Handheld robotic device for endoscopic neurosurgery: system integration and pre-clinical evaluation.

The Expanded Endoscopic Endonasal Approach, one of the best examples of endoscopic neurosurgery, allows access to the skull base through the natural orifice of the nostril. Current standard instruments lack articulation limiting operative access and surgeon dexterity, and thus, could benefit from robotic articulation. In this study, a handheld robotic system with a series of detachable end-effectors for this approach is presented. This system is comprised of interchangeable articulated 2/3 degrees-of-freedom 3 mm instruments that expand the operative workspace and enhance the surgeon's dexterity, an ergonomically designed handheld controller with a rotating joystick-body that can be placed at the position most comfortable for the user, and the accompanying control box. The robotic instruments were experimentally evaluated for their workspace, structural integrity, and force-delivery capabilities. The entire system was then tested in a pre-clinical context during a phantom feasibility test, followed up by a cadaveric pilot study by a cohort of surgeons of varied clinical experience. Results from this series of experiments suggested enhanced dexterity and adequate robustness that could be associated with feasibility in a clinical context, as well as improvement over current neurosurgical instruments.

Ex Vivo Perfusion of Porcine Pancreas and Liver Sourced from Commercial Abattoirs after Circulatory Death as a Research Resource: A Methodological Study.

BACKGROUND: Machine perfusion (MP) is increasingly used for human transplant organ preservation. The use of MP for research purposes is another opportunity for this technology. The porcine pancreas and liver are similar in anatomical size and function to their human counterparts, making them an excellent resource for research, but they have some important differences from human organs which can influence their research use. In this paper, we describe a technique developed and tested for the retrieval of porcine organs for use in research on perfused viable organs. METHODS: Whole-organ porcine pancreata and livers were harvested at a commercial abattoir, following standard slaughterhouse processes. The standard slaughterhouse process involved a thoracotomy and mid-line laparotomy, and all the thoracoabdominal organs were removed. The pancreas, fixed in the retroperitoneum, was carefully dissected from its attachments to the surrounding structures, and tissue planes between the pancreas, spleen, duodenum, and colon were meticulously identified and dissected. Vessel exposure and division: The aorta, portal vein (PV), hepatic vein (HV), and hepatic artery (HA) were dissected and isolated, preserving the input and output channels for the liver and pancreas. A distal 3 cm of the aorta was preserved and divided and served as the input for the pancreas perfusions. The liver, PV, HV, and HA were preserved and divided to preserve the physiological channels of the input (PV and HA) and output (HV) for the liver perfusions. The porcine hepatic and pancreas anatomy shares significant resemblance with the gross anatomy found in humans, and this was taken into consideration when designing the perfusion circuitry. The porcine pancreas and spleen shared a common blood supply, with branches arising from the splenic artery. The organs were flushed with cold, heparinised normal saline and transported in a temperature-regulated receptacle maintained at a core temperature between 4 and 8 °C, in line with the standards of static cold storage (SCS), to a dedicated perfusion lab and perfused using our novel perfusion machine with autologous, heparinised porcine blood, also collected at the abattoir.

The Application of Machine Perfusion as an Enhanced ex vivo Model for Optical Imaging.

Optical imaging techniques such as spectral imaging show promise for the assessment of tissue health during surgery; however, the validation and translation of such techniques into clinical practise is limited by the lack of representative tissue models. In this paper, we demonstrate the application of an organ perfusion machine as an ex vivo tissue model for optical imaging. Three porcine livers are perfused at stepped blood oxygen saturations. Over the duration of each perfusion, spectral data of the tissue are captured via diffuse optical spectroscopy and multispectral imaging. These data are synchronised with blood oxygen saturation measurements recorded by the perfusion machine. Shifts in the optical properties of the tissue are demonstrated over the duration of the each perfusion, as the tissue becomes reperfused and as the oxygen saturation is varied.

Robotic Handle Prototypes for Endoscopic Endonasal Skull Base Surgery: Pre-clinical Randomised Controlled Trial of Performance and Ergonomics.

