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_1369_Библиотеки_им_академика_М_И_Перельмана.pdf
21 Current and Future Platforms for Robotic Colorectal Surgery
Fig. 21.7 Telelap ALF-X reusable instruments
303
surgeries and might require a larger operating room spatial footprint, limiting the
areas of its use. Furthermore, laparoscopic stapling devices are needed, but may be
easier for assistants to use with increased access to the surgical field. Currently, the
Telelap ALF-X platform is only marketed in the European Union, but there are plans
to apply for FDA clearance and market in the United States in the near future. SOFAR
S.p.A may integrate with TransEnterix to accomplish this goal.
Telesurgery
The technological advancements in robotic surgery have made the idea of telesurgery
a reality. With telesurgery, patients can acquire unique surgical expertise despite being
great distances from highly specialized surgeons. The military has envisioned the use
of telesurgery in forward operating bases near combat zones with limited medical
staff. If telesurgery could be employed in civilian life, it could allow advanced surgical care in any region with limited resources including rural communities, third world
countries, and even the international space station. However, implementation of telesurgery has been limited due to data transmission latency. Once cables are no longer
used to connect the surgical console to the robot, the data must be compressed, transmitted, and then uncompressed at the receiving location. This creates a latency period,
which can degrade surgical performance. Studies have revealed that basic tasks can be
satisfactorily performed with up to a 600-ms time delay, but complex procedures have
a significant increase in errors with delays greater than 300 ms [15–17]. Despite the
issue with latency, Jacques Marescaux of Strasbourg, France performed the first transatlantic cholecystectomy on a patient in Strasbourg while sitting on a surgical console
304
J.N. Harr and D. Nagle
in New York City in 2001 [18]. Currently, telementoring is being employed allowing
for colorectal surgeons to provide real-time intraoperative feedback during complex
cases, but latency times and medical–legal factors have dissuaded telesurgery use in
the United States. Although still limited, telesurgery continues to be explored.
Stanford Research International (SRI), who has helped pioneer robotic surgery
platforms from the 1980s under contract to the U.S. Army and funding from the
NIH, developed the M7 surgical robot in 1998 [19]. The current version has two
anthropomorphic robotic arms, which move through 7 degrees of freedom, and in
which conventional surgical tools can be swapped rapidly by a technician. The
advantage of the M7 not offered by other platforms is the incorporation of auditory,
visual, and tactile sensations, as well as haptic feedback. Additionally, the robotic
platform software compensates for jarring or turbulence on a moving platforms
(such as in vehicles, aircraft, or in space) virtually eliminating tremor. In 2006, the
M7 successfully completed a real-time abdominal surgery on a patient simulator
remotely in the Aquarius Underwater Laboratory 60 ft underwater off the coast of
Key Largo, Florida as part of the ninth NASA Extreme Environment Mission
Operations [20]. Similarly, in 2007, the M7 was used to complete basic exercises
aboard a NASA C-9 aircraft simulating the microgravity of space [21]. The M7 was
also used to perform the first automated ultrasound-guided tumor biopsy [20].
Another robotic platform focusing on telesurgery is the Raven, developed by
physicians and scientists at the BioRobotics Laboratory affiliated with the University
of Washington in 2005, and is sponsored by the Department of Defense [22]. The
current version of the robot (Raven II) weighs 22 kg, and has two articulated,
tendon- driven arms in which different surgical instruments can be easily exchanged.
It can be easily disassembled/assembled for transport by nonengineers, and the
communication links have been designed for long-distance remote control. The
unique feature of this platform is that the Robot Operating System software contains
a popular open-source robotics code, allowing other labs and researchers to connect
the Raven II to other devices and share ideas. Other robotic labs including Harvard,
Johns Hopkins University, the University of Nebraska-Lincoln, UCLA, and UC
Berkeley have also received Raven II robots to further research and problem-solve
the current limitations of robotic surgery. The Raven II has also been tested in
underwater NASA training habitats, remote desert locations, unmanned aerial vehicles, as well as zero-gravity astronaut training drills [23–26].
Robotic Endoscopy
The gold standard for the diagnosis of colon and rectal disease is video- colonoscopy.
This allows for direct visualization, tissue sampling for diagnosis, and interventions.
