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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_605_Библиотеки_им_академика_М_И_Перельмана.pdf
424
Biomedical Engineering in Gastrointestinal Surgery
Figure 10.40 Mode of action of the Aer-O-scope: (A) The tip is pushed forward by
CO
pressure which is insufflated into the space between the migrating balloon and
2
the scaling balloon. (B) Reverse motion: CO
ated, whereas CO
All from r GI View Ltd. All rights reserved.
is now insufflated into the space between cecum and the balloon.
2
behind the migrating balloon is evacu-
2
scanner balloons. As the balloons are gently pushed through the colon by
the operator and with aid of the CO
pressure, their diameter and shape
2
are constantly adjusted to suit colonic anatomy.
When the Aer-O-scope disposable scanner reaches the cecum, CO
between the rectal balloon and scanner balloons is vented through the
rectum. The space between the cecum and scanner balloons is than
inflated with CO
. The pressure levels gently push the scanner balloons
2
backward. Reverse motion is facilitated by the operator retracting the
supply cable.
The wormlike automated robotic endoscope of the Chinese
University of Hong Kong (China)
[46] was originally developed to
propel a camera capsule. Locomotion is achieved again based upon the
inchworm principle. The extensor is actuated hydraulically.
2
10.1.3.3 Robotically Driven Instrumentation
At least two prototypes of computer-based platforms are currently known
which are based upon a logical and plausible idea: To create a robotized
version of the mechanical platforms as described in Section 9.9:
Multifunctional Endoscopes and Mechanical Platforms. Since mechanical
platforms utilize traction cable actuation (Bowden wires), electromechanical control should allow partial compensation of hysteresis.
Mechatronic Support Systems and Robots
Figure 10.41 (A) In red (gray in print) DoFs of the slave system: deflection, translation, and rotation of the arm, closing of the grasper, deflections and translation of
the endoscope. In yellow (white in print) frames associated with the endoscopic
camera, the channels, and the instrument. (B) DoFs of one of two master interfaces:
translations along x, y, z, rotations around x, y, z and “gripper”. From De Donno A.,
Zorn L., Zanne P., Nageotte F., de Mathelin M. Introducing STRAS: a new flexible robotic
system for minimally invasive surgery. In: Conference: robotics and automation (ICRA),
2013 IEEE international conference on; 2013. p. 121320
10.1.3.3.1 Single Access and Transluminal Robotic Assistant for Surgeons (ISIS-STRAS)
[47].
425
The design is a motorized version of the ANUBIS platform (see
Section 9.9: Multifunctional Endoscopes and Mechanical Platforms).
All Bowden wire-based functionalities are carried out by motorization
[47]
(Fig. 10.41).
The internal structure is shown in
Fig. 10.42.
The STRAS can be teleoperated by a single person and should be
suitable for NOTES. However, in the first paper
[47] some weaknesses
were pointed out (e.g., manmachine interf ace) which still have to be
eliminated prior to clinical use.
The well-designed ANUBIS platform is cer tainly a good starting
point to realize the badly needed computerized platform for
NOTES.
10.1.3.3.2 C-SPOT
The SPOT design of the Technische Universita¨tMu¨nchen (TUM) (see
Section 9.9: Multifunctional Endoscopes and Mechanical Platforms) was
upgraded in a similar way (
Fig. 10.43). All functionalities including forward/
backward movement of the “mother-endoscope” and of the overtube are
motorized.
426
Biomedical Engineering in Gastrointestinal Surgery
Master
interfaces
Left instrument
controller
Velocity
references
Left instrument
module
Left T/RM
Joint
positions
Positions
Tracking errors for
force feedback
Joint
positions
low-level
references
errors
PC
high level
control
High-level
references
Central controller
Main scope
controller
Main scope
handle
Errors
Positions
Right instrument
controller
Right instrument
module
Right T/RM
Main scope
translation
Figure 10.42 Electrical architecture of the STRAS: Squares represent control parts.
Circles represent mechanical elements (T/RM: translation/rotation module). From De
Donno A., Zorn L., Zanne P., Nageotte F., de Mathelin M. Introducing STRAS: a new flexible robotic system for minimally invasive surgery. In: Conference: robotics and automation (ICRA), 2013 IEEE international conference on; 2013. p. 121320
[47].
The system is controlled by a novel interface which was originally
developed for the “HVSPS” (Highly Versatile Single Port System) mechatronic support system of the MITI institute of the TUM
[48] (Fig. 10.44).
The basic idea was to use control interfaces which are more or less similar
to conventional endoscopic and surgical instruments. The users are perfectly
familiar with these types of handling. A specific training is not required.
Mechatronic Support Systems and Robots
427
Figure 10.43 The C-SPOT: All functionalities are motorized and controlled by a novel
surgical interface. From r D. B. Roppenecker, Y. S. Krieger, S. V. Brecht, T. C. Lueth,
Institute of Micro Technology and Medical Device Technology (MiMed), Technische
Universität München.
