Robotics in neurosurgery

1. ROBOTICS IN NEUROSURGERY
Dr AJAY KUMAR/Dr. SORABH KUMAR GUPTA
Bin kolkata

2. • The world's first surgical robot was the 'Heartthrob', which was developed and
used for the first time in Vancouver, BC, Canada in 1983.
• The very first surgical robot was used in orthopaedic surgical procedure on
March 12, 1983, at the UBC Hospital in Vancouver.
• Other related robotic devices developed at the same time included a surgical
scrub nurse robot, which handed operative instruments on voice command, and
a medical laboratory robotic arm.
• In 1985 a robot, the Unimation Puma 200, was used to place a needle for a brain
biopsy using CT guidance

3. • The first robotized operating microscope for neurosurgical applications was the
MKM system introduced by Zeiss in 1993.
• The system consisted of a robot arm holding different tools, including a
microscope head. The working radius and the dynamics of the MKM were
relatively restricted, so it was mainly applied for procedures of the frontal skull
base.
• In 1995, Giorgi and colleagues attempted another robotized solution for an
operating microscope. They attached a microscope head (Möller- Wedel VM
500) to an industrial robot arm. The microscope could be directed by a joystick
placed where conventional microscope handles are typically located.
• In a second generation of the device, the same authors integrated 3
synchronized charge coupled device cameras around the microscopes front lens.
This allowed tracking of infrared markers in the surgical field.

4. • The NeuroMate was the first neurosurgical robot, commercially available in
1997.
• Originally developed in Grenoble by Alim-Louis-Benabid’s team, it is now owned
by Renishaw.
• With installations in the United States, Europe and Japan, the system has been
used in 8000 stereotactic brain surgeries by 2009.
• IMRIS Inc.'s SYMBIS(TM) Surgical System will be the version of NeuroArm, the
world’s first MRI-compatible surgical robot, developed for world-wide
commercialization.
• Medtech's Rosa is being used by several institutions, including the Cleveland
Clinic in the U.S, and in Canada at Sherbrooke University and the Montreal
Neurological Institute and Hospital in Montreal (MNI/H).
• Between June 2011 and September 2012, over 150 neurosurgical procedures at
the MNI/H have been completed robotized stereotaxy, including in the
placement of depth electrodes in the treatment of epilepsy, selective resections,
and stereotaxic biopsies

6. • Robotics provides mechanical assistance with surgical tasks, contributing greater
precision, accuracy and allowing automation and augment surgical performance,
by steadying a surgeon’s hand or scaling the surgeon’s hand motions.
• work in tandem with human operators to combine advantages of human thinking
with capabilities of robots to provide data, optimize localization on a moving
subject, to operate in difficult positions, or to perform without muscle fatigue.
• Surgical robots require spatial orientation between the robotic manipulators and
the human operator, which can be provided by Virtual Reality environments that
re-create the surgical space and enables surgeons to perform with the advantage
of mechanical assistance but without being alienated from the sights, sounds, and
touch of surgery.

7. • virtual reality (VR) is a computer-generated 3-D environment that provides real-
time interactivity for the user.
• On a computer, VR is experienced primarily through 2 of the 5 senses: sight and
hearing. The simplest form of VR is a 3-D image that can be interactively
explored with a personal computer, usually by manipulating keys or the mouse
so that the content of the image moves in some direction or zooms in or out.
• More sophisticated systems involve the use of a headset as display and haptic
devices.

8. • An absolute virtual environment requires sensory information be processed at
speeds equal to or faster than the human brain can perceive it to eliminate the
delay between sensory input and output.
• For instance, with haptics, the refresh speed must be 500 Hz, or ,2 milliseconds, for
humans to perceive the feedback as continuous. If the refresh speed is any slower,
the operator will be able to feel the pauses between information updates.
• Another challenge is the difficulty of accurately modeling human tissue in VR;
current 3-dimensional models derive the surface texture of the brain and replicate
it, which means that a virtual brain does not quite resemble the real thing
• ongoing challenges of both VR and surgical robotics are the high cost of technology
development, the complexity of re-creating human senses and the limitations of
computer processing

9. • One of the main advantages of computer elaboration, and particularly of a VR
environment, is that it allows anatomic, metabolic, and functional data from
different sources to be combined (or registered together) in the same 3-D space.
• This 3-D VR representation can be examined in detail, shared and discussed with
others, and related precisely to physical reality
• Haptics is an expanding field that focuses on replicating human touch. The
discrepancy between human touch and the sensations provided by haptic
technology is significant, but the field of haptics is constantly incorporating more
complex understandings of human touch into new products.
• Haptics technology is taking advantage of different mechanical and electrical
developments to apply forces, vibrations, motions, or even weak electric shocks to
provide a virtual sense of touch.