However, the invasiveness of this technique, as well as patient discomfort requiring
sedation, poses limitations. Subsequently, robotic platforms for colonoscopies have
been proposed to address these limitations. These platforms reduce pain and possibly the risk of perforation by minimizing excessive stretching of the bowel, by
21 Current and Future Platforms for Robotic Colorectal Surgery
limiting air insufflation and reducing the pushing action exerted by the endoscopist.
These devices also are more flexible, which decreases the distortion of the colon and
also allows for a more comfortable and safer procedure. Present devices are currently not employed clinically in the US, and have limited, if any, interventional
capabilities. However, the next step in technological advancement is the addition of
interventional capabilities, as well as with adding its concurrent use into laparoscopic/robotic colorectal operations since current standard intraoperative colonoscopies are burdensome due to excessive insufflation and colonic distortion.
305
Soft Colonoscopy Robotic Platform
The Vanderbilt STORM (Science and Technology of Robotics in Medicine) Lab has
further developed the magnetic air capsule system first introduced by Dr. Valdastri
[27]. This platform navigates an endoscopic capsule through magnetic coupling,
which pulls the capsule through the colon, as opposed to a traditionally pushed endoscope, which stretches the colonic wall generating pain [28, 29]. This device is a
tethered capsule that contains an endoscopic camera, white light LEDs, a therapeutic
tool channel, and air/water channels for insufflation and cleaning. The camera has a
550 × 582 pixel resolution and a 120° field of view. The small size of the capsule and
the soft, flexible tether increases patient comfort, minimizing sedation. The robotic
platform uses an external permanent magnet connected to a 6 degrees of freedom
robotic arm with a 7th custom-degree of freedom at the end-effector increasing dexterity to maneuver the endoscopic capsule. The robotic arm is controlled by an input
device and joystick, which interacts with a real-time motion control system and provides haptic feedback. This technology theoretically can reduce the physical demands
of performing the procedure, expand the pool of medical personnel able to operate
the system, and may allow for tele-endoscopy in rural areas or for military personnel
overseas. Currently, this device is not on the market, but preclinical studies have demonstrated feasibility and accuracy compared to conventional colonoscopy [29].
Endotics
The Endotics (Era Endoscopy S.r.I) robotic platform was developed in Italy and
uses a computer-assisted propulsion system with locomotion similar to that of an
earthworm [30]. The Endotics system is composed of a sterile, disposable probe
and a workstation (Fig. 21.8). The head of the probe contains a steerable tip, a
vision system with a CMOS camera and LED light source, and channels for a water
jet and air, as well as an instrument channel (Fig. 21.9). The body of the probe is
highly flexible, conforms to the shape of the colon, and contains two vacuummechanical clampers that are located in the proximal and distal part of the probe.
The locomotion is achieved by the coordinated adherence and release of the
306
Fig. 21.8 Endotics
workstation
Fig. 21.9 Endotics
disposable probe
J.N. Harr and D. Nagle
clampers to the colon mucosa and is operated by a handheld controller similar to
those seen with home gaming systems. For locomotion, the operator can steer the
head of the probe 180° in every direction, and then activate the forward or backward
motion through an automated series of steps: the proximal clamper adheres to the
mucosa and the central part of the body is elongated; the distal clamper adheres to
the mucosa and the proximal clamper is released; the central part of the body is
contracted so that the proximal clamper may adhere to the mucosa; and finally, the
distal clamper is released. This sequence is repeated several times allowing the
21 Current and Future Platforms for Robotic Colorectal Surgery
307
probe to move in a worm-like fashion [31]. This clamping mechanism is safe and
does not produce bowel wall lesions or mucosal lacerations. Early clinical studies
have shown an equivalent diagnostic accuracy to the standard colonoscope, with a
sensitivity of 93.3 %, and a specificity of 100 %, and no patients requested or
required sedation [32, 33]. Benefits of this system are that it is safe with the disposable probe, eliminating the risk of cross-infection, and that it is cost effective since
it eliminates costs related to perforation, cross-contamination, work-related injuries, sterilization and sedation, and decreases room turnover time. Furthermore, the
company touts a fast learning curve with the intuitive handheld controller. However,
the main limitation currently is increased colonoscopy times.
GI View Ltd.
