Surgical Robotics: Systems Applications and Visions

This is the first clinical study regarding transoral robotic surgery TORS for sellar tumors that can compress the optic chiasm and result in bitemporal hemianopsia. This minimally invasive technique, performed using the da Vinci Surgical System, seems feasible as an innovative neurosurgical procedure that could minimize or obviate the adverse effects and disadvantages of the classical transsphenoidal route. Finally, while spinal surgery is another potential area for the use of robotics in neurosurgery, its application has remained behind the substantial increase in minimally invasive spinal procedures.

Recent retrospective and prospective studies comparing robotic surgery and conventional surgery have produced uneven results for robot-assisted open surgery. Vitreoretinal surgery poses three fundamental problems for surgeons: First, the surgeon must carefully position the instruments so as to avoid exerting excessive force on trocars entry sites and minimize the risk of iatrogenic damage to the eye.

The second problem regards the difficulty in estimating the distance between the instrument tips and the target tissue under microscopy. Instruments are usually manipulated while observing the shadow they cast and estimating their distance; however, this maneuver is particularly challenging for novice surgeons. Informatics systems have been developed to aid the surgeon in performing microsurgical procedures. Mitchell et al 22 developed a stability system consisting of a palm-held device through which the surgeon and the system cooperate in controlling the instrument via force sensors: One of the areas in vitreoretinal surgery where robotics has gained a place alongside conventional manual techniques is ERM peeling.

Experimental studies have shown that robotic assistance could make performance more accurate. In , Sunshine et al tested a microforce sensor embedded in a handpiece for measuring the forces generated during vitrectomy in rabbits and chorionic membrane peeling in chicken eggs.

The results showed that minimal differences in forces exerted during normal maneuvers and forces slightly above the threshold were sufficient for creating complications. The use of a force sensor with audio feedback showed that the force required for ERM peeling was less than that needed for manual peeling. Systems coupled with OCT technologies can help the surgeon understand where to start peeling the membrane by identifying a larger space between the retina and the ERM.

The use of this technique may eventually obviate the need for injecting indocyanine green dye, which is currently used to identify the internal limiting membrane and may be toxic for the retina.

A future clinical trial with this technique is planned using subretinal injection of tissue plasminogen activator tPA for submacular hemorrhages and stem cells in patients with age-related macular degeneration. Vessel cannulation is necessary in the treatment of vascular disorders such as retinal vein occlusion, arteriovenous malformation, and retinal microaneurysm.

The procedure is more difficult to perform peripherally than in the areas near the optic nerve due to the difference in vessel lumen diameter and the lack of anchorage to underlying structures as is the case at the edge of the optic nerve. Vessels are also larger near the optic nerve and rapidly decrease in size in peripheral tissues. Robotic assistance in technically demanding procedures like microcannulation of retinal veins may be warranted because of the small diameter of the veins and physiological hand tremor.

Robotic assistance might filter out tremor and also help guide surgical movement to positioning a microcannula in the retinal blood vessel and maintain its position for several minutes during which drugs are injected to dissolve the thrombi that have formed. Ueta et al 27 first described in , and then later reported in 28 on a system for microvessel cannulation of porcine eyes.

Comparison of robot-assisted and manual procedures carried out by two expert surgeons showed greater precision in the initial stage of cannulation and particularly in the second stage of maintaining the tip inside the vessel lumen long enough for the drug release. The robot helps to maintain the tip inside the vessel because there is no human tremor effect. On the other hand, in the manual procedure, this is impossible because the amplitude of the normal hand tremor of the surgeon even if this was experienced by an expert surgeon is greater than the vessel diameter and the tip would exit easily from the lumen if a manual procedure is attempted.

In a more recent study published in , Gijbels et al 29 reported successful intravascular drug release in 20 of 25 porcine eyes with the use of robot assistance by a young surgeon. Vascular occlusion was visualized via OCT and fluorangiography. By using the robotic system Preceyes micromanipulator, Preceyes b.

The cannulation was successful for several minutes, being extended in their study up to 20 minutes. Saline was not able to release the occlusion, but using a plasmin derivate was successful with an injection of a few minutes. This suggested that the procedure may be performed in human eyes at a force below human tactile perception. Although much engineering effort has been dedicated to the development of robotic assistance in vitreoretinal surgery, the first in vivo application of robotic assistance in ophthalmology was an operation for pterygium in Recent progress in robotic assistance in minimally invasive laser surgery marked a step forward in increasing the precision, reproducibility, and simple automated maneuvers in surgery for glaucoma, cataracts, and corneal transplant.

Becker et al 32 integrated a robotic assistance system with laser technology for retinal photocoagulation and reported an increase in efficiency and a reduction in error. Yang et al 33 tested the possible application of automated photocoagulation in artificial models. Two vitreoretinal surgeons performed the same procedure manually and with a manipulator attached to an endolaser. In the latter case, the manipulator corrected the errors between the real target and the laser beam directed by the operator.

Surgical Robotics: Systems Applications and Visions - Google Книги

A robotic manipulator for laser tissue repair of the sclera was tested by Garcia et al. The Espresso platform 36 was developed for minor invasive laser surgery with the intent to personalize treatment. The contact force exerted by a device to increase ocular stability of the surgical instrument was directly related to intraocular pressure when preoperative anatomic characteristics are acquired, as typically occurs during tomometry.

Yang et al 37 reported better results with the Micron Robot System for retinal laser photocoagulation than with the manual procedure. The Micron Robot System comprises the handheld manipulator, an optical tracking system, and a real-time controller. The vision system delivers visual feedback to the Micron controller, such as the locations of the laser tip and aiming beam, the 3D surface of a target, and the tracking of the surface.

