Robotic Minimally Invasive Surgery Research Articles

Survival after a nationwide adoption of robotic minimally invasive surgery for early-stage cervical cancer – A population-based study

AimLately, the safety of minimally invasive surgery (MIS) in the treatment of cervical cancer (CC) has been questioned. This study aimed to evaluate the risk of recurrence and survival after a nationwide adoption of robotic MIS for the treatment of early-stage CC in Denmark. MethodsPopulation-based data on all Danish women with early-stage CC, who underwent radical hysterectomy January 1st 2005–June 30th 2017 were retrieved from the Danish Gynecologic Cancer Database and enriched with follow-up data on recurrence, death and cause of death. The cohort was divided into two groups according to the year of robotic MIS introduction at each cancer centre. Chi-squared or Fischer test, the Kaplan Meier method and multivariate Cox regression were used for comparison between groups. ResultsOne thousand one hundred twenty-five patients with CC were included; 530 underwent surgery before (group 1) and 595 underwent surgery after (group 2) the introduction of robotic MIS. The 5-year rate of recurrence was low: 8.2% and 6.3% (p = 0.55) in group 1 and 2, respectively. In adjusted analyses, this corresponded to a five-year disease-free survival, hazard ratio (HR) 1.23 [95% confidence interval (CI) 0.79-1.93]. No difference in site of recurrence (P = 0.19) was observed. The cumulative cancer-specific survival was 94.1% and 95.9% (P = 0.10) in group 1 and 2, respectively, corresponding to a HR 0.60 [95% CI 0.32–1.11] in adjusted analyses. ConclusionIn this population-based cohort study, the Danish nationwide adoption of robotic MIS for early-stage CC was not associated with increased risk of recurrence or reduction in survival outcomes.

Development of a New Medical Robot System for Minimally Invasive Surgery

This article presents the development of a new medical robot system comprising a spherical remote center motion (RCM) mechanism with modular design and two mechanical decoupling methods for Minimally Invasive Surgery (MIS). We achieved excellent comprehensive performance indices through a novel multi-objective optimization model comprising four optimization objective functions, three constrained conditions and two optimization variables. In order to enhance the manipulability, remove the coupling between motors, and reduce the control difficulty, two new decoupling mechanism means were proposed to remove coupling motion between the wrist and pincers, coupling motion between the translational joint of mobile platform and four interface disks of surgical instrument as a results of rear drive motor, respectively. The control system architecture is designed to include intuitive motion control, incremental motion control, and proportional motion control. Master-slave attitude registration and surgical instrument replacement strategies improve the master-slave control efficiency. We tested the spherical RCM mechanism performance indices and developed two mechanical decoupling methods and a master-slave control algorithm. Our experimental test results validated that fixing point accuracy, the coupling motions, the positioning and repeated positioning accuracy of the MIS robot, and master-slave control algorithm meet the requirements of MIS. Successful animal experiments confirmed effectiveness of the novel MIS robot system.

Texture differentiation using audio signal analysis with robotic interventional instruments

Robotic minimally invasive surgery (RMIS) has played an important role in the last decades. In traditional surgery, surgeons rely on palpation using their hands. However, during RMIS, surgeons use the visual-haptics technique to compensate the missing sense of touch. Various sensors have been widely used to retrieve this natural sense, but there are still issues like integration, costs, sterilization and the small sensing area that prevent such approaches from being applied. A new method based on acoustic emission has been recently proposed for acquiring audio information from tool-tissue interaction during minimally invasive procedures that provide user guidance feedback. In this work the concept was adapted for acquiring audio information from a RMIS grasper and a first proof of concept is presented. Interactions of the grasper with various artificial and biological texture samples were recorded and analyzed using advanced signal processing and a clear correlation between audio spectral components and the tested texture were identified.

