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3 Asensus Surgical: Senhance Surgical System
Finally, the Senhance System is built around the concept of digital surgery that
aims to digitize the interface between surgeon and patient. With the introduction of
the Intelligent Surgical Unit (ISU), the Senhance System has received a major
upgrade to include real-time augmented intelligence, enabling the platform to offer
a variety of advanced digital capabilities.
21
Robotic Arms
The Senhance System is approved for three arms in the United States and four arms
in Europe. Each arm is the same and is mounted on a movable base. The base can
be positioned on either side of the operating table at various angles as long as the
excursion of the arm encompasses the expected range of motion of the operative
instrument attached to that arm. The arm makes larger motions by raising up or
down and cantilevering in and out. Finer motions are made by the distal end of the
arm, which has the ability to magnetically attach various instruments and can articulate in several axes at once. When readied for use, the arm is maneuvered into position adjacent to the corresponding trocar. The selected instrument is magnetically
attached to the arm, and under visual guidance, it is guided into the operative eld.
Notably, neither the robotic arm nor the instrument is tethered to the trocar at any
stage of the process. Subsequently, the arm undergoes a brief 3-second fulcrum
sequence initiated by pressing the fulcrum button located on its side. Once this
sequence is completed, the arm is primed for use, and a similar procedure is repeated
for the remaining arms.
Senhance System Console
The Senhance Surgical System surgeon console (Fig.3.2) is based on an opendesign concept to facilitate operating room communication and improve surgeon
ergonomics (Fig.3.3). The console consists of an ergonomically designed chair that
is attached to the base of the console, a 32 inch 4K 3D monitor, eye tracker for controlling camera movement, and surgeon handles that mimic laparoscopic instrument
handles. Similar to the accelerator pedal in a car, robotic motion of the arms and
instruments only occurs when a foot pedal located on the base of the console is
depressed. Clutching is accomplished by releasing the foot pedal and repositioning
the hands to a more comfortable position, followed by depressing the foot pedal to
resume operating.
22
Fig. 3.2 Senhance system
surgeon console
Fig. 3.3 Surgeon
ergonomics vs. open
surgery and traditional
robotic surgery
A. Trivedi and S. Wong
Straight Stick Instruments
The Senhance System offers a full line of 3 and 5mm straight stick instruments
(Fig.3.4). These reusable instruments do not have a specic number of lives and like
laparoscopic instruments, they can be resterilized, and used again and again. They can
also be repaired similar to laparoscopic instruments. At the start of a case, on the back
table, the instruments to be used are attached to a corresponding adapter. This adapter
magnetically attaches to the robotic arm during use of the instrument. Instrument
exchange involves guiding the instrument out of the patient under vision, removing
the current instrument from the arm, and attaching the new instrument magnetically to
the arm. Once the new instrument is attached, the instrument is guided into the trocar
and body under vision. A unique feature of the Senhance System is the rotation dial
located on the surgeon handles (Fig.3.5). The handles have a dial that can be easily
rotated by the surgeon to allow for innite 360-degree rotation of the instrument. This
practical feature makes tasks like suturing more ergonomic as the wrists of the
3 Asensus Surgical: Senhance Surgical System
Fig. 3.4 Senhance 3 and
5mm straight stick
instruments
Fig. 3.5 Surgeon handle
instrument rotation dial
23
surgeon do not move and the dial turns the needle holder along the axis of the instrument to drive the needle through the tissue. Needle retrieval and reloading are also
made easier by the ability to fully rotate the instrument with the dial.
Articulating Instruments
The Senhance System has introduced a line of 5mm instruments that partially articulate (Fig.3.6). The articulating portfolio consists of graspers and needle drivers.
The instruments have 7° of freedom, 63° of articulation, and 360-degree independent rotation of the shaft and instrument tip. For tasks like suturing, the independent
360-degree rotation of the tip can be used to drive the needle through tissue following the curve of the needle.
24
Fig. 3.6 Articulating needle driver
Fig. 3.7 Senhance
ultrasonic dissector
A. Trivedi and S. Wong
Energy
The Senhance System includes monopolar, bipolar, and ultrasonic energy sources.
Monopolar instruments include curved scissors, a Maryland dissector, and an L-hook.
Bipolar instruments consist of a Maryland dissector and grasping forceps. These instruments are available in both 3 and 5mm sizes. Advanced energy includes a 5mm ultrasonic dissector that uses torsional ultrasonic energy to coagulate the tissue (Fig.3.7).
