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Medical Robotics: Minimally Invasive Surgery

Medical Robotics: Minimally Invasive Surgery

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Medical Robotics: Minimally Invasive Surgery

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602 pages
7 hours
Dirilis:
Oct 18, 2012
ISBN:
9780857097392
Format:
Buku

Deskripsi

Advances in research have led to the use of robotics in a range of surgical applications. Medical robotics: Minimally invasive surgery provides authoritative coverage of the core principles, applications and future potential of this enabling technology.

Beginning with an introduction to robot-assisted minimally invasive surgery (MIS), the core technologies of the field are discussed, including localization and tracking technologies for medical robotics. Key applications of robotics in laparoscopy, neurology, cardiovascular interventions, urology and orthopaedics are considered, as well as applications for ear, nose and throat (ENT) surgery, vitreoretinal surgery and natural orifice transluminal endoscopic surgery (NOTES). Microscale mobile robots for the circulatory system and mesoscale robots for the gastrointestinal tract are investigated, as is MRI-based navigation for in vivo magnetic microrobots. Finally, the book concludes with a discussion of ethical issues related to the use of robotics in surgery.

With its distinguished editor and international team of expert contributors, Medical robotics: Minimally invasive surgery is a comprehensive guide for all those working in the research, design, development and application of medical robotics for surgery. It also provides an authoritative introduction for academics and medical practitioners working in this field.
  • Provides authoritative coverage of the core principles, applications and future potential of medical robotics
  • Introduces robot-assisted minimally invasive surgery (MIS), including the core technologies of the field and localization and tracking technologies for medical robotics
  • Considers key applications of robotics in laparoscopy, neurology, cardiovascular interventions, urology and orthopaedics
Dirilis:
Oct 18, 2012
ISBN:
9780857097392
Format:
Buku

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Medical Robotics - Elsevier Science

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Introduction

P. Gomes,     Cambridge Consultants, UK

Surgeons continuously push barriers to develop surgical procedures and techniques which result in patient benefits and better clinical outcomes. As the trend towards minimally invasive surgery (MIS) increases, surgery becomes more technically demanding for surgeons and more challenging for medical device technologists. It is clear that robotics has now an established foothold in medicine as an enabling technology for MIS as this book demonstrates. Written by both medical practitioners and engineers, the book covers a wide range of clinical applications: laparoscopy, gastrointestinal, neurology, cardiovascular, otorhinolaryngology, vitreoretinal, urology, orthopaedics. Commercially available and under-development surgical robots are discussed; insights into future directions are provided.

The first recorded robotic surgical procedure took place on 11 April 1985, at the Memorial Medical Center, Long Beach, CA, USA (Kwoh et al., 1988). An industrial robot was used to assist a computerized tomography (CT) guided brain biopsy. The rationale was to use a sturdy mechanical structure to hold a guide steadily in position so that a probe could be inserted to reach a surgical target deep in the brain in a linear trajectory avoiding vital structures of the brain. The straight trajectory was defined by the surgeon using CT guidance such that there was no neurological damage caused by the probe. The gold standard procedure at the time was to use a manually adjustable stereotactic frame and it was intended, with the use of the robot, to achieve improved accuracy and a faster procedure. Although the robot used was capable of autonomous motion, it was locked in position, with power removed for safety once aligned with the trajectory, while the surgeon inserted the biopsy needles, through the guide, into the patient’s brain.

There was a long gap of six years until the next milestone in robotic surgery: the first time a robotic device was used to autonomously remove a significant amount of tissue from a patient, in a transurethral resection of the prostate (TURP), a minimally invasive surgical procedure. The device used was the Probot, a special purpose robot developed at Imperial College London, and first used in surgery in April 1991 in London, UK (Davies et al., 1991). John E. A. Wickham was the urologist surgeon who operated with the Probot system. Wickham coined the term MIS and vigorously promoted this type of surgery (Wickham, 1987). MIS refers to any procedure which is less invasive than open surgery for the same purpose.

