Forceps Operations Research Articles

New surgery technique combining robotics and laparoscopy using the Hugo™ RAS system.

Hybrid total laparoscopic hysterectomy combines conventional laparoscopic surgery and robot-assisted devices: the camera and assistant forceps are operated by a robotic device, whereas the surgeon performs laparoscopic procedures, enabling surgery with a completely fixed field of view and significantly reducing errors in forceps grasping and needle misalignment. Here, we examined whether using two arms of the Hugo™ robot-assisted surgery system, one for the camera and one for the assistant, would improve surgical accuracy compared with conventional total laparoscopic hysterectomy. The surgical system reduced surgeon errors in grasping the forceps during training and stabilized forceps operation. Compared with conventional laparoscopic surgery, the use of the surgical system did not result in different operative durations. The stable surgical procedure was considered a major advantage. This new technique involving new equipment can improve surgeon training and performance. In the future, we will develop new techniques to improve surgical performance.

Rapid cycle deliberate practice: application in forceps simulation training for gynecology and obstetrics residents

Background Rapid Cycle Deliberate Practice (RCDP) has gained prominence in recent years as an innovative teaching method in simulation-based training for adult and pediatric emergency medical skills. However, its application in the training of forceps delivery skills among obstetrics and gynecology residents remains unexplored. This study aimed to assess the impact of RCDP in this domain. Methods Conducted in March 2021, this randomized controlled study involved 60 second-year obstetrics and gynecology residents undergoing standardized training. Participants were randomly assigned to the RCDP group or the traditional teaching method (TTM) group, each comprising 30 residents. The RCDP group followed the RCDP practice mode, while the TTM group adhered to conventional simulation teaching. Post-training assessment of operational proficiency was conducted immediately and after one year. Independent operational confidence and training satisfaction were evaluated through questionnaire surveys and the Satisfaction with Simulation Experience (SSE) scale. Data analysis utilized SPSS 23.0. Results The RCDP group displayed significantly higher immediate post-training forceps operation scores compared to the TTM group (92.00 [range: 90.00–94.00] vs. 88.00 [range: 86.75–92.00]; z = 3.79; p < .001). However, no significant difference emerged in forceps operation scores after one year (86.00 [range: 85.00–88.00] vs. 85.50 [range: 84.00–88.25]; z = 0.54; p = .59). The RCDP group exhibited notable performance improvement over the TTM group (z = 3.49; p < .001). Independent operation confidence showed no significant discrepancy (p > .05). Importantly, the RCDP group reported higher satisfaction scores, particularly in the Debriefing and Reflection subscale (44.00 [range: 43.00–45.00] vs. 41.00 [range: 41.50–43.00]; z = 5.24; p < .001), contributing to an overall superior SSE score (z = 4.74; p < .001). Conclusions RCDP exhibits immediate efficacy in elevating forceps delivery skills among residents. However, sustained skill enhancement necessitates innovative approaches, while RCDP’s value lies in tailored feedback and reflection for enriched medical education.

Adjustment of the Length Variation With Wire-driven Using the Stand Looper Tension Technique for Surgical Robot Applications.

The wire-driven method used in the field of surgical robots has the advantage of light weight. However, in the process of pull and push for the operation of forceps, the length of the wire is not match, causing malfunction. To solve this problem, the application of looper-tension technology would be suitable. This paper contributes to adjusting the length of the wire by inserting a stand between the wire-driven joints and adding a looper-tension between the stands to adjust the rotation radius of the roll. The method consisting of three rolls and loopers for connection between the stands minimizes errors by adjusting the length of the loop in a balanced state due to the rotation change of the roll during the pull and push of the robot arm. The angle and tension applied to the looper are 25° and 8.6MPa, respectively. An output response can be obtained when the reference operating point fluctuates by ± 50% of the input angle and tension, and if the reference operating point fluctuates by ± 30% while the input angle and tension are fixed, the output response occurs oppositely. When a .15kg object is loaded up/down with 1.5newton using forceps, the change in length of pull and push coincides. The advantage is that the error of wire pull, and push operation can be reduced, and accurate operation can be expected. Since the proposed technology is applied between joints, the integration process is not complicated, and the weight is light.

