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434 Biomedical Engineering in Gastrointestinal Surgery
means of a remotely controlled “surgical submarine” had to be given up
because of unsurmountable technical platforms.
In the mid-term, it seems probable that untethered systems could play
a role in diagnostics, but it is not very likely that they will become helpful
therapeutic tools.
10.3 SPECIAL ASPECTS OF ROBOTERIZED SURGERY
10.3.1 Haptic Feedback
Tactile perception is a part of a complex human sensory system consisting of
1. propr ioception (body awareness),
2. mechanoreception (touch),
3. thermoreception (temperature),
4. nociception (pain).
In surgery it is of utmost importance to feel a quality of the tissue and
the anatomy:
• to identify the surgical planes,
• to locate a tumor,
• to grip tissue firmly but atraumatically,
• to cut and to spread with adequate force,
• to apply the adequate tension when a knot is tied.
In open (conventional/classical) surgery, palpation is an essential part
of surgical exploration. It is crucial for palpation of the tissue to discriminate the different layers and anatomical structures. It is the precondition
to cut and to spread tissue with adequate force, to find the best trade-off
when grasping between a secure grip and trauma or to apply optimal tension when a knot is tied.
In laparoscopic surgery tactile feedback is hampered but not at all
completely eliminated. However, in robotic masterslave systems a direct
(mechanical) control of the tip of the instrument via the respective handling device is no longer possible. Accordingly, the creation of artificial
haptic feedback would be utmost desirable.
At first glance, however, to create robotic haptic feedback seems to be
nearly unsurmountable.
Touch or tactile perception is one of the five somatosensory senses
encompassing our capability to perceive pressure, stretch, and vibration
(
Fig. 10.52).
Mechatronic Support Systems and Robots
Figure 10.52 With the exception of (bimanual) palpation, tactile feedback is mediated by the respective instrument. All from MITI.
435
The loss of tactile perception is mostly compensated by visual control
(otherwise, a DaVinci system would be of no use in clinical care), but,
nevertheless, the use of the full range of surgical skills is limited.
Accordingly, it would be most desirable to find technical solutions to provide the user with tactile information via the interface. The task is
challenging.
The problem may become a bit less complicated if it is considered
that haptic feedback in surgery is mainly mediated by the hand instruments in use. Direct manual palpation is of minor importance. Since a
tool—a technical system—is per se better suitable to measure forces, the
task should become easier to solve.
The main resistive forces which have to be transmitted to the interface are
• orthogonal force to the yaws,
• axial resistive force,
• lateral forces.
Orthogonal force is exerted to the yaws of the instrument when the
tip is opened or closed, e.g., to grasp the tissue, or to secure a needle in a
stable position, or to cut (
Fig. 10.53A).
The opening force plays a role if different plans have to be spread
apart (
Fig. 10.53B).
If the instrument is moved forward or backward, the amount of resistive force when pushing or pulling is also decisive (
Last but not least, lateral force has to be transmitted as well (
Fig. 10.54).
Fig. 10.55A).
The next level is to reflect the forces if the two actors are working
together (
Fig. 10.55B).
436
Biomedical Engineering in Gastrointestinal Surgery
Figure 10.53 (A) Optimal fixation without harm to the object; (B) particular fine
touch is required to spread apart different planes. All from MITI.
Figure 10.54 (A) Elevation of the liver; (B) pulling adhesions from the gallbladder:
the adequate amount of traction is decisive. All from MITI.
Figure 10.55 Haptic feedback is more than the perception of orthogonal forces!
(A) Orthogonal force when piercing the tissue with the needle; (B) tractioncountertraction if a knot is tied. All from MITI.
In at least two systems, haptic feedback was already successfully
implemented: the Senhance Surgical Robot System and the
MiroSurge device reflect forces. The clinical effectiveness has still
to be evaluated.
437Mechatronic Support Systems and Robots
10.3.2 ManMachine Interaction
The way that the surgeon can interact in an intuitive way with the
machine is the “Achilles heel” of robotic surgery. As shown above, a variety of technical solutions have been offered up to now.
“Joystick”-like solutions require significant accommodation of the surgeon which seems to be easier for younger surgeons than for those who
did not grow up with modern consumer IT devices. The handling of the
DaVinci with its two rings is a compromise, whereas the Senhance system
uses two laparoscopy-shaped handling devices.