A Hybrid Active/Passive Wrist Approach for Increasing Virtual Fixture Stiffness in Comanipulated Robotic Minimally Invasive Surgery

In minimally invasive surgery (MIS), the incision point acts as a fulcrum about which the surgical instrument pivots. Most robotic MIS systems foresee procedures to carefully align the robot with the incision in the patient. Such procedures disrupt the normal workflow. This hampers the clinical translation of such assistive technology. In contrast, backdrivable, wristed (BW) robots, especially when operated as comanipulation devices, have a minimal impact on the traditional surgical workflow in MIS, as they are readily equipped with algorithms that automate fulcrum point estimation. To improve safety, accuracy and/or task completion time, virtual fixtures can be implemented at the distal instrument tip, using an assistive BW system. This letter formalizes the problems related to such distal virtual fixtures. It then develops a hybrid active/passive wrist control strategy to improve the performance of virtual fixtures with BW systems while minimizing stability issues. Aside from an analytical example, experimental validation is added to show that the new algorithm increases the achievable stiffness of distal virtual fixtures.

Nationwide Introduction of Minimally Invasive Robotic Surgery for Early-Stage Endometrial Cancer and Its Association With Severe Complications

ImportanceMinimally invasive laparoscopic surgery (MILS) for endometrial cancer reduces surgical morbidity compared with a total abdominal hysterectomy. However, only a minority of women with early-stage endometrial cancer undergo MILS.ObjectiveTo evaluate the association between the Danish nationwide introduction of minimally invasive robotic surgery (MIRS) and severe complications in patients with early-stage endometrial cancer.Design, Setting, and ParticipantsIn this nationwide prospective cohort study of 5654 women with early-stage endometrial cancer who had undergone surgery during the period from January 1, 2005, to June 30, 2015, data from the Danish Gynecological Cancer Database were linked with national registers on socioeconomic status, deaths, hospital diagnoses, and hospital treatments. The women were divided into 2 groups; group 1 underwent surgery before the introduction of MIRS in their region, and group 2 underwent surgery after the introduction of MIRS. Women with an unknown disease stage, an unknown association with MIRS implementation, unknown histologic findings, sarcoma, or synchronous cancer were excluded, as were women who underwent vaginal or an unknown surgical type of hysterectomy. Statistical analysis was conducted from February 2, 2017, to May 4, 2018.ExposureMinimally invasive robotic surgery, MILS, or total abdominal hysterectomy.Main Outcomes and MeasuresSevere complications were dichotomized and encompassed death within 30 days after surgery and intraoperative and postoperative complications diagnosed within 90 days after surgery.ResultsA total of 3091 women (mean [SD] age, 67 [10] years) were allocated to group 1, and a total of 2563 women (mean [SD] age, 68 [10] years) were allocated to group 2. In multivariate logistic regression analyses, the odds of severe complications were significantly higher in group 1 than in group 2 (odds ratio [OR], 1.39; 95% CI, 1.11-1.74). The proportion of women undergoing MILS was 14.1% (n = 436) in group 1 and 22.2% in group 2 (n = 569). The proportion of women undergoing MIRS in group 2 was 50.0% (n = 1282). In group 2, multivariate logistic regression analyses demonstrated that a total abdominal hysterectomy was associated with increased odds of severe complications compared with MILS (OR, 2.58; 95% CI, 1.80-3.70) and MIRS (OR, 3.87; 95% CI, 2.52-5.93). No difference was found for MILS compared with MIRS (OR, 1.50; 95% CI, 0.99-2.27).Conclusions and RelevanceThe national introduction of MIRS changed the surgical approach for early-stage endometrial cancer from open surgery to minimally invasive surgery. This change in surgical approach was associated with a significantly reduced risk of severe complications.

New insights into early recovery after robotic surgery for endometrial cancer

ObjectiveTo assess early recovery of physical health after robotic minimally invasive surgery (RMIS) for early-stage endometrial cancer using the European Organisation of Research and Treatment of Cancer Computer Adaptive Test Core questionnaire (EORTC CAT Core). The EORTC CAT Core provides individualised measurements while maintaining comparability. A hypothesis of individual complete recovery to baseline within three post-surgical weeks was evaluated. MethodsNinety-four women who underwent RMIS for early-stage endometrial cancer were included consecutively. The EORTC CAT Core was distributed before surgery and prospectively every week during the first post-operative month. Repeated measures models were fitted for each of the four domains (physical functioning, role function, fatigue, and pain) and tested for impact of age, ASA score, minor/major surgery, and the individual baseline scores (poorest, intermediate, best). ResultsWomen with the lowest physical functioning, lowest role function, highest fatigue level, and highest pain level at baseline all recovered within three weeks. Women with the highest physical functioning, highest role function, lowest level of fatigue, and lowest level of pain at baseline did not reach their individual baselines within the first post-operative month but had the most favourable domain-scores three weeks post-operatively. ConclusionThe individual woman's physical health baseline score is predictive for her postoperative recovery following RMIS for early-stage endometrial cancer. Women with the best physical health had the best postoperative functions and lowest level of symptoms; however their recovery to baseline was prolonged. Computer adaptive testing may be a valuable tool for individualised pre-operative information and supportive care during surveillance.

