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Biomedical Engineering in Gastrointestinal Surgery
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%
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0
MIS
NOTES
1989 1990 1991 1992 1993 1994
2004 2005 2006 2007 2008 2009
Lap. CHE
1995 1996
2010 2011
Figure 9.35 Laparoscopic cholecystectomy (Lap. CHE) was successfully introduced
into clinical practice in less than 5 years. After the same period time, NOTES is still in
its beginning (MIS: minimally invasive surgery). From MITI.
Figure 9.36 NOTES cases of the German NOTES registry: After a peak in 2009, the
number of cases continuously declined until 2014. In 2015, an increase was documented again. From MITI.
385Combined Laparoscopic-Endoscopic Procedures and NOTES
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2
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CHAPTER 10
Mechatronic Support Systems
and Robots
A surgical intervention needs manual skills (dexterity), but also cognitive
capabilities and precise procedural knowledge. The surgeon has to be able
to manage the task in a flexible way, and each procedure is more or less
unique. Insof ar, the use of robots in surgery appeared to most surgeons,
up to now, like a vision of Jules Vernes (
coined in 1921 by the Czech writer Karel Capek. In one of his books he
described human-like machines able to work twice as fast as humans.
These machines were called robots from the word robota (hard work).
After many experiments in the 1940s the breakthrough of modern industrial robots came with the patent of the US American George Devol concerning a manipulator with repeat memory.
However, at least some interventional procedures could benefit from
the major advantages of robotic support with its high precision, easy
repeatability, and speed. Compared to humans, it will never become tired,
inattentive, or nervous.
In bone surgery, drilling or milling could be taken over by a robot.
The bone offers a rigid environment, and the material is similar in its
quality to wood or metal. Accordingly, the first “robots” were actually
developed for knee and hip surgery. Soon, the next “robots” followed
for camera guidance in laparoscopy or as masterslave robots for cardiovascular surgery.
Fig. 10.1). The term “robot” was
A ‘robot’ is defined as a mechanical or virtual artificial agent, usually an electro-
mechanical machine that is guided by a computer program or electronic circuitry.
Wikipedia
This definition is extremely broad and not very helpful. If we consider
medical applications of robots, we prefer the term “mechatronic support
system” in order to emphasize the difference to industrial applications.
In the meantime, quite a wealth of machines and devices has been
developed which could be denominated as “robots” or mechatronic support
systems for medical purposes.
Biomedical Engineering in Gastrointestinal Surgery. © 2017 Elsevier Inc.
Tab le 1 0 . 1 gives a chronological overview.
All rights reserved.
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Biomedical Engineering in Gastrointestinal Surgery
Figure 10.1 The first vision of a masterslave system in the operating room. This
depiction was published in Le Rictus, Journal Humoristique 1914.
Table 10.1 Early mechatronic support systems and robots in interventional medicine
Year System Designer,
manufacturer
1992 ROBODOC ISS Hip and knee
Application Country
United States
replacement
1994 AESOP Computer
Motion
1998 CASPAR ortoMAQUET Hip and knee
Camera guidance in
laparoscopy
United States
Germany
replacement
1999 NeuroMate IMMI, ISS Instrument guidance in
United States
neurosurgery
1999 ZEUS Computer
Motion
1999 DaVinci Intuitive
Surgical
2000 OTTO SurgiScope,
Masterslave system for
United States
cardiovascular surgery
Masterslave system for
United States
cardiovascular surgery
Brachytherapy Germany
joyumarie
2002 EndoAssist Armstrong
Healthcare
Camera guidance in
laparoscopy
United
Kingdom
Mechatronic Support Systems and Robots
Figure 10.2 We suggest three different classes of mechatronic support systems:
Programmable robots, mainly for orthopedic surgery; active guidance systems for
camera control or biopsy; masterslave systems, e.g., for laparoscopy and NOTES.
389
Today, the number of experimental or commercial robots is immense.
In order to facilitate an overview, we suggest the classification shown in
Fig. 10.2.
Devices such as the ROBODOC were used for cementless hip
replacement. If the hole for the endoprosthesis was drilled by the machine,
the contact area between the implant and bone was more than doubled.
More than 15,000 surgeries were performed with the ROBODOC or the
similar system CASPAR, until they vanished out of the ORs practically
overnight in 2003. In a massive press campaign starting in Germany, these
systems were reproached to cause significantly more “collateral” tissue
damage than manual hip and knee surgery. For several years, machines of
this type were more or less a taboo in ORs all over the world. However, a
revival can be observed. In 2014 FDA approval was achieved for the socalled “TSolution One Surgical System” which combines the presurgical
planning workstation TPLAN with a computer-assisted tool like the
former ROBODOC, now called TCAT. In 2015, the CE mark was
obtained. The system is provided by THINK Surgical, Fremont, CA,
United States. Some clinical reports are already available.
In visceral surgery, there has never been an application of programmable robots.
390 Biomedical Engineering in Gastrointestinal Surgery
It is very unlikely that there will ever be any, since programmable
robots need rigid anatomical structures like the bone. Bone is very
stable and keeps the position if properly fixed. Position and dimension
can be measured very precisely by X-ray examination, which provides
reliable data for programming the machine.
