PLAFOKON: a new concept for a patient-individual and intervention-specific flexible surgical platform.

BACKGROUND: Research in the field of surgery is mainly driven by aiming for trauma reduction as well as for personalized treatment concepts. Beyond laparoscopy, other proposed approaches for further reduction of the therapeutic trauma have failed to achieve clinical translation, with few notable exceptions. We believe that this is mainly due to a lack of flexibility and high associated costs. We aimed at addressing these issues by developing a novel minimally invasive operating platform and a preoperative design workflow for patient-individual adaptation and cost-effective rapid manufacturing of surgical manipulators. In this article, we report on the first in-vitro cholecystectomy performed with our operating platform. METHODS: The single-port overtube (SPOT) is a snake-like surgical manipulator for minimally invasive interventions. The system layout is highly flexible and can be adapted in design and dimensions for different kinds of surgery, based on patient- and disease-specific parameters. For collecting and analyzing this data, we developed a graphical user interface, which assists clinicians during the preoperative planning phase. Other major components of our operating platform include an instrument management system and a non-sterile user interface. For the trial surgery, we used a validated phantom which was further equipped with a porcine liver including the gallbladder. RESULTS: Following our envisioned preoperative design workflow, a suitable geometry of the surgical manipulator was determined for our trial surgery and rapidly manufactured by means of 3D printing. With this setup, we successfully performed a first in-vitro cholecystectomy, which was completed in 78 min. CONCLUSIONS: By conducting the trial surgery, we demonstrated the effectiveness of our PLAFOKON operating platform. While some aspects - especially regarding usability and ergonomics - can be further optimized, the overall performance of the system is highly promising, with sufficient flexibility and strength for conducting the necessary tissue manipulations.

New Method for Surgical Diagnostics - a Robotic Telemedical Approach.

Apart from the tremendous increase in the demand for telemedicine during the COVID-19 pandemic, the use of telemedical technology offers many advantages, such as better coverage of rural areas and improved access to specialists. While current telediagnostic possibilities are often limited to a verbal consultation, the field of surgery has already made use of robotics for one of the most challenging areas of medicine: invasive procedures. Since comprehensive diagnostics are a prerequisite for each surgery, we built upon the knowledge gained in telesurgery and developed a telediagnostic system that allows for an extensive perioperative and emergency examination. It is based on a robotic platform consisting of a remote lead robotic arm at the physician's site and a follower robot at the patient's site. Mirroring all movements directly and using force-feedback, both parties can precisely interact, enabling tasks such as auscultation, percussion, and palpation without the need for extensive training. Our overall setup also includes the possibility to measure and monitor all relevant vital parameters and can be used to perform ear and nasopharyngeal inspections as well as an automatic swab to screen for COVID or other contagious diseases prior to hospital admission. In this paper, we focus on the potential of this technology for the surgical community by demonstrating the ease of adding an ultrasound probe to our modular setup to perform a high-quality emergency ultrasound examination. While the system is not yet ready for everyday use in a hospital and drawbacks such as a high cost persist, our setup paves the way for the future use of telediagnostics in surgery.

Toward telemedical diagnostics-clinical evaluation of a robotic examination system for emergency patients.

Introduction: The SARS-CoV-2 pandemic has affected global public healthcare for several years. Numerous medical professionals have been infected since the outbreak in 2019, resulting in a shortage of healthcare providers. Since traditional personal protective wear was insufficient to eliminate the virus transmission reliably, new strategies to avoid cross-infection were imperative while enabling high-quality medical care. In the project ProteCT, we investigated the potential of robotic-assisted examination in providing medical examination via a telemedical approach. Material and Methods: We constructed a fully functional examination cabin equipped with cameras, microphones, screens and robotic arms to evaluate usability and perception. Therefore, we conducted a preliminary study with 10 healthy volunteers and 10 physicians to gain first insights and optimize the setup. In a second step, we performed telemedical examinations of actual patients from the local emergency department to compare the robotic approach with the classical method of measuring vital signs, auscultation, palpation and percussion. Results: The preliminary study identified basic requirements, such as the need for force-feedback and telemedical training for physicians. In the main study, acceptance was high and most patients indicated they would use a telemedical system again. Our setup enabled the physician to make the same diagnoses as by classic examination in the emergency department in most cases. Discussion: The potential acceptance of a telemedical system such as ProteCT is high. Robotic telemedical approaches could complement future healthcare beyond the Corona pandemic to reach rural areas or even war zones. Moreover, the daily clinical use of robotic telemedicine could improve patients' safety, the quality of perioperative management and the workflow in any medical facility. Conclusion: The development of telemedical and telerobotic systems is a multidisciplinary and complex challenge. However, acceptance of the proposed system was high among patients and physicians, indicating the potential use of similar systems for future healthcare.

