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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_537_Библиотеки_им_академика_М_И_Перельмана
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The surgical system is initially used for scaffold implantation into the
greater omentum with a follow-up of free flap application after 3months,
which included the gastrocolic vascular pedicle harvesting. Average
duration of the RAS lasted about 20% longer than the average duration of
the open surgeries that is determined to be approximately an hour. No
complications were detected during either one of the surgical methods with
the proper integration of the scaffolds for expected bone formation. The
authors concluded the benefit of Xi system’s minimal invasiveness during
regenerative surgery.
RAS and traditional surgery are compared for mandibular contouring in
[5] taking place in craniofacial bone surgery. Patients diagnosed with
mandibular deformity requiring mandibular contouring surgery in the age
range of 18–30 are observed in the study. Patient satisfaction scale, surgical
auxiliary measurement index, surgical pain scale, perioperative period, and
complications at 1, 4, and 24weeks after surgery are analyzed to compare
the two methods’ effectiveness. The researchers determined no statistically
significant differences to the following during the comparison of RAS and
the traditional method:
Operative time (approximately 15 min longer average RAS)
Operating room time (approximately 10% longer RAS)
Amount of bleeding
No adverse events, blood transfusions, or unplanned intensive care unit
admissions
Length of hospital stays
Duration of tube drainage
Volume of drainage
Postoperative complication follow-ups indicated no serious
complications, such as fracture or infection, and minor complications such
as local hematoma, oral skin injury, and abnormal sensation are treated
easily in both groups. Overall, bone shaving accuracy and higher safety of
RAS over the traditional surgical method utilized indicated the advantages
of RAS in [5].
Robotics is used for cranioplastic surgery applications in [11]. Skull
reconstruction by using the CT data is accomplished by using the software,
and the authors designed the measurement index. There was no significant
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difference between the robotic and traditional surgery groups determined in
the line of osteotomy.
2 Soft Robotics in Facial Plastic Surgery
A soft robot is defined by a variety of researchers [35–41]; however, in its
most simplistic definition, it is a robot that contains compliant materials that
have reduced rigidity in its design, control, and fabrication. The key aspect
of soft robotics is the flexibility of its overall structure by preventing the use
of rigid materials when compared to the typical robot with rigid links. Soft
materials provide a resource to design medical devices that cause lesser
tissue damage within the body in comparison to classic techniques and
traditional robots because they can deform before causing damage. Soft
materials include:
Thin layers of plastics, such as polyethylene (PE), polyethylene
terephthalate (PET), or polypropylene (PP)
Elastomers, such as polydimethylsiloxane (and polyurethane)
Metals such as nickel titanium (NiTi, Nitinol) that exhibit super elasticity
and that have been manufactured to have very low cross-sectional area.
The need for such a change in the design of the typical robot arose from
the automation need for interaction of robots with objects that require
reduced stress and/or differ in their designs that the typical robots cannot
interact with these entities due to their geometric structures/designs. The
following image displays an example of why soft robotics applications exist
based on the trans-nasal skull base surgery (left), and geometric primitives
(right) may require local manipulation of the device that can be designed as
a soft robot [42]. The need for maneuvering the existing tubular structure is
a reason to incorporate robotics into the tubular structure that resulted in
tubular continuum robots.
The design space for such robots is challenging noting that each
component tube can be individually parameterized based on its length,
segmental curvatures, diameter, and material properties. Selection of these
parameters requires concentric arrangements and design of actuated tubes
by considering the workspace constraints that resulted in the use of
computationally constrained optimization and heuristics for determining the
structures and expected movements of the soft robots’ design. Tubular
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continuum robots (TCR) have been considered for surgical applications in
mainly for trans-nasal surgery [43], cardiac surgery [44], and neurosurgery
[45]. TCR can be used for percutaneous application as steerable needles
within tissue, and they can also be used as manipulators either
teleoperatively or semiautomatically through natural orifices or small
incisions.
Soft robotics is used for wearable rehabilitation technology
development, which also relates to facial plastic surgeries [22]. Wearable
rehabilitation technology relates to facial rehabilitation [53–58] as well as
exosuits [47, 48] and gloves [49–52]. Facial paralysis is known as the
inability to move muscles on the face that can occur either on one or both
sides of the face. Facial paralysis can be resulting from a nerve damage due
to congenital conditions, trauma, or disease. Face paralysis can be classified
as a temporary or a permanent condition and as a complete or partial
paralysis. The treatment decision is made accordingly. The development of
a soft robotic solution makes sense given the geometric nature of faces and
the associated structure of the nerve system with its sensitivity to hard
objects. An application of soft-robotics is displayed in Fig. 1. This figure
demonstrates a method of how soft robotics can be simply applied for transnasal surgery.
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Fig. 1 The image on the left is the skull area used for trans-nasal surgery that can be transformed
into right image with the use of soft robotics
One of the ideas behind the development of soft robotics for facial
rehabilitation is to restore the muscle’s natural ability on the paralyzed side
of the face by using the natural nerve signals attained from the regularly
functioning side of the face [22]. For instance, nerve signals generated
during smiling on the healthy side of the face provide input signals to a
control mechanism; this mechanism functions by using actuators and
sensors with zygotic and temporal branches’ use on the health side of the
face, and the output of the systems is the signals generated to stimulate the
nerves of the face through the manufactured soft robotics design. The
design of such a therapeutic device requires additional considerations, such
as careful choices of materials, geometric design, safety factors, and
biomechanical calculations, due to the involvement of liquid and sensors.
Face’s soft nature requires the use of soft and lightweight actuators that
need to be safe and powerful for efficient and safe production of motion by
converting energy and signals going into the system [34, 58–60].
Biomechanical considerations in the design of facial rehabilitation require
careful force applications on the face [63–67]. The liquid used needs to be
safe with the right level of resistance, such as glycerol [61, 62]. Molding
and lamination methods are traditionally used in the manufacturing of soft
robotics development by performing piecemeal method, and cohesiveness is
rarely discussed for the manufacturing process. 3D printing is one of the
ways to produce such a wearable technology that is conducted for the first
time in [22]. The advantages of 3D printing are the ability to customize the
design to be printed per patient needs, cost-effectiveness, fast production,
ease of testing, and the ability to upgrade the design through fast iterations
with the associated testing on the patient for effectiveness. The materials
used in the 3D printing process need to be carefully chosen so that they are
safe and capable of fitting on the complicated nature of the face with the
design chosen to be user comforting and friendly, such as silicone and
polyester. The cost-effectiveness of the materials chosen and ease of the
design’s reproducibility play important roles in the development, testing,
and production of the design.
One way to design and manufacture this wearable design is by
integrating sensors, actuators, and fluid into 3D printed design. The novelty
of the soft robotics solution developed in [22] is stated to be the prototype
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itself that permits a variety of sensor and actuator combinations to be
adapted in the developed prototype by using vacuum actuation, low hazard
fluid use, fabric used for the device, 3D printing of the device, and
patterned buckling in the design.
Microrobots are composed of complex systems that use a variety of
micro-actuators and micro-sensors by utilizing algorithms for intelligent
signal and information processing. Just like typical robots, microrobots also
move, apply forces, manipulate objects, etc. Some principles of robotics
and micro-robotics match with the consideration of a possible scale-down
effect. Microrobots offer unique features, such as treating hard-to-reach
sites in the human body [74]. Precise actuation of these nano-scaled robots
by maneuvering them either individually or collectively during surgeries
and imaging applications is possible [69]. An increased interest in the use of
microrobots has been arising in biomedical engineering applications with
the use of magnetically actuated microrobots, such as microgrippers,
bacteria-based platforms, and soft microparticles. One of the best parts of
microrobots is their minimal invasiveness in medical applications through
locomotion and controlled interaction with their environment [68]. The
expected microrobot treatment is to reach a treatment area for a certain
period of time and remove or degrade the problem occurred without causing
adverse or toxic effects. In applications, magnetically actuated microrobots
have recently been developed for in vivo biomedical applications, including
helical swimmers [70], microgrippers [71], bacteria-based platforms [72],
and soft microparticles [73]. Additional intelligence by including sensing
and actuation is shown to be possible in [68] by selecting appropriate
materials and methods for the fabrication process in these microrobots.
Further advancements in microrobots utilization with the corporation of
artificial intelligence and 3D printing into it advanced the areas of
microrobots in applications [69]. To this date, to the best of our knowledge,
there are no applications of microrobots in facial plastic surgery, and plastic
surgery overall.
3 Head, Neck, and Transoral Surgeries
There are technical challenges that require careful handling during surgical
procedures within throat regions such as the base of the tongue and tonsils.
Classic surgical methods require removal of cancerous tissue after a large
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neck incision and cutting of the bottom jaw that can cause a scar in the
associated region. After such a surgery, extensive hospital stays, and
extensive rehabilitation needs as well as difficulty in swallowing and
speaking occurs. Tumor dissection during robotic-assisted surgeries is
possible with advanced endoscope usage that allows attainment of 3D highresolution images.
Da Vinci robot (Intuitive Surgical, Inc., Sunnyvale, CA, USA) is the
first robot reported to be used for head and neck surgery in 2003 [15]. This
initial robotics application conducted on pigs consisted of four different
head and neck surgical procedures: partial parotidectomy, thymectomy,
submandibular gland resection, and selective neck dissection [75]. Classic
head and neck surgeries (i.e., open surgeries) require making an incision in
skin and muscle for the visional aspect of the surgery in the relevant
surgical area. Robot-assisted surgeries that relate to oral and maxillofacial
surgery/head and neck surgery included, but were not limited to, robotassisted radical tonsillectomy, surgery for the base of tongue neoplasms,
and salivary gland pathology removal, such as benign neoplasms, malignant
neoplasms, salivary stones, removal of benign, or malignant parapharyngeal
space tumors [81]. Some of the head and neck surgeries are performed
using robots that are known to be minimally invasive. Only a few small
incisions are placed on the surgical area during robotics-assisted surgeries
(RAS) for ease of access to the body. Assistance of robots in head and neck
surgeries is particularly seen in transoral robotic surgeries (TORS) and
cancer. Transoral robotic surgical procedures are used for reconstructing the
inset of soft tissue flaps in difficult-to-reach areas, placement of dental
endosseous implants, cleft lip and palate surgery, and obstructive sleep
apnea surgery [82–85]. Ease of access to malignancies during RAS for
removal in the upper aerodigestive tract with the ease of access to the
oropharynx and larynx has been improved. This enhanced level of access
also changed the shape of surgical procedures and uses of the technology
for multiple facets of head and neck diseases [76]. Advantages of the da
Vinci robotic system over endoscopic surgery include the following [21]:
1.
A 3D magnified vision by using a binocular stereoscopic endoscope
2.
EndoWrist technology used for development of robotic arms
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Da Vinci’s Food and Drug Administration (FDA)-approved SP system
is designed and developed as a single port, flexible robotic system and for
urological surgery in 2014. The motion range of da Vinci’s SP system
robotic arm is much smaller than da Vinci’s Si/Xi system; therefore, SP
system is more suitable for robotic head and neck surgeries through
transoral route and remote access port with a narrow and deep working
space as three robot arms are inserted through a single arm [21].
Applications of head and neck tumor removal using the da Vinci robot
system included transoral, transaxillary, retroauricular, and modified facelift
approach [2, 20, 155, 156].
For instance, robotic neck surgery using the da Vinci SP through a
transoral or retroauricular approach is conducted in [21]. The analysis of 63
patients’ head and neck tumor removal surgery had no significant
complications using da Vinci’s SP system as it was explained to be “easy to
insert three robotic arms into a long and narrow working space because all
robotic arms and an endoscope are inserted through a single arm.” As a part
of the SP system’s navigation function, “the endoscopic arm could be made
into the shape of a ‘cobra’ to secure proper visualization of the surgical site,
which helps surgeons identify specific anatomic structures such as cranial
nerve or vessels.” The average operative time was determined to be about
3.5h with an average of 7-day hospital stay. The authors did not experience
any conversion of robotic surgery into open surgery and reported the da
Vinci SP system’s advanced technical advantage over the previous Si/Xi
system in performing robotic surgery [21]. One other example of head and
neck surgery is the application of da Vinci for head and neck squamous cell
carcinoma on four patients to avoid a long visible lateral neck scar in [163].
Concomitant robotic selective neck dissection via a gasless postauricular
facelift approach is used along with TORS. The authors concluded
preliminary results of robotic selective neck dissection via a gasless
postauricular facelift approach to be feasible and safe with excellent
postoperative cosmetic outcomes. Researchers indicated the need for further
research to support the results.
Another important advantage of robotics is the reduction/elimination of
radiation need in surgical operations [88, 89]. Malignant neoplasm
treatment/management of the oropharynx using TORS in oral and
maxillofacial surgery/head and neck surgeries has been seen in practice
[15]. Noting that human papilloma virus–associated oropharyngeal
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squamous cell carcinoma cases have been rising for the last two decades
globally, but specifically in Western countries [86, 87],
prevention/reduction of radiation therapy had been particularly beneficial
for patients [88]. In addition, TORS has been observed to be beneficial for
increasing quality of life when radiotherapy and chemoradiotherapy are
reduced as well as tracheotomy and/or gastrostomy tube usage requirement
[89].
Cadaveric models have played a significant role in the development of
robotic surgeries to highlight their significance and limitations that are
associated with the techniques applied. For instance, use of robotics in
transoral canine models and cadavers is conducted in [77, 78]. In this use,
limitations of transoral access to the skull base was faced in the canine
model, while different approaches used in cadaver-based testing had much
more success.
Access to the skull base is accomplished through additional approaches
such as creation of wide anterior maxillary antrostomies, a posterior nasal
septectomy, and bilateral sublabial incisions. In particular, anterior and
midline accesses were much more successful through the combination of
the transoral and cervical approaches in comparison to the transoral
approach [77]. Access of the robotic arm through Nostril into the
antrostomies to progressively advance to the skull base is used in the
applications. Access to the clivus, pterygopalatine fossa, nasopharynx,
suprasellar and parasellar regions, sella turcica, medial orbits, and
cribriform plate is determined to be possible through this technique. Ample
repair of defects and tremor-free dissection are determined to be the main
advantages of the robotic technique [78].
Animal models also had a significant impact on the development of
robotic applications in head and neck surgeries. Endo-neck robotic surgery
was first applied on a porcine model in 2003 by Stanford university’s
medical professionals [79]. A single parotidectomy, a single thymectomy
and three submandibular resections were performed, and only one episode
of subcutaneous emphysema complication was encountered. Robotics use is
determined to be feasible in neck surgery with this application. Additional
studies are conducted for furthermore investigation by the researchers on
animals and cadavers and we leave the details to the readers to learn more
about the relevant content [80].
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Simulator of da Vinci is also used in TORS applications with several
models developed for applications such as an ovine parotid surgery and
facial nerve dissection model, a murine model of microsurgical parotid
tumor excision, a microvascular anastomosis model, and laryngectomy
models [90–97]. Application of simulation for craniofacial surgical
procedure was rather limited [98, 99]. One simulation application that is
determined to be a useful, realistic, and effective method for training is a
high-fidelity 3D printed silicone facial flap simulator; this tool is a more
comprehensive approach when compared to sketching of a facial defect’s
repairment in two dimensions [99].
A 5-year comprehensive study is conducted in [7] to investigate the
differences between traditional and robotic-assisted head and neck
reconstructive surgeries. A total of 53 cases are analyzed by the authors,
with 36 patients having a tumor of 4 cm or greater size. In this study, 14
patients had Stage 3 and 28 patients had Stage 4 TNM (tumor, node,
metastasis).
The authors indicated the importance of securing additional space in the
deep and narrow space left after robotic surgery when robotic ENT cancer
surgery will be conducted after the conventional head and neck
reconstruction surgery. The researchers used a radial forearm flap for
majority of the surgeries.
There are factors that need to be considered during robotics applications
in head/neck surgeries. Due to the ever-changing surgical explorations in
this surgical area, chances of impairment and critical structure damaging
increases in places such as cranial nerves, the brain, and vessels with impact
on physiological conditions that include tasting and smelling senses,
swallowing, and phonation [100]. For instance, intra-temporal facial nerve
damage during otological surgery is an example of such a damage [17].
Such surgeries can result in patients’ dependency on ontracheostomy and
gastrostomy tubes, which impacts the quality of life [101, 102].
Classic surgical techniques are beneficial under certain conditions, such
as bleeding that appears as a common event that is seen in transoral robotic
surgeries [103]. A better understanding of the microscopic and endoscopic
landmarks allowed a safe dissection for previously considered unresectable
tumors on skull base [104].
Reconstruction techniques applied to transoral resection patients have
demonstrated that an oropharyngeal defect could be reconstructed using a
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robotic surgical system without mandibulotomy and microvascular
anastomosis by relying on the robot’s precision and superior visualization
[126, 127]. Transoral resection is usually performed in T1 and T2 lesions,
and the operative field heals by secondary intention with no need for an
additional reconstructive procedure [3]. For instance, robotics is used as a
part of transoral surgery to treat 7 patients with T1 or T2 lesions that had
early cancer of the oral cavity, oropharynx, and larynx in [3].
While majority of low-classification tumors have TORS procedures
performed for resection, primarily consisting of T1 and T2 lesions, T3 and
T4 tumors are often treated via open approaches or with chemoradiation
therapy noting that resection of advanced-stage malignancies is outside of
current FDA approval for transoral robotic approaches at the time this work
is completed [135]. However, it is determined in [23] that a significant
prevalence of T3 and T4 tumors (32%) resected via the TORS approach and
reconstructed via multiple modalities.
Other applications of robotic surgical systems in this area included
treatment of head and neck cancers through the oral cavity without an
external incision [128, 129]. TORS may reduce functional morbidity and
toxicities due to the minimal invasiveness [131–133]. Therefore, positive
functional outcomes with low complication rates have been observed during
TORS; reconstruction and flap selection following TORS should be tailored
to the patient and unique oropharyngeal defect. Functional outcomes are
promising with low complication rates among these patients. An increase in
free flap reconstruction among patients with larger TORS defects and
following chemoradiation therapy has been observed in the literature while
locoregional flaps have shown excellent functional outcomes with limited
morbidity [4]. In [23], upon analysis of the 18 distinct modalities of
reconstructive surgeries that had TORS approach, including nine unique
free flap types, the most performed reconstruction was determined to be the
radial forearm free flap (RFFF), accounting for 46.5% of 260
reconstructions performed.
Effective use of a robotic surgical system for aesthetic accuracy with
well-hidden scars is explained in [24]. The authors reported how to remove
a midline neck mass by explaining retroauricular technique used for
successful removal of lesions that resulted in satisfactory cosmetic
outcomes with well-hidden scars. Retroauricular approach is determined to
be the most versatile option in the literature, allowing proper dissection at
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