1657

Multimedia Contents 63. Medical Robotics Medicaland Computer-Integrated Rob Surgery atF|63 | F Part

Russell H. Taylor, Arianna Menciassi, Gabor Fichtinger, Paolo Fiorini, Paolo Dario

63.1 Core Concepts ...... 1658 The growth of medical robotics since the mid- 63.1.1 Medical Robotics, 1980s has been striking. From a few initial efforts Computer-Integrated Surgery, in stereotactic brain surgery, orthopaedics, endo- and Closed-Loop Interventions... 1658 scopic surgery, microsurgery, and other areas, the 63.1.2 Factors Affecting the Acceptance field has expanded to include commercially mar- of Medical Robots...... 1658 keted, clinically deployed systems, and a robust 63.1.3 Medical Robotics System and exponentially expanding research community. Paradigms: Surgical CAD/CAM This chapter will discuss some major themes and and Surgical Assistance ...... 1660 illustrate them with examples from current and 63.2 Technology...... 1662 past research. Further reading providing a more 63.2.1 Mechanical Design comprehensive review of this rapidly expanding Considerations ...... 1662 field is suggested in Sect. 63.4. 63.2.2 Control Paradigms ...... 1663 Medical robots may be classified in many ways: 63.2.3 Virtual Fixtures by manipulator design (e.g., kinematics, actua- and Human–Machine tion); by level of autonomy (e.g., preprogrammed Cooperative Systems ...... 1664 versus teleoperation versus constrained coopera- 63.2.4 Safety and Sterility ...... 1665 tive control), by targeted anatomy or technique 63.2.5 Imaging and Modelling (e.g., cardiac, intravascular, percutaneous, la- of Patients ...... 1666 paroscopic, microsurgical); or intended operating 63.2.6 Registration ...... 1666 environment (e.g., in-scanner, conventional op- 63.3 Systems, Research Areas, erating room). In this chapter, we have chosen to and Applications ...... 1667 focus on the role of medical robots within the 63.3.1 Nonrobotic Computer-Assisted context of larger computer-integrated systems Surgery: Navigation including presurgical planning, intraoperative and Image Overlay Devices ...... 1667 execution, and postoperative assessment and 63.3.2 Orthopaedic Systems ...... 1667 follow-up. 63.3.3 Percutaneous Needle First, we introduce basic concepts of computer- Placement Systems ...... 1668 integrated surgery, discuss critical factors affecting 63.3.4 Telesurgical Systems...... 1670 the eventual deployment and acceptance of 63.3.5 Microsurgery Systems ...... 1671 medical robots, and introduce the basic system 63.3.6 Endoluminal Robots ...... 1671 paradigms of surgical computer-assisted planning, 63.3.7 Sensorized Instruments execution, monitoring, and assessment (surgical and Haptic Feedback ...... 1672 CAD/CAM) and surgical assistance. In subsequent 63.3.8 Surgical Simulators sections, we provide an overview of the technol- and Telerobotic Systems ogy of medical robot systems and discuss examples for Training...... 1674 of our basic system paradigms, with brief addi- 63.3.9 Other Applications tional discussion topics of remote telesurgery and and Research Areas...... 1675 robotic surgical simulators. We conclude with some 63.4 Conclusion and Future Directions...... 1675 thoughts on future research directions and provide Video-References...... 1676 suggested further reading. References...... 1676 lists some itional imag- 63.1 ), magnetic reso- CT significantly improve sur- to perform procedures by ontinues, add MRI), positron emission tomography to the actual patient. this Typically, is done of Medical Robots ), etc.), lab test results, and other information. Broadly, the advantages offered by medical robots registered PET 63.1.2 Factors Affecting the Acceptance Medical robotics isresearch field. ultimately Although anrobotic the systems application-driven development requires significant of innovation andlead medical can to very real, fundamentalmedical advances robots in technology, mustcant provide advantages measurable if and theydeployed. signifi- are The to situation be isthese complicated widely advantages by accepted are the often and difficult fact toan that measure, extended can take periodimportance to to assess, different and groups. may Table be of varying mation about theimages patient, which (computed can tomographynance include ( imaging medical ( ( of the more important factorsplating that the development researchers of contem- a newshould medical consider robot in system assessing their proposed approach. may be grouped intotential of three a areas. medical Thegeons’ robot first to technical is capability the po- This patient-specific information is combinedtistical information with about sta- human anatomy,and physiology, disease to produce aresentation comprehensive computer of rep- the patient,produce an which optimized interventional can plan. In then theing operat- room, be the used preoperative patient model to be and plan must ing or otherof sensing the is procedure, used toverify to update that monitor the the the patientfully model, progress executed. planned After and the procedure procedure to isimaging, has complete, modeling, further been and success- computer-assistedis assessment performed for patientquent interventions, follow-up if and any should toall be plan the required. Further, patient-specific subse- dataning, generated execution, during and the follow-up plan- phasesThese can data be can subsequently retained. be analyzedimprove the statistically rules to and methodscedures. used to plan future pro- by identifying corresponding landmarkson or the structures preoperativemeans model of and additional imaging (x-ray, the ultrasound,by video), patient, the either by userobot itself. of If the a patient’sthe anatomy tracked model has and pointing changed, then plan device,planned are procedure updated or is appropriately, carried and by outrobot. the with the As assistance the of the intervention c as Action ation, quality Statistical analysis oduction, explor Patient-specific evaluation Patient-specific ). The process starts with infor- computer-integrated surgery CIS Model Plan illustrates this view of computer- 63.1 Computer-Integrated Surgery, and Closed-Loop Interventions Figure Fundamental information flow in computer-integrated important to health careufacturing is as to industrial computer-integrated production. man- 63.1.1 Medical Robotics, Medical robots have atally change similar surgery potential and interventional to medicineof fundamen- as part a broader,exploits information-intensive the environment complementary that strengthscomputer-based technology. The of robots may humans be thought and of as information-driven surgical toolsman that surgeons enable to hu- treatsafety, individual improved patients efficacy, with and greater would reduced otherwise morbidity be than possible.and Further, information the consistency infrastructurecal robotic associated and computer-assisted with surgery systemsthe medi- have potential to make control, and laboratory processes. Although robots have often been first introduced tocrete processes automate such or as improve welding dis- or or test to probe placement providecannot access safely go, to their greater environments long-termten impact where come has of- indirectly humans asintegration of essential entire enablers production or of service computer processes. A fundamental property of robotic systemsity is their to abil- couplein complex information order to to physicalplace, perform action supplement, a or usefulhas had transcend task. a profound This human influence on many abilityety, performance fields including of industrial to pr our soci- re- 63.1 Core Concepts integrated surgery ( Robots at Work information records, etc.) records, genetics, text genetics, Patient-specific statistics, rules) statistics, (anatomic atlases, (anatomic (images, lab results, lab (images, General information General

Information

Part F Fig. 63.1 surgery

Part F | 63.1 1658 Medical Robotics and Computer-Integrated Surgery 63.1 Core Concepts 1659

Table 63.1 Assessment factors for medical robots or computer-integrated surgery systems (after [63.1]) Assessment Important Assessment Summary of key leverage factor to whom method New treatment Clinical Clinical and trials Transcend human sensory-motor limits (e.g., in options researchers, pa- preclinical microsurgery). Enable less invasive procedures tients with real-time image feedback (e.g., fluoro- scopic or MRI-guided liver or prostate therapy). 63.1 | F Part Speed up clinical research through greater con- sistency and data gathering Quality Surgeons, patients Clinician judg- Significantly improve the quality of surgical ment; revision technique (e.g., in microvascular anastomosis), rates thus improving results and reducing the need for revision surgery Time and cost Surgeons, hospi- Hours, hospital Speed operating room (OR) time for some in- tals, insurers charges terventions. Reduce costs from healing time and revision surgery. Provide effective intervention to treat patient condition Less invasiveness Surgeons, patients Qualitative judg- Provide crucial information and feedback ment; recovery needed to reduce the invasiveness of surgical times procedures, thus reducing infection risk, recov- ery times, and costs (e.g., percutaneous spine surgery) Safety Surgeons, patients Complication and Reduce surgical complications and errors, revision surgery again lowering costs, improving outcomes and rates shortening hospital stays (e.g., robotic total hip replacement (THR), steady-hand brain surgery) Real-time feed- Surgeons Qualitative assess- Integrate preoperative models and intraopera- back ment, quantitative tive images to give surgeon timely and accurate comparison of information about the patient and intervention plan to obser- (e.g., fluoroscopic x-rays without surgeon expo- vation, revision sure, percutaneous therapy in conventional MRI surgery rates scanners). Assure that the planned intervention has in fact been accomplished Accuracy or pre- Surgeons Quantitative com- Significantly improve the accuracy of therapy cision parison of plan to dose pattern delivery and tissue manipulation actual tasks (e.g., solid organ therapy, microsurgery, robotic bone machining) Enhanced doc- Surgeons, clinical Databases, Exploit CIS systems’ ability to log more varied umentation and researchers anatomical at- and detailed information about each surgical follow-up lases, images, and case than is practical in conventional manual clinical observa- surgery. Over time, this ability, coupled with tions CIS systems’ consistency, has the potential to significantly improve surgical practice and shorten research trials exploiting the complementary strengths of humans and patient’s body. These capabilities can both enhance the robots summarized in Table 63.2. Medical robots can ability of an average surgeon to perform procedures that be constructed to be more precise and geometrically only a few exceptionally gifted surgeons can perform accurate than an unaided human. They can operate in unassisted and can also make it possible to perform hostile radiological environments and can provide great interventions that would otherwise be completely infea- dexterity for minimally invasive procedures inside the sible. ] 2 surgeon process by enhanc- /CAM . cooperative control interface. CAD ). ]) 1 , manipulate surgical instruments under 63.3.3 hands-on ) and image-guided placement of therapy surgical assistants 63.3.2 Surgery is often highly interactive; many decisions Broadly, robotic surgical assistants may be broken Limitations Prone to fatigue and inattention Limited fine motion control dueLimited to manipulation tremor ability and dexterityscale outside natural Cannot see through tissue Bulky end-effectors (hands) Limited geometric accuracy Hard to keep sterile Affected by radiation, infection Poor judgment Hard to adapt to newLimited situations dexterity Limited hand–eye coordination Limited haptic sensing (today) Limited ability to integrate and interpret complex information ing the surgeon’s ability tospecific execute role surgical plans. played The on by the the application, but robotthe current depends systems geometric tend somewhat accuracy to ofto exploit the function robot concurrently and/ordevices. with its Typical x-ray ability examples ordelivery include other robots imaging radiation such as therapy (Accuray, Accuray’s Inc., CyberKnife Sunnyvale, [63. orthopaedic CA), joint shaping reconstructions of (discussedSect. bone further in in needles (Sect. The primary valueovercome of some these of systemslimitations is of the the that surgeon. perception Examples theyto include and the can manipulate ability manipulation surgicalprecision instruments by eliminating with hand tremor, superhuman form the highly ability dexterous to tasks inside per- the patient’sthe body, or ability to perform surgeryically on a remote patient from who is theis phys- surgeon. still Although a setup serious time concern with most surgeon extender can be critical in this are made by the surgeonecuted in immediately, usually the with operating direct room visual andfeedback. or ex- Generally, haptic the goal of surgicalto robotics replace is the not surgeon so muchability as to to treat the improve his patient. or Thecontrolled her robot surgical is tool thus in a which computer- often control shared of in the one robot way is surgeon or and a another computer. between We thus the often human speakrobots of as medical into two subcategories.extender robots The firstthe direct control category, of the surgeon,operation usually through a or tele- CIS sur- both virtual for ev- morbid- or scale) CAM / human promote consistency CAD no-fly zones promote surgical safety systems to information inherently available . Just as in manufacturing, robots ) to prevent surgical instruments assessments of serious surgical in- , emphasizing the analogy to manu- CIS 63.2.3 /CAM Complementary strengths of human surgeons and robots (after [63. /CAM Excellent geometric accuracy Untiring and stable Immune to ionizing radiation Can be designed to operatemotion at and many payload different scales of Able to integrate multiple sourcessensor of data numerical and Strengths Excellent judgment Excellent hand–eye coordination Excellent dexterity (at natural Able to integrate and actsources on multiple information Easily trained Versatile and able to improvise CAD Paradigms: Surgical and Surgical Assistance (Sect. capturing detailed online information CAD A third advantage is the inherent ability of med- A second, closely related capability is the poten- Robots Humans while ery procedure. Consistentand execution tensioning (e.g., of innents spacing sutures in or jointquality reconstructions) in factor. is placing If itselfflight of saved an data compo- important and recorder routinely analyzed, the with a medical robot can be used both in ity and mortality cidents and, potentially,ining in statistical many analyses casesFurthermore, exam- such to data developfor surgical can better simulators, provide surgical asveloping well valuable skill plans. as input assessment asurgeons. and database for certification de- tools for fixtures from causing unintentionaltures. damage Furthermore, to the delicatewithin integration struc- of the medical information robots infrastructure of a larger by improving a surgeon’s technical performance andmeans by of active assists such as system can provide theproved surgeon monitoring with and significantly onlinefurther im- decision improving safety. supports, thus ical robots and tial of medical robots to gical facturing 63.1.3 Medical Robotics System We call theregistration, execution, monitoring, process and assessment of computer-assisted planning, Table 63.2 Robots at Work

Part F

Part F | 63.1 1660 Medical Robotics and Computer-Integrated Surgery 63.1 Core Concepts 1661

Fig. 63.2 The da Vinci telesurgical robot (after [63.3]) extends a sur- geon’s capabilities by providing the immediacy and dexterity of open surgery in a minimally invasive surgi- cal environment (photos courtesy of

Intuitive Surgical, Sunnyvale) 63.1 | F Part

Stereo video

Instrument manipulators Surgeon interface manipulators Motion controller systems, the greater ease of manipulation that such sys- Johns Hopkins University (JHU) Steady Hand micro- tems offer has the potential to reduce operative times. surgery robot [63.4–6] shown in Fig. 63.3 and discussed One widely deployed example of a surgeon extender is in Sect. 63.3, the Rio orthopaedic robot [63.8](Mako thedaVincisystem[63.3] (Intuitive Surgical Systems, Surgical Systems, Ft. Lauderdale, Florida), the DLR Sunnyvale, CA) shown in Fig. 63.2. Other examples Miro system [63.9], the Surgica Robotica’s Sergenius (among many) incude the Sensei catheter system [63.7] system (Surgica Robotica, Udine), and Titan Medical’s (Hansen Medical Systems, Mountain View, CA.). the Amadeus System (Titan Medical, Toronto, Canada).

a) b) Stereo display Video microscope ftool

Cv ( fhandle – Cscale ftool) fhandle

∙ xcmd

Robot interface

Force and OCT sensing tools Robot c)

