1. History, current and future applications
Medical Robotics
History, current and future applications

2. Overview Introduction Classification Application of Medical Robotics
Design of Robotic Telesurgery
Historic Companies and Systems
Existing surgical systems
Strengths and Limitations
Ethical and Safety Considerations
Challenges, Future and Conclusion

3. Introduction(1) Definition: Robotic systems for surgery
There are computer-integrated surgery (CIS) systems first, and “medical robots” second. The robot itself is just one element of a larger system designed to assist a surgeon in carrying out a surgical procedure..” [Taylor, 2003]

4. Information flow in CIS
Introduction(2)
CIS
Information flow in CIS

5. Introduction(3) Motivation:
Started with the weaknesses and strengths of minimally invasive surgery (MIS)
Smaller incisions, shorter post-operative time, reduced infection, faster rehabilitation, lesser pain, better cosmetics, ...
Eye-hand coordination, difficulty in moving arms, degree of motion

6. Introduction(4)
MIS
Minimally invasive surgery uses techniques of surgical access and exposure that significantly reduce trauma to the body compared to traditional incisions.

7. Classification
Depending on the degree of surgeon interaction during the procedure:
Supervisory-controlled;
Telesurgical;
Shared-control;

8. Application of Medical Robotics(1)
Laboratory Robots
For pre-programmed tasks
High repetitions
Perform multiple-tests in parallel
Manufacturers include, Thermo Electron Corp, Hamilton Co, Central Research Laboratories (CRL), A Dover Diversified Co etc.

9. Application of Medical Robotics(2)
Telesurgery
Surgeon sits at a console
Has controls to move the robotic arms
Does not operate on the patient directly
Mainly used in minimally invasive surgeries

10. Application of Medical Robotics(3)
Surgical Training
Robots used as surgical training simulators
Used for medical resident students
Residents lack expertise and this helps in avoiding legal, social and economic problems
The Second Generation Robotic Telesurgical System for Laparoscopy during tests in the Experimental Surgery Lab at UC San Francisco

11. Application of Medical Robotics(4)
Telemedicine and Teleconsultation
Telecommunciation channels to communicate with other physicians/patients
Control an external camera which in turn controls an endoscopic camera – used to share images with a remote surgeon

12. Application of Medical Robotics(5)
Rehabilitation
Assistive robots
Wheelchair with intelligent navigational control system

13. Application of Medical Robotics(6)
Remote surgery
Surgeon can be anywhere in the world
Remotely controls the robotic surgical system
Very useful for treating wounded people in battlefields

14. Application of Medical Robotics(7)
Laparoscopic Surgery
Performed in the abdominal cavity using MIS
Abdomen cavity is expanded using CO2
Uses Laparoscopic instrument
Fiber optic channels to illuminate the inside of abdominal cavity
Lens optics to transmit image
CCD camera at the outer end
Image displayed on high resolution TV

15. Application of Medical Robotics(8)
Laparoscopic Surgery
Traditional laparoscope instruments have limitations
Has 4 DOFs - Arbitrary orientation of instrument tip not possible
Reduction in dexterity
Reduction in motion reversal due to fulcrum at entry point
Friction at air tight trocar – reduction in force feedback
Lack of tactile sensing

16. Design of Robotic Telesurgery(1)
Minimally Invasive Surgery
Surgery performed by making small incisions < 10mm dia
Reduces post-operative pain and hospital stays
Form of telemanipulation
Instruments have a camera attached to transmit inside image to the surgeon

17. Design of Robotic Telesurgery(2)
The Concept
Telerobotics is a natural tool to extend capabilities in MIS
The goal is to restore the manipulation and sensation capabilities of the surgeon
Using a 6 DOF slave manipulator, controlled through a spatially consistent and intuitive master

18. Design of Robotic Telesurgery(3)
The Concept
Telesurgical system concept

19. Design of Robotic Telesurgery(4)
Considerations:
Compatibility
Backdrivabilit
Actuator’s impedance
Actuators receive tool-to-tissue force
Loss of power can lead to dropping of a heavy tool and undesirable high accelerations in the actuator

20. Design of Robotic Telesurgery(5)
Considerations:
Human-Machine Interface
Video system used to capture images inside the patient
Backlash-loss of motion between a set of movable parts
Choose the appropriate mechanism for the required transmission
Choose passive gravity balance over active gravity balance

21. Design of Robotic Telesurgery(6)
Haptic Feedback
Sensation of touch lost in robotic surgery
Receiving haptic information and using it to control the robotic manipulators
Needed to achieve high fidelity
Types
Force (kinesthetic) feedback
Tactile (cutaneous) feedback

22. Design of Robotic Telesurgery(7)
Haptic Feedback
Hand tie – tradition suturing mechanism
Instrument tie – estimate of performance (same type of feedback as resolved-force feedback)
Robotic tie – suturing task performed by da Vinci®

