Multi-mode information fusion navigation system for robot-assisted vascular interventional surgery.

BACKGROUND: Minimally invasive vascular intervention (MIVI) is a powerful technique for the treatment of cardiovascular diseases, such as abdominal aortic aneurysm (AAA), thoracic aortic aneurysm (TAA) and aortic dissection (AD). Navigation of traditional MIVI surgery mainly relies only on 2D digital subtraction angiography (DSA) images, which is hard to observe the 3D morphology of blood vessels and position the interventional instruments. The multi-mode information fusion navigation system (MIFNS) proposed in this paper combines preoperative CT images and intraoperative DSA images together to increase the visualization information during operations. RESULTS: The main functions of MIFNS were evaluated by real clinical data and a vascular model. The registration accuracy of preoperative CTA images and intraoperative DSA images were less than 1 mm. The positioning accuracy of surgical instruments was quantitatively assessed using a vascular model and was also less than 1 mm. Real clinical data used to assess the navigation results of MIFNS on AAA, TAA and AD. CONCLUSIONS: A comprehensive and effective navigation system was developed to facilitate the operation of surgeon during MIVI. The registration accuracy and positioning accuracy of the proposed navigation system were both less than 1 mm, which met the accuracy requirements of robot assisted MIVI.

A Modular 3-Degrees-of-Freedom Force Sensor for Robot-Assisted Minimally Invasive Surgery Research.

Effective force modulation during tissue manipulation is important for ensuring safe, robot-assisted, minimally invasive surgery (RMIS). Strict requirements for in vivo applications have led to prior sensor designs that trade off ease of manufacture and integration against force measurement accuracy along the tool axis. Due to this trade-off, there are no commercial, off-the-shelf, 3-degrees-of-freedom (3DoF) force sensors for RMIS available to researchers. This makes it challenging to develop new approaches to indirect sensing and haptic feedback for bimanual telesurgical manipulation. We present a modular 3DoF force sensor that integrates easily with an existing RMIS tool. We achieve this by relaxing biocompatibility and sterilizability requirements and by using commercial load cells and common electromechanical fabrication techniques. The sensor has a range of ±5 N axially and ±3 N laterally with errors of below 0.15 N and maximum errors below 11% of the sensing range in all directions. During telemanipulation, a pair of jaw-mounted sensors achieved average errors below 0.15 N in all directions. It achieved an average grip force error of 0.156 N. The sensor is for bimanual haptic feedback and robotic force control in delicate tissue telemanipulation. As an open-source design, the sensors can be adapted to suit other non-RMIS robotic applications.

Robotic Assistance for Intraocular Microsurgery: Challenges and Perspectives.

Intraocular surgery, one of the most challenging discipline of microsurgery, requires sensory and motor skills at the limits of human physiological capabilities combined with tremendously difficult requirements for accuracy and steadiness. Nowadays, robotics combined with advanced imaging has opened conspicuous and significant directions in advancing the field of intraocular microsurgery. Having patient treatment with greater safety and efficiency as the final goal, similar to other medical applications, robotics has a real potential to fundamentally change microsurgery by combining human strengths with computer and sensor-based technology in an information-driven environment. Still in its early stages, robotic assistance for intraocular microsurgery has been accepted with precaution in the operating room and successfully tested in a limited number of clinical trials. However, owing to its demonstrated capabilities including hand tremor reduction, haptic feedback, steadiness, enhanced dexterity, micrometer-scale accuracy, and others, microsurgery robotics has evolved as a very promising trend in advancing retinal surgery. This paper will analyze the advances in retinal robotic microsurgery, its current drawbacks and limitations, as well as the possible new directions to expand retinal microsurgery to techniques currently beyond human boundaries or infeasible without robotics.

Design and experimental testing of a force-augmenting exoskeleton for the human hand.

BACKGROUND: Many older Americans suffer from long-term upper limb dysfunction, decreased grip strength, and/or a reduced ability to hold objects due to injuries and a variety of age-related illnesses. The objective of this study was to design and build a five-fingered powered assistive exoskeleton for the human hand, and to validate its ability to augment the gripping and pinching efforts of the wearer and assist in performing ADLs. METHODS: The exoskeleton device was designed using CAD software and 3-D printed in ABS. Each finger's movement efforts were individually monitored by a force sensing resistor at each fingertip, and proportionally augmented via the microcontroller-based control scheme, linear actuators, and rigid exoskeleton structure. The force production of the device and the force augmenting capability were assessed on ten healthy individuals with one 5-digit grasping test, three pinching tests, and two functional tests. RESULTS: Use of the device significantly decreased the forearm muscle activity necessary to maintain a grasping effort (67%, p < 0.001), the larger of two pinching efforts (30%, p < 0.05), and the palmer pinching effort (67%, p < 0.001); however, no benefit by wearing the device was identified while maintaining a minimal pinching effort or attempting one of the functional tests. CONCLUSION: The exoskeleton device allowed subjects to maintain independent control of each digit, and while wearing the exoskeleton, in both the unpowered and powered states, subjects were able to grasp, hold, and move objects such as a water bottle, bag, smartphone, or dry-erase marker.

s-CAM: An Untethered Insertable Laparoscopic Surgical Camera Robot with Non-Contact Actuation.

