“An integrated pneumatic tactile feedback actuator array for robotic surgery.”
Franco, M. L., C. H. King, et al. (2009).
Int J Med Robot 5(1): 13-9.
BACKGROUND: A pneumatically controlled balloon actuator array has been developed to provide tactile feedback to the fingers during robotic surgery. METHODS: The actuator and pneumatics were integrated onto a robotic surgical system. Potential interference of the inactive system was evaluated using a timed robotic peg transfer task. System performance was evaluated by measuring human perception of the thumb and index finger. RESULTS: No significant difference was found between performance with and without the inactive mounted actuator blocks. Subjects were able to determine inflation location with > 95% accuracy and five discrete inflation levels with both the index finger and thumb with accuracies of 94% and 92%. Temporal tests revealed that an 80 ms temporal separation was sufficient to detect balloon stimuli with high accuracy. CONCLUSIONS: The mounted balloon actuators successfully transmitted tactile information to the index finger and thumb, while not hindering performance of robotic surgical movements.
“Toward image guided robotic surgery: system validation.”
Herrell, S. D., D. M. Kwartowitz, et al. (2009).
J Urol 181(2): 783-9; discussion 789-90.
PURPOSE: Navigation for current robotic assisted surgical techniques is primarily accomplished through a stereo pair of laparoscopic camera images. These images provide standard optical visualization of the surface but provide no subsurface information. Image guidance methods allow the visualization of subsurface information to determine the current position in relationship to that of tracked tools. MATERIALS AND METHODS: A robotic image guided surgical system was designed and implemented based on our previous laboratory studies. A series of experiments using tissue mimicking phantoms with injected target lesions was performed. The surgeon was asked to resect “tumor” tissue with and without the augmentation of image guidance using the da Vinci robotic surgical system. Resections were performed and compared to an ideal resection based on the radius of the tumor measured from preoperative computerized tomography. A quantity called the resection ratio, that is the ratio of resected tissue compared to the ideal resection, was calculated for each of 13 trials and compared. RESULTS: The mean +/- SD resection ratio of procedures augmented with image guidance was smaller than that of procedures without image guidance (3.26 +/- 1.38 vs 9.01 +/- 1.81, p <0.01). Additionally, procedures using image guidance were shorter (average 8 vs 13 minutes). CONCLUSIONS: It was demonstrated that there is a benefit from the augmentation of laparoscopic video with updated preoperative images. Incorporating our image guided system into the da Vinci robotic system improved overall tissue resection, as measured by our metric. Adding image guidance to the da Vinci robotic surgery system may result in the potential for improvements such as the decreased removal of benign tissue while maintaining an appropriate surgical margin.
“Objective evaluation of expert and novice performance during robotic surgical training tasks.”
Judkins, T. N., D. Oleynikov, et al. (2009).
Surg Endosc 23(3): 590-7.
BACKGROUND: Robotic laparoscopic surgery has revolutionized minimally invasive surgery for the treatment of abdominal pathologies. However, current training techniques rely on subjective evaluation. The authors sought to identify objective measures of robotic surgical performance by comparing novices and experts during three training tasks. METHODS: Five novices (medical students) were trained in three tasks with the da Vinci Surgical System. Five experts trained in advanced laparoscopy also performed the three tasks. Time to task completion (TTC), total distance traveled (D), speed (S), curvature (kappa), and relative phase (Phi) were measured. RESULTS: Before training, TTC, D, and kappa were significantly smaller for experts than for novices (p < 0.05), whereas S was significantly larger for experts than for novices before training (p < 0.05). Novices performed significantly better after training, as shown by smaller TTC, D, and kappa, and larger S. Novice performance after training approached expert performance. CONCLUSION: This study clearly demonstrated the ability of objective kinematic measures to distinguish between novice and expert performance and training effects in the performance of robotic surgical training tasks.
“Robotic single-port transumbilical surgery in humans: initial report.”
Kaouk, J. H., R. K. Goel, et al. (2009).
BJU Int 103(3): 366-9.
OBJECTIVE: To describe our initial clinical experience of robotic single-port (RSP) surgery. PATIENTS AND METHODS: The da Vinci S robot (Intuitive, Sunnyvale, CA, USA) was used to perform radical prostatectomy (RP), dismembered pyeloplasty, and radical nephrectomy. A robot 12-mm scope and 5-mm robotic grasper were introduced through a multichannel single port (R-port, Advanced Surgical Concepts, Dublin, Ireland). An additional 5-mm or 8-mm robotic port was introduced through the same umbilical incision (2 cm) alongside the multichannel port and used to introduce robotic instruments. Vesico-urethral anastomosis and pelvi-ureteric anastomosis were successfully performed robotically using running intracorporeal suturing. RESULTS: All three RSP surgeries were performed through the single incision without adding extra umbilical ports or 2-mm instruments. For RP, the operative duration was 5 h and the estimated blood loss was 250 mL. The hospital stay was 36 h and the margins of resection were negative. For pyeloplasty, the operative duration was 4.5 h, and the hospital stay was 50 h. Right radical nephrectomy for a 5.5-cm renal cell carcinoma was performed in 2.5 h and the hospital stay was 48 h. The specimen was extracted intact within an entrapment bag through the umbilical incision. There were no intraoperative or postoperative complications. At 1 week after surgery, all patients had minimal pain with a visual analogue score of 0/10. CONCLUSIONS: Technical challenges of single-port surgery that may limit its widespread acceptance can be addressed by using robotic technology. Articulation of robotic instruments may render obsolete the long-held laparoscopic principles of triangulation especially for intracorporeal suturing. We report the initial series of robotic surgery through a single transumbilical incision.