As was the case with industrial robotics, surgical robotics started under the premise that higher accuracy and speed could be achieved in surgery, particularly when precise targeting (such as that required in neurosurgery) or repetitive tasks (such as resecting a prostate gland with a wire loop resectoscope in a TURP) were required. This is corroborated by first reports of robot-assisted surgeries. Kwoh et al. (1988) claim improved accuracy and faster procedures as the rationale for their adoption of robotics in brain biopsy. Davies et al. (1991) indicate a dramatic potential reduction of TURP times from 1 h to 5 min.

It was not before 1994 that the US Food and Drug Administration cleared Computer Motion’s ZEUS® Robotic Surgical System; this became the first commercial robotic device to assist surgeons in the operating room. ZEUS had three robotic arms, which were controlled remotely by the surgeon. Two robotic arms acted like extensions of the surgeon’s arms, following the surgeon’s movements while allowing for more precise executions by scaling down movements and eliminating tremors resulting from fatigue. The third arm was a voice-activated endoscope named AESOP® (automated endoscopic system for optimal positioning), the function of which was to manipulate a video camera inside the patient according to voice controls provided by the surgeon. AESOP® eliminated the need for a member of the surgical team to hold the endoscope and allowed the surgeon to directly and precisely control the operative field of view, providing a steady picture during MIS. Following patent legal disputes between Computer Motion and its competitor Intuitive Surgical (Sunnyvale, CA, USA), the two companies merged in 2003 and Computer Motion’s products were discontinued in favour of Intuitive’s da Vinci® robotic system.

Although the quest for increased accuracy seems to have been fulfilled, albeit dependent on factors such as imaging and image processing, registration of imaging to the robotic system, and calibration of instrumentation, the claim of reduced times has not been as successfully met and, despite significant improvements in efficiency and workflow, set-up times often make robotic procedures lengthier than their conventional counterparts. This poses a conflict for surgeons and healthcare providers, as fewer procedures can be carried out by the surgeon, and has made the health economics case for surgical robotics a difficult one to argue. However, despite procedure times remaining important and a fundamental market driver, other reasons are driving the adoption of surgical robotics: patient demand, reduction of surgical errors, augmenting surgical capabilities and enabling MIS.

Adding to the surgical and technical complexities, commercial, regulatory and legal restraints can slow down progress and, sometimes, delay and even block the development of new devices. A device that has a higher price than a current one has to show cost effectiveness and requires development of a reimbursement case to gain acceptance in the market place. The ultimate objective of surgical robotics is to improve surgical outcome but the higher costs need to be offset by significantly greater measurable clinical benefits. The regulatory burden on medical device approval is high; the process is slow and favours incremental development rather than radical advances. Intellectual property protection is a double-edged sword and acts both as a driver and as a restraint in the development of surgical robotics and advanced medical technology in general. Although research and innovation are incentivised, because inventors can fend off competitors for a period of time, manufacturers are also forced to design workarounds to avoid patent litigation and may indeed be discouraged from innovating in a particular field altogether.

The practice of robotic surgery is still largely dominated by the da Vinci® system, as manifested by recurrent references throughout this book, but other commercial players have now entered the market with surgical robotic products or are appearing on the horizon with medium and long-term propositions. Surgical robotics is currently a vibrant research topic and new research directions may lead to the development of very different robotic surgical devices in the future: small, special purpose, procedure-specific, lower cost, possibly disposable robots rather than the current large, versatile and capital expensive systems. This is a departure from current multimillion dollar, multifunction ‘platform’ robotic systems, towards low-cost, specific-function, even single-use, micro- or nano-devices. It is too early to predict the winning propositions. Several are reviewed in this book and illustrate what the future may bring.

Chapter 1, by Valentina Vitiello, Ka-Wai Kwok and Guang-Zhong Yang, provides an overview of robot-assisted minimally invasive surgery, including flexible robots for interventional procedures, and introduces recent developments in the integration of synergistic controls such as virtual fixtures, dynamic active constraints, and perceptual docking.

