Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5193_Библиотеки_им_академика_М_И_Перельмана.pdf
4 The Hugo RAS
Fig. 4.1 The Hugo RASTM
system is composed of a
system tower (left),
surgeon console (middle),
and up to four arm carts
(right)
TM
31
contributes to the ease of transferring the system from one operating room to the
other. The concept of the development of a robotic system that could incorporate
laparoscopic devices that are developed and marketed by the same company facilitates cost reduction.
The system is composed of an open console, a system tower, and four independent arm carts (Fig.4.1). Additional components available are an embedded simulator on the surgeon’s console and the Touch Surgery platform for recording and
analyzing the surgical videos.
The Surgeon’s Console
The surgeon console has an open design, meaning that the vision is based on a
standard 3D monitor placed in front of the surgeon and there is no need to be
immersed in the vision of the operating eld (Fig.4.2). Once the technology of
the 3D monitors has matured to its current form, the ability to achieve a highdenition 3D view of the operative eld, without losing focus, or losing the 3D
vision, eliminated the need for a separate vision display for each eye. To enable a
similar experience, a large 32-inch 3D monitor is positioned in close proximity to
the surgeon simulating a theater view. The surgeon wears 3D passive (polarized)
glasses, which can be worn on top of standard eyeglasses, transferring the view of
each camera to the corresponding eye only to achieve a 3D view. These glasses do
not compromise the standard view outside of the monitor and can be worn seamlessly throughout the operation. The large 3D monitor can also be viewed by
anyone who wears similar 3D glasses; therefore, the 3D vision is not limited to the
console surgeon only.
As a safety feature, there are several trackers (Fig.4.3) on the surgeon’s 3-D
glasses that are recognized by an eye-tracking system, and if the surgeon diverts its
gaze from the screen, the system automatically disables the control over the
robotic arms.
32
Fig. 4.2 The Hugo RASTM
surgeon console has an
open-console design with a
32-inch 3D monitor. The
robotic arms are controlled
using hand controllers and
foot pedals
Y. Mintz and R. Brodie
Fig. 4.3 The 3-D glasses
have incorporated trackers
that are sensed by the
eye-tracking system. If the
trackers are not facing the
eye-tracking system, the
controllers are disabled
The controllers are of a pistol grip design, with a double-function trigger
(Fig.4.4). A quick tap on the trigger enables or disables the arms function, while a
continuous press on the trigger activates the “clutch” function that enables repositioning of the controllers without moving the robotic arms. Built-in foot pedals
4 The Hugo RAS
Fig. 4.4 The Hugo RASTM arms and instruments are controlled by the two hand controllers and
the foot pedals. The hand controllers are of a pistol grip design, with a double-function trigger. A
quick tap on the trigger enables/disables control over the corresponding arm. A continuous press
on the trigger enables a “clutch” mechanism of the corresponding arm. The foot pedals control the
activation of the energy instruments, camera movement, simultaneous arms “clutch,” and swapping between the third and fourth arm
Fig. 4.5 The control pad
enables control of the
surgeon console
ergonomics, the
instruments, and the
display. It is attached to the
arm rest and is used prior
to the operation for setup
and during the operation if
necessary
TM
33
(Fig. 4.4) activate the monopolar, bipolar, and future advanced bipolar energy
instruments and staplers. Moving the camera arm is achieved by a combined action
of pressing the camera foot pedal together with moving the controllers. Pressing on
the “clutch” pedal frees both of the controllers to move without affecting the robotic
arms. A side pedal switches between the third and fourth arms. Switching the control of the arms can also be done from the control pad. The control pad is attached
to the arm rest and enables control of the console ergonomics, instruments, and
camera display (Fig.4.5). The control pad enables adjustments of the ergonomics
through the height of the arm rest, the monitor, and the reach to the foot pedals.
Instrument settings can be adjusted separately to motion scaling and rotation speed
as well as enabling camera rotation. The display can be set to either a 3D view or 2D
view from each camera, the contrast and brightness can be adjusted, as well as zoom
up to X5. Different lters of view are available from the Storz camera.
