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SECTION 1 Development of the NOTES Concept
https://t.me/med1917
was 2 days (range < 24 hours to 23 days) and 47% of patients
were discharged within 24 hours of surgery. We see no
reason why SILS cannot be applied to cancer resections,
provided that the surgeon carries out the same oncological
dissection that they would use in either an open or conventional laparoscopic resection. For small lesions and benign
disease a dilated transverse umbilical incision is probably
appropriate. For larger sized tumors and bulky specimens
we would continue to advocate a longitudinal umbilical
incision that can be extended as appropriate [56] . In case of
technical diffi culty any SILS procedure can be easily and
immediately converted to standard laparoscopic or the incision extended. The rapid recovery from SILS also puts into
question the necessity of expensive and elaborate multimodal fast - track rehabilitation programs following large bowel
laparoscopic colorectal surgery [57] . If colorectal SILS can
be performed nationally and our results replicated, the
potential economic savings for healthcare providers and
benefi ts to patients would be substantial.
Chapter video clips
Video 8.1 Single - port cholecystectomy using three separate
fascial umbilical trocars.
Video 8.2 Single - port cholecystectomy using industrial LESS
port (TriPort, Olympus, Japan).
Video 8.3 Single - port sleeve gastrectomy for morbid obesity
using industrial LESS port (Quadport, Olympus,
Japan). (Courtesy of Dr Ramos and Dr Galvao, Gastro
Obeso Center, Sao Paulo, Brazil.)
Video 8.4 Single - port splenectomy using industrial LESS port
(TriPort, Olympus, Japan).
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CHAPTER 8 Single-port Surgery
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43 Saint Louis University Hospital is one of fi rst to perform total
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47 Chambers W , Bicsak M , Lamparelli M , Dixon AR . Single - incision
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48 Geisler DP , Condon ET , Remzi FH . Single incision laparoscopic
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55 Volkmann E , Hungness E , Soper NJ , Swanstrom L . Surgeon
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9
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Computer -assisted NOTES: From Augmented
Reality to Automation
Luc Soler , Stéphane Nicolau, Michel de Mathelin, & Jacques Marescaux
University Hospital of Strasbourg, IRCAD (Research Institute Against Digestive Cancer), Strasbourg, France
Introduction
Introducing an optical device into the abdomen of a patient
so as to carry out surgical procedures via a miniaturized
camera represented the major change the surgical world
experienced during the twentieth century: the “minimally
invasive” surgery (MIS) era was born. This revolution is
about to experience a new twist linked to the appearance of
a new original technique named natural orifi ce translumenal endoscopic surgery (NOTES), which could replace traditional laparoscopic surgery in a large set of procedures. By
replacing the rigid optic, which is introduced through the
skin, by a fl exible optic, which is introduced via a natural
orifi ce such as the stomach, vagina, or colon, this new technique should suppress all visible incisions.
Though the benefi ts for patients have clearly been proved
for laparoscopic surgery, and whatever they will be for
NOTES, such minimally invasive techniques raise new diffi culties for surgeons, reducing thus their ability to carry out
gestures. The fi rst diffi culty comes from the loss of several
senses such as the sense of touch and a modifi cation of the
force feedback feeling. In NOTES, this loss is greatly amplifi ed due to the length of instruments, making it diffi cult to
feel when an instrument and an organ are in contact. This
lack of force feedback is also featured by current robotic
systems such as the da Vinci robot from Intuitive Surgical,
currently the most frequently used surgical robot worldwide. The use of stereoscopic vision, however, allowed for
the decrease of that perception limit, compensating it by a
three-dimensional (3D) view of the operative scene fi lmed
by two cameras. But this technique will be diffi cult to implement for translumenal endoscopic surgery, since it requires
the extreme miniaturization of cameras while maintaining
high image resolution. Another solution consists of using
virtual reality and augmented reality (AR). Indeed, virtual
reality allows for providing a pre -operative 3D view of
patients, operated from their medical image (CT scan or
MRI). This virtual copy of patients can then be used in a
pre-operative simulator, which provides a realistic 3D view
of patients. AR allows that virtual image to be superimposed
upon the real patient view. It is thus possible to make up for
the lack of sense of touch thanks to an improved visualized
image augmented with virtual information, thus making the
patient transparent. This virtual transparency will therefore
allow the fi nding of tumors or vessels not by locating them
by touch but simply by visualizing them thanks to AR.
