This paper provides a broad overview of medical robot systems used in surgery. After introducing basic concepts of computer-integrated surgery, surgical CAD/CAM, and surgical assistants, it discusses some of the major design issues particular to medical robots. It then illustrates these issues and the broader themes introduced earlier with examples of current surgical CAD/CAM and surgical assistant systems. Finally, it provides a brief synopsis of current research challenges and closes with a few thoughts on the research/industry/clinician teamwork that is essential for progress in the field.

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Medical robotics in computer-integrated surgery

Robotic surgery is a new and exciting emerging technology that is taking the surgical profession by storm. Up to this point, however, the race to acquire and incorporate this emerging technology has primarily been driven by the market. In addition, surgical robots have become the entry fee for centers wanting to be known for excellence in minimally invasive surgery despite the current lack of practical applications. Therefore, robotic devices seem to have more of a marketing role than a practical role. Whether or not robotic devices will grow into a more practical role remains to be seen.

Our goal in writing this review is to provide an objective evaluation of this technology and to touch on some of the subjects that manufacturers of robots do not readily disclose. In this article we discuss the development and evolution of robotic surgery, review current robotic systems, review the current data, discuss the current role of robotics in surgery, and finally we discuss the possible roles of robotic surgery in the future. It is our hope that by the end of this article the reader will be able to make a more informed decision about robotic surgery before “chasing the market.”

Robotic Surgery: A Current Perspective

Purpose Glioblastoma multiforme (GBM) is the most common primary brain tumor in adults, and radiation is one of the main treatment modalities. However, cure rates remain low despite best available therapies. Immunotherapy is a promising modality that could work synergistically with radiation, which has been shown to increase antigen presentation and promote a proinflammatory tumor microenvironment. Programmed-death-1 (PD-1) is a surface receptor expressed on activated and exhausted T cells, which mediate T cell inhibition upon binding with its ligand PD-L1, expressed on many tumor types including human GBMs. We tested the combination of anti-PD-1 immunotherapy with stereotactic radiosurgery in a mouse orthotopic GBM model. Methods and Materials We performed intracranial implantation of mouse glioma cell line GL261 transfected with luciferase into C57BL/6 mice. Mice were stratified into 4 treatment groups: ( 1 ) control; ( 2 ) radiation only; ( 3 ) anti-PD-1 antibody only; and ( 4 ) radiation plus anti-PD-1 antibody. Overall survival was quantified. The mice were killed on day 21 after implantation to assess immunologic parameters in the brain/tumor, cervical lymph nodes, and spleen. Results Improved survival was demonstrated with combination anti-PD-1 therapy plus radiation compared with either modality alone: median survival was 25 days in the control arm, 27 days in the anti-PD-1 antibody arm, 28 days in the radiation arm, and 53 days in the radiation plus anti-PD-1 therapy arm ( P Conclusions The combination of PD-1 blockade and localized radiation therapy results in long-term survival in mice with orthotopic brain tumors. These studies provide strong preclinical evidence to support combination trials in patients with GBM.

Anti-PD-1 blockade and stereotactic radiation produce long-term survival in mice with intracranial gliomas.

In the future, it will become more common for humans to team up with robotic systems to perform tasks that humans cannot realistically accomplish alone. Even for autonomous and semiautonomous systems, teleoperation will be an important default mode. However, teleoperation can be a challenging task because the operator is remotely located. As a result, the operator's situation awareness of the remote environment can be compromised and the mission effectiveness can suffer. This paper presents a detailed examination of more than 150 papers covering human performance issues and suggested mitigation solutions. The paper summarizes the performance decrements caused by video images bandwidth, time lags, frame rates, lack of proprioception, frame of reference, two-dimensional views, attention switches, and motion effects. Suggested solutions and their limitations include stereoscopic displays, synthetic overlay, multimodal interfaces, and various predicative and decision support systems.