34
Y. Mintz and R. Brodie
There are two main advantages in an open-console design:
Improved surgeon ergonomics: the surgeon is sitting down comfortably, with an
arm rest to avoid arm fatigue, and without a xed body position.
Direct visual communication: enables seamless communication with the surgical
team and view of the patient as well as the arm’s conguration and movement.
System Tower
The system tower is the central processing unit of the Hugo RASTM. The surgeon’s
console is connected via a data cable to the system, while it is connected to electricity power on its own. Up to four robotic arms can be connected and controlled
simultaneously, or less according to the procedure. The arms are connected via a
single cable for data and power. The tower is composed of four major components:
the interactive display, the vision system, the electrosurgery generator, and the video
recording and analytics engine (Fig.4.6).
The interactive display is a touch screen that serves the OR team for the setup of
the system, as well as the operational screen for the assistant surgeon. During the
system setup, the screen displays the necessary steps needed to perform and conrm
Fig. 4.6 The system tower
has an interactive display
screen that functions either
as the surgeon’s view
monitor or for setup of the
system. The vision system
is based on Storz camera
and light source, and the
electrosurgery generator is
based on the
Valleylab™ FT10
4 The Hugo RAS
TM
35
while monitoring the advancement of the setup, calibration of the arms, and readiness of the system. Once the system is ready and all arms docked, it can be switched
to the “surgeons view,” which displays a full-screen camera view.
The vision system is based on the Karl Storz 3D HD TipCAM1 S™ (Karl Storz
SE & Co KG, Tuttlingen, Germany) with a Storz light source. Either a 0- or
30-degree 3D laparoscope is available, which is connected to the robotic arm using
an endoscope adapter. This adapter holds the endoscope in place and enables movements of the endoscope according to the arm movements, as well as rotating the
endoscope 180° from 30° up to 30° down by a single switch. Once the rotation is
completed, the upside-down image is ipped digitally to maintain the correct surgical view. Flipping the camera, choosing the zoom and lters applied can be controlled from the control pad on the surgeon’s console.
The electrosurgical generator is the Medtronic Valleylab™ FT10 enabling connection to the robotic monopolar device and one other monopolar device, as well as
to a bipolar device and the LigaSureTM. The generator with its tissue sensing technology is specically adapted to the Hugo RASTM in order to enable activation from
the surgeon’s console and deliver energy to the robotic devices.
Arm Cart
The core technology of the Hugo RASTM is based on the arm carts. The modular
system design enables docking from different locations and angles, and the maneuverability of the arm outside and inside the body is determined by the arm’s conguration. The arm cart is quite robust; however, it has seven motion hinges and joints
to congure it into the desired position when docked, and six more moving joints to
maneuver the instruments. A unique feature is the tilting joint that locks the arm
within a range of angles from −45 to +30° (Fig.4.7). This xed angle serves as the
starting point for instrument motion and extends their maneuverability. The tilting
angle not only compensates for the patient positioning, for example, tilt and roll of
the OR table, but also serves to separate better between the arms to avoid external
collisions. Another unique feature of the arm is the alignment of the arm according
to the OR table. Once the arm is locked in place, a green/red laser line is projected
Fig. 4.7 The unique tilting joint of the Hugo RASTM enables docking from +30° to −45° related
to the true horizon. This tilt compensates for the patient’s positioning and enables insertion of the
instrument without compromising on arm maneuverability
36
Fig. 4.8 A laser line is projected on the oor once the arm cart is locked in place. Using the laser
alignment dial, the laser line is aligned in parallel to the OR table, and then the arm receives it
angle in relation to the OR table. The angles of the arms could be from 0 to 360° while the head of
the patient represents the 0° and the patients legs represent 180°
Y. Mintz and R. Brodie
on the oor that can be aligned parallel to the OR table using the laser alignment
dial (Fig.4.8). Once aligned and conrmed, each arm receives its angle according
to its position, and the angle is displayed on a small screen on the arm itself. This
screen serves also to display any alarms regarding that arm. For safety reasons, the
arm components are covered with touch sensors that halt the system and send an
alarm when activated. This prevents injury to potential ngers or cables entrapped
within the arm’s components.