Moreover, this information could be used to automatically
guide a robotic system, or to add force feedback feeling in a
new generation of robots dedicated to NOTES.
A second well -known limitation of these techniques is the
gesture complexity due to the loss of orientation and inversion of movements. In laparoscopy, this inversion is due to
the fi xed point located at the instrument entry port on the
skin. In NOTES, the loss of orientation is due to the fl exibility of the endoscope. Such diffi culties can again be partially
solved thanks to AR and/or robotics. Indeed, AR techniques
combined with instrument tracking can provide the location
and internal orientation of instruments. Another limitation
is due to the lack of dexterity of the fl exible instruments
classically used for NOTES. An effi cient solution should
include the development of an effi cient user interface for
the control of a NOTES robot and its instruments.
We propose to present here several results obtained for
the development of new computer -assisted NOTES. First we
will present work and results obtained for patient modeling,
pre-operative NOTES planning and simulation, and AR.
Second, we will present current developments in NOTES
Natural Orifi ce Translumenal Endoscopic Surgery (NOTES): Textbook and Video Atlas, First Edition. Edited by Anthony N. Kalloo, Jacques Marescaux,
Ricardo Zorron.
© 2012 John Wiley & Sons, Ltd. Published 2012 by John Wiley & Sons, Ltd.
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CHAPTER 9 Computer-assisted NOTES
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Figure 9.1 Comparison between direct volume rendering of a body and a virtual coloscopy (left) and surface rendering after the delineation process of
the same body and virtual coloscopy (right).
robotics, with several different approaches, the external
motorization of long and fl exible systems, and the internal
micro-robot.
From medical image to augmented reality
for NOTES
Pre -operative virtual patient modeling
From a medical image of the patient, standard software can
provide an effi cient direct volumetric rendering [1]. The
direct volume rendering technique is available on the visualization workstation of almost all radiological departments
from 3D Digital Imaging and Communications in Medicine
(DICOM) images such as MRI or CT scan. The main benefi t
of this 3D visualization is the lack of pre -processing, no
delineation being required to obtain useful results. In clinical
routine, volume rendering is thus of great interest for all
contrasted malformation pathologies, in particular vascular
or bone malformation, but also for thoracic and digestive
pathologies. In the case of the coloscanner, volume rendering is also used routinely to perform virtual coloscopy.
However, there are several limitations that can be prohibitive depending on the medical application. First, without
manual interaction the user cannot visualize independently
the organs he/she wants to see if they have the same gray
level in the DICOM data. Second, it is not possible to
compute any organ volume since independent structures are
not delineated. For the same reason, it is not possible to
simulate an organ resection without cutting neighboring
structures.
To overcome this limit, each anatomic and pathologic
structure in the medical image has to be delineated. Such
delineation is usually a long and diffi cult manual task for
radiologists with standard software. To overcome this limitation, several commercial software packages have been
developed which allow users to do the 3D patient model
themselves using automatic algorithms (Myrian © from
Intrasense; Ziostation © from Ziosoft; Synapse © Vincent
from Fujinon; Iqqa
®
Liver from Edda Technology; ScoutTM
Liver from Pathfi nder). Nevertheless, using such software
requires specifi c training and can remain a long process, the
automated segmentation process not being guaranteed in
clinical routine due to great variations in the medical image
quality. This is why several companies today offer online 3D
modeling services from an uploaded DICOM image for
dental, vascular, and digestive pathologies (MeVis Distant
Services AG, PolyDimensions GmbH, Edda Technology, 3DR
Laboratories). In the same way, since 2003, we have set up
several free collaborations with distant university hospitals
(Brussels, Montreal, Lausanne, and Strasbourg) in order to
offer a similar experimental 3D modeling service named
MEDIC@. More than 800 clinical cases have thus been
modeled in 3D for the thoraco -abdominal area. Similarly to
other existing distant services, this distant 3D modeling
service has shown its effi ciency in providing an accurate and
fast 3D model of a patient ’s anatomy and pathology (see fi rst
part of Video 9.1, Figure 9.1). Such web -based services
should certainly represent the future fi rst step of any
computer -assisted surgery.
