World J Urol (2000) 18: 289±295 Ó Springer-Verlag 2000D. StoianoviciRobotic surgeryAbstract The industrial revolution demonstrated the desired task, which can be easily modi®ed by software.capability of robotic systems to facilitate and improve The task may be preprogrammed, as for automobilemanufacturing. As a result, robotics extended to various production lines, or de®ned on-line by the operatorother domains, including the delivery of health care. in more complex tasks requiring immediate humanHence, robots have been developed to assist hospital decision.sta, to facilitate laboratory analyses, to augment pa- The economic advantages, increased precision andtient rehabilitation, and even to advance surgical per- improved quality demonstrated by industrial robotsformance. As robotics lead usefulness and gain wider stimulated the application of robots for health careacceptance among the surgical community, the urologist delivery. There are four main categories of medical ap-should become familiar with this new interdisciplinary plications in which robots have been pursued: support-®eld and its ``URobotics subset: robotics applied to ive, laboratory, rehabilitative, and surgical. Supportiveurology. This article reviews the current applications and laboratory robots have been developed as patient,and experience, issues and debates in surgical robotics, hospital sta, and laboratory assistants. For example,and highlights future directions in the ®eld. Help-Mate  (Transitions Research Corporation, Milford, CT) is a commercially available robot which serves as a courier inside hospitals, delivering patient meals, medications, and X-rays. Robotic applications have been intensely investigated to assist people withDuring the course of the past century, man has devel- manipulative disabilities. These would enable the personoped numerous automated tools to increase productiv- to control arti®cial limbs and help locomotion [30, 48].ity, quality, and product performance. As the need for The utilization of robots in surgery was pioneered inproduction versatility emerged, man created program- the 1980s in the ®elds of neurosurgery and orthopedicmable tools which could easily adapt to new operations. surgery [2, 4, 6, 43]. Intracranial neurosurgical proce-These systems, usually termed as robots, are mechanical dures were a major focus of the ®rst robotic systems, insystems controlled by microprocessors and equipped part because a high degree of precision was required forwith sensors and motors. Computer algorithms utilize localization and manipulation within the brain, and alsothe environmental information and operator input pro- because cranial anatomy provided relatively ®xed land-vided by the sensors, to determine appropriate motor marks. Three broad types of devices have been devel-commands for the mechanical system to perform the oped to improve spatial accuracy and surgical precision [18, 25]: neuronavigators, stereotactic localizers, and robotic assistants. In orthopedic surgery, robots have been developed to cut or ream bone. The RoboDocD. Stoianovici (&) system (Integrated Surgical Systems, Inc., Sacramento,URobotics Laboratory, JHBMC-D0300, CA) prepares the proximal femur to accept an unce-5200 Eastern Avenue, Baltimore, MD 21224, USA mented total hip prosthesis . The cavity it creates ise-mail: firstname.lastname@example.org 10 times more accurate than can be achieved by manualTel.: +1-410-550-1980; Fax: +1-410-550-0773 reaming.Present address: Medical robotics has since expanded to other surgicalAssistant Professor of Urology and Mechanical Engineering,Director of Medical Robotics, The James Buchanan Brady applications, including urology. Robotic devices to assistUrological Institute, Johns Hopkins Medical Institutions, urologists with transurethral resection of the prostate,Baltimore, Maryland, USA percutaneous renal access, laparoscopy, and brachy-
290therapy are currently in developing stages or already in sequence of overlapping cuts in successive larger rings,clinical use. Many prototype robotic systems have been starting at the hypothetical bladder neck. Clinical trialsdeveloped and at present several systems are available in ®ve patients demonstrated that the entire resectioncommercially. Despite the large variety of surgical ®elds could be performed rapidly with hemostasis achievedand applications, these systems present several common manually after the ®nal cut. Unfortunately, trials iden-characteristics. ti®ed the need for modi®cations including an alternative The most common con®guration encountered in to transrectal ultrasound (TRUS) for prostate imagingsurgical applications is the manipulator, a structure as it was found to be insuciently accurate [31, 32].presenting an arm-like con®guration. Due to the com- Although not absolutely prevailing, this system was theplexity of most surgical tasks, the applicability of pre- ®rst recorded robotic surgery in humans unaided by theprogrammed robots in surgery is limited [3, 5]. Most of surgeon, and the ®rst urobot.the surgical robots today, take advantage of the sur- The group at the Imperial College also investigated ageons perception and judgment through the use of an robotic system to assist the urologist with intraoperativeon-line input device through which the surgeon dictates percutaneous