Hugo Instruments
All instruments of the Hugo RASTM can be mounted on any of the arms. Other than
the laparoscope, which is 10mm in diameter, the current instruments are 8mm. All
instruments are wristed with 7° of freedom (Fig.4.9). The monopolar scissors are
currently the main instrument serving for dissection, coagulation, and cutting. A
bipolar grasper and a bipolar dissector complement the working energy instruments. Four different graspers are available for tissue handling and two needle
drivers for suturing.
Further instruments are anticipated to be released: the robotic LigasureTM, the
robotic SigniaTM, and a wristed hook. These will be available for clinical use once
they receive the necessary CE mark.
There are two types of trocars available. Disposable transparent 8 and 11mm
trocars, which are similar to the standard Medtronic trocars, and reusable 8, 11, and
4 The Hugo RAS
Fig. 4.9 The currently
available instruments for
the Hugo RASTM are from
left to right: extra large
needle driver, large needle
driver, toothed grasper,
double fenestrated grasper,
Cardier forceps, bipolar
fenestrated grasper, bipolar
Maryland forceps, and
monopolar scissors
Fig. 4.10 The disposable
trocars of the Hugo
RASTM. On the left, an
8mm trocar with its
dilating obturator. On the
right, an 11mm trocar with
an optical dilating
obturator used for the
camera port
TM
37
12mm metal trocars with a disposable valve mechanism. All trocars have a unique
circular head for the attachment to the robotic arm. The 11mm disposable trocar
that is intended for the laparoscope has a bladeless optical canula that enables insertion of the rst trocar under visual guidance (Fig.4.10).
Docking theArms
Since there are four separate arms, the entire docking of the system is different than
the nonmodular robot design. Each arm is docked separately but altogether construct a docking architecture that is suited best and designed specically to the procedure and patient positioning. In order to facilitate the docking process, the
company provides setup guides for each procedure, specifying the location, tilt, and
angles of each arm, and the OR table positioning (Fig.4.11). Since the docking
process involves four arms that need to be wheeled in proximity to the patient, this
process may take some time; therefore, it should be done in parallel by all the OR
team by following the specic instructions in the setup guide.
38
Fig. 4.11 A setup guide provided by Medtronic as a recommendation for docking during leftupper quadrant procedures such as Nissen fundoplication. In the setup guide, the arm’s location
around the OR table, the tilt and angle of each arm, the trocar positioning, and the OR table tilt and
roll are specied
Y. Mintz and R. Brodie
The setup guide creates a standardized and reproducible docking that, once
learned, should take up to 5 minutes. The location of the arms, their tilt, and angles
are predetermined according to the specic surgery in order to achieve optimal,
quick, and reproducible docking. The ability to position the arms anywhere around
the OR table, coupled with the tilting joint and the increased maneuverability gained
by the six moving joints, yields a superior range of motion of the instruments as
well as avoiding external arm collisions (Fig.4.12).
The stepwise docking procedure begins by positioning the arm carts in place.
Once the arm cart is locked in place, it is aligned parallel to the OR table using
the laser guiding system. Once aligned, the arm receives its angle. The head of
the patient represents the 0-degree angle while the feet represent 180°, thereby
creating a complete circle of 360°. The tilt angle is set and the arm is then swiveled until the angle displayed on the arm reaches the docking angle depicted in
the setup guide. The port latch is then opened and connected to the trocar to
complete the docking. Once all four arms are docked, the angles are reviewed
on the interactive display of the system tower and conrmed. This conrmation
enables control from the surgeon’s console. Trocar positioning is similar to laparoscopic trocar positioning that are determined according to the surgery and
body habitus of the patient. Some adjustments are sometimes needed to maintain 8cm distance from the trocars.
