Background Interest in human factors has increased across healthcare communities and institutions as the value of human centred design in healthcare becomes increasingly clear. However, as human factors is becoming more prominent, there is growing evidence of confusion about human factors science, both anecdotally and in scientific literature. Some of the misconceptions about human factors may inadvertently create missed opportunities for healthcare improvement. Methods The objective of this article is to describe the scientific discipline of human factors and provide common ground for partnerships between healthcare and human factors communities. Results The primary goal of human factors science is to promote efficiency, safety and effectiveness by improving the design of technologies, processes and work systems. As described in this article, human factors also provides insight on when training is likely (or unlikely) to be effective for improving patient safety. Finally, we outline human factors specialty areas that may be particularly relevant for improving healthcare delivery and provide examples to demonstrate their value. Conclusions The human factors concepts presented in this article may foster interdisciplinary collaborations to yield new, sustainable solutions for healthcare quality and patient safety.

https://qualitysafety.bmj.com/content/qhc/22/10/802.full.pdf

The science of human factors: separating fact from fiction

Robotic surgery is transforming the current surgical practice, not only by improving the conventional surgical methods but also by introducing innovative robot-enhanced approaches that broaden the capabilities of clinicians. Being mainly of man–machine collaborative type, surgical robots are seen as media that transfer pre- and intraoperative information to the operator and reproduce his/her motion, with appropriate filtering, scaling, or limitation, to physically interact with the patient. The field, however, is far from maturity and, more critically, is still a subject of controversy in medical communities. Limited or absent haptic feedback is reputed to be among reasons that impede further spread of surgical robots. In this paper, objectives and challenges of deploying haptic technologies in surgical robotics are discussed, and a systematic review is performed on works that have studied the effects of providing haptic information to the users in major branches of robotic surgery. It attempts to encompass both classical works and the state-of-the-art approaches, aiming at delivering a comprehensive and balanced survey both for researchers starting their work in this field and for the experts.

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Haptics in Robot-Assisted Surgery: Challenges and Benefits

Following an extensive literature search and a consensus conference with subject matter experts the following conclusions can be drawn: 1. Robotic surgery is still at its infancy, and there is a great potential in sophisticated electromechanical systems to perform complex surgical tasks when these systems evolve. 2. To date, in the vast majority of clinical settings, there is little or no advantage in using robotic systems in general surgery in terms of clinical outcome. Dedicated parameters should be addressed, and high quality research should focus on quality of care instead of routine parameters, where a clear advantage is not to be expected. 3. Preliminary data demonstrates that robotic system have a clinical benefit in performing complex procedures in confined spaces, especially in those that are located in unfavorable anatomical locations. 4. There is a severe lack of high quality data on robotic surgery, and there is a great need for rigorously controlled, unbiased clinical trials. These trials should be urged to address the cost-effectiveness issues as well. 5. Specific areas of research should include complex hepatobiliary surgery, surgery for gastric and esophageal cancer, revisional surgery in bariatric and upper GI surgery, surgery for large adrenal masses, and rectal surgery. All these fields show some potential for a true benefit of using current robotic systems. 6. Robotic surgery requires a specific set of skills, and needs to be trained using a dedicated, structured training program that addresses the specific knowledge, safety issues and skills essential to perform this type of surgery safely and with good outcomes. It is the responsibility of the corresponding professional organizations, not the industry, to define the training and credentialing of robotic basic skills and specific procedures. 7. Due to the special economic environment in which robotic surgery is currently employed special care should be taken in the decision making process when deciding on the purchase, use and training of robotic systems in general surgery. 8. Professional organizations in the sub-specialties of general surgery should review these statements and issue detailed, specialty-specific guidelines on the use of specific robotic surgery procedures in addition to outlining the advanced robotic surgery training required to safely perform such procedures.

