Image-guided surgical planning of percutaneous nephrolithotomy with patient-specific CTRs.

PURPOSE: We propose the utilization of patient-specific concentric-tube robots (CTRs) whose designs are optimized to enhance their volumetric reachability of the renal stone, thus reducing the morbidities associated with percutaneous nephrolithotomy procedures. By employing a nested optimization-driven scheme, this work aims to determine a single surgical tract through which the patient-tailored CTR is deployed. We carry out a sensitivity analysis on the combined percutaneous access and optimized CTR design with respect to breathing-induced excursion of the kidneys based on preoperative images. Further, an investigation is also performed of the appropriateness and effectiveness of the percutaneous access provided by the proposed algorithm compared to that of an expert urologist. METHODS: The method is based on an ellipsoidal approximation to the renal calculi and a grid search over candidate skin areas and available renal calyces using an anatomically constrained kinematic mapping of the CTR. Percutaneous access is selected for collision-free CTR deployment to the centroid of the stones with minimal positional error at the renal calyx. Further optimization of the CTR design results in a robot tailored to the therapeutic anatomical features of each clinical case. The study examined 14 sets of clinical data of PCNL patients, analyzing stone reachability using preoperative images and breathing-induced motions of the kidney. An experienced urologist qualitatively assessed the adequacy of percutaneous access generated by the algorithm. RESULTS: An assessment conducted by an expert urologist found that the percutaneous accesses produced by the proposed approach were found to be comparable to those chosen by the expert surgeon in most clinical cases. The simulated results demonstrated a mean volume coverage of [Formula: see text] for static anatomy and [Formula: see text] and [Formula: see text] when considering a 1 cm excursion of the kidney in the craniocaudal directions due to respiration or tool-tissue interaction. CONCLUSION: The optimization-driven scheme for determining a single tract surgical plan, coupled with the use of a patient-specific CTR, shows promising results for improving percutaneous access in PCNL procedures. This approach clearly shows the potential for enhancing the quality and suitability of percutaneous accesses, addressing the challenges posed by staghorn and non-staghorn stones during PCNL procedures. Further research involving clinical validation is necessary to confirm these findings and explore the potential clinical benefits of the approach.

Modeling of and Experimenting with Concentric Tube Robots: Considering Clearance, Friction and Torsion.

Concentric tube robots (CTRs) are a promising prospect for minimally invasive surgery due to their inherent compliance and ability to navigate in constrained environments. Existing mechanics-based kinematic models typically neglect friction, clearance, and torsion between each pair of contacting tubes, leading to large positioning errors in medical applications. In this paper, an improved kinematic modeling method is developed. The effect of clearance on tip position during concentric tube assembly is compensated by the database method. The new kinematic model is mechanic-based, and the impact of friction moment and torsion on tubes is considered. Integrating the infinitesimal torsion of the concentric tube robots eliminates the errors caused by the interaction force between the tubes. A prototype is built, and several experiments with kinematic models are designed. The results indicate that the error of tube rotations is less than 2 mm. The maximum error of the feeding experiment does not exceed 0.4 mm. The error of the new modeling method is lower than that of the previous kinematic model. This paper has substantial implications for the high-precision and real-time control of concentric tube robots.

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.

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.

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.

Targeting Epilepsy Through the Foremen Ovale: How Many Helical Needles are Needed?

Laser ablation of the hippocampus offers medically refractory epilepsy patients an alternative to invasive surgeries. Emerging commercial solutions deliver the ablator through a burr hole in the back of the head. We recently introduced a new access path through the foremen ovale, using a helical needle, which minimizes the amount of healthy brain tissue the needle must pass through on its way to the hippocampus, and also enables the needle to follow the medial axis of the hippocampus more closely. In this paper, we investigate whether helical needles should be designed and fabricated on a patient-specific basis as we had previously proposed, or whether a small collection of pre-defined needle shapes can apply across many patients. We propose a new optimization strategy to determine this needle set using patient data, and investigate the accuracy with which these needles can reach the the medial axis of the hippocampus. We find that three basic tube shapes (mirrored as necessary for left vs. right hippocampi) are all that is required, across 20 patient datasets (obtained from 10 patient CT scans), to reduce worst-case maximum error below 2 mm.

A simulation study to investigate the use of concentric tube robots for epilepsy surgery.