Figure 10.44 (A) The HVSPS attached to the guidance device SOLOASSIST; (B) the
actuators and the camera arm. All from MITI.
428
Biomedical Engineering in Gastrointestinal Surgery
The design of the interface was derived from a thorough analysis of
the needs of the users (surgeons and gastroenterologists) who would use
NOTES platforms
[49].
The control module for the mother-endoscope (backward/forward,
rotation, steering of the flexible tip) is shaped like the handpiece of a flexible endoscope.
The entire interface consists of three modules: two modules for the
actuators and one module for the camera (
Fig. 10.45).
The core of the position measurement is a 3D controller (Novint
Falcon, Albuquerque, NM, United States) which delivers the x-, y-, zcoordinates in an area of a cube with 101.6-mm edge length. To record
instrument rotation and bending, a laparoscopic instrument with a flexible
tip (SILS Dissector XL, Covidien Surgical, Mansfield, MA, United States)
was connected with a cardan joint to the 3D controller. The user interface
offers the following nine DOFs: The x-, y-, z-coordinates measured by the
3D controller, two angles α and β, describing the bending of the instrument and measured by slide potentiometers, the rotation angle of the flexible tip γ, and the rotation angle δ of the whole instrument measured by
precision rotary potentiometers, as well as the opening and closing angle σ
of the instrument by a slide potentiometer and two additional buttons
i and o. The voltage signals of the potentiometers were captured by a
Figure 10.45 Control unit of the C-SPOT: (A) Single use design; (B) dual use design;
(C) dual use of the C-SPOT interface: to the left: endoscopist; to the right: surgeon.
All from MITI.
Mechatronic Support Systems and Robots
429
microcontroller board (Arduino Mega 2560, Smart Projects, Scarmagno,
Italy). A program which in parallel records all signals was developed with
LabView. Thus, the voltage signals are translated into movement signals.
As shown in
Fig. 10.46, a quick and reliable precise response to the
steering signals is obtained.
10.1.3.3.3 MASTER (Master and Slave Transluminal Endoscopic Robot)
The MASTER (EndoMaster Pte Ltd, Singapore) is another type of an
overtube-like endoscopic masterslave system
[50].
The MASTER device is attached to an ordinary dual channel endoscope. The robotic module has two arms, one with a forceps and the
other one with a dissection hook
[51] (Fig. 10.47A).
(A) (B)
Response to a step entry
1.2
1
0.8
0.6
x (cm)
0.4
0.2
0.0
0.5 1 1.5 2 2.5 3 3.5 4 4.5
X: 2.606
Y: 1.193
X: 2.495
Y: 0
t (s)
X: 2.67
Y: 1.043
Unit step order
Slave trajectory
5
y (cm)
Setpoint tracking of two Falcons in a
4
3
2
1
0
–1
–2
–3
–4
–5
–6
–5 –4 –3 –2 –1 0 1 2 3 4
master–slave configuration
x (cm)
Master trajectory
Slave trajectory
Figure 10.46 (A) Step response of the system; (B) masterslave trajectory. All from MITI.
Figure 10.47 The MASTER system is an overtube system mounted onto a conven-
tional endoscope: (A) Tip: one actuator is shaped as a dissection hook, one as a
grasper; (B) interface. From Sun Z, Ang RY, Lim EW, Wang Z, Ho KY, Phee SJ.
Enhancement of a master-slave robotic system for natural orifice transluminal endoscopic surgery. Ann Acad Med Singapore 2011;40(5):22330
[50].
430
Biomedical Engineering in Gastrointestinal Surgery
Figure 10.48 The Endomina system: (A) Control platform; (B) the two actuators
mounted onto a conventional endoscope. From Cauche N, Hiernaux M, Chau A,
Huberty V, Ibrahim M, Delchambre A, et al. Endomina: the endoluminal universal robotized triangulation system: description and preliminary results in isolated pig stomach.
Gastrointest Endosc 2013;77(58):AB2045
[53].
The two ar ms are operated via a rather large manmachine interface
(
Fig. 10.47B).
The MASTER is definitively a big step ahead toward advanced interventional endoscopy and NOTES. However, the available tools (instruments) are limited to a grasper and a dissection hook.
Originally designed for NOTES, the focus has now shift to interventional
endoluminal endoscop y
[52]. The first human trials hav e been performed.
10.1.3.3.4 Endomina
The Endomina (Endo Tools Therapeutics, Gosselies, Belgium) is a similar
design. However, the two actuators are not integrated into an overtube
but mounted apart from each other onto the endoscope
[53] (Fig. 10.48).
Currently, the system is mainly designed for the endoluminal treatment of morbid obesity, gastroesophageal reflux disease, and ESD. It got a
CE mark in 2011 and the first 50 clinic cases were done in May 2016.
In principle, it is also suitable for NOTES, since all standard endoscopic
instruments can be used, but sealing the entry site airtight might be difficult.