Survival after a nationwide introduction of robotic surgery in women with early-stage endometrial cancer: a population-based prospective cohort study

PurposeThe purpose of the study was to evaluate the association between a nationwide introduction of robotic minimally invasive surgery (RMIS) and survival in women with early-stage endometrial cancer. Materials and methodsProspective data on consecutive women with early-stage endometrial cancer who underwent surgery during January 2005 to June 2015 in Denmark were identified in the nationwide Danish Gynaecological Cancer Database. Data were linked with national registries regarding comorbidity, education, income and death. The cohort was divided according to the time they underwent surgery: Group 1 before RMIS introduction in their respective region and Group 2 after RMIS introduction. Five-year overall survival was compared by multivariate Cox proportional hazards models stratified by histopathological risk between Groups 1 and 2 and between surgical modalities within Group 2: total abdominal hysterectomy (TAH), laparoscopic minimally invasive surgery (LMIS) and RMIS. ResultsWomen in Group 1 (N = 3091) had significantly lower overall survival compared with those in Group 2 (N = 2563; hazard ratio [HR], 1.22; 95% confidence interval [CI], 1.05–1.42). Age, smoking, socioeconomic status, American Society of Anaesthesiologists (ASA) score, comorbidity and histopathological risk influenced the overall survival. Following RMIS adoption, TAH was associated with higher mortality compared with LMIS and RMIS (HR, 1.42; 95% CI 1.02–1.97 and HR, 1.70; 95% CI 1.31–2.19 for LMIS and RMIS, respectively). There was no significant survival difference between RMIS and LMIS (HR, 1.19; 95% CI 0.85–1.68). ConclusionThe national introduction of robotic surgery for early-stage endometrial cancer was associated with improved survival irrespective of age, body mass index, ASA score, comorbidity, smoking, socioeconomic status and histopathological risk.

Autonomy in surgical robots and its meaningful human control

Abstract This article focuses on ethical issues raised by increasing levels of autonomy for surgical robots. These ethical issues are explored mainly by reference to state-ofart case studies and imminent advances in Minimally Invasive Surgery (MIS) and Microsurgery. In both area, surgicalworkspace is limited and the required precision is high. For this reason, increasing levels of robotic autonomy can make a significant difference there, and ethically justified control sharing between humans and robots must be introduced. In particular, from a responsibility and accountability perspective suitable policies for theMeaningfulHuman Control (MHC) of increasingly autonomous surgical robots are proposed. It is highlighted how MHC should be modulated in accordance with various levels of autonomy for MIS and Microsurgery robots. Moreover, finer MHC distinctions are introduced to deal with contextual conditions concerning e.g. soft or rigid anatomical environments.

A robotic laparoscopic tool with enhanced capabilities and modular actuation

Due to the improved treatment outcomes, research on robotic MIS (Minimally Invasive Surgery) thrived in the past decades. A benchmark example is the da Vinci system that dominates robotic laparoscopy via its technology excellence and strong holding of intellectual properties. This study provides an alternative approach to realize robotic laparoscopic surgeries, by presenting the development and experimentation of the SMARLT (Strengthened Modularly Actuated Robotic Laparoscopic Tool) for MIS. A dual continuum mechanism is used in the design to achieve enhanced distal dexterity, improved reliability, increased payload capability, and actuation modularity. With kinematics modelling and actuation compensation, the SMARLT can be manipulated by a generic manipulator to carry out typical laparoscopic MIS tasks, such as tissue peeling, suturing, and knot tying. Payload capability was also experimentally characterized. The SMARLT-manipulator system essentially formed a continuum-rigid hybrid structure that makes full use of the advantages from each component: the continuum mechanism as a wrist for distal dexterity and other rigid parts for position accuracy and payload capability. With the experimental demonstration of the desired functionalities, the SMARLT design can lead to promising opportunities for commercialization.