The Aer-O-Scope™, introduced by the Israeli company GI View Ltd., uses a selfpropelled pneumatic intubation system by employing balloons and low-pressure CO2
gas, and exerts ten times less pressure on the colonic wall than the standard colonoscope [34]. The Aer-O-Scope™ consists of disposable scanner, which contains an
imagining capsule with a CMOS camera, and a soft, flexible cable containing channels
for air, suction, and a water jet (Fig. 21.10). The imaging system provides two simultaneous views for visualization of the colon, including a standard forward-looking view,
as well as a 360° “omni-view” providing visualization ahead of the capsule, behind the
Fig. 21.10 Aer-OScope™ disposable probe
and optical head
308
Fig. 21.11 Aer-O- Scope™
workstation
J.N. Harr and D. Nagle
capsule, and of all sides of the capsule, increasing visualization behind haustral folds,
and subsequently, polyp detection rates. The disposable scanner connects to a PC-based
workstation, which is equipped with an ergonomic joystick that controls navigation,
insufflation, irrigation, and suction (Fig. 21.11). The computer-assisted platform
receives and processes transmitted pneumatic controls and pressure measurements
within the camera and scanner to safely advance and withdraw the Aer-O-Scope™
within the colon lumen. The Aer- O- Scope™ has recently received FDA 510(k) clearance and is expected to be introduced in the United States in 2016. The advantages of
this system are with the single-use endoscope preventing cross-contamination, the lowpressure pneumatic propulsion, and the 360° visualization of the colon. The handheld
joystick has an intuitive design, decreasing the learning curve, and allowing physicians
to be trained in half a day [34]. Currently, there is no published data on the cost of the
system or the cost effectiveness compared to traditional colonoscopy, but is expected to
reduce costs by decreasing complications, allowing for quicker room turnover, and
increasing polyp detection. Also, there is no published data on sedation requirements.
Another limitation is the lack of a working instrument channel for biopsies and interventions. However, the low-pressure CO
propulsion system and visualization capa-
2
bilities would offer several advantages for intraoperative colonoscopies.
Conclusions
Robotic surgery is a rapidly evolving field, driven by technological advances and end
user enthusiasm. It is not yet clear whether the proposed advantages of robotic surgery are durable and meaningful. Thoughtful clinical analysis, best answered with
21 Current and Future Platforms for Robotic Colorectal Surgery
309
randomized clinical trials, is difficult to structure into practice prior to technical
advances. Therefore, the real benefits of robotic surgery, whether to patient, surgeon,
or both, are not yet clearly identified. As always, well-designed studies, ideally randomized, will hopefully clarify these issues but may not be performed prior to widespread adoption of the technology.
References
1. Satava RM. Surgical robotics: the early chronicles: a personal historical perspective. Surg
Laparosc Endosc Percutan Tech. 2002;12(1):6–16.
2. Weber PA, Merola S, Wasielewski A, Ballantyne GH. Telerobotic-assisted laparoscopic right
and sigmoid colectomies for benign disease. Dis Colon Rectum. 2002;45(12):1689–94.
3. Jimenez-Rodriquez RM, Diaz-Pavon JM, de la Portilla de Juan F, Prendes-Sillero E, Dussort
HC, Padillo J. Learning curve for robotic-assisted laparoscopic rectal cancer surgery. Int
J Colorectal Dis. 2013;28(6):815–21.
4. Bolenz C, Gupta A, Hotze T, Ho R, Cadeddu JA, Roehrborn CG, Lotan Y. Cost comparison of
robotic, laparoscopic, and open radical prostatectomy for prostate cancer. Eur Urol. 2010;57
(3):453–8.
5. Tholey G, Desai JP, Castellanos AE. Force feedback plays a significant role in minimally inva-
sive surgery: results and analysis. Ann Surg. 2005;241(1):102–9.
6. Talasaz A, Patel RV. Integration of force reflection with tactile sensing for minimally invasive
robotics-assisted tumor localization. IEEE Trans Haptics. 2013;6(2):217–28.
7. Moradi Dalvand M, Shirinzadeh B, Nahavandi S, Smith J. Effects of realistic force feedback
in a robotic assisted minimally invasive surgery system. Minim Invasive Ther Allied Technol.
2014;23(3):127–35.
8. Juo YY, Agarwal S, Luka S, Satey S, Obias V. Single-incision robotic colectomy (SIRC) case
series: initial experience at a single center. Surg Endosc. 2015;29(7):1976–81.
9. Buchs NC, Pugin F, Bolonte F, Hagen ME, Morel P, Ris F. Robotic transanal endoscopic micro-
surgery: technical details for the lateral approach. Dis Colon Rectum. 2013;56(10):1194–8.
