1. Advances in Telesurgery and Surgical Robotics
Dr S. Sanyal

2. 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

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

4. 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

5. Definitions
Telepresence surgery: Computerized surgical workstation ↔ remote operative site; force feedback (haptic)
Cooperative telesurgery: tele-surgeon / local (remote) assistant cooperation

6. Definitions – cont’d
Telerobotics: Remote control with a robotic arm, in conjunction with a laparoscope

7. 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

8. 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

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

10. 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

11. 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 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)

12. Telesurg components @ MIT

13. Surgeon’s master tool handle @ MIT

14. Surgeon’s master tool handle @ MIT

15. Master phantom haptic interface arm

16. Slave phantom haptic interface arm

17. Tele-operation slave tool

18. Tele-operation slave tool

19. Tele-operational details – Tool

20. Tele-operational details – Interchangeable tool tips

21. Experimental task - grasp / transfer

22. Experimental task - Grasp and transfer with orientation

23. Experimental task - Clip application

24. Experimental task – grasper / gripper and shear / scissors

25. Lap experiment box @ MIT

26. Lap MIT

27. Lap MIT

28. 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

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

30. 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

31. 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

32. 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

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

34. UC Berkeley

35. UCB

36. Robotic manipulator @ UCB

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

38. Robotic endo-manipulator
Endo-platform with biopsy forceps

39. Minute threading

40. Threaded robotic instruments – knot tying

41. 2-G UCSF

42. Lap UCSF

43. 4-DOF lap haptic interface

44. 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

45. 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

46. 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

47. IMA – LAD CABG

48. 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

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

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

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

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

53. 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

54. 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

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

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

57. Karlsruhe Gynec endo surgery simulations

58. Gynec surgery simulations – cont’d

59. Dextrous mini robots 1 – Camera attachment
2 – Equipped with a needle for biopsy
3 – Moves around abdominal cavity – spiral pattern – moves without slipping

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

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

62. 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

63. Conclusion
Cutting edge research today,
surgical technology tomorrow