Fully insertable robotic imaging devices represent a promising future of minimally invasive laparoscopic vision. Emerging research efforts in this field have resulted in several proof-of-concept prototypes. One common drawback of these designs derives from their clumsy tethering wires which not only cause operational interference but also reduce camera mobility. In this paper, a tetherless insertable surgical camera (s-CAM) robot with non-contact transabdominal actuation is presented for single-incision laparoscopic vision. Wireless video transmission and control communication using onboard power help eliminate cumbersome tethering wires. Furthermore, magnetic based camera actuation gets rid of intrinsic physical constraints of mechanical driving mechanisms, thereby improving camera mobility and reducing operational interference. In addition, a custom Bluetooth low energy (BLE) application profile and a real-time operating system (RTOS) based multitask programming framework are also proposed to facilitate embedded software design for insertable medical devices. Initial ex vivo test results of the s-CAM design have demonstrated technical feasibility of a tetherless insertable laparoscopic camera. Effective imaging is confirmed at as low as 500 lx illumination. Wireless laparoscopic vision is accessible within a distance of more than 10 m. Transabdominal BLE communication is stable at over -52 dBm and shows its potential for wireless control of insertable medical devices. RTOS based sfotware event response is bounded within 1 ms while the CPU usage is at 3∼5%. The device is able to work for 50 min with its onboard power. For the mobility, the robot can translate against the interior abdominal wall to reach full abdomen quadrants, tilt between -180∘ and +180∘, and pan in the range of 0∘∼360∘. The s-CAM has brought robotic laparoscopic imaging one step further toward less invasiveness and more dexterity.

Characterization of the Workspace and Limits of Operation of Laser Treatments for Vascular Lesions of the Lower Limbs.

The increase of the aging population brings numerous challenges to health and aesthetic segments. Here, the use of laser therapy for dermatology is expected to increase since it allows for non-invasive and infection-free treatments. However, existing laser devices require doctors' manually handling and visually inspecting the skin. As such, the treatment outcome is dependent on the user's expertise, which frequently results in ineffective treatments and side effects. This study aims to determine the workspace and limits of operation of laser treatments for vascular lesions of the lower limbs. The results of this study can be used to develop a robotic-guided technology to help address the aforementioned problems. Specifically, workspace and limits of operation were studied in eight vascular laser treatments. For it, an electromagnetic tracking system was used to collect the real-time positioning of the laser during the treatments. The computed average workspace length, height, and width were 0.84 ± 0.15, 0.41 ± 0.06, and 0.78 ± 0.16 m, respectively. This corresponds to an average volume of treatment of 0.277 ± 0.093 m3. The average treatment time was 23.2 ± 10.2 min, with an average laser orientation of 40.6 ± 5.6 degrees. Additionally, the average velocities of 0.124 ± 0.103 m/s and 31.5 + 25.4 deg/s were measured. This knowledge characterizes the vascular laser treatment workspace and limits of operation, which may ease the understanding for future robotic system development.

Interactive 3D Force/Torque Parameter Acquisition and Correlation Identification during Primary Trocar Insertion in Laparoscopic Abdominal Surgery: 5 Cases.

Laparoscopic procedures have become indispensable in gastrointestinal surgery. As a minimally invasive process, it begins with primary trocar insertion. However, this step poses the threat of injuries to the gastrointestinal tract and blood vessels. As such, the comprehension of the insertion process is crucial to the development of robotic-assisted/automated surgeries. To sustain robotic development, this research aims to study the interactive force/torque (F/T) behavior between the trocar and the abdomen during the trocar insertion process. For force/torque (F/T) data acquisition, a trocar interfaced with a six-axis F/T sensor was used by surgeons for the insertion. The study was conducted during five abdominal hernia surgical cases in the Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University. The real-time F/T data were further processed and analyzed. The fluctuation in the force/torque (F/T) parameter was significant, with peak force ranging from 16.83 N to 61.86 N and peak torque ranging from 0.552 Nm to 1.76 Nm. The force parameter was observed to positively correlate with procedural time, while torque was found to be negatively correlated. Although during the process a surgeon applied force and torque in multiple axes, for a robotic system, the push and turn motion in a single axis was observed to be sufficient. For minimal tissue damage in less procedural time, a system with low push force and high torque was observed to be advantageous. These understandings will eventually benefit the development of computer-assisted or robotics technology to improve the outcome of the primary trocar insertion procedure.

A Transparent Teleoperated Robotic Surgical System with Predictive Haptic Feedback and Force Modelling.

In recent years, robotic minimally invasive surgery has transformed many types of surgical procedures and improved their outcomes. Implementing effective haptic feedback into a teleoperated robotic surgical system presents a significant challenge due to the trade-off between transparency and stability caused by system communication time delays. In this paper, these time delays are mitigated by implementing an environment estimation and force prediction methodology into an experimental robotic minimally invasive surgical system. At the slave, an exponentially weighted recursive least squares (EWRLS) algorithm estimates the respective parameters of the Kelvin-Voigt (KV) and Hunt-Crossley (HC) force models. The master then provides force feedback by interacting with a virtual environment via the estimated parameters. Palpation experiments were conducted with the slave in contact with polyurethane foam during human-in-the-loop teleoperation. The experimental results indicated that the prediction RMSE of error between predicted master force feedback and measured slave force was reduced to 0.076 N for the Hunt-Crossley virtual environment, compared to 0.356 N for the Kelvin-Voigt virtual environment and 0.560 N for the direct force feedback methodology. The results also demonstrated that the HC force model is well suited to provide accurate haptic feedback, particularly when there is a delay between the master and slave kinematics. Furthermore, a haptic feedback approach that incorporates environment estimation and force prediction improve transparency during teleoperation. In conclusion, the proposed bilateral master-slave robotic system has the potential to provide transparent and stable haptic feedback to the surgeon in surgical robotics procedures.

A Review of Exoskeletons Considering Nurses.

Daily tasks of nurses include manual handling to assist patients. Repetitive manual handling leads to high risk of injuries due to the loads on nurses' bodies. Nurses, in hospitals and care homes, can benefit from the advances in exoskeleton technology assisting their manual handling tasks. There are already exoskeletons both in the market and in the research area made to assist physical workers to handle heavy loads. However, those exoskeletons are mostly designed for men, as most physical workers are men, whereas most nurses are women. In the case of nurses, they handle patients, a more delicate task than handling objects, and any such device used by nurses should easily be disinfected. In this study, the needs of nurses are examined, and a review of the state-of-the-art exoskeletons is conducted from the perspective of to what extent the existing technologies address the needs of nurses. Possible solutions and technologies and particularly the needs that have not been addressed by the existing technologies are discussed.

A Dexterous Robotic System for Autonomous Debridement of Osteolytic Bone Lesions in Confined Spaces: Human Cadaver Studies.

This article presents a dexterous robotic system for autonomous debridement of osteolytic bone lesions in confined spaces. The proposed system is distinguished from the state-of-the-art orthopedics systems because it combines a rigid-link robot with a continuum manipulator (CM) that enhances reach in difficult-to-access spaces often encountered in surgery. The CM is equipped with flexible debriding instruments and fiber Bragg grating sensors. The surgeon plans on the patient's preoperative computed tomography and the robotic system performs the task autonomously under the surgeon's supervision. An optimization-based controller generates control commands on the fly to execute the task while satisfying physical and safety constraints. The system design and controller are discussed and extensive simulation, phantom and human cadaver experiments are carried out to evaluate the performance, workspace, and dexterity in confined spaces. Mean and standard deviation of target placement are 0.5 and 0.18 mm, and the robotic system covers 91% of the workspace behind an acetabular implant in treatment of hip osteolysis, compared to the 54% that is achieved by conventional rigid tools.

An analysis of international use of robots for COVID-19.

This article analyses data collected from press reports, social media, and the scientific literature on 338 instances of robots used explicitly in response to COVID-19 from 24 Jan, 2020, to 23 Jan, 2021, in 48 countries. The analysis was guided by four overarching questions: (1) What were robots used for in the COVID-19 response? (2) When were they used? (3) How did different countries innovate? and 4) Did having a national policy on robotics influence a country's innovation and insertion of robotics for COVID-19? The findings indicate that robots were used for six different sociotechnical work domains and 29 discrete use cases. When robots were used varied greatly on the country; although many countries did report an increase at the beginning of their first surge. To understand the findings of how innovation occurred, the data was examined through the lens of the technology's maturity according to NASA's Technical Readiness Assessment metrics. Through this lens, findings note that existing robots were used for more than 78% of the instances; slightly modified robots made up 10%; and truly novel robots or novel use cases constituted 12% of the instances. The findings clearly indicate that countries with a national robotics initiative were more likely to use robotics more often and for broader purposes. Finally, the dataset and analysis produces a broad set of implications that warrant further study and investigation. The results from this analysis are expected to be of value to the robotics and robotics policy community in preparing robots for rapid insertion into future disasters.

Application of a Robotic Tele-Echography System for COVID-19 Pneumonia.

To date, coronavirus disease 2019 (COVID-19) has infected millions of people worldwide. Ultrasound plays an indispensable role in the diagnosis, monitoring, and follow-up of patients with COVID-19. In this study, we used a robotic tele-echography system based on a 5G communication network for remote diagnosis. The system has great potential for lung, heart, and vasculature information, medical staff protection, and resource sharing, can be a valuable tool for treating patients during the pandemic, and can be expected to expand to more specialized fields.

Envisioning the future of colorectal surgery: preclinical assessment and detailed description of an endoluminal robotic system (ColubrisMX ELS).

BACKGROUND: The EndoLuminal Surgical System (ELS) is an emerging non-linear robotic system specifically designed for transanal surgery that allows for excision of colorectal neoplasia and luminal defect closure. METHODS: An evaluation of ELS was conducted by a single surgeon in a preclinical setting at the EndoSurgical Center of Florida in Orlando, between October 1st, 2020 and December 31st, 2020, using porcine colon as a model. Mock lesions measured 2.5 to 3.5 cm were excised partial-thickness. Specimen quality and excision time was assessed and evaluated. RESULTS: Twenty consecutive robotic transanal minimally invasive surgery (TAMIS) operations utilizing the ELS system were successfully performed without fragmentation. The mean and standard deviation procedure time for all 20 cases was 18.41 ± 14.15 min. The latter 10 cases were completed in substantially less time, suggesting that ELS requires at least 10 preclinical cases for a surgeon to become familiar with the technology. A second task, namely suture closure of the partial-thickness defect, was performed in 9 of the 20 cases. Mean time and standard deviation for this task measured 27.89 ± 10.07 min. There were no adverse events. CONCLUSIONS: ELS was successful in performing the tasks of partial-thickness disc excision and closure in a preclinical evaluation. Further study is necessary to determine its clinical applicability.

Real-Time Multi-Modal Sensing and Feedback for Catheterization in Porcine Tissue.

OBJECTIVE: In this study, we introduce a multi-modal sensing and feedback framework aimed at assisting clinicians during endovascular surgeries and catheterization procedures. This framework utilizes state-of-the-art imaging and sensing sub-systems to produce a 3D visualization of an endovascular catheter and surrounding vasculature without the need for intra-operative X-rays. METHODS: The catheterization experiments within this study are conducted inside a porcine limb undergoing motions. A hybrid position-force controller of a robotically-actuated ultrasound (US) transducer for uneven porcine tissue surfaces is introduced. The tissue, vasculature, and catheter are visualized by integrated real-time US images, 3D surface imaging, and Fiber Bragg Grating (FBG) sensors. RESULTS: During externally-induced limb motions, the vasculature and catheter can be reliably reconstructed at mean accuracies of 1.9±0.3 mm and 0.82±0.21 mm, respectively. CONCLUSIONS: The conventional use of intra-operative X-ray imaging to visualize instruments and vasculature in the human body can be reduced by employing improved diagnostic technologies that do not operate via ionizing radiation or nephrotoxic contrast agents. SIGNIFICANCE: The presented multi-modal framework enables the radiation-free and accurate reconstruction of significant tissues and instruments involved in catheterization procedures.

Stochastic Force-based Insertion Depth and Tip Position Estimations of Flexible FBG-Equipped Instruments in Robotic Retinal Surgery.

Vitreoretinal surgery is among the most delicate surgical tasks during which surgeon hand tremor may severely attenuate surgeon performance. Robotic assistance has been demonstrated to be beneficial in diminishing hand tremor. Among the requirements for reliable assistance from the robot is to provide precise measurements of system states e.g. sclera forces, tool tip position and tool insertion depth. Providing this and other sensing information using existing technology would contribute towards development and implementation of autonomous robot-assisted tasks in retinal surgery such as laser ablation, guided suture placement/assisted needle vessel cannulation, among other applications. In the present work, we use a state-estimating Kalman filtering (KF) to improve the tool tip position and insertion depth estimates, which used to be purely obtained by robot forward kinematics (FWK) and direct sensor measurements, respectively. To improve tool tip localization, in addition to robot FWK, we also use sclera force measurements along with beam theory to account for tool deflection. For insertion depth, the robot FWK is combined with sensor measurements for the cases where sensor measurements are not reliable enough. The improved tool tip position and insertion depth measurements are validated using a stereo camera system through preliminary experiments and a case study. The results indicate that the tool tip position and insertion depth measurements are significantly improved by 77% and 94% after applying KF, respectively.

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.

A Compression Valve for Sanitary Control of Fluid-Driven Actuators.

With significant research focused on integrating robotics into medical devices, sanitary control of pressurizing fluids in a precise, accurate and customizable way is highly desirable. Current sanitary flow control methods include pinch valves which clamp the pressure line locally to restrict fluid flow; resulting in damage and variable flow characteristics over time. This paper presents a sanitary compression valve based on an eccentric clamping mechanism. The proposed valve distributes clamping forces over a larger area, thereby reducing the plastic deformation and associated influence on flow characteristic. Using the proposed valve, significant reductions in plastic deformation (up to 96%) and flow-rate error (up to 98%) were found, when compared with a standard pinch valve. Additionally, an optimization strategy presents a method for improving linearity and resolution over the working range to suit specific control applications. The valve efficacy has been evaluated through controlled testing of a water jet propelled low-cost endoscopic device. In this case, use of the optimized valve shows a reduction in the average orientation error and its variation, resulting in smoother movement of the endoscopic tip when compared to alternative wet and dry valve solutions. The presented valve offers a customizable solution for sanitary control of fluid driven actuators.

Automatically steering cardiac catheters in vivo with respiratory motion compensation.

A robotic system for automatically navigating ultrasound (US) imaging catheters can provide real-time intra-cardiac imaging for diagnosis and treatment while reducing the need for clinicians to perform manual catheter steering. Clinical deployment of such a system requires accurate navigation despite the presence of disturbances including cyclical physiological motions (e.g., respiration). In this work, we report results from in vivo trials of automatic target tracking using our system, which is the first to navigate cardiac catheters with respiratory motion compensation. The effects of respiratory disturbances on the US catheter are modeled and then applied to four-degree-of-freedom steering kinematics with predictive filtering. This enables the system to accurately steer the US catheter and aim the US imager at a target despite respiratory motion disturbance. In vivo animal respiratory motion compensation results demonstrate automatic US catheter steering to image a target ablation catheter with 1.05 mm and 1.33° mean absolute error. Robotic US catheter steering with motion compensation can improve cardiac catheterization techniques while reducing clinician effort and X-ray exposure.

A Proposed Clinical Evaluation of a Simulation Environment for Magnetically-Driven Active Endoscopic Capsules.

Background A simulation environment for magnetically-driven, active endoscopic capsules (Abu-Kheil Y, Seneviratne L, Dias J, A simulation environment for active endoscopic capsules. 2017 IEEE 30th international symposium on Computer Based Medical Systems (CBMS), Thessaloniki, pp 714-719, 2017), can perform four main operations: capsule tele- operation, tracking of a specific region of interest, haptic feedback for capsule navigation and virtual reality navigation.Methods The main operations of the simulation environment can be clinically evaluated. In this paper, we proposed a clinical evaluation for the main functions of the simulation environment. There main testing procedures for the navigation strategies are proposed; i) vision-based tele-operation, ii) vision/haptic-based navigation without head control, and iii) vision/haptic-based navigation with head control. The navigation ways can be compared with each other in terms of introduction time, visualization and procedure comfort. Human-subject studies are to be conducted in which 20 students and 12 expert gastroenterologists participated.

Computer-Aided Orthopedic Surgery: Incremental Shift or Paradigm Change?

Computer-aided orthopedic surgery (CAOS) is now about 25 years old. Unlike neurosurgery, computer-aided surgery has not become the standard of care in orthopedic surgery. In this paper, we provide the technical and clinical context raised by this observation in an attempt to elucidate the reasons for this state of affairs. We start with a brief outline of the history of CAOS, review the main CAOS technologies, and describe how they are evaluated. We then identify some of the current publications in the field and present the opposing views on their clinical impact and their acceptance by the orthopedic community worldwide. We focus on total knee replacement surgery as a case study and present current clinical results and contrasting opinions on CAOS technologies. We then discuss the challenges and opportunities for research in medical image analysis in CAOS and in musculoskeletal radiology. We conclude with a suggestion that while CAOS acceptance may be more moderate than that of other fields in surgery, it still has a place in the arsenal of useful tools available to orthopedic surgeons.