Robotic Telemanipulation Systems Research Articles

Angiographic evaluation of graft patency in robotic-assisted coronary artery bypass surgery: 8 year follow-up

Robotic telemanipulation systems have emerged as facilitating tools that enhance minimally invasive cardiac surgery.The purpose of this study was to evaluate graft patency by a combination of invasive and non-invasive coronary angiography methods in robotic-assisted coronary artery surgery(CABG) for optimal quality control. Between April 2004 and February 2012, patients who had robotic-assisted CABG were called to have cardiac catheterization or multislice computed tomographic angiography to evaluate graft patency. One hundred patients out of a total 250 cases were followed for graft patency for a mean period of 60.3 ± 23.8 (range 12-94) months. Mean operative time and left internal mammary artery harvest time was 165.96 ± 19.5 and 41.74 ± 5.9 (range 30-55) min. Postoperative graft patency rate was 94% and freedom from target vessel re-interventions was 98%. Robotic-assisted CABG can be accomplished with low morbidity, mortality and re-intervention rates. It is a safe procedure in selected patients and produces excellent mid-term graft patency.

History and Current Status of Robotic Totally Endoscopic Coronary Artery Bypass

Robotic totally endoscopic coronary artery bypass (TECAB) is a minimally invasive endoscopic surgical approach using the daVinci robotic telemanipulation system to perform coronary artery bypass grafting on the arrested or beating heart. It is a procedure that can be a useful alternative to the classic open procedure performed through sternotomy. After extensive modeling in cadavers, the first clinical case was performed in June 1998 placing a left internal thoracic artery graft (LITA) to the left anterior descending artery completely robotically on the arrested heart. During the early and late 2000s, international groups have adopted this evolving technology, which has included iterations such as beating-heart TECAB, use of bilateral ITA grafting and radial artery grafting, as well as 3- and 4-vessel TECAB. TECAB is combined with percutaneous coronary intervention in hybrid procedures. Despite increasing complexity of endoscopic coronary bypass surgery, conversion rates to open bypass surgery have dropped significantly and operative times have decreased. Published major morbidities and mortality rates in arrested-and beating-heart TECAB have been cumulatively in the 0-2% range and are considered well within the expected range for these highly complex surgical procedures. Long-term survival and freedom from major adverse events also meet the standards of open bypass surgery.

Application of a Robotic Telemanipulation System in Stereotactic Surgery

To assess the clinical usefulness, accuracy, and safety of telemanipulation for frameless stereotactic surgery using the CAS-BH5 robot system, we prospectively evaluated 10 patients (age: 5–79 years; mean: 44 years) who underwent telemanipulation frameless stereotactic operations from September to December 2005. The CAS-BH5 robot system consists of three main parts: a planning subsystem, a surgical localization subsystem, and a telemanipulation subsystem. Specifically, CAS-BH5 is capable of network communication, video transmission, graphic simulation and human-machine interaction, and thus facilitates remote planning and transmission of neuronavigation data, monitoring and manipulating. Telemanipulation was performed via a digital data network with a speed of 2,000 kilobytes per second by a neurosurgeon in Beijing while the patients were located in Yan’an, 1,300 km away. Remote fiducial registration was performed with a mean accuracy of 1.05 mm and the standard difference between the planned and actual trajectory was 0.13 mm. The mean time from fiducial registration to closure was 30.2 ± 1.66 min. At 12-month follow-up, 90% of patients had improved neurologically. There were no complications. This preliminary data indicates that telemanipulation in frameless stereotactic surgeries is feasible, reliable and safe. In the future, we believe that telemanipulation will facilitate collaboration between surgeons, enhance training, allow for sharing of resources, and have wide applications in the field of neurosurgery.

Robot-assisted endoscopic airway reconstruction in rabbits, with the aim to perform robot-assisted thoracoscopic bronchoplasty in human subjects

Robotic telemanipulation systems have been introduced recently to enhance the surgeon's dexterity and visualization in endoscopic surgery and thus facilitate refined dissection, suturing, and knot tying. This study examined the technical feasibility of performing safe and efficient robot-assisted, hand-sewn endoscopic airway reconstruction in a rabbit model. A total of 18 tracheal anastomoses were performed in rabbits, with 6 anastomoses performed endoscopically using the da Vinci Surgical system (Robot group), 6 anastomoses performed using traditional thoracoscopic surgical instruments (VATS group), and 6 anastomoses performed using open surgical instruments (Open group). Anastomosis time and complications were recorded. The effectiveness of anastomoses was evaluated by postoperative observation of all rabbits for 8 weeks and measurement of anastomotic stricture and pathologic findings. These parameters and anastomosis time were compared between groups. In all cases in the Robot group, the procedure was completed endoscopically. No perioperative or postoperative complications were encountered. Mean procedure time of the Robot group was 14.1 +/- 2.6 minutes (mean +/- standard deviation). Anastomosis time in the Robot group was significantly shorter than in the VATS group (33.5 +/- 5.2 minutes, P = .0039) and was not significantly different in the Open group (11.4 +/- 2.3 minutes, P = .1282). All anastomoses in the Robot group remained mechanically intact, and all parameters were comparable with those of the open surgery group. The technical feasibility of performing safe and efficient robot-assisted endoscopic airway reconstruction was repeatedly demonstrated in a rabbit model. Robotic assistance significantly improved the time associated with and the quality of endoscopic airway reconstruction.

Robotic Implantation of a Multichamber Cardiac Resynchronization Therapy Defibrillator

Transvenous implantation of a cardiac resynchronization therapy defibrillator (CRT-D) may not be feasible due to anatomic constraints. One of the most notable advances in minimal-access heart surgery has been the introduction of robotic telemanipulation systems. We present a challenging case in which a CRT-D system was implanted using a robotic approach. Feasibility of such an approach expands the horizons for delivery of CRT-D therapy.

Robotic cardiovascular surgery

Cardiovascular surgery has traditionally been performed through a median sternotomy, allowing the surgeon generous access to the heart and surrounding great vessels. Recently, less invasive methods have been developed to allow the surgeon the same amount of dexterity and accessibility to the heart, thus resulting in a paradigm shift in cardiac surgery. Originally, long instruments without pivot points were used, however; with the application of robotic telemanipulation systems that allow for improved dexterity, the surgeon is able to perform cardiac surgery from a distance not previously possible. In this rapidly evolving field, this article reviews the recent history and clinical results of robotics in cardiovascular surgery.

The Use of Robotics in Cardiovascular Surgery

Traditionally, cardiovascular surgery has been performed through a median sternotomy, which allows the surgeon generous access to the heart and surrounding great vessels. As a paradigm shift in the size and location of incisions occurs in cardiac surgery, new methods have been developed to allow the surgeon the same amount of dexterity and accessibility to the heart in confined spaces and in a less invasive manner. Initially, long instruments without pivot points were used, however, more recent robotic telemanipulation systems have been applied that allow for improved dexterity, enabling the surgeon to perform cardiac surgery from a distance not previously possible. In this rapidly evolving field, the recent history and clinical results of using robotics in cardiovascular surgery shall be reviewed.

Robotic arrhythmia surgery and resynchronization

Over the last decade, significant technological advancements have occurred in cardiac surgery. One such breakthrough has been the use of robotic telemanipulation systems, which allow the surgeon to perform cardiac surgery through a minimally invasive approach. As a result, surgery for atrial fibrillation and resynchronization therapy for congestive heart failure have been increasingly incorporated into the surgeon's armamentarium.

Robotic Applications in Cardiac Surgery

Traditionally, cardiac surgery has been performed through a median sternotomy, which allows the surgeon generous access to the heart and surrounding great vessels. As a paradigm shift in the size and location of incisions occurs in cardiac surgery, new methods have been developed to allow the surgeon the same amount of dexterity and accessibility to the heart in confined spaces and in a less invasive manner. Initially, long instruments without pivot points were used, however, more recent robotic telemanipulation systems have been applied that allow for improved dexterity, enabling the surgeon to perform cardiac surgery from a distance not previously possible. In this rapidly evolving field, we review the recent history and clinical results of using robotics in cardiac surgery.

Early experience in robot-assisted laparoscopic Heller myotomy

Heller myotomy for achalasia is routinely performed laparoscopically. This offers patients significant benefits compared to open surgery. Surgeons, however, are limited in their manipulation and visualization during laparoscopic interventions. Robotic telemanipulation systems were introduced with the objective of alleviating these limitations. The purpose of this study was to demonstrate the efficacy and safety of performing a Heller myotomy with the use of a robotic telemanipulation system. Fourteen patients were operated on with the da Vinci robot system. Robotic system set-up time, per- and postoperative complications, blood loss, operating time and hospital stay were recorded. Follow-up included manometry and symptom score. The robotic system set-up time was 15 min (10-15). Thirteen procedures (13/14: 93%) were completed by laparoscopic surgery. One procedure was converted because of inadequate exposure. One peroperative mucosal perforation was closed laparoscopically. The median blood loss was 10 mL (10-200). Median operating time was 90 min (75-150). Hospitalization ranged from 2 to 8 days (median 3). No complications occurred during a 30-day postoperative period. Dysphagia was relieved in 12/14 patients (86%). Heartburn was present postoperatively in 2/14 patients (14%). Manometry showed a significant decrease in median lower oesophageal sphincter (LOS) pressure from 2.9 preoperatively to 1 kPa postoperatively (P = 0.008). Robot-assisted laparoscopic Heller myotomy was demonstrated to be safe and effective in reducing basal LOS pressure and dysphagia. The results of this study clearly support the feasibility of the use of this system in performing a delicate laparoscopic surgical procedure. The use of a robotic system was experienced as being highly supportive in manipulation and visualization by the surgical team involved.

Evolving revascularization approaches for myocardial ischemia

Stable angina pectoris secondary to ischemic heart disease is a common and disabling condition. Medical therapy aims to relieve symptoms, improve exercise capacity, and decrease cardiac events by reducing myocardial oxygen demand or improving coronary blood supply to the ischemic myocardium. If medical treatment is inadequate, invasive revascularization procedures to improve coronary perfusion are considered. Percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass graft (CABG) surgery are well-established and widely used myocardial revascularization techniques. Recent advances in PTCA have attempted to address the problem of restenosis, initially through the deployment of bare metal intracoronary stents and, more recently, with drug-eluting stents. Developments in CABG have focused on reducing the invasiveness of the procedure and minimizing the incidence of serious complications. Refinements include the use of mechanical stabilizers, endoscopic harvesting of conduit vessels, robotic telemanipulation systems, and fully automated anastomotic devices. Surgical laser transmyocardial revascularization and therapeutic angiogenesis represent newer approaches to coronary revascularization. Therapeutic angiogenesis aims to deliver an angiogenic growth factor or cytokine to the myocardium to stimulate collateral blood vessel growth throughout the ischemic tissue. The angiogenic factor may be administered as a recombinant protein or as a transgene within a plasmid or gene-transfer vector. Ongoing angiogenic gene therapy clinical trials are evaluating which factors, vectors, and delivery techniques hold the greatest promise for management of patients with chronic stable angina.

Mems Tactile Sensors for Surgical Instruments

AbstractThe development of sophisticated endoscopic tools and the recent introduction of robotics are expanding the applications of minimally invasive surgery. The lack of tactile feedback in the currently available endoscopic and robotic telemanipulation systems however represents a significant limitation. A need has arisen for the development of surgical instruments having integrated sensors. Current efforts to integrate sensors into or onto surgical tools has focused on fabrication of sensors on silicon, polyimide, or some other substrate and then attaching the sensors to a tool by hand or machine with epoxy, tape, or some other glue layer. Attaching the sensor in this manner has certain deficiencies. In particular, this method of attaching sensors to a surgical tool limits the sensors size, increases its thickness, and further constrains where the sensor can be placed. A method of fabricating tactile sensors on surgical instruments that addresses these deficiencies is discussed.

Robotics and coronary artery surgery.

Significant progress in cardiac surgery, and specifically the surgical management of coronary artery disease, has been due in large part to enabling technology. Robotic systems have been recently developed and refined for use in cardiac surgery to facilitate, among other procedures, a totally endoscopic approach to coronary artery bypass surgery. These systems enhance precision through endoscopic approaches by specifically addressing the inherent limitations of conventional endoscopic coronary microsurgical instrumentation via computerized, digital interface, telemanipulation technology. With a combined experience of 125 patients, several groups have independently demonstrated the clinical feasibility of totally endoscopic coronary artery bypass with two commercially available robotic telemanipulation systems. Additional enabling technology is needed to overcome the challenges currently limiting development and widespread application of totally endoscopic off-pump multivessel coronary artery bypass surgery.

Robotic Surgery in a Routine Procedure An Evaluation of 40 Robot-Assisted Laparoscopic Cholecystectomies

Background: Laparoscopic surgery offers distinct benefits to patients but places a burden on surgeons regarding manoeuvrability of instruments and visualization of the operating field. The introduction of robotic telemanipulation systems offers a solution to these problems in videoscopic surgery.

Feasibility of robot-assisted laparoscopic surgery: an evaluation of 35 robot-assisted laparoscopic cholecystectomies.

Laparoscopic surgery offers patients distinct benefits but is not without its disadvantages to surgeons in terms of maneuverability and visualization. Robotic telemanipulation systems were introduced with the objective of providing a solution to the problems in this field of surgery. The feasibility of robot-assisted surgery was assessed by performing 35 laparoscopic cholecystectomies with the da Vinci robotic system. Time necessary for system setup and operation was recorded, as were complications, technical problems, postoperative hospital stay, morbidity, and mortality. Thirty-four of 35 cholecystectomy procedures were completed laparoscopically with the da Vinci system. Technical problems occurred in three cases, resulting in one intraoperative complication (a minilaparotomy caused by the loss of an instrument part). Median hospitalization was 2 days. There were no postoperative deaths or morbidity within 30 days after surgery. System setup time decreased as the experience of the operating team increased. Operating times were comparable with those reported for standard laparoscopic cholecystectomy. Robot-assisted surgery was repeatedly proven as a safe and feasible approach to laparoscopic cholecystectomy.

Robotics in Laparoscopic Surgery: Current Status and Future Perspectives

Background : Laparoscopic surgery has been introduced to limit the burden of surgical damage to the abdominal wall and peritoneum. Methods : Description of procedure and results of robotic laparoscopic surgery. Results : Laparoscopic surgery has resulted in reduction of postoperative pain, surgery-related complications and scarring. Laparoscopic techniques, however, are challenging for the surgeon owing to the disadvantages of inverted and restricted manipulation and the indirect two-dimensional view. In order to solve these problems, robotic telemanipulation systems were developed and introduced to the market at the end of the past decade. This article describes and discusses the current status and future perspectives of robotic systems in endoscopic surgery. Conclusion : Robotic laparoscopic surgery overcomes some of the disadvantages of conventional laparoscopic surgery.

Experimental Off-Pump Coronary Bypass Using a Robotic Telemanipulation System

We hypothesized that a high-quality anastomosis between the left internal thoracic artery and the left anterior descending coronary artery could be constructed off-pump using a 4-degrees-of-freedom robotic telemanipulation system, endoscopic myocardial stabilization, and two-dimensional visualization. Nine swine were used. Three ports were created on the left chest for the endoscope and the two robotic arms, and another port was created on the right chest for the endostabilizer. Quality of anastomosis was assessed by angiography, analysis of flow, survival after proximal coronary ligation, and histopathology. All nine anastomoses were completed successfully in 22 ± 3.6 minutes without the need for repair stitches. Left internal thoracic artery flow was 21.6 ± 2.5 ml/min with diastolic dominant pattern. Eight animals (89%) survived for 60 minutes with the proximal left anterior descending coronary ligated. Angiographic patency was 100% with Fitzgibbon grade A in all. Histopathology of the anastomosis demonstrated minor changes in the integrity of the endothelium and the internal elastic lamina and absence of medial necrosis. We have demonstrated in our robotic off-pump coronary bypass model that a high-quality anastomosis can be constructed between the left internal thoracic artery and the left anterior descending coronary artery. These results support continued research towards robotic endoscopic off-pump CABG.

Feasibility of robot-assisted laparoscopic cholecystectomy

To enhance the surgeon's dexterity in laparoscopic surgery, robotic telemanipulation systems have recently been introduced into the operating theatre. Feasibility of robot-assisted surgery was evaluated in this study during 20 laparoscopic cholecystectomies. The procedures were performed with the Da Vinci® robotic telemanipulation system (Intuitive Surgical). System set-up time, complications, technical problems and OR-time were recorded. The surgeon succeeded in completing the cholecystectomy laparoscopically in 19 out of 20 cases. Robot-related technical problems did occur in a low number of cases. This did not result in complications or harmful situations to the patient. OR time in robot-assisted cases exceeded the time needed for conventional laparoscopic cholecystectomy, mainly caused by time-loss during set-up.

Implementation of Sensory Feedback and Trajectory Tracking in Active Telemanipulation Systems

This paper presents an approach to the implementation of sensory feedback in a robotic telemanipulation system. The system considered here consists of kinematically similar master-slave robotic manipulators. We propose a control scheme whereby the slave tracks the motion commanded by the human operator through the master mechanism. The scheme also accommodates, in a unified manner, different sources of sensory feedback. These include combined effects of the interaction with unknown environments and changes in structural properties of the slave manipulator due to additional unknown loads. The control algorithm is based on continuously sliding variable structure control, which is a nonlinear and highly robust control scheme. Due to the robustness of the scheme, the need for a priori information about the environment and the load is minimal. This information can be passed on to the system in the form of upper bounds of the interaction forces and additional loads. Experimental studies with a Pneumatic Haptic Interface (PHI) system were conducted to evaluate the performance of the proposed scheme. We used a virtual slave with percent 25 uncertainty to verify the robustness of the controller. We have shown that the proposed scheme can accurately estimate the environmental interaction torques and can robustly track the trajectories commanded by the human operator.