Scope andCamera
The Senhance System has the unique ability to work with a number of scope and
camera systems in both 2D or 3D modes. Existing scope and camera systems used
in laparoscopy can be attached to a corresponding adapter that allows the camera to
be magnetically mounted on the robotic arm. Adapters are available for both 5 and
10mm 0, 30, and 45-degree scopes. Currently, the Senhance System has adapters
for scopes and cameras from Stryker, Storz, Olympus, and ConMed. The compatibility with a wide variety of differing scopes and cameras allows for the use of
3 Asensus Surgical: Senhance Surgical System
Fig. 3.8 ICG use on
Senhance system with
Stryker camera and scope
Fig. 3.9 Intelligent
surgical unit
25
features that are specic to that video system such as uorescence imaging and
familiar navigation menus (Fig.3.8).
Intelligent Surgical Unit
The Senhance Robotic System Intelligent Surgical Unit or ISU was cleared by the
FDA, CE Marked, and approved by the PMDA as the rst-of-its-kind augmented intelligence machine vision system for use in robotic surgery (Fig.3.9). The ISU enables
the real-time use of an array of digital tools that can be used during live surgery to offer
the surgeon clinical insights to improve efciency, precision, and safety. The ISU processes information in real time from the laparoscope and the surgeon console to enable
precise camera control and to add a variety of digital overlays to the live video stream.
Advanced Intelligent Surgical Unit Features
Eye Tracking The addition of the ISU allows for further advancement in the eye-
tracking abilities of the Senhance System that are used to move the camera. The ISU
allows for the target location in the operative eld to remain perfectly centered
when zooming in or out while using an angled scope. This feature eliminates the
parallax error often encountered in laparoscopy when an angled camera is moved
in or out.
26
Fig. 3.10 Point-to-point measurement
A. Trivedi and S. Wong
Point-to-Point Measurement The ISU allows for real-time distance measurements
to be performed during surgery. A feature called “point-to-point measurement” can
be selected from a menu on the operating screen during surgery (Fig.3.10). This
feature projects a small circle at the tip of two of the working instruments and a realtime measurement of the distance between the circles is displayed at the bottom
center of the screen. As each instrument is moved around the operative eld, the
measured distance between the two circles is updated in real time. This allows for
accurate and reproducible distance measurement for any surgery. Examples of use
cases include accurately measuring the distance from the pylorus during a sleeve
gastrectomy and measuring the exact margin from a tumor during colon surgery.
Go To “Go To” is another feature of the ISU that allows the surgeon to easily repo-
sition the visual eld. When the feature is activated, the camera moves automatically to center the visual eld around the tip of a selected instrument. This is
accomplished by the ISU using digital instrument tracking.
Follow Us “Follow Us” is an ISU feature that digitally identies the tips of two
working instruments and wherever those instruments are moved, the camera will
follow keeping the visual eld centered between the two instruments. Additionally,
if the two instruments are moved apart, the camera zooms back and if the two instruments are brought together, the camera zooms in. This feature allows for efcient
movement of the camera to survey the operative eld.
Digital Tags The ISU allows for the placement of up to nine digital tags in the
operative eld to mark tissue and structures (Fig.3.11). The unique feature of the
digital tags is that they remain xed to the location to which they were originally
3 Asensus Surgical: Senhance Surgical System
Fig. 3.11 Digital tags
27
Fig. 3.12 Senhance connect
attached. If the tissue is moved, the tags move with the tissue. This unique feature
allows for the marking of important structures and allows the operative team to easily reference the marked areas. The tags can be easily deleted or repositioned
as needed.
Senhance Connect
Senhance Connect is a hardware- and software-based product that integrates with
the Senhance Surgical System to allow for the live-streaming of surgery and realtime virtual collaboration, tele-mentoring, teaching, and support (Fig.3.12). The
28
Senhance Connect system has multistream video capabilities consisting of the surgical video feed as well as two independent cameras that can be placed anywhere in
the operating room.
A. Trivedi and S. Wong
Usage andIndication Guidelines
As the Senhance System gains wider acceptance, its range of applications continues
to grow. At present, it is approved for bariatric, colorectal, general surgery, as well
as benign gynecological procedures and pediatric applications. Outside the United
States, it is also approved for urological procedures, with approval pending within
the United States.
Introduction oftheNext-Generation Surgical Platform:
TheLUNA Robotic System
In the early 2023, Asensus Surgical unveiled its second-generation surgical robotic
platform, named LUNA (Fig.3.13). Currently in the developmental stages, LUNA
is engineered to enhance and extend the capabilities established by the existing
Senhance Robotic System. The LUNA system introduces a suite of advanced features, including an open-surgeon console equipped with innovative unconstrained
handles that provide tactile feedback, a 4K Ultra-HD 3D viewing monitor, a standalone interactive touchscreen, and camera control through eye-tracking. The system
is designed with up to four independent robotic arms that feature a distinctive instrument drive mechanism that can accommodate a variety of advanced surgical tools.
