Robotic Forceps Research Articles

Current status and future perspectives of robotic liver surgery.

Robotic liver resection has been reported in case series since the early 2000s. The surgical robot is capable of precise operation using articulated forceps with seven degrees of freedom. The robot also eliminates tremors and provides a good surgical field with highly detailed 3D high-definition images. The clinical results demonstrating their usefulness have been increasing year by year. Initially, a shorter hospital stay was observed in comparison with open hepatectomy. Recent reports have also shown lower conversion and complication rates in comparison with laparoscopic hepatectomy. The clamp and crush method with bipolar forceps, sealing devices, ultrasonic shears, and the combined procedure of Cavitron ultrasonic surgical aspirator and robotic forceps as hybrid procedures have been reported as effective methods of parenchymal transection in robotic surgery. Theoretically, the advantages of the robotic platform allow for more complex liver resection around hilar structures and major blood vessels, as well as for vascular reconstruction or biliary reconstruction. The application of robotic liver surgery for hilar cholangiocarcinoma, living donor hepatectomy, and living donor liver transplantation has been reported. Robotic liver surgery is becoming more popular for certain indications; however, it is important to further evaluate its long-term surgical and oncological outcomes and costs in comparison with conventional laparoscopic and open liver surgery, based on accumulated experience.

A newly developed surgeon‐controlled suction device in robotic‐assisted thoracoscopic surgery

AbstractIntroductionAssistant surgeons usually clean the surgical field with a suction cannula in robotic‐assisted surgery. This manipulation requires skill and experience to avoid interfering with the operation of the console surgeon. Recently, we created a new suction device that a console surgeon can manipulate with the robotic arms.Materials and Surgical TechniqueA small metal suction tip with as a lumen and small side pores for suction and can be connected to a silicone tube connected to wall suction. The tip of the silicone tube can be grasped with robotic forceps and used for organ retraction as well as suction. The suction device has been used in eight lung lobectomy cases and four lung segmentectomy cases to date. There were no major difficulties related to the new suction device except for metal tip disconnection and blood clots clogging.DiscussionOur newly developed surgeon‐controlled suction device is inexpensive, easy to handle, and useful for suction, blunt dissection, and organ retraction in robotic‐assisted thoracoscopic surgery, especially when performing lymph node dissection.

Multidirectional Traction Method Using SURGICEL NU-KNIT and Surgical Suture in Robot-assisted Laparoscopic Surgery for Endometrial Cancer

To describe a novel approach to robot-assisted laparoscopic total hysterectomy (RH) for endometrial cancer that minimizes cancer sell spillage and develops a stable surgical field. Demonstration of the multidirectional traction method with narrated video footage. Many reports have indicated that RH for endometrial cancer has the same or superior short-term results compared with conventional laparoscopic hysterectomy (LH), and the long-term prognosis is the same [1,2]. However, there are no randomized controlled trials of RH versus LH, and some previous reports [3] have suggested that RH has a worse prognosis than LH, so the long-term prognosis should be considered with caution. Factors that may affect the long-term prognosis include the use of uterine manipulators [4] and compression of the uterine body with robotic forceps without tactile sensation [3]. However, to the best of our knowledge, no surgical technique capable of avoiding these factors has been established yet. Herein, we report a multidirectional traction method using SURGICEL NU-KNIT (Ethicon; Johnson & Johnson Medical Ltd., Tokyo, Japan), a local hemostatic agent, and surgical sutures. Cut 2-0 Prolene (Ethicon; Johnson & Johnson Medical Ltd., Tokyo, Japan) with straight needles (ST-70) thread to 35 cm, stick a 1×2 cm piece of SURGICEL NU-KNIT, and make knots Fig. 1. This implement is used to puncture the incisional margins of the peritoneum and then the abdominal wall to bring the thread to the surface of the body, where it is grasped with forceps and fixed. By repeating this operation, multidirectional traction can be obtained Fig. 2. A manipulating suture is also attached to the uterus to minimize the compression of the uterine body with robotic forceps. The multidirectional traction method allows for reproducible stable surgical field development and minimizes cancer cell spillage by reducing uterine grasping by robotic forceps without the use of uterine manipulators.

394. USEFULNESS OF INTRAOPERATIVE RECURRENT LARYNGEAL NERVE MONITORING IN REDUCING RECURRENT LARYNGEAL NERVE PARALYSIS AFTER ROBOT-ASSISTED THORACOSCOPIC ESOPHAGECTOMY

Abstract Background Robot-assisted thoracoscopic esophagectomy (RAMIE) is a precise and safe procedure with its advantages. On the other hand, RAMIE has several disadvantages. The lack of tactile function must be fully recognized, and surgical procedures must take the characteristics into account. We examined whether the findings obtained by intraoperative recurrent nerve monitoring (NIM) are useful in reducing recurrent laryngeal nerve paralysis (RLNP) after RAMIE. Methods Overall, 81 cases of RAMIE through February 2023 were included in the study. NIM was performed in 41 patients in the first term using a combination of continuous and intermittent methods (NIM group). In the subsequent 40 patients, NIM was not performed (non-NIM group) in order to confirm the learning effect of NIM and to shorten the operation time. RLNP was confirmed by a combination of symptoms and postoperative laryngoscopy. Clinical and oncological factors and short-term outcomes of the two groups were compared. Results All postoperative RLNP occurred on the left side. Six patients (14.6%) in the NIM group had Grade 1 or higher RLNP. The causes of RLNP were all found during thoracic manipulation; 4 cases of over-traction of RLN and 2 cases of crush injury by robotic forceps. There was a significant decrease in RLNP of Grade 2 or higher; 4 patients (9.7%) in the NIM group and 0 in the non-NIM group (p = 0.04). In the non-NIM group, there was a reduction in thoracic operative time, total operative time, and thoracic blood loss. Conclusion NIM made us aware of surgical maneuvers that cause RLNP after RAMIE. Although the proficiency of the RAMIE technique may have played a role in the reduction of RLNP in the later period, avoidance of risky surgical procedures due to the learning effect from the NIM was thought to have contributed to the decrease in RLNP.

Robot-Assisted Radical Cystectomy with Modified Vesica Ileale Padovana (VIP) Neobladder Configuration Using a Hybrid Approach: Initial Experience.

We developed a new technique to fold a neobladder (NB) simply by using a modified Vesica Ileale Padovana (VIP) with a hybrid approach. We provide a step-by-step description of our technique as it was used in this initial experience. A total of 10 male patients with a median age of 66 years underwent robot-assisted radical cystectomy (RARC) with an orthotopic NB via a hybrid approach from March 2022 to February 2023. After the isolation of the bladder and bilateral pelvic lymphadenectomy, Wallace plate creation was performed, and the robot was undocked. We extracorporeally performed the removal of the specimen and a side-to-side ileoileal anastomosis, and then the VIP NB posterior plate was rotated 90 degrees counterclockwise using a 45 cm detubularized ileum. The robot was redocked; then, circumferential urethra-ileal anastomosis, side-to-middle anterior wall closure, and ureteric afferent limb anastomosis were performed. The median estimated blood loss was 524 mL, and the mean operative time was 496 min. Patients had a high continence rate, and no high-grade complications were observed. The NB configuration using the modified VIP method for a hybrid approach is a feasible surgical technique to minimize the movement of robotic forceps. In particular, it may be more useful in Asian individuals with narrow pelvises.

Method for Extracting Intentional Motion Using Force Sensor in Hand-held Robotic Forceps and Its Effect on Performance

Method for Extracting Intentional Motion Using Force Sensor in Hand-held Robotic Forceps and Its Effect on Performance

3.5 mm compliant robotic surgical forceps with 4 DOF : design and performance evaluation

Minimally invasive surgery (MIS) is a viable alternative to general surgery with distinct advantages. Robotically assisted MIS, has been demonstrated to achieve higher accuracy and repeatability in comparison with those of manual procedures. Despite these advantages, owing to the nature of some surgical procedures in which dexterous tissue manipulations in deep narrow areas of the human body are necessary, there is a need for further miniaturized tools with smaller bending radii. To cater to this requirement, this study proposes a new compliant mechanism based surgical robotic forceps. It can generate four degrees of freedom at the tip of the forceps including two bending motions in two perpendicular axes, grasping and rotation. A better combination of the stress distribution through the elastic material, grasping force, and range of motion was determined based on a series of finite element analyses. In addition, the manufactured prototype underwent a series of laboratory experiments to evaluate its effectiveness. Details of the mechanism, finite element analysis, prototype implementation, and evaluations are presented in this paper.

