Evaluation of a robotic arm-assisted endoscope to facilitate endoscopic submucosal dissection (with video).

BACKGROUND AND AIMS: Endoscopic submucosal dissection (ESD) is considered technically difficult and challenging using a conventional flexible endoscope, mainly due to the lack of proper countertraction to expose the submucosal dissection plane. This study aimed to evaluate the feasibility of a traction method using a dexterous robotic arm in ex vivo gastric ESD. METHODS: ESD was performed in a total of 45 procedures using a portable endoscopic tool handler (PETH) (n = 30) and using the conventional method (n = 15) at various locations in the stomach. For each procedure, the performance data were recorded, including the total procedure time (minutes), incision time (minutes), dissection speed (mm2/minute), and blind dissection rate (%), to enable a comparison of the 2 ESD methods. RESULTS: The total procedure time was significantly shorter with PETH-ESD than in conventional ESD (23 vs 36 minutes, P = .011). This result is mainly attributed to the dissection speed, which was significantly faster, by more than 2.5 times, using the PETH (122.3 ± 76.5 vs 47.5 ± 26.9 mm2/minute, P < .001). The blind dissection rate was greatly decreased in PETH-ESD (0 vs 20%, P < .001). There was no significant difference in the incision time (6.1 ± 5.0 vs 5.5 ± 2.9 min, P = .612). CONCLUSIONS: The countertraction method using the PETH significantly improved the dissection speed and reduced blind dissection by enhancing direct visualization of the submucosal plane. With the advantages of multidirectional traction, fine tension control, and regrasping, this new device is expected to improve the performance of ESD and further facilitate advanced endoscopic procedures.

Real-Time Shape Estimation of Hyper-Redundant Flexible Manipulator Using Coiled Fiber Sensors.

The shape of flexible endoscopic surgical robot should be obtained to increase control accuracy and prevent unwanted tissue damage. To estimate the shape of flexible manipulator, space efficiency, cost-effectiveness, system complexity, and ease of calibration should be considered to integrate sensors into the manipulator. In this article, we propose a real-time method to estimate the shape of a hyper-redundant manipulator having embedded coiled fiber sensors. The main advantage of this method is guaranteeing shape recognition even when the manipulator is subjected to an external load. The fiber sensors are highly flexible, compact, and inexpensive, as well as they can functionally measure both compressive and tensile strain of hyper-redundant manipulator. The sensor design was optimized to achieve durability and sensitivity. The numbers of sensor and the placements were determined by the analysis of the kinematics and moment distribution of the manipulator. The accuracy of shape estimation was validated experimentally under both free-loading and loading conditions. The proposed method achieved real-time estimating capability with a mean maximum error of each joint position smaller than 3.54% in free-loading condition and 5.47% in loading condition.

Endoscopic surgery robot that facilitates insertion of the curved colon and ensures positional stability against external forces: K-COLON.

BACKGROUND: Although various endoscopic surgery robots developed in previous studies are versatile and have high lesion accessibility, they have limitations in terms of reaching the target lesion through the curved path in the large intestine and providing a stable tasking environment for the operator. METHODS: An endoscopic surgery robot was developed for performing surgery in the large intestine. The robot was easily inserted into the target lesion in the curved colon through the mounted soft actuator and demonstrated high structural stiffness through the insertion of the sigmoidal auxiliary tendons. RESULTS: The robot was able to access the target lesion in the curved colon through teleoperation alone. Further, it was confirmed that the high structural stiffness overtube improved the overall task performance in the user test. CONCLUSIONS: The proposed robotic system demonstrated the possibility and potential of performing advanced endoscopic surgery in the large intestine.

Sigmoidal Auxiliary Tendon-Driven Mechanism Reinforcing Structural Stiffness of Hyper-Redundant Manipulator for Endoscopic Surgery.

The overtube of an endoscopic surgery robot is fixed when performing tasks, unlike those of commercial endoscopes, and this overtube should have high structural stiffness after reaching the target lesion so that sufficient tension can be applied to the lesion tissue with the surgical tool and there are fewer changes in the field of view of the endoscopic camera from this reaction force. Various methods have been proposed to reinforce the structural stiffnesses of hyper-redundant manipulators. However, the safety, rapid response, space efficiency, and cost-effectiveness of these methods should be considered for use in actual clinical environments, such as the gastrointestinal tract. This study proposed a method to minimize the positional changes of the overtube end tip due to external forces using only auxiliary tendons in the optimized path without additional mechanical structures. Overall, the proposed method involved moving the overtube to the target lesion through the main driving tendon and applying tension to the auxiliary tendons to reinforce the structural stiffness. The complete system was analyzed in terms of energy, and the sigmoidal auxiliary tendons were verified to effectively reinforce the structural stiffness of the overtube consisting of rolling joints. In addition, the design guidelines of the overtube for actual endoscopic surgery were proposed considering hollowness, retroflexion, and high structural stiffness. The positional changes due to external forces were confirmed to be reduced by 60% over the entire workspace.

