Editorial Original Articles Review Article Case Report Clinical Topics

Vol.49, No.11&12 November/December 2006 Editorial New Surgical Robotics for Clinical Use in Neurosurgery Makoto Hashizume................................................................................................................................................ 333 Original Articles Development of Surgical Manipulator System “HUMAN” for Clinical Neurosurgery Koji Nishizawa, Masakatsu G Fujie, Kazuhiro Hongo, Takeyoshi Dohi, Hiroshi Iseki ............................. 335 An Analysis of Ambulance-transported Cases of Attempted Suicide in 3 Prefectures (Akita, Aomori, and Iwate) in the Northern Tohoku Area in Japan Chikara Yonekawa, Hajime Nakae, Kimitaka Tajimi, Yutaka Motohashi, Yasushi Asari, Shigeatsu Endo, Sergio A Perez Barrero ........................................................................................................... 345 Gender Differences in Symptom Experience at End-of-Life among Elderly Patients Dying at Home with Advanced Cancer in Japan Yoshihisa Hirakawa, Yuichiro Masuda, Masafumi Kuzuya, Akihisa Iguchi, Kazumasa Uemura ................................................................................................................................................ 351 Change of Plasma High Sensitive —C reactive protein levels in climbers Shintaro Suzuki, Yuji Kiuchi, Tetsuya Nemoto, Kenta Kobayashi, Hidekazu Ota ..................................... 358 The Effectiveness of a New Law to Reduce Alcohol-impaired Driving in Japan Takashi Nagata, David Hemenway, Melissa J Perry ........................................................................................ 365 Review Article Child Abuse in Japan: Current problems and future perspectives Makiko Okuyama .................................................................................................................................................. 370 Case Report A Case of Juvenile Temporal Arteritis with Eosinophilia Accompanied with Eosinophilic Vasculitis of Both Lower Legs and Swelling of the Bilateral Inguinal Lymph Nodes Taro Mikami, Seiko Kou, Hiroshi Sakamoto, Kuniaki Bando, Eriko Takebayashi, Hitoshi Komatsu, Youichi Iemoto ...................................................................................................................... 375 Clinical Topics in Japan Symptoms and Treatment of Andropause Shigeo Horie ........................................................................................................................................................... 382 Table of Contents ......................................................................................................................................... 385 Acknowledgement to Reviewers ....................................................................................................... 391 Editorial New Surgical Robotics for Clinical Use in Neurosurgery Makoto Hashizume*1 Minimally invasive surgery (MIS) has become so the system to microsurgery such as neurosurgery explosively popularized throughout the world where there are so many critical conditions to be because there is a significant difference in the resolved. The target area is surrounded by the so postoperative quality of life of the patients with important normal tissue that the access to the MIS from that with open surgery. The patients deeper targeting area is limited. The paper by can enjoy earlier recovery to normal life or nor- Nishizawa et al. in this issue of the journal is mal activity after MIS than after conventional considered significant, as they have developed open surgery. Although there are clear benefits, new surgical robotics with the concept of MIS via MIS has also some disadvantages for the sur- a single insertion part and the prior-confirmation geons. Long instruments placed through fixed based safety control. It required several technical entry points creating a fulcrum effect, with the developments to enable the performance of MIS surgical field viewed on a 2-D screen and with the via a single hole. They made neurosurgery in camera under an assistant’s control, create an one-opening craniotomy under fine and accurate unnatural environment where the surgeon loses control to avoid damage to the surrounding orientation, the eye-hand-target axis, and visual important normal tissues. depth perception. All these obstacles reduce the The issue of interference between mechanical surgeon’s normal dexterity and limit his ability to elements was solved by developing a hollow deal with difficult situations. flexible torque tube with one end segment of the Computer-aided surgery, known as Robotic hollow pipe. This mechanism allows the torque surgery, is proposed to overcome some of the and thrust for rotation and translation move- drawbacks of traditional