Continuum Robots for Medical Interventions.

Continuum robots are not constructed with discrete joints but, instead, change shape and position their tip by flexing along their entire length. Their narrow curvilinear shape makes them well suited to passing through body lumens, natural orifices, or small surgical incisions to perform minimally invasive procedures. Modeling and controlling these robots are, however, substantially more complex than traditional robots comprised of rigid links connected by discrete joints. Furthermore, there are many approaches to achieving robot flexure. Each presents its own design and modeling challenges, and to date, each has been pursued largely independently of the others. This article attempts to provide a unified summary of the state of the art of continuum robot architectures with respect to design for specific clinical applications. It also describes a unifying framework for modeling and controlling these systems while additionally explaining the elements unique to each architecture. The major research accomplishments are described for each topic and directions for the future progress needed to achieve widespread clinical use are identified.

Eccentric Tube Robots as Multiarmed Steerable Sheaths.

This paper presents a novel continuum robot sheath for use in single-port minimally invasive procedures such as neuroendoscopy in which the sheath is designed to deliver multiple robotic arms. Actuation of the sheath is achieved by using precurved superelastic tubes lining the working channels used for arm delivery. These tubes perform a similar role to push/pull tendons, but can accomplish shape change of the sheath via rotation. A kinematic model using Cosserat rod theory is derived which is based on modeling the system as a set of eccentrically aligned precurved tubes constrained along their length by an elastic backbone. The specific case of a two-arm sheath is considered in detail. Simulation and experiments are used to investigate the validate the concept and model.

In Vivo Molding of Airway Stents.

Like ready-to-wear clothing, medical devices come in a fixed set of sizes. While this may accommodate a large fraction of the patient population, others must either experience suboptimal results due to poor sizing or must do without the device. Although techniques have been proposed to fabricate patient-specific devices in advance of a procedure, this process is expensive and time consuming. An alternative solution that provides every patient with a tailored fit is to create devices that can be customized to the patient's anatomy as they are delivered. This paper reports an in vivo molding process in which a soft flexible photocurable stent is delivered into the trachea or bronchi over a UV-transparent balloon. The balloon is expanded such that the stent conforms to the varying cross-sectional shape of the airways. UV light is then delivered through the balloon curing the stent into its expanded conformal shape. The potential of this method is demonstrated using phantom, ex vivo and in vivo experiments. This approach can produce stents providing equivalent airway support to those made from standard materials while providing a customized fit.

Modeling Tube Clearance and Bounding the Effect of Friction in Concentric Tube Robot Kinematics.

The shape of a concentric tube robot depends not only on the relative rotations and translations of its constituent tubes, but also on the history of relative tube displacements. Existing mechanics-based models neglect all history-dependent phenomena with the result that when calibrated on experimental data collected over a robot's workspace, the maximum tip position error can exceed 8 mm for a 200-mm-long robot. In this paper, we develop a model that computes the bounding kinematic solutions in which Coulomb friction is acting either to maximize or minimize the relative twisting between each pair of contacting tubes. The path histories associated with these limiting cases correspond to first performing all tube translations and then performing relative tube rotations of sufficient angle so that the maximum Coulomb friction force is obtained along the interface of each contacting tube pair. The robot tip configurations produced by these path histories are shown experimentally to bound position error with respect to the estimated frictionless model compared to path histories comprised of translation or mixed translation and rotation. Intertube friction forces and torques are computed as proportional to the intertube contact forces. To compute these contact forces, the standard zero-clearance assumption that constrains the concentrically combined tubes to possess the same centerline is relaxed. The effects of clearance and friction are explored through numerical and physical experiments and it is shown that friction can explain much of the prediction error observed in existing models. This model is not intended for real-time control, but rather for path planning-to provide error bounds and to inform how the ordering of tube rotations and translations can be used to reduce the effect of friction.

Steering a Multi-armed Robotic Sheath Using Eccentric Precurved Tubes.

This paper presents a novel continuum robot sheath for use in single-port minimally invasive procedures such as neuroendoscopy in which the sheath is designed to deliver multiple robotic arms. Articulation of the sheath is achieved by using precurved superelastic tubes lining the working channels used for arm delivery. These tubes perform a similar role to push/pull tendons, but can accomplish shape change of the sheath via rotation as well as translation. A kinematic model using Cosserat rod theory is derived which is based on modeling the system as a set of eccentrically aligned precurved tubes constrained along their length by an elastic backbone. The specific case of a two-arm sheath is considered in detail and its relationship to a concentric tube balanced pair is described. Simulation and experiment are used to investigate the concept, map its workspace and to evaluate the kinematic model.