Fig.63.3a-c The Johns Hopkins Steady Hand microsurgical robot (after [63.4–6]) extends a surgeon’s capabilities by providing the ability to manipulate surgical instruments with very high precision while still exploiting the surgeon’s natural hand–eye coordination. (a) The basic paradigm of hands-on compliant guiding. The commanded velocity of the robot is proportional to a scaled difference between the forces exerted by the surgeon on the tool handle and (optionally) sensed tool-to-tissue forces. (b) Current laboratory setup, showing the robot, stereo video microscope, stereo display with information overlays, display console for optical coherence tomography (OCT) system, and a sensorized tool. (c) An earlier recent version of the Steady Hand robot currently being used for experiments in microcannulation of 100 m blood vessels , 21 ], and /CAM ]used 18 10 point co- CAD ] were essen- 22 RCM ] frequently have , 21 20 surgical , , 3 ], as well as by nu- remote center of mo- 3 17 ]and thus supports robot- 17 , are complementary concepts. ]. Finally, a third approach uses an 26 63.3. – 24 ) distal to the robot’s structure. In surgery, RCM ( surgical assistance However, the specialized requirements of surgical It is important to realize that incides with theThis entry approach point has intodeveloped the da been patient’s Vinci used body. robot by [63. the commercially merous research groups, usingdesigns a [63. variety of kinematic assisted interventions that do not require a pivot point, 23] as wellapproach as mechanically several research constrainssurgical systems. the tool The motion totion second rotate of about the a 63.2.1 Mechanical Design Considerations Many early medical robots [63. tially modified industrialmany robots. advantages, including This lowand approach cost, shortened has high development reliability, times.cations If are suitable made modifi- systems to can ensure be very safetythey successful can and clinically also sterility, [63. beresearch such invaluable use. for rapid prototyping and applications have tendedized to designs. encourage For morepercutaneous example, special- laparoscopic needle surgery placementinvolve and the procedures passage typically about or a manipulation commonThere entry of are point instruments three into basicproach the design uses patient’s approaches. body. a Theto first passive pivot ap- wrist about to thein allow insertion the point the commercial and instrument has Aesop been and used Zeus robots [63. the robot is positioned so that the active external wrist9 [63. on soft tissues requiresponsiveness. compactness, These systems dexterity, [63. and re- relatively high speed,drivable low mechanisms. stiffness, and highly back- tems is providing the required assistance withoutan posing undue burden onof the control surgeon’s attention. interfaces A arehead variety common, tracking, including joysticks, voicetracking recognition of systems, the andexample, surgeon the visual and Aesop endoscope surgical positionerboth [63. instruments, a foot-actuated for joystick andrecognition a very system. effective voice Again,cussed further in Sect. examples are dis- and They are nothave at aspects of all both. incompatible, and many systems ) ]); ]); 3 15 MIS , 14 the tasks all telesurgical sys- ] frequently have c) d) 20 – snake five-degree-of-freedom 17 ) d ( 4.2 mm ]) for microsurgery in deep auxiliary surgical support ]); 13 12 f) e) b) JHU/Columbia ]) concentric tube robot (after [63. Two-handed manipulation system for use ) 16 ) e c ( ( ]); , generally work alongside the surgeon and per- 11 Dexterity enhancement inside a patient’s body: A second category, 63.2 Technology The mechanical design of a surgicalcially robot on depends cru- its intendedwith application. For high example, robots precision,dexterity stiffness are often and veryshaping (possibly) suitable or for limited stereotactic orthopaedic needle bone robots for placement, these applications and [63. medical high gear ratios and consequently,high low back-drivability, stiffness, androbots for low complex, minimally speed. invasive surgery On ( the other hand, robots form such routine taskstioning, as or tissue endoscope retraction, holding. limb Oneof posi- primary such advantage systems isber of their people potential required to inthat the reduce advantage operating the room, can num- although routinely only performed be by an achievedautomated. Other assisting advantages if can individual include can improved task be performance (e.g., a steadier(e.g., endoscopic elimination view), of excessive safety retraction forces),ply or sim- giving the surgeon athe greater procedure. feeling One of of control the over key challenges in these sys- Robots at Work The end-effectors of the The Intuitive da Vinci Si system and wrist with a typical surgi- Columbia/Vanderbilt high dexterity system for single port ac-

) ) )

a) f a b Part F cal instrument (Photos courtesy of Intuitive Surgical) (after [63. tem (after [63. ( in endogastric surgery (after3 mm [63. wrist and gripper (after [63. and narrow spaces; Fig.63.4a–f cess surgery (after [63. ( (

Part F | 63.2 1662 Medical Robotics and Computer-Integrated Surgery 63.2 Technology 1663 potentially extending robotic surgery to other field of be smaller and that relatively nonintrusive means for surgery. mounting it must be developed. The emergence of minimally invasive surgery has Finally, robotic systems intended for use in spe- created a need for robotic systems that can provide cific imaging environments pose additional design chal- high degrees of dexterity in very constrained spaces lenges. First, there is the geometric constraint that the inside the patient’s body, and at smaller and smaller robot (or at least its end-effector) must fit within the scales. Figure 63.4 shows several typical examples of scanner along with the patient. Second, the robot’s me- atF|63.2 | F Part current approaches. One common response has been to chanical structure and actuators must not interfere with develop cable-actuated wrists [63.3]. However, a num- the image formation process. In the case of x-ray and ber of investigators have investigated other approaches, CT, satisfying these constraints is relatively straight- including bending structural elements [63.11], shape- forward. The constraints for MRI are more challeng- memory alloy actuators [63.27, 28], microhydraulic ing [63.48]. systems [63.29], and electroactive polymers [63.30]. Similarly, the problem of providing access to surgical 63.2.2 Control Paradigms sites inside the body has led several groups to develop semiautonomously moving robots for epicardial [63.31] Surgical robots assist surgeons in treating patients by or endoluminal applications [63.32, 33]. moving surgical instruments, sensors, or other devices Two growing trends MIS are natural orifice trans- in relation to the patient. Generally, these motions are luminal surgery (NOTES) [63.34, 35] and single port controlled by the surgeon in one of three ways: laparoscopy (SPL) [63.36]: the idea is to get access to  Preprogrammed, semi-autonomous motion: The de- the abdominal cavity by using natural orifices and in- sired behavior of the robot’s tools is specified inter- ternal incisions (in NOTES) or existing human scars actively by the surgeon, usually based on medical (e.g., the navel, in SPL). From the mechanical design images. The computer fills in the details and ob- viewpoint, there is the need to develop deployable sur- tains the surgeon’s concurrence before the robot gical instruments or accessorised endoscopes and to is moved. Examples include the selection of nee- combine flexibility (to reach the target) and stability dle target and insertion points for percutaneous of the platform (to achieve precision). Clashing of in- therapy and tool cutter paths for orthopaedic bone struments and difficulty in triangulation are the main machining. limitations which companies and research groups try to  Teleoperator control: The surgeon specifies the de- approach [63.37, 38]. sired motions directly through a separate human The problem of distal operation, already present interface device and the robot moves immedi- in MIS, is becoming more dramatic in NOTES and ately. Examples include common telesurgery sys- SPL and several solutions for helping surgical tasks re- tems such as the da Vinci [63.3]. Although physical quiring triangulation have been developed by different master manipulators are the most common input de- research groups [63.39]. They are based on magnetic vices, other human interfaces are also used, notably fields which can generate an internal force without con- voice control [63.21]. straining the internal tool to the access port [63.40–42].  Hands-on compliant control: The surgeon grasps Another significant development in recent years the surgical tool held by the robot or a control has been the emergence and widespread deployment handle on the robot’s end-effector. A force sensor of three-dimensional (3-D) printing and other rapid senses the direction that the surgeon wishes to move prototyping technologies for clinically usable medical the tool and the computer moves the robot to com- devices and medical robot components, as well as for ply. Early experiences with Robodoc [63.17]and construction of realistic patient-specific models [63.43, other surgical robots [63.25] showed that surgeons 44]. This trend has promoted very rapid progress in found this form of control to be very convenient and medical robot design and will be increasingly important natural for surgical tasks. Subsequently, a number of in coming years. groups have exploited this idea for precise surgical Although most surgical robots are mounted to the tasks, notably the JHU Steady Hand microsurgical surgical table, to the operating room ceiling, or to the robot [63.4] shown in Fig. 63.3, the Rio orthopaedic floor, there has been growing interest in developing robot [63.8] (Mako Surgical Systems, Ft. Laud- systems that directly attach to the patient [63.45, 46], erdale, Florida) and the Imperial College Acrobot and clinically deployed examples exist [63.47]. The orthopaedic system [63.49] shown in Fig. 63.5c,d. main advantage of this approach is that the relative position of the robot and patient is unaffected if the These control modes are not mutually exclusive and patient moves. The challenges are that the robot must are frequently mixed. For example, the Robodoc sys- no- The ) d , c et al. (af- ( . Davies 63.2.3 in which the robot ]. Although direct mo- Clinically deployed ]) represents the first 5 , 18 4 , i. e., the ability to move an , ]) uses hands-on compliant 17 49 The Robodoc system (af- ) b , a ter [63. robots for orthopaedic( surgery. guiding together with a formfixtures of to virtual prepare the femurfor and knee tibia replacement surgery ter [63. Acrobot system of Fig.63.5a–d clinically applied robot forreconstruction joint surgery and hasused been for both primaryhip and replacement revision surgery asknee well replacement as surgery. transparency shared control modes and Human–Machine Cooperative Systems , in which the robot’s tool is constrained from 63.5c,d represents a successful clinical applica- Teleoperation and hands-on control are both com- d) tion scaling is not possible,in the fact the that direction thelimitation tool that moves relatively the unimportanta surgeon when surgical pulls microscope. working The it biggest with hands-on makes drawbacks control are this that isdegree inherently of remoteness incompatible between with thegical surgeon any tool and and the that sur- it iscontrol not of practical to instruments provide with hands-on distal dexterity. patible with controller constrains or augments the motionsby specified the surgeon, as discussed in Sect. gical systems, sincecan there be easier is to introduce less intoThey existing hardware, exploit surgical a settings. and surgeon’s natural eye–hand they coordination in an intuitively appealing way, andto they can provide be force adapted scaling [63. 63.2.3 Virtual Fixtures Although one goal ofcontrol both is teleoperation often and hands-on instrument with the freedom andexpect dexterity he/she with might a handheldis tool, actually the controlling the fact robot’smore that motion possibilities. The a creates simplest many is computer afly safety barrier zone or entering certain portionsphisticated versions of include virtual its springs, dampers, or workspace.complex kinematic More constraints that so- help aa surgeon tool, align maintain aanatomical desired relationship. force, The or Acrobot system maintainFig. shown a in desired , ap- 51 ) or three- /CAM 2-D c) CAD ] used both cooper- 25 ] or remote surgery [63. ] uses preprogrammed virtual 50 49 , ) derived from the implant shape 26 , otion of robotic devices with some ) medical images. However, they can 21 , 63.1.3 ] uses hands-on control to position the LARS robot. [63. 3 3-D 18 , [63. 17 MIS Hands-on control combines the precision, strength, Teleoperated control provides the greatest versatil- Each mode has advantages and limitations, de- ]. It permits motions to be scaled, and (in some b) a) 52 research systems) facilitatesmaster haptic feedback and between slavecomplexity, cost, systems. and The disruptionroom main to work flow standard associated drawbacks with operating having are and separate slave master robots. and tremor-free m of the immediacyThese of systems freehand tend surgical to manipulation. be less expensive than telesur- dimensional ( also provide useful complexsory motions feedback combining in sen- Examples might teleoperated include or passinga hands-on a needle suture systems. into ortioned a inserting the vessel tip. On after thetion the other of hand, surgeon motions interactive has specifica- basedof preposi- on deforming anatomy real-time would visual be very appreciation difficult. ity for interactive surgery applications,ous such as dexter- plications where the planning uses two- ( tem [63. robot close toprogrammed the motions patient’s for femurthe boneJHU IBM/ or machining. knee Similarly, ative and and telerobotic pre- control modes.controlled The Acrobot [63. cooperatively and its planned position relative to medical images. pending on thecomplex task. paths Preprogrammed to motions be permit specifications of generated the specific from task to relatively beare performed. simple most They often encountered in surgical fixtures (Sect. Robots at Work

Part F

Part F | 63.2 1664 Medical Robotics and Computer-Integrated Surgery 63.2 Technology 1665 tion of the concept, which has many names, of which Situation assessment virtual fixtures seems to be the most popular [63.53, Task strategy and decisions 54]. A number of groups are exploring extensions of Sensory-motor coordination the concept to active cooperative control, in which the surgeon and robot share or trade off control of the ● Display robot during a surgical task or subtask. As the ability of computers to model and follow along surgical tasks ● Sensors atF|63.2 | F Part improves, these modes will become more and more im- ● Online references and decision report portant in surgical assistant applications. Figure 63.6 ● Manipulation illustrates the overall concept of human–machine co- enhancement Atlases operative systems in surgery, and Fig. 63.7 illustrates ● Cooperative control and macros the use of registered anatomical models to generate HMCS system Libraries constraint-based virtual fixtures. These approaches are equally valid whether the surgeon interacts with the sys- Fig. 63.6 Human–machine cooperative systems (HMCS)in tem through classical teleoperation or through hands-on surgery compliant control. See also Chap. 43. Both teleoperation and hands-on control are like- wise used in human–machine cooperative systems for Registered model Constraint rehabilitation and disability assistance systems. Con- generation strained hands-on systems offer special importance for rehabilitation applications and for helping people with movement disorders. Similarly, teleoperation and intel- 2 Path min||W (Jtip Δq –ΔPdes)|| ligent task following and control are likely to be vital Δq for further advances in assistive systems for people with Tool tip guidance ΔPdes Subject to virtual fixture