Other experimental prototypes, such as the Scorpion-shaped endoscopic robot (Kyushu University, Japan)
robot for endoluminal surgery
[55], deserve to be mentioned as well, but
[54] or the new flexible snake
none of these is already mature for clinical use.
10.2 NONTETHERED (CABLE-LESS) SYSTEMS/MODULAR ASSEMBLING RECONFIGURABLE MINIATURE ROBOTS
To overcome the limitations of single robotic units, a revolutionary idea was
the development of modular assembling reconfigurable mini robots.
Mechatronic Support Systems and Robots
431
Modular miniature robots consist of diverse miniature subunits, which could
be assembled together to construct a fully functional miniature robot.
Reconfigurable modular robots proved to be robust and adaptive in different
working environments
[56]. These features may also be applied in surgical
applications considering the intracorporal workspace. Such a robotic device
can be controlled via wireless bidirectional communication by the surgeon.
10.2.1 ARES
An assembling reconfigurable endoluminal surgical (ARES) system was
proposed by the working groups of Harada et al.
[58] and tested in vitro with satisfactory results. In the above systems,
millimeter-sized robotic modules may be ingested and then assembled
into an articulated robot in the gastric cavity. During the assembly procedure, the stomach may be filled with a liquid to achieve distension and to
aid the self-assembly of the minirobotic modules. The modules are assembled according to the target location in order to perform a precise surgical
procedure (
Fig. 10.49). Two robotic schemes were proposed: the homo-
geneous and the heterogeneous scheme. The homogeneous scheme is
composed of identical modules except for one or two surgical or diagnostic modules. The heterogeneous scheme consists of one or more central
branching modules, structural modules, and functional modules. With
this scheme, the mini robot has a variety of topologies realized through
reconfiguration, by repeated docking and undocking of the modules. The
prototypes reported above are of dimension 13 mm in diameter and
23 mm in length for the homogeneous scheme and 15.4 mm in diameter
and 36.5 mm in length for the heterogeneous scheme. In theory, the size
of the modules should be at least as small as the commercial capsule endoscopes (27 mm 3 11 mm), that is small enough to be ingestible. A variety
[57] and Nagy et al.
Figure 10.49 Natural orifice surgery using a miniature in vivo robot platform: The
modules have already been delivered into the abdominal cavity via the stomach.
From MITI.
432 Biomedical Engineering in Gastrointestinal Surgery
of different surgical tools can be added and used cooperatively during
complicated surgical procedures with high accuracy. Furthermore, additional modules can be added later to the miniature robotic structure.
The functionality of the modular reconfigurable mini robots is based on
the assembly of the modules. The subunits must be assembled into a precise
array in order to achieve a particular functionality for the mini robot. The
mechanism of self-assembly is based on magnets. The magnets are placed on
the mating faces and the force attracts the different modules toward each
other and the magnetic torque orients them. Moreover, the use of electromagnets provides a reversible connection allowing for disconnection or
reconfiguration. Each mini module is able to connect to any other module
with the aim of increasing the number of possible configurations of the miniature robot. However, during the assembling procedure, a large number of
forces like gravity, magnetic force, fluid drag, and friction are involved. As a
result, further to the desired end-state of the modular mini robot, other states
are possible ranging from misaligned assembly to no interaction at all.
Depending on the desired operation that the robot must carry out, some of
the misaligned states can be considered as successful. However, for a successful and safe surgical operation, the kinematic configuration of the modular
mini robot has to be accurate with 100% success rate for the self-assembly.
The most important characteristic of the modular micro robots is their
ability for active locomotion and intervention. Although the actuation of
the ARES micro robot has been well described and tested, to our knowledge there is no analysis on the exact method of locomotion of the entire
system once inside the stomach or the abdominal cavity. A wormlike or
spiderlike motion may be desirable. Further more, the use of external
magnets is a favorable option.
The long-term functionality of the wireless modular mini robots is constrained by the limits of their power supply. The use of on-board batteries
similar to capsule endoscopes is usually employed. In this way, each module
carries its own battery with consequently significant reduction of the available volume for payload and tools. Another option is that of using “power
modules”; therefore, only one or a few modules need to be powered.
Beyond the power supply , external control and positioning of the intraabdominal device is requir ed. Usually external magnets are used (
Fig. 10.50).
10.2.2 ARAKNES
A few years ago, the so-called “Array of Robots Augmenting the
KiNematics of Endoluminal Surgery” project (ARAKNES) supported by
the European community was started to overcome these problems
(
Fig. 10.51). The ambitious approach to promote scarless surgery by
Mechatronic Support Systems and Robots
433
Figure 10.50 (A) The assembled modules ready to act; (B) surgeon console used for
control of the NOTES robot. From Lehman AC, Dumpert J, Wood NA, Redden L, Visty
AQ, Farritor S, et al. Natural orifice cholecystectomy using a miniature robot. Surg
Endosc 2009;23(2):2606
[59].
Figure 10.51 Endoscopy view of the robot attachment (A and B) and positioning
(C and D) using magnetic coupling with the external magnetic handle. From
ARAKNES project.