In MIS, where there is no direct view of the surgical site, surgeons need to know with confidence and in real time where the surgical tools are within the patient’s body so therapy is delivered to the correct anatomical location in a safe manner. Moreover, in computer-assisted and robotic surgery, the physical locations of the patient and of the surgical instruments have to be accurately mapped to each other and, in image-based surgery, to a preoperative patient’s computer model reconstructed from magnetic resonance (MR) or CT images. This is the focus of Chapter 2, where Neil Glossop discusses technologies enabling localisation and position tracking and reviews general requirements for such sensors. Glossop also surveys the main position sensors currently in use and under development, as well as the advantages and drawbacks of the various technologies available and emerging.

Chapter 3, by Tyler Cossetto, Kourosh Zareinia and Garnette Sutherland, focuses on neurosurgery and reviews the evolution of neurosurgical robots, from the first experiences by Kwoh et al. (1988) to robots designed to operate with intraoperative magnetic resonance imaging (MRI) resection control to allow for correction for brain shift. An example of the latter, the neuroArm, an image-guided MR-compatible robot for microsurgery and stereotaxy, first used in May 2008 to carry out the surgical removal of a brain lesion, is presented in detail. The chapter also discusses what the future in robotic neurosurgery may bring.

Marco Zenati and Mohsen Mahvash examine robotic systems for cardiovascular interventions in Chapter 4, including available commercial robots, other robotic concepts at the research stage and a discussion of likely future trends. The chapter contains a review of heart conditions and various interventional approaches for treatment, and a reflection on the evolving roles of cardiac surgeons and cardiologists which are being redefined and shaped by technology.

The following two chapters are dedicated to orthopaedic surgery. Chapter 5, by Antony Hodgson, provides a review of the state-of-the-art in orthopaedic robotics and describes five systems commercially available today, encompassing autonomous, active-constraints/collaborative and passive toolholders. Four of the systems are used in joint replacement arthroplasty, the fifth in spinal pedicle screw placement. Autonomous and collaborative systems pave the way for bone-conserving procedures that fit within the broad definition of MIS.

One of the five systems referred to by Hodgson is the object of an in-depth analysis of robot-assisted total knee replacement (TKR) surgery in Chapter 6, written by Christopher Plaskos, Jan Koenig, and Corey Ponder. The chapter provides background information and an overview of conventional and MIS TKR and reports extensive clinical experience with the Apex Robotic Technology (ART) system. The chapter concludes with developments needed to allow widespread adoption of robotic technology in orthopaedics.

Robotic devices available commercially for laparoscopic, cardiovascular, neurological and orthopaedic indications are discussed in the first six chapters. The remainder of the book addresses new applications of robotic technology in ear, nose and throat (ENT), eye, gastrointestinal and natural orifice transluminal endoscopic surgery (NOTES) surgeries.

In Chapter 7, Brett Bell, Marco Caversaccio and Stefan Weber discuss robotics in ENT surgery, a particularly challenging application owing to the small size and complicated layout of the anatomical structures, especially in the middle ear. For nose surgery, MIS has the additional advantage of reduced aesthetic impact. In the absence of commercially available robotic systems specific to head and neck surgery, the authors evaluate the use of the da Vinci® telemanipulator in this specialty and present research efforts directed at procedure-specific devices.

Chapter 8, written by Thijs Meenink, Ron Hendrix, Maarten Beelen, Henk Nijmeijer, Maarten Steinbuch, Gerrit Naus, Eric van Oosterhout and Marc de Smet, focuses on robot-assisted vitreoretinal surgery. As in ENT, the accuracy required to perform eye surgery is challenging and robotics can overcome human limitations. The chapter describes in detail a proof-ofconcept demonstrator of a novel master–slave robotic device and lays out the plans for its development to a clinical system.