10. Hompes R, Rauh SM, Ris F, Tuynman JB, Mortensen NJ. Robotic transanal minimally inva-
sive surgery for local excision of rectal neoplasms. Br J Surg. 2014;101(5):578–81.
11. Gomez Ruiz M, Parra IM, Palazuelos CM, Martin JA, Fernandez CC, Diego JC, Fleitas
MG. Robotic-assisted laparoscopic transanal total mesorectal excision for rectal cancer: a prospective pilot study. Dis Colon Rectum. 2015;58(1):145–53.
12. SurgiBot patient-side robotic surgery. http://www.transenterix.com/technology/surgibot. Accessed
5 Apr 2015.
13. Developing next generation robotic surgical technologies. http://www.titanmedicalinc.com/
product. Accessed 5 Apr 2015.
14. Welcome to Telelap ALF-X. http://alf-x.com. Accessed 5 Apr 2015.
15. Lum MJ, Rosen J, Lendvay TS, Wright AS, Sinanan MN, Hannaford B. TeleRobotic funda-
mentals of laparoscopic surgery (FLS): effects of time delay—pilot study. Conf Proc IEEE
Eng Med Biol Soc. 2008;2008:5597–600.
16. Lum MJH, Rosen J, King H, Friedman DC, Lendvay TS, Wright AS, Sinanan MN, Hannaford
B. Teleoperation in surgical robotics—network latency effects on surgical performance. Conf
Proc IEEE Eng Med Biol Soc. 2009;2009:6860–3.
17. Rayman R, Primak S, Patel R, Moallem M, Morady R, Tavakoli M, Subotic V, Galbraith N,
van Wynsberghe A, Croome K. Effects of latency on telesurgery: an experimental study. Med
Image Comput Comput Assist Interv. 2005;8(Pt 2):57–64.
18. Marescaux J, Clement JM, Tassetti V, Koehl C, Cotin S, Russier Y, Mutter D, Delingette H,
Ayache N. Virtual reality applied to hepatic surgery simulation: the next revolution. Ann Surg.
1998;228(5):627–34.
310
19. Products and solutions. http://www.sri.com/engage/products-solutions/m7-surgical-robot.
Accessed 5 Apr 2015.
20. Doarn CR, Anvari M, Low T, Broderick TJ. Evaluation of teleoperated surgical robots in an
enclosed undersea environment. Telemed J E Health. 2009;15(4):325–35.
21. Kamler K. How I survived a zero-g robot operating room: extreme surgeon. Popular Mechanics—
online edition. 2007. http://www.popularmechanics.com/science/health/a2256/4230102.
22. Rosen J, Hannaford B. Doc at a distance. IEEE Spectrum. 2006;8(10):34–9.
23. Lum MJH, Friedman DCW, Sankaranarayanan G, King H, Fodero K, Leuschke R, Hannaford
B, Rosen J, Sinanan MN. The raven: design and validation of a telesurgery system. Int J Robot
Res. 2009;28(9):1183–97.
24. Haidegger T, Sandor J, Benyo Z. Surgery in space: the future of robotic telesurgery. Surg
Endosc. 2011;25:681–90.
25. Harnett BM, Doarn CR, Rosen J, et al. Evaluation of unmanned airborne vehicles and mobile
robotic telesurgery in an extreme environment. Telemed J E Health. 2008;14:539–44.
26. Lum M, Friedman D, King H, Donlin R, Sankaranarayanan G, Broderick TJ, Sinanan MN, Rosen
J, Hannaford B. Teleoperation of a surgical robot via airborne wireless radio and transatlantic
internet links. In: Field and service robotics. Berlin, Germany: Springer; 2008. p. 305–314.
27. Valdastri P, Ciuti G, Verbeni A, Menciassi A, Dario P, Arezzo A, Morino M. Magnetic air capsule
robotic system: proof of concept of a novel approach for painless colonoscopy. Surg Endosc.
2012;26(5):1238–46.
28. Soft Colonoscopy Robotic Platform. https://my.vanderbilt.edu/stormlab/research/medical-
capsule- robots/soft-colonoscopy-platform. Accessed 5 Apr 2015.