severe physical disabilities. See Chap. 64 for a further interface Robot GΔq≥g discussion of human–machine cooperation in assistive systems. State 63.2.4 Safety and Sterility Fig. 63.7 Human–machine cooperative manipulation using con- Medical robots are safety-critical systems, and safety straint-based virtual fixtures, in which patient-specific constraints should be considered from the very beginning of the are derived from registered anatomical models (after [63.53]) design process [63.55, 56]. Although there is some difference in detail, government regulatory bodies re- rays (for disposable tools), autoclaving, soaking or gas quire a careful and rigorous development process with sterilization, and the use of sterile drapes to cover un- extensive documentation at all stages of design, im- sterile components. Soaking or gas sterilization are less plementation, testing, manufacturing, and field support. likely to damage robot components, but very rigor- Generally, systems should have extensive redundancy ous cleaning is required to prevent extraneous foreign built into hardware and control software, with multiple matter from shielding microbes from the sterilizing consistency conditions constantly enforced. The basic agent. consideration is that no single point of failure should Careful attention to higher levels of application cause the robot to go out of control or to injure a pa- protocols is also essential. Just like any other tool, sur- tient. Although there is some difference of opinion as to gical robots must be used correctly by surgeons, and the best way to make trade-offs, medical manipulators careful training is essential for safe practice. Surgeons are usually equipped with redundant position encoders must understand both the capabilities and limitations and ways to mechanically limit the speed and/or force of the robot and of the surgical process as well, since that the robot can exert. If a consistency check fail- safety is a systemic property. This adds new require- ure is detected, two common approaches are to freeze ments to training programs, which must include robotic robot motion or to cause the manipulator to go limp. capabilities and nontechnical skills (Sect. 63.3.8). In Which is better depends strongly on the particular ap- surgical CAD/CAM applications, the surgeon must un- plication. derstand how the robot will execute the plan and be Sterilizability and biocompatibility are also crucial able to verify that the plan is being followed. If the considerations. Again, the details are application depen- surgeon is interactively commanding the robot, it is dent. Common sterilization methods include gamma essential that the robot interpret these commands cor- / ], 60  . ], we 59 AB [63. T represents .Thereis AB p McKay /CAM and CAD . Then the process of ]. Following [63. B Besl ng, gesture recognition, whose coordinates can be . Typical features can in- . The most common for / 59 ; B / , A & r  AB 58 . p .& and Ref and AB C AB is assumed to be a rigid transfor- r T A A A T /; / / & v ; B A z z B /: AB ; ;  63.4. A B . Œ& A R y v y represents a rotation and . ; ; AB D B A T AB / x x . . r A AB T v R D D . D distance r r A B B AB D v v One common class of methods is based on the iter- Real-time data fusion for such purposesmodels as from updating intraoperative images Methods for human–machinecluding communication, real-time in- visualization of dataural models, language nat- understandi etc. Methods for characterizingmodels, uncertainties and systems in and for data, in using developing robust this planning information and control methods. An in-depth examination of this research is beyond v T AB where an extensive literature oncoordinate systems techniques associated with for robots, coregistering sensors,ages, im- and the patient [63. briefly summarize the main concepts here. Supposewe that have coordinates clude artificial fiducial objects (pins, implanted spheres, rods, etc.) or anatomicalmarks, ridge features curves, such or surfaces. as point land- ated closest-point algorithm of medical robotics involve finding a setgeometric of features corresponding the scope of thisof article. these topics A may morereading be in complete found Sect. discussion in the suggested further Generally,    63.2.6 Registration Geometric relationships arerobotics, fundamental especially in in medical surgical a translation, but nonrigiding transformations increasingly are common. becom- There are hundredsods of meth- for computing such that determined in both coordinate systems anda then transformation finding that minimizes somed distance function corresponding to comparabledinate locations systems in Ref two coor- registration is simply that of finding a function mation of the form ) of patient 63.2.3 of images (Sect. enhance physical reality ]. Although care- virtual reality virtual fixtures and computational models to the Methods for characterizing treatment plansdividual and task in- steps suchtion, or as limb manipulation suturing, for needle purposes ofmonitoring, inser- planning, control, and intelligent assistance Optimization methods for treatmentinteractive control planning of and systems Methods for registering the Medical imageto segmentation construct and andmodels update image patient-specific fusion anatomic Biomechanical propertyelling measurement for and analyzingmations mod- and and predicting functionalplanning, tissue factors control, and affecting defor- rehabilitation surgical an actual patient Finally, it is important to remember that a well-      63.2.5 Imaging and Modelling of Patients As the capabilities of medical robotsthe continue to evolve, use ofchanging patient-specific computer anatomy will systems become increas- ingly to important. There model is a dynamically community robust addressing and a diverse research verytopics, broad including range the of creationels research of from medical patient-specific images, mod- techniques formodels updating based these upon real-timedata, and image the use and of these otheritoring models for sensor of planning and surgical mon- procedures.research topics Some include the of following: the pertinent rectly. Similarly, it isof essential its that task the environment correspondtual robot’s correctly model to environment. the The ac- necessary availability to of the tasktion development models of of autonomous is roboticification execu- gestures of as taskful correctness well design [63.57 as andinate the implementation the formal can likelihoodmanipulator, ver- practically of this elim- a willbadly runaway do registered condition little totrol by good the the the if patient procedure. thethere images If must be robot used the well-documented and planned to is robot procedures for fails con- recovery for (and anymanually). possibly reason, continuing the procedure designed robot system can actually safety. The robot istary not lapses of subject attention. Its to motionsand can fatigue be there or more is precise momen- lessdamage chance some delicate that structure. a Inbe slip fact, programmed to the of provide system the can scalpel may preventing a tool from enteringless a the forbidden surgeon region explicitly un- overrides the system. Robots at Work

Part F

Part F | 63.2 1666 Medical Robotics and Computer-Integrated Surgery 63.3 Systems, Research Areas, and Applications 1667

for example, 3-D robot coordinates aj may be found transformation for a collection of points known to be on the surface X 2 of an anatomical structure that can also be found in TkC1 D arg min .bj  Taj/ : T asegmented3-D image. Given an estimate Tk of the j transformation between image and robot coordinates, the method iteratively finds corresponding points bj on The process is repeated until some suitable termination the surface that are closest to T a and then finds a new condition is reached.

k j 63.3 | F Part

63.3 Systems, Research Areas, and Applications

Medical robots are not ends in themselves. As the late widespread and increasing acceptance in such fields as Hap Paul often remarked, the robot is a surgical tool neurosurgery, otolaryngology, and orthopaedics. Since designed to improve the efficacy of a procedure.(Paul much of the technology of these systems is compatible was the founder of Integrated Surgical Systems. Along with surgical robots and since technical problems such with William Bargar, he was one of the first people to as registration are common among all these systems, we recognize the potential of robots to fundamentally im- may expect to see a growing number of hybrid applica- prove the precision of orthopaedic surgery.) tions combining medical robots and navigation.

63.3.1 Nonrobotic Computer-Assisted 63.3.2 Orthopaedic Systems Surgery: Navigation and Image Overlay Devices Orthopaedic surgery represents a natural surgical CAD/CAM application, and both surgical navigation In cases where the role of the robot is placing in- systems and medical robots have been applied to or- struments on targets determined from medical images, thopaedics. Bone is rigid and is easily imaged in CT surgical navigation is often a superior alternative. In and intraoperative x-rays, and surgeons are accustomed surgical navigation [63.61], the positions of instru- to doing at least some preplanning based on these im- ments relative to the reference markers on the patient ages. Geometric accuracy in executing surgical plans are tracked using specialized electromechanical, op- is very important, for example, bones must be shaped tical, electromagnetic, or sonic digitizers or by more accurately to ensure proper fit and positioning of com- general computer vision techniques. After the relation- ponents in joint replacement surgery. Similarly, os- ships between key coordinate systems (patient anatomy, teotomies require both accurate cutting and placement images, surgical tools, etc.) are determined through of bone fragments. Spine surgery often requires screws a registration process (Sect. 63.2.6), a computer work- and other hardware to be placed into vertebrae with- station provides graphical feedback to the surgeon to out damage to the spinal cord, nerves, and nearby blood assist in performing the planned task, usually by dis- vessels. playing instrument positions relative to medical images, The Robodoc system shown in Fig. 63.5a,b repre- as shown in Fig. 63.8a. Although the registration is usu- sents the first clinically applied robot for joint recon- ally performed computationally, a simple mechanical struction surgery [63.17, 18]. Since 1992, it has been alignment of an image display with an imaging device applied successfully to both primary and revision hip can be surprisingly effective in some cases. One exam- replacement surgery, as well as knee surgery. Since this ple [63.62] is shown in Fig. 63.8b. system exhibits many of the characteristics of surgi- The main advantages of surgical navigation sys- cal CAD/CAM, we will discuss it is some detail. In tems are their versatility, their relative simplicity, and the surgical CAD phase, the surgeon selects the de- their ability to exploit the surgeon’s natural dexterity sired based on preoperative CT images and interactively and haptic sensitivity. They are readily combined with specifies the desired position of the implant compo- passive fixtures and manipulation aids [63.65, 66]. The nents. In the surgical CAM phase, surgery proceeds main drawbacks, compared to active robots, are those normally up to the point where the patient’s bones are associated with human limitations in accuracy, strength, to be prepared to receive the implant. The robot is ability to work in certain imaging environments, and moved up to the operating table, the patient’s bones dexterity inside the patient’s body (Table 63.2). are attached rigidly to the robot’s base, and the robot is Because these advantages often outweigh the lim- registered to the CT images either by use of implanted itations, surgical navigation systems are achieving fiducial pins or by use of a 3-D digitizer to match bone ]); 63 ]) uses image 62 Sensory ) c JHU ( ]) ical position the 64 ) shows several clini- b ( MRI, and ultrasound) Information en- , 63.9 CT Display from a typical surgical Overlay of laparoscopic ultrasound ) ) a d a mirror to alignof the a virtual cross-sectional image imagecorresponding with the phys in the patient’s body; overlay system (after [63. onto the da Vinci surgicalmonitor robot (after video [63. navigation system, here the Medtronic StealthStation; Fig.63.8a–d hancement for surgical assistance. ( substitution display of surgical force information onto da Vinci surgical robot video monitor (after( [63. , where the process involves use of pa- Placement Systems /CAM tient images to identifyplanning needle targets trajectories; within inserting theverifying the their patient needles placement; and performing and some actionas such an injection oring taking the a results. biopsy Inis sample; most and acceptable, cases, assess- which anbecause accuracy is of the not 1–2 target easy mm tend is to to not achieve deform directly freehand, The visible, and procedures soft deflect, typically rely tissues andoperative on imaging needles some (x-ray, often formfor of bend. both guidance intra- and verification. Thesequence surgical motion typically has threethe decoupled needle phases: tip place atpivoting the around entry the point, needleinto orient the tip, body the along and needle aare straight insert by trajectory. often These the motions performed needle freehand,information with feedback varying for the degrees physician. of sive, However, semiautonomous, pas- and active robotic systemsall have been introduced.cally Figure deployed systems for needle placement. 63.3.3 Percutaneous Needle Needle placementtous procedures in image-guided have intervention, typicallythrough become performed the ubiqui- skin butcedures also fit through cavities. within TheseCAD pro- the broader paradigm of surgical ]orcom- d) b) 45 ] system for 49 ]. provide numerous 69 63.4 68]. A recent example of to an approximate initial , 63.5c,d. Similarly, several 67 have been introduced or pro- ] (Mako Surgical, Ft. Laud- 8 images. After registration, the sur- CT Subsequently, several other robotic systems for c) a) surfaces to the starting position. Then,chines the the desired robot shape with autonomouslywhile a ma- high-speed the rotary cutter surgeon monitorsthe progress. robot During monitors cutting, other cutting safety forces, sensor, and bonethe either motion, surgeon the and can robotprocedure pause controller is or execution paused at forber any of any error reason, time. recovery procedures there available Ifprocedure to are permit the to a the be num- eral resumed defined or checkpoints. restarted Oncebeen at the machined, surgery one desired proceeds shape ofmal manually manner. has sev- in the nor- joint replacement surgery posed. The references in Sect. geon’s hand guides the robot erdale, Florida) and the Acrobot [63. examples. Notable hands-onRio guided surgical systems robot include [63. knee surgery shown in Figs. groups have recently proposed small orthopaedic robots attaching directly to the patient’s bones [63. pletely freehand systems such as thesystem NavioPFS (Blue surgical Belt Technlogies,combine Pittsburgh, surgical Pa.) navigation with which verytrol fast of on-off a con- surgical cutter [63. a hybrid passive-active robot is [63. Robots at Work

Part F

Part F | 63.3 1668 Medical Robotics and Computer-Integrated Surgery 63.3 Systems, Research Areas, and Applications 1669

a) b) Fig.63.9a–e Clinically deployed sys- tems for in-scanner needle placement. (a,b) The Neuromate system (af- ter [63.19]) for stereotactic procedures in the brain uses a novel noncontact sensing system for robot-to-image

registration; (c) Johns Hopkins sys- 63.3 | F Part tem for in-CT needle placement (after [63.70, 71]); (d,e) Manually c) d) activated device for in-MRI transrectal needle placement into the prostate (after [63.72]) d)

e)

Freehand Needle Placement Systems the scanner bore, while the needle driver is tracked in Freehand needle placement with CT and MRI guidance MRI with active coils. uses skin markers to locate the entry point [63.62], ref- erence to the scanner’s alignment laser to control needle Active Robots for Needle Placement direction, and markers on the needle to control depth. Neurosurgery was one of the first clinical applications With ultrasound, the primary reliance is on surgeon ex- of active robots [63.19, 20, 22], a natural application perience or the use of some sort of needle guide to drive for surgical CAD/CAM. The entry and target points the needle to target while it passes in the ultrasound are planned on CT/MRI images, the robot coordinate plane. Tracked ultrasound snapshots guidance com- system is registered to the image coordinate system bines orthogonal viewpoints with frozen ultrasound im- (typically with markers affixed to the patient’s head), age frames [63.73]. Mechanical needle guides [63.61], and then the robot positions a needle or drill guide. hand-held navigation guidance [63.74], and optical The marker structure may be a conventional stereotac- guides have been combined with most imaging modal- tic head frame or, as in the Neuromate system [63.19], ities. These include laser guidance devices [63.75], registration is achieved by simultaneous tracking of the augmented reality systems [63.76]. Augmented reality robot and markers attached to the patient’s skull. Spatial with 2-D ultrasound [63.77]andCT/MRI slices [63.62] constraints in needle placement led to the development (Fig. 63.8b) was developed, where a semi-transparent of structures achieving remote center of motion (RCM) mirror is used together with a flat-panel display to cre- or fulcrum motion [63.24, 25]. In these systems, the ate the appearance of a virtual image floating inside the RCM is positioned at the entry point, typically with body in the correct position and size. an active Cartesian stage or a passive adjustable arm, and the robot sets the needle direction and (sometimes) Passive and Semiautonomous Devices the depth. To speed up imaging, planning, registra- for Needle Placement tion, and execution, the robot can work concurrently Passive, encoded manipulator arms were proposed for with imaging devices, such as variants of an RCM- image-guided needle placement [63.78], where follow- based system that was deployed with x-ray [63.24]and ing a registration step, the position and orientation CT guidance [63.70, 71]. In [63.71], a marker structure of a passive needle guide is tracked and the corre- was incorporated in the needle driver to register the sponding needle path is displayed on CT or MRI robot with a single image slice. MRI has an excellent images. Semiautonomous systems allow remote, in- potential for guiding, monitoring, and controlling ther- teractive image-guided placement of needles, such as apy, invoking intensive research on MRI-compatible transrectal prostate needle placement in MRI environ- robotic systems for needle placement [63.79] and other ment [63.72] with an actuated manipulator from outside more interactive procedures [63.50]. Ultrasound guid- ] ] , , ], ], 96 25 99 23 108 , , flight – 25 23 106 nce the in- ]. 95 ], voice con- enha 25 to [63. systems to manipulate MRI ]. There has also been re- nce. Although originally uxiliary support systems is ] developed a successful methods 26 , 98 3 , both as auxiliary surgical support ] have begun analyzing such data MIS during surgical procedures. Several au- ], and computer vision [63. 104 ] focuses on semi-automation of surgi- surgeon extender et al. [63. – 25 , ]. 105 101 10 . Of these, Intuitive Surgical’s da Vinci3 [63. 100 Green ]andas 94 A common goal in surgeon extender systems is One emerging area for research exploits the in- A primary challenge for a However, the primary uses of telesurgical systems 97]. to provide aspecifically, measure to of give telepresence theforming to open surgeon the surgery the surgeon, from sensation insidework, the of patient. per- Inprototype early system formanipulation, telesurgery force combining feedback,ergonomic design, remote stereoscopic etc. imaging, Subsequently, severalcial commer- telesurgical systemsfor have MIS been appliedhas clinically been the mostdeployed successful, as with over of 2500has 2013. systems demonstrated Experience that withcritical a these high-dexterity systems for wrist surgeontargeted is at accepta often cardiac surgery, asterventions, well the most as successful more clinical generaldate applications in- are to radical prostatectomies,provements where in significant outcomes im- and have been hysterectomy, reported wherepared [63. the to conventional clinical laparoscopyied are benefits [63. still com- being stud- herent ability ofdata telesurgical recorders systems tothors act [63. as to permit the surgeon to command theher robot while hands his or are otherwisehave occupied. Typical included approaches instrument-mounted conventional foot joystickstrol switches [63. [63. [63. for such purposesing as surgical measuring gestures and surgicalfor motions, surgical skill, and simulators. learn- providing Another data search emerging area [63. for re- ational difficulties due todelay the of long intrinsic distance communication safety tele-surgery affect and usability make and uncommon. the regular use of tele-surgery quite have been with the surgeon anderating patient room. in Teleoperated the robots sameover op- have 15 been years used in for cal gestures between thebased surgeon on and learned the models. robot, Other research often [63. cent work to develop telesurgical systemsimaging for use environments within such as formation available to theprocedures. surgeon during telesurgical systems to hold92– endoscopes or retractors [63. surgical instruments [63. exploits augmented reality ]. ar- 88 , ], and 14 82 ], and there ]. Whatever ]. The oper- ]aswellas populated 89 64 ] in 2001, exper- 51 ]forareview.)Overthe ] using transrectal ultra- due to their usefulness in ]. These robots fall within ], gallbladder [63. 15 80 ace, or thinly 87 81 , ] and Japan91 [63. 63.8d shows one example of the 64 90 85] and reviewed most recently , (see [63. 84 ]. Figure active cannulas 83 ]. Concentric tube robots (also interchange- 86 eas has continued tohave be been recognized some [63. spectaculara transatlantic demonstrations cholecystectomy [63. including iments in Italy [63. The concepts ofresence telemedicine, telesurgery, in and surgery telep- the date potential from for thefective telesurgical interventions 1970s. in systems Since remote to then, orsuch hostile facilitate as environments ef- the battlefield, sp 63.3.4 Telesurgical Systems more nearly routine use in Canada52 [63. ance offers many unique advantages:pensive is and relatively compact, inex- provides real-timenot images, involve does any ionizingpose significant radiation, materials and constraints doessign. on Several not the robotic robot im- systems de- prostate have interventions been proposed [63. for sound guidance. Forplacement other applications, examples ultrasound-guided include experimental needle systems for liver [63. breast [63. use of informationment overlay in to a assistform telesurgical in of application needle image [63. place- feedbackneedles to is hit available, desired steeringis targets flexible while a avoiding ubiquitous obstacles approaches problem, having [63. led to several novel in [63. ably called past few years, mechanics-based modelsnulas of have active can- rapidlyparallel matured efforts due of several to research the groups simultaneous [63. Today, these modelssubfield provide of the research basis onspecific for teleoperative design, control, an and surgery- active motioncal planning applications research. suggested Surgi- and for are concentric in various tube stages ofpurely robots development, conceptual ranging from to animalthe next studies, several which years will excitingresearch. make for translational clinical medicine), consist ofnested several within one precurved another. Actuators elasticat grasp their these tubes bases tubes and extendapplying them telescopically axial while rotations. also Theseoverall device movements to cause elongate the dle-sized and device bend, that providing moves aa in tentacle. nee- a Chronologically, a manner precursor analogouscentric to to tube current robots con- was an earlywhere steerable needle a design curveddle stylet to induce was steering [63. used at the tip of a nee- the broader class of continuouslycontinuum flexible robots robots called Robots at Work