23. Design of Robotic Telesurgery(8)
Haptic Feedback
Experimental results
Accuracy cannot be improved to the level of hand ties by using force feedback
Hand tie had the lowest NSD. Repeatability can be improved by using force feedback in robotic surgical systems
Both instrument and robot reduces the performance margin between expert and novice users

24. Design of Robotic Telesurgery(9)
Haptic Feedback
Fidelity – ability to detect compliance variations in the environment
P (Position error) +FF (kinesthetic force feedback) control architecture – to determine if the use of force sensor on slave manipulator will provide fidelity

25. Historic Companies and Systems(1)
First Robotic assisted surgery 1988
– PUMA 560
– Light duty industrial robotic arm to guide laser/needle for sterostactic brain surgery

26. Historic Companies and Systems(2)
First Robotic urological surgery 1992
– PROBOT-assisted TURP in Guy’s Hospital in London leaded by Wickham

27. Historic Companies and Systems(3)
First commercially available robotic system, 1992
– ROBODOC for orthopaedic hip surgery

28. Historic Companies and Systems(4)
First RCT of transatlantic telerobotics surgery
– Between Guy’s and John Hopkins Hospitals
– PAKY-RCM percutaneous access robot (Kavoussi group developed in 1996)

29. Existing surgical systems(1)
AESOP (Computer Motion), 1994
– Automated Endoscopic System for Optimal Positioning – a voice-activated robotic arm for camera holder
– First approved surgical robotic system by FDA

30. Existing surgical systems(2)
AESOP

31. Existing surgical systems(3)
ZEUS (Computer Motion)
– Marketed in 1998

32. Existing surgical systems(4)
Da Vinci (Intuitive Surgical)
– Initially developed by US Department of Defence in 1991
– Intuitive Surgical acquired the prototype and commercialized the system
– Approved by FDA in July 2000

33. Existing surgical systems(5)
Da Vinci Surgical® system by Intuitive Surgical, Inc.

34. Existing surgical systems(6)
Da Vinci Surgical® system by Intuitive Surgical, Inc.
Surgical Console - 3D display and master control
Patient side cart - two or three instrument arms and one endoscope arm
EndoWrist Instrument - 7 DOFs, quick-release levers
InSite Vision System - high resolution 3D endoscope and image processing equipment

35. Existing surgical systems(7)
Da Vinci Surgical® system by Intuitive Surgical, Inc.

36. Existing surgical systems(8)
Da Vinci Surgical® system by Intuitive Surgical, Inc.
Video

37. Existing surgical systems(9)
Advantages of Da Vinci Surgical®:
Technically
– Patented Endowrist: 6 degrees of movement
– 3-D vision (Dual channel endoscopy) and magnified view (x12)
– Tremor suppression and scaling of movement
Surgeon
– Ergonomic advantage
– Shorter learning curve
Patient
– Better outcome

38. Existing surgical systems(10)
Advantages:

39. Existing surgical systems(11)
6 degree movements

40. Existing surgical systems(12)
Da Vinci surgical system in a general procedure setting

41. Existing surgical systems(13)
da Vinci® Surgical System U.S. Installed Base 1999 – 2008

42. Strengths and Limitations(1)
Physical separation
Wrist action
Tremor elimination
Optional motion scaling
Three-dimensional stereoscopic image
Electronic information transfer (Telesurgery)

43. Strengths and Limitations(2)
Reluctance to accept this technology (trust)
Additional training
Fail proof?
Most of the sensors use IR transmission
Highly efficient visual instruments are needed
Cannot be pre-programmed
Task-specific robots are required
Latency in transmission of mechanical movements by the surgeon
Longer operating time

44. Strengths and Limitations(3)
Cost for the Da Vinci system:
The average base cost of a System is $1.5 million
Approximately $ 160,000 maintenance cost a year
Operating room cost, $150 per hour
Hospital stay cost, $600 per day
Time away from work, $120 per day

45. Ethical and Safety Considerations
When there is a marginal benefit from using robots, is it ethical to impose financial burden on patients or medical systems?
If a robot-assisted surgery fails because of technical problems, is it the surgeon who is responsible or others?

46. Challenges, Future and Conclusion
Haptic feedback
A safe, easy sterilizable, accurate, cheap and compact robot
Reliable telesurgical capabilities
Compatibility with available medical equipment and standardizing
Autonomous robot surgeons

47. Reference
Robotics in surgery: history, current and future applications. New York: Nova Science Pub-. lishers; 2007
J.E. Speich, J. Rosen, 'Medical Robotics,' In Encyclopedia of Biomaterials and Biomedical Engineering, pp , Marcel Dekker, New York, 2004.
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48. Thanks!