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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_605_Библиотеки_им_академика_М_И_Перельмана.pdf
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Biomedical Engineering in Gastrointestinal Surgery
Movement is activated by pressing a foot switch. Releasing the foot switch
stops the motion. There are two modes of operation, standard mode is
left/right and up/down (pan and tilt). By simply clicking once on the foot
switch, the surgeon can select the zoom/unzoom mode. Clicking the foot
switch again, the system is returned to the pan/tilt mode
[4].
10.1.1.1 Automated Endoscope System for Optimal Positioning
The most successful system at that time was the AESOP (Computer
Motion, Goleta, CA, United States). The company was initially funded
by a research g rant from NASA in the framework of the US space
program. FDA approval was granted in 1994 (
Fig. 10.7).
The system promised to give back to the surgeon the control upon
the view and to enable him to perform “solo-surgery” or “one man surgery.” He/she was no longer dependent upon often inattentive or tired
assistants who perform camera control in laparoscopic surgery. The vision
was exciting. The commercial administrators of the hospitals expected a
significant decrease in staff costs and willingly provided the financial
means to procure the new “robots.”
It was a horizontally acting arm with three active and two passive
joints. Usually, it was mounted to a rail of the OR table, but it could
also be operated from the transport trolley. When it was first introduced,
the robotic arm was either controlled manually or remotely with a
foot switch or hand control. More recent generations of AESOP
Figure 10.7 The Automated Endoscopic System for Optimal Positioning (AESOP):
(A) The AESOP on the transport trolley; (B) mounted to the OR table. All from MITI.
Mechatronic Support Systems and Robots
Figure 10.8 (A) ImagTrac; (B) field of view: the content of the square, light box is
seen on the monitor. The rest of the circular field of view is invisible for the surgeon.
All from MITI.
395
(AESOP 3000) were voice controlled. Voice control required constant
chattering by the surgeon, which other members of the team often found
distracting. Voice control was rather slow, which encouraged the surgeon
to act in a single visual field rather than jumping back and forth among
several fields
[5]. Nonetheless, quite a number of AESOPs were in clinical
use all over the world until the initial hype disappeared. In one of the last
papers on its use, both a prolongation of the OR time as well as a
relatively low acceptance by the surgeons were described
[6]. In addition,
the takeover of Computer Motion by Intuitive Surgical (Sunnyvale, CA,
United States) has certainly contributed to the fact that the AESOP
vanished from the market.
The ImagTrac of Olympus, Tokyo, Japan, offered an interesting
technical alternative to any other camera guidance system: The camera
was firmly attached to a mechanical holder. Instead of a mechanical
movement of the camera, the center of the visual field was changed
electronically (
Fig. 10.8).
A voice-activated zoom function allows change between overview and
detailed view. In the zoom-in position it is possible to select four different
fields of view without moving the camera. However, the device did not
achieve a clinical breakthrough.
10.1.1.2 Currently Available Active Camera Holders
The ViKY system (Endocontrol Medical, La Tronche, France) is based
upon a steel ring which is held in place above the abdominal wall by a
mechanical retractor attached to the OR table (
Fig. 10.9).
It is steered by a very efficient, rather intuitive voice control system.
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Biomedical Engineering in Gastrointestinal Surgery
Figure 10.9 (A) The robot unit is directly secured to the positioning arm system
which is attached to the surgical table via an OR rail clamp. (B) The robot unit is centered around the trocar for the camera lens and then locked into place. (C) The
endoscope is attached with the appropriate adapter. All from MITI.
Mechatronic Support Systems and Robots
397
In some regards, the ViKY is technically similar to the FIPS endoarm.
Various reports on clinical applications are available, e.g., upon transrectal ultrasound during radical prostatectomy
abdominal surgery
[10].
[7,8], gynecology [9], and
A newcomer is the AutoLap image-guided robotic laparoscope positioning system produced by MST Medical Surgery Technologies,
Yokneam, Israel. Its positioning unit is attached to the OR bed
(
Fig. 10.10).
A motor unit connects to a hor izontal arm holding the laparoscope,
enabling motorized movement of the laparoscope.
The position and movement of the laparoscope can either be modified
by moving the system directly or by a wireless button-based interface
which is provided either as a wearable ring (attached to the surgeon’s finger) or as a button clipped to the surgical instrument.
A new interface is the “Follow-me” mode. Using image-analysis software and algorithms, the positioner virtually tags surgical tools within the
surgical cavity and centers the view automatically to the area of interest.
In addition, it provides automatic zoom adaption, camera horizon correction, and tissue collision warning.
The AutoLap system is cleared by FDA and CE, and is in commercial
use with a wide range of general, gynecology, and urology procedures.
The SOLOASSIST of Aktormed GmbH, Barbing, Germany, is supposedly the most popular system worldwide at this time. The arm is
mounted to the OR table rail. Initially, it was actuated by hydraulic force,
but the current generation (SOLOASSIST II) is driven by electrical
motors.
Figure 10.10 (A) The AutoLap in laparoscopic surgery; (B) 1, wireless button inter-
face; 2, the motor unit bearing the telescope; 3, automatic camera control by pattern
recognition. All courtesy of MST Medical Surgery Technologies.
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Biomedical Engineering in Gastrointestinal Surgery
The SOLOASSIST emulates an arm working within several deg rees of
movement (
Fig. 10.11). The endoscopic camera is registered in the trocar
point which is used as a center of rotation. Starting from this point of origin, the device calculates automatically the required individual movements of the axes in order to obtain the entire movement required.
