments are often characterized by a spatial separation of hand actions (operating a remote control) and their intended action effects (displayed movements of an unmanned vehicle, a robot, or an avatar on a screen). Often non-corresponding proximal and distal movement effects put high demands on the human information processing system. The present study aimed to investigate how modern technological environments influence processes of planning and controlling actions. Participants performed ipsi- or contralateral movements in response to colored stimuli, while the stimulus location had to be ignored. They did not see the stimuli and hands directly, but received visual feedback (with retained or reversed spatial relations) on a projection screen in front of them. Visual feedback retaining spatial relations led to the usual Simon effect. However, visual feedback reversing spatial relations inverted the Simon effect in ipsilateral responses, and eliminated it in contralateral responses (Exp. 1). Impairing the proximal movement-effect loop so that proprioceptive/tactile information from the moving hand was no longer a reliable source for planning and controlling actions attenuated compatibility effects (Exp. 2). Moreover, distal action effects predominated action control even for opposing body-related effects. It seemed that action control of transformed movements depended on the reliability of proprioceptive/tactile and visual information. When the amount of feature overlap between proprioception and vision was low and proprioceptive (visual) information was no longer reliable, then distal (proximal) action effects stepped forward and became crucial in controlling transformed actions.     

Artificial tactile sensing approach in aortic-repair-laparoscopy: aorta cross clamping during surgery

Abdominal aortic aneurysm is one of the most common diseases of the vascular system for which the most definitive treatment is surgery. Laparoscopy is a primary method of minimally invasive surgery that could be useful in aortic repair surgeries. Although this method of surgery has significant advantages, the difficulty of exactly distinguishing the aorta from its surrounding tissues is its main drawback; this can cause many problems during the aorta cross clamping process. One of the most important limitations is that it is a time-consuming process; aorta cross clamping leads to increases in surgery duration. Artificial tactile sensing is an innovative technology aiming to make tactile data more available for surgeons, especially in situations where developments in technology make the surgeons less efficient. In this paper, considering the present problems during aortic repair laparoscopy, applicability of a novel tactile robotic system capable of cross clamping an artery during laparoscopy was evaluated. Having considered a small, 5-degree-of-planar-freedom robot and imitated surgeon’s palpation using software, the path followed by the tip of the new tactile robotic system was extracted. It is shown that this new tactile robotic system is well capable of dissecting an artery from its adjacent tissues in a short time with an acceptable accuracy. The functional principles of the tactile robotic system capable of cross clamping the aorta during laparoscopy will also be presented.     

Application of artificial tactile sensing approach in kidney-stone-removal laparoscopy

Artificial tactile sensing is a novel method for obtaining different characteristics of a hard object embedded in a soft tissue. In this regard, artificial palpation is one of the most valuable achievements of artificial tactile sensing that can be used in various fields of medicine and more specifically in surgery. In this study, considering the present problems and limitations in kidney-stone-removal laparoscopy, a new application will be presented for artificial tactile sensing approach. Having imitated surgeon's palpation during open surgery and modeled it conceptually, indications of stone existence that appear on the surface of kidney (due to exerting mechanical load) were determined. A number of different cases were created and solved by the software. Using stress distribution contours and stress graphs, it is illustrated that the created stress patterns on the surface of kidney not only show the existence of stone inside, but also its exact location. In fact, the reliability and accuracy of artificial tactile sensing method in detection of kidney stone during laparoscopy is demonstrated by means of finite element analysis. Also, in this paper, the functional principles of tactile system capable of determining the exact location of stone during laparoscopy will be presented.     

Co-activation of the secondary somatosensory and auditory cortices facilitates frequency discrimination of vibrotactile stimuli

The contribution of the auditory cortex to tactile information processing was studied by measuring somatosensory evoked magnetic fields (SEFs). Three kinds of vibrotactile stimuli with frequencies of 180, 280 and 380 Hz were randomly delivered on the right index finger with a probability of 40, 20 and 40%, respectively. Twenty normal subjects participated in four kinds of tasks: a control condition to ignore these stimuli, a simple task to discriminate the 280-Hz stimulus from the other two stimuli (discrimination task for the vibrotactile stimuli, Ts task), a feedback task modified from the Ts task by adding acoustic feedback of the vibratory frequency at 1300 ms poststimulus (tactile discrimination with auditory clues, TA), and an easy version of the TA task (TA-easy) to discriminate the 280-Hz stimulus (20% target) from the 180- or 380-Hz stimuli (80% nontarget). The Ts and TA tasks required accurate perception of the vibrotactile frequencies to discriminate among the three kinds of stimuli. Under such a task demand, the post hoc auditory feedback in the TA task was expected to induce acoustic imagery for the tactile sensation. The SEFs for the nontarget stimuli were analyzed. A middle-latency component (M150/200) was specifically evoked by the three discrimination tasks. In the Ts and TA-easy tasks, the M150/200 source indicated inferior parietal cortical activities (SII area). In the TA task, 11 subjects showed activity in both the SII area and the superior temporal auditory region and increased accuracy of discrimination compared with the Ts task, in contrast with other subjects who showed activity only in the SII area and small changes in task accuracy between the Ts and TA tasks. Asynchronous auditory feedback for the vibrotactile sensation induced the auditory cortex activity in the SEFs in relation to the progress in tactile discrimination, which suggested an induction of acoustic imagery to complement the tactile information processing.     