Part F

Part F | 63.3 1670 Medical Robotics and Computer-Integrated Surgery 63.3 Systems, Research Areas, and Applications 1671

63.3.5 Microsurgery Systems doscopy and therapy of the spinal cord able to safely navigate in the subarachnoid space and to avoid danger- Although microsurgery is not a consistently defined ous contact with the internal delicate structures thanks term, it generally indicates procedures performed on to a system based on hydrojets. Hydrojets come from very small, delicate structures, such as those found the lateral surface of the catheter and, appropriately in the eye, brain, spinal cord, small blood vessels, tuned and oriented, allow the tip of the endoscope nerves, or the like. Microsurgical procedures are com- to proceed without touching the spinal cord internal atF|63.3 | F Part monly performed under direct or video visualization, walls. The shared control system of the neuroendo- using some form of magnification (e.g., microscope, scope, based on processing, segmentation, and analysis surgical loupes, high-magnification endoscope). The of the endoscopic images, assists the safe advancement surgeon typically has little or no tactile appreciation of the tool in real time [63.131]. of the forces being exerted by the surgical instruments and physiological hand tremor can be a significant 63.3.6 Endoluminal Robots factor limiting surgical performance. Robotic systems can help overcome these human sensory-motor limi- The term endoluminal surgery was first coined by tations, and efforts to develop specialized systems for Cuschieri et al. [63.132] as a major component of en- applications such as ophthalmology [63.6, 109–115]) doscopic surgery. Endoluminal procedures consist of and otology [63.116–118], Several groups have also bringing a set of advanced therapeutic and surgical tools experimented with magnetic manipulation for these ap- to the area of interest by navigating in the lumina (i. e., plications [63.113, 119]. There have been several efforts the tube-like structures) of the human body, such as the to compare microsurgical anastamosis procedures using gastrointestinal (GI) tract, the urinary tract, the circu- laparoscopic telesurgical systems to conventional mi- latory system, etc. Currently, most endoluminal robots crosurgery. Schiff et al. [63.120] among others reported are designed for gastrointestinal applications, although significant reductions in tremor with either robot and there has been some initial work for other areas. There significantly improved technical quality and operative are several advantages (from a robotics research per- times compared to conventional microsurgery. As the spective) of working in the GI tract. The GI tract is not nubber of da Vinci systems has proliferated, such appli- sterile and relatively large in diameter. Further it can be cations are increasingly common [63.121]. A number of punctured intentionally to reach other abdominal cavi- groups have implemented telesurgery systems specif- ties in NOTES approaches. ically for microsurgery [63.13, 122–124] [63.95, 109]. Traditionally, catheters and flexible endoscopes for These systems are in various stages of development, endoluminal procedures have been inserted and ma- from laboratory prototype to preliminary clinical exper- nipulated manually from outside the body with the imentation. assistance of one or more visualization systems (e.g., Not all microsurgical robots are teleoperated. For direct endoscopic video, x-ray fluoroscopy, ultrasound). example, the cooperatively controlled JHU Steady One major challenge is limited dexterity making it dif- Hand robots [63.4, 5] [63.6, 115] shown in Fig. 63.3 ficult to reach the desired target. Typically, flexible are being developed for retinal, head-and-neck, neuro- endoscopes have a bendable tip that can be steered by surgery, and other microsurgical applications. A mod- means of cable drives, and catheters may have only ified version of this system has also been used for a fixed bend on a guide wire. There is also the inher- microinjections into single mouse embryos [63.125]. ent difficulty of pushing a rope, which some companies There have also been efforts to develop completely are trying to address by using external magnetic field hand-held instruments that actively cancel physiolog- (e.g., [63.133]). Once the target site is reached, these ical tremor, for example, Riviere et al. [63.126–128] limitations become even more significant. Very simple have developed an ophthalmic instrument using op- instruments can be inserted through working channels tical sensors to sense handle motion and adaptive or slid over guide wires, but dexterity is severely lim- filtering to estimate the tremulous component of in- ited and there is no force feedback beyond what can be strument motion. A micromanipulator built into the felt through the long, flexible instrument shaft. instrument deflects the tip with an equal but opposite These limitations have led a number of researchers motion, compensating the tremor. Simple mechanical to explore integration of more degrees of freedom in devices [63.129] for reducing tremor in specific tasks the catheter/endoscope body, as well as the design have also been developed. of intelligent tips with higher dexterity and sensing An additional type of hand-held microsurgical capabilities. Early work by Ikuta et al. led to the and micro-therapeutic devices is reported in [63.130], development of a five-segment, 13 mm-diameter sig- which describes an active microendoscope for neuroen- moidscope using shape-memory alloy (SMA) actuators. ] 144 ]. CMOS camera 145 Clamper Elongator fields [63. MRI 63.11c and described et al. [63. swallowable cameras with Ritter cycle of the robot, consisting of: of Steering Tail a recent working prototype used for CMOS Clamper ) gait b ( ] or by modified the ) LED ]. In order to overcome dramatic powering Medical robot for colonoscopy (af- 143 a ( 142 1 2 3 4 ]): , and Haptic Feedback 33 28 CMOS camera video tumor fighter application is illustrated in Fig. b) a) Rinsing 63.3.7 Sensorized Instruments Surgical procedures almost always involveof some physical form interaction between surgical instruments Fig.63.10a,b a screening methodtransforming highly simple tolerated byillumination patients. and For transmission functionalitiesful into diagnostic use- devices,explored several variegated research solutions groups formotions. An active have example of capsule legged locomotion capsules loco- GI for in [63. problems, magnetic capsules propelledmagnets [63. by permanent clinical trials (1) proximal clamping, (2) elongation,and (3) (4) distal retraction; clamping, ter [63. have been proposed. Anmagnetic earlier manipulation of application an of object within electro- thethe body was ]. In ]which ) CMOS GI tract ] provides ]. )-based illu- ]. It presents 135 29 63.11a,b shares 140 LED [63. endoscopic devices GI ]. Although the applica- Rebello ] that allow the right branch 63.10). This device consists 139 , 134 138 ] shown in Fig. et al. developed 3 mm-diameter ac- ](Fig. 31 33 ], and similar devices combining flexi- Ikuta 137 et al. [63. )-instrumented surgical devices and the same -based devices in endoluminal and microsurgi- et al. [63. Several examples exist of instrumented catheter tips Another approach to endoluminal robots is repre- The natural evolution of MEMS mination system. Thanks torobotic its colonoscope intrinsic flexibility, applies the that forces are on tenditional colon times colonoscopies. lower tissues This than systemtested those is [63. produced now by clinically tra- Subsequently, bility and painlesssome operation companies have [63. been proposed by with force sensors [63. camera and a light-emitting diode ( tive endovascular devicesincorporating a using novel hydraulic bandmicro-stereolithographic pass techniques actuators [63. valve fabricated using tion is notRiviere endoluminal, the HeartLander system of 1995 Burdick et al. developed ananism inchworm-like mech- for usea in central extensor theloons for for colon. friction propulsion enhancement This with andtissue. the device A inflatable slippery more colon combined bal- advancedautonomous inchworm design robotic for colonoscope aDario semi- was developed by of the circulatory systems to beforce found by generated estimating the betweenBasically, the these sensorized tip endoluminal devices and belong to the the vessel larger group walls. of( micro-electromechanical systems sensing technologies can besurgery. also A exploited survey for article by micro- of a central siliconebased elongator, on two suction clampingthe and systems colon tissue, gentle and mechanical aa silicone grasping complementary steerable metal-oxide-semiconductor of ( tip integrating an excellent overview of sensorizedMEMS catheters and other cal applications. sented by systemsthrough that the body, move rather than under beingon their pushed. Early such own work power systems is well summarized in [63.136 many of the characteristics ofinchworm-like these gait systems. to It traverse usesand the an to surface perform of simpleon the operation. the heart An combination between instructiveendoscopic flexibility paper and devices stiffness for of allowingbility painless and manoeuvra- stabletasks anchoring has when been performing recently published surgical [63. a number of design criteria anding solutions for endoscopic transform- devices from diagnosticsurgical tools paltforms. to stable is represented by endoscopic capsules141 [63. keep the promise to make endoscopy of the Robots at Work