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European Association of Endoscopic Surgeons (EAES) consensus statement on the use of robotics in general surgery

Cutaneous haptic feedback can be used to enhance the performance of robotic teleoperation systems while guaranteeing their safety. Delivering ungrounded cutaneous cues to the human operator conveys in fact information about the forces exerted at the slave side and does not affect the stability of the control loop. In this work we analyze the feasibility, effectiveness, and implications of providing solely cutaneous feedback in robotic teleoperation. We carried out two peg-in-hole experiments, both in a virtual environment and in a real teleoperated environment. Two novel 3-degree-of-freedom fingertip cutaneous displays deliver a suitable amount of cutaneous feedback at the thumb and index fingers. Results assessed the feasibility and effectiveness of the proposed approach. Cutaneous feedback was outperformed by full haptic feedback provided by grounded haptic interfaces, but it outperformed conditions providing no force feedback at all. Moreover, cutaneous feedback always kept the system stable, even in the presence of destabilizing factors such as communication delays and hard contacts.

Cutaneous haptic feedback to ensure the stability of robotic teleoperation systems

In traditional open surgery, surgeons use their fingertip palpation to investigate the hidden anatomical structures of tissue. However, in the current commercially available minimally invasive robotic surgery (MIRS) systems, while surgical instruments interact with tissues, surgeons do not sense any tactile information. Therefore, tactile sensors are required to be integrated into the tips of surgical instruments to mimic the perception of the surgeon's fingertips. The electrically based tactile sensors that exist at present cannot usually operate under static loading conditions. In addition, they are not compatible with magnetic resonance imaging (MRI) devices. Therefore, this research was aimed at restoring tactile information by developing an MRI compatible optical fiber tactile sensor. The sensor consists of only one single moving part. Thanks to this novel design, the sensor does not require the use of an array of sensors to measure the distributed tactile information. This capability simplifies the integration of the sensor into any suitable space available at the tips of surgical instruments. In addition, the sensor performs under both static and dynamic loading conditions. A theoretical model of the sensor and a finite-element model of the sensor-tissue interaction were developed. To validate the sensor, a prototype of the sensor was fabricated and tested.

Discretely Loaded Beam-Type Optical Fiber Tactile Sensor for Tissue Manipulation and Palpation in Minimally Invasive Robotic Surgery

Background- Surgeons may cause tissue damage by incorrect laparoscopic pinch force control. Unpredictable tissue and grasper properties may cause slips or ruptures. This study investigated how different forms of haptic feedback influence the surgeon’s ability to generate a safe laparoscopic grasp while pulling tissues of variable stiffness using graspers with different force transmission ratios. The results will help define design requirements for training facilities and instruments. Methods- For this study, 10 participants lifted an object barehanded, with tweezers, or with one of two laparoscopic graspers until they where able to complete five consecutive safe lifts under different tissue stiffness conditions. The participants were presented with indirect visual feedback of pinch force, object location, and target location. Results- Lifting with instruments (tweezers or graspers) required 4.5 to 14.5 times as many practice trials as barehanded lifting, where no slips were recorded. Additionally, slips occurred more often with a decreasing force transmission ratio of the graspers and with increasing tissue stiffness. The maximal pinch force was higher in lifting with instruments than in barehanded lifting (26–60%) irrespective of the stiffness conditions. Using a grasper, the slip margin often was not high enough in the stiffest condition, resulting in slippage of up to 84%. Conclusions- Without the direct tactile feedback that occurs with normal skin–tissue contact, subjects using graspers have trouble anticipating slippage when lifting tissue with variable stiffness. Performance drops with a decreased force transmision ratio of the instrument and increased tissue stiffness. Furthermore, the pinch forces are not adapted to the variable stiffness conditions. The same pinch force is applied irrespective of tissue stiffness. It takes participants longer to learn a safe laparoscopic grasp than to learn barehanded lifts. Additionally, to perform safe laparoscopic surgery, care should be taken when graspers with a low force transmission ratio are used.