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It is difficult to imagine where technological advances may lead; however, two future areas of focus for robotics are telemedicine and retinal implantation of stem cells. By coupling telecommunications technologies and robotic assistance, telerobotics could permit remote control of a platform by operators thousands of kilometers away from their patients. In this way, hand movement and vision are transformed into electrodigital signals, as done in teletraining in medical education and remote specialist exams.

Robotic assistance could also benefit cell therapy and regenerative stem cell therapy in ophthalmology. Stem cells possess properties that can be harnessed for the treatment of systemic and eye diseases: Studies have reported on subretinal transplantation of autologous iris pigment epithelium in the treatment of age-related macular degeneration. Iris pigment epithelial cells are amenable to transplantation, easy to harvest, and similar to retinal pigment epithelial cells.

In these and later studies, no rejection reactions were observed. Such cells have also been used as vectors for the release of target molecules 43 , 44 and successfully implanted into the vitreous accumulate at the optic nerve head, suggesting their potential in cell therapy for neurodegenerative diseases such as glaucoma. Their potential in gene therapy will depend on whether they can produce neurotrophic factors for use by the optic nerve and for the evaluation of other cells, including mesenchymal, embryonal, neural, corneal limbar, adipocyte precursors, and Schwann cells.

Robotic surgery could play a key role in cell regeneration, particularly during delicate intraocular procedures to introduce them into the intraretinal or subretinal space, because the risk of iatrogenic injury due to hand tremor or poor visualization would be devastating. In addition to these novel areas, other possible applications are nanotechnologies including nanorobots and nanodevices that can be introduced into the vascular system or anatomic cavities such as the eye or skull.

A review listed the possible therapeutic possibilities of this technology in neurosurgery. Robot-assisted surgery has revolutionized many surgical subspecialties. Overcoming this limitation is particularly important for ocular surgery.

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Since eye surgery is commonly performed under topical or local anesthesia, sudden voluntary or involuntary movement may result in iatrogenic damage to the patient unless the platform is equipped with a safety release mechanism the surgeon can activate. In manually controlled vitreoretinal surgical procedures, the surgeon can quickly remove the surgical instruments from the scleral entry points should the patient move suddenly.

Such safety features would need to be incorporated in the design of robotic platforms. Conventional microsurgery of the eye is carried out under direct visualization of anatomical structures via optic microscopy. While the anterior segment can be visualized directly, the posterior segment, with the retina and vitreous, is visualized via special lenses and visualization systems.

Neither commercially available platforms nor systems currently under development have been able to combine the theoretical advantages of robot-assisted procedures in a single device. Many systems have not yet been validated in vivo. While recent studies have underlined the strengths and weaknesses of the systems tested so far, it will take clinical trials to demonstrate their potential in vivo.

The use of a platform like the da Vinci System, jointly shared by several hospital services, for pterygium surgery in vivo, 31 is a remarkable example of resource sharing among different users. However, this type of robotic surgery, like others, necessitates longer operating time and higher equipment purchase and maintenance costs than conventional pterygium surgery, without any real advantage for the patient. Current limitations notwithstanding, we believe that robot-assisted eye surgery will expand therapeutic options, reduce complication rates, and continue to redefine procedures for treating clinical conditions that are still incurable today.

There are numerous studies documenting computerized systems that filter out hand tremor and optimize speed of movement, control of force, and direction and range of movement. In addition, tissue physiological and chemical data can be detected by sensors embedded in the instrument tip so as to collect direct and indirect signals of tissue stress. Further research is needed to validate robot-assisted procedures.

Once standardized such procedures may be tested in humans.

This study was conducted without the support of any commercial or financial relationships that could be construed as a potential conflict of interest. The authors report no conflicts of interest in this work. National Center for Biotechnology Information , U. Journal List Eye Brain v. Published online Feb 1. Raffaele Nuzzi and Luca Brusasco.

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This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https: By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. Abstract Background Robot-assisted surgery has revolutionized many surgical subspecialties, mainly where procedures have to be performed in confined, difficult to visualize spaces. Evidence acquisition We analyzed the advantages and disadvantages of surgical robots, as well as the present applications and future outlook of robotics in neurosurgery in brain areas related to vision and ophthalmology.

Robotic Surgery: Applications, Limitations, and Impact on Surgical Education

Discussion Limitations to robotic assistance remain, that need to be overcome before it can be more widely applied in ocular surgery. Conclusion There is heightened interest in studies documenting computerized systems that filter out hand tremor and optimize speed of movement, control of force, and direction and range of movement. Introduction Advances in tissue engineering and drug development continue to drive the need for innovative surgical techniques that can be performed in confined, difficult to visualize spaces and that allow the removal of small quantities of material from within the eye.

Potential advantages of surgical robots The extraordinary growth rate in the use of robot-assisted surgery is linked to its advantages over conventional surgical techniques. Open in a separate window.

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Written from a systems-oriented perspective, this volume discusses various applications from surgical disciplines that include orthopedics, urology, cardiac surgery and neurosurgery. Hardcover , pages. To see what your friends thought of this book, please sign up. To ask other readers questions about Surgical Robotics , please sign up. Lists with This Book. This book is not yet featured on Listopia. Aug 26, Gunnar Nelson rated it really liked it. Presents brief overview tie future applications. Jan 16, Jared rated it it was amazing. Got what I expected from it. Sabiston Textbook of Surgery.

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Citation Styles for "Surgical robotics : systems applications and visions"

Da Vinci robot assisted Anderson-Hynes dismembered pyeloplasty: Robotics and the pediatric surgeon. Robotic pediatric cardiac surgery: Application of robotics in congenital cardiac surgery. A prospective analysis of robotic-assisted surgical procedures. Robot-assisted vs laparoscopic adrenalectomy: