Advances in Telesurgery and Surgical Robotics

Advances in Telesurgery and Surgical Robotics Dr Sanjoy Sanyal MBBS, MS (Surgery), ADPHA, ADHRD Presented at 9 th National Medical Dental Conference in Seychelles, February 2006

Preface (added 2009)
This PPT represents developments in the field during late ‘90s and early 2000s, in:
Stanford University School of Medicine
University of California Berkeley (UCB)
UC San Francisco (UCSF)
Massachusetts Inst. of Technology (MIT)
Escort Heart Institute Research Centre (EHIRC), New Delhi, India
Telesurgery / surgical robotics has advanced considerably now.

The research pioneers
Stanford Research Institute (SRI) @ Stanford University School of Medicine
Human Machine Systems Lab (HMSL) @ MIT
Robotic Intelligent Machines Laboratory (RIML) @ UC Berkeley
Robotic Telesurgical Workstation for Laparoscopy (RTWL) @ UCSF

World’s first telesurgery
September 2001 : Tele- chole
Prof Jacques Marescaux , New York & European Institute of Telesurgery, Strasbourg
Round distance =14,000 km
Round Trip Time = 200 msec; video and hi-speed fibre-optic link
June 2001 : Johns Hopkins University, Baltimore & Rome Policlinico Casilino University
http://news.bbc.co.uk/2/hi/science/nature/1552211.stm

Background
Traditional surgery
Tri-dimensional
Cognitive input
Tactile feedback
Stereoscopic vision with depth perception
Time lag -ve
Telesurgery
Two-dimensional
Cognitive feedback limited
Tactile feedback –ve
Binocular vision without depth perception
Time lag +ve

Definitions
Telepresence surgery : Computerized interface @ surgical workstation ↔ remote operative site; force feedback (haptic)
Cooperative telesurgery : tele-surgeon / local (remote) assistant cooperation
http://www2.telemedtoday.com/articles/telesurgery.shtml
http:// web.mit.edu/hmsl/www/Telesurgery /

Definitions – cont’d
Telerobotics : Remote control with a robotic arm, in conjunction with a laparoscope

Definitions – cont’d
Telementoring : Experienced surgeon acts as tutor / instructor ( preceptor ) for remote surgeon via interactive video
Teleproctoring ( proctor=supervisor of exams ): Documentation of performance for privileging purposes

Technical aspects
Image transmission : T1 transmission (H-320 compression standard)
Fibre-optic cable
Microwave
Satellite
Lag time : should be < 330 ms
Vestibulo-Ocular Reflex disruption (3-D vertigo; Simulator sickness within 20 minutes)
Movement scaling : 1cm -> 1mm
Haptic : Force feedback

Haptic
Force reflection / feedback; Graduated tactile input
– resistance at remote site is transmitted to near site by servo motors @ both sites

Robotic vs. human arm
DOF : Number of ways an arm can move
Human arm : 7-DOF
Human hand : >20-DOF
Robotic arm : Like human hand, arm and moveable elbow - but with a fused wrist
Robotic arm : 4-6 DOF

Telesurg dynamics @ MIT
Surgeon’s fingers placed in rings of instruments
Rings are connected to motors , gears and belts
Precisely translate surgeon’s hand / finger motions into digital signals
Transmitted through computer- telecomm link
To robotic arms @ remote surgical station
Visual input : 2 remote CCD cameras (15 fps each -> 3-D effect ) -> Surgeon’s monitor -> Mirror -> Optical 3-D glasses (stereoscopic vision)
http:// web.mit.edu/hmsl/www/Telesurgery

Telesurg components @ MIT

Surgeon’s master tool handle @ MIT

Master phantom haptic interface arm

Slave phantom haptic interface arm

Tele-operation slave tool

Tele-operational details – Tool

Tele-operational details – Interchangeable tool tips

Experimental task - grasp / transfer

Experimental task - Grasp and transfer with orientation

Experimental task - Clip application

Experimental task – grasper / gripper and shear / scissors

Lap experiment box @ MIT

Lap simulator-1 @ MIT

Lap simulator-2 @ MIT

Dynamics of robotics @ UC
Surgeon – remote location – TV console – set of handheld controls ~ videogame joysticks
Joystick : Pencil-sized; 1 for each hand
Computer : Program translates surgeon’s movements
End-effectors : Robotic instruments enter body to perform actual operation
Early models : 3-fingered hand
Present : Hydraulic-powered, single-digit, 3-4” x ½”, 4-jointed (rotate, swivel, to-fro), 2-pronged end grasper
Anthropomorphic movements
http:// robotics.eecs.berkeley.edu /medical/

Details of robots
‘ Robo-doc ’: 2 robots working in concert
Holding robots
Companion robots / milli-robots / robotic manipulators

Holding robots
Pair of large robotic arms
Hydraulic-actuated
Sits on moveable platform
Driven remotely by surgeon’s joysticks
Performs like a surgeon’s shoulder, allowing positioning of its hydraulic arms

Holding robots – cont’d
Holds 2 nd robot, wheels instruments into position by patient’s side
Guides them through dexterity-requiring surgical procedures (suturing, dissection)
Holds instruments steady while surgeon sutures and ties knots

Companion / Milli-robots / Robotic manipulators
Sterile, disposable, steel, mm-scale, fingertip-sized
Slender, jointed, finger-like tools
Connected by wires and tubes to larger robot
Pair of gripping forceps at one end to carry surgical tools
Contains miniscule video-camera

Companion robot – cont’d
Inserted into body for actual surgical tasks (cutting, suturing) – 10-20 mm incisions
Inserts cameras
Provide tactile feedback though force-deflecting joysticks
Provides 7 DOF

Setup @ UC Berkeley

Equipment @ UCB

Robotic manipulator @ UCB

Mini robot controls @ UCB Roll-pitch-roll ‘wrist’, gripper and multi-fingered manipulators

Robotic endo-manipulator Endo-platform with biopsy forceps

Minute threading

Threaded robotic instruments – knot tying

2-G RTWL @ UCSF In a joint project between RIML of UCB and Department of Surgery of University of California San Francisco ( UCSF ), a Robotic Telesurgical Workstation for Laparoscopy (RTWL) was developed

Lap interface @ UCSF

4-DOF lap haptic interface

Robotic Cardiac Surgery @ EHIRC
Escort Heart Inst. Research Centre in New Delhi, India
Implemented da Vinci Tele-manipulation system
Intuitive Surgical Inc., Mountain View, CA, USA
Computer enhanced system
Surgeon’s console
Cart-mounted robotic manipulators
http://www.ehirc.com/individuals/services/treatment/robotic_surgery.html#

Surgeon’s console @ EHIRC
Display system : 3-D pictures of chest cavity
Surgeon sits at console and gets 3-D view of chest interior
Hand motions are captured, transformed and transmitted to tiny robotic manipulators

Robotic manipulators @ EHIRC
Robot is not autonomous; surgeon-controlled
Hold tiny instruments, which go inside the patient's chest.
Surgeon's hand movements transmitted to these instruments
CABG, mitral valve repair, ASD closure

IMA – LAD CABG

Totally endoscopic CABG
Advantages
Only 3-incisions, each 1 cm on the side and lower chest
Less pain
Faster healing and recovery
Short hospital stay

Technical innovations
Teletactation (Tactile feedback)
CyberGlove ® with CyberTouch
Dextrous master glove
Spatial cognition – Hand assist
Surgical simulations / Virtual reality
Dextrous mini-robots

Teletactation – Tactile feedback
Sensing tactile information through tactile sensors that transmit feel of tissue to surgeon’s finger

CyberTouch – CyberGlove ®
Vibro-tactile, thermal simulators on each finger and palm
Tactile feedback option enables feel of virtual object

CyberGlove ®
Flexible sensors measure position / movement of fingers and wrist

Dextrous master glove
Thumb , index , wrist flexion sensors and wrist rotation sensor
Senses positions of surgeon's fingers/wrist
Used as master to drive slave robotic hand

Spatial cognition – Hand assist in telesurgery Non-dominant hand in-vivo possibly enhances spatial skills through tactile cues, which generate a more accurate 3-D representation of anatomy

Lap chole simulation Simulated fat and fascia Dissected away; cystic duct clipped

Lap chole simulation – cont’d Cystic artery and duct divided successfully in simulated conditions

Karlsruhe Gynec endo surgery simulations

Gynec surgery simulations – cont’d http://www- kismet.iai.fzk.de/VRTRAIN/phD_main.html http://www- kismet.iai.fzk.de/VRTRAIN/GIF/PHD/surgSim.jpg

Dextrous mini robots
1 – Camera attachment
2 – Equipped with a needle for biopsy
3 – Moves around abdominal cavity – spiral pattern – moves without slipping
http://news.bbc.co.uk/1/hi/health/4647258.stm

Summary
Technically demanding, labor intensive, time consuming, expensive research
Learning curve with similar characteristics
Expensive installation, maintenance and infrastructure

Future applications
Emergency trauma care
– 1 st ‘Golden Hour’
Battlefield surgery
Remote area assistance
One-to-many telementoring
Space station surgery

Cutting edge research today, surgical technology tomorrow

Conclusion
“ Science knows no country, because knowledge belongs to humanity, and is the torch which illuminates the world .” Louis Pasteur
“ Don't be afraid to take a big step. You can't cross a chasm in two small jumps .”
David Lloyd George

Advances in Telesurgery and Surgical Robotics

by Sanjoy Sanyal

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Advances in Telesurgery and Surgical Robotics Presentation Transcript