Development of Integrated Leader Controller for Forceps/Retractor Manipulation in Single-Port Water-Filled Laparo-Endoscopic Surgery

Single-port water-filled laparo-endoscopic surgery (WaFLES) is a surgical procedure used for treatment in an environment filled with isotonic water in the abdominal cavity under a single-port condition. In this study, we developed two leader controllers for the forceps manipulator and retractor to generate and maintain a surgical workspace for a single-port WaFLES support robot. The development of the specific controller for each device increased the operation time and complicated the motion, such as regripping. We integrated the two functions as a controller to prevent the problem above. We performed grasping and retracting tasks in the virtual surgical workspace to evaluate the proposed controller. Based on the experimental results, we clarified the effect on the operation time by a different mechanism and observed that arranging the switch decreased the operation time. In addition, one of the proposed leader controllers improved operability in terms of operation time during selection and switching from the retractor to the forceps manipulator. However, the arrangement of the switch could adversely affect controller operability when switching from a simple operation (requiring only position control during retractor operation) to a complex operation (requiring both position and posture control during forceps operation). Furthermore, manipulation errors were observed using either of the proposed controllers. Therefore, the sensing procedure of the controller should be improved by addressing these errors in software and hardware.

Evaluations of Gripping Motion during Forceps Operation to Improve Sensitivity of Stiffness Discrimination

In the endoscopic surgery, the forceps attached many kinds of gripping clip have been used, and stiffness discrimination is changed by its gripping clip. Therefore, it is important to evaluate the grasping sense characteristics with a focus on design elements such as gripping clip and handle shape. On the other hand, it is assumed that stiffness discrimination changes according to the gripping motion during forceps operation, it is also important to evaluate the relationship between gripping motion and stiffness discrimination. In this study, to consider the design policy of forceps shape that reduce the difference in sensation between direct palpation and using forceps, a sensory test was carried out by Scheffé’s method of paired comparison with the measurement of operating amount by thumb joint and middle finger joint. The specimens were used a silicon rubber with different stiffness as a substitute for materials as an object of the sensory test, and they were used elastic strain sensor in the measurement of operating amount of thumb joint and middle finger joint. From the results of principal component analysis with Score by Scheffé’s method and operating amount of thumb joint and middle finger joint, gripping motion can be classified by its characteristics, and we narrowed down the candidates for gripping motion with high sensitivity to stiffness discrimination. As a result, we clarified that the mode of signal by CM joint of thumb and MP joint of middle finger is highly sensitive to stiffness discrimination.

Effects of Gripping Object’s Characteristics on Thumb Movement during Forceps Operation and Ability to Discriminate Stiffness

Effects of Gripping Object’s Characteristics on Thumb Movement during Forceps Operation and Ability to Discriminate Stiffness

Suction-fixing surgical device for assisting liver manipulation with laparoscopic forceps.

Noninvasiveness and stability are significant issues in laparoscopic liver resection. Inappropriate grasping force can cause damage or serious bleeding to the liver. In addition, instability of grasping can result unsafe operations or wavered cutting. We propose a surgical device to improve stability of liver manipulation. A proposed device adheres to the liver surface with suction fixation, then tunes its stiffness to being hard and shapes like as a bulge on the liver surface to be grasped with laparoscopic forceps. It consists of two soft beams, a chamber sponge, membrane covering the device upper, suburb extrusion wing membrane, a vacuuming tube and to-be-grasped bars. The beams are designed as being non-stretchable and easy to bend. The device is connected to a medical vacuuming pump to vacuum air in the device and then gets hard to transfer forceps operation well. This stiffness tuning mechanism by pneumatic control features the device for achieving good liver shape followability and forceps operation propagation less invasively. The proposed device was tested with rubber phantoms and porcine livers on shape followability, stiffness transition, liver invasiveness and operational usability in the experiments. Performance of the proposed device was assessed in experiments. The device showed good object-shape followability. It held the liver with 2.43-N force for vertical lifting and 4.90-N shear force with - 80kPa vacuuming pressure. Invasiveness was reduced to acceptable level of liver damage. In usability test, the device grasped the liver stably and transferred surgical forceps operations to the liver surface well. The proposed device showed effective performance to improve laparoscopic liver manipulation. It held the liver stably and less invasively and transferred forceps operation force to the liver surface well.