Constrained Kinematic Control in Minimally Invasive Robotic Surgery Subject to Remote Center of Motion Constraint

This paper presents kinematic control of surgical robotic systems subject to Remote Center of Motion (RCM) constraint in Minimally Invasive Robotic Surgeries (MIRS). A novel kinematic formulation for surgical systems is derived and the movement restriction in incision point, known as RCM constraint, is resolved by active control of the system through a so-called RCM-constrained Jacobian. The proposed minimal Jacobian matrix can realize fixed/moving trocar constraint effectively in comparison with the state-of-the-arts. In the following, an analysis related to the dexterity of the constrained system is introduced and an index for manipulability of the constrained system is introduced. The proposed approach is validated through several numerical simulations as well as experiments in a 7DoFs and 9DoFs MIRS scenarios. The results show the efficiency and the precision of the proposed method.

Metabolomic and BH3 profiling of esophageal cancers: novel assessment methods for precision therapy

BackgroundEsophageal cancers accounted for nearly 16,000 deaths in 2016. The number of patients with esophageal cancers increases every year. Neoadjuvant chemoradiotherapy (nCRT) prior to esophagectomy is a standard treatment for esophageal cancers. The patients who have no residual tumor (pathological complete response (pCR)) at surgery are the most likely to experience long term survival. Accurately determining which patients will have a pCR will improve prognostic information for patients and families, confirm lack of response to nCRT, or avoid surgery if no residual tumor is present. Imaging, endoscopy, and liquid biomarkers have all failed to detect pCR without performing an esophagectomy.MethodsIn this study, we are enrolling patients with esophageal adenocarcinoma and squamous cell carcinoma. Patients will undergo standard evaluation including CT scans, laboratory tests, endoscopy with biopsies, and evaluation by a thoracic surgeon. Tissue biopsy is required for enrollment that will be sent for BH3 profiling and metabolomics. Patients will be treated with standard nCRT followed by surgery. Patients with metastatic disease are not eligible. Surgery at the National Cancer Institute will be minimally-invasive robotic surgery. Patients will remain on study indefinitely with regular clinic visits and imaging tests.DiscussionThe mitochondria are critically involved in the intrinsic pathway apoptosis. Bcl-2 homology domain 3 (BH3) profiling is a technique to measure a cell’s susceptibility to apoptosis. BH3 profiling measures the relative interactions of proteins that induce or block apoptosis. The collective balance of these proteins determines whether a cell is near the threshold to undergo apoptosis. If the cell is near this threshold, then the tumor may be more likely to die when treated with nCRT. The mitochondria secrete metabolites that may be detectable as biomarkers. Metabolomics is a global assessment of all metabolite changes that has been performed for detection, monitoring, prognosis, and treatment response in cancers. Stratification of patients based on whether pCR occurs or not may elucidate metabolomic signatures that may be associated with response. We are asking whether BH3 profiling or a metabolomic signature will correlate with tumor death after nCRT for esophageal cancer.Trial registrationNCT03223662; Clinicaltrials.gov. July 21, 2017.

Selecting incision-dominant cases for robotic liver resection: towards outpatient hepatectomy with rapid recovery.

The premise of minimally invasive surgery (MIS) is to minimize facial and muscle injury in order to enhance recovery from surgery. Robotic MIS surgery for resection of tumors in solid organs is gaining traction, though clear superiority of this approach is lacking and robotic surgery is more expensive. Our philosophy in robotically-assisted hepatectomy has been to employ this approach for cases where location of tumors make difficult a classical laparoscopic approach (superior/posterior tumors), and cases where the incision for an open operation dominates the course of recovery. This is a retrospective review of a prospectively collected database. In this study we report 97 cases of liver resection subjected to the robotic approach, of which 90% were resected robotically. The mean operative time was 186±9 min; mean blood loss was 111±15 mL, and complications occurred in 9%. Two thirds of the patients remained in hospital 3 days or less, including three patients subjected to hemihepatectomy (2 left and 1 right). Fourteen individuals were discharged on the same day. The strongest predictors of long hospital stay (>3 days) were major hepatectomy (P=0.007), complications (P=0.008), and operative time >210 min (P=0.001). With thoughtful case selection, this is a first demonstration that hepatectomy can be conducted as an out-patient or short-stay procedure.

