Towards an Action Recognition Framework for Endovascular Surgery.

Objective knowledge about instrument manoeuvres in endovascular surgery is essential for evaluating surgical skills and developing advanced technologies for cathlab routines. To the recent day, endovascular navigation has been exclusively assessed in laboratory scenarios. By contrast, information contained in available fluoroscopy data from clinical cases has been disregarded. In this work, we pioneer a learning-based framework for motion activity recognition in fluoroscopy sequences. The architecture is composed of two networks for instrument segmentation and action recognition. In this preliminary study, we demonstrate feasibility of recognising instrument manoeuvres automatically in our ex vivo datasets.Clinical relevance-The proposed framework contributes to image-based and automated assessment of endovascular tasks. This facilitates robotic control development, surgical education, and smart clinical documentation.

In-Vivo Validation of a Novel Robotic Platform for Endovascular Intervention.

OBJECTIVE: In-vivo validation on animal setting of a pneumatically propelled robot for endovascular intervention, to determine safety and clinical advantage of robotic cannulations compared to manual operation. METHODS: Robotic assistance and image-guided intervention are increasingly used for improving endovascular procedures with enhanced navigation dexterity and accuracy. However, most platforms developed in the past decade still present inherent limitations in terms of altered clinical workflow, counterintuitive human-robot interaction, and a lack of versatility. We have created a versatile, highly integrated platform for robot-assisted endovascular intervention aimed at addressing such limitations, and here we demonstrate its clinical usability through in-vivo animal trials. A detailed in-vivo study on four porcine models conducted with our robotic platform is reported, involving cannulation and balloon angioplasty of five target arteries. RESULTS: The trials showed a 100% success rate, and post-mortem histopathological assessment demonstrated a reduction in the incidence and severity of vessel trauma with robotic navigation versus manual manipulation. CONCLUSION: In-vivo experiments demonstrated that the applicability of our robotic system within the context of this study was well tolerated, with good feasibility, and low risk profile. Comparable results were observed with robotics and manual cannulation, with clinical outcome potentially in favor of robotics. SIGNIFICANCE: This study showed that the proposed robotic platform can potentially improve the execution of endovascular procedures, paving the way for clinical translation.

Progress in robotics for combating infectious diseases.

The world was unprepared for the COVID-19 pandemic, and recovery is likely to be a long process. Robots have long been heralded to take on dangerous, dull, and dirty jobs, often in environments that are unsuitable for humans. Could robots be used to fight future pandemics? We review the fundamental requirements for robotics for infectious disease management and outline how robotic technologies can be used in different scenarios, including disease prevention and monitoring, clinical care, laboratory automation, logistics, and maintenance of socioeconomic activities. We also address some of the open challenges for developing advanced robots that are application oriented, reliable, safe, and rapidly deployable when needed. Last, we look at the ethical use of robots and call for globally sustained efforts in order for robots to be ready for future outbreaks.

An MR-Safe Endovascular Robotic Platform: Design, Control, and Ex-Vivo Evaluation.

OBJECTIVE: Cardiovascular diseases are the most common cause of global death. Endovascular interventions, in combination with advanced imaging technologies, are promising approaches for minimally invasive diagnosis and therapy. More recently, teleoperated robotic platforms target improved manipulation accuracy, stabilisation of instruments in the vasculature, and reduction of patient recovery times. However, benefits of recent platforms are undermined by a lack of haptics and residual patient exposure to ionising radiation. The purpose of this research was to design, implement, and evaluate a novel endovascular robotic platform, which accommodates emerging non-ionising magnetic resonance imaging (MRI). METHODS: We proposed a pneumatically actuated MR-safe teleoperation platform to manipulate endovascular instrumentation remotely and to provide operators with haptic feedback for endovascular tasks. The platform task performance was evaluated in an ex vivo cannulation study with clinical experts ( N = 7) under fluoroscopic guidance and haptic assistance on abdominal and thoracic phantoms. RESULTS: The study demonstrated that the robotic dexterity involving pneumatic actuation concepts enabled successful remote cannulation of different vascular anatomies with success rates of 90%-100%. Compared to manual cannulation, slightly lower interaction forces between instrumentation and phantoms were measured for specific tasks. The maximum robotic interaction forces did not exceed 3N. CONCLUSION: This research demonstrates a promising versatile robotic technology for remote manipulation of endovascular instrumentation in MR environments. SIGNIFICANCE: The results pave the way for clinical translation with device deployment to endovascular interventions using non-ionising real-time 3D MR guidance.