Human Performance Issues and User Interface Design for Teleoperated Robots

Medical image analysis

Purpose To demonstrate the computed tomography, conformal irradiation, and treatment planning capabilities of a small animal radiation research platform (SARRP). Methods and Materials The SARRP uses a dual-focal spot, constant voltage X-ray source mounted on a gantry with a source-to-isocenter distance of 35 cm. Gantry rotation is limited to 120° from vertical. X-rays of 80–100 kVp from the smaller 0.4-mm focal spot are used for imaging. Both 0.4-mm and 3.0-mm focal spots operate at 225 kVp for irradiation. Robotic translate/rotate stages are used to position the animal. Cone-beam computed tomography is achieved by rotating the horizontal animal between the stationary X-ray source and a flat-panel detector. The radiation beams range from 0.5 mm in diameter to 60 × 60 mm2. Dosimetry is measured with radiochromic films. Monte Carlo dose calculations are used for treatment planning. The combination of gantry and robotic stage motions facilitate conformal irradiation. Results The SARRP spans 3 ft × 4 ft × 6 ft (width × length × height). Depending on the filtration, the isocenter dose outputs at a 1-cm depth in water were 22–375 cGy/min from the smallest to the largest radiation fields. The 20–80% dose falloff spanned 0.16 mm. Cone-beam computed tomography with 0.6 × 0.6 × 0.6 mm3 voxel resolution was acquired with a dose of Conclusion The capability of the SARRP to deliver highly focal beams to multiple animal model systems provides new research opportunities that more realistically bridge laboratory research and clinical translation.

High-resolution, small animal radiation research platform with x-ray tomographic guidance capabilities.

Robotic assistance for ultrasound-guided prostate brachytherapy

The purpose of this paper is to present our results in developing a dynamic model of the Mitsubishi PA-10 robot arm for the purpose of low-velocity trajectory tracking using low-feedback gains. The PA-10 is ideal for precise manipulation tasks because of the backdrivability, precise positioning capabilities, and zero backlash afforded by its harmonic drive transmission (HDT). However, the compliance and oscillations inherent in harmonic drive systems, and the lack of any technical information on the internal dynamics of the transmission, make the development of an accurate dynamic model of the robot extremely challenging. The novelty of this research is therefore the development of a systematic algorithm to extract the model parameters of a harmonic drive transmission in the robot arm to facilitate model-based control. We have modeled all seven joints of the Mitsubishi PA-10, and we have done several experiments to identify the various parameters of the harmonic drive system. We conclude with a sample trajectory-tracking task that demonstrates our model-based controller for the Mitsubishi PA-10 robot arm.

Modeling and control of the Mitsubishi PA-10 robot arm harmonic drive system

A small animal radiation platform equipped with on-board cone-beam CT and conformal irradiation capabilities is being constructed for translational research. To achieve highly localized dose delivery, an x-ray lens is used to focus the broad beam from a 225 kVp x-ray tube down to a beam with a full width half maximum (FWHM) of approximately 1.5 mm in the energy range 40-80 keV. Here, we report on the dosimetric characteristics of the focused beam from the x-ray lens subsystem for high-resolution dose delivery. Using the metric of the average dose within a 1.5 mm diameter area, the dose rates at a source-to-surface distance (SSD) of 34 cm are 259 and 172 cGy min(-1) at 6 mm and 2 cm depths, respectively, with an estimated uncertainty of +/-5%. The per cent depth dose is approximately 56% at 2 cm depth for a beam at 34 cm SSD.

https://iopscience.iop.org/article/10.1088/0031-9155/52/10/007/pdf

The small-animal radiation research platform (SARRP): dosimetry of a focused lens system.

Cardiovascular disease is one of the leading causes of death in the United States and also a major disease nationwide. Over 700,000 coronary artery bypass graft (CABG) procedures are performed annually all around the world, of which 350,000 are performed in the United States. The use of mechanical stabilizers to isolate and immobilize the surface region of the heart is not without its limitations such as hemodynamic deterioration, and arrythmia induction requiring inotropic support. Consequently, the use of mechanical stabilizers leads to a poor immobilization of the surgical field in spite of significant forces of traction and retraction used with these devices. The primary goal of this research is to develop effective haptic (sense of touch) and visual servoing methods with the long-term goal of eliminating the need for mechanical stabilizers and extracorporeal support for CABG procedures. We present in this paper the results from our initial work in the area of tracking a deformable membrane using vision and providing haptic feedback to the user, based on the visual information through the vision hardware and the material properties of the membrane. In our first experiment, we track the deformation of a rubber membrane in real-time through stereovision while providing haptic feedback to the user interacting with the reconstructed membrane through the PHANToM haptic device. In the second experiment, we verify the ability of our vision system to track a point on a surface undergoing a complex 3D motion.

C. Kennedy

Papers

High-resolution, small animal radiation research platform with x-ray tomographic guidance capabilities.

Robotic assistance for ultrasound-guided prostate brachytherapy

Modeling and control of the Mitsubishi PA-10 robot arm harmonic drive system

The small-animal radiation research platform (SARRP): dosimetry of a focused lens system.

A Novel Approach to Robotic Cardiac Surgery Using Haptics and Vision