Quantitative Analysis of Technological Innovation in Urology

To assess major areas of technological innovation in urology in the last 20 years using patent and publication data. Patent and MEDLINE databases were searched between 1980 and 2012 electronically using the terms urology OR urological OR urologist AND "surgeon" OR "surgical" OR "surgery". The patent codes obtained were grouped in technology clusters, further analyzed with individual searches, and growth curves were plotted. Growth rates and patterns were analyzed, and patents were correlated with publications as a measure of scientific support and of clinical adoption. The initial search revealed 417 patents and 20,314 publications. The top 5 technology clusters in descending order were surgical instruments including urinary catheters, minimally invasive surgery (MIS), lasers, robotic surgery, and image guidance. MIS and robotic surgery were the most emergent clusters in the last 5 years. Publication and patent growth rates were closely correlated (Pearson coefficient 0.78, P <.01), but publication growth rate remained constantly higher than patent growth, suggesting validated scientific support for urologic innovation and adoption into clinical practice. Patent metrics identify emergent technological innovations and such trends are valuable to understand progress in the field of urology. New surgical technologies like robotic surgery and MIS showed exponential growth in the last decade with good scientific vigilance.

Multi-optimization of a spherical mechanism for minimally invasive surgery

In order to obtain the remote center motion (RCM) mechanism with better performance indexes and avoid the collision of multi-manipulators in minimally invasive surgery (MIS), a novel multi-objective optimization model was presented. There were two optimization objectives: a global kinematic performance index and a comprehensive stiffness index. Other indexes to characterize the design requirements such as collision probability, workspace, mechanism parameter, mass, and wall thickness were considered as constraints. Angles between two adjacent joints and cross-section dimensions of links were chosen as the design variables. The non-dominated sorting genetic algorithm II (NSGA-II) was adopted to solve the complex multi-objective optimization problem. Then, a 3-degree of freedom (DoF) MIS robotic prototype based on optimization results has been built up. The experiments to test the spatial position change of the remote center point and to test the absolute position accuracy and repetitive position accuracy of the MIS robot were achieved, and the experimental results meet the requirements of MIS.

From Macro to Micro: Autonomous Multiscale Image Fusion for Robotic Surgery

Minimally invasive surgery (MIS), performed through a small number of keyhole incisions, has become the standard of care for many general surgical procedures, reducing trauma, blood loss, and other complications and offering patients the prospect of a faster recovery with less postoperative pain. These improvements for the patient, however, require higher dexterity and complex instrument control by the surgeons. Keyhole incisions constrain the motion of surgical instruments, while the loss of stereovision when using a laparoscope or endoscope means that depth perception is much poorer than in traditional open surgery. The desire to tackle these issues has been the main driver behind the development of robotic MIS systems with stereovision. In particular, the da Vinci robot (Intuitive Surgical, Inc., Sunnyvale, California) is a successful surgical platform, used widely in the treatment of gynecological and urological cancers. While human guidance is essential for MIS, recent studies [1] have suggested that automation of some surgical subtasks, particularly those that are tedious and repetitive or require high precision, can be beneficial in improving accuracy and reducing the cognitive load of the surgeon. For example, several studies have investigated automation of surgical suturing subtasks, including using a suturing tool under fluorescence guidance [2], and other studies have explored areas such as autonomous tissue dissection [3].

Multi-Axis Force/Torque Sensor Based on Simply-Supported Beam and Optoelectronics.