10. • Neurosurgery was one of the first organ systems in which robotic surgery was
introduced, due to the high precision that was required to localize and manipulate
within the brain, and the relatively fixed landmarks of the cranial anatomy.
• Robots today have found applications in neurosurgical practice for guiding
instruments along predefined trajectories or providing physical guidance during
stereotactic procedures in brain and in spinal operations.
• Furthermore, robotized C arms are somewhat established as tools in intra
operative fluoroscopy. Experimental applications include positioning of trans
cranial magnet stimulation stimulators and robotized brain retractors.

11. Programmable Universal Machine for Assembly industrial
robot (1985 – Advanced Research & Robotics,Oxford)
• The PUMA was the first time a robot was ever used for neurosurgery. The
surgeon inputted the x-y coordinates on a probe based on a preoperative image
of an intracranial lesion.
• He then used programs which calculated the stereotactic coordinates (frame-
based), which then guided the drilling of the biopsy. This was possible with the
introduction of a Cartesian robot (Compass International, Rochester, MN) which
placed a stereotactic head frame around the patient’s head.
• It then uses fiducial markers to record an image of the patient’s brain. The
device lacked safety features, but the potential of this technology excited
scientists all over. Robotics became increasingly used in frame-based
stereotactic techniques.

12. NeuroMate (1987 - Integrated Surgical Systems, Sacramento,
CA)
• NeuroMate was the first neurorobotic device to be approved by FDA, as well
as the first to be commercially available.
• Preoperative imaging helped the surgeon plan the procedure, and a passive
robotic arm was able to perform limited tasks in over 1000 procedures.
• However, this technology still relied on preoperative images to position the
robot, and was prone to errors when the brain shifted.

13. Minerva (1991 University of Lausanne, Lausanne, Switzerland)
• first system to provide image guidance in real-time, allowing the surgeon
to change the trajectory as the brain moved, resulting in frameless
stereotaxy.
• Important because the structure of the brain and fiducial markers was
assumed to be in the same position before. The position of surgical tools
in relation to intracranial imaging could now be seen.
• Intraoperative imaging can compensate for these shifts and
deformations. This was accomplished by placing a robotic arm inside a
computed tomography (CT) scanner, and improvements in
neuronavigation tools. The implementation of CT greatly improved 3-D
localization, improving accuracy.
• The system also improved safety features which were lacking on the
pervious models. However, the system was still limited because it could
only perform single dimension incursions, and the patient had to be
inside the CT system. As a result, the project was discontinued 2 years
later in 1993

14. Robot-Assisted Microsurgery System (1995 NASA, Washington
• RAMS was the first robotic system that resembled present day robotic surgical
suites. It was the first system that was compatible with magnetic resonance
imaging (MRI), as it was able to filter out electromagnetic fields that distorted
images.
• Intraoperative imaging could now be fully integrated into the operating room
unlike the Minerva. The system was based on master-slave control with 6 degrees
of freedom, allowing 3-D manipulation, and not just limited to stereotactic
procedures.
• Along with adjustable tremor filters and motion scaling (dexterity enhancements),
it was able to improve the precision of the surgeon by 3-folds, and the benefits of
robotic surgery were beginning to be seen. The systems currently on the market
are surprisingly very similar in capabilities to RAMS.

15. The Steady Hand System (1995 –John Hopkins University,
Baltimore)
• Along with RAMS, it defined the new standard of robotic systems in
microsurgery.
• The new wave of systems all enhanced dexterity by filtering out tremor and
featured the master-slave interface.
• The main improvement over RAMS was the fact that this system could also
detect force in the handles. This was important because surgeons had no idea
how hard they were pressing against a surface before.
• Despite its great improvements, it was somewhat surprising that this system
was never used in clinical applications.

