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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_605_Библиотеки_им_академика_М_И_Перельмана.pdf
414
Biomedical Engineering in Gastrointestinal Surgery
Figure 10.29 Patient Cart and CIT in the working configuration for transportation,
the boom can be lowered and folded into a very compact configuration. From Titan
Medical, Inc.
Figure 10.30 The “core” of the SPORT is the central unit. From Titan Medical, Inc.
The so-called “Patient Cart and CIT” is the “slav e” part of the system. Since
the mono-port approach is focused upon, only one arm or “boom” is conceived
(TitanMedical).Itcarriestheso-calledcentralunit.Theshaftwithanouter
diameter of 22 mm encompasses two instruments and the camera (
Fig. 10.30).
Mechatronic Support Systems and Robots
Figure 10.31 The flexible effectors: (A) They can easily be exchanged during surgery;
(B) a selection of available instruments (disposable). From Titan Medical, Inc.
415
The mode of action is comparable to other single port and NOTES
mechatronic platforms (see Section 9.9: Multifunctional Endoscopes and
Mechanical Platforms).
Two flexible actor arms and the camera unit are inserted together in the
straight shape into the abdomen. Then, they are unfolded and triangulation
is achieved (
Fig. 10.31). The augmented degrees of freedom of the flexible
actors require more driving elements. These are provided in the chassis of
the instrument which is connected to the central unit (
The stereoscopic camera is also mounted to a flexible arm (
Fig. 10.32).
Fig. 10.33)
to always provide a good view on the tips of the instrument in their variable position.
Though nothing is known up to now about practical applicability, the
SPORT is elegantly designed and meets many requirements of the user
which had not yet been addressed. The system will be significantly less
expensive than the main competitor.
10.1.2.3.2 Senhance Surgical Robot System
TransEnterix, Inc, Morrisville, NC, United States, formerly known by the
SPIDER device (see Section 7.4.2.1: The SPIDER Surgical System),
attempted to pr oduce a robotized version of the mechanical design SPIDER,
at that time known as “SurgiBot.” In 2015, the company acquired the
surgical robotics division of the Italian health care company SOFAR S.p.A.,
Trezzano Rosa, Italy The idea was to combine the SurgiBot and Senhance
to augment the market opportunity and to accelerate the commercialization
timeline of the new system to initiate a new w ave of robotic surgery .
416
Biomedical Engineering in Gastrointestinal Surgery
Figure 10.32 (A) A pair of endeffectors; (B) details of the instruments chassis. Note
the line of five driving elements. All from Titan Medical, Inc.
Figure 10.33 The operating unit consisting of a steerable camera and two flexible
endeffectors. From Titan Medical, Inc.
Mechatronic Support Systems and Robots
Figure 10.34 The Senhance Surgical Robot System: (A) Surgical console with slave
unit in the background; (B) The four arms of the system in detail. All from
TransEnterix, Inc.
417
The Senhance system consists of a remote-control unit called the
“cockpit,” with haptic handles, a 3D high-definition (HD) monitor, an
infrared eye-tracking system (ETS), a keyboard and touchpad, one foot
pedal, up to four detached and independent robotic arms, a connection
node, and reusable endoscopic instruments (
The detached independent robotic arms (
Fig. 10.34A).
Fig. 10.34B) can be posi-
tioned as needed by the surgeon, who can choose access points based on
real laparoscopic indications without restrictions imposed by technology.
In this way, the surgeon may access different surgical fields just by swapping the positions of the camera and the instruments and choosing the
arms with which to work. The cockpit is open and offers a broad view of
the whole surg ical area as well as easy access to the patient for positive
interaction between surgeon and assistant. The haptic feedback allows the
surgeon to feel the force used through the instruments and the natural
resistance of the tissues. This force feedback is particularly useful for
suturing to guarantee the feeling of the needle passing through the tissue
and the pull of the stitch. The ETS allows accurate movement of the 3D
endoscopic view. The surgeon can move the camera directly by gaze,
without leaving the handles holding the instruments, and the picture can
be zoomed in and out by the surgeon’s head moving forward and backward. The port dimension is the same as that for standard laparoscopy
(5 mm) and smaller than that of the DaVinci system (8 mm).
Senhance has different safety tools: a go/no-go foot pedal to control
movements, control of the highest usable force during surgery, a sensitive
grip for precise manipulation, restricted movement speed, and an emergency stop with warning lights and sounds. Senhance includes a large set
of fully reusable instruments, which could offer specific advantages in
terms of cost with respect to the DaVinci system, for which each
418 Biomedical Engineering in Gastrointestinal Surgery
instrument is designed for a limited number of procedures. In addition,
different laparoscopic instruments can be adapted for Senhance robotic
arms. A possible limitation of Senhance is the lack of wristed instrumentation (except for the RADIA needle driver), which represents the main
strength of the DaVinci robot
[32].