Pre -operative surgical planning
Existing 3D delineation software platforms are usually
linked to surgical planning tools developed by the same
teams [2–6]. In the same way, we have developed a surgical
planning system (3D VSP), which runs on a standard multimedia computer. Beside the 3D visualization of delineated
and modeled structures, this system allows each structure to
be made transparent, and enables the user to interact with
them, to navigate anywhere, and therefore to simulate any
kind of endoscopy: laparoscopy, fi broscopy, gastroscopy,
colonoscopy, cholangioscopy, and transvaginal NOTES [7].
It furthermore allows the user to perform virtual resections
defi ned by interactively positioned cutting planes and
provides the volume of all visualized structures. In NOTES
surgery, it is often diffi cult to fi nd the best perforation
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Figure 9.2 Patient-specifi c NOTES planning using 3D VSP ©IRCAD for transgastric (left) and transcolonic (right) approaches. In both cases the external
view (left window of each image) allows location of the camera position (in red), the internal view simulating the endoscopic vision of the fl exible
instrument (right window of each image).
Figure 9.3 NOTES simulator ©Digital trainers, from real patient pre -operative 3D modeling. Left, two endoscopic views of virtual navigation in larynx
and in stomach. Right, two different external views in the same areas.
location in the lumen (in the stomach or colon, essentially).
Such software brings great benefi ts here, the perforation
location being defi ned precisely from the real patient
anatomy (Figure 9.2).
Moreover, because of its compatibility with current standards and operating systems (Windows, Mac OS, and Linux),
this system can be used on a laptop fi tted with a 3D graphic
card and can therefore be used during the intervention to
improve control of the gesture. The resulting NOTES surgical
planning can thus be optimized.
opment of such a simulation based on the open source
Simulation Open Framework Architecture (SOFA) engine
[8], in partnership with Digital Trainers and Karl Storz. This
engine offers the opportunity to add mechanical, dynamic,
and visual properties to each 3D modeled organ. Thus, by
adding a dynamic model of breathing and the heart beating
and mechanical models for each 3D modeled anatomic
structure, the system adds virtual life to the virtual patient.
Moreover, collisions between organs and between organs
and surgical instruments and associated deformations of soft
tissues are automatically computed in real time. The result-
Pre -operative surgical simulation
In comparison with planning, which allows the defi nition of
the surgical strategy, the objective of simulation is to increase
realism in order to test surgeons ’ ability to carry out a
planned surgical procedure, or to train them. Moreover, this
simulation, which adds deformation, will be mandatory for
an accurate intraoperative guidance through AR. Although
there are today several simulators for fl exible endoscopic
procedures (CAE Healthcare LapVR or Simbionix LapMen-
ing simulator thus offers a real -time simulation of instrument interaction, two views being available, the endoscopic
view and an external cutting view (Figure 9.3).
This real -time simulation can be used for patient -specifi c
pre-operative training and education. It could also be used
for intraoperative AR, the remaining work being, fi rst, to
register the patient, and, second, to track in real time the
real endoscope movements that will be reproduced in the
simulator.
tor), not a single one has been developed for NOTES. Moreover, the existing fl exible endoscopic simulators are not
patient-specifi c, which means that it is impossible to add
pre-operatively a 3D modeled patient in such a simulator.
To overcome these limitations, we are working on the devel-
Augmented reality for intraoperative assistance
in NOTES
Pre-operative surgical planning and simulation will mainly
improve the effi ciency of MIS procedures thanks to better
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Figure 9.4 Use of structured light combined with breathing movement simulation for the real -time augmented reality of organs in movement without
any skin markers.
pre-operative knowledge of a patient ’s anatomy and real
pre-operative training. But pre -operative use of virtual
reality is not suffi cient to ensure safety during the surgical
procedure. Such an improvement can be provided by an
intraoperative use of virtual reality through the AR concept.
Indeed, AR consists of superimposing the pre -operative 3D
patient modeling onto the real intraoperative patient view.
AR provides a transparency view of patients and can also
guide surgeons thanks to the virtual improvement of their
real surgical tools, which are tracked in real time during the
procedure. We have developed two kinds of AR software
applications: interactive augmented reality (IAR) and fully
automatic augmented reality.