Part F

Part F | 63.3 1672 Medical Robotics and Computer-Integrated Surgery 63.3 Systems, Research Areas, and Applications 1673 and patient anatomy, and surgeons are accustomed a) b) c) to use their haptic appreciation of tool-to-tissue in- teraction forces in performing surgical procedures. In situations such as where the clumsiness of instrumen- tation or human sensory-motor limitations limit the surgeon’s ability to feel these forces, surgeons have Rear body been trained to rely on visual or other cues to com- Front body 63.3 | F Part pensate. Apart from the need for haptic feedback for diagnostic procedures and tissue identification, it has d) Robotic arm External permanent been demonstrated that reduced tactile and force infor- magnet mation can result in the application of unnecessarily large forces on the patient during surgery, with pos- sible harm to the patient [63.146]. The quality of haptic feedback available in currently deployed sur- 10 mm gical robots is poor or nonexistent. Current research addresses the limitations firstly by integrating force and other sensors into surgical end-effectors and sec- ondly by developing improved methods for processing and conveying the sensed information to the surgeon. Gl tract training However, the debate of the usefulness of force feed- Capsule unit phantom back in robot-assisted surgery is still open and is made vision module more complex by the many scientific and technical permanent magnet sensors & electronics difficulties due to the intrinsic presence of (possibly variable) communication time delay in the robotic sys- Fig.63.11a–d Mobility inside the body. (a,b) HeartLander de- tem [63.147]. vice for crawling across the surface of the heart (after [63.31]). Although the most obvious way to display haptic (c) Legged capsule for gastrointestinal diagnosis and therapy (af- information in a telesurgical system is directly through ter [63.28, 148]), (d) magnetic capsule for exploration of the GI the master hand controllers, this method has several tract, showing left capsule and components and right magnetic limitations, including friction and limited bandwidth in dragging platform based on a permanent magnet driven by a robotic the hand controllers. Although these issues may be ad- manipulator (after [63.143]) dressed through specialized design (which may raise costs and require other compromises) and improved sensors and actuated by direct-current (DC) motors control, there has been considerable interest in sensory whose output torque is sensed and fed back through substitution schemes [63.149–151] in which force or motors integrated in a grasping handle. A similar ap- other sensor information is displayed visually, aurally, proach was used by Menciassi et al. [63.156]for or by other means. Figure 63.8c shows one example of a microsurgery gripper equipped with semiconductor sensory substitution for warning when a da Vinci robot strain gauges and a PHANTOM (SensAble Technolo- is about to break a suture [63.63]. gies, Inc.) haptic interface. More recent work at Johns Starting in the 1990s, several groups [63.151–153] Hopkins has focused on incorporation of optical fiber have sensorized surgical instruments for microsurgery force [63.157–160]andOCT [63.161–163] sensors into and MIS by equipping them with force sensors. Gen- microsurgical tools. Both video and auditory sensory erally, these efforts relied on sensory substitution to substitution [63.164], as well as direct feedback to display force data, either for freehand or telesurgi- robotic devices have been used to help surgeons con- cal application. For example, Poulose et al. [63.152] trol tool-tissue interaction forces and distance. demonstrated that a force sensing instrument used to- Several researchers [63.165] have focused on spe- gether with an IBM/JHU LARS robot [63.25] could cialized fingers and display devices for palpation tasks significantly reduce both average retraction force and requiring delicate tactile feedback (e.g., for detecting variability of retraction force during Nissen fundoplica- hidden blood vessels or cancerous tissues beneath nor- tion. The first surgical robot with force feedback used in mal tissues). There has also been work to integrate non- in vivo experiments was the JPL-NASA RAMS system, haptic sensors into surgical instruments, for example, which was tested on animal models for vascular anas- Fischer et al. have developed instruments measuring tomosis [63.154] and carotid arteriotomies [63.155]. both force and tissue oxygenation levels [63.166]. This Rosen et al. [63.153] developed a force-controlled tele- information can be used for such purposes as assessing operated endoscopic grasper equipped with position tissue viability, distinguishing between different tissue ]. )al- 176 ]. The GPU 175 ] simulator instruments 173 sensorized training systems combine vi- ]. ], which has been successfully 174 ], which simulates the operator 170 system and a computer back end to 172 ]. Specific to robotic surgery is the Si ], which enables good haptic feedback. 171 and by measuring the execution time, path virtual-reality 177 3-D A hybrid simulator uses a box with objects or or- Finally, gans as aperformance mechanical of simulator, theputer but trainee which in gives are guidance monitored addition foran the by the objective task a execution feedback and Thanks com- to based this on feedback, theof preplanned an assistance experienced and metrics. surgeon judgement are notexample, strictly the necessary, for ProMIS (Hapticaa typical Inc., hybrid Boston, simulator USA) foras training is basic suturing skills and such passed knot through dedicated tying. ports and Surgicalthe the same instruments trainee haptic receives are feedback asnipulation in in the real box. surgery In duringtrainee’s addition, ma- performance ProMIS analyzes by the trackingtion the in instrument posi- length, and smoothness ofcent task execution. hybrid Another simulator re- platform is for ultrasound-guided percutaneous the needle in- Perksertion Tutor training [63. open-source applied in teaching of ultrasound-guidedjections facet joint [63. in- RoSS system [63. console of the da Vincical robotic currently system. markets Intuitive the Surgi- dv-Trainer [63. for the da Vinci system, comprising thefrom surgeon console a da Vinci simulate the patient-side manipulators,is and being its evaluated efficacy [63. sualization and haptic interfacesinteract to efficiently enable surgeons and to putational naturally models with of real-time patient com- anatomy [63. development of these systemsciplinary is inherently effort, a including multidis- ics, real-time the computer development of high-bandwidth graph- hapticreal-time devices, biomechanicaltissue modeling interactions, expertise in of training assessment,human–machine and organs, information exchange, tool– etc. [63. Research in these areasergistic with is comparable closely developments relatedand in to systems technology and for performing syn- ample, modeling real of interventions, organ motion foris in ex- response necessary to to forces improvement the procedures. accuracy Haptic ofsimilar feedback needle requirements devices place- whether must thesimulated meet forces or displayed are measuredon. directly in Finally, telesurgery, as and noted so earlier, and real-timeneeded imaging to are createuse realistic critical biomechanical of sources models. the The of computer data graphical processor ( lows the simulation10 kHz of [63. organsSimilarly, at new rates physics-based graphical inport the libraries excess development sup- of of low cost virtual reality simu- . LapTrainer with SimuVi- see one, do one, teach one , and manipulating instruments ], whereas results on concurrent gery requires different skills than ] divides training simulators into 3-D 168 ] and many teaching hospitals have 169 167 and Telerobotic Systems for Training images in (Simulab Inc., Seattle, USA) is a training system Finally, it is important to note that sensorized surgi- Survey [63. Mechanical simulators are boxes where objects or 63.3.8 Surgical Simulators Medical education is undergoingThe significant traditional changes. paradigming for is often surgical summarized technical as train- through entry portals. Thesetroduction considerations of led surgical todegrees simulation in- of systems complexity and of realismother varying for minimally invasive endoscopic procedures. and Nowadays, train- ing simulators havein achieved the widespread field of acceptance doscopy, anaesthesia, surgery, intensive interventional care, radiology,fields. flexible and The en- other usemon of that simulators working forto groups training have evaluate is been theseguidelines so set [63. training com- up systems inextensive order based simulation on trainingbeing centers. validated shared on Simulators their basicand are parameters construct) (face, [63. content open surgery, such as spatialof orientation, 2-D interpretation types, and controlling retractionchemic so tissue damage. as not to cause is- cal tools have important application beyonduse their direct in surgical procedures,biomechanical for studies example, to one measure organ usechanical and is properties tissue to in me- improve surgical simulators. This method can bethe surgical effective trainee directly in observes the open experthands, surgeon surgery, sees where the instrument motion,gan and manipulation. However, follows in the endoscopic surgery or- difficult it to is observe the surgeon’s hand movementsside (out- the body) and thebody surgical and tool only actions (insidetion, visible the endoscopic on sur a video monitor). In addi- and predictive validity ofnot available. simulation training are still with a simulated laparoscopemounted that digital consists camera of in an a open boom- box trainer. sion three groups, depending on the type ofmechanical, technology used: hybrid, and virtual reality. organs are placedstruments. and The manipulated manipulation is using observedparoscope surgical through and in- a a la- is screen. The observed simulated byfeedback surgical to the an task trainee. Generally, experienced theretion are processes surgeon, no registra- and who theafter any simulator gives training must session. The be reassembled Robots at Work

Part F

Part F | 63.3 1674 Medical Robotics and Computer-Integrated Surgery 63.4 Conclusion and Future Directions 1675 lators that correct render the interaction of instruments Making a comparison between these different cate- and anatomical parts, and thus can support large train- gories of simulators is not trivial. Basically, box trainers ing classes [63.178]. and hybrid simulators require some experienced techni- The variety of interface devices and virtual reality cians for the set up and some organizational logistics laparoscopic simulators is quite wide and increasing due to legal and ethical factors related to the storage numbers of systems are becoming commercially avail- of freshly explanted organs. The most evident advan- able. The Phantom interface is used in conjunction with tage of these simulators is that the tactile response from atF|63.4 | F Part virtual simulators to provide users with realistic haptic the manipulated objects is the same as in real surgery feedback (SensAble Technologies Inc., Woburn, MA, and complicated models of organs and tissue–tool inter- USA). The Xitact LS500 laparoscopy simulator (Xi- action are not required. On the other hand, completely tact S.A., Lausanne, Switzerland) is a modular virtual- virtual-reality trainers are potentially very flexible, can reality simulation platform with software for training take advantage of powerful graphical engines, but they and assessing performance in laparoscopic tasks. It is an are limited by the availability of realistic calibration open system including all or some of these subsystems: data for the anatomical and biomechanical models. Al- laparoscopic tools, mechanical abdomen, a personal though demonstrations exist of the ability of simulators computer (PC) providing the virtual-reality scenario, to record, objectively score, and hone the psychomo- a haptic interface, a force feedback system and a track- tor skills of novice surgeons [63.189], the debate about ing system for the tools. Several other systems for their value is still open because no multicentre trails virtual reality simulation exist that exploit the hardware has yet been conducted to determine their efficacy. from Xitact or Immersion Medical, Inc. (Gaithers- Furthermore, it has been shown that simulation train- burg, MD, USA) and that are dedicated to specific ing must be included in structured curricula in robotic surgical tasks: Lapmentor [63.179], the Surgical Edu- surgery, where trainees are also introduced to basic con- cation platform [63.180], LapSim [63.181], Procedicus cepts of robotics and, in particular, to the so called MIST [63.182], EndoTower [63.183], the Reachin la- non technical skills, e.g., organization, leadership and paroscopic trainer [63.184], Simendo [63.185], and communication, which significantly affect the surgical the Vest system [63.186]. Specifically for training eye outcome [63.190]. surgeons, the surgical simulator EYESi [63.187]uses advanced computer technology and virtual reality to 63.3.9 Other Applications simulate the feel of real eye surgery, making it possi- and Research Areas ble for surgeons at all levels to acquire new skills and perfect their techniques in preparation for surgery on The research areas described above illustrate major the human eye. Training for dexterity skills in robotic themes within medical robotics, but they are by no surgery is supported by the new virtual simulator XRON means exhaustive. Many important application areas developed at the University of Verona, which interfaces such as otolaryngology [63.191–194] and radiation physics-based simulation with several commercial joy- therapy have necessarily been excluded for space rea- sticks and provides evaluation metrics of interactive sons. For a fuller exploration, readers should consult the tasks [63.188]. further reading suggestions in Sect. 63.4.

63.4 Conclusion and Future Directions

Medical robotics (and the larger field of computer- sessment methods, and the capture and playback of integrated interventional medicine) has great potential clinical cases to revolutionize clinical practice by:  Promoting more effective use of information at all levels, both in treating individual patients and in im-  Exploiting technology to transcend human limita- proving treatment processes. tions in treating patients  Improving the safety, consistency, and overall qual- From being the stuff of late-night comedy and sci- ity of interventions ence fiction 20 years ago, the field has reached a critical  Improving the efficiency and cost-effectiveness of threshold, with clinically useful systems and commer- robot-assisted patient care cial successes. The scope and number of research pro-  Improving training through the use of validated grams has grown exponentially in the past 8 years, and simulators, quantitative data capture and skill as- this chapter is by no means a comprehensive survey , 1201–1210 (1999) IEEE Int. Conf. Robot. Autom. (ICRA),(2000) San pp. Francisco 618–621 mar, D. Stoianovici, P.Juan, Gupta, L. Z.X. Kavoussi: Wang, Steady-handmicrosurgical E. robotic augmentation, Int. de- system J. for Robotics18 Res. comb: Task performance inparison between stapedotomy: surgeons of com- different experience these groups has uniquefrom expertise, effective, and highly success interactive comes upon partnerships this drawing expertise. Building theseterm teams takes commitment, a long- andare the largely successes the inthese pay-off teams. recent Second, from years itlems investments is in important with to creating well-defined workin on clinical which prob- the andmately criteria technical related for goals, to measuringIn real working success advantages toward in are thesemeasurable treating goals, ulti- and it patients. meaningful is milestones importantsize and to to have rapid empha- iterationstages. with Finally, clinician itrecognize involvement is at the essential all level thatto of all achieve success team commitmentdoing. and members that that is they required enjoy what they are 63.4 R. Taylor, P. Jensen, L. Whitcomb, A. Barnes, R. Ku- 63.5 D. Rothbaum, J. Roy, G. Hager, R. Taylor, L. Whit- ,ed. Standard Hand- activity, involving team http://handbookofrobotics.org/view-chapter/63/videodetails/829 http://handbookofrobotics.org/view-chapter/63/videodetails/830 http://handbookofrobotics.org/view-chapter/63/videodetails/831 http://handbookofrobotics.org/view-chapter/63/videodetails/832 http://handbookofrobotics.org/view-chapter/63/videodetails/833 http://handbookofrobotics.org/view-chapter/63/videodetails/834 http://handbookofrobotics.org/view-chapter/63/videodetails/835 http://handbookofrobotics.org/view-chapter/63/videodetails/825 http://handbookofrobotics.org/view-chapter/63/videodetails/826 http://handbookofrobotics.org/view-chapter/63/videodetails/827 http://handbookofrobotics.org/view-chapter/63/videodetails/828 http://handbookofrobotics.org/view-chapter/63/videodetails/823 http://handbookofrobotics.org/view-chapter/63/videodetails/824 Reconfigurableand modular robotavailable NOTES for from applications SPRINT robot for single portavailable surgery from A micro-robot operating inside eye available from CardioArm available from Snake robot for surgery inavailable tight from spaces IREP robot – Insertable roboticavailable effectors from in single port surgery Variable stiffness manipulator basedavailable layer on from jamming Intuitive surgical Da Vinci singleavailable from port robotic system SPORT system by Titan Medical available from Robot for single port surgeryavailable by from Nebraska University Magnetic and needlescopic instruments foravailable from surgical procedures Da Vinci Surgery on aavailable from grape Da Vinci Xi introduction |available from Engadget by M. Kutz (McGraw-Hill, New York 2003) pp. 325– Image guided robotic radiosurgery, Neurosurgery 44(6), 1299–1306 (1999) telesurgery system: Overview and application, surgery and medical robotics. In: book of Biomedical Engineering and Design 353 VIDEO 833 VIDEO 834 VIDEO 835 VIDEO 829 VIDEO 830 VIDEO 831 VIDEO 832 VIDEO 825 VIDEO 826 VIDEO 827 VIDEO 828 VIDEO 823 VIDEO 824 In the future, we can expect to see continued re- academics, researcher clinicians, and industry. Each of Video-References 63.2 J.R. Adler, M.J. Murphy, S.D. Chang,63.3 S.L. Hankock: G.S. Guthart, J.K. Salisbury: The intuitive References 63.1 R.H. Taylor, L. Joskowicz: Computer-integrated of the field.cally In impossible in less fact, than 100 such pages.emerging Many important a systems and survey applications wouldout. are be Interested necessarily readers left practi- arereading urged section for to more refer complete to treatments.ular, the In the survey partic- articles further and booksthis in listed section at collectively the end contain of ographies somewhat than fuller space permits bibli- here. search in all aspectsopment, of with technology increasing and emphasistions. system on devel- As clinical this applica- searchers work remember proceeds, several it basicand principles. is arguably The important first, most thatcal important, robotics re- principle is fundamentally is a that medi- Robots at Work

Part F

Part F | 63 1676 Medical Robotics and Computer-Integrated Surgery References 1677