Figure 10.11 (A) The lightweight camera holder SOLOASSIST; (B) the SOLOASSIST in
surgery. The universal joint is sterilized. The arm is covered by sterile drapes. All from
Aktormed GmbH.
Mechatronic Support Systems and Robots
399
An integrated release function per mits manual movement of the
SOLOASSIST at the push of a button. The control panel is integrated
into the extension arm (
Fig. 10.12).
The system provides a large range of movement with a 360˚ panoramic view at an inclination of the endoscope between B10˚ and 90˚ to
the perpendicular (
Fig. 10.13).
The range of movement compares very favorably with that of similar
designs. In case of need, the position of the arm can easily be modified to
an optimal position. After a brief recalibration, the surgery can be
continued.
An ergonomic joystick for the surgeon’s nondominant hand is used as
an input device. It can be mounted to all common MIC tools.
The sterile joystick at the instrument can be operated easily with the
index finger of the surgeon’s nondominant hand during normal movements of the instrument’s handle.
The joystick of the SOLOASSIST moves the camera intuitively 360˚
by tipping (up-and-down and oblique movements). Furthermore, two
small buttons offer the opportunity to move the camera diagonally forward and backward (in and out) (
Fig. 10.14).
Despite its large scope of movement, the SOLOASSIST is lightweight
and compact and is fastened directly to the OR table by means of a
quick-acting clamp. Thus, repositioning and registering with reference to
Figure 10.12 The control panel is integrated into the extension arm. The first button
helps to define the entry point (TP, trocar point). Button 2 indicates whether the joystick is in use or not. Button 3: If the limits of the workspace are reached (i.e., if one
or more axes are close to the maximum angle), this is indicated by a yellow light.
Button 4 indicates if an internal malfunction has occurred. Button 5: On/off switch. If
it is pushed during operation, the arm is unlocked and can be moved freely by the
surgeon to the position selected. If the button is released, the arm is immediately
blocked in the new position. From Aktormed GmbH.
Figure 10.13 Range of movement: (A) Lateral view; (B) top view. The highlighted
areas can be reached by the tip of the arm which carries the telescope. From
Aktormed GmbH.
Figure 10.14 (A) The joystick attached to the surgical instrument. Since it is clamped
by a small screw, it fits to all commercially available tools. (B) Control of the degrees
of freedom. Conventional reprocessing (sterilization) is possible. All from Aktormed
GmbH.
Mechatronic Support Systems and Robots
Figure 10.15 Fastening the SOLOASSIST to the OR bed: (A) The device is raised to
the standard rail and is hooked up; (B) after the device has been placed on the standard rail of the OR table, it is aligned centrally to the OR table and the clamp screw
is tightened safely by hand. All from Aktormed GmbH.
401
the patient is not necessary even if the OR table is moved in the meantime (
Fig. 10.15).
To enable the surgeon to convert to major surgery in case of emergency, the SOLOASSIST can be rapidly mounted or removed.
Start-Up of the System
The directions of the camera arm have to be configured after the
setup. After insertion of the first trocar, the tip of the camera holder is
moved to the trocar point and configured by pressing a button on the
console unit (
Fig. 10.16). The entrance point, movements, and directions
are saved and defined in a system of coordinates for the complete procedure. For safety reasons, the system stops the movements when movements in the coordinate system are recognized as out of range. These
measures minimize misguidance and unintended tipping of the joystick
[11].
The procedure of positioning and calibration takes a few seconds only.
The ease of how it can be performed contributes significantly to user
acceptance.
Operating costs are low, since the only disposable item is the plastic
bag to cover the arm. The universal joint, the joystick, the endoscope
clamp, and the tension sleeve are sterilizable (
Fig. 10.17).
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Biomedical Engineering in Gastrointestinal Surgery
Figure 10.16 Calibration: (A) The arm is manually moved to bring the probe tip of
the universal joint into contact with the entry site; (B) the TP button (arrow) on the
operating panel is pressed. The “ready” button flashes green as soon as the calibration is successfully finished. All from Aktormed GmbH.
Figure 10.17 Sterilizable components of the SOLOASSIST. From Aktormed GmbH.
Clinical Experience
The first report was published in 2011 in an ENT journal
papers from gynecology
[13] and laparoscopic surgery [11] followed.
Studies upon more than 1000 cas es a re already available
[12]. Soon,
[14].There
is one very interesting paper which demons trates that the use of a camera holder (SOLOASSIST) reduces postoperative pain as compared to
manual camera control
[15]. The use of camera guidance is as safe a s
Mechatronic Support Systems and Robots
Figure 10.18 EMARO (exterior view).
403
human control. It prolongs the operative time slightly, but overall staff
time is reduced.
Most probably, the newest active telescope manipulator is the EMARO of
Riverfield, Inc., Tokyo , Japan (
Fig. 10.18). In some regards it is remarkable to
the FreeHand system also based on a mobile unit which is positioned close to
the OR bed (it is not attached directly to the table). The four degrees of freedom (vertical, lateral, longitudinal, and rotational) are controlled by sensing
vertical and horizontal movements of the surgeon’ s head through a gyroscope
that is worn on the forehead. The additional tw o degrees of freedom (longitudinal, rotational) are controlled by a foot pedal. In addition, all four degrees of
freedom can be used by means of a manual switch or the console panel. Each
axis of motion can be moved in five speeds.
The most remarkable feature of the EMARO is that it is driven pneumatically. Up to now, pneumatic manipulation technologies were mostly
avoided since they were not able to provide a smooth and continuous
movement which is required for the precise manipulation of surgical
devices. The sophisticated activation system with continuous air pressure
control is claimed to be able to manipulate the telescope as well as conventional driving systems.
Up to now, no clinical reports are available.