Endoscopic endonasal skull base surgery is a promising alternative to transcranial approaches. However, standard instruments lack articulation, and thus, could benefit from robotic technologies. The aim of this study was to develop an ergonomic handle for a handheld robotic instrument intended to enhance this procedure. Two different prototypes were developed based on ergonomic guidelines within the literature. The first is a forearm-mounted handle that maps the surgeon's wrist degrees-of-freedom to that of the robotic end-effector; the second is a joystick-and-trigger handle with a rotating body that places the joystick to the position most comfortable for the surgeon. These handles were incorporated into a custom-designed surgical virtual simulator and were assessed for their performance and ergonomics when compared with a standard neurosurgical grasper. The virtual task was performed by nine novices with all three devices as part of a randomised crossover user-study. Their performance and ergonomics were evaluated both subjectively by themselves and objectively by a validated observational checklist. Both handles outperformed the standard instrument with the rotating joystick-body handle offering the most substantial improvement in terms of balance between performance and ergonomics. Thus, it is deemed the more suitable device to drive instrumentation for endoscopic endonasal skull base surgery.

Autonomous pick-and-place using the dVRK.

PURPOSE: Robotic-assisted partial nephrectomy (RAPN) is a tissue-preserving approach to treating renal cancer, where ultrasound (US) imaging is used for intra-operative identification of tumour margins and localisation of blood vessels. With the da Vinci Surgical System (Sunnyvale, CA), the US probe is inserted through an auxiliary access port, grasped by the robotic tool and moved over the surface of the kidney. Images from US probe are displayed separately to the surgical site video within the surgical console leaving the surgeon to interpret and co-registers information which is challenging and complicates the procedural workflow. METHODS: We introduce a novel software architecture to support a hardware soft robotic rail designed to automate intra-operative US acquisition. As a preliminary step towards complete task automation, we automatically grasp the rail and position it on the tissue surface so that the surgeon is then able to manipulate manually the US probe along it. RESULTS: A preliminary clinical study, involving five surgeons, was carried out to evaluate the potential performance of the system. Results indicate that the proposed semi-autonomous approach reduced the time needed to complete a US scan compared to manual tele-operation. CONCLUSION: Procedural automation can be an important workflow enhancement functionality in future robotic surgery systems. We have shown a preliminary study on semi-autonomous US imaging, and this could support more efficient data acquisition.

An intuitive surgical handle design for robotic neurosurgery.

PURPOSE: The expanded endoscopic endonasal approach, a representative example of keyhole brain surgery, allows access to the pituitary gland and surrounding areas through the nasal and sphenoid cavities. Manipulating rigid instruments through these constrained spaces makes this approach technically challenging, and thus, a handheld robotic instrument could expand the surgeon's capabilities. In this study, we present an intuitive handle prototype for such a robotic instrument. METHODS: We have designed and fabricated a surgical instrument handle prototype that maps the surgeon's wrist directly to the robot joints. To alleviate the surgeon's wrist of any excessive strain and fatigue, the tool is mounted on the surgeon's forearm, making it parallel with the instrument's shaft. To evaluate the handle's performance and limitations, we constructed a surgical task simulator and compared our novel handle with a standard neurosurgical tool, with the tasks being performed by a consultant neurosurgeon. RESULTS: While using the proposed handle, the surgeon's average success rate was [Formula: see text], compared to [Formula: see text] when using a conventional tool. Additionally, the surgeon's body posture while using the suggested prototype was deemed acceptable by the Rapid Upper Limb Assessment ergonomic survey, while early results indicate the absence of a learning curve. CONCLUSIONS: Based on these preliminary results, the proposed handle prototype could offer an improvement over current neurosurgical tools and procedural ergonomics. By redirecting forces applied during the procedure to the forearm of the surgeon, and allowing for intuitive surgeon wrist to robot-joints movement mapping without compromising the robotic end effector's expanded workspace, we believe that this handle could prove a substantial step toward improved neurosurgical instrumentation.

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.

Ultrasound 3D reconstruction of malignant masses in robotic-assisted partial nephrectomy using the PAF rail system: a comparison study.