Causes and management of intraoperative complications in robot-assisted anatomical pulmonary resection for lung cancer.

BackgroundTo perform safe robot-assisted anatomical lung resections, the details of intraoperative complications need to be shared among thoracic surgeons. However, only limited data are available.MethodsThis retrospective, single-institutional study evaluated 134 patients who underwent robot-assisted anatomical lung resection. We examined the causes, management, and outcomes of all intraoperative complications.ResultsOf the 134 eligible patients, 118 (88%) underwent lobectomy and 16 (12%) underwent segmentectomy. Intraoperative complications occurred in 17 (12.7%) patients. These complications included pulmonary artery (PA) injuries in seven patients, pulmonary vein (PV) injuries in three, azygos vein (AV) injury in one, superior vena cava (SVC) injury in one, bronchial injuries in three, and lung injuries in four. Most PA injuries were at a distal side and controlled by pressure, fibrin sealant, or stapling of the proximal side. In the three PV injuries, right upper PV was sandwiched by robotic instruments, V6 was punctured by the tip of the Maryland bipolar forceps, and the distal side of V2t was injured during tunneling of a minor interlobar fissure. These were controlled the same way as the PA injuries. The AV injury occurred during hilar lymph node (LN) dissection and was controlled by suturing. The SVC injury was caused by interference of the robotic forceps and the suction tube outside the field of view during upper mediastinal LN dissection. The injury was controlled by continuous pressure while layering polyglycolic acid sheets and fibrin glue. In the three bronchial injuries, B10 was injured during subcarinal LN dissection, right main bronchus was injured during upper bronchus dissection and the stapling failure of the bronchus occurred by strong traction. They were all repaired by suturing. All lung parenchymal injuries were caused by manipulation of robotic instruments outside the field of view. The lung injuries were repaired by suturing with pledgets. No cases were converted to thoracotomy. The 30-day mortality rate was 0.7%. The cause of mortality was pneumonia.ConclusionsIn robot-assisted anatomical pulmonary resection for lung cancer, most major intraoperative complications can be safely managed robotically without conversion to thoracotomy.

Design and Evaluation of a Robotic Forceps With Flexible Wrist Joint Made of PEEK Plastic

This letter presents the design and evaluation of a robotic forceps in which the wrist joint is made of polyetheretherketone (PEEK) plastic. Due to the structural improvement of enclosing a flexible backbone of PTFE tube inside the wrist joint, the developed forceps simultaneously fulfills the requirements of small diameter, bending dexterity, sufficient axial stiffness, and even the control rigidity. The proposed robotic forceps employs pneumatic drive with wire actuation mechanism. For accurate motion control and external force estimation, we developed a novel inverse dynamics model considering the coupled dynamic effect between the wrist joint and the gripper motions. The position control accuracy of the wrist joint bending angle is at the level of 1 <inline-formula xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink"><tex-math notation="LaTeX">$^\circ$</tex-math></inline-formula> and is not affected by the simultaneous open–close motion of the gripper. The translation and grasping forces are beyond 4.5 N, enabling powerful tasks in laparoscopic surgery. Furthermore, the robotic forceps is capable of multi-DOF external force estimation. The estimation accuracy of the translation force is about 0.2 N, and the estimation accuracy of grasping force remains within 0.2 N regardless of the bending angle of the wrist joint. The performance evaluation results demonstrate that the developed forceps is eligible to be used in robotic-assisted laparoscopic surgery.

An Articulated Robotic Forceps Design With a Parallel Wrist-Gripper Mechanism and Parasitic Motion Compensation

Abstract In this paper, a novel four degrees-of-freedom (4DOF) articulated parallel forceps mechanism with a large orientation workspace (±90deg in pitch and yaw, 360deg in roll rotations) is presented for robotic minimally invasive surgery. The proposed 3RSR-1UUP parallel mechanism utilizes a UUP center leg that can convert thrust motion of the 3RSR mechanism into gripping motion. This design eliminates the need for an additional gripper actuator, but also introduces the problem of unintentional gripper opening/closing due to parasitic motion of the 3RSR mechanism. Here, position kinematics of the proposed mechanism, including the workspace, is analyzed in detail, and a solution to the parasitic motion problem is provided. Human-in-the-loop simulations with a haptic interface are also performed to confirm the feasibility of the proposed design.