The colonoscopic vacuum model-simulating biomechanical restrictions to provide a realistic colonoscopy training environment.

INTRODUCTION: Practicing endoscopic procedures is fundamental for the education of clinicians and the benefit of patients. Despite a diverse variety of model types, there is no system simulating anatomical restrictions and variations in a flexible and atraumatic way. Our goal was to develop and validate a new modelling approach for adhesion forces between colon and abdominal wall. METHODS: An inlay for a standard mechanical trainer was designed and 3D printed. Colon specimens were fixed to the inlay along colon ascendens (CA) and colon descendens (CD) by a vacuum. Our system, which we refer to as Colonoscopy Vacuum Model (CoVaMo), was validated with 11 test persons with varying level of expertise. Each performed one colonoscopy and one polypectomy in the CoVaMo and in the Endoscopic Laparoscopic Interdisciplinary Training Entity (ELITE). Achieved adhesion forces, times required to fulfill different tasks endoscopically and a questionnaire, assessing proximity to reality, were recorded. RESULTS: Mean adhesion forces of 37 ± 7 N at the CA and 30 ± 15 N at the CD were achieved. Test subjects considered CoVaMo more realistic than ELITE concerning endoscope handling and the overall anatomy. Participants needed statistically significantly more time to maneuver from anus to flexura sinistra in CoVaMo (377 s ± 244 s) than in ELITE (58 s ± 49 s). CONCLUSION: We developed a training environment enabling anatomically and procedural realistic colonoscopy training requiring participants to handle all endoscope features in parallel. Fixation forces compare to forces needed to tear pig colon off the mesentery. Workflow and inlay can be adapted to any arbitrary ex vivo simulator.

Telemedical percussion: objectifying a fundamental clinical examination technique for telemedicine.

PURPOSE: While demand for telemedicine is increasing, patients are currently restricted to tele-consultation for the most part. Fundamental diagnostics like the percussion still require the in person expertize of a physician. To meet today's challenges, a transformation of the manual percussion into a standardized, digital version, ready for telemedical execution is required. METHODS: In conjunction with a comprehensive telemedical diagnostic system, in which patients can get examined by a remote-physician, a series of three robotic end-effectors for mechanical percussion were developed. Comprising a motor, a magnetic and a pneumatic-based version, the devices strike a pleximeter to perform the percussion. Emitted sounds were captured using a microphone-equipped stethoscope. The 84 recordings were further integrated into a survey in order to classify lung and non-lung samples. RESULTS: The study with 21 participants comprised physicians, medical students and non-medical-related raters in equal parts. With 71.4% correctly classified samples, the ventral motorized device prevailed. While the result is significantly better compared to a manual or pneumatic percussion in this very setup, it only has a small edge over the magnetic devices. In addition, for all ventral versions non-lung regions were rather correctly identified than lung regions. CONCLUSION: The overall setup proves the feasibility of a telemedical percussion. Despite the fact, that produced sounds differ compared to today's manual technique, the study shows that a standardized mechanical percussion has the potential to improve the gold standard's accuracy. While further extensive medical evaluation is yet to come, the system paves the way for future uncompromised remote examinations.

COVID-19 and beyond: development of a comprehensive telemedical diagnostic framework.

PURPOSE: During the COVID-19 pandemic, a threatening bottleneck of medical staff arose due to a shortage of trained caregivers, who became infected while working with infectious patients. While telemedicine is rapidly evolving in the fields of teleconsultation and telesurgery, proper telediagnostic systems are not yet available, although the demand for contactless patient-doctor interaction is increasing. METHODS: In this project, the current limitations were addressed by developing a comprehensive telediagnostic system. Therefore, medical examinations have been assessed in collaboration with medical experts. Subsequently, a framework was developed, satisfying the relevant constraints of medical-, technical-, and hygienic- aspects in order to transform in-person examinations into a contactless procedure. Diagnostic steps were classified into three groups: assisted procedures carried out by the patient, teleoperated examination methods, and adoptions of conventional methods. RESULTS: The Telemedical Diagnostic Framework was implemented, resulting in a functional proof of concept, where potentially infectious patients could undergo a full medical examination. The system comprises, e.g., a naso-pharyngeal swab, an inspection of the oral cavity, auscultation, percussion, and palpation, based on robotic end-effectors. The physician is thereby connected using a newly developed user-interface and a lead robot, with force feedback control, that enables precise movements with the follower robot on the patient's side. CONCLUSION: Our concept proves the feasibility of a fully telediagnostic system, that consolidates available technology and new developments to an efficient solution enabling safe patient-doctor interaction. Besides infectious situations, this solution can also be applied to remote areas.