PURPOSE: Patients with pharmacoresistant refractory epilepsy may require epilepsy surgery to prevent future seizure occurrences. Conventional surgery consists of a large craniotomy with straight rigid tools with associated outcomes of morbidity, large tissue resections, and long post-operative recovery times. Concentric tube robots have recently been developed as a promising application to neurosurgery due to their nonlinear form and small diameter. The authors present a concept study to explore the feasibility of performing minimally invasive hemispherotomy with concentric tube robots. METHODS: A model simulation was used to achieve the optimal design and surgical path planning parameters of the concentric tube robot for corpus callosotomy and temporal lobectomy. A single medial burr hole was chosen to access the lateral ventricles for both white matter disconnections. RESULTS: The concentric tube robot was able to accurately reach the designated surgical paths on the corpus callosum and the temporal lobe. CONCLUSION: In a model simulation, the authors demonstrated the feasibility of performing corpus callosotomy and temporal lobectomy using concentric tube robots. Further advancements in the technology may increase the applicability of this technique for epilepsy surgery to better patient outcomes.

Transurethral Anastomosis after Transurethral Radical Prostatectomy: A Phantom Study on Intraluminal Suturing With Concentric Tube Robots.

Current surgical approaches to radical prostatectomy are associated with high rates of erectile dysfunction and incontinence. These complications occur secondary to the disruption of surrounding healthy tissue, which is required to expose the prostate. The urethra offers the least invasive access to the prostate, and feasibility has been demonstrated of enucleating the prostate with an endoscope using Holmium laser, which can itself be aimed by concentric tube robots. However, the transurethral approach to radical prostatectomy has thus far been limited by the lack of a suitable means to perform an anastomosis of the urethra to the bladder after prostate removal. Only a few intraluminal anastomotic devices currently exist, and none are small enough to pass through the urethra. In this paper we describe a new way to perform an anastomosis in the small luminal space of the urethra, harnessing the dexterity and customizability of concentric tube manipulators. We demonstrate a successful initial proof-of-concept anastomosis in an anthropomorphic phantom of the urethra and bladder.

Investigating exploration for deep reinforcement learning of concentric tube robot control.

PURPOSE: Concentric tube robots are composed of multiple concentric, pre-curved, super-elastic, telescopic tubes that are compliant and have a small diameter suitable for interventions that must be minimally invasive like fetal surgery. Combinations of rotation and extension of the tubes can alter the robot's shape but the inverse kinematics are complex to model due to the challenge of incorporating friction and other tube interactions or manufacturing imperfections. We propose a model-free reinforcement learning approach to form the inverse kinematics solution and directly obtain a control policy. METHOD: Three exploration strategies are shown for deep deterministic policy gradient with hindsight experience replay for concentric tube robots in simulation environments. The aim is to overcome the joint to Cartesian sampling bias and be scalable with the number of robotic tubes. To compare strategies, evaluation of the trained policy network to selected Cartesian goals and associated errors are analyzed. The learned control policy is demonstrated with trajectory following tasks. RESULTS: Separation of extension and rotation joints for Gaussian exploration is required to overcome Cartesian sampling bias. Parameter noise and Ornstein-Uhlenbeck were found to be optimal strategies with less than 1 mm error in all simulation environments. Various trajectories can be followed with the optimal exploration strategy learned policy at high joint extension values. Our inverse kinematics solver in evaluation has 0.44 mm extension and [Formula: see text] rotation error. CONCLUSION: We demonstrate the feasibility of effective model-free control for concentric tube robots. Directly using the control policy, arbitrary trajectories can be followed and this is an important step towards overcoming the challenge of concentric tube robot control for clinical use in minimally invasive interventions.

Learning the Complete Shape of Concentric Tube Robots.

Concentric tube robots, composed of nested pre-curved tubes, have the potential to perform minimally invasive surgery at difficult-to-reach sites in the human body. In order to plan motions that safely perform surgeries in constrained spaces that require avoiding sensitive structures, the ability to accurately estimate the entire shape of the robot is needed. Many state-of-the-art physics-based shape models are unable to account for complex physical phenomena and subsequently are less accurate than is required for safe surgery. In this work, we present a learned model that can estimate the entire shape of a concentric tube robot. The learned model is based on a deep neural network that is trained using a mixture of simulated and physical data. We evaluate multiple network architectures and demonstrate the model's ability to compute the full shape of a concentric tube robot with high accuracy.

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.

Asymptotically Optimal Kinematic Design of Robots using Motion Planning.