4 The Hugo RAS
Fig. 4.12 A view of the
docking setup of a robotic
cholecystectomy using
three arms only. The
right-hand arm is docked
on the left side of the
patient, the camera arm is
located in between the split
legs, and the left-hand arm
is docked on the right side
of the patient. The
gallbladder is retracted
using an EndoGrab
retractor (Virtual Ports
LTD., Hod Hasharon,
Israel) prior to docking the
robot. In this setup, there is
no assistant trocar and the
clips are placed through
the left upper trocar
following temporary
undocking of this arm
TM
39
Clinical Experience withtheHugo RAS
TM
The Hugo RAS™ system received Conformité Européenne (CE) mark for urologic
and gynecologic procedures in 2019 [3]. The rst clinical procedures performed
with the Hugo RASTM were in Chile in June 2021. Approval for general surgery
procedures was received 2years later in October 2022.
According to the company, as of December 2023, more than 5600 procedures
were performed by the Hugo RASTM worldwide. These include more than 3000
urologic cases, more than 1200 gynecologic cases, and more than 1200 general
surgery procedures.
Academic publications are beginning to emerge with 54 peer-reviewed publications in the English literature, which include 625 patients by December 2023. The
operations performed included urologic procedures such as ureterolithostomy, ureteral reimplant, pyeloplasty, nephrectomy [4], partial nephrectomy [5–7], radical
prostatectomy [6, 8–16], and radical cystectomy with conduit and neobladder
reconstruction [17].
Gynecologic procedures such as sacrocolpopexy [18–21], total hysterectomy
and salpingo-oophorectomy [3], and general surgery procedures such as colorectal
surgery [22–24], Nissen fundoplication [25], cholecystectomy [23, 26–28], Hiatal
40
Y. Mintz and R. Brodie
hernia repair [23], Heller myotomy [29], transabdominal adrenalectomy [30], inguinal hernia [31], Roux en Y gastric bypass [32], sleeve gastrectomy [23], and subtotal gastrectomy [23].
Generally, in their publications, the authors describe their experience with this
new system and conclude that the Hugo RASTM has signicant advantages based on
the maneuverability and improved angulation of the arms due to the ability to dock
each arm separately. The open console was noted to improve communication between
the surgeon and the operating room staff. Additionally, many studies noted that there
was not much of a learning curve necessary for those surgeons who were already
familiar with and competent in other robotic platforms such as the da Vinci. The
prominent disadvantage of the HUGO RASTM system across all experiences and specialties is the limited variability of instruments, especially an advanced energy instrument and uorescence imaging capabilities. Questions remain surrounding the true
cost-effectiveness of robotic systems that is not unique to HUGO RASTM.
Future Developments
Currently, the Hugo RASTM is a modular robotic system enabling complete operations such as radical prostatectomy, Heller myotomy, hernia repairs, cholecystectomy, and more. Operations that need advanced energy devices and staplers are
performed in a hybrid procedure, that is, using laparoscopic devices through assistant
ports. The development of several robotic devices is in the nal stages of developments, and some are awaiting CE mark approval. Energy devices in the pipeline
include a robotic hook, robotic LigasureTM, and robotic SigniaTM stapler. The addition
of these instruments will complete the Hugo RASTM system and enable advanced
procedures performed totally robotic. The huge advantage in incorporating these
specic instruments, according to the company, will be the comparable cost to their
counterparts’ laparoscopic devices. Since the LigasureTM and SigniaTM stapler are
developed and marketed by the same company, adjustments of these same devices
just to be controlled robotically should not signicantly affect their cost.
Since the Hugo RASTM vision system is based on the Storz TipCAM1 S™,
upgrading to the Storz Image1 S™ RubinaTM to enable ICG uorescence is not an
engineering challenge, and, according to the company, CE mark approval for the
robotic control of the RubinaTM is pending.
References
1. Sheetz KH, Clain J, Dimick JB.Trends in the adoption of robotic surgery for common surgical procedures. JAMA Network Open. 2020;3(1):e1918911.
2. Morrell ALG, etal. The history of robotic surgery and its evolution: when illusion becomes
reality. Rev Col Bras Cir. 2021;48:e20202798.
3. Monterossi G, et al. The rst European gynaecological procedure with the new surgical
robot Hugo RAS.A total hysterectomy and salpingo-oophorectomy in a woman affected by
BRCA-1 mutation. Facts Views Vis Obgyn. 2022;14(1):91–4.