Frontiers of Medical Robotics: From Concept to Systems to Clinical Translation.

Medical robotics is poised to transform all aspects of medicine-from surgical intervention to targeted therapy, rehabilitation, and hospital automation. A key area is the development of robots for minimally invasive interventions. This review provides a detailed analysis of the evolution of interventional robots and discusses how the integration of imaging, sensing, and robotics can influence the patient care pathway toward precision intervention and patient-specific treatment. It outlines how closer coupling of perception, decision, and action can lead to enhanced dexterity, greater precision, and reduced invasiveness. It provides a critical analysis of some of the key interventional robot platforms developed over the years and their relative merit and intrinsic limitations. The review also presents a future outlook for robotic interventions and emerging trends in making them easier to use, lightweight, ergonomic, and intelligent, and thus smarter, safer, and more accessible for clinical use.

Design and Evaluation of a Percutaneous Fragment Manipulation Device for Minimally Invasive Fracture Surgery.

Reduction of fractures in the minimally invasive (MI) manner can avoid risks associated with open fracture surgery. The MI approach requires specialized tools called percutaneous fragment manipulation devices (PFMD) to enable surgeons to safely grasp and manipulate fragments. PFMDs developed for long-bone manipulation are not suitable for intra-articular fractures where small bone fragments are involved. With this study, we offer a solution to potentially move the current fracture management practice closer to the use of a MI approach. We investigate the design and testing of a new PFMD design for manual as well as robot-assisted manipulation of small bone fragments. This new PFMD design is simulated using FEA in three loading scenarios (force/torque: 0 N/2.6 Nm, 75.7 N/3.5 N, 147 N/6.8 Nm) assessing structural properties, breaking points, and maximum bending deformations. The PFMD is tested in a laboratory setting on Sawbones models (0 N/2.6 Nm), and on ex-vivo swine samples (F = 80 N ± 8 N, F = 150 ± 15 N). A commercial optical tracking system was used for measuring PFMD deformations under external loading and the results were verified with an electromagnetic tracking system. The average error difference between the tracking systems was 0.5 mm, being within their accuracy limits. Final results from reduction maneuvers performed both manually and with the robot assistance are obtained from 7 human cadavers with reduction forces in the range of (F = 80 N ± 8 N, F = 150 ± 15 N, respectively). The results show that structurally, the system performs as predicted by the simulation results. The PFMD did not break during ex-vivo and cadaveric trials. Simulation, laboratory, and cadaveric tests produced similar results regarding the PFMD bending. Specifically, for forces applied perpendicularly to the axis of the PFMD of 80 N ± 8 N deformations of 2.8, 2.97, and 3.06 mm are measured on the PFMD, while forces of 150 ± 15 N produced deformations of 5.8, 4.44, and 5.19 mm. This study has demonstrated that the proposed PFMD undergoes predictable deformations under typical bone manipulation loads. Testing of the device on human cadavers proved that these deformations do not affect the anatomic reduction quality. The PFMD is, therefore, suitable to reliably achieve and maintain fracture reductions, and to, consequently, allow external fracture fixation.

Robot-Assisted Fracture Surgery: Surgical Requirements and System Design.

The design of medical devices is a complex and crucial process to ensure patient safety. It has been shown that improperly designed devices lead to errors and associated accidents and costs. A key element for a successful design is incorporating the views of the primary and secondary stakeholders early in the development process. They provide insights into current practice and point out specific issues with the current processes and equipment in use. This work presents how information from a user-study conducted in the early stages of the RAFS (Robot Assisted Fracture Surgery) project informed the subsequent development and testing of the system. The user needs were captured using qualitative methods and converted to operational, functional, and non-functional requirements based on the methods derived from product design and development. This work presents how the requirements inform a new workflow for intra-articular joint fracture reduction using a robotic system. It is also shown how the various elements of the system are developed to explicitly address one or more of the requirements identified, and how intermediate verification tests are conducted to ensure conformity. Finally, a validation test in the form of a cadaveric trial confirms the ability of the designed system to satisfy the aims set by the original research question and the needs of the users.