Optimizing Tube Precurvature to Enhance Elastic Stability of Concentric Tube Robots.

Robotic instruments based on concentric tube technology are well suited to minimally invasive surgery since they are slender, can navigate inside small cavities and can reach around sensitive tissues by taking on shapes of varying curvature. Elastic instabilities can arise, however, when rotating one precurved tube inside another. In contrast to prior work that considered only tubes of piecewise constant precurvature, we allow precurvature to vary along the tube's arc length. Stability conditions for a planar tube pair are derived and used to formulate an optimal design problem. An analytic formulation of the optimal precurvature function is derived that achieves a desired tip orientation range while maximizing stability and respecting bending strain limits. This formulation also includes straight transmission segments at the proximal ends of the tubes. The result, confirmed by both numerical and physical experiment, enables designs with enhanced stability in comparison to designs of constant precurvature.

A multiport MR-compatible neuroendoscope: spanning the gap between rigid and flexible scopes.

OBJECTIVE Rigid endoscopes enable minimally invasive access to the ventricular system; however, the operative field is limited to the instrument tip, necessitating rotation of the entire instrument and causing consequent tissue compression while reaching around corners. Although flexible endoscopes offer tip steerability to address this limitation, they are more difficult to control and provide fewer and smaller working channels. A middle ground between these instruments-a rigid endoscope that possesses multiple instrument ports (for example, one at the tip and one on the side)-is proposed in this article, and a prototype device is evaluated in the context of a third ventricular colloid cyst resection combined with septostomy. METHODS A prototype neuroendoscope was designed and fabricated to include 2 optical ports, one located at the instrument tip and one located laterally. Each optical port includes its own complementary metal-oxide semiconductor (CMOS) chip camera, light-emitting diode (LED) illumination, and working channels. The tip port incorporates a clear silicone optical window that provides 2 additional features. First, for enhanced safety during tool insertion, instruments can be initially seen inside the window before they extend from the scope tip. Second, the compliant tip can be pressed against tissue to enable visualization even in a blood-filled field. These capabilities were tested in fresh porcine brains. The image quality of the multiport endoscope was evaluated using test targets positioned at clinically relevant distances from each imaging port, comparing it with those of clinical rigid and flexible neuroendoscopes. Human cadaver testing was used to demonstrate third ventricular colloid cyst phantom resection through the tip port and a septostomy performed through the lateral port. To extend its utility in the treatment of periventricular tumors using MR-guided laser therapy, the device was designed to be MR compatible. Its functionality and compatibility inside a 3-T clinical scanner were also tested in a brain from a freshly euthanized female pig. RESULTS Testing in porcine brains confirmed the multiport endoscope's ability to visualize tissue in a blood-filled field and to operate inside a 3-T MRI scanner. Cadaver testing confirmed the device's utility in operating through both of its ports and performing combined third ventricular colloid cyst resection and septostomy with an endoscope rotation of less than 5°. CONCLUSIONS The proposed design provides freedom in selecting both the number and orientation of imaging and instrument ports, which can be customized for each ventricular pathological entity. The lightweight, easily manipulated device can provide added steerability while reducing the potential for the serious brain distortion that happens with rigid endoscope navigation. This capability would be particularly valuable in treating hydrocephalus, both primary and secondary (due to tumors, cysts, and so forth). Magnetic resonance compatibility can aid in endoscope-assisted ventricular aqueductal plasty and stenting, the management of multiloculated complex hydrocephalus, and postinflammatory hydrocephalus in which scarring obscures the ventricular anatomy.

Biocompatible Pressure Sensing Skins for Minimally Invasive Surgical Instruments.