Surgical assistant manipulator with diagonal joints and multi-stage telescopic screws for laparoscopic solo surgery.

A surgeon in a sterilized area can perform robotically assisted laparoscopic solo surgery while controlling a laparoscope-holding robot for view stabilization and a forceps robot for pulling organs. At present, no locally operated surgical assistant manipulator with a mechanical remote center of motion (RCM) is available to operate within a small space while providing a wide range of movement. The present study describes a new locally operated detachable end-effector manipulator (LODEM) with diagonal joints and multi-stage telescopic screws. A forceps manipulator attached to commercial surgical forceps was developed. This manipulator uses RCM diagonal joints for the yaw and pitch axes, providing an intuitive pivot point and free rotation, and telescopic nested screws with multiple sliders clamp the commercial forceps for the axis of insertion. The manipulator placed above the abdominal wall using a fixed arm connected to a bed rail is motor controlled by a handheld interface with button switches for precise traction and is controlled manually for easy rough positioning. Positional accuracy at the tip with a load of 5N was under 0.5mm. Mechanical deflection was under 2.1mm. The manually controlled force was under 4.4N. Successful simulated laparoscopic cholecystectomy using the prototype manipulator to handle the target and maintain stability was performed on a surgically realistic gallbladder model. A LODEM with diagonal joints and multi-stage telescopic screws was developed to facilitate minimally invasive, robotically assisted laparoscopic solo surgery by a surgeon working near the patient. This electric motor-controlled laparoscopic instrument holder by the surgeon in the surgical field could be used for such applications.

An Electrical Bioimpedance Scanning System for Subsurface Tissue Detection in Robot Assisted Minimally Invasive Surgery.

In Robot Assisted Minimally Invasive Surgery, discriminating critical subsurface structures is essential to make the surgical procedure safer and more efficient. In this paper, a novel robot assisted electrical bio-impedance scanning (RAEIS) system is developed and validated using a series of experiments. The proposed system constructs a tri-polar sensing configuration for tissue homogeneity inspection. Specifically, two robotic forceps are used as electrodes for applying electric current and measuring reciprocal voltages relative to a ground electrode which is placed distal from the measuring site. Compared to existing electrical bioimpedance sensing technology, the proposed system is able to use miniaturized electrodes to measure a site flexibly with enhanced subsurfacial detection capability. This paper presents the concept, the modeling of the sensing method, the hardware design, and the system calibration. Subsequently, a series of experiments are conducted for system evaluation including finite element simulation, saline solution bath experiments and experiments based on ex vivo animal tissues. The experimental results demonstrate that the proposed system can measure the resistivity of the material with high accuracy, and detect a subsurface non-homogeneous object with 100% success rate. The proposed parameters estimation algorithm is able to approximate the resistivity and the depth of the subsurface object effectively with one fast scanning.

Initial Experience of Robot-Assisted Adrenalectomy in Japan: What is the Optimal Selection of Robotic Forceps for Adrenalectomy?

Minimally invasive adrenalectomy is the preferred technique for managing adrenal tumors. Laparoscopic adrenalectomy is widely performed and covered by insurance in Japan, but robot-assisted adrenalectomy is not. To investigate the best forceps combinations for performing robot-assisted adrenalectomy safely, we performed robot-assisted adrenalectomy for two left and two right adrenal adenomas using different robotic forceps combinations (bipolar forceps, monopolar curved scissors, Vessel Sealer Extend, and SynchroSeal) for each case. Although we evaluated a small number of RAs, lower blood loss was observed in patients where the vessel sealing devices were used. The extent of dissection is small for adrenalectomy, and robotic bipolar vessel sealing tools may not be necessary, especially for the small adrenal tumors. However, considering the risk benefits, the combination of forceps with Vessel Sealer Extend (by the left arm) and monopolar curved scissors (by the right arm) will become one of the best forceps combinations for performing robot-assisted adrenalectomy safely.