renal access . They employed a passive,robotic movement during the procedure. There are now encoded, 5 degree of freedom (dof) manipulator,particularly eective and relatively new types of on-line equipped with electromagnetic brakes mounted onto thecontrolled systems which are called ``synergetic [45, 47]. operating table. The access needle was manually posi-In these systems the surgeon and the robot impart mo- tioned as prescribed by a computer, which triangulatedtion by commonly holding the instrument. The surgeon the calyx location from multiple C-arm X-rays .remains in control of the procedure while the device Initial experiments evaluating system performanceprovides steady-hand manipulation of the instrument. demonstrated a targeting accuracy of less than 1.5 mmFinally, an important class of surgical robots utilizes though in vitro experiments. In vivo experiments haveimaging technology to position, guide (track) and not been performed to date.monitor the robot as it performs the task under X-ray Similarly, the medical robotic research group at the¯uoroscopy, computed tomography (CT), ultrasound, Johns Hopkins University developed an experimentalor magnetic resonance (MR) imaging. This article pre- system to perform percutaneous renal access . Thissents a brief review of several robotic systems, current system primarily diers from the Imperial College sys-research, applications, and future goals in surgical tem in that it employs an active robot (LARS, developedrobotics. in collaboration with IBM) and it employs a bi-planar ¯uoroscopy imager. The surgeon chooses the target ca- lyx in the two normal images, after which the robotPresent state of surgical robotics positions the needle and inserts it to the desired location. In vitro and ex vivo porcine experiments demonstratedThe development of surgical robots is highly demanding an impressive accuracy of less than 1.0 mm. Live porcinecompared to other ®elds, due to the enhanced safety, percutaneous renal access experiments revealed a successsterilization, compactness, operating room require- rate of placing a needle on the ®rst attempt of only 50%ments, compatibility with medical imaging equipment, . Problems encountered were related to kidney dis-and the special ergonomics required. Testing and eval- placement by needle insertion, needle de¯ection, and ribuation of the surgical robots is a laborious process, interference, although this system demonstrated theundergoing several non-clinical stages and endorsements feasibility of performing fully automated robotic needlebefore clinical assessment. Moreover, robotics for soft placement in soft tissue.tissue operation, such as the urologic systems, should After extensive observations of surgeons performingadapt to the deformability and mobility of the operated needle insertion, our urobotics research group at Johnorgan. Although these diculties have delayed the Hopkins (http://urology.jhu.edu/research/urobotics/)evolvement of surgical robotics until the late 1980s, re- developed a robotic system, PAKY-RCM that mimicscent innovative research has allowed the development of and improves upon the surgeons standard technique.several purpose-designed systems. This section outlines The system is based on an active and radiolucent needleseveral surgical systems, some of which are presently driver, PAKY (percutaneous access of the kidney) .used in the operating room, while some other are still PAKY employs a novel kinematic principle, the frictionunder development. transmission with axial loading , which was uniquely The ®rst ``urobot was introduced in 1989 by a group suited for a miniaturized radiolucent construction pro-at the Imperial College in London, for performing viding motorized needle actuation. PAKY is mountedtransurethral resection of the prostate (TURP) [14, 15]. into the remote center of motion (RCM) robot, whichThe relatively ®xed positioning of the prostate and the has an extremely low pro®le, making it compatible withfact that TURP requires repetitive movements in a portable X-ray ¯uoroscopy units (C-Arm) and CTspeci®c geometric pattern, made robots good candidates scanners (Fig. 1).for performing this operation. The development in- The system is at present being used for percutaneousvolved several design stages, trials, and re®nements. renal access at John Hopkins, oering an unquestion-When activated, the robot automatically generated a able improvement in needle placement accuracy and
291 open MR scanner . The robot is located between the vertical donuts, above the surgeons head, and presents two long arms that extend into the imaging region, close to the patient. The system is designed to serve as an image-guided surgical assistant, integrating pre-opera- tive planning and intra-operative MRI. It is expected that the system will shortly undergo laboratory testing. Several devices have been developed for laparoscopy. They are manipulator arms helping the surgeon manipulate and position the laparoscope or advanced laparoscopic instruments under computer control [40, 44]. Perhaps the most successful commercial surgical ro- bot to date has been the automated endoscopic system for optimal positioning (AESOP), which is a robotic laproscopic camera holder from Computer Motion, Inc., Goleta, CA (http://www.computermotion.com/) that has been