Interactive Augmented Reality [9–13] involves moving
the 3D model of the patient in order to superimpose it accurately onto the real patient (see Video 9.1). This positioning
being done in real time using interactive software, it allows
correction of all visible mistakes or bad registrations. On the
other hand, such augmented reality is necessarily user dependent, the result being thus totally dependent on the
user’s expertise. Therefore, it is impossible to ensure accuracy of IAR, so it must not be used to guide a robotic system
even if it is effi cient in providing easier intraoperative understanding of patient anatomy using pre -operative data.
This limitation has to be overcome by automatic augmented reality, which is composed of two main components:
automatic registration and automatic tracking of tools. The
automatic registration is a high -
level problem to solve in
NOTES surgery, always applied to soft organs in movement.
Indeed, pre -operative acquisitions usually provide a 3D
vision of organs without any movement. During a surgical
procedure, organ movements due to breathing create a big
difference between the patient -specifi c model and the real
organ shape and position. To solve such a problem, two main
approaches have been proposed. Shekhar et al. [14] performed intraoperative low -dose CT acquisition on pigs and
thus provided the real shape of organs during the surgical
procedure. Although they showed that radiation exposure
can remain within acceptable limits, we believe that such a
technique will only be accepted by patients if an MRI device
replaces the CT scan. Moreover, such a strategy is extremely
expensive since a 3D image acquisition device is required.
We have proposed another approach, which consists of a
predictive real -time simulation of organ deformation using
skin tracking [15,16] (Figure 9.4). This system is based on
skin surface reconstruction, allowing recovery of the patient
shape in real time. Then, this information is used to deform
in real time the pre -operative 3D patient model. Experimental results with patients show that this solution provides
accurate results (2 mm of accuracy for real -time registration
of deformable organs).
The resulting automatic augmented reality thus provides
a real -time vision of organ position and shape. However, this
vision takes neither the pneumoperitoneum nor the surgeon
interaction into account. There is today no work on solving
this limitation. However, research work is focusing on the
use and analysis of 3D intraoperative medical images such
as MRI or US, with endoscopic video images to correct organ
deformations due to pneumoperitoneum and surgeon interaction. The combination of such analysis with real -time
simulation will certainly offer a truly effi cient solution to
this unsolved problem.
Automatic surgical instrument tracking is a second issue
to be solved. There is currently a large set of tracking systems,
essentially based on optics and electromagnetic fi elds. Optical
tracking cannot be effi cient for endoscopy or NOTES because
the instruments are fl exible, which means that the external
position of the handle does not explain the internal shape
and position of the end tip. Thus, we have developed a new
automatic tracking system providing in real time the 3D
shape and location of the fl exible endoscope [7] (see Video
9.2). This system is based on the Aurora tracking system
developed by NDI. It is composed of a 1.20 m long and
2.2 mm diameter tube. It can thus be introduced into the
operating channel of a fl exible endoscope. This tube contains seven 8 mm × 1 mm miniature electromagnetic coils
distributed on its length and which can be located by a tracking system commercialized by the NDI company under the
name Aurora ( ©NDI). Locating these various coils like a
GPS, the software developed in tandem with that device
allows both reconstruction of the tube shape and location in
three dimensions and measurement of the distance between
two interactively selected positions of the tube. Our preclinical validation performed on pigs shows an accurate precision
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of 1 mm for distance measurements (see Table 9.1). Distances were computed on the liver through a transgastric
approach with the METRIS system, and compared in a
second step with a millimeter ruler measurement. By combining this tracking system tool with an automatic AR view
of the patient, it is thus possible to provide an interesting
virtual transparency showing the accurate position and
shape of the fl exible endoscope and an approximate position
and shape of organs (Figure 9.5).
Even though it is not accurate enough, this information
remains interesting for surgeons in NOTES, due to the
current lack of orientation when they use a fl exible endoscope. However, it remains insuffi cient to accurately guide
and control a robot. As we will see, real -time intraoperative
endoscopic or medical image analysis will therefore be mandatory to assume such guidance.
Robotics for NOTES
A robot is a mechanical and information system designed to
replace or assist humans in a variety of complex tasks. For
several years, new robotics systems have been designed to
overcome the human limits in NOTES procedures. The
Table 9.1 METRIS accuracy for distance measurement.