Ultra-soft and highly stretchable tissue-adhesive hydrogel based multifunctional implantable sensor for monitoring of overactive bladder.

A highly stretchable and tissue-adhesive multifunctional sensor based on structurally engineered islets embedded in ultra-soft hydrogel is reported for monitoring of bladder activity in overactive bladder (OAB) induced rat and anesthetized pig. The use of hydrogel yielded a much lower sensor modulus (1 kPa) compared to that of the bladder (300 kPa), while the strong adhesiveness of the hydrogel (adhesive strength: 260.86 N/m) allowed firm attachment onto the bladder. The change in resistance of printed liquid metal particle thin-film lines under strain were used to detect bladder inflation and deflation; due to the high stretchability and reliability of the lines, surface strains of 200% could be measured repeatedly. Au electrodes coated with Platinum black were used to detect electromyography (EMG). These electrodes were placed on structurally engineered rigid islets so that no interfacial fracture occurs under high strains associated with bladder expansion. On the OAB induced rat, stronger signals (change in resistance and EMG root-mean-square) were detected near intra-bladder pressure maxima, thus showing correlation to bladder activity. Moreover, using robot-assisted laparoscopic surgery, the sensor was placed onto the bladder of an anesthetized pig. Under voiding and filling, bladder strain and EMG were once again monitored. These results confirm that our proposed sensor is a highly feasible, clinically relevant implantable device for continuous monitoring OAB for diagnosis and treatment.

Effect of frequency difference on sensitivity of beats perception.

Two vibrations with slightly different frequencies induce the beats phenomenon. In tactile perception, when two pins of different frequencies stimulate the fingertips, an individual perceives a beats caused by a summation stimulus of the two vibrations. The present study demonstrates experimentally that humans can perceive another vibration based on the beats phenomenon when two tactile stimuli with slightly different frequencies are stimulated on the finger pad with a small contactor in different locations at the same time. Moreover, we examined the amplitude of the detection threshold to be able to perceive beats phenomenon on the index finger with 5 carrier frequency (63.1, 100, 158.5, 251.2, and 398.1 Hz) and 4 beats frequency (2.5, 3.98, 6.31, and 10 Hz) when two stimuli 1 mm distance apart are vibrated at a slightly different frequency. From the experiments, it is concluded that the amplitude threshold to be able to perceive beats decreases as the standard frequency increases under 398 Hz. Furthermore, from comparing the absolute detection threshold and beats detection threshold, as the carrier frequency increases, the required amplitude at two pins for the detection of beats decreases compared to absolute vibration.

An ergonomic comfort workspace analysis of master manipulator for robotic laparoscopic surgery with motion scaled teleoperation system.

BACKGROUND: In robotic surgery, a surgeon controls a surgical robot through a master manipulator in motion scaled teleoperation environment. However, there are no clear criteria for the master's workspace. METHODS: From the user experiment, we proposed an Ergonomic Comfort Workspace considering ergonomics and performed a verification experiment using the actual surgeons' dataset. RESULTS: From the user experiment, with comfortable posture, there was no significant difference (p-value < 0.05) between the master workspace when the task space is increased, and the workspace is defined as an ergonomic comfort workspace. Using the JIGSAWS dataset, elementary surgical tasks using surgical robots, verify the effectiveness of the ergonomic comfort workspace (ECW). It was confirmed that more than 95% of surgical task data were almost included in the ECW. CONCLUSIONS: The proposed ECW of the master for robotic laparoscopic surgery enables surgeons to perform surgery with high comfort and precision.

Intuitive endoscopic robot master device with image orientation correction.

BACKGROUND: The camera of an endoscope is fixed to the device, and the image rotates together with the endoscope. This can lead to visual confusion for the user and incorrect image reading. The problem also occurs with endoscopic robots. Using a master device with the same degrees of freedom as the endoscope to control an endoscopic robot causes visual-motor misorientation, making intuitive control difficult. METHODS: The roll misorientation between the image and master device handle was removed by measuring and correcting for the roll axis displacement of the master device. This enabled intuitive manipulation of the master device. The work speed and number of mistakes were experimentally measured with and without image correction. RESULTS: The tasks were completed significantly faster and more accurately with image orientation correction than without. CONCLUSIONS: The proposed method enables intuitive manipulation of the master device by correcting the image orientation in endoscopic robot control.