基于生物力学信息数字化机器人辅助手术系统

目的 建立一套数字化机器人辅助手术系统再现真实手术过程,并通过仿真系统与外部力反馈设备的结合实现对虚拟环境中机器人的控制和力觉反馈。方法 系统的设计包括：基于生物力学理论的人体组织建模、基于有限元方法人体组织生物力学模型的计算、外部力反馈设备的设计、控制算法设计等。通过多层次模型、系统集成等方法,实现基于生物力学信息并具有交互特性的虚拟机器人辅助骨折牵引复位手术平台。结果 当主手控制系统和虚拟环境生成机通过局域网连接成功后,该系统完成了闭环信息传递过程。结论 该系统可以实现对虚拟环境中手术机器人的主从控制、视觉反馈和力觉反馈。该项研究为数字化模拟外科手术相关技术的发展起到推进作用,模拟手术在提高手术成功率、新医生的培训方面具有很强的优势。     

A proof-of-principle robot with potential for the development of a hand-held tactile instrument for minimally-invasive artery cross-clamping

One of the most common diseases of the vascular system is abdominal aortic aneurysm (AAA), for which the most definitive treatment is surgery. Minimally invasive aorta surgery is a novel method of surgery performed through small incisions and offers significant advantages including less pain, shorter hospital stay, faster patient recovery, less possibility of infection, etc. However, lack of sense of touch is the main drawback of this type of aorta surgery that would incapacitate the surgeon to exactly distinguish the aorta from its surrounding tissues which could cause various problems during the aorta cross-clamping process. One of the most important drawbacks is that it makes the aorta cross-clamping process the most time-consuming process of aortic repair surgery. The artificial tactile sensing approach is a novel method that can be used in various fields of medicine and, more specifically, in minimally invasive surgeries, where using the ‘tactile sense’ is not possible. In this paper, considering the present problems during aortic-repair-laparoscopy and imitating the movement of surgeons’ fingers during aorta cross-clamping, a novel tactile-based artery cross-clamping robot is introduced and its function is evaluated experimentally. It is illustrated that this new tactile-based artery cross-clamping robot is well capable of dissecting an artery from its adjacent tissues in a short time with an acceptable accuracy.     

手术机器人面临的一大挑战———力触觉反馈

机器人手术作为一种微创手术技术,由于其高度的精准性,已经得到了外科医生的广泛认可。但机器人手术最大的局限之一就是外科医生缺乏操作的“手感”（即力触觉反馈）,增加了手术的不确定性和风险性,从而限制了手术机器人的进一步发展。文中从手术机器人力触觉反馈系统的组成、关键技术、以及当前的研究现状等几个方面,对该反馈系统进行了综述。力触觉反馈包括力反馈与触觉反馈。该系统的实现依赖力触觉的传感与再现,本文介绍了常用的力触觉传感器、再现设备及感觉模拟技术,并分析了各项技术的优缺点。对力触觉反馈系统在手术机器人的研究进展进行了概述。在汇总以前研究的基础上,对相关研究做了展望。     

Artificial lungs: current state and trends of clinical use and research and development

This article describes recent progress in the field of artificial lungs, centering on the current state and trends in clinical use and research and development. Trends in the recent clinical use in Japan can be found in shipment-number-based surveys as well as in the questionnaire surveys for clinical extracorporeal membrane oxygenation (ECMO) and percutaneous cardiopulmonary support (PCPS). It is likely that the use of artificial lungs for open-heart surgery has peaked, and this can be attributed to the rapid expansion and popularization of off-pump coronary artery bypass grafting surgery. In contrast, the increase in the number of artificial lungs used in assisted circulation cases is showing significant growth. Along with such clinical trends, research and development toward next-generation systems is active in the field of assisted circulation, focusing on emergency or long-term use of PCPS or ECMO. Approaches include enhancing the performance of conventional systems in terms of long-term durability and hemocompatibility, developing a novel device by integrating the oxygenator with the blood pump, and developing an implantable type of artificial lung such as an intravenous oxygenator. Next-generation devices not only will benefit a multitude of patients but also represent an important target with the prospect for expansion of the market for artificial lungs. In the future, further expansion of research and development in this field, as well as progress in practical and clinical applications of innovative devices, is expected.     