This paper presents 800-µm thick, biocompatible sensing skins composed of arrays of pressure sensors. The arrays can be configured to conform to the surface of medical instruments so as to act as disposable sensing skins. In particular, the fabrication of cylindrical geometries is considered here for use on endoscopes. The sensing technology is based on polydimethylsiloxane synthetic silicone encapsulated microchannels filled with a biocompatible salt-saturated glycerol solution, functioning as the conductive medium. A multi-layer manufacturing approach is introduced that enables stacking sensing microchannels, mechanical stress concentration features, and electrical routing via flexcircuits in a thickness of less than 1 mm. The proposed approach is inexpensive and does not require clean room tools or techniques. The mechanical stress concentration features are implemented using a patterned copper layer that serves to improve sensing range and sensitivity. Sensor performance is demonstrated experimentally using a sensing skin mounted on a neuroendoscope insertion cannula and is shown to outperform previously developed non-biocompatible sensors.

Cardioscopic Tool-delivery Instrument for Beating-heart Surgery.

This paper describes an instrument that provides solutions to two open challenges in beating-heart intracardiac surgery - providing high-fidelity imaging of tool-tissue contact and controlling tool penetration into tissue over the cardiac cycle. Tool delivery is illustrated in the context of tissue removal for which these challenges equate to visualization of the tissue as it is being removed and to control of cutting depth. Cardioscopic imaging is provided by a camera and illumination system encased in an optical window. When the optical window is pressed against tissue, it displaces the blood between the camera and tissue allowing clear visualization. Control of cutting depth is achieved via precise extension of the cutting tool from a port in the optical window. Successful tool use is demonstrated in ex vivo and in vivo experiments.

Untethered magnetic millirobot for targeted drug delivery.

This paper reports the design and development of a novel millimeter-sized robotic system for targeted therapy. The proposed medical robot is conceived to perform therapy in relatively small diameter body canals (spine, urinary system, ovary, etc.), and to release several kinds of therapeutics, depending on the pathology to be treated. The robot is a nearly-buoyant bi-component system consisting of a carrier, in which the therapeutic agent is embedded, and a piston. The piston, by exploiting magnetic effects, docks with the carrier and compresses a drug-loaded hydrogel, thus activating the release mechanism. External magnetic fields are exploited to propel the robot towards the target region, while intermagnetic forces are exploited to trigger drug release. After designing and fabricating the robot, the system has been tested in vitro with an anticancer drug (doxorubicin) embedded in the carrier. The efficiency of the drug release mechanism has been demonstrated by both quantifying the amount of drug released and by assessing the efficacy of this therapeutic procedure on human bladder cancer cells.

Concentric Tube Robot Design and Optimization Based on Task and Anatomical Constraints.

Concentric tube robots are catheter-sized continuum robots that are well suited for minimally invasive surgery inside confined body cavities. These robots are constructed from sets of pre-curved superelastic tubes and are capable of assuming complex 3D curves. The family of 3D curves that the robot can assume depends on the number, curvatures, lengths and stiffnesses of the tubes in its tube set. The robot design problem involves solving for a tube set that will produce the family of curves necessary to perform a surgical procedure. At a minimum, these curves must enable the robot to smoothly extend into the body and to manipulate tools over the desired surgical workspace while respecting anatomical constraints. This paper introduces an optimization framework that utilizes procedureor patient-specific image-based anatomical models along with surgical workspace requirements to generate robot tube set designs. The algorithm searches for designs that minimize robot length and curvature and for which all paths required for the procedure consist of stable robot configurations. Two mechanics-based kinematic models are used. Initial designs are sought using a model assuming torsional rigidity. These designs are then refined using a torsionally-compliant model. The approach is illustrated with clinically relevant examples from neurosurgery and intracardiac surgery.

Magnetic Ball Chain Robots for Endoluminal Interventions.

This paper introduces a novel class of hyperredundant robots comprised of chains of permanently magnetized spheres enclosed in a cylindrical polymer skin. With their shape controlled using an externally-applied magnetic field, the spherical joints of these robots enable them to bend to very small radii of curvature. These robots can be used as steerable tips for endoluminal instruments. A kinematic model is derived based on minimizing magnetic and elastic potential energy. Simulation is used to demonstrate the enhanced steerability of these robots in comparison to magnetic soft continuum robots designed using either distributed or lumped magnetic material. Experiments are included to validate the model and to demonstrate the steering capability of ball chain robots in bifurcating channels.

Modeling Tendon-actuated Concentric Tube Robots.

Mechanics-based models have been developed to describe the shape of tendon-actuated continuum robots. Models have also been developed to describe the shape of concentric tube robots, i.e., nested combinations of precurved superelastic tubes. While an important class of continuum robots used in endoscopic and intracardiac medical applications combines these two designs, existing models do not cover this combination. Tendon-actuated models are limited to a single tube while concentric tube models do not include tendon-produced forces and moments. This paper derives a mechanics-based model for this hybrid design and assesses it using numerical and physical experiments involving a pair of tendon-actuated tubes. It is demonstrated that, similar to concentric tube robots, relative twisting between the tendon-actuated tubes is an important factor in determining overall robot shape.

Closed-form Kinematic Model and Workspace Characterization for Magnetic Ball Chain Robots.

Magnetic ball chains are well suited to serve as the steerable tips of endoluminal robots. While it has been demonstrated that these robots produce a larger reachable workspace than magnetic soft continuum robots designed using either distributed or lumped magnetic material, here we investigate the orientational capabilities of these robots. To increase the range of orientations that can be produced at each point in the workspace, we introduce a comparatively-stiff outer sheath from which the steerable ball chain is extended. We present an energy-based kinematic model and also derive an approximate expression for the range of achievable orientations at each point in the workspace. Experiments are used to validate these results.

A novel ex vivo tracheobronchomalacia model for airway stent testing and in vivo model refinement.

OBJECTIVES: We sought to develop an ex vivo trachea model capable of producing mild, moderate, and severe tracheobronchomalacia for optimizing airway stent design. We also aimed to determine the amount of cartilage resection required for achieving different tracheobronchomalacia grades that can be used in animal models. METHODS: We developed an ex vivo trachea test system that enabled video-based measurement of internal cross-sectional area as intratracheal pressure was cyclically varied for peak negative pressures of 20 to 80 cm H2O. Fresh ovine tracheas were induced with tracheobronchomalacia by single mid-anterior incision (n = 4), mid-anterior circumferential cartilage resection of 25% (n = 4), and 50% per cartilage ring (n = 4) along an approximately 3-cm length. Intact tracheas (n = 4) were used as control. All experimental tracheas were mounted and experimentally evaluated. In addition, helical stents of 2 different pitches (6 mm and 12 mm) and wire diameters (0.52 mm and 0.6 mm) were tested in tracheas with 25% (n = 3) and 50% (n = 3) circumferentially resected cartilage rings. The percentage collapse in tracheal cross-sectional area was calculated from the recorded video contours for each experiment. RESULTS: Ex vivo tracheas compromised by single incision and 25% and 50% circumferential cartilage resection produce tracheal collapse corresponding to clinical grades of mild, moderate, and severe tracheobronchomalacia, respectively. A single anterior cartilage incision produces saber-sheath type tracheobronchomalacia, whereas 25% and 50% circumferential cartilage resection produce circumferential tracheobronchomalacia. Stent testing enabled the selection of stent design parameters such that airway collapse associated with moderate and severe tracheobronchomalacia could be reduced to conform to, but not exceed, that of intact tracheas (12-mm pitch, 0.6-mm wire diameter). CONCLUSIONS: The ex vivo trachea model is a robust platform that enables systematic study and treatment of different grades and morphologies of airway collapse and tracheobronchomalacia. It is a novel tool for optimization of stent design before advancing to in vivo animal models.

Hybrid Tendon and Ball Chain Continuum Robots for Enhanced Dexterity in Medical Interventions.

A hybrid continuum robot design is introduced that combines a proximal tendon-actuated section with a distal telescoping section comprised of permanent-magnet spheres actuated using an external magnet. While, individually, each section can approach a point in its workspace from one or at most several orientations, the two-section combination possesses a dexterous workspace. The paper describes kinematic modeling of the hybrid design and provides a description of the dexterous workspace. We present experimental validation which shows that a simplified kinematic model produces tip position mean and maximum errors of 3% and 7% of total robot length, respectively.

Robotic Instruments Inside the MRI Bore: Key Concepts and Evolving Paradigms in Imaging-enhanced Cranial Neurosurgery.

Intraoperative MRI has been increasingly used to robotically deliver electrodes and catheters into the human brain using a linear trajectory with great clinical success. Current cranial MR guided robotics do not allow for continuous real-time imaging during the procedure because most surgical instruments are not MR-conditional. MRI guided robotic cranial surgery can achieve its full potential if all the traditional advantages of robotics (such as tremor-filtering, precision motion scaling, etc.) can be incorporated with the neurosurgeon physically present in the MRI bore or working remotely through controlled robotic arms. The technological limitations of design optimization, choice of sensing, kinematic modeling, physical constraints, and real-time control had hampered early developments in this emerging field, but continued research and development in these areas over time has granted neurosurgeons far greater confidence in using cranial robotic techniques. This article elucidates the role of MR-guided robotic procedures using clinical devices like NeuroBlate and Clearpoint that have several thousands of cases operated in a "linear cranial trajectory" and planned clinical trials, such as LAANTERN for MR guided robotics in cranial neurosurgery using LITT and MR-guided putaminal delivery of AAV2 GDNF in Parkinson's disease. The next logical improvisation would be a steerable curvilinear trajectory in cranial robotics with added DOFs and distal tip dexterity to the neurosurgical tools. Similarly, the novel concept of robotic actuators that are powered, imaged, and controlled by the MRI itself is discussed in this article, with its potential for seamless cranial neurosurgery.

Using robotics to move a neurosurgeon's hands to the tip of their endoscope.

A major advantage of surgical robots is that they can reduce the invasiveness of a procedure by enabling the clinician to manipulate tools as they would in open surgery but through small incisions in the body. Neurosurgery has yet to benefit from this advantage. Although clinical robots are available for the least invasive neurosurgical procedures, such as guiding electrode insertion, the most invasive brain surgeries, such as tumor resection, are still performed as open manual procedures. To investigate whether robotics could reduce the invasiveness of major brain surgeries while still providing the manipulation capabilities of open surgery, we created a two-armed joystick-controlled endoscopic robot. To evaluate the efficacy of this robot, we developed a set of neurosurgical skill tasks patterned after the steps of brain tumor resection. We also created a patient-derived brain model for pineal tumors, which are located in the center of the brain and are normally removed by open surgery. In comparison, testing with existing manual endoscopic instrumentation, we found that the robot provided access to a much larger working volume at the trocar tip and enabled bimanual tasks without compression of brain tissue adjacent to the trocar. Furthermore, many tasks could be completed faster with the robot. These results suggest that robotics has the potential to substantially reduce the invasiveness of brain surgery by enabling certain procedures currently performed as open surgery to be converted to endoscopic interventions.

Percutaneous intracardiac beating-heart surgery using metal MEMS tissue approximation tools.

Achieving superior outcomes through the use of robots in medical applications requires an integrated approach to the design of the robot, tooling and the procedure itself. In this paper, this approach is applied to develop a robotic technique for closing abnormal communication between the atria of the heart. The goal is to achieve the efficacy of surgical closure as performed on a stopped, open heart with the reduced risk and trauma of a beating-heart catheter-based procedure. In the proposed approach, a concentric tube robot is used to percutaneously access the right atrium and deploy a tissue approximation device. The device is constructed using a metal microelectromechanical system (MEMS) fabrication process and is designed to both fit the manipulation capabilities of the robot as well as to reproduce the beneficial features of surgical closure by suture. The effectiveness of the approach is demonstrated through ex vivo and in vivo experiments.

A Soft Robotic Balloon Endoscope for Airway Procedures.

Soft robots can provide advantages for medical interventions given their low cost and their ability to change shape and safely apply forces to tissue. This article explores the potential for their use for endoscopically-guided balloon dilation procedures in the airways. A scalable robot design based on balloon catheter technology is proposed, which is composed of five balloons together with a tip-mounted camera and LED. Its design parameters are optimized with respect to the clinical requirements associated with balloon dilation procedures in the trachea and bronchi. Possessing a lumen to allow for respiration and powered by the pressure and vacuum sources found in a clinical procedure room, the robot is teleoperated through the airways using a game controller and real-time video from the tip-mounted camera. The robot design includes proximal and distal bracing balloons that expand radially to produce traction forces. The distal bracing balloon is also used to perform balloon dilation. Three actuation balloons, located between the bracing balloons, produce elongation and bending of the robot body to enable locomotion and turning. An analysis of the actuation balloons, which incorporate helical coils to prevent radial collapse, provides design formulas by relating geometric parameters to such performance criteria as maximum change in actuator length and maximum robot bending angle. Experimental evaluation of a prototype robot inside rigid plastic tubes and ex vivo porcine airways is used to demonstrate the potential of the approach.