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Effect of laparoscopic grasper force transmission ratio on grasp control

Little is known about the influence of augmented feedback, on laparoscopic grasp control. To gain more knowledge on the influence of this on the learning curve, two experiments were conducted. In the first experiment, four groups learned a single-handed laparoscopic lifting task. Three groups received augmented feedback (visual, haptic, or a combination of feedback modes) on slip and excessive pinch force. In the second experiment, a two-handed task had to be accomplished to investigate whether paying reduced attention would influence grasp-force control. The surgeons and novices either received tactile feedback or no augmented feedback on grasp forces. In both experiments, learning sessions and a retention test followed a pretest. In the two-handed task, novices who received tactile feedback could control their pinch force in order to remain within the required limits unlike participants who did not receive augmented feedback. Approximately, one-third of the participants who received augmented feedback became dependent on the signal. Regardless of their level of experience, participants benefited from augmented feedback. This research supports the claim that there is a need for augmented tactile feedback when learning laparoscopic grasp control. It enhances learning and goes beyond what could be achieved without.

The Effect of Augmented Feedback on Grasp Force in Laparoscopic Grasp Control

During laparoscopic grasping, tissue damage may occur due to use of excessive grasp forces and tissue slippage, whereas in barehanded grasping, humans control their grasp to prevent slippage and use of excessive force (safe grasp). This study investigates the differences in grasp control during barehanded and laparoscopic lifts. Ten novices performed lifts in order to compare pinch forces under four conditions: barehanded; using tweezers; a low-efficient grasper; and a high-efficient grasper. Results showed that participants increased their pinch force significantly later during a barehanded lift (at a pull-force level of 2.63 N) than when lifting laparoscopically (from pull-force levels of 0.77 to 1.08 N). In barehanded lifts all participants could accomplish a safe grasp, whereas in laparoscopic lifts excessive force (up to 7.9 N) and slippage (up to 38% of the trials) occurred frequently. For novices, it can be concluded that force feedback (additional to the hand-tool interface), as in skin-tissue contact, is a prerequisite to maintain a safe grasp. Much is known about grasp control during barehanded object manipulation, especially the control of pinch forces to changing loading, whereas little is known about force perception and grasp control during tool usage. This knowledge is a prerequisite for the ergonomic design of tools that are used to manipulate objects.

Force feedback requirements for efficient laparoscopic grasp control

During laparoscopic grasping, excessive grasp forces and tissue slippage may well lead to tissue damage. Because surgeons have difficulty gauging the force exerted on the grasped tissue, it is desirable to train them in applying the right degree of force in order to prevent tissue damage. Previously it was demonstrated that grasp force control can be learned when augmented tactile feedback is provided in a training task. The present paper discusses the design of a new laparoscopic grasper with augmented tactile feedback. Two grasper handles were developed and tested. Each of them contained augmented tactile feedback actuators.

A laparoscopic grasper handle with integrated augmented tactile feedback, designed for training grasp control

Background: In order to develop new and better laparoscopic bowel instruments, which reduces patient risks, the opinions and experience that surgeons have with current laparoscopic bowel grasper haptics is important In this study we explored this by means of a questionnaire Method: A total of 386 online- questionnaires, were sent to laparoscopic surgeons working in European hospitals They were all members of the European Association of Endoscopic Surgery and perform laparoscopic obesities or bowel surgery Surgeons where divided into different age and experience groups Results: A total of 174 completely filled out forms were analyzed In total, 16% of the surgeons cannot prevent damage when they pinch too hard, although they (10%) might have seen or felt it Seven percent of the respondents were not able to see or feel tissue slippage Whereas 31% can see or feel slippage they cannot do anything to prevent it Overall, most of the respondents would appreciate technical changes in the laparoscopic bowel graspers to reduce tissue damage Of all the respondents, 79% maintain that it is necessary to have a new laparoscopic grasper with augmented feedback The majority of the respondents (77%) would like to have tactile feedback as an indication of the level of pinch force There are not many differences in the opinions of surgeons at different skill levels Conclusion: From the results of the questionnaire and the other comments made by respondents it is evident that research and developments in the field of new laparoscopic graspers should continue

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Eleonora P. Westebring-van der Putten

Papers

Effect of laparoscopic grasper force transmission ratio on grasp control

The Effect of Augmented Feedback on Grasp Force in Laparoscopic Grasp Control

Force feedback requirements for efficient laparoscopic grasp control

A laparoscopic grasper handle with integrated augmented tactile feedback, designed for training grasp control

The opinion and experience of surgeons with laparoscopic bowel grasper haptics