PURPOSE: In robotic-assisted partial nephrectomy (RAPN), the use of intraoperative ultrasound (IOUS) helps to localise and outline the tumours as well as the blood vessels within the kidney. The aim of this work is to evaluate the use of the pneumatically attachable flexible (PAF) rail system for US 3D reconstruction of malignant masses in RAPN. The PAF rail system is a novel device developed and previously presented by the authors to enable track-guided US scanning. METHODS: We present a comparison study between US 3D reconstruction of masses based on: the da Vinci Surgical System kinematics, single- and stereo-camera tracking of visual markers embedded on the probe. An US-realistic kidney phantom embedding a mass is used for testing. A new design for the US probe attachment to enhance the performance of the kinematic approach is presented. A feature extraction algorithm is proposed to detect the margins of the targeted mass in US images. RESULTS: To evaluate the performance of the investigated approaches the resulting 3D reconstructions have been compared to a CT scan of the phantom. The data collected indicates that single camera reconstruction outperformed the other approaches, reconstructing with a sub-millimetre accuracy the targeted mass. CONCLUSIONS: This work demonstrates that the PAF rail system provides a reliable platform to enable accurate US 3D reconstruction of masses in RAPN procedures. The proposed system has also the potential to be employed in other surgical procedures such as hepatectomy or laparoscopic liver resection.

Deep learning-based fetoscopic mosaicking for field-of-view expansion.

PURPOSE: Fetoscopic laser photocoagulation is a minimally invasive surgical procedure used to treat twin-to-twin transfusion syndrome (TTTS), which involves localization and ablation of abnormal vascular connections on the placenta to regulate the blood flow in both fetuses. This procedure is particularly challenging due to the limited field of view, poor visibility, occasional bleeding, and poor image quality. Fetoscopic mosaicking can help in creating an image with the expanded field of view which could facilitate the clinicians during the TTTS procedure. METHODS: We propose a deep learning-based mosaicking framework for diverse fetoscopic videos captured from different settings such as simulation, phantoms, ex vivo, and in vivo environments. The proposed mosaicking framework extends an existing deep image homography model to handle video data by introducing the controlled data generation and consistent homography estimation modules. Training is performed on a small subset of fetoscopic images which are independent of the testing videos. RESULTS: We perform both quantitative and qualitative evaluations on 5 diverse fetoscopic videos (2400 frames) that captured different environments. To demonstrate the robustness of the proposed framework, a comparison is performed with the existing feature-based and deep image homography methods. CONCLUSION: The proposed mosaicking framework outperformed existing methods and generated meaningful mosaic, while reducing the accumulated drift, even in the presence of visual challenges such as specular highlights, reflection, texture paucity, and low video resolution.

All-Optical Rotational Ultrasound Imaging.

Miniaturised high-resolution imaging devices are valuable for guiding minimally invasive procedures such as vascular stent placements. Here, we present all-optical rotational B-mode pulse-echo ultrasound imaging. With this device, ultrasound transmission and reception are performed with light. The all-optical transducer in the probe comprised an optical fibre that delivered pulsed excitation light to an optical head at the distal end with a multi-walled carbon nanotube and polydimethylsiloxane composite coating. This coating was photoacoustically excited to generate a highly directional ultrasound beam perpendicular to the optical fibre axis. A concave Fabry-Pérot cavity at the distal end of an optical fibre, which was interrogated with a tuneable continuous-wave laser, served as an omnidirectional ultrasound receiver. The transmitted ultrasound had a -6 dB bandwidth of 31.3 MHz and a peak-to-peak pressure of 1.87 MPa, as measured at 1.5 mm from the probe. The receiver had a noise equivalent pressure <100 Pa over a 20 MHz bandwidth. With a maximum outer probe diameter of 1.25 mm, the probe provided imaging with an axial resolution better than 50 µm, and a real-time imaging rate of 5 frames per second. To investigate the capabilities of the probe, intraluminal imaging was performed in healthy swine carotid arteries. The results demonstrate that the all-optical probe is viable for clinical rotational ultrasound imaging.

A Continuum Robot and Control Interface for Surgical Assist in Fetoscopic Interventions.

Twin-twin transfusion syndrome requires interventional treatment using a fetoscopically introduced laser to sever the shared blood supply between the fetuses. This is a delicate procedure relying on small instrumentation with limited articulation to guide the laser tip and a narrow field of view to visualize all relevant vascular connections. In this letter, we report on a mechatronic design for a comanipulated instrument that combines concentric tube actuation to a larger manipulator constrained by a remote centre of motion. A stereoscopic camera is mounted at the distal tip and used for imaging. Our mechanism provides enhanced dexterity and stability of the imaging device. We demonstrate that the imaging system can be used for computing geometry and enhancing the view at the operating site. Results using electromagnetic sensors for verification and comparison to visual odometry from the distal sensor show that our system is promising and can be developed further for multiple clinical needs in fetoscopic procedures.