Image-Guided Surgical Robotic System for Percutaneous Reduction of Joint Fractures.

Complex joint fractures often require an open surgical procedure, which is associated with extensive soft tissue damages and longer hospitalization and rehabilitation time. Percutaneous techniques can potentially mitigate these risks but their application to joint fractures is limited by the current sub-optimal 2D intra-operative imaging (fluoroscopy) and by the high forces involved in the fragment manipulation (due to the presence of soft tissue, e.g., muscles) which might result in fracture malreduction. Integration of robotic assistance and 3D image guidance can potentially overcome these issues. The authors propose an image-guided surgical robotic system for the percutaneous treatment of knee joint fractures, i.e., the robot-assisted fracture surgery (RAFS) system. It allows simultaneous manipulation of two bone fragments, safer robot-bone fixation system, and a traction performing robotic manipulator. This system has led to a novel clinical workflow and has been tested both in laboratory and in clinically relevant cadaveric trials. The RAFS system was tested on 9 cadaver specimens and was able to reduce 7 out of 9 distal femur fractures (T- and Y-shape 33-C1) with acceptable accuracy (≈1 mm, ≈5°), demonstrating its applicability to fix knee joint fractures. This study paved the way to develop novel technologies for percutaneous treatment of complex fractures including hip, ankle, and shoulder, thus representing a step toward minimally-invasive fracture surgeries.

Intra-operative fiducial-based CT/fluoroscope image registration framework for image-guided robot-assisted joint fracture surgery.

PURPOSE: Joint fractures must be accurately reduced minimising soft tissue damages to avoid negative surgical outcomes. To this regard, we have developed the RAFS surgical system, which allows the percutaneous reduction of intra-articular fractures and provides intra-operative real-time 3D image guidance to the surgeon. Earlier experiments showed the effectiveness of the RAFS system on phantoms, but also key issues which precluded its use in a clinical application. This work proposes a redesign of the RAFS's navigation system overcoming the earlier version's issues, aiming to move the RAFS system into a surgical environment. METHODS: The navigation system is improved through an image registration framework allowing the intra-operative registration between pre-operative CT images and intra-operative fluoroscopic images of a fractured bone using a custom-made fiducial marker. The objective of the registration is to estimate the relative pose between a bone fragment and an orthopaedic manipulation pin inserted into it intra-operatively. The actual pose of the bone fragment can be updated in real time using an optical tracker, enabling the image guidance. RESULTS: Experiments on phantom and cadavers demonstrated the accuracy and reliability of the registration framework, showing a reduction accuracy (sTRE) of about [Formula: see text] (phantom) and [Formula: see text] (cadavers). Four distal femur fractures were successfully reduced in cadaveric specimens using the improved navigation system and the RAFS system following the new clinical workflow (reduction error [Formula: see text], [Formula: see text]. CONCLUSION: Experiments showed the feasibility of the image registration framework. It was successfully integrated into the navigation system, allowing the use of the RAFS system in a realistic surgical application.

Navigation system for robot-assisted intra-articular lower-limb fracture surgery.

PURPOSE: In the surgical treatment for lower-leg intra-articular fractures, the fragments have to be positioned and aligned to reconstruct the fractured bone as precisely as possible, to allow the joint to function correctly again. Standard procedures use 2D radiographs to estimate the desired reduction position of bone fragments. However, optimal correction in a 3D space requires 3D imaging. This paper introduces a new navigation system that uses pre-operative planning based on 3D CT data and intra-operative 3D guidance to virtually reduce lower-limb intra-articular fractures. Physical reduction in the fractures is then performed by our robotic system based on the virtual reduction. METHODS: 3D models of bone fragments are segmented from CT scan. Fragments are pre-operatively visualized on the screen and virtually manipulated by the surgeon through a dedicated GUI to achieve the virtual reduction in the fracture. Intra-operatively, the actual position of the bone fragments is provided by an optical tracker enabling real-time 3D guidance. The motion commands for the robot connected to the bone fragment are generated, and the fracture physically reduced based on the surgeon's virtual reduction. To test the system, four femur models were fractured to obtain four different distal femur fracture types. Each one of them was subsequently reduced 20 times by a surgeon using our system. RESULTS: The navigation system allowed an orthopaedic surgeon to virtually reduce the fracture with a maximum residual positioning error of [Formula: see text] (translational) and [Formula: see text] (rotational). Correspondent physical reductions resulted in an accuracy of 1.03 ± 0.2 mm and [Formula: see text], when the robot reduced the fracture. CONCLUSIONS: Experimental outcome demonstrates the accuracy and effectiveness of the proposed navigation system, presenting a fracture reduction accuracy of about 1 mm and [Formula: see text], and meeting the clinical requirements for distal femur fracture reduction procedures.