Particle image velocimetry in the investigation of flow past artificial heart valves

Full-field measurement of instantaneous velocities in the flow field of artificial heart valves is vital as the flow is unsteady and turbulent. Particle image velocimetry (PIV) provides us the ability to do this as compared to other point measurement devices where the velocity is measured at a single point in space over time. In the development of a PIV system to investigate the flow field of artificial heart valves, many problems associated with the project arose and were subsequently resolved. Experience gained in the setting up of an environment conducive for PIV studies of artificial heart valves; from seed particle selection to refractive index matching, and the evolution of computer algorithms to satisfy the varied flow conditions in artificial heart valves are presented here. Velocity profiles and distributions are computed and drawn for a porcine tissue heart valve based on measurements with the PIV system developed.     

Tactile/proprioceptive integration during arm localization is intact in individuals with Parkinson's disease

It has been theorized that sensorimotor processing deficits underlie Parkinson's disease (PD) motor impairments including movement under proprioceptive control. However, it is possible that these sensorimotor processing deficits exclude tactile/proprioception sensorimotor integration: prior studies show improved movement accuracy in PD with endpoint tactile feedback, and good control in tactile-driven precision-grip tasks. To determine whether tactile/proprioceptive integration in particular is affected by PD, nine subjects with PD (off-medication, UPDRS motor = 19–42) performed an arm-matching task without visual feedback. In some trials one arm touched a static tactile cue that conflicted with dynamic proprioceptive feedback from biceps brachii muscle vibration. This sensory conflict paradigm has characterized tactile/proprioceptive integration in healthy subjects as specific to the context of tactile cue mobility assumptions and the intention to move the arm. We found that the individuals with PD had poorer arm-matching acuracy than age-matched control subjects. However, PD-group accuracy improved with tactile feedback. Furthermore, sensory conflict conditions were resolved in the same context-dependent fashion by both subject groups. We conclude that the somatosensory integration mechanism for prioritizing tactile and proprioception feedback in this task are not disrupted by PD, and are not related to the observed proprioceptive deficits.     

Extending a teleradiology system by tools for visualization and volumetric analysis through a plug-in mechanism

This paper describes ongoing research concerning interactive volume visualization coupled with tools for volumetric analysis. To establish an easy to use application, the three-dimensional-visualization has been embedded in a state of the art teleradiology system, where additional functionality is often desired beyond basic image transfer and management. Major clinical requirements for deriving spatial measures are covered by the tools, in order to realize extended diagnosis support and therapy planning. Introducing a general plug-in mechanism, this work exemplarily describes the useful extension of an approved application. Interactive visualization was achieved by a hybrid approach taking advantage of both the precise volume visualization based on the Heidelberg ray-tracing model and the graphics acceleration capabilities of modern workstations. Several tools for volumetric analysis extend the three-dimensional-viewing. They are controlled by adequate input devices to select locations in the data volume, measure anatomical structures or initiate a segmentation process. Moreover, a haptic interface can be connected to provide a more realistic feedback while navigating within the three-dimensional-reconstruction. The work is closely related to research in the field of heart, liver and head surgery. In cooperation with our medical partners the development of tools as presented facilitates the integration of image analysis into the clinical routine.     

Study on real-time force feedback for a master–slave interventional surgical robotic system

In robot-assisted catheterization, haptic feedback is important, but is currently lacking. In addition, conventional interventional surgical robotic systems typically employ a master–slave architecture with an open-loop force feedback, which results in inaccurate control. We develop herein a novel real-time master–slave (RTMS) interventional surgical robotic system with a closed-loop force feedback that allows a surgeon to sense the true force during remote operation, provide adequate haptic feedback, and improve control accuracy in robot-assisted catheterization. As part of this system, we also design a unique master control handle that measures the true force felt by a surgeon, providing the basis for the closed-loop control of the entire system. We use theoretical and empirical methods to demonstrate that the proposed RTMS system provides a surgeon (using the master control handle) with a more accurate and realistic force sensation, which subsequently improves the precision of the master–slave manipulation. The experimental results show a substantial increase in the control accuracy of the force feedback and an increase in operational efficiency during surgery.     

Light-guided lumpectomy: device and case report

We describe the development, design, fabrication, and testing of an optical wire to assist in the surgical removal of small lesions during breast-conserving surgery. We modify a standard localization wire by adding a 200-μm optical fiber alongside it; the resulting optical wire fit through an 18 gauge needle for insertion in the breast. The optical wire is anchored in the lesion by a radiologist under ultrasonic and mammographic guidance. At surgery, the tip is illuminated with an eye-safe, red, HeNe laser, and the resulting glowball of light in the breast tissue surrounds the lesion. The surgeon readily visualizes the glowball in the operating room. This glowball provides sufficient feedback to the surgeon that it is used (1) to find the lesion and (2) as a guide during resection. Light-guided lumpectomy is a simple enhancement to traditional wire localization that could improve the current standard of care for surgical treatment of small, nonpalpable breast lesions.