A Cooperative Human-Robot Interface for Constrained Manipulation in Robot-Assisted Endonasal Surgery

Endoscopic endonasal surgery (EES) is a minimally invasive technique for removal of pituitary adenomas or cysts at the skull base. This approach can reduce the invasiveness and recovery time compared to traditional open surgery techniques. However, it represents challenges to surgeons because of the constrained workspace imposed by the nasal cavity and the lack of dexterity with conventional surgical instruments. While robotic surgical systems have been previously proposed for EES, issues concerned with proper interface design still remain. In this paper, we present a cooperative, compact, and versatile bimanual human-robot interface aimed to provide intuitive and safe operation in robot-assisted EES. The proposed interface is attached to a robot arm and holds a multi-degree-of-freedom (DOF) articulated forceps. In order to design the required functionalities in EES, we consider a simplified surgical task scenario, with four basic instrument operations such as positioning, insertion, manipulation, and extraction. The proposed cooperative strategy is based on the combination of force based robot control for tool positioning, a virtual remote-center-of-motion (VRCM) during insertion/extraction tasks, and the use of a serial-link interface for precise and simultaneous control of the position and the orientation of the forceps tip. Virtual workspace constraints and motion scaling are added to provide safe and smooth control of our robotic surgical system. We evaluate the performance and usability of our system considering reachability, object manipulability, and surgical dexterity in an anatomically realistic human head phantom compared to the use of conventional surgical instruments. The results demonstrate that the proposed system can improve the precision, smoothness and safety of the forceps operation during an EES.

Operative vaginal delivery: outcomes for mothers and newborns

Hypothesis/aims of study. The frequency of surgical abdominal delivery in Russia, as in the world, continues to grow, reaching 29.3% in 2017. Operative vaginal delivery is an alternative to abdominal delivery in the second stage of labor. This study was aimed at analyzing the outcome of labor for mothers and newborns using different operative vaginal delivery methods.&#x0D; Study design, materials and methods. We studied 293 cases of childbirth in the period from 2015 to 2018. Three groups were distinguished: (I) the main group consisting of 172 women delivered by the operation of applying obstetric forceps (OF); (II) the comparison group including 85 patients delivered by the operation of vacuum extraction (VE) with the fetal head being near the pelvic floor; and (III) the control group comprising 34 cases of vaginal birth without use of instrumental delivery. In group I, 114 patients were delivered by the low forceps operation (subgroup IA), and 60 individuals by the mid forceps operation (subgroup IB).&#x0D; Results. Vaginal lacerations were found in 21.3% of cases in group I, less often less often in groups II (10.6%, p 0.05) and III (2.9%, p 0.05). Vaginal hematoma occurred in one patient of group III (2.9%) and three women of group I (1.7%, p 0.05). There were no cases of damage to the anal sphincter. The greatest blood loss was recorded in subgroup IB (554 44.9 ml), when compared to subgroup IA (473 20.7 ml; p 0.05), group II (418 24.9 ml; p 0.05), and group III (347 33.4 ml; p 0.05). There were no differences in blood loss between the outlet OF and VE groups (p 0.05). Most newborns were born in good condition (84.5%, 77.6%, and 88.2% of cases in groups I, II, and III, respectively). Cephalohematoma in newborns was more common after VE (32.9%) than after OF (9.2%, p 0.01) and in control (5.9%, p 0.01). No retinal hemorrhage was recorded in newborns. There were no significant differences in the frequency of children being transferred to the childrens hospital (7.5%, 9.4%, and 8.8% of cases in groups I, II, and III, respectively; p 0.05).&#x0D; Conclusion. The use of OF is an effective and safe method of vaginal operative delivery. It does not increase the fetal injury rate, the frequency of newborn cephalohematoma being 3.5 times less than with VE. Complications of OF and VE (except for a greater number of vaginal lacerations in cases of OF), blood loss, and the course and duration of the postpartum stay in the maternity ward are comparable.