Distance
1 (mm)
METRIS 7.1 15.2 5.2 13.4
Ruler 8 16 6 14.3
Distance
2 (mm)
Distance
3 (mm)
Distance
4 (mm)
resulting designs can be separated into three main families
[17,18] of master -slave systems, i.e., slave robots interactively controlled from a master interface manipulated by the
surgeon, while automation remains unique [19] until now:
• laparoscopic robots adapted to NOTES, controlling from
the outside rigid instruments that are introduced through a
natural orifi ce inside the patient;
• NOTES robotized fl exible platforms controlling from the
outside long fl exible instruments that are introduced through
a natural orifi ce inside the patient [17];
• NOTES internal miniature robots that are introduced
inside the patient [18].
Laparoscopic robots adapted to NOTES
MIS involves introducing long instruments through small
orifi ces controlled from outside of the patient by the surgeon.
A fi rst possible approach consists of replacing the arms of
surgeons that hold instruments by robotic arms, remote
controlled by a master interface under the control of a
surgeon. Such a design is symbolized in laparoscopy by the
da Vinci surgical system (Intuitive Surgical, Sunnyvale, CA,
USA). The application of such robotic systems to NOTES
implies placing the different instruments through a single
translumenal orifi ce.
Rigidity and length of current da Vinci instruments being
a limitation, the transgastric approach is not feasible with
this robot. The fi rst works proposed to use hybrid techniques
combining transvaginal and transcolonic access [20], or
combining transumbilical and tranvaginal access [21]. Then,
several single -access NOTES techniques were performed,
essentially through transumbilical access [22,23], but also
through transvesical access [24]. The transumbilical approach
was developed by using a really interesting option provided
by the da Vinci robot: the inversion of hand control, the right
Figure 9.5 Automatic augmented reality for NOTES, combining an automatic patient registration performed through an optical stereoscopic system (in
the rectangle) with an electromagnetic system (in the circle). Tool and organ shape and orientation are then visible in real time through the virtual
transparency visible on the left screen, which is zoomed in the right image.
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Figure 9.6 The instrumentation developed by Intuitive Surgical for single -port-access surgery (VeSPA, Intuitive Surgical, Sunnyvale, CA, USA).
hand controlling the left tool and reciprocally. However,
with usual instrumentation, the da Vinci robot remains not
well suited to such NOTES approaches. Intuitive Surgical has
thus developed new dedicated instruments described and
tested by Haber et al. [25]. This newly designed prototype
multichannel port allows the placement of an 8.5 mm scope,
a 12 mm cannula for the assistant, and new crossing curved
cannulae for the robotic instruments (Figure 9.6). VeSPA
instruments and accessories are differentiated by a semi rigid shaft, allowing them to be inserted through curved
cannulae. In addition, the instruments do not have a wrist
at the distal end of the instrument. The VeSPA instruments
and accessories include needle driver, Cadiere grasper, right angle Maryland retractor, curved scissors, hook, clip applier,
and suction irrigator.
architecture and the technology used to move their distal
part. We could distinguish three types of platforms: snake like robots, fl exible endoscopic basis with tele -manipulated
small arms, and robotized fl exible endoscopes.
The fi rst class of fl exible systems is highly articulated
snake-like robots with a single working channel [26–28].
These robots are made of numerous links connected together
with the ability to move the distal end from the outside of
the patient while the fl exible robotized system is thrust
through a natural orifi ce. One type of snake -like robot uses
multiple super -elastic NiTi backbones for actuation and was
designed for MIS of the throat or upper airways [26]. Such
systems using shape memory alloys (SMA) for actuation can
be made very compact; however, they usually have relatively low stiffness and require high activation voltage,
leading to heat dissipation problems. The Highly Articulated
NOTES robotized fl exible platforms
Several fl exible robotics systems have been designed to overcome the limitations due to rigid instruments. Of course, one
should be aware that there always exists a tradeoff between
fl exibility and the ability to exert forces in all directions. The
different prototypes can be classifi ed according to their
Robotic Probe (HARP) [27] is made of two concentric articulated tubes that can be made alternatively rigid or limp by
pulling on cables in the outside driving mechanism. This
snake-like robot can take a 3D shape in space and has
been tested in animal studies inside the intrapericardial
environment and for abdominal laparoscopy. The NeoGuide
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Endoscopic System (NES) [28] consists of a cable -driven
endoscope with multiple articulated segments. The distal
end is tele -operated using a joystick -like interface. The NES
can be rigidifi ed on demand by pulling on cables. This
feature is useful to bring fl exible instruments inside the
patient through a stable basis. The NES has a video camera
at the distal end and one classical operator channel. It has
been successfully used on patients for polyp removal in clinical tests. For the sake of completeness, we should also report
the use of the robotized catheter system Sensei of Hansen
Medical in urologic applications [29,30]. The Sensei system
operates by guiding standard catheters through an active
steerable sheath, mainly for vascular applications. It consist
of a haptic interface from Immersion which tele -manipulates
the motorized catheter -driving mechanism and the steerable
hollow tube.