Ten years ago, all gall bladder removals were done via open surgery in the US. Today, nearly all of these cholecystectomies are performed laparoscopically through three small incisions. The first single-incision laparoscopic surgery (SILS) for cholecystectomy was reported in 1997. SILS, also known as LESS (laparo-endoscopic single site) surgery, has the potential to reduce postoperative pain and port-site complications and, with careful incision closure, can result in no visible scars. Natural orifice surgery (NOS) and NOTES are the ultimate paradigm as there is no external incision. In Chapter 9, Jason Reynoso, Avishai Meyer, Jayaraj Unnirevi and Dmitry Oleynikov review the MIS, SILS and NOTES approaches, presenting overviews, techniques, advantages, disadvantages and clinical applications for the three approaches. Existing robotic technology and technology in development are described and future trends are indicated and analysed.

Chapter 10, by Jenna Gorlewicz, Robert Webster III and Pietro Valdastri, focuses on untethered mobile robots for gastrointestinal MIS which can enter the body through a natural orifice or a small incision and make their way to a target surgical site. An overview of commercial wireless capsule endoscopes is provided. An analysis of the major modules of robotic capsules, which enhance diagnosis and deliver therapy, and of the current technical progress of each of these modules is presented. Perspectives on the future of mobile surgical devices are put forward.

Chapter 10 reviews the state-of-the-art in mesoscale robots (1–100 mm) for the gastrointestinal tract, while Chapter 11 addresses microrobots (a few tens of micrometres) for the circulatory system. Although the former can move freely through the GI tract using peristalsis and can be relatively large, the latter require active locomotion and have tighter size constraints, because the diameters of blood vessels range from 25 mm for the aorta down to 0.01 mm for the capillaries. In chapter 11, Karim Belharet, David Folio and Antoine Ferreira discuss MRI-based navigation for in vivo magnetic microrobots and propose an image-processing technique and control algorithms for path planning, tracking and control using a clinical MRI system.

In the final chapter of this book, Chapter 12, Noel Sharkey and Amanda Sharkey debate ethical issues posed by the use of robotics in healthcare and warn of the difficulties that could arise in the future. Their concerns address the patient’s experience of robotic surgery, remote telesurgery, automated hospitals and medical care, the marketing of medical robotic systems, surgical training and issues of cost versus access. They conclude that there is much to suggest that medical robotics technology will be of great benefit over the coming years, but we must not let the promise of revolutionary new technology blind us to the difficulties and ethical issues involved in the early stages of developing such technologies.

The editor would like to express her thanks and gratitude to the authors, technologists and clinicians, industrialists and researchers, for their contributions. Without their expertise, dedication, hard work, generosity with their valuable time and willingness to share their knowledge, insights and research results, this book would not have been realised.

Sincere thanks also to the staff at Woodhead Publishing for their professional support and input into this project. Special thanks to Laura Overend, Commissioning Editor, for her invitation to edit this book, her guidance when needed, her patience with my belated responses and for driving this project to its successful conclusion; to Lucy Beg, Publications Coordinator, for liaising and managing all the communications with the authors; and to Cathryn Freear, Senior Project Editor, for working on the manuscript and preparing it for handover to the production department.

References

Davies, B. L., Hibberd, R. D., Ng, W. S., Timoney, A. G., Wickham, J. E. A. A surgeon robot for prostatectomies. Fifth International Conference on Advanced Robotics (ICAR), 1991:871–875.

Kwoh, Y. S., Hou, J., Jonckheere, E. A., Hayati, S. A robot with improved absolute positioning accuracy for CT guided stereotactic brain surgery. IEEE Trans Biomed Eng February. 1988; 35(2):153–160.

Wickham, J. E. A. The new surgery. Br Med J. 1987; 295(6613):1581–1582.