used in many clinical areas, including urolog-Fig. 1 The PAKY ± RCM robot for image guided percutaneous ical laparoscopic surgery. AESOP was the ®rst surgicalaccess robot to receive the approval of the Federal Drug Administration (FDA) and is now used clinically atprocedure time while reducing the radiation exposure to several institutions. At Johns Hopkins, there has beenpatient and urologist . At the present time, PAKY is considerable success in using this robot for a variety ofunder continued evaluation and new C-Arm based im- laparoscopic urologic procedures [26, 27, 33]. In theirage guidance algorithms are under development. studies, Kavoussi et al.  found that neither operative Another image-guided robot that has been evaluated set-up nor breakdown time was increased with the use ofclinically is a robot developed at the Politecnico of Mi- a robotic assistant. In fact, robotic surgical assistantslan, Italy, which is intended to perform a transperineal may be more economical than human assistants for la-prostate biopsy [38, 39]. Using transrectal ultrasound, paroscopic surgery  and laparoscopic camera posi-this system has demonstrated an accuracy of 1±2 mm in tioning was signi®cantly steadier with less inadvertentpositioning the needle. Four video cameras recorded the movements when under robot control . Partin et al.position and con®guration of the patients body and  have also reported their experience of using twointegrated this with a TRUS image of the prostate to robots (laparoscope and retraction) to perform oneallow positioning of the robot and needle. The surgeon surgeon laparoscopy with no human assistance (Fig. 2).chooses the biopsy site from the TRUS images and the AESOP was also used to assist in a variety of lapa-robot obtains the sample. Broad clinical use is unlikely roscopic urologic procedures, including nephrectomy,in the near future due to the expense and set-up time. pyeloplasty, retroperitoneal and pelvic lymph nodeNevertheless, this biopsy robot demonstrated the dissections, and bladder neck suspension .advantages of a robotic system including increasedaccuracy, more reliability as the robot maintained itsposition without any drift, needed less time for theprocedure, and decreased patient discomfort. An important and most recent class of image-guidedsystems concerns the development of basic or moreadvanced magnetic resonance (MR) compatible instru-mentation, such as robotic assistants [10, 23, 29]. AMR-guided system for non-invasive surgery with high-intensity focused ultrasound (HIFU) has been developedby Hynynen et al. . The system was actuated byultrasonic (piezoelectric) motors . A MR compatibleneedle insertion manipulator, also using ultrasonic ac-tuation, was built by Masamune et al. at the MedicalPrecision Engineering laboratory of the University ofTokyo . The system was designed for neurosurgeryapplications and tested on phantoms. A new system is atpresent under development as a collaboration betweenthe Mechanical Engineering Laboratory, AIST-MITI,Japan and the Department of Radiology at the Brigham Fig. 2 Two AESOP robots performing one surgeon laparoscopyand Womens Hospital, Boston, MA. The latest version with no human assistance at the Johns Hopkins Medicalcomprises a 5-dof manipulator and a ``double donut Institutions
292 Advanced laparoscopic instruments have also beendeveloped for increasing maneuvrability and dexterity,improving force feedback, and providing the sense oftouch in laparoscopic procedures. A three-®nger, wristarticulated, 7-dof miniature laparoscopic hand wasdeveloped by DAUM GmbH, Germany to increase``down-the-hole dexterity. Two versions of this devicehave been developed. (Fig. 3): One is cable operatedfrom a special glove-like device worn by the surgeon; theother uses the same miniature hand, but it is activelydriven and controlled by a data glove in a master-slavearchitecture. The former case allows for remote opera-tion of the mini-hand. The system has not yet been Fig. 4 Laparoscopic instrument for remote palpation developed at Harvard Universityclinically tested. In vitro force feedback and dexterityexperiments performed by our urobotics group charac-terized the ®rst-generation EndoHand in comparison to includes 3D video and audio communications, and twocurrent laparoscopic instruments. Although it falls short teleoperated 7-dof manipulators (6-dof arm + 1-dofin both dexterity and tactile feedback, signi®cant gripper). The system is operated from a bilateral hapticpromise is shown in its ability to perform sophisticated interface with force feedback, which has identical ar-manipulation of objects, and to work at a larger range of chitecture with the manipulators (Fig. 5). The systemangles to the target tissue . has been used successfully to allow a remote surgeon to Regarding remote palpation technology, signi®cant perform open surgery with only a surgical assistant inresults have been obtained by the medical robotics group the operating room. Cornum and colleagues have re-at Harvard University. One of a surgeons most im- ported on their experience with the system for in vivoportant tools is a highly developed sense of touch. New porcine nephrectomy and repair of bladder and urethralsurgical techniques, however, separate the surgeons injuries .hands from the surgical site (laparoscopy, robotic ma- A recent generation of the SRI system has been de-nipulation). To compensate for this de®ciency, the re- veloped for laparoscopy by Intuitive Surgical, Inc.,search group at Harvard developed a variety of tactile Mountain View, CA (http://www.intusurg.com/). Thissensors that can be mounted in a probe or surgical in- system, named ``da Vinci, has two primary compo-strument [19±22]. They have also developed tactile dis- nents: the control console operated by the surgeon andplay devices, which recreate the tactile stimulus directly the surgical arm unit, which holds and manipulates de-onto the surgeons ®ngertip (Fig. 4). Results of prelim- tachable surgical instruments. These pencil-sized in-inary in-vitro and animal experiments, demonstrated struments are equipped with a wrist, which providesthat tactile sensing and display can convey important additional dexterity. The system operates through 1 cmsmall-scale shape information from an inaccessible lo- ports. Three surgical arms are maneuvered into placecation to the surgeons ®nger tips [19, 20]. Important and inserted into the patients body. The ®rst arm holdsquestions remain to be addressed in hardware develop- the laparoscope while the other two arms may accom-ment, signal processing, and systems integration areas modate a variety of wrested instruments, such as needle[9, 21, 22]. driver, scissors, dissectors, scalpel, etc . In early A remotely operated system for open surgical pro- January 2000, Intuitive Surgical Inc. announced that bycedures funded by the DARPA (Defense AdvancedProjects Agency) has been developed at the StanfordResearch Institute (SRI), Menlo Park, CA. This systemFig. 3 The DAUM EndoHands: Local and remote Fig. 5 The SRI teleoperation system
293using the da Vinci system, several cardiac centers inEurope have successfully perform totally endoscopiccoronary artery bypass (TECAB) procedures on abeating heart. Figure 6 presents the da Vinci system inthe operating room in Dresden, Germany. This was the ®rst time that cardiac bypass surgerywas performed solely through less than 1-cm incisionswithout cardiopulmonary bypass (CPB). Just 2 monthslater the da Vinci system completed a mitral valve repairsolely through four ports at the Deutsches HerzzentrumCardiac Clinic in Munich, Germany. It is expected thatin the near future this robotic system will extend itsrange of application to other surgical domains, be ap-proved by the FDA, and investigated in the UnitedStates. A competitive system, Zeus, was also designed forlaparoscopic surgery by Computer Motion, Inc., Goleta,CA. It consists of three modi®ed AESOP robots: one forthe laparoscope and two for the instruments, and apurpose-built bilateral haptic interface (Fig. 7). A sur-gical assistant positions the robots and laparoscopicports locally. The surgeon operates the system from theremotely located haptic interface, which handles in asimilar way to the usual laparoscopic instruments. As Fig. 7 Force-feedback experiments with Zeus at the Johns Hop- kins Medical Institutionsthe surgeon moves the haptic handles, the roboticmanipulators in the operating room move in a similarfashion. Concurrently, force-feedback is returned to the In addition, da Vincis instruments present an extrasurgeon on the gripper . The system has not yet re- ``wrist, oering improved ¯exibility.ceived FDA approval, being labeled as an investigation Other commercial robotic systems include the ROBO-device. Compared to da Vinci, the Zeus appears safer DOC System for hip replacement surgery  and theand requires signi®cantly lower preoperative set-up. On NeuroMate robotic arm for stereotactic brain surgery;the other hand, Zeus exhibits lower maneuvrability and both are from Integrated Surgical Systems (http://provides force feedback only on the grippers, whereas da www.robodoc.com/).Vinci has complete feedback on all axes. This is mainly Many experimental surgical systems are under de-due to the fact that Zeus is based on the AESOPSs, velopment in academic institutions around the world. Atwhich have not been designed for master-slave opera- the Carnegie Mellon University and Shadyside Hospitaltions, whereas da Vinci is a purpose-designed system. in Pittsburgh, clinical focus is on orthopedic applica- tions . Representative groups in Europe include the TIMC-IMAG group in Grenoble, France, with a recent project on robotic pericardial punctures [46, 47], and the Charite Hospital in Berlin, Germany, where one focus area is maxiofacial applications . Future directions Robotic applications open wide possibilities of improv- ing upon current surgical techniques as well as allowing the development of new procedures, which could not be performed without the aid of this new class of surgical tools. Among many other advantages, these new instruments potentially improve the precision of ma- nipulation as compared to manual procedures, and provide improved mapping between the patient and his volumetric image as given by sophisticated imaging equipment. This requires the development of miniature, extremely high-dexterity robots that are able to operateFig. 6 The da Vinci Surgical System in the Dresden operating inside the image scanners, such as ``open as well asroom conventional ``closed bore CT and MR imagers.
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