levels, Otolaryngol. Head Neck Surg. 128,71–77 hip replacement, IEEE Eng. Med. Biol. 14, 307–313 (2003) (1995) 63.6 A. Uneri, M. Balicki, J. Handa, P. Gehlbach, 63.19 Q. Li, L. Zamorano, A. Pandya, R. Perez, J. Gong, R. Taylor, I. Iordachita: New steady-hand eye F. Diaz: The application accuracy of the NeuroMate robot with microforce sensing for vitreoretinal robot – A quantitative comparison with frameless surgery research, Proc. Int. Conf. Biomed. Robotics and frame-based surgical localization systems, Biomechatronics (BIOROB), Tokyo (2010) pp. 814– Comput. Assist. Surg. 7(2), 90–98 (2002) 819 63.20 P. Cinquin, J. Troccaz, J. Demongeot, S. Lavallee, atF|63 | F Part 63.7 A. Amin, J. Grossman, P.J. Wang: Early experi- G. Champleboux, L. Brunie, F. Leitner, P. Sautot, ence with a computerized robotically controlled B. Mazier, A. Perez, M. Djaid, T. Fortin, M. Chenic, catheter system, J. Int. Card. Electrophysiol. 12, A. Chapel: IGOR: image guided operating robot, 199–202 (2005) Innov. Technonogie Biol. Med. 13, 374–394 (1992) 63.8 B. Hagag, R. Abovitz, H. Kang, B. Schmidtz, 63.21 H. Reichenspurner, R. Demaino, M. Mack, M. Conditt: RIO: Robotic-arm interactive ortho- D. Boehm, H. Gulbins, C. Detter, B. Meiser, R. Ell- pedic system MAKOplasty: User interactive haptic gass, B. Reichart: Use of the voice controlled orthopedic robotics. In: Surgical Robotics: Sys- and computer-assisted surgical system Zeus tems Applications and Visions, ed. by J. Rosen, for endoscopic coronary artery surgery bypass B. Hannaford, R. Satava (New York, Springer 2011) grafting, J. Thorac. Cardiovasc. Surg. 118, 11–16 pp. 219–246 (1999) 63.9 R. Konietschke, D. Zerbato, R. Richa, A. To- 63.22 Y.S. Kwoh, J. Hou, E.A. Jonckheere, S. Hayati: bergte,P.Poignet,F.Froehlich,D.Botturi,P.Fior- A robot with improved absolute positioning accu- ini, G. Hirzinger: Of new features for telerobotic racy for CT guided stereotactic brain surgery, IEEE surgery into the MiroSurge System, J. Appl. Bion- Trans. Biomed. Eng. 35, 153–161 (1988) ics Biomech. Integr. 8(2), 116 (2011) 63.23 J.M. Sackier, Y. Wang: Robotically assisted laparo- 63.10 L. Mettler, M. Ibrahim, W. Jonat: One year of expe- scopic surgery. From concept to development, rience working with the aid of a robotic assistant Surg. Endosc. 8,63–66(1994) (the voice-controlled optic holder AESOP) in gy- 63.24 D. Stoianovici, L. Whitcomb, J. Anderson, R. Tay- naecological endoscopic surgery, Hum. Reprod. lor, L. Kavoussi: A modular surgical robotic system 13, 2748–2750 (1998) for image-guided percutaneous procedures, Proc. 63.11 N. Simaan, R. Taylor, P. Flint: High dexterity Med. Image Comput. Comput. Interv. (MICCAI), snake-like robotic slaves for minimally invasive Cambridge (1998) pp. 404–410 telesurgery of the throat, Proc. Int. Symp. Med. 63.25 R.H. Taylor, J. Funda, B. Eldridge, K. Gruben, Image Comput. Comput. Interv. (2004) pp. 17–24 D. LaRose, S. Gomory, M. Talamini, L.R. Kavoussi, 63.12 N. Suzuki, M. Hayashibe, A. Hattori: Develop- J. Anderson: A telerobotic assistant for laparo- ment of a downsized master-slave surgical robot scopic surgery, IEEE Eng. Med. Biol. Mag. 14,279– system for intragastic surgery, Proc. ICRA Surg. 287 (1995) Robotics Workshop, Barcelona (2005) 63.26 M. Mitsuishi, T. Watanabe, H. Nakanishi, T. Hori, 63.13 K. Ikuta, K. Yamamoto, K. Sasaki: Development of H. Watanabe, B. Kramer: A telemicrosurgery sys- remote microsurgery robot and new surgical pro- tem with colocated view and operation points cedure for deep and narrow space, Proc. IEEE Conf. and rotational-force-feedback-free master ma- Robot. Autom. (ICRA) (2003) pp. 1103–1108 nipulator, Proc. 2nd Int. Symp. Med. Robot. 63.14 R.J. Webster, J.M. Romano, N.J. Cowan: Mechanics Comput. Assist. Surg., Baltimore (1995) pp. 111– of precurved-tube continuum robots, IEEE Trans. 118 Robotics 25(1), 67–78 (2009) 63.27 K. Ikuta, M. Tsukamoto, S. Hirose: Shape memory 63.15 R.J. Webster, B.A. Jones: Design and kine- alloy servo actuator system with electric resis- matic modeling of constant curvature continuum tance feedback and application for active endo- robots: A review, Int. J. Robotics Res. 29(13), 1661– scope. In: Computer-Integrated Surgery,ed.by 1683 (2010) R.H. Taylor, S. Lavallee, G. Burdea, R. Mosges (MIT 63.16 J. Ding, R.E. Goldman, K. Xu, P.K. Allen, Press, Cambridge 1996) pp. 277–282 D.L. Fowler, N. Simaan: Design and coordina- 63.28 A. Menciassi, C. Stefanini, S. Gorini, G. Pernorio, tion kinematics of an insertable robotic effectors P. Dario, B. Kim, J.O. Park: Legged locomotion in platform for single-port access surgery, IEEE/ASME the gastrointestinal tract problem analysis and Trans. Mechatron. 99, 1–13 (2012) preliminary technological activity, Proc. IEEE/RSJ 63.17 R.H. Taylor, H.A. Paul, P. Kazandzides, B.D. Mit- Int. Conf. Intell. Robots Syst. (IROS) (2004) pp. 937– telstadt, W. Hanson, J.F. Zuhars, B. Williamson, 942 B.L. Musits, E. Glassman, W.L. Bargar: An image- 63.29 K. Ikuta, H. Ichikawa, K. Suzuki, D. Yajima: Multi- directed robotic system for precise orthopaedic degree of freedom hydraulic pressure driven surgery, IEEE Trans. Robot. Autom. 10,261–275 safety active catheter, Proc. IEEE Int. Conf. (1994) Robotics Autom. (ICRA), Orlando (2006) pp. 4161– 63.18 P. Kazanzides, B.D. Mittelstadt, B.L. Musits, 4166 W.L. Bargar, J.F. Zuhars, B. Williamson, P.W. Cain, 63.30 S.Guo,J.Sawamoto,Q.Pan:Anoveltype E.J. Carbone: An integrated system for cementless of microrobot for biomedical application, Proc. ,4– , 379– 23 ,ed.by 1,67–79 413 application , 261–267 (1999) 3 first clinical ure bone-mounted robot , 10, 93–99 (2005) 54 525–537 (2004) , 329–339 (2001) 6 Computer-Integrated Surgery (24), 2109–2115 (2010) 35 (2012) , 917–922 (2003) com/Medical-Manufacturing-Technology-3D- printing-medical-device-development/index. html son: Praxiteles: A miniat for minimal accessJ. total Med. knee arthroplasty, Robot.(2005) Int. Comput. Assist. Surg. A miniature microsurgicalsensor for instrument enhanced force tip feedbackassisted during manipulation, robot- force IEEE Trans. Robot.19 Autom. fer, D. Horne,G. Kiriyanthan, B. Y. Barzilay, A. Bruskin, Silberstein, D.V. Sackerer, Alexandrovsky, M. C. Stüer, Hardenbrook, D.G. R. Burger, J. Gordon, Maeurer, N. R. Knoller, K. Schmieder, I. Schoenmayr,B. Pechlivanis, Meyer, I.-S. M. A. Kim, Shoham: Clinical acceptance Friedlander, curacy and assessment of ac- spinal implants guided with SpineAssist surgical robot –Spine Retrospective study, MRI/fMRI compatible robot technology -tool for A neuroscience and critical image guided interven- tion, Proc. IEEE Int.Orlando Conf. Robotics (2006) Autom. (ICRA), J. Cobb, B.L. Davies: The of a hands-on robotic kneeput. surgery system, Aided Com- Surg. P. Newhook, G.R.A Sutherland: review Surgical and robotics: ment, neurosurgical Neurosurgery prototype develop- D. Mutter, M. Vix, S.E. Butner, M.K.lantic Smith: robot-assisted Transat- telesurgery, Nature M. Ghodoussi, D.W. Birch, C.S. Mckinley, P. Trudeau, Dutta, C.H.on Goldsmith: surgical The precision impact anding of robotic-assisted task remote latency telepresence completion surgery, Comput. dur- Aided Surg. straints in medicalgenerated by robot anatomy, IEEE Trans. using Robotics virtual fixtures for robotic cardiacMed. surgery, Image Proc. Comput. Comput. 4th Interv. Int. (2001) Conf. robots. In: R. Taylor, S. Lavallée, G.Press, Burdea, Cambridge R. 1996) Moesges pp. (MIT 287–296 related software Inform. Technol.in surgical Biomed. robots, IEEE Trans. T. Villa: Robotic surgery – Formal verification of 380 (2001) 19 (2007) 63.45 C. Plaskos, P. Cinquin, S. Lavallee, A.J. Hodg- 63.46 P.J. Berkelman, L. Whitcomb, R. Taylor, P. Jensen: 63.47 D.P. Devito, L. Kaplan, R. Dietl, M. Pfeif- 63.48 K. Chinzei, R. Gassert, E. Burdet: Workshop on 63.49 M. Jakopec, S.J. Harris, F.R.Y. Baena, P. Gomes, 63.50 D.F. Louw, T. Fielding, P.B. McBeth, D. Gregoris, 63.51 J. Marescaux, J. Leroy, M.63.52 Gagner, F. Rubino, M. Anvari, T. Broderick, H. Stein, T. Chapman, 63.53 M. Li, M. Ishii, R.H. Taylor: Spatial motion63.54 con- S. Park, R.D. Howe, D.F. Torchiana: Virtual fixtures 63.55 B. Davies: A discussion of safety issues for medical 63.56 P. Varley: Techniques of development of safety- 63.57 R. Muradore, D. Bresolin, L. Geretti, P. Fiorini, , 613–616 (2012) 49 https://www. (2013) (6), 210–216 (2010) 2 http://medicaldesign. , 2293–2298 (2010) 24 , 782–792 (2003) 19 (4), 385–394 (2013) (6), 871–878 (2012) 20 15 , 2308–2316 (2007) , 114–117 (2004) 21 http://www.mimed.mw.tum.de/research/ 60 IEEE/RSJ Int. Conf. Intell. Robots Syst.pp. (IROS) 1047–1052 (2005) heartlander: A novel epicardial crawling robotmyocardial for injections, Proc. 19th Int.put. Congr. Com- Assist. Radiol. Surg. (2005) pp. 735–739 gical tools andRobotics augmenting Autom. devices, IEEE Trans. M.C. Carrozza, P.ment Dario: of locomotion devices Analysis for thenal and gastrointesti- tract, develop- IEEE(2002) Trans. Biomed. Eng. S.L. Hill, C.A. Vaughn, C.A.Flexible Magee, transgastricperitoneoscopy: S.V. A Kantsevoy: novelproach ap- to diagnostictions and in therapeutic the interven- dosc. peritoneal cavity, Gastrointest. En- translumenal surgery: FlexibleWorld platform J. review, Gastrointest. Surg. scopic access surgery, Tech. Gastrointest.11,84–93(2009) Endosc. karlstorz.com/cps/rde/xchg/SID-8BAF6233- DF3FFEB4/karlstorz-en/hs.xsl/8872.htm V.A. Huynh,S.C. A.P. Kencana, Chung: K.scopic Natural wedge hepatic Yang, orifice resection in Z.L. antal transgastric experimen- model Sun, using endo- anand intuitively slave controlled transluminal master TER), endoscopic Surg. Endosc. robot (MAS- 3d-printing-rapid-technologies/ 3D printingment, Medical and Design, medical-device develop- G. Petroni, P.Design Valdastri, A. offor Menciassi, a P. single-port Dario: novelMechatron. laparoscopy, bimanual IEEE/ASME robotic Trans. system gies, P. Dario, A.platform Menciassi: for AnIEEE endoluminal Minimally Int. robotic Conf. Invasive Biomed.(BIOROB), Robotics Surgery, Biomechatronics Pisa Proc. (2012) pp. 7–12 P. Valdastri: Finecamera tilt by tuning localNephrectomy of magnetic Experience a actuation:Surg. on laparoscopic Innov. Two-Port Human Cadavers, M.T. Goova, I.Completely Zeltser, F.J. transvaginal Kehdy, NOTES J.A.using cholecystectomy magnetically Cadeddu: anchoredEndosc. instruments, Surg. 63.31 N. Patronik, C. Riviere, S.E. Qarra, M.A. Zenati: The 63.32 P. Dario, B. Hannaford, A. Menciassi:63.33 Smart sur- L. Phee, D. Accoto, A. Menciassi, C. Stefanini, 63.34 N. Kalloo, V.K. Singh, S.B. Jagannath, H. Niiyama, 63.35 S.N. Shaikh, C.C. Thompson: Natural orifice 63.36 M. Neto, A. Ramos, J. Campos: Single port laparo- 63.37 Karl Storz Endoskope - Anubis: 63.38 S.J. Phee, K.Y. Ho, D. Lomanto, S.C. Low, 63.44 S. G. O’Reilly: Medical manufacturing technology: 63.39 M. Piccigallo, U. Scarfogliero, C. Quaglia, 63.43 T. Leuth: MIMED: 3D printing - Rapid technolo- 63.41 S. Tognarelli, M. Salerno, G. Tortora, C. Quaglia, 63.42 M. Simi, R. Pickens, A. Menciassi, S.D. Herrell, 63.40 D.J. Scott, S.J. Tang, R. Fernandez, R. Bergs, Robots at Work

Part F

Part F | 63 1678 Medical Robotics and Computer-Integrated Surgery References 1679