The main features of the Senhance are:
• preoperative simulation,
• force-controlled tools,
• automated fulcrum point identification,
• real-time patient monitoring to enable VR overlay,
• laser scanners for safe robot positioning.
A CE mark has already been achieved. The first clinical results have been
already published, mainly from gynecology, with favorable results
[3335].
It may be assumed that papers from laparoscopic surgery and urology
will follow soon.
The denomination “Senhance Surgical Robot System” is rather new.
The former name was ALF-X. “Senhance” was selected to symbolize the
combination of both senses and enhancement (alluding to eyetracking
and haptics).
10.1.2.3.3 MiroSurge
The MiroSurge was developed by the German Aerospace Center (DLR),
Oberpfaffenhofen, Germany. This versatile and lightweight design is based
on three robotic arms (MIRO) and the respective instruments (MICA).
The robotic arm has a kinematically redundant and fully torque-
controlled structure. Due to the compact shape of each MIRO, the setup
may easily contain three or even more MIROs working together in close
proximity at one operating table (
Fig. 10.35).
Due to sophisticated control modes, the arms can even be directly
moved at will by the medical staff. Since the mass is comparatively low
(B10 kg), the arm can easily be mounted to the table or removed. The
specialized instrument (MICA) offers full G-DOF action within the abdomen, offering haptic feedback. The instrument may be separated into the
distal end (interchangeable instrument) and the propulsion unit
[36].
Though technically mature, the MiroSurge is not yet commercially
available.
10.1.3 Computerized Platforms for NOTES
The NOTES community is convinced that computerized platforms are
essential to achieve a clinical breakthrough of scarless surgery
[37] (see
Mechatronic Support Systems and Robots
Figure 10.35 MiroSurge telemanipulator: Three MIRO robots mounted on an operating table. White MIROs carrying MICA instruments with force/torque sensing, transparent MIRI carrying a stereo endoscope. From Tobergte A, Passig G, Kuebler B, Seibold
U, Hagn UA, Fröhlich FA, et al. MiroSurge—advanced user interaction modalities in minimally invasive robotic surgery. Presence 2010;19(5):40014
[36].
419
Section 9.9: Multifunctional Endoscopes and Mechanical Platforms).
According to Yeung
[38], this type of platform can be categorized into three
different groups: electromechanically controlled conventional endoscopes,
systems with elements of autonomous location, and real robotically driven
instrumentation devices. Some examples are given in
Table 10.3.
10.1.3.1 Electromechanically Controlled Conventional Endoscopes
It is a logical idea to motorize the control of flexible endoscopes to offer
the chance to gain electronic control of the instrument. Some examples are
the RS-ALC (robotic steering and automated lumen centralization) design
[39], the EOR (endoscopic operation robot) [40], or the invendoscope of
the second generation (Invendo Medical GmbH, Kissing, Germany).
In these systems, electromechanical control is limited to the steering
of the endoscope. The instrument(s) have to be manually activated.
10.1.3.2 Systems With Elements of Autonomous Locomotion
Early in the history of flexible endoscopy the users dreamt of a
suitable solution to move the scope forward automatically, in particular in
colonoscopy. Numerous experimental designs were developed, but only a
few passed the test of time.
The well-known NeoGuide Endoscopy System (Intuitive Surgical,
formerly NeoGuide, San Jose, CA, United States) has to be mentioned
420 Biomedical Engineering in Gastrointestinal Surgery
Table 10.3 Computerized platforms for advanced flexible endoscopy
and NOTES
Electromechanical control of conventional endoscopes
Robotic steer ing and automated lumen centralization
[38]
Development
status
FDA CE Sale
---
(RS-ALC) (Enschede, The Netherlands)
Endoscopic operating robot (EOR) (Kyushu Institute of
---
Technology, Fukuoka, Japan)
Invendoscope (Invendo Medical GmbH, Kissing,
YYY
Germany)
Systems with elements of autonomous locomotion
Neoguide (Intu itive Surgical, Sunnyvale, CA, United
YNN
States)
Aer-O-scope (GI View Ltd, Ramat Gan, Israel) Y Y Y
Endotics (Era Endoscopy s.r.l., Peccioli, Italy) N Y Y
CUHK double-balloon endoscope (Chinese University
---
of Hong Kong, China)
Robotic driven instrumentation
ISIS-Scope/STRAS system (KARL STORZ, Tuttlingen,
---
Germany/IRCAD, Strasbourg, France)
C-SPOT (TUM, Munich, Germany) - - MASTER (EndoMASTER Pte Ltd, Singapore,
---
Singapore)
Endomina (Endo Tools Therapeutics, Gosselies, Belgium) Y - Y
Scorpion-shaped endoscopic robot (Kyushu University
---
Japan, Fukuoka, Japan)
Viacath (Hansen Medical, Mountain View, CA, United
YYY
States)
CUHK robotic gripper (Chinese University of
---
Hong Kong, China)
Imperial College robotic flexible endoscope (Imperial
---
College, London, United Kingdom)
here, although it does not actively move the endoscope forward
(
Fig. 10.36). However, it improves the insertion of the endoscope consid-
erably by use of computer assistance.