Erratum to “Development of a Novel Gastrointestinal Endoscopic Robot Enabling Complete Remote Control of All Operations: Endoscopic Therapeutic Robot System (ETRS)”

[This corrects the article DOI: 10.1155/2019/6909547.].

Training System for Endoscopic Surgery Aiming to Provide the Sensation of Forceps Operation

In Japan, a rising number of endoscopic surgery operations have boosted an expectation for the development of a training environment for qualified surgeons. The endoscopic surgery operation requires the operator to operate forceps by hand based on two-dimensional operative field information displayed on the monitor. The characteristics of the operation include a lack of stereoscopic visual field information and movement of the tip of the forceps, which is symmetric about the trocar. These are issues that require an empirical solution from the operator. It is desirable that these issues have already been overcome before the operator starts practicing as an operating surgeon. To this end, it is effective to train the operator in the sensation of forceps operation, which associates the operative field vision with the forceps operation by hand. Therefore, this study includes digitizing the forceps operation by qualified surgeons and providing it to the trainee as visual and force information in order to build a training device that facilitates the cultivation of the sensation of forceps operation.

PS01.129: A NEW ANIMAL TRAINING MODEL FOR MEDIASTINAL LYMPHADENECTOMY WITH A SINGLE-PORT MEDIASTINOSCOPIC CERVICAL APPROACH

Abstract Background Single-port mediastinoscope-assisted transhiatal esophagectomy for thoracic esophageal cancer is a minimally invasive surgery and can be applied to patients with low pulmonary function. However, special skills are needed to safely perform this surgical procedure as a curative operation without complications such as recurrent laryngeal nerve paralysis. To date, no animal training models for this surgical procedure has not been established. In this study, we developed a new animal training model for mediastinal lymphadenectomy with a single-port mediastinoscopic cervical approach. Methods A domestic pig was intubated, with a normal tracheal tube, and placed in a spine position. Because pigs do not have clavicles, skin incision was made on the cephalic side of the left forelimb. Anterior cervical muscles were cut and cephalic parts of thymus and left thyroid were resected to deploy the operation field. Esophagus and left recurrent laryngeal nerve were identified behind the trachea. A wound edge protector (Lap-Protector) and EZ Access was attached to the wound. An artificial pneumomediastinum was created using 5–6 mmHg of CO2 gas and three 5mm ports were inserted to EZ Access. Operator dissected connective tissues around esophagus and vessels mainly using a bipolar sealing device. At the right side of the esophagus, fat tissue with 106recL lymph nodes was dissected from tracheal wall. After dissection was reached to the carina level, esophagotracheal ligament was cut and dissection on the left side of esophagus was carried out to the level of aortic arch. By displacing the trachea to the front side, 109R, 107 and 109L lymph node were dissected. Results Because pig's tracheal cartilage is sub-circumferential, mobility of trachea is relatively poor, and risks of tracheal membranous portion damage are low. Although there are some anatomical differences between pigs and human, this animal training model reproduces surgical procedures of mediastinal lymphadenectomy in human such as forceps operation techniques in narrow fields and effects of artificial pneumomediastinum. Conclusion We established a new animal training model for mediastinal lymphadenectomy with a single-port mediastinoscopic cervical approach. This model reproduces surgical procedures in human and is useful for training surgeons who wish to start performing mediastinal lymphadenectomy by mediastinoscopic cervical approach. Disclosure All authors have declared no conflicts of interest.

他者の鉗子操作に没入することで鉗子操作感覚の獲得を目指す訓練装置の構築

他者の鉗子操作に没入することで鉗子操作感覚の獲得を目指す訓練装置の構築

腹腔鏡下手術トレーニングシステムの構築

Laparoscopic surgery is a difficult surgical procedure as compared with open operation. Therefore, training is necessary for surgeons to perform laparoscopic surgery. In this paper, a training system in which trainees can train a process by themselves that makes a forceps arrive at the target position during ligation based on the evaluation results of hands movement and an operation time, is proposed. First, an acceleration of the forceps is measured by 9-axis sensors attached to the forceps and frequency analysis is performed to the measured acceleration. When the spectrum of the trainee's acceleration in low frequency band is larger than the threshold value determined from pre-measured spectrum of the skilled surgeon's acceleration, the hands movement is regarded as superfluous. Second, an operation time of the trainee's forceps operation which makes the forceps arrive at the target position during ligation is compared with that of the skilled surgeon. Finally, the evaluation results of trainee's hands movement and operation time in comparison with those of the skilled surgeon are displayed on the monitor screen.

操作妨害機能を用いた鉗子操作技術評価に関する研究

Against the background of increasing the number of cases of endoscopic surgery, more effective training system has been requested from doctors. By the way, it is important to assess the proficiency level of operating an endoscopic forceps. Then, this study aims to develop an assessment system for the operation skill of endoscopic forceps. In our system, the operation skill of endoscopic forceps is assessed by adding the disturbance to a trainee who is practicing the forceps operation. Three doctors were employed as the test subjects of this study and the differences in their proficiency levels were confirmed in our experiments.

Persistent occiput posterior.

Persistent occiput posterior (OP) is associated with increased rates of maternal and newborn morbidity. Its diagnosis by physical examination is challenging but is improved with bedside ultrasonography. Occiput posterior discovered in the active phase or early second stage of labor usually resolves spontaneously. When it does not, prophylactic manual rotation may decrease persistent OP and its associated complications. When delivery is indicated for arrest of descent in the setting of persistent OP, a pragmatic approach is suggested. Suspected fetal macrosomia, a biparietal diameter above the pelvic inlet or a maternal pelvis with android features should prompt cesarean delivery. Nonrotational operative vaginal delivery is appropriate when the maternal pelvis has a narrow anterior segment but ample room posteriorly, like with anthropoid features. When all other conditions are met and the fetal head arrests in an OP position in a patient with gynecoid pelvic features and ample room anteriorly, options include cesarean delivery, nonrotational operative vaginal delivery, and rotational procedures, either manual or with the use of rotational forceps. Recent literature suggests that maternal and fetal outcomes with rotational forceps are better than those reported in older series. Although not without significant challenges, a role remains for teaching and practicing selected rotational forceps operations in contemporary obstetrics.

J1630103 鉗子操作力を提示する腹腔鏡下手術トレーニングシステムの開発

Laparoscopic surgery is a difficult procedure compared with open abdominal surgery. Therefore, training is necessary for surgeon to enhance the surgical skill for laparoscopic surgery. In this paper, we propose a novel training system to train an operation of ligation in laparoscopic surgery. The developed training system presents operator's operating force of the forceps, sudden operation of the forceps and straining of the shoulder to the operator. The operator's operating force of the forceps is measured by strain gauges and is displayed to the monitor together with the target force which was pre-measured from skilled-surgeon, so that the operator can learn appropriate operating force of the forceps. In addition, operator's forceps operation and surface electromyogram of the back muscle are measred, and when the operator's sudden operation of the forceps and straining of the shoulder are detected, the operator is warned acoustically. Fundamental tests were carried out to verify working state of the developed training system.