Intra-operative cavernous nerve monitoring and mapping during radical prostatectomy: a case report of corpus cavernosum electromyography

Radical prostatectomy has a high risk of not only neurogenic bladder, which is being monitored through pudendal sensory evoked potentials and bulbocavernous reflex, but also erectile dysfunction (ED) and impotence. Corpus cavernous electromyography (CC-EMG) is a potential method to monitor from cavernous nerves to corpus cavernosum correlated directly with erectile function. This case report describes how to capture this CC-EMG signals of a man undergoing robotic radical prostatectomy using robotic forceps as a stimulation probe. With a good response of CC-EMG maintained during operation, this case represents a good clinical outcome regarding post-operative erectile function as well. Intraoperative nerve monitoring and mapping should include CC-EMG monitoring techniques during any surgeries manipulating low sacral levels in pelvic area, and further refinement and validation of CC-EMG monitoring should continue to use it clinically meaningful.

A safe, reliable, and efficient robot-assisted port site closure for robot-assisted gastrectomy

IntroductionThe overall incidence of port site hernias in laparoscopy and robot-assisted surgeries ranges from 0% to 5.2%. Sufficient port site closure is essential to reduce and prevent the occurrence of port site hernia. However, complete fascial closure of 8-mm robot-port site appears to be difficult. In this study, we propose a safe and reliable robot-assisted port-site closure for robot-assisted gastrectomy. Materials and methodsThe robotic arm was tilted 60–70° cranially or caudally to create a small gap between the port and the skin margin that was cut open for port insertion. While viewing through the robotic camera and grasping the polydioxanone (PDS) thread, the Lapa-Her-Closure was inserted into the peritoneal cavity through the gap. The Lapa-Her-Closure was removed after the PDS thread was grasped with robotic forceps. Subsequently, the Lapa-Her-Closure was inserted into the abdominal cavity by tilting the arm cranially or caudally, in contrast to the previous step. The PDS thread was inserted into the loop wire using robotic forceps. After tightening the loop wire and grasping the PDS thread, the Lapa-Her-Closure was removed, and the PDS thread was ligated to complete the abdominal wall closure, with total closure of the fascia and peritoneum. Results and conclusionsWe utilized this port site closure technique in 12 patients who underwent robot-assisted gastrectomy for gastric cancer. The procedure was accomplished safely and efficiently in all cases without any technical problems. In conclusion, our port site closure is safe, reliable, and efficient procedure that can be performed using basic surgical techniques.

Robot-Assisted Electrical Impedance Scanning system for 2D Electrical Impedance Tomography tissue inspection.

The electrical impedance tomography (EIT) technology is an important medical imaging approach to show the electrical characteristics and the homogeneity of a tissue region noninvasively. Recently, this technology has been introduced to the Robot Assisted Minimally Invasive Surgery (RAMIS) for assisting the detection of surgical margin with relevant clinical benefits. Nevertheless, most EIT technologies are based on a fixed multiple-electrodes probe which limits the sensing flexibility and capability significantly. In this study, we present a method for acquiring the EIT measurements during a RAMIS procedure using two already existing robotic forceps as electrodes. The robot controls the forceps tips to a series of predefined positions for injecting excitation current and measuring electric potentials. Given the relative positions of electrodes and the measured electric potentials, the spatial distribution of electrical conductivity in a section view can be reconstructed. Realistic experiments are designed and conducted to simulate two tasks: subsurface abnormal tissue detection and surgical margin localization. According to the reconstructed images, the system is demonstrated to display the location of the abnormal tissue and the contrast of the tissues' conductivity with an accuracy suitable for clinical applications.

Locally operated assistant manipulators with selectable connection system for robotically assisted laparoscopic solo surgery.

By integrating locally operated surgical assistant robots in a sterilized area, a surgeon can perform safe robotically assisted laparoscopic solo surgery while controlling a laparoscope-holding robot and a forceps robot. At present, there is no leader-follower control system with switchable connection for the leader device in which each assistant follower robot can provide the manipulation intuitively and easily. In the present study, a new locally operated leader-follower selectable control system has been developed. The leader-follower system was developed to connect one leader operating device and one of two selectable follower assistant manipulator devices with different numbers of axes, kinematics models, sensors, and actuators for view stabilization and pulling organs. The system is constructed using the middleware of the ORiN-based medical robot architecture MRLink. The system is regulated by the robot integrator application with unilateral leader-follower PTP using the relative displacement between the leader device and the selected follower device through providers of device interface including the information and control commands. The execution cycle for updating the position was 50ms, and the time delay to catch up with the same position was 100ms. Two assistant manipulators controlled by the leader-follower selectable system could successfully produce the desired view and handle the target organ model for 17min in a simulated laparoscopic cholecystectomy. A locally operated leader-follower selectable control system was constructed to facilitate minimally invasive, robotically assisted laparoscopic solo surgery by a doctor working near the patient. This system could be used for such applications.