The system detects the insertion depth of the endoscope and the position of the tip of the colonoscope and based on that it creates a real-time
3D map of the patient’s colon
[41]. The system’s sensor attaches to the
Mechatronic Support Systems and Robots
Figure 10.36 (A) The NeoGuide system; (B) the shaft of the flexible endoscope with
a shape memory function. From Eickhoff A, Jakobs R, Kamal A, Mermash S, Riemann
JF, van Dam J. In vitro evaluation of forces exerted by a new computer-assisted colonoscope (the NeoGuide Endoscopy System). Endoscopy 2006;38(12):12249
[41].
421
patient and that sensor indicates the depth of the insertion of the endoscope. The NeoGuide system also has the ability to measure the angle of
articulation at the tip. By linking these two data inputs, they are able to
track the tip of the scope at any given depth. As the colonoscope is
advanced, the computer directs each following segment to take the same
shape that the tip had at a given insertion depth. The insertion tube consequently changes its shape at different insertion depths in a “follow-theleader” manner. The NeoGuide system has a steering mechanism with a
simple joystick thumb control. In addition to maneuverability, the
NeoGuide system has the ability to become rigid, providing a “bird’s eye”
view, which is similar to laparoscopy that allows having a wide field of
view. The stability is also an advantage. According to the developers, the
NeoGuide scope would be able to raise and support tissues, which is very
important for NOTES procedures
[42].
An early attempt of a “self-propelled” forward movement of the colonoscope was the first version of the Invendo system. It was based on a sleeve
technology (desinvagination of a hose). However, the procedure was
significantly prolonged as compared to conventional colonoscopy
[43] and
the idea was left.
422
Biomedical Engineering in Gastrointestinal Surgery
10.1.3.2.1 Endotic
A real self-driven colonoscope is the Endotic system of Era Endoscopy
s.r.l. (Peccioli, Italy) (
Fig. 10.37).
Propagation is achieved by the inchworm principle: it requires two
actuators, a clamper, and an extensor. The clamper binds to the colon
while the extensor uses positive displacement to push the scope along the
colon (
examination, but is less fast than conventional colonoscopy
Figure 10.37 The Endotic colonoscope: (A) Steerable tip: integrated LED camera,
suction, and insufflation, as well as a working channel; (B) the scope is provided as
a sterile disposable; (C) control console.
Fig. 10.38). The system facilitates a safer and almost pain-free
[44].
Figure 10.38 (A) The inchworm-like locomotion: The outer shaft of the scope is
arrested at the spot by a vacuum. (B) The extensor pushes the tip forward. (C) The
tip of the scope aspirates the wall and is now fixated to the new segment of the
colon. The vacuum at the outer shaft is released and the outer shaft is pulled forward. (D) The cyclic process is started again with the fixation of the outer shaft
within the new segment. All from MITI.
Mechatronic Support Systems and Robots
423
The same principle is used in double-balloon enteroscopy (see
Section 5.7: Endoscopy). In this case, balloons are used as stoppers.
10.1.3.2.2 Aer-O-Scope
The Aer-O-scope (GI View Ltd, Ramat Gan, Israel) consists of a workstation and a disposable scope unit (
Fig. 10.39).
The main elements of the scope are the rectal introducer, the supply
cable with the balloons on it and the optical head with camera and
LEDs
[45].
The disposable scanner is connected to the workstation and via the
ultraflexible multiluminal cable supplies gas, water, suction, and lowvoltage current. Using a joystick the physician has complete control over
the disposable scanner orientation for navigation and visualization. The
Aer-O-scope disposable scanner is equipped with two working channels
for the provision of therapeutic access. The rectal introducer is inserted
through the rectum. The rectal balloon is inflated to seal the anus and the
physician gently maneuvers the tube into the colon. The Aer-O-scope
has a unique omniview panoramic camera that helps the physician see
and navigate around the turns (
inflated and CO
fills the space between the rectal balloon and the
2
Fig. 10.40). The scanner balloons are
Figure 10.39 Aer-O-scope: (A) Disposable probe; (B) workstation with joystick. All
from r GI View Ltd. All rights reserved.