Training system for endoscopic surgery with haptic guide function and augmented reality

Presently, the number of cases of endoscopic surgery which can reduce both physical and mental burdens of a patient has been increasing. Although a variety of training environments has been prepared, more effective training methods have been expected from the doctors who are engaging in medical education. This study is focused on an approach for teaching calligraphy, where a teacher grasps both an ink brush and the student's hand and moves them to an appropriate direction with befitting force. In order to streamline the training efficiency of endoscopic surgery, we propose a function of haptic guidance for the operation of endoscopic forceps. We develop the experimental devices which dynamically control the movement of endoscopic forceps in order to realise the haptic guide function. This paper introduces the system structure and its software, and we discuss about the training effects through the experimental results.

Reintroducing Kielland forceps

It is always reassuring to find that the conclusions made in a contemporary article in a biomedical journal mirror the conclusions and decision made in a judicial review. Tempest et al. recently reported on over 1200 forceps, ventouse, or manual rotations performed in mothers with arrest of descent, with the fetal head not in an occiput anterior position (BJOG 2013;120:1277–84). They conclude that ‘assisted vaginal birth by Keilland forceps is likely to be the safest and most effective’ mode of delivery. In 2007 the Scottish Court of Sessions ruled in a case in which a transverse arrest of descent was treated with a trial of rotational forceps that failed (Dinley versus Lothian Health Board). The birth was completed abdominally and the baby went on to develop encephalopathy, and ultimately, cerebral palsy. The plaintiff alleged negligence both in the decision to try a forceps rotation and the conduct of the operation itself. Lord Hodge weighed the evidence and expert opinions, and concluded that even though some experts consider that a trial of forceps was not appropriate, a substantial volume of medical literature supports this approach as safe and effective. Moreover, the excellent documentation by the operating clinician established that the requirements for such a rotational delivery to be appropriate had been met, and the procedure was performed properly. The doctor and health facility were found not guilty of negligence. Both the justice system and Tempest et al. have identified the prerequisites for a forceps rotation to be justifiable. These include: an experienced operator, adequate anaesthesia, certainty of fetal position and station, and access to acute emergency abdominal delivery and neonatal resuscitation. In my hospital, these can only be achieved by moving the mother to an operating room, having anaesthesia and paediatric teams present, and being prepared to abandon the attempt at forceps delivery if it proves to be too difficult. We duplicate the old ‘double set–up’ approach used in the days before the antepartum diagnosis of placenta praevia could be made easily, so we are under no pressure to complete the delivery with forceps. So, given this alignment of solicitors and surgeons, why are fewer and fewer forceps operations attempted in contemporary practice? MJ Dickson, in his letter regarding the Tempest paper (BJOG 2013;120:1438), highlighted the problems. As a surgical procedure is attempted less and less, collective experience wanes, as does confidence and competence. With fewer competent and confident practitioners as models, learners are not exposed to success and thus ‘lack the training’ to attempt the procedure. Before this valuable tool in the work box of the accoucheur is relegated to the ‘dustbin of history’ we must actively bring it back into practice. This is a moment amidst free fetal DNA and epigenetics for senior obstetricians to shine. Those of us with competence and confidence need to take advantage of the teaching experiences beckoning in labour and delivery. Ian Treharne presents the intriguing idea of a ‘Keilland forceps club’ (letter in this issue), with an experienced mentor to enhance clinical training. Perhaps every institution needs one? None declared. Deputy Editor-in-Chief profile available at www.BJOG.org

2P1-C05 内視鏡手術シミュレータにおける鉗子操作反力推定モデルの構築(医療ロボティクス・メカトロニクス)

In laparoscopic surgery simulators, to realize the operational sense as if a surgeon operates a forceps in the real surgery, the haptic parameters for a forceps are very important. In this paper, the model to estimate the reaction force for a forceps operation in laparoscopic surgery simulators is discussed to realize the operational sense in a laparoscopic surgery simulator. A sensor forceps in which various sensors is installed has been developed, and the movements and the reaction forces of the sensor forceps are measured when some surgeons use the forceps. The haptic parameters of the model are investigated based on the measured data. By using the obtained parameters in the laparoscopic surgery simulator, a trainer is able to realize more realistic reaction force.