In the abdominal anatomy, the conditions are by far less favorable.
The contrast difference between the tissues is very low. Plain X-ray is
practically useless. Cross-section imaging like CT or MRI is better (with
addition of contrast media) but the precision we are accustomed to in
bone surgery is not at all reached (see Chapter 5: Diagnostic Procedures).
Even more important is the fact that the configuration of the internal
organs permanently changes due to pulse, respiration, gravity, and
peristalsis. Accordingly, the development of support systems in visceral
surgery has differed completely.
10.1 COMPUTERIZED SYSTEMS
Applications of mechatronic support systems in visceral surgery encompass
camera guidance or surgical manipulations with so-called “masterslave
systems”.
10.1.1 Active Camera Holders
Minimally invasive surgery—videosurgery—needs a laparoscopic camera
to get an insight into the surgical site. Since the surgeon has to manipulate his instruments, an assistant has to take over camera guidance (see
Chapter 7: Operative (Surgical) Laparoscopy).
In open surgery, the surgeon is the master of his view, i.e., he is able
to look at what he wants to see. In laparoscopic surgery, the view has to
be presented by the camera assistant, which self-evidently leads to some
disadvantages. High-quality laparoscopic surgery needs a perfect functional interaction between both members of the surgical team which is
not always guaranteed. Difficulties arise if the camera assistant is not adequately experienced to understand what has to be shown in a particular
situation, or even worse if his opinion differs from the surgeon’s. With
growing fatigue, camera guidance becomes increasingly inattentive and
unstable. This is why soon after the introduction of laparoscopic surgery
many attempts were made to transfer the task of camera guidance to a
machine. As shown below, one of the most crucial challenges is to create
a suitable interface between the surgeon and the device.
Mechatronic Support Systems and Robots
Figure 10.3 The “FIPS” endoarm: (A) The system mounted to the OR table; (B) the
height adjustment of the endoarm is achieved by a simple crank which moves the
gear rod. From MITI.
391
Soon, attempts were made to transfer this task to a machine.
One of the first devices specially designed to move a rigid endoscope
with four degrees of freedom was the so-called FIPS endoarm (KARL
STORZ GmbH, Tuttlingen, Germany) (
Fig. 10.3). The invariant point
of constrained motion coincides with the trocar puncture site through the
abdominal wall.
The FIPS camera guiding system consisted of a power supply unit, the
operating table attachment, and the guiding device which was clipped
onto the handle of the surgical instrument (
Fig. 10.4).
Though the FIPS never became more than a prototype and the design
was comparatively simple as regarded from today, it was an easy-to-use
assisting system which was, at that time, a real competitor to similar
systems.
The EndoAssist of Armstrong Healthcare, High Wycombe, United
Kingdom and the AESOP (Automated Endoscope System for Optimal
Positioning) of Computer Motion, Goleta, CA, United States, were temporarily successful on the market.
The EndoAssist (Armstrong Healthcare) was a free-standing unit (not
attached to the OR table) with a curved camera driver (
Fig. 10.5A).
Unique in its kind was the steering approach: Movement was executed by a head-mounted infrared emitter. The sensor which receives the
signals is placed above the surgical monitor and translates the head
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Biomedical Engineering in Gastrointestinal Surgery
Figure 10.4 Basic design of the FIPS endoarm. From Buess GF, Arezzo A, Schurr MO,
Ulmer F, Fisher H, Gumb L, et al. A new remote-controlled endoscope positioning system
for endoscopic solo surgery. Surg Endosc 2000;14:3959
[1].
Figure 10.5 The EndoAssist: (A) The unit: the arrow shows the camera driver of the
EndoAssist; (B) head-mounted infrared emitter (left arrow) and the camera driver
being positioned (right arrow). All from MITI.
Mechatronic Support Systems and Robots
393
movements into adequate movements of the camera (Fig. 10.5B). A foot
clutch ensured that there was no unintended change of position if they
were not conceived by the surgeon.
Whenever the operating table was moved, the device had to be
aligned which was a major drawback of the design.
The device had an arc of pan of 350˚. Tilt was from 45˚ below the
horizon to 90˚ vertically and allowed a zoom of 300 mm
Though some clinical experience is available
[2].
[3] it did not become
really popular, supposedly because of the difficult handling.
The EndoAssist has now been replaced by the second generation camera holder FreeHand (Prosurgics, Cambridge, United Kingdom).
It is more compact, easier to set up and use, and substantially more
affordable than its predecessor (
Fig. 10.6).
The camera holder is now attached to the rail of the OR bed. It consists of the electronic control box, a lockable articulating arm, and the
motor unit mounted to the fixating arm.
The system provides hands-free control of pan, tilt, and zoom.
Movement of the camera is controlled by head-movements similar to that
of the former EndoAssist. The surgeon carries a small, lightweight headset.
An infrared transmitter in the headset sends a signal to an indicator unit
mounted in a line-of-sight position on the monitor. When the desired
direction of movement is selected, an array of light-emitting diodes in the
indicator unit confirms the selected direction in the shape of an arrow.
Figure 10.6 FreeHand: The design resembles in some regards the FIPS. From
Prosurgics.