plans, IEEE Robotics Autom. Mag. 18(3), 24–32 63.72 A. Krieger, R.C. Susil, C. Menard, J.A. Coleman, (2011) G. Fichtinger, E. Atalar, L.L. Whitcomb: Design of 63.58 J.B. Maintz, M.A. Viergever: A survey of medi- a novel MRI compatible manipulator for image cal image registration, Med. Image Anal. 2,1–37 guided prostate intervention, IEEE Trans. Biomed. (1998) Eng. 52, 306–313 (2005) 63.59 S. Lavallee: Registration for computer-integrated 63.73 T. Ungi, P. Abolmaesumi, R. Jalal, M. Welch, surgery: methodology, state of the Art. In: I. Ayukawa, S. Nagpal, A. Lasso, M. Jaeger, Computer-Integrated Surgery, ed. by R.H. Taylor, D. Borschneck, G. Fichtinger, P. Mousavi: Spinal atF|63 | F Part S. Lavallee, G. Burdea, R. Mosges (MIT Press, Cam- needle navigation by tracked ultrasound snap- bridge 1996) pp. 77–98 shots, IEEE Trans. Biomed. Eng. 59(10), 2766–2772 63.60 P.J. Besl, N.D. McKay: A method for registration of (2012) 3-D shapes, IEEE Trans. Pattern Anal. Mach. Intell. 63.74 D. DallAlba, B. Maris, P. Fiorini: A compact nav- 14, 239–256 (1992) igation system for free hand needle placement 63.61 R.J. Maciunas: Interactive Image-Guided Neuro- in percutaneous procedures, Proc. IEEE/RSI Int. surgery (AANS, Park Ridge 1993) Conf. Intell. Robots Syst. (IROS), Vilamoura (2012) 63.62 G. Fichtinger, A. Degeut, K. Masamune, E. Balogh, pp. 2013–2018 G. Fischer, H. Mathieu, R.H. Taylor, S. Zinreich, 63.75 G.A. Krombach, T. Schmitz-Rode, B.B. Wein, L.M. Fayad: Image overlay guidance for needle J. Meyer, J.E. Wildberger, K. Brabant, R.W. Gun- insertion on CT scanner, IEEE Trans. Biomed. Eng. ther: Potential of a new laser target system for 52, 1415–1424 (2005) percutaneous CT-guided nerve blocks: Technical 63.63 T. Akinbiyi, C.E. Reiley, S. Saha, D. Burschka, note, Neuroradiology 42, 838–841 (2000) C.J. Hasser, D.D. Yuh, A.M. Okamura: Dynamic 63.76 M. Rosenthal, A. State, J. Lee, G. Hirota, J. Acker- augmented reality for sensory substitution in man, K. Keller, E.D. Pisano, M. Jiroutek, K. Muller, robot-assisted surgical systems, Proc. 28th Annu. H. Fuchs: Augmented reality guidance for needle Int. Conf. IEEE Eng. Med. Biol. Soc. (2006) pp. 567– biopsies: A randomized, controlled trial in phan- 570 toms, Proc. 4th Int. Conf. Med. Image Comput. 63.64 J. Leven, D. Burschka, R. Kumar, G. Zhang, S. Blu- Comput. Interv. (2001) pp. 240–248 menkranz, X. Dai, M. Awad, G. Hager, M. Marohn, 63.77 G. Stetten, V. Chib: Overlaying ultrasound images M. Choti, C. Hasser, R.H. Taylor: DaVinci can- on direct vision, J. Ultrasound Med. 20,235–240 vas: A telerobotic surgical system with integrated, (2001) robot-assisted, laparoscopic ultrasound capabil- 63.78 H.F. Reinhardt: Neuronagivation: A ten years re- ity, Proc. Med. Image Comput. Comput. Interv. view. In: Computer-Integrated Surgery,ed.by Palm Springs (2005) R. Taylor, S. Lavallée, G. Burdea, R. Moegses (MIT 63.65 R.H. Taylor, H.A. Paul, C.B. Cutting, B. Mittelstadt, Press, Cambridge 1996) pp. 329–342 W. Hanson, P. Kazanzides, B. Musits, Y.Y. Kim, 63.79 E. Hempel, H. Fischer, L. Gumb, T. Hohn, A. Kalvin, B. Haddad, D. Khoramabadi, D. Larose: H. Krause, U. Voges, H. Breitwieser, B. Gutmann, Augmentation of human precision in computer- J. Durke, M. Bock, A. Melzer: An MRI-compatible integrated surgery, Innov. Technol. Biol. Med. 13, surgical robot for precise radiological interven- 450–459 (1992) tions, Comput. Aided Surg. 8, 180–191 (2003) 63.66 J. Troccaz, M. Peshkin, B. Davies: The use of local- 63.80 Z. Wei, G. Wan, L. Gardi, G. Mills, D. Downey, izers, robots and synergistic devices in CAS, Lect. A. Fenster: Robot-assisted 3D-TRUS guided Notes Comput. Sci. 1205, 727–736 (1997) prostate brachytherapy: system integration and 63.67 G. Brisson, T. Kanade, A.M. DiGioia, B. Jaramaz: validation, Med. Phys. 31, 539–548 (2004) Precision freehand sculptig of bone, Proc. Med. 63.81 E. Boctor, G. Fischer, M. Choti, G. Fichtinger, Image Comput. Comput.-Assist. Interv. (MICCAI) R.H. Taylor: Dual-armed robotic system for in- (2004) pp. 105–112 traoperative ultrasound guided hepatic ablative 63.68 R.A. Beasley: Medical Robots: Current systems and therapy: A prospective study, Proc. IEEE Int. Conf. research directions, J. Robotics 2012, 401613 (2012) Robot. Autom. (ICRA) (2004) pp. 377–382 63.69 S. Kuang, K.S. Leung, T. Wang, L. Hu, E. Chui, 63.82 J. Hong, T. Dohi, M. Hashizume, K. Konishi, W. Liu, Y. Wang: A novel passive/active hybrid N. Hata: An ultrasound-driven needle-insertion robot for orthopaedic trauma surgery, Int. J. Med. robot for percutaneous cholecystostomy, Phys. Robotics Comput. Assist, Surg. 8, 458–467 (2012) Med. Biol. 49, 441–455 (2004) 63.70 S. Solomon, A. Patriciu, R.H. Taylor, L. Kavoussi, 63.83 G. Megali, O. Tonet, C. Stefanini, M. Boc- D. Stoianovici: CT guided robotic needle biopsy: cadoro, V. Papaspyropoulis, L. Angelini, P. Dario: A precise sampling method minimizing radiation A computer-assisted robotic ultrasound-guided exposure, Radiology 225, 277–282 (2002) biopsy system for video-assisted surgery, Proc. 63.71 K. Masamune, G. Fichtinger, A. Patriciu, R. Susil, Med. Image Comput. Comput. Interv. (MICCAI), R. Taylor, L. Kavoussi, J. Anderson, I. Sakuma, Utrecht (2001) pp. 343–350 T. Dohi, D. Stoianovici: System for robotically as- 63.84 R.J. Webster III, J.S. Kim, N.J. Cowan, sisted percutaneous procedures with computed G.S. Chirikjian, A.M. Okamura: Nonholonomic tomography guidance, J. Comput. Assist. Surg. 6, modeling of needle steering, Int. J. Robotics Res. 370–383 (2001) 25(5-6), 509–525 (2006) ,90 6 , 101–110 6367 rd: The BlueDRAGON – ll, I. Simon: Telepresence: (7), 689–698 (2013) , 819–822 (2004) (4), 896–900 (2009) 63 309 73 (2), 356–366 (2011) 25 (9), 34–38 (2013) 3 7(1), 27–34 (2012) Taylor, G.D. Hager: Augmented reality during robot-assisted laparoscopic partial nephrectomy: Toward real-time 3D-CT to stereoscopic video reg- istration, Urology B. Schiltz, M. Jung,Augmented M. reality to Hagen, the O. rescue Ratib,invasive of P. the surgeon. Morel: minimally Theposition usefulness of of stereoscopicrobotic images the console, Int. J. in inter- Med. Robotics thesist. Comput. As- Surg. Da Vinci ity image guidance in minimallytectomy, invasive Lect. prosta- Notes Comput.(2010) Sci. M. Mitsuishi: Microsurgical robotic systemreoretinal for surgery, vit- Int. J.Surg. Comput. Assist. Radiol. P. Kazanzides, C.M. Riviere, Balicki, E.man, X. B. Gower, Vagvolgyi, P. He, Gehlbach, R.work J. Handa: X. toward Richa, Recent a microsurgical Liu, assistant for K. retinal Olds, R. Sznit- (1992) D. Skarecky: Robot-assisted versusprostatectomy: open A radical comparisonoutcomes, of Urology one surgeon’s Y.-S. Lu, A.I. Neugut, T.J.Robotically Herzog, assisted D.L. vs Hershman: laparoscopic hysterectomy among women with benignJ. gynecologic Am. disease, Med. Assoc. M. Sinanan, B.a Hannafo system fordynamics measuring of the minimally kinematics invasive surgicalvivo, and tools Proc. the in- IEEE Int.(2002) Conf. pp. Robotics 1876–1881 Autom. (ICRA) D.D. Yuh, G.D.segmentation Hager: of robot-assisted surgical Automatic motions, detectionProc. Med. Image and Comput. Comput.-Assist. Interv. (MICCAI) (2005) pp. 802–810 J. Schmidhuber: A system for roboticthat heart surgery learns toral networks, tie Proc. Int. knots(IROS) Conf. (2006) Intell. using pp. Robots 543–548 recurrent Syst. neu- of methods for objective surgicalSurg. skill Endosc. evaluation, rative surgery usingInt. learned Conf models, Robotics Autom. Proc.5292 (ICRA) IEEE (2011) pp. 5285– R.H. Advanced teleoperator technologyinvasive of surgery minimally (abstract), Surg. Endosc. Z. Yang, A. Darzi, P.Ä.Ä. Edwards: Augmented real- 63.107 F. Volonté, N.C. Buchs, F. Pugin, J. Spaltenstein, 63.108 D. Cohen, E. Mayer, D. Chen, A. Anstee, J. Vale, G.- 63.109 Y. Ida, N. Sugita, T. Ueta, Y. Tamaki, K. Tanimoto, 63.110 R. Taylor, J. Kang, I. Iordachita, G. Hager, 63.99 T. Ahlering, D. Woo, L. Eichel, D. Lee, R. Edwards, 63.100 J.D. Wright, C.V. Ananth, S.N. Lewin, W.M. Burke, 63.101 J. Rosen, J.D. Brown, L. Chang, M. Barreca, 63.102 H.C. Lin, I. Shafran, T.E. Murphy, A.M. Okamura, 63.103 H. Mayer, F. Gomez, D. Wierstra, I. Nagy, A. Knoll, 63.104 C.E. Reiley, H.C. Lin, D.D. Yuh, G.D. Hager: A review 63.105 N. Padoy, G. Hager: Human-machine collabo- 63.106 L.-M. Su, B.P. Vagvolgyi, R. Agarwal, C.E. Reiley, 63.98 P. Green, R. Satava, J. Hi , 19 10, 285–296 (2005) ans. Robotics Autom. , 825–841 (2003) (3–4), 371–378 (2008) 19 3 (1), 13–18 (2012) 6 (4), 1117–1122 (2010) 67 (2), 209–225 (2010) , 1389 (2002) 26 16 , ed. by J. Rosen, B. Hannaford, R.M. Satava , 521–529 (2013) (3), 267–279 (1996) 842–853 (2003) elin, G. Morel,Autonomous J. 3-D Leroy, positioningments L. of Soler, in surgical instru- J. robotizedvisual Marescaux: servoing, laparoscopic IEEE surgery Tr using M.J. Breault:evaluation Development of and pre-robotic andsystems initial robotic for retraction clinical surgery,Health Proc. Care Robotics, 2nd Newcastle Workshop (1989) Med. pp. 91– K. Zareinia: Merging machines with microsurgery: Clinical experience with neuroArm,118 J. Neurosurg. MOUSe: A novelcontrolling the human-machine position interfaceTrans Robot. of for Autom. a laparoscope, IEEE Percutaneous intracerebral navigationcycled by spinning duty- of flexible bevel-tippedNeurosurgery needles, D. Sabbadini, A.jczy: A Togno, new L.parscopic telerobotic surgery using application: Angelini, satellites Remote and optical A.K. la- figer networks for Be- data exchange,15 Int. J. Robotics Res. K. Tanaka, N. Sugita, K. Tanoue, K.Y. Konishi, S. Fujino, Ieiri, Y.M. Hashizume: Ueda, Impact of network H. time-delay and force Fujimoto, feedback on M.Assist. tele-surgery, Radiol. Mitsuishi, Int. Surg. J. Comput. C. Letoublon, F. Bouchard: Alaparoscopic compact, endoscope compliant manipulator,Int. Proc. Conf. IEEE Robotics Autom. (ICRA) (2002) pp. 1870– M. Curry, L.lor: Akst, A robotic R. assistant for Yung,robotic trans-oral endo-laryngeal surgery: J. fexible The (Robo-ELF) Richmon, scope, J. R. Robotic. Surg. Tay- R. Alterovitz, K. Reed, V. Kallem,A.M. W. Okamura: Park, S. Robotic Misra, needlemodeling, steering: planning, Design, andSurgical Robotics – image Systems Applications guidance.sions and Vi- In: (New York, Springer 2011) R. Rohling: Hand-heldIEEE/ASME steerable Trans. needle Mechatron. device, surgery, telepresence andEndosc. telementoring, Surg, and control of concentric-tube robots,Robotics IEEE Trans. 101 1875 63.97 A. Krupa, J. Gangloff, Doignon, C. M.F. deMath- 63.92 J.A. McEwen, C.R. Bussani, G.F. Auchinleck, 63.95 G.R. Sutherland, S. Lama, L.S. Gan, S. Wolfsberger, 63.96 A. Nishikawa, T. Hosoi, K. Koara, T. Dohi: FAce 63.85 J.A. Engh, D.S. Minhas, D. Kondziolka, C.N. Riviere: 63.90 A. Rovetta, R. Sala, R. Cosmi, X. Wen, S. Milassesi, 63.91 J. Arata, H. Takahashi, S. Yasunaka, K. Onda, 63.93 P. Berkelman, P. Cinquin, J. Troccaz, J. Ayoubi, 63.94 K. Olds, A. Hillel, J. Kriss, A. Nair, H. Kim, E. Cha, 63.86 N. Cowan, K. Goldberg, G. Chirikjian, G. Fichtinger, 63.87 S. Okazawa, R. Ebrahimi, J. Chuang, S. Salcudean, 63.89 G.H. Ballantyne: Robotic surgery, telerobotic 63.88 P.E. Dupont, J. Lock, B. Itkowitz, E. Butler: Design Robots at Work

Part F

Part F | 63 1680 Medical Robotics and Computer-Integrated Surgery References 1681