In highly constrained settings, e.g., a tentaclelike medical robot maneuvering through narrow cavities in the body for minimally invasive surgery, it may be difficult or impossible for a robot with a generic kinematic design to reach all desirable targets while avoiding obstacles. We introduce a design optimization method to compute kinematic design parameters that enable a single robot to reach as many desirable goal regions as possible while avoiding obstacles in an environment. Our method appropriately integrates sampling based motion planning in configuration space into stochastic optimization in design space so that, over time, our evaluation of a design's ability to reach goals increases in accuracy and our selected designs approach global optimality. We prove the asymptotic optimality of our method and demonstrate performance in simulation for (i) a serial manipulator and (ii) a concentric tube robot, a tentacle-like medical robot that can bend around anatomical obstacles to safely reach clinically- relevant goal regions.

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.

A concentric tube-based 4-DOF puncturing needle with a novel miniaturized actuation system for vitrectomy.

BACKGROUND: Vitreoretinal surgeries require precise, dexterous, and steady instruments for operation in delicate parts of the eye. Robotics has presented solutions for many vitreoretinal surgical problems, but, in a few operations, the available tools are still not dexterous enough to carry out procedures with minimum trauma to patients. Vitrectomy is one of those procedures and requires some dexterous instruments to replace straight ones for better navigation to affected sides inside the eyeball. METHOD: In this paper, we propose a new vein puncturing solution with a 4-DOF motion to increase the workspace inside the eye. A two-member concentric tube-based 25G needle is proposed whose shape is optimized. To operate the concentric tube needle, a novel and miniaturized actuation system is proposed that uses hollow shaft motors for the first time. The presented prototype of actuation system has a stroke of 100 mm in a small size of 148 × 25 × 65 mm (L × W × H), suitable for approaching distant positions inside the eyeball. RESULTS: Experimental results validate that the targeting accuracy of the needle is less than one millimeter and the needle tip can apply a force of 23.51 mN which is enough to perform puncturing. Furthermore, the proposed needle covers maximum workspace of around 128.5° inside the eyeball. For the actuation system, experiments show that it can produce repeatable motions with accuracy in submillimeter. CONCLUSION: The proposed needle system can navigate to the sites which are difficult to approach by currently available straight tools requiring reinsertions. Along with the miniaturized actuation system, this work is expected to improve the outcome of vitrectomy with safe and accurate navigation.

Development of a compact continuum tubular robotic system for nasopharyngeal biopsy.

Traditional posterior nasopharyngeal biopsy using a flexible nasal endoscope has the risks of abrasion and injury to the nasal mucosa and thus causing trauma to the patient. Recently, a new class of robots known as continuum tubular robots (CTRs) provide a novel solution to the challenge with miniaturized size, curvilinear maneuverability, and capability of avoiding collision within the nasal environment. This paper presents a compact CTR which is 35 cm in total length, 10 cm in diameter, 2.15 kg in weight, and easy to be integrated with a robotic arm to perform more complicated operations. Structural design, end-effector design, and workspace analysis are described in detail. In addition, teleoperation of the CTR using a haptic input device is developed for position control in 3D space. Moreover, by integrating the robot with three electromagnetic tracking sensors, a navigation system together with a shape reconstruction algorithm is developed. Comprehensive experiments are conducted to test the functionality of the proposed prototype; experiment results show that under teleoperation, the system has an accuracy of 2.20 mm in following a linear path, an accuracy of 2.01 mm in following a circular path, and a latency time of 0.1 s. It is also found that the proposed shape reconstruction algorithm has a mean error of around 1 mm along the length of the tubes. Besides, the feasibility and effectiveness of the proposed robotic system being applied to posterior nasopharyngeal biopsy are demonstrated by a cadaver experiment. The proposed robotic system holds promise to enhance clinical operation in transnasal procedures.

Hand-held transendoscopic robotic manipulators: A transurethral laser prostate surgery case study.

Natural orifice endoscopic surgery can enable incisionless approaches, but a major challenge is the lack of small and dexterous instrumentation. Surgical robots have the potential to meet this need yet often disrupt the clinical workflow. Hand-held robots that combine thin manipulators and endoscopes have the potential to address this by integrating seamlessly into the clinical workflow and enhancing dexterity. As a case study illustrating the potential of this approach, we describe a hand-held robotic system that passes two concentric tube manipulators through a 5 mm port in a rigid endoscope for transurethral laser prostate surgery. This system is intended to catalyze the use of a clinically superior, yet rarely attempted, procedure for benign prostatic hyperplasia. This paper describes system design and experiments to evaluate the surgeon's functional workspace and accuracy using the robot. Phantom and cadaver experiments demonstrate successful completion of the target procedure via prostate lobe resection.

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.