Vision-based real-time position control of a semi-automated system for robot-assisted joint fracture surgery.

PURPOSE: Joint fracture surgery quality can be improved by robotic system with high-accuracy and high-repeatability fracture fragment manipulation. A new real-time vision-based system for fragment manipulation during robot-assisted fracture surgery was developed and tested. METHODS: The control strategy was accomplished by merging fast open-loop control with vision-based control. This two-phase process is designed to eliminate the open-loop positioning errors by closing the control loop using visual feedback provided by an optical tracking system. Evaluation of the control system accuracy was performed using robot positioning trials, and fracture reduction accuracy was tested in trials on ex vivo porcine model. RESULTS: The system resulted in high fracture reduction reliability with a reduction accuracy of 0.09 mm (translations) and of [Formula: see text] (rotations), maximum observed errors in the order of 0.12 mm (translations) and of [Formula: see text] (rotations), and a reduction repeatability of 0.02 mm and [Formula: see text]. CONCLUSIONS: The proposed vision-based system was shown to be effective and suitable for real joint fracture surgical procedures, contributing a potential improvement of their quality.

Powered exoskeleton with palm degrees of freedom for hand rehabilitation.

Robotic rehabilitation is a currently underutilised field with the potential to allow huge cost savings within healthcare. Existing rehabilitation exoskeletons oversimplify the importance of movement of the hand while undertaking everyday tasks. Within this study, an investigation was undertaken to establish the extent to which the degrees of freedom within the palm affect ability to undertake everyday tasks. Using a 5DT data glove, bend sensing resistors and restrictors of palm movement, 20 participants were recruited to complete tasks that required various hand shapes. Collected data was processed and palm arching trends were identified for each grasping task. It was found that the extent of utilizing arches in the palm varied with each exercise, but was extensively employed throughout. An exoskeleton was subsequently designed with consideration of the identified palm shapes. This design included a number of key features that accommodated for a variety of hand sizes, a novel thumb joint and a series of dorsally mounted servos. Initial exoskeleton testing was undertaken by having a participant complete the same exercises while wearing the exoskeleton. The angles formed by the user during this process were then compared to those recorded by 2 other participants who had completed the same tasks without exoskeleton. It was found that the exoskeleton was capable of forming the required arches for completing the tasks, with differences between participants attributed to individual ergonomic differences.

Preliminary analysis of force-torque measurements for robot-assisted fracture surgery.

Our group at Bristol Robotics Laboratory has been working on a new robotic system for fracture surgery that has been previously reported [1]. The robotic system is being developed for distal femur fractures and features a robot that manipulates the small fracture fragments through small percutaneous incisions and a robot that re-aligns the long bones. The robots controller design relies on accurate and bounded force and position parameters for which we require real surgical data. This paper reports preliminary findings of forces and torques applied during bone and soft tissue manipulation in typical orthopaedic surgery procedures. Using customised orthopaedic surgical tools we have collected data from a range of orthopaedic surgical procedures at Bristol Royal Infirmary, UK. Maximum forces and torques encountered during fracture manipulation which involved proximal femur and soft tissue distraction around it and reduction of neck of femur fractures have been recorded and further analysed in conjunction with accompanying image recordings. Using this data we are establishing a set of technical requirements for creating safe and dynamically stable minimally invasive robot-assisted fracture surgery (RAFS) systems.

A vision-based system for fast and accurate laser scanning in robot-assisted phonomicrosurgery.