The snake -like systems do not provide triangulation of the
instruments. Furthermore, they usually have a unique
working channel that limits their use to very simple procedures. Several NOTES robotic platforms are currently being
developed with a fl exible endoscopic basis and small articulated arms that can provide triangulation. The fi rst system
is the ViaCath [31] consisting of a master console (Laprotek),
slave drive mechanisms, and two long -shafted fl exible
instruments that run alongside a standard gastroscope. The
Laprotek surgeon console is a 7 degrees of freedom (DOF)
haptic interface. The slave system has 7 DOF if we include
the opening and closing of the gripper. It has been used ex
vivo and in animal studies. It exhibits some drawbacks, such
as the whole system does not enter easily inside the natural
orifi ce (an overtube is needed), the instruments cannot be
changed without removing the complete system, and the
instrument can produce at most 0.5 N of lateral force. A
second generation of the ViaCath endolumenal robotics
system is under development to overcome these problems
by developing poly -articulated instruments that go inside an
overtube. Another experimental system has been developed
at the National University of Singapore [32,33]. It consists
of two polyarticulated 4 DOF (one manual translation and
three active rotations) miniaturized instruments attached at
the tip of a fl exible gastroscope with two working channels.
Motor -driven cables going through the two working channels drive the small arms. The arms are tele -manipulated
using a prototype master system. This system has been tested
in vivo for a liver wedge resection. The main drawbacks of
the system are the lack of interoperability of the instruments, which cannot be changed during the procedure, and
the fact that only 3 out of 4 DOF of each arm can be actively
controlled together. Other custom -designed master consoles
for robotized NOTES with 6 DOF interfaces can also be
found in the literature [34]. Note that tests have shown that
joystick-like interfaces are not suitable for NOTES procedures [35].
The systems described above suffer from the lack of interoperability of the instruments, which cannot be easily
changed during the surgical procedure without removing
the whole system. A fl exible NOTES robot has been designed
at the University of Strasbourg and IRCAD in order to overcome this drawback [36,37] (see Video 9.3). The system is
based on an existing classical two -channel fl exible gastroscope (from Karl Storz) whose handles have been replaced
by motors. Two 4 -way fl exible hollow tubes are connected
to the distal end and are actively controlled using motors.
Three active steering mechanisms are added in order to drive
classical fl exible instruments inside one channel of the gastroscope and inside both steerable hollow tubes. The instrument steering mechanisms control the translation and the
rotation around its axis of each instrument. The whole
system has 12 active DOF that are controlled by the surgeon
through a 14 DOF haptic interface built with 2 Omega
systems from Immersion, i.e., one 7 DOF haptic interface for
each tele -manipulating hand (Figure 9.7). This complete
fl exible robotized system provides triangulation, enough
degrees of freedom in order to perform surgical gestures
usually done in laparoscopic MIS, compatibility with classical fl exible instrumentation used in gastroenterology, and
possible change of instrumentation during the procedure.
The system developed in Strasbourg benefi ts also from
automatic active physiological motion compensation software [38–40]. It consists of actively stabilizing the endo-
Figure 9.7 The NOTES robot prototype from Strasbourg. Left, 14 DOF haptic interface; center, pluggable driving mechanisms; right, 12 DOF
end-effector.
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scopic view by using visual servoing algorithms, so that the
surgeon can tele -manipulate the instruments on a moving
organ as if it were totally still (see Video 9.3).
NOTES internal miniature robots
A fl exible robotics platform as described in the previous
section will certainly improve NOTES practice in the near
future. However, there are some issues that cannot be easily
solved, like providing a global view of the surgical site,
retracting organs, cleaning the lens, and so on. This is a good
reason for exploring other approaches while keeping in
mind that the fi nal goal is to provide tools to the surgeon
that make NOTES at least as practical as classical MIS. Miniature surgical robots provide an interesting alternative
[17,18,41]. Miniature surgical robots can be introduced
inside the patient through a single incision or a natural
orifi ce. Several of those miniature robots dedicated to specifi c tasks could be introduced at the same time. The fi rst
miniature surgical robots were miniature pan -tilt cameras,
either fi xed [41] or mobile [42], providing auxiliary views
of the surgical procedures. The mobile miniature robot is a
cylindrical system made of two independent wheels with a
camera in the middle. By controlling each wheel separately,
the mobile robot can move across the abdominal cavity and
orientate the camera in any direction. This system has been
successfully tested in vivo. A modifi ed version of this miniature mobile robot has been successfully used to perform a
biopsy of the liver [18,41]. The next step consists of providing cutting and grasping capabilities for these systems. A
miniature cylindrical robot with a camera and two deployable arms on each side has been developed with these abilities [43,44]. The arms have 4 active DOF each and solve the
triangulation issue. Each robot arm is remotely controlled
using two Novint Falcon 3 DOF tele -manipulators, buttons,
and foot pedals [45]. This system has been successfully used
in vivo for a cholecystectomy on animal models. There are
still issues to be solved, like changing instruments or stabilizing the robotic platform; however, it is an interesting development path of NOTES worth pursuing.
Conclusion
This chapter describes the state of the art in virtual reality
and robotics applied to NOTES. Virtual reality provides a
pre-operative 3D view of patients, operated from their
medical image (CT scan or MRI). This virtual copy of patients
can be used in a pre -operative simulator, which provides a
realistic 3D view of patients. Augmented reality then allows
that virtual image to be superimposed onto the real patient
view. It is thus possible to make up for the lack of sense of
touch thanks to an improved visualized image augmented
with virtual information, thus making the patient transparent. This virtual transparency will therefore allow surgeons
to fi nd tumors or vessels not by locating them by touch but
simply by visualizing them thanks to augmented reality.
Moreover, augmented reality techniques combined to
instrument tracking provide the location and internal orientation of instruments.
Robotics give a new vision of the future of surgery by
replacing the usual fl exible tools requiring complex human
control by a computer -assisted motorized instrumentation.
Current research is based on three main concepts. The fi rst
one involves an adaptation of existing laparoscopic robots to
NOTES. The second one involves developing robotized fl exible platforms controlling from outside long fl exible instruments. The last one consists in developing internal miniature
robots. These three approaches present advantages and
limits.
The main benefi t of the fi rst approach is that it is based
on a known system, simplifying the education of surgeons
and reducing the learning curve. Being the closest to usual
laparoscopic surgery, it seems to fi t well with surgeon
needs in single -port access and transumbilical approaches.
However, its main drawback is that this approach does not
allow transgastric surgery, the developed instrumentation
not being compatible. In comparison with the fi rst solution,
the second approach is based on less -expensive platforms.
Well adapted to any NOTES approach, the resulting platforms are the closest to known fl exible endoscopes but offer
greater ergonomics through a user friendly human -machine
interface. The main drawback is the size of fl exible instruments. Too small, the instruments reduce possible forces
applied at the end tip and avoid complex organ retraction.
Too big, it becomes diffi cult to enter natural orifi ces. The
good balance remains diffi cult to fi nd. To reduce invasion,
the last approach seems to be an interesting alternative.
Using magnets can also provide good forces, which are
impossible to obtain with the previous solutions. The main
drawback is the cost, the lack of forces without magnets, and
the possible magnet danger when several magnetic instruments are used in parallel.
Future solutions will certainly combine approaches
through augmented reality guided systems using external
motorized instruments. In order to overcome current limits
of real -time tracking of deformable organs and tools, medical
imaging systems will certainly be included in the OP room.
More advanced research foresees to do more by using
magnets so as to produce non -invasive intraoperative medical
imaging in MRI, to control position and orientation of internal devices [46]. Image -guided minimally invasive hybrid
NOTES should be the next step in NOTES evolution.
Acknowledgment
Augmented reality works have been co -funded by the European Community 7th Framework ICT program, in the
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