1

Introduction to robot-assisted minimally invasive surgery (MIS)

V. Vitiello, K.-W. Kwok and G.-Z. Yang,     The Hamlyn Centre for Robotic Surgery, Imperial College London, UK

Abstract:

It is well recognised that the performance of minimally invasive surgery (MIS) imposes an increasing burden on surgeons’ manual dexterity and visuomotor control. Tissue deformation, restricted workspace, and a limited field-of-view make manual operation of the procedure difficult. With the advent of robot assisted MIS, manual dexterity is enhanced by microprocessor controlled mechanical wrists, allowing motion scaling and tremor removal. Further enhancement of three-dimensional (3D) vision and intra-operative image guidance permits improved clinical uptake of the technology, ensuring better operative safety and consistency. This chapter provides a detailed overview of robotic surgical systems and introduces recent developments in the integration of synergistic controls such as virtual fixtures, dynamic active constraints, and perceptual docking.

Key words

minimally invasive surgery

medical robotics

robot-assisted surgery

virtual fixtures

perceptual docking

1.1 Introduction

In the past few decades, surgical practice has been revolutionised by the introduction of advanced instrumentation enabling a paradigm shift from traditional open surgery to minimally invasive surgery (MIS). The main advantage of MIS is attributed to a reduction in patient trauma, resulting in faster recovery and lower hospitalisation costs. However, the very nature of MIS, laparoscopy for example, which involves the use of long, rigid tools inserted into the patient via small incisions, can introduce a range of ergonomic challenges. The loss of wrist articulation together with the fulcrum effect caused by the inversion of motion direction at the trocar, limits the manual dexterity of the surgeon. In addition, the use of a separate display to convey the visual feedback from a laparoscopic camera separates the visuomotor axes, thus affecting the hand-eye coordination of the surgeon (Howe and Matsuoka, 1999).

Improved control and dexterity is one of the main benefits of robotic technologies for MIS. Mechatronically enhanced surgical instruments have been designed to compensate for the loss of wrist articulation caused by the traditional approach. Together with the introduction of master–slave control, this has contributed to the safety and consistency of MIS (Camarillo et al., 2004). However, even with the current state-of-the-art robotic surgical systems, such as the da Vinci from Intuitive Surgical Inc. (Guthart and Salisbury, 2000), tools are still rigid and require careful port placement to ensure required access and workspace for a given procedure. Safe performance of surgical interventions within the tight confines of the chest or cluttered peritoneal cavity involving large-scale tissue deformation is a significant challenge. Current medical robotics research is therefore focused on the integration of multiple control modalities such as perceptual docking and virtual fixtures together with enhanced visualisation and intraoperative image guidance.

Historically, most initial research in medical robotics has been directed to overcoming known limitations of industrial robots, particularly in terms of adaptability and autonomy. The main perceptual differences between humans and robots lie in the ability of processing qualitative and quantitative information. Robots can integrate a large amount of quantitative data precisely through different sensors, thus being able to perform and repeat repetitive tasks with good stability and positional accuracy. On the other hand, surgeons are superior in combining diverse sources of qualitative information for making difficult decisions. Such skills are critical to the success of any surgical intervention, but existing surgical robots are still limited to simple procedures under the direct control of surgeons. Unlike industrial automation, robotic systems for surgery must be considered as a ‘surgeon’s extender’ rather than a ‘surgeon’s replacement’ (Camarillo et al., 2004; Howe and Matsuoka, 1999).

It is important to note that robotic-assisted surgery is only one of the various specialties falling under the broader category of computer-aided surgery (CAS). In this context, the robot represents a single component of a multifunctional system specifically designed to augment the capabilities of surgeons and to improve the overall outcome of surgical procedures. Through a combined use of automated and manually controlled surgical devices, such a system also incorporates preoperative planning, intraoperative registration, and image-guided navigation and visualisation (Taylor and Stoianovici, 2003). In this regard, medical imaging plays a fundamental role in the development of CAS systems and there is a unique opportunity in combining the two. To better understand the benefits and technical challenges of robot-assisted MIS, this chapter provides a detailed overview of robotic surgical systems and introduces recent developments in the integration of multiple control modalities such as perceptual docking and virtual fixtures.

1.2 Minimally invasive surgery and robotic

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