PURPOSE: Surgical quality in phonomicrosurgery can be improved by open-loop laser control (e.g., high-speed scanning capabilities) with a robust and accurate closed-loop visual servoing systems. A new vision-based system for laser scanning control during robot-assisted phonomicrosurgery was developed and tested. METHODS: Laser scanning was accomplished with a dual control strategy, which adds a vision-based trajectory correction phase to a fast open-loop laser controller. The system is designed to eliminate open-loop aiming errors caused by system calibration limitations and by the unpredictable topology of real targets. Evaluation of the new system was performed using CO(2) laser cutting trials on artificial targets and ex-vivo tissue. RESULTS: This system produced accuracy values corresponding to pixel resolution even when smoke created by the laser-target interaction clutters the camera view. In realistic test scenarios, trajectory following RMS errors were reduced by almost 80 % with respect to open-loop system performances, reaching mean error values around 30 µ m and maximum observed errors in the order of 60 µ m. CONCLUSION: A new vision-based laser microsurgical control system was shown to be effective and promising with significant positive potential impact on the safety and quality of laser microsurgeries.

New software tools for enhanced precision in robot-assisted laser phonomicrosurgery.

This paper describes a new software package created to enhance precision during robot-assisted laser phonomicrosurgery procedures. The new software is composed of three tools for camera calibration, automatic tumor segmentation, and laser tracking. These were designed and developed to improve the outcome of this demanding microsurgical technique, and were tested herein to produce quantitative performance data. The experimental setup was based on the motorized laser micromanipulator created by Istituto Italiano di Tecnologia and the experimental protocols followed are fully described in this paper. The results show the new tools are robust and effective: The camera calibration tool reduced residual errors (RMSE) to 0.009 ± 0.002 mm under 40× microscope magnification; the automatic tumor segmentation tool resulted in deep lesion segmentations comparable to manual segmentations (RMSE= 0.160 ± 0.028 mm under 40× magnification); and the laser tracker tool proved to be reliable even during cutting procedures (RMSE= 0.073 ± 0.023 mm under 40× magnification). These results demonstrate the new software package can provide excellent improvements to the previous microsurgical system, leading to important enhancements in surgical outcome.

Comparative evaluation of user interfaces for robot-assisted laser phonomicrosurgery.

This research investigates the impact of three different control devices and two visualization methods on the precision, safety and ergonomics of a new medical robotic system prototype for assistive laser phonomicrosurgery. This system allows the user to remotely control the surgical laser beam using either a flight simulator type joystick, a joypad, or a pen display system in order to improve the traditional surgical setup composed by a mechanical micromanipulator coupled with a surgical microscope. The experimental setup and protocol followed to obtain quantitative performance data from the control devices tested are fully described here. This includes sets of path following evaluation experiments conducted with ten subjects with different skills, for a total of 700 trials. The data analysis method and experimental results are also presented, demonstrating an average 45% error reduction when using the joypad and up to 60% error reduction when using the pen display system versus the standard phonomicrosurgery setup. These results demonstrate the new system can provide important improvements in terms of surgical precision, ergonomics and safety. In addition, the evaluation method presented here is shown to support an objective selection of control devices for this application.

Using an intravenous catheter system to prevent needlestick injury.

AIM: To identify the effect of a sharps awareness campaign and the introduction of a safety catheter device on the annual incidence of needlestick injuries between 2003 and 2007. METHOD: In 2003, a sharps awareness campaign began in San Martino Hospital in Genoa, Italy. In 2005, a safety catheter was introduced and healthcare workers were trained in its use. Data for all occupational accidents from 2003 to 2007 were collected and analysed. RESULTS: After introduction of the sharps awareness campaign and use of safety catheters, reported incidents of sharps injuries involving catheters fell from 19 in 2004 to two in 2007 and in neither of those two cases were needlestick prevention devices used. Overall, the rate of needlestick injuries was 24.1 per 100,000 cases when conventional catheters were used and 0.4 per 100,000 cases with safety catheters. CONCLUSION: The sharps awareness campaign and newly adopted needlestick prevention device may have contributed to the prevention of percutaneous injuries caused by catheters. Until the onset of the campaign, the reported annual incidence of needlestick injuries was six. This increased to a peak of 19 reported injuries in 2004, which could be attributed to improved reporting effected by the campaign.