Additionally, Asensus is developing a comprehensive range of 5mm fully articulating instruments for LUNA, known as TrueWrist Instruments. Furthermore, LUNA’s
synergy with the Intelligent Surgical Unit (ISU) will allow for real-time machine
vision, augmented intelligence, and deep learning capabilities in the operating suite.
In 2024, Asensus Surgical was acquired by Karl Storz. The development and commercialization of LUNA will continue under the new partnership.
Fig. 3.13 LUNA robotic surgical system
The Hugo RAS
TM
YoavMintz andRonitBrodie
Introduction toModular Robots
Over the past decade, robotic-assisted surgery procedures have increased dramatically [1]. This trend is associated with the inux of new robotic systems and more
robotic designs. The different designs differentiate in the surgeon’s console, the
conguration of the arm carts, and the concept of single-port or multiport instrument insertion.
Surgeons Console Design
There are two main surgeon console designs: either an immersive view or openconsole design. The immersive view design, as in the da Vinci robotic system
(Intuitive Surgical, Sunnyvale, CA, USA), emerged in order to enable a reliable 3D
view of the operating eld, which was crucial not only to have a true threedimensional view of the organs but also to allow the surgeon to manipulate effectively the articulating instruments that break the boundaries of two-dimensional
operation in standard laparoscopy. While the 3D technology of cameras and monitors was not good enough, due to problems with clear vision, areas out of focus, and
the necessity to stay straight in front of the monitor, Intuitive Surgical Inc. solved
the problem by introducing the immersive view technology. In this concept, the 3D
4
Y. Mintz (*)
Department of General Surgery, Hadassah Hebrew University Medical Center,
Jerusalem, Israel
Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
e-mail: ymintz@hadassah.org.il
R. Brodie
Department of General Surgery, Hadassah Hebrew University Medical Center,
Jerusalem, Israel
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
S. Samreen et al. (eds.), The SAGES Manual of Robotic Surgery,
https://doi.org/10.1007/978-3-031-86927-3_4
29
30
Y. Mintz and R. Brodie
view is achieved from a 3D laparoscope by transmitting each camera view to its
corresponding eye, avoiding any other vision source, and allowing the human brain
to achieve the 3D view as if you are looking through a binocular. Once the 3D technology matured to its current form, the open-console option appeared again. In this
technology, the 3D monitor displays both cameras’ input, while the passive 3D
glasses worn by the surgeon lter the view and allow each eye to view the corresponding camera only. The high-denition 3D laparoscopes and monitors with
advanced 3D technology deliver an immersive view of the operating eld without
the need to be totally immersed and disconnected from the operating room.
Arm Cart Design
There are two different concepts for the arm cart design. Either the traditional
design where all arms fan out from a single-central column arm cart or the modular
design, which include multiple independent arms that each can be positioned and
controlled separately. While the traditional arm cart enables a simpler and quicker
docking, the axis point of the arm motion is based on the column itself that is outside the surgical table. This results in limited docking options, demanding a large
distance between the arms to avoid external collisions, and limits the operation
eld toward a single abdominal quadrant. The latest design of the da Vinci Xi
addressed these limitations with its boom-mounted architecture and the motion
axis of the arms. In this design, the arm’s pivot point is above the surgical bed and
the docking is possible from all sides to target all quadrants without the need for
redocking [2].
The modular design of robotic systems such as in the Hugo RASTM (Medtronic,
Minneapolis, MN, USA), the Versius® (CMR Surgical, Cambridge, UK), and the
Senhance® (Asenesus Surgical, Durham, NC, USA) allows the positioning of each
arm separately. Detaching the arms from a common column enables to choose the
best location for each arm and the best direction of instrument insertion without the
limitation of being attached to other arms. This design, therefore, improves the
docking angles, thereby allowing better maneuverability of the instruments and
avoiding external collisions.
The Hugo RAS™ System
The Hugo RASTM (Medtronic, Minneapolis, MN, USA) is a modular robotic system
with an open-surgeon’s console. It was designed specically to address three major
issues. The rst was to improve the docking angles and instrument maneuverability,
the second was to increase the usage versatility and ease of mobilization, and the
third was cost reduction.
The development process of the Hugo RASTM began in 2013 with a collaboration
of Medtronic and the German Aerospace Center (DLR). The modular design enables
multiple docking options, with 1–4 arms as necessary. Having smaller components