surgery, Proc. Hamlyn Symp. Med. Robotics, Lon- surgeons in microsurgery, Comput. Aided Surg. 4, don (2011) pp. 3–4 15–25 (1999) 63.111 B. Becker, S. Yang, R. MacLachlan, C. Riviere: To- 63.124 K. Hongo, S. Kobayashi, Y. Kakizawa, J.I. Koyama, wards vision-based control of a handheld micro- T. Goto, H. Okudera, K. Kan, M.G. Fujie, manipulator for retinal cannulation in an eyeball H. Iseki, K. Takakura: NeuRobot: Telecontrolled phantom, Proc. IEEE RAS EMBS Int. Conf. Biomed. micromanipulator system for minimally inva- Robotics Biomechatronics (BIOROB) (2012) pp. 44– sive microneurosurgery-preliminary results, Neu- 49 rosurgery 51, 985–988 (2002) atF|63 | F Part 63.112 M. Balicki, T. Xia, M.Y. Jung, A. Deguet, B. Vagvol- 63.125 A. Kapoor, R. Kumar, R. Taylor: Simple bioma- gyi, P. Kazanzides, R. Taylor: Prototyping a hybrid nipulation tasks with a steady hand cooperative cooperative and tele-robotic surgical system manipulator, Proc. 6th Int. Conf. Med. Image for retinal microsurgery, Proc. MICCAI Workshop Comput. Comput. Assist. Interv. (MICCAI), Montreal Syst. Archit. Comput. Assist. Interv. Tor. (2011), (2003) pp. 141–148 Insight, http://www.midasjournal.org/browse/ 63.126 R. MacLachlan, B. Becker, J. Cuevas-Tabarés, publication/815 G. Podnar, L. Lobes, C. Riviere: Micron: An ac- 63.113 C. Bergeles, B.E. Kratochvil, B.J. Nelson: Visually tively stabilized handheld tool for microsurgery, servoing magnetic intraocular microdevices, IEEE IEEE Trans. Robotics 28(1), 195–212 (2012) Trans. Robotics 28(4), 798–809 (2012) 63.127 B. Becker, R. MacLachlan, L. Lobes, G. Hager, 63.114 Patent N. Simaan, J. T. Handa, R. H. Taylor: C. Riviere: Vision-based control of a hand- A system for macro-micro distal dexterity en- held surgical micromanipulator with virtual hancement in microsurgery of the eye, Patent US fixtures, IEEE Trans. Robotics 29(3), 674–683 20110125165 A1 (2011) (2013) 63.115 X. He, D. Roppenecker, D. Gierlach, M. Bal- 63.128 C. Riviere, J. Gangloff, M. de Mathelin: Robotic icki, K. Olds, J. Handa, P. Gehlbach, R.H. Tay- compensation of biological motion to enhance lor, I. Iordachita: Toward a clinically applicable surgical accuracy, Proceedings IEEE 94(9), 1705– steady-hand eye robot for vitreoretinal surgery, 1716 (2006) Proc. ASME Int. Mech. Eng. Congr., Houston (2012) 63.129 W. Armstrong, A. Karamzadeh, R. Crumley, T. Kel- p. 88384 ley, R. Jackson, B. Wong: A novel laryngoscope 63.116 J.K. Niparko, W.W. Chien, I. Iordachita, J.U. Kang, instrument stabilizer for operative microlaryn- R.H. Taylor: Robot-assisted, sensor-guided goscopy, Otolaryngol. Head Neck Surg. 132, 471–477 cochlear implant electrode insertion (Abstract (2004) in Proceedings), Proc. 12th Int. Conf. Cochlear 63.130 L. Ascari, C. Stefanini, A. Menciassi, S. Sahoo, Implant. Other Implant. Auditory Technol., P. Rabischong, P. Dario: A new active microendo- Baltimore (2012) scope for exploring the sub-arachnoid space in 63.117 D. Schurzig, R.F. Labadie, A. Hussong, T.S. Rau, the spinal cord, Proc. IEEE Conf. Robotics Autom. R.J. Webster: Design of a tool integrating force (ICRA) (2003) pp. 2657–2662 sensing with automated insertion in cochlear 63.131 U. Bertocchi, L. Ascari, C. Stefanini, C. Laschi, implantation, IEEE/ASME Trans. Mechatron. 17(2), P. Dario: Human-robot shared control for 381–389 (2012) robot-assisted endoscopy of the spinal cord, 63.118 B. Bell, C. Stieger, N. Gerber, A. Arnold, C. Nauer, Proc. IEEE/RAS/EMBS Int. Conf. Biomed. Robot. V. Hamacher, M. Kompis, L. Nolte, M. Caver- Biomechatronics (2006) pp. 543–548 saccio, S. Weber: A self-developed and con- 63.132 A. Cuschieri, G. Buess, J. Perissat: Operative Man- structed robot for minimally invasive cochlear ual of Endoscopic Surgery (Springer, Berlin, Hei- implantation, Acta Oto-Laryngol. 132(4), 355–360 dleberg 1992) (2012) 63.133 Stereotaxis: The epoch (TM) solution: The heart of 63.119 J.R. Clark, L. Leon, F.M. Warren, J.J. Abbott: Mag- innovation, http://www.stereotaxis.com/ (2013) netic guidance of cochlear implants: Proof-of- 63.134 Endosense, TactiCath Quartz – The First Con- concept and initial feasibility study, Trans. ASME- tact Force Ablation Catheter: http://neomed.net/ W-J. Medical Devices 6(4), 35002 (2012) portfolio/endosense_sa (2013) 63.120 J. Schiff, P. Li, M. Goldstein: Robotic microsur- 63.135 K.J. Rebello: Applications of MEMS in surgery, Pro- gical vasovasostomy and vasoepididymostomy: ceedings IEEE 92(1), 43–55 (2004) A prospective randomized study in a rat model, 63.136 I. Kassim, W.S. Ng, G. Feng, S.J. Phee: Review of J. Urol. 171, 1720–1725 (2004) locomotion techniques for robotic colonoscopy, 63.121 S. Parekattil, M. Cohen: Robotic microsurgery. Proc. Int. Conf. Robotics Autom. (ICRA), Taipei In: Robotic Urologic Surgery, ed. by V.R. Patel (2003) pp. 1086–1091 (Springer, London 2012) pp. 461–470 63.137 Endotics: The endotics system, http://www. 63.122 P.S. Jensen, K.W. Grace, R. Attariwala, J.E. Colgate, endotics.com/en/product (2012) M.R. Glucksberg: Toward robot assisted vascular 63.138 Gi-View: The AeroScope, http://www.giview.com/ microsurgery in the retina, Graefes Arch. Clin. Exp. (2013) Ophthalmol. 235, 696–701 (1997) 63.139 Invendo-Medical: Gentle colonoscopy with in- 63.123 H. Das, H. Zak, J. Johnson, J. Crouch, D. Fram- vendoscopy, http://www.invendo-medical.com/ baugh: Evaluation of a telerobotic system to assist (2013) , 3 (4), 4 , 10–17 (2003) 8 (3), 584–589 (2001) 48 (15), 16567–16583 (2012) (1), 200–206 (2013) 20 (3), 318–323 (1995) 33 (2), 1316–1324 (2013) 14 4 062–1076 (2012) Robot-assisted microsurgery: A feasibility study in the rat, Neurosurgery Force sensingtissue microinstrument properties forIEEE/ASME and Trans. measuring Mechatron. pulse inP. microsurgery, Gehlbach, R.A Taylor, Force-sensing I. microsurgical Iordachita,detects J. instruments forces Handa: that belowRetina human tactile sensation, S.J. Phee, J. Handa, P. Gehlbach,millimetric, R. Taylor: 0.25 A sub- mNfiber-optic resolution force-sensing fully tool integrated forsurgery, Int. retinal J. Comput. micro- Assist.383–390 Radiol. Surg. (2009) P. Gehlbach,sensing R.H. micro-forceps Taylor, forsurgery, I. robot Proc. assisted Iordachita: Eng. retinal pp. Med. Force 1401–1404 Biol., San Diego (2012) Miniature fiber-optic force sensornal microsurgery for based on vitreoreti- low-coherence Fabry- Perot interferometry,1 Biomed. Opt. Express J. Handa, R.H. Taylor, J.coherence Kang: tomography Single microsurgical instruments fiber optical for computer and robot-assistedProc. retinal Med. Image surgery, Comput. Comput.-Assist. Interv. (MICCAI), London (2009) pp. 108–115 P. Gehlbach, J. Kang, P. Kazanzides,teractive R. OCT Taylor: annotation In- and visualization system for vitreoretinal surgery,Augment. Proc. Environ. MICCAI Comput. Interv. Workshop (AE-CAI),(2012) Nice freehand-scanning OCT implemented withtime real- scanning speedExpress variance correction, Opt. P. Gehlbach, J.lor, McGready, J. I. Handa: Iordachita, Auditorytion R. improves force surgical Tay- precision feedback during simulated substitu-ophthalmic surgery, Investig.Sci. Ophthalmol. Vis. Remote palpation technology,Biol. IEEE Eng. Med. lamini, M.force Marohn, sensing surgical R. instrumentsing for available Taylor: augment- surgeon information, Proc.Conf. Ischemia IEEE Biomed. Int. and Robot. BiomechatronicsPisa (2006) (BioRob), T. Grantcharov, N.K. Francis, G.B. Hanna, J.J.mowicz: Jaki- Consensus guidelines for validation of 63.155 P.D.L. Roux, H. Das,63.156 S. Esquenazi, A. P.J. Menciassi, A. Kelly: Eisinberg, M.C. Carrozza, P. Dario: 63.157 S. Sunshine, M. Balicki, X. He, K. Olds, J. Kang, 63.158 I. Iordachita, Z. Sun, M. Balicki, J.U. Kang, 63.159 I. Kuru, B. Gonenc, M. Balicki,63.160 J. Handa, X. Liu, I.I. Iordachita, X. He, R.H. Taylor, J.U. Kang: 63.161 M. Balicki, J.-H. Han, I. Iordachita, P. Gehlbach, 63.162 M. Balicki, R. Richa, B. Vagvolgyi, J. Handa, 63.163 X. Liu, Y. Huang, J.U. Kang: Distortion-free 63.164 N. Cutler, M. Balicki, M. Finkelstein, J. Wang, 63.165 R.D. Howe, W.J. Peine, D.A. Kontarinis, J.S.63.166 Son: G. Fischer, T. Akinbiyi, S. Saha, J. Zand, M. Ta- 63.167 F.J. Carter, M.P. Schijven, R. Aggarwal, ,541– , 2035– 42 ,ed.by 42 1(3), 26–41 (3), 252–262 , 59–72 (2011) 16 4 , 551–560 (2006) , 1212–1221 (1999) 25 46 , 199–207 (2010) ds for haptic feedback in 28 (8), 643–649 (2000) Computer Integrated Surgery 16 (1), 169–179 (2008) 13 , 499–508 (2004) , 461–465 (1999) , 215–222 (1995) (2010) doscopy: Fromchallenges, current IEEE Rev. Biomed. achievements Eng. to open flexible . . . and stiff, too IEEE Pulse experiments on a leggedin microrobot locomoting a tubular,ment, compliant Int. J. and Robotics Res. slippery environ- magnetic steering and locomotion of capsuledoscope en- for diagnostic andprocedures, surgical Robotica endoluminal K. Ikeda, H. Aihara,H. I. Tajiri: Pangtay, Feasibility T. ofa Hibi, stomach guided S. capsule exploration Kudo, endoscope, with Endoscopy fanini, P. Dario: Design and fabricationlegged of a capsule motor for thegastrointestinal active tract, exploration of IEEE/ASMEtron. the Trans. Mecha- teleoperated robot-assisted surgery, Ind.31 Robot through sensory substitution,3 Contr. Eng. Pract. tion of tactilesurgery, Proc. sensation 2ndput. during Int. Comput.-Assist. Conf. Interv. retinal (MICCAI), Med.(1999) Cambridge micro- Image Com- A.C. Barnes, C.Human Yang, versus R.H. robotic organ Taylor, retraction M.A. duringparoscopic la- Talamini: nissen fundoplication,13 Surg. Endosc. M. Sinanan:ated Force endoscopic grasper controlledsurgery for – minimally Experimental and performance invasive IEEE evaluation, Trans. teleoper- Biomed. Eng. Robotic assistance inMicrosurg. microsurgery, J. Reconstr. 545 (2010) Magnetic stereotaxis: Computerguided assisted, image remote movementbrain. In: of implantsR.H. Taylor, in S. the (MIT Lavallee, Press, G.C. Cambridge Burdea, 1995) R. pp. Mosges 363–369 R.D. Howe:surgery: The Examination benefit ofence: blunt of Teleoperators Virtual Environ. dissection, force Pres- (2007) feedback in tion: A historical survey, Automatica 2057 (2006) 63.141 G. Ciuti, A. Menciassi, P. Dario: Capsule en- 63.140 A. Loeve, P. Breeveld, J. Dankelman: Scopes too 63.142 C. Stefanini, A. Menciassi, P. Dario: Modeling and 63.143 G. Ciuti, P. Valdastri, A. Menciassi, P.Dario: Robotic 63.144 J.F. Rey, H. Ogata, N. Hosoe, K. Ohtsuka, N. Ogata, 63.148 M. Quirini, A. Menciassi, S. Scapellato, C. Ste- 63.149 A.M. Okamura: Metho 63.150 M.J. Massimino: Improved63.151 force P. perception Gupta, P. Jensen, E. de Juan: Quantifica- 63.152 P.K. Poulose, M.F. Kutka, M. Mendoza-Sagaon, 63.153 J. Rosen, B. Hannaford, M.63.154 MacFarlane, M. Siemionow, K. Ozer, W. Siemionow, G. Lister: 63.145 R.C. Ritter, M.S. Grady, M.A. Howard, G.T. Gilles: 63.146 C.R. Wagner, N. Stylopoulos, P.G. Jackson, 63.147 P.F. Hokayem, M.W. Spong: Bilateral teleopera- Robots at Work

Part F

Part F | 63 1682 Medical Robotics and Computer-Integrated Surgery References 1683

virtual reality surgical simulators, Surg. Endosc. 63.178 D. Zerbato, L. Vezzaro, L. Gasperotti, P. Fiorini: Vir- 19, 1523–1532 (2005) tual training for US guided needle insertion, Proc. 63.168 A. Gavazzi, W.V. Haute, K. Ahmed, O. Elhage, Comput. Assist Radiol. Surg., Berlin (2012) pp. 27– P. Jaye, M.S. Khan, P. Dasgupta: Face, content and 30 construct validity of a virtual reality simulator for 63.179 Lapmentor: http://www.simbionix.com robotic surgery (SEP Robot), Ann. R. Coll. Surg. 63.180 Surgical Education platform: http://www.meti. Engl. 93, 146–150 (2011) com 63.169 F.H. Halvorsen, O.J. Elle, E. Fosse: Simulators in 63.181 LapSim: http://www.surgical-science.com atF|63 | F Part surgery, Minim. Invasive Ther. 14, 214–223 (2005) 63.182 MIST: http://www.mentice.com 63.170 T. Ungi, D. Sargent, E. Moult, A. Lasso, C. Pinter, 63.183 EndoTower: http://www.verifi.com R. McGraw, G. Fichtinger: Perk Tutor: An open- 63.184 Laparoscopic Trainer: http://www.reachin.se source training platform for ultrasound-guided 63.185 Simendo: http://www.simendo.nl needle insertions, IEEE Trans. Biomed. Eng. 59(12), 63.186 Vest System: http://www.select-it.de 3475–3481 (2012) 63.187 EYESI: http://www.vrmagic.com/ 63.171 E. Moult, T. Ungi, M. Welch, J. Lu, R. McGraw, 63.188 U. Verona: Xron - Surgical simulator by ALTAIR lab, G. Fichtinger: Ultrasound-guided facet joint in- http://metropolis.scienze.univr.it/xron/ (2013) jection training using Perk Tutor, Int. J. Comput. 63.189 F. Cavallo, G. Megali, S. Sinigaglia, O. Tonet, Assist. Radiol. Surg. 8(5), 831–836 (2013) P. Dario: A biomechanical analysis of surgeon’s 63.172 T.K.A. Kesavadas, G. Srimathveeravalli, S. Karim- gesture in a laparoscopic virtual scenario. In: puzha, R. Chandrasekhar, G. Wilding, G.K.Z. Butt: Medicine Meets Virtual Reality,Vol.14,ed.by Efficacy of robotic surgery simulator (RoSS) for the J.D. Westwood, R.S. Haluck, H.M. Hoffmann, davinci surgical system, J. Urol. 181(4), 823 (2009) G.T. Mogel, R. Phillips, R.A. Robb, K.G. Vosburgh 63.173 C. Perrenot, M. Perez, N. Tran, J.-P. Jehl, J. Fel- (IOS, Amsterdam 2006) pp. 79–84 blinger, L. Bresler, J. Hubert: The virtual reality 63.190 S. Yule, R. Flin, S. Paterson-Brown, N. Maran: simulator dV-Trainer is a valid assessment tool for Non-technical skills for surgeons: A review of the robotic surgical skills, Surg. Endosc. 26(9), 2587– literature, Surgery 139, 140–149 (2006) 2593 (2012) 63.191 K.T. Kavanagh: Applications of image-directed 63.174 R. Korets, J. Graversen, M. Gupta, J. Landman, robotics in otolaryngologic surgery, Laryngoscope K. Badani: Comparison of robotic surgery skill ac- 194, 283–293 (1994) quisition between DV-Trainer and da Vinci surgi- 63.192 J. Wurm, H. Steinhart, K. Bumm, M. Vogele, cal system: A randomized controlled study, J. Urol. C. Nimsky, H. Iro: A novel robot system for fully 185(4), e593 (2011) automated paranasal sinus surgery, Proc. Com- 63.175 K. Moorthy, Y. Munz, S.K. Sarker, A. Darzi: Objec- put. Assist. Radiol. Surg. (CARS) (2003) pp. 633– tive assessment of technical skills in surgery, Br. 638 Med. J. 327, 1032–1037 (2003) 63.193 M. Li, M. Ishii, R.H. Taylor: Spatial motion con- 63.176 C. Basdogan, S. De, J. Kim, M. Muniyandi, H. Kim, straints in medical robot using virtual fixtures M.A. Srinivasan: Haptics in minimally invasive generated by anatomy, IEEE Trans. Robot. 2,1270– surgical simulation and training, IEEE Comput. 1275 (2006) Graph. Appl. 24(2), 56–64 (2004) 63.194 G. Strauss, K. Koulechov, R. Richter, A. Di- 63.177 M. Altomonte, D. Zerbato, S. Galvan, P. Fiorini: etz, C. Trantakis, T. Lueth: Navigated control Organ modeling and simulation using graphical in functional endoscopic sinus surgery, Int. processing, Poster Sess. Comput. Assist. Radiol. J. Med. Robot. Comput. Assist. Surg. 1, 31–41 Surg., Berlin (2007) (2005)