Analysis of tendon tension and hysteresis by tendon twisting and development of anti-twist tendon mechanism of robotic surgical instruments.

BACKGROUND: Control of the joints of robotic surgical instruments is difficult owing to hysteresis, and tendon twisting due to axial rotation of surgical tools also causes hysteresis. Therefore, a new mechanism is needed to prevent tendon twisting. METHODS: Tendon tension and hysteresis change were analysed by observing the movement of the joint depending on whether the tendons twisted for the same input signal. An anti-twist tendon mechanism to prevent twisting was developed. A 3-mm needle driver applied with the proposed mechanism was manufactured. RESULTS: The anti-twist mechanism makes no tension change because of twisting or friction between the tendon and the system, that is, the operating performance was the same regardless of rotation. CONCLUSION: The proposed mechanism has been verified and can be applied to small surgical instruments 3 mm in size. These findings can be applied in the development of instruments for precise surgeries such as microsurgery.

Intuitive master device for endoscopic robots with visual-motor correspondence.

BACKGROUND: Master devices exclusively used for endoscopes with position control are being developed as an isomorphic form of endoscopes. These master devices are difficult to intuitively operate because the movement direction of the endoscopic image and control handle do not match. METHODS: To solve this problem, a master device was developed. Its movement direction is compatible with that of the endoscopic image. It analyzes image movements according to flexible endoscopic ureteroscope movements for each degree of freedom. A driving testbed experiment was conducted that modelled the internal structure of a kidney. RESULTS: The time taken in the experiment was shorter when using the proposed master device than the existing isomorphic master device. The proposed device yielded fewer mistakes. CONCLUSIONS: It was confirmed the proposed device is effective in exclusive use for endoscopes because of its feasibility of position control and movement direction's coinciding with that of the endoscopic image.

Feasibility of Laser Lithotripsy for Midsize Stones Using Robotic Retrograde Intrarenal Surgery System easyUretero in a Porcine Model.

Purpose: To test the safety and feasibility of laser lithotripsy for midsize renal stones using a newly developed robotic retrograde intrarenal surgery (RIRS) system (easyUretero) in a porcine model. Materials and Methods: Three urologic surgeons representing three different RIRS experience levels (beginner, intermediate, and expert) participated. Four female pigs (aged 6 months) underwent manual or robotic RIRS. Under general anesthesia, a nephrostomy tract was created ventrally, and calcium stones (diameter, 1.0-1.5 cm) were inserted at renal calices. For manual RIRS, surgeons operated a flexible ureteroscope. For robotic RIRS, the ureteroscope was attached to the robotic slave device. The Auriga XL™ Holmium laser was used for lithotripsy. Lasering and stone retrieval time were measured. Kidneys and ureters were inspected for injury at the end of each session. Results: For the expert, both lasering and stone retrieval by manual RIRS were quicker than by robotic RIRS (22.8 ± 11.0 s/stone vs 234.5 ± 102.5 s/stone, p = 0.02; 41.5 ± 0.5 s/stone vs 79.3 ± 8.1 s/stone, p = 0.02). For the intermediate and beginner, lasering and stone retrieval times were not significantly different between manual and robotic procedures (127.8 ± 93.2 s/stone vs 284.8 ± 112.3 s/stone, p = 0.08; 86.0 ± 30.5 s/stone vs 84.1 ± 21.4 s/stone, p = 0.92). All stones were removed. Grade 1 ureteral and renal injuries occurred in both manual RIRS and robotic RIRS. Conclusions: The laser lithotripsy using the easyUretero robotic system is safe and feasible in a porcine model, even for less-experienced surgeons.

In Vivo Feasibility Test of a New Flexible Ureteroscopic Robotic System, easyUretero, for Renal Stone Retrieval in a Porcine Model.

PURPOSE: Using a new robotic endoscopic platform system developed for retrograde intrarenal surgery (RIRS) called easyUretero (ROEN Surgical Inc.), we evaluated the feasibility and safety of renal stone retrieval in a porcine model. MATERIALS AND METHODS: Six female pigs were used for our in vivo study. First, 0.3-cm-sized phantom stones were inserted into the kidneys of each pig via the ureteral access sheath. Next, renal stone retrieval was attempted using manual RIRS in three pigs and robotic RIRS in three pigs. Three surgeons performed extraction of 10 stones in each session. RESULTS: The mean stone retrieval time by manual RIRS was significantly shorter than that by robotic RIRS (399.9±185.4 sec vs. 1127.6±374.5 sec, p=0.001). In contrast, the questionnaire regarding usability showed high satisfaction in the surgeons' fatigue category for surgeons using robotic RIRS. The radiation exposure dose was also lower in robotic RIRS than in manual RIRS (0.14 µSv vs. 45.5 µSv). Postoperative ureteral injury assessment revealed Grade 0 in manual RIRS cases and Grades 0, 1, and 2 in robotic RIRS cases. CONCLUSION: The easyUretero system is a new robotic RIRS system that was developed in Korea. The results of the present study suggest that using easyUretero for stone retrieval during RIRS is safe and ergonomic.

Bed-mounted laparoscopic surgical robot system with novel positioning arm mechanism.

BACKGROUND: Commercialised laparoscopic surgical robotic systems require a large operating room and can only be used in large hospitals. If the robotic system is to be used in a small- or medium-sized hospital, the occupied volume must be reduced further. METHODS: In this paper, we propose a bed-mounted system that can be installed in a general operating room. Furthermore, we proposed a novel positioning arm suitable for a bed-mounted surgical robot system. RESULTS: The surgical possibility of the proposed bed-mounted system has been verified. Furthermore, the surgical possibility of the proposed system was confirmed using in vivo animal experiments. CONCLUSIONS: A bed-mounted laparoscopic robotic system and a novel positioning arm was proposed. The study's ultimate goal is to enable robotic surgery in small and medium-sized hospitals by introducing the proposed bed-mounted laparoscopic robot system, allowing many people to receive high-quality medical services.

The usefulness and ergonomics of a new robotic system for flexible ureteroscopy and laser lithotripsy for treating renal stones.

PURPOSE: To investigate the usefulness and ergonomics of a newly developed robotic system for flexible ureteroscopy (easyUretero). MATERIALS AND METHODS: During in vitro testing, six participants performed renal stone removal four times in an artificial kidney-ureter-bladder model. Each participant manipulated a single-use digital flexible ureteroscope (LithoVue) with their hands and the robotic system, sequentially. We compared the task completion times of each participant. The ergonomics of and operational satisfaction with each procedure were assessed by questionnaires. In vivo tests evaluated the operability and safety of the robotic system in two live female pigs. We checked that all the steps of flexible lithotomy for renal stones could be completed individually. RESULTS: The task completion time with the robotic system during in vitro testing was significantly longer than with manual ureteroscopy regardless of the operator's competence level (expert professors: 282.6±92.4 seconds vs. 73.6±43.3 seconds, p<0.001; fellows: 247.5±57.7 seconds vs. 95.8±43.7 seconds, p<0.001; residents: 281.3±111.0 seconds vs. 188.6±138.6 seconds, p<0.001). The residents took more time to remove the upper and mid caliceal stones with the robotic system. The ergonomic evaluation was better for the robotic system, but operational satisfaction was lower, and there was no statistical difference among the groups. In vivo tests showed that all the steps of robotic flexible ureteroscopy could be completed without difficulty. No safety issues were encountered during the procedure. CONCLUSIONS: The robotic system (easyUretero) was ergonomic and safe for flexible ureteroscopy and laser lithotripsy for renal stones.

easyEndo robotic endoscopy system: Development and usability test in a randomized controlled trial with novices and physicians.

BACKGROUND: Some difficulties are common when using endoscopes. Steering is not intuitive, the endoscope weight is a physical burden to physicians and communication problems often occur between operators. METHOD: To overcome these, we developed a robotic endoscopy system and conducted a usability test to compare conventional and robotic manipulation. Nine novices and eighteen physicians participated with the physicians being divided into intermediate and expert groups. The participants performed endoscope insertion into a simulator (physicians) or lesion marking on a testbed (novices) and simulate biopsies. RESULT: Novices completed the tasks faster and with a lower workload when using robotic manipulation, whereas the experts showed the opposite trend. Still, the intermediates showed no significant difference as trials proceeded. Nevertheless, the learning curve analysis showed that the learning rate in all groups is greater for robotic manipulation (21.02% on average) than for conventional manipulation (13.75%) and predicted that physicians can reach manual performance. CONCLUSION: The proposed robotic endoscopy system may allow solo-manipulation using one controller and may be more intuitive and convenient to use than conventional manipulation.

A highly intuitive and ergonomic redundant joint master device for four-degrees of freedom flexible endoscopic surgery robot.

BACKGROUND: Studies have been conducted on slave-specific master devices with a similar kinematic structure to the slave to enhance intuitiveness. However, for the four-degrees of freedom (DOFs) slave of a flexible endoscopic surgery robot, only four DOFs in the master device causes low ergonomic performance. METHODS: To enhance ergonomic performance, a second yaw joint was added as a redundant joint after considering the range of wrist motion and the workspace shape. Three experiments were performed to compare the intuitiveness and ergonomic performance of the proposed device with four-DOFs slave-specific and six-DOFs general-purpose master devices. RESULTS: Significant differences were observed in terms of intuitiveness performance between the slave-specific and the general-purposed master device. On the other hand, there was no significant difference in ergonomic performance between the master devices with redundant joint. CONCLUSIONS: Compared with a general-purpose master device, the proposed one exhibited noticeably improved intuitiveness performance and comparable ergonomic performance.

A novel encountered-type master device with precise manipulation for robot-assisted microsurgery.

BACKGROUND: The unconstrained master devices have emerged as attractive alternatives to the existing linkage-based counterparts. However, the conventional unconstrained master device's manipulation methods have several disadvantages in efficiency and precision. METHODS: We propose an encountered-type master device based on an electromagnetic tracking solution with a prismatic joint at the tip, capable of continuous spatial manipulation with the tip supported on the surface. We performed path-following task and pointing tasks to analyze the performance of the master device. RESULTS: The most convenient, efficient, accurate positioning and precise pointing were possible with a closed loop support condition. Moreover, the tasks under this condition were also completed with higher accuracy, and precision when applying lower motion scale factors. CONCLUSIONS: The proposed master device allowed precise and accurate manipulation for microsurgical tasks. Compared with the conventional unconstrained master devices, the proposed master device provides the ability to perform precise work with a clutching-free motion.

A novel microsurgery robot mechanism with mechanical motion scalability for intraocular and reconstructive surgery.

BACKGROUND: Intraocular surgery and reconstructive surgery are challenging microsurgery procedures that require two types of motion: precise motion and larger motion. To effectively perform the requisite motion using a robot, it is necessary to develop a manipulator that can adjust the scale of motion between precise motion and less precise, yet larger motion. AIMS: In this paper, we propose a novel microsurgery robot using the dual delta structure (DDS) to mechanically scale the motion to seamlessly adjust between precise and larger motion. MATERIALS & METHODS: The DDS forms a lever mechanism that enables the motion scaling at the end-effector using two delta platforms. Seamless scale adjustment enables the robot to effectively perform various surgical moves. RESULTS: A prototype robot system was developed to validate the effectiveness of the DDS. The experiment results in various scale settings validated the scaling mechanism of the DDS. CONCLUSION: Through a graphical simulation and measurement experiment, the robot's precision level and attainable workspace has been confirmed adequate for intraocular and reconstructive surgery.

An anatomic study on the junctura tendinum in the 4th intermetacarpal space and its clinical implication.

We report results of anatomic study in the fourth intermetacarpal space, focusing on the pattern of junctura tendinum and variations of extensor tendons of the little finger with its clinical implication on snapping of the little finger. Fifty unpaired cadaveric hands were dissected from the wrist to the middle phalanx of the ring and little fingers. The type of junctura tendinum was judged based on Von Schroder's classification and the relationship with EDC were recorded. EDC to the little finger and EDM were dissected and the numbers were recorded. Forty six hands (92%) exhibited a junctura tendinum in the fourth intermetacarpal space and it was Type III in 42 hands (84%). The EDC-little finger was absent in 76% (38 of 50 hands). When present, EDC-little finger originated most commonly as single thin tendon. The absence of an EDC-little finger was associated with increased incidence of Type III junctura tendinum (37 of 38 hands). An EDM was present in all 50 hands running from the fifth dorsal compartment. Based on these clinical and anatomic studies, we considered that the snapping of the little finger is more likely subluxation of junctura tendinum rather than subluxation/dislocation of EDC of the little finger.

K-FLEX: A flexible robotic platform for scar-free endoscopic surgery.

BACKGROUND: Despite its high lesion accessibility and versatility, endoscopic platforms have suffered from designing flexible manipulators with high payload capability sufficient to perform advanced endoscopic procedures. METHODS: A flexible robotic platform, K-FLEX, has been developed with a design of 17 mm in overall diameter. To overcome the shape distortion and deflection in payload handling, a strong continuum manipulator has been designed to have maximum resistance to the distortion. The kinematic analysis and mapping strategy have been established for the master-slave teleoperation. RESULTS: The proposed manipulator has shown 7.5 mm in trajectory variation to lift the weight of 300 g. Finally, the feasibility of the integrated K-FLEX system has been verified through three kinds of simulated surgical tasks. CONCLUSIONS: The initial prototype of the proposed robot showed the possibility of advanced endoscopic surgery with improved payload capability.