29. Arezzo A, Menciassi A, Valdastri P, Ciuti G, Lucarini G, Salerno M, Di Natali C, Verra M,
Dario P, Morino M. Experimental assessment of a novel robotically-driven endoscopic capsule
compared to traditional colonoscopy. Dig Liver Dis. 2013;45(8):657–62.
30. Endotics: a metamorphosis in robotic locomotion transforming endoscopic technologies.
http://www.endotics.com. Accessed 5 Apr 2015.
31. Perri F, Lacobellis A, Gentile M, Tumino E, Andriulli A. The intelligent, painless, “germ-free”
colonoscopy: a Columbus’ egg for increasing population adherence to colorectal cancer
screening? Dig Liver Dis. 2010;42(12):839–43.
32. Cosentino F, Tumino E, Rubis Passoni G, Morandi E, Capria A. Functional evaluation of the
Endotics System, a new disposable self-propelled robotic colonoscope: in vitro tests and clinical trial. Int J Artif Organs. 2009;32(8):517–27.
33. Tumino E, Sacco R, Bertini M, Bertoni M, Parisi G, Capria A. Endotics system vs colonoscopy
for the detection of polyps. World J Gastroenterol. 2010;16(43):5452–6.
34. Aer-O-Scope overview. http://www.giview.com/crc-screening/aeroscope-colonoscope- overview.
html. Accessed 5 Apr 2015.
J.N. Harr and D. Nagle
Acknowledgements
I would like to thank God, first and foremost, for providing me the opportunity to
edit and help guide this incredible group of authors. I have been blessed with my
parents, Vicente and Teodora Obias—thank you for all of your unconditional love
and support. Throughout this endeavor, there are many more individuals whose
efforts I would like to thank, but the person most central in this has been my beautiful wife, Sharon. Without her guidance (and help), this textbook would never have
been finished.
To all of the authors and coauthors, thank you again for spending your hardearned time writing chapters for this inaugural textbook. I have thanked many of
you in person and do so again. I would also like to thank Maria Smilios who helped
start this textbook and Colton Coreschi who helped finish it.
From the bottom of my heart, thank you all.
Vincent Obias
© Springer International Publishing Switzerland 2017
V. Obias (ed.), Robotic Colon and Rectal Surgery,
DOI 10.1007/978-3-319-43256-4
311
Index
A
Abdominal air insufflation, 4
Additional experience phase, 13
Adhesions, 289
Aer-O-Scope™, 307
Alexis™, 34
American College of Surgeons National Surgical
Quality Improvement Program
Database (ACS-NSQIP), 282
American Society of Colon and Rectal Surgeons
Young Surgeons group, 195
American Society of Reproductive Medicine
(ASRM), 244
Aminosalicylates (5-ASA), 154
Anastomotic leak rate, 200
Anesthesia, 132
Anterior mesh fixation, 136–137
Aromatase inhibitors, 249
Articulated instruments, 176
B
Bilateral salpingo-oophorectomy, 144–147
BioRobotics laboratory, 304
CO
embolism, 264
2
Colon Cancer Laparoscopic or Open
Combined oral contraceptives (COCs), 248
Concluding phase, 13
Concomitant rectopexy, 148
Conscious inhibition/gentleness, 178
Conventional laparoscopy, 59
Cost analysis, 42
Credentialing and privileges in robotics, 18
Crohn’s disease
Cumulative sum analysis (CUSUM), 214
Cystocele, 142
Resection study (COLOR II)
trial, 8, 210
da Vinci assisted single port
colectomies, 166
diagnosis, 165
genetic susceptibility, 164
hemicolectomy, 166
ileocecal resection, stricturoplasty, 165
medical therapy, 165
nonspecific symptoms, 165
robot, 166
transmural inflammatory process, 164
C
Capnothorax, 263, 264
Cardiopulmonary complications, 263
Cardiovascular, 117
Charge-coupled device camera (CCD), 107
Cholecystectomy, 5–6
Circumferential margins (CRM), 8
Clinical Outcomes of Surgical Therapy
(COST) study, 7, 209
© Springer International Publishing Switzerland 2017
V. Obias (ed.), Robotic Colon and Rectal Surgery,
DOI 10.1007/978-3-319-43256-4
D
da Vinci Firefly Imaging System, 105,
da Vinci robot, 42
da Vinci surgical systems (dVSS), 17, 18, 43,
da Vinci Xi patient cart, 297
da Vinci Xi system, 137
107–108
51, 191, 195
master-slave configuration, 19
313