Since we do not even yet know how handheld laparoscopic instruments with wrist-like tip articulation should ideally be designed
it is difficult to decide upon surgeon preference in “robotic” surgery.
It seems probable that hand controllers with a linkage structure similar
to the human upper extremity are most favorable
[62].
However, direct manipulation of the surgical instr ument is just one
aspect of the interaction between the surgeon and the system. Camera
control, activation of electrical force for dissection and coagulation, the
adjustment of the field of view, etc. are mediated by buttons and pedals.
A more intuitive or even adaptive cooperative assistance could significantly decrease surgical workload
[63]. A first step into this direction is
the eye-tracking-based automatic camera guidance which is implemented
in the Senhance system.
A next step could be a purpose designed natural language user interface
and knowledge navigator like SIRI (speech interpretation and recognition
interface) of Apple, Inc. (Cupertino, CA, United States): verbal orders could
replace mechanical signals. The long-term aim is to make the system as
cooperative as a human assistant (see Chapter 14: Visceral Surgery of the
Future: Pr ospects and Needs).
[60,61],
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CHAPTER 11
Tracking and Navigation Systems
Tracking and navigation systems are gaining increasing importance in surgery. Initially, they were predominantly used in more or less rigid surgical
environments such as orthopedics, ENT, and neurosurgery, but today
they are also used in visceral surgery.
While “tracking” refers to the acquisition of position information, the
whole process of positioning, precisely displaying information in correlation with specific reference objects, is referred to as “navigation.”
The field of application in visceral surgery reaches from tracking
objects (beds, devices, etc.) and staff within the whole surgical unit to the
positioning of patients, staff, and instruments in the OR suite. The most
sophisticated use-case is surgical navigation during the surgical intervention. In this specific case, tracking and navigation systems can provide
surgeons with exact information about the location of objects within the
body without actually viewing them. Moreover, these systems can provide three-dimensional views of surgical instruments, in relation to the
anatomy of a patient’s body and visualize the insertion path. Commonly,
preoperative images, such as the volume images of MRI or CT devices,
are used as a data basis. Additionally, intraoperative imaging procedures,
such as computed tomography, MRI, X-ray, or ultrasound, can be used
to provide an actual (real-time) 3D dataset.
The surgical navigation system matches the position of the surgical
equipment, such as the endoscope, with corresponding points in the
tracking field. It computes the relationship between a patient’s coordinate
system and the image dataset. After registration-the alignment of the
coordinate system of the patient (“real” coordinate system) and the corresponding volume dataset (“virtual” coordinate system) in at least three
corresponding points-the position of the probe or the surgical instrument
equipped with the tracking sensor can be virtually displayed in the image
dataset. Alternatively to this paired point-based registration, surface
matching routines can be used. If required, additional images during
Biomedical Engineering in Gastrointestinal Surgery. © 2017 Elsevier Inc.
All rights reserved.
443
444
Biomedical Engineering in Gastrointestinal Surgery
surgery can be acquired, registered, and included in the running navigation (intraoperative image acquisition)
[1].
The wide range of applications with very different requirements
cannot be covered by one universal technology. Fortunately, a wide variety of real-time locating systems (RTLS) is already available, meeting
more or less the needs of the user. Depending upon the specific application, factors such as accuracy, range, update-rate, durability, scalability,
and price have to be considered. The “global positioning system” (GPS),
which is one of the most known and common technologies, should be,
in theory, ideally suitable. However, indoor use for medical purposes is
more or less impossible
[2].
Early tracking systems were mostly mechanical digitizers, but because
of the high accuracy and the large workspace, today optical tracking
systems (OTS) are mostly used for navigation systems. On the other
hand, they depend on the “line-of-sight,” which prevents use for some
applications. It is one of the main challenges of BME to identify in detail
the strengths and weaknesses of each single technology to define optimal
solutions for specific problems.
The basic principle is simple: An RTLS consists of three components
as shown in
Fig. 11.1, but the specific designs vary considerably.
The most important technologies will be described in the following,
including optical and electromagnetic tracking, fiber bragg grating (FBG)
localization, and a wide range of radio-based systems. In addition,
other solutions including combined methods and distance measurement
methods are briefly explained.
Figure 11.1 The components of an RTLS. The reference point (“anchor”) is stationary.
The tag (marker) is attached onto a device or a person. The resulting position to the
reference is calculated in the computer. From MITI.