Development of Multi Degrees-of-Freedom Haptic Forceps Robot with Three Actuated Fingers

Surgical robots have been studied and developed to assist surgeons. Master-slave flexible forceps robots that are components of a flexible endoscopic surgical robot are useful to realize novel minimally invasive surgical procedures that are difficult for conventional rigid medical devices. Although driving force for the tip portion of a flexible forceps robot is mechanically transmitted by wires through the flexible portion, friction and backlash changed by the posture of the flexible portion make it difficult to realize precise end effector control. Furthermore, transmission of haptic sensation is necessary to realize safer operation. In this study, a multi degrees-of-freedom (DoF) haptic forceps robot with three fingers is presented as an end effector of a flexible forceps robot. Transmission of driving force in flexible structure that causes performance deterioration is eliminated by arranging motors near the end effector. To transmit haptic sensation to operators, bilateral control is implemented to a master-slave system composed of the haptic forceps robot and a multi DoF input device. Additionally, control on modal space is implemented to verify finger dexterity. The utility of the haptic forceps robot is experimentally validated.

Load Reduction Control on Tool-Insertion Port for Laparoscopic Surgical Robot Using Semi-Active Joints

In robotic surgery, the load exerted on the insertion port in the patient’s abdominal wall due to misalignment of the robot’s remote center of motion and the insertion port or external forces acting on the tip of the forceps during surgery, can not only stress the patient’s body but also increase the friction between the robotic forceps and the trocar, and adversely affect fine surgical manipulations or the accuracy of force estimation. To reduce such loads on the insertion port in robotic surgery, this study proposes a control method for a surgical assist robotic arm with semi-active joints. The control method was implemented on a six-degree-of-freedom pneumatically driven vertical multi-joint robotic arm with a two-axis gimbal joint (two semi-active joints) that only executes torque control, which was previously developed by the authors, and verified through an experiment. The load on the insertion port is reduced by applying torque control on the semi-active joints to compensate for the external forces on the forceps. We constructed a control system that includes a disturbance compensator and conducted a velocity-control experiment by subjecting the forceps constrained by the insertion port to an external force. The results showed that when the torque was compensated for by the semi-active joints, the load on the insertion port was reduced by 65% and 52% when the external force on the tip of the forceps was 0 N and 3 N, respectively.

Motion Control and External Force Estimation of a Pneumatically Driven Multi-DOF Robotic Forceps

Robotic forceps with a rigid-link joint mechanism is orthodox for current robotic-assisted surgery systems. However, external force estimation without force sensors during operations is difficult for such electrically driven forceps. This work introduces a pneumatically driven multi-DOF (DOF: degree of freedom) forceps using a rigid-link mechanism with less interference of the wire drive between joints and realizes external force estimation by utilizing high back-drivability of pneumatic cylinders. We developed a position controller with dynamic compensation of the mechanical friction, in which the rotational angles of the three movable joints of the forceps are independently controlled. Moreover, we designed an external force observer in the position controller by applying the disturbance observer scheme. The results of the performance evaluation experiments are as follows. First, in the joint position control experiments, smooth and stable controllability is confirmed for sinusoidal reference inputs with the mean absolute errors of less than 2°. The resolution of the joint position control is approximately 1° for the response of step increasing reference inputs, which is acceptable for laparoscopic surgery. Second, the external force observer can correctly estimate the translational and the grasping forces with less than 20% errors of the maximum output forces. The practical sensitivities of the external force estimation are better than 0.5 N for translational forces and 0.2 N for grasping forces. The achieved performance of the developed forceps can be applicable for interactive force control in some particular surgical tasks such as suturing, ligation, organ traction and exclusion.