This paper presents a multi-axis force/torque sensor based on simply-supported beam and optoelectronic technology. The sensor’s main advantages are: (1) Low power consumption; (2) low-level noise in comparison with conventional methods of force sensing (e.g., using strain gauges); (3) the ability to be embedded into different mechanical structures; (4) miniaturisation; (5) simple manufacture and customisation to fit a wide-range of robot systems; and (6) low-cost fabrication and assembly of sensor structure. For these reasons, the proposed multi-axis force/torque sensor can be used in a wide range of application areas including medical robotics, manufacturing, and areas involving human–robot interaction. This paper shows the application of our concept of a force/torque sensor to flexible continuum manipulators: A cylindrical MIS (Minimally Invasive Surgery) robot, and includes its design, fabrication, and evaluation tests.

Master–slave real-time control strategy in Cartesian space for a novel surgical robot for minimally invasive surgery

Robot-assisted systems can enhance the precision of surgical procedures, and have been widely used in minimally invasive surgery (MIS). This paper proposes the master–slave real-time control strategy for a novel surgical robot for MIS. The robot is equipped with two instrument manipulators and one laparoscope manipulator. The control strategy solves problems of kinematics transformation on consistency principle, intra-operative re-mapping and tremor attenuation in real-time. The kinematics model of slave instrument manipulators is established, and the master–slave control method in Cartesian space is proposed. Intra-operative re-mapping and real-time tremor attenuation algorithms are also proposed as auxiliary functions to improve surgical robot’s performance. The proposed methods are verified by respective experiments. Finally, animal experiment is performed to verify the correctness and efficiency of the control strategy in this research.

Intuitive control algorithm of a novel minimally invasive surgical robot

Background: Minimally invasive surgery (MIS) based on computer and robot-assisted technology is becoming more and more popular.Methods: Intuitive motion control implemented by kinematic algorithm of the slave manipulator based on the 3D Display (DD) is proposed to eliminate absonant hand-eye coordination, kinematic dissimilarity and workspace mismatch of the master-slave manipulator and is applied in the novel minimally invasive surgical (MIS) robot developed in our lab. Forward and inverse kinematics of MIS robot are analyzed based on the screw theory. The kinematic algorithm of MIS robot based on the DD is achieved.Results: The trajectory tracking results that the movement trends between the master and slave manipulators consistently validate the effectiveness of forward and inverse kinematics. The simulation results of the kinematic algorithm by virtue of Simulink and SimMechanics sub-modules of the MATLAB and intuitive control experiment that the root mean square error of cumulative position increments is less than 0.5 mm validate effectiveness of intuitive control algorithm.Conclusion: Successful animal experiments furthermore validate the effectiveness of intuitive control algorithm.

Kinematic Design of a Generalized Double Parallelogram Based Remote Center-of-Motion Mechanism for Minimally Invasive Surgical Robot

Robot-assisted minimally invasive surgery (MIS) has shown tremendous advances over the traditional techniques. To improve dexterity and back-drivability of the existing planar remote center-of-motion (RCM) mechanism, on which an active prismatic joint is required to drive the surgical tool move in–out of the patient's body, a two degrees-of-freedom (DOFs) planar RCM mechanism is proposed by constructing virtual parallelograms in this paper. The mechanism can be considered as a generalized double parallelogram; both of the actuated joints are revolute joints. This feature enhances the intrinsic back-drivability of the mechanism. The mathematical framework is introduced first to prove that the mechanism could execute RCM. Then, the inverse kinematics of the planar mechanism is solved, and the Jacobian matrix is derived in this paper. Further, the singularity and the kinematic performance based on the kinematic equations are investigated, and the workspace of the mechanism is verified. Finally, a prototype was built to test the function of the proposed RCM mechanism. The results show that the mechanism can fulfill the constraint of MIS, and it can be used as the basic element of the active manipulator in an MIS robot.

Sensorless Force Sensing for Minimally Invasive Surgery.

Robotic minimally invasive surgery (R-MIS) has achieved success in various procedures; however, the lack of haptic feedback is considered by some to be a limiting factor. The typical method to acquire tool-tissue reaction forces is attaching force sensors on surgical tools, but this complicates sterilization and makes the tool bulky. This paper explores the feasibility of using motor current to estimate tool-tissue forces and demonstrates acceptable results in terms of time delay and accuracy. This sensorless force estimation method sheds new light on the possibility of equipping existing robotic surgical systems with haptic interfaces that require no sensors and are compatible with existing sterilization methods.