MIS.1 This technology ments successfully transmitted to the joint at includes master-slave telemanipulator systems. the tip of the manipulator, resulting in the pro- The goals of these surgical systems are to enhance duction of fine and high performance with an manipulation capabilities and to increase the per- accuracy of less than 10␮m. There is no need for formance precision. It provides secure precise concern over collision among the arms holding procedures without any limitation in whichever the manipulators and medical staff. There is a direction the operator desires. The da Vinci is the serious problem in Japan that some parties have most popular surgical robotic system among the discontinued the development of therapeutic commercially available types. More than 430 sets tools. This paper is thus highly evaluated as the of the da Vinci are already installed all over the authors have confirmed the basic function of the world at present. More than 300 sets are installed new robotics in clinical settings. in the United States and more than 50 sets are in The authors evaluated the feasibility of robotics Europe. Robotic surgery provides you with a 3 for clinical use, especially focused on safety con- dimensional view as well as 7 degrees of freedom trol. Actual movement of the manipulator takes of the instruments with an articulate at the tip. It places only after prior calculation of the position is easier for you to perform complicated proce- that would result from the input manipulate. They dures such as ligature or suturing with a needle in a confined space. That is the reason why more *1 Department of Disaster and Emergency Medicine, Graduate than 40 percent of all prostatectomies have been School of Medical Sciences, Kyushu University, Fukuoka performed with the surgical robotic system in the Correspondence to: Makoto Hashizume MD, PhD, FACS, Department United States. of Disaster and Emergency Medicine, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, However, the size of the robotics is so large at Fukuoka-shi, Fukuoka 812-8582, Japan. Tel: 81-92-642-6222, this moment that it has been impossible to apply Fax: 81-92-642-6224, E-mail: [email protected] JMAJ, November/December 2006 — Vol. 49, No. 11 • 12 333 call the safety control system “prior-confirmation the function rather than the structure of the based safety control.” It prevents any movement organ or disease.2 In this concept, termed bio- of the manipulator beyond the predetermined surgery by Randall Wolf, MD, the purpose will range in the field of neurosurgery. These fine and be to change the biological processes of the body accurate control systems as well as safety control though direct modification of cellular, molecular, make it possible to perform MIS via one-opening metabolic, and perhaps even genetic processes. craniotomy in neurosurgery, which was impos- The new robotic system developed by Nishizawa sible in conventional methods. This provides et al. will lead us to the second step towards the possibility of expanding MIS to other fields attaining the goal. of microsurgery. Although the working area is limited to that within 1 cm3 in the present robotic References system, the utility and possibility would be fur- 1. Hashizume M, Tsugawa, K. Robotic surgery and cancer: the ther expanded with the development of technol- present state, problems and future vision. Jpn J Clin Oncol. 2004;34(5):227–237. ogy on molecular image or genetic information. 2. Satava RM. Robotic surgery: from past to future — a personal The goal of future surgery will be to change journey. Surg Clin N Am. 2003;83:1491–1500. 334 JMAJ, November/December 2006 — Vol. 49, No. 11 • 12 Original Article Development of Surgical Manipulator System “HUMAN” for Clinical Neurosurgery JMAJ 49(11 • 12): 335–344, 2006 Koji Nishizawa,*1,2 Masakatsu G Fujie,*3 Kazuhiro Hongo,*4 Takeyoshi Dohi,*5 Hiroshi Iseki*6 Abstract Surgery using manipulator systems for medical treatment has recently attracted considerable attention as a method for realizing certain minimally invasive surgeries. In the field of navel surgery, some manipulator systems for medical treatments are used in Europe and the United States. However, it is inappropriate to apply these systems to neurosurgery because the size of the manipulators is too large, and only one of them can be used in one insertion part. To solve this problem, we developed the manipulator system “HUMAN”, which has an insertion part with a diameter of 10 mm and contains one endoscope and three manipulators. In this paper, we propose the concept for realizing minimally invasive surgery, and discuss the mechanism and control of our developed system based on this concept. A clinical application using this system was successfully performed in August

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