16. NeuRobot (Shinshu University School of Medicine, Japan)
• The NeuRobot was the first system that performed tele controlled surgery
through an endoscope.
• The 10-mm endoscope contained twin tissue forceps, a camera, a light source,
and a laser.
• The investigators removed a tumor from a patient, and found the system to be
more accurate and less invasive then traditional methods
• The SpineAssist Robot (Major Surgical Technologies, Haifa, Israel)….. The
sodacan sized SpineAssist Robot was the first FDA approved robotic system for
spinal surgery.
• The device is guided by imaging and is placed directly on the spine for more
accurate tool placement and less invasive surgery.

17. Early History
 1980s-Researches hit a limit for advancing traditional neurosurgery
 The magnification of surgery is too small for human surgeons
 1985-Puma Programmable Universal Machine for Assembly industrial
robot (Advanced Research & Robotics, Oxford, CT)
 The surgeon inputs x-y coordinates and uses programs which calculated
the stereotactic coordinates in frame based surgeries
 1987-Neuromate (Integrated Surgical Systems, Sacramento, CA)
 Uses preoperative images and passive robotic arms

18. History (continued)
 1991-Minerva (University of Lausanne, Lausanne, Switzerland)
Used real time images from a CT scan allowing the surgeon to
change markings during the procedure
 1995-Robot-Assisted Microsurgery System (NASA, Washington DC)
Uses MRI images during surgery in order to give surgeon a clear
picture of the brain
 1995-The Steady Hand System (John Hopkins University, Baltimore,
MD)
Detects the amount of pressure a surgeon uses
 2000s- NeuRobot (Shinshu University School of Medicine, Matsumoto,
Japan)
Endoscopic

19. PUMA
RAMS Neurobot
The Steady Hand SystemNeuromate

20. Spine assist robot

21. Current Technology
• The neurosurgical robot consists of the following components at the most basic
level: robotic arm, feedback sensors, controllers which instructs the robot (end-
effector), a wireless localization system and a data processing center (the brain).
• The end-effector is able to control the robotic arm and use tools such as a probe,
endoscope, or retractor. The tool can usually be manipulated with 6 degree of
freedom.
• Sensors provide the surgeon with the necessary feedback from the surgical site,
which is processed by the computer, returning information such as the location of
a tool within a site.

22. • In the case of robotically-assisted minimally-invasive surgery, instead of directly
moving the instruments, the surgeon uses methods to control the instruments;
either a direct telemanipulator or through computer control.
• A tele manipulator is a remote manipulator that allows the surgeon to perform
normal movements associated with the surgery whilst the robotic arms carry
out those movements using end-effectors and manipulators to perform the
actual surgery on the patient.
• In computer-controlled systems surgeon uses a computer to control robotic
arms and its end-effectors.
• One advantage of using the computerised method is that the surgeon does not
have to be present, but can be anywhere in the world, leading to the possibility
for remote surgery.

23. most important advantages are
• the ability to perform surgery on a smaller scale (microsurgery),
• increased accuracy and precision (stereotactic surgery),
• access to small corridors (minimally invasive surgery),
• ability to process large amounts of data (image-guided surgery),
• the ability for telesurgery, and
• deducing the surgeon’s physiological tremor by 10-folds
• Eliminates fatigue

24. Surgical robots can be classified into three broad categories
on the basis of how the surgeon interacts with them
1. Supervisory-Controlled Systems….procedure is planned
beforehand and the surgeon specifies the motions which the robot goes through.
The robot performs exactly the same motions automatically during the operation,
with the surgeon watching to ensure that there are no errors

25. 2. Telesurgical Systems
• The surgeon directly performs the operation with a haptic interface. Using a
force feedback joystick control, the surgeon carries out motions that the surgical
manipulator replicates.
• The surgeon is able to see inside the cranial framework with real-time
intraoperative imaging

26. 3. Shared-Control System
• The robot undergoes steady-hand manipulations of the surgical instrument while
the surgeon controls the whole procedure. The surgeon and robot are jointly
performing tasks

27. Current State
• 1. Supervisory-Controlled Systems
– Surgeon performs motion before surgery and robot repeats motion
• 2. Telesurgical Systems
– Surgeon uses haptic interface to control robot
• 3. Shared-Control System
– Surgeon and robot share the surgery

28. NeuroArm (2006 – University of Calgary, Alberta, Canada)
• The $30 million NeuroArm project packages all the features that a neurosurgeon
would need to directly manipulate any intra-cranial function
• Designed based on biomimicry, the controller’s hand movements (master) are
replicated by robotic arms (slave) which hold surgical tools.
• The NeuroArm comprises 2 arms, each with 7 degrees of freedom, and a third
arm with 2 cameras which provides the surgeon with a 3-D stereoscopic view.
• NeuroArm is able to carry out microsurgical techniques and soft tissue
manipulations such as biopsy, microdissection, thermocoagulation, blunt
dissection, grasping of tissue, cauterizing, manipulation of a retractor, tool
cleaning, fine suturing, suction, microscissors, needle drivers, and bipolar forceps.
• All the tools are exchanged at the end-effector, which also provides haptic force
feedback to the surgeon.
• The 3rd component of the NeuroArm which makes it unique is the workstation.

29. • to replicate the surgical arena, the workstation provides the surgeon with 3 areas
of feedback: sound, sight, and touch.
• The surgical microscope (binoculars) give stereoscopic views of the brain’s complex
folds, while MRIs and robotic sensors create a 3-dimensional map of brain for the
surgeon on the displays. The microsurgical tools and real-time MRIs increase the
accuracy of the surgeon 1000-folds.
• The workstation includes a computer processor, hand controllers for robotic
arms, joystick controller for cameras and lights, 3 different displays and recorders.
• Video Display presents a 3-D stereoscopic view to give surgeon sense of depth.
• MR Display shows the patients MR scan and tracks the location of the tool in real-
time (pre, post, and intraoperative).
• Control Panel Display shows operation status, force feedback, and control
configuration.

30. • NeuroArm also incorporates safety features such as filtering out hand tremors,
fail safe switches that prevent accidental movements, and force sensors which
provide the sense of touch.
• With a combination of intraoperative MRIs and fiducial markers, the neuroArm
can also program the boundaries of the surgical field during presurgical
planning.
• The materials used to build the components have been thoroughly tested for
MR compatibility. The robotic arms are made out of titanium and polyether
etherketone (plastic polymer) because they have the least image distortion.

31. • NeuroArm evolved as a potential method for improving the integration of
imaging with microsurgery and stereotaxy.
• It has the potential to perform surgery within the bore of a high-field magnet,
which would allow high quality intra-operative imaging without interrupting the
rhythm of surgery.
• Surgeons will be able to see and manipulate imaging data from the remote
workstation of neuroArm without compromising sterility or unduly prolonging
the surgical procedure
• NeuroArm is a teleoperated magnetic resonance compatible image-guided
robot

32. The NeuroArm workstation is remote from the operating room.
(Inset)…the neuroArm robot with bipolar forceps in the right
manipulator and suction in the left.
One of the most unique features of neuroArm is its sensory immersive
workstation. This workstation allows the surgeon to access the surgical site
remotely and provides some of the sensations of surgery through visual, aural,
and haptic technologies

33. Telementoring and Telesurgery (The Socrates System)
• The Socrates system the first
telecollaboration system to be approved
by the FDA, and was first used in Canada
when a neurosurgical center in Halifax,
Nova Scotia tele mentored a smaller
center in Saint John, New Brunswick.
• the mentor had direct control of the
endoscope camera, real-time
neuronavigation data, and two-way video
and audio communications with the
operative site. He was even able to
control the robotic arm, AESOP, if
necessary to give him full control of the
surgical field in the remote site.

34. • It is called telementoring when the local surgical team is performing the
operation with an expert mentor watching through the interface for errors.
• It is called telesurgery when the mentor performs the surgery directly with
a surgical team watching to learn techniques (and as a safety precaution
should mechanisms fail). Although the mentors have full control of the
robotic arm’s movements during telesurgery, the surgeons in the remote
area could override the mentor’s control as a safety feature.

35. • The future of neurosurgery will include a system which can perform a wide
spectrum of neurosurgical procedures, an increasing usage of telementoring
and telesurgery, improvements in artificial intelligence, and virtual reality.
• The future of neurorobotics will see robots with ambidextrous abilities, more
degrees of freedom, kinesthetic feedback, and a more user-friendly interface.
• Greater integration of artificial intelligence and nanotechnology will soon
create surgical procedures that cannot be done without it, revolutionizing
neurosurgical practice

36. THANK YOU