“Complete Transvaginal NOTES Nephrectomy Using Magnetically Anchored Instrumentation.”
Raman, J. D., R. A. Bergs, et al. (2009).
J Endourol.
Abstract Background and Purpose: Evolution of minimally invasive techniques has prompted interest in natural orifice transluminal endoscopic surgery (NOTES). Challenges for NOTES include loss of instrument rigidity, reduction in working envelopes, and collision of instrumentation. Magnetic anchoring and guidance system (MAGS) is one surgical innovation developed at our institution whereby instruments that are deployed intra-abdominally are maneuvered by the use of an external magnet. We present our initial animal experience with complete transvaginal NOTES nephrectomy using MAGS technology. Materials and Methods: Transvaginal NOTES nephrectomy was performed in two female pigs through a vaginotomy, using a 40-cm dual-lumen rigid access port inserted into the peritoneal cavity. A MAGS camera and cauterizer were deployed through the port and manipulated across the peritoneal surface by way of magnetic coupling via an external magnet. A prototype 70-cm articulating laparoscopic grasper introduced through the vaginal access port facilitated dissection after deployment of the MAGS instruments. The renal artery and vein were stapled en-bloc using an extra-long articulating endovascular stapler. Results: NOTES nephrectomies were successfully completed in both pigs without complications using MAGS instrumentation. The MAGS camera provided a conventional umbilical perspective of the kidney; the cauterizer, transvaginal grasper, and stapler preserved triangulation while avoiding instrument collisions. Operative duration for the two cases was 155 and 125 minutes, and blood loss was minimal. Conclusions: NOTES nephrectomy using MAGS instrumentation is feasible. We believe this approach improves shortcomings of previously reported NOTES nephrectomies in that triangulation, instrument fidelity, and visualization are preserved while hilar ligation is performed using a conventional stapler without need for additional transabdominal trocars.
“Maximizing console surgeon independence during robot-assisted renal surgery by using the fourth arm and TileProâ„¢.”
Rogers, C. G., R. Laungani, et al. (2009).
Journal of Endourology 23(1): 115-121.
Purpose: We describe multiple uses of the fourth robotic arm and TilePro™ on the da Vinci® S surgical system to maximize console surgeon independence from the assistant during robot-assisted renal surgery. Materials and Methods: We prospectively evaluated the use of the fourth robotic arm and TilePro on the da Vinci S during robot-assisted radical nephrectomy (RRN) and robot-assisted partial nephrectomy (RPN). The fourth robotic arm was used to provide kidney retraction, place the renal hilum on stretch, control vascular structures, apply and remove bulldog clamps during partial nephrectomy, and secure renal capsular stitches. TilePro was used to project intraoperative ultrasonography and preoperative CT images onto the console screen. Results: From January 2006 to June 2008, 90 robot-assisted kidney procedures were performed, of which the fourth robotic arm was used in 46 cases (RRN, 18; RPN, 24; nephroureterectomy, 4). The fourth robotic arm facilitated consistent kidney retraction for dissection of the renal hilum and mobilization of the kidney. The robotic Hem-o-Lok clip applier effectively controlled renal hilar vessels during eight RPN cases and secured renal capsular stitches during two RPN cases. Bulldog clamps were successfully applied to the renal artery during RPN using the fourth arm in two cases. TilePro was used during 22 RPN cases to project intraoperative ultrasonographic images and preoperative CT images onto the console screen as a picture-on-picture image to guide tumor resection. Conclusions: Robotic instruments used with the fourth robotic arm may give the console surgeon greater independence from the assistant during robot-assisted kidney surgery by facilitating steps such as kidney retraction, hilar dissection, and vascular control. The TilePro feature of the da Vinci S can be used to project intraoperative ultrasonography and preoperative imaging onto the console screen, potentially guiding tumor localization and resection during RPN without the need to leave the console to view external images. © Mary Ann Liebert, Inc. 2009.
“Augmented Reality During Robot-assisted Laparoscopic Partial Nephrectomy: Toward Real-Time 3D-CT to Stereoscopic Video Registration.”
Su, L. M., B. P. Vagvolgyi, et al.
Urology.
Objectives: To investigate a markerless tracking system for real-time stereo-endoscopic visualization of preoperative computed tomographic imaging as an augmented display during robot-assisted laparoscopic partial nephrectomy. Methods: Stereoscopic video segments of a patient undergoing robot-assisted laparoscopic partial nephrectomy for tumor and another for a partial staghorn renal calculus were processed to evaluate the performance of a three-dimensional (3D)-to-3D registration algorithm. After both cases, we registered a segment of the video recording to the corresponding preoperative 3D-computed tomography image. After calibrating the camera and overlay, 3D-to-3D registration was created between the model and the surgical recording using a modified iterative closest point technique. Image-based tracking technology tracked selected fixed points on the kidney surface to augment the image-to-model registration. Results: Our investigation has demonstrated that we can identify and track the kidney surface in real time when applied to intraoperative video recordings and overlay the 3D models of the kidney, tumor (or stone), and collecting system semitransparently. Using a basic computer research platform, we achieved an update rate of 10 Hz and an overlay latency of 4 frames. The accuracy of the 3D registration was 1 mm. Conclusions: Augmented reality overlay of reconstructed 3D-computed tomography images onto real-time stereo video footage is possible using iterative closest point and image-based surface tracking technology that does not use external navigation tracking systems or preplaced surface markers. Additional studies are needed to assess the precision and to achieve fully automated registration and display for intraoperative use. © 2009 Elsevier Inc. All rights reserved.