This work presents a design overview of a novel high DoF (degrees-of-freedom) system being developed for minimally invasive surgery of the throat. The system is designed to allow remote operation of 2-3 tools with high tip dexterity to enable suturing and soft-tissue manipulation while using the patient's mouth as the only entry port. The slave is a 34 DoF unit equipped with three snake-like distal dexterity units for surgical tool manipulation. Each of these units is a multi-backbone snakelike mechanism equipped with a detachable milli parallel manipulator allowing interchangeable tools to be used. The paper presents the outline of the kinematic analysis of the snake-like units and proposes one possible actuation redundancy resolution to allow further downsize scalability while reducing the risk of buckling of the primary backbone of the snake-like units. Finally, The work presents a first early experiment with a prototype of the snake-like unit.

A dexterous system for laryngeal surgery

Study Design. Retrospective, multicenter study of robotically-guided spinal implant insertions. Clinical acceptance of the implants was assessed by intraoperative radiograph, and when available, postoperative computed tomography (CT) scans were used to determine placement accuracy. Objective. To verify the clinical acceptance and accuracy of robotically-guided spinal implants and compare to those of unguided free-hand procedures. Summary of Background Data. SpineAssist surgical robot has been used to guide implants and guide-wires to predefined locations in the spine. SpineAssist which, to the best of the authors' knowledge, is currently the sole robot providing surgical assistance in positioning tools in the spine, guided over 840 cases in 14 hospitals, between June 2005 and June 2009. Methods. Clinical acceptance of 3271 pedicle screws and guide-wires inserted in 635 reported cases was assessed by intraoperative fluoroscopy, where placement accuracy of 646 pedicle screws inserted in 139 patients was measured using postoperative CT scans. Results. Screw placements were found to be clinically acceptable in 98% of the cases when intraoperatively assessed by fluoroscopic images. Measurements derived from postoperative CT scans demonstrated that 98.3% of the screws fell within the safe zone, where 89.3% were completely within the pedicle and 9% breached the pedicle by up to 2 mm. The remaining 1.4% of the screws breached between 2 and 4 mm, while only 2 screws (0.3%) deviated by more than 4 mm from the pedicle wall. Neurologic deficits were observed in 4 cases yet, following revisions, no permanent nerve damage was encountered, in contrast to the 0.6% to 5% of neurologic damage reported in the literature. Conclusion. SpineAssist offers enhanced performance in spinal surgery when compared to free-hand surgeries, by increasing placement accuracy and reducing neurologic risks. In addition, 49% of the cases reported herein used a percutaneous approach, highlighting the contribution of SpineAssist in procedures without anatomic landmarks.

Clinical acceptance and accuracy assessment of spinal implants guided with SpineAssist surgical robot: retrospective study.

This paper provides an overview of recent trends and developments in medical robotics for minimally invasive soft tissue surgery, with a view to highlight some of the issues posed and solutions proposed in the literature. The paper includes a thorough review of the literature, which focuses on soft tissue surgical robots developed and published in the last five years (between 2004 and 2008) in indexed journals and conference proceedings. Only surgical systems were considered; imaging and diagnostic devices were excluded from the review. The systems included in this paper are classified according to the following surgical specialties: neurosurgery; eye surgery and ear, nose, and throat (ENT); general, thoracic, and cardiac surgery; gastrointestinal and colorectal surgery; and urologic surgery. The systems are also cross-classified according to their engineering design and robotics technology, which is included in tabular form at the end of the paper. The review concludes with an overview of the field, along with some statistical considerations about the size, geographical spread, and impact of medical robotics for soft tissue surgery today.

A review of medical robotics for minimally invasive soft tissue surgery

Spine surgery has experienced much technological innovation over the past several decades. The field has seen advancements in operative techniques, implants and biologics, and equipment such as computer-assisted navigation and surgical robotics. With the arrival of real-time image guidance and navigation capabilities along with the computing ability to process and reconstruct these data into an interactive three-dimensional spinal "map", so too have the applications of surgical robotic technology. While spinal robotics and navigation represent promising potential for improving modern spinal surgery, it remains paramount to demonstrate its superiority as compared to traditional techniques prior to assimilation of its use amongst surgeons.The applications for intraoperative navigation and image-guided robotics have expanded to surgical resection of spinal column and intradural tumors, revision procedures on arthrodesed spines, and deformity cases with distorted anatomy. Additionally, these platforms may mitigate much of the harmful radiation exposure in minimally invasive surgery to which the patient, surgeon, and ancillary operating room staff are subjected.Spine surgery relies upon meticulous fine motor skills to manipