Advances in Telesurgery and Surgical Robotics Dr S. Sanyal

World’s first telesurgery September 2001: Tele- chole Prof Jacques Marescaux, New York & European Institute of Telesurgery, Strasbourg Round distance =14,000 km RTT = 200 msec ; video and hi-speed fibre-optic link June 2001: Johns Hopkins University, Baltimore & Rome Policlinico Casilino University http://news.bbc.co.uk/2/hi/science/nature/1552211.stm

The research pioneers SRI @ Stanford U School of Medicine HMSL @ MIT IMRL @ UC Berkeley and UCSF

Background Traditional surgery Tri-dimensional Cognitive input Tactile feedback Stereoscopic vision with depth perception Time lag -ve Telesurgery Two-dimensional Cognitive feedback limited Tactile feedback –ve Binocular vision without depth perception Time lag +ve

Definitions Telepresence surgery: Computerized interface @ surgical workstation ↔ remote operative site; force feedback (haptic) Cooperative telesurgery: tele-surgeon / local (remote) assistant cooperation http://www2.telemedtoday.com/articles/telesurgery.shtml http://web.mit.edu/hmsl/www/Telesurgery/

Definitions – cont’d Telerobotics: Remote control with a robotic arm, in conjunction with a laparoscope http://www2.telemedtoday.com/articles/telesurgery.shtml

Definitions – cont’d Telementoring: Experienced surgeon acts as tutor / instructor (preceptor) for remote surgeon via interactive video Teleproctoring (proctor=supervisor of exams): Documentation of performance for privileging purposes http://www2.telemedtoday.com/articles/telesurgery.shtml

Technical aspects Image transmission: T1 transmission (H-320 compression standard) Fibre-optic cable Microwave Satellite Lag time: should be < 330 ms VOR disruption (3-D vertigo; Simulator sickness within 20 minutes) Movement scaling: 1cm → 1mm Haptic: Force feedback

Haptic Force reflection / feedback; Graduated tactile input – resistance at remote site is transmitted to near site by servo motors @ both sites

Robotic vs. human arm DOF: Number of ways an arm can move Human hand: >20-DOF Robotic arm: Like human hand, arm and moveable elbow - but with a fused wrist Robotic arm: 4-6 DOF

Telesurg dynamics @ MIT Surgeon’s fingers placed in rings of instruments Rings are connected to motors, gears and belts Precisely translate surgeon’s hand / finger motions into digital signals Transmitted through computer- telecomm link To robotic arms @ remote surgical station Visual input: 2 remote CCD cameras (15 fps each → 3-D effect) → Surgeon’s monitor → Mirror → Optical 3-D glasses (stereoscopic vision) http://web.mit.edu/hmsl/www/Telesurgery

Telesurg components @ MIT

Surgeon’s master tool handle @ MIT

Surgeon’s master tool handle @ MIT

Master phantom haptic interface arm

Slave phantom haptic interface arm

Tele-operation slave tool

Tele-operation slave tool

Tele-operational details – Tool

Tele-operational details – Interchangeable tool tips

Experimental task - grasp / transfer

Experimental task - Grasp and transfer with orientation

Experimental task - Clip application

Experimental task – grasper / gripper and shear / scissors

Lap experiment box @ MIT

Lap simulator-1 @ MIT

Lap simulator-2 @ MIT

Dynamics of robotics @ UC Surgeon – remote location – TV console – set of handheld controls ~ videogame joysticks Joystick: Pencil-sized; 1 for each hand Computer: Program translates surgeon’s movements End-effectors: Robotic instruments enter body to perform actual operation Early models: 3-fingered hand Present: Hydraulic-powered, single-digit, 3-4” x ½”, 4-jointed (rotate, swivel, to-fro), 2-pronged end grasper Anthropomorphic movements http://robotics.eecs.berkeley.edu/medical/

Details of robots ‘Robo-doc’: 2 robots working in concert Holding robots Companion robots / milli-robots / robotic manipulators

Holding robots Pair of large robotic arms Hydraulic-actuated Sits on moveable platform Driven remotely by surgeon’s joysticks Performs like a surgeon’s shoulder, allowing positioning of its hydraulic arms

Holding robots – cont’d Holds 2nd robot, wheels instruments into position by patient’s side Guides them through dexterity-requiring surgical procedures (suturing, dissection) Holds instruments steady while surgeon sutures and ties knots

Companion / Milli-robots / Robotic manipulators Sterile, disposable, steel, mm-scale, fingertip-sized Slender, jointed, finger-like tools Connected by wires and tubes to larger robot Pair of gripping forceps at one end to carry surgical tools Contains miniscule video-camera

Companion robot – cont’d Inserted into body for actual surgical tasks (cutting, suturing) – 10-20 mm incisions Inserts cameras Provide tactile feedback though force-deflecting joysticks Provides 7 DOF

Setup @ UC Berkeley

Equipment @ UCB

Robotic manipulator @ UCB

Mini robot controls @ UCB Roll-pitch-roll ‘wrist’, gripper and multi-fingered manipulators

Robotic endo-manipulator Endo-platform with biopsy forceps

Minute threading

Threaded robotic instruments – knot tying

2-G RTWL @ UCSF

Lap interface @ UCSF

4-DOF lap haptic interface

Robotic Cardiac Surgery @ EHIRC da Vinci Tele-manipulation system Intuitive Surgical Inc., Mountain View, CA, USA Computer enhanced system Surgeon’s console Cart-mounted robotic manipulators http://www.ehirc.com/individuals/services/treatment/robotic_surgery.html#

Surgeon’s console @ EHIRC Display system: 3-D pictures of chest cavity Surgeon sits at console and gets 3-D view of chest interior Hand motions are captured, transformed and transmitted to tiny robotic manipulators

Robotic manipulators @ EHIRC Robot is not autonomous; surgeon-controlled Hold tiny instruments, which go inside the patient's chest. Surgeon's hand movements transmitted to these instruments CABG, mitral valve repair, ASD closure

IMA – LAD CABG

Totally endoscopic CABG Advantages Only 3-incisions, each 1 cm on the side and lower chest Less pain Faster healing and recovery Short hospital stay

Technical innovations Teletactation (Tactile feedback) CyberGlove® with CyberTouch Dextrous master glove Spatial cognition – Hand assist Surgical simulations Dextrous mini-robots

Teletactation –Tactile feedback Sensing tactile information through tactile sensors that transmit feel of tissue to surgeon’s finger

CyberTouch – CyberGlove® Vibro-tactile, thermal simulators on each finger and palm Tactile feedback option enables feel of virtual object

CyberGlove® Flexible sensors measure position / movement of fingers and wrist

Dextrous master glove Thumb, index, wrist flexion sensors and wrist rotation sensor Senses positions of surgeon's fingers/wrist Used as master to drive slave robotic hand

Spatial cognition – Hand assist in telesurgery Non-dominant hand in-vivo possibly enhances spatial skills through tactile cues, which generate a more accurate 3-D representation of anatomy

Lap chole simulation Simulated fat and fascia Dissected away; cystic duct clipped

Lap chole simulation – cont’d Cystic artery and duct divided successfully in simulated conditions

Karlsruhe Gynec endo surgery simulations

Gynec surgery simulations – cont’d http://www-kismet.iai.fzk.de/VRTRAIN/phD_main.html http://www-kismet.iai.fzk.de/VRTRAIN/GIF/PHD/surgSim.jpg

Dextrous mini robots 1 – Camera attachment 2 – Equipped with a needle for biopsy 3 – Moves around abdominal cavity – spiral pattern – moves without slipping http://news.bbc.co.uk/1/hi/health/4647258.stm

Summary Technically demanding, labour intensive, time consuming, expensive research Learning curve with similar characteristics Expensive installation, maintenance and infrastructure

Future applications Emergency trauma care – 1st ‘Golden Hour’ Battlefield surgery Remote area assistance One-to-many telementoring Space station surgery

Pre-conclusion “Science knows no country, because knowledge belongs to humanity, and is the torch which illuminates the world.” Louis Pasteur “Don't be afraid to take a big step. You can't cross a chasm in two small jumps.” David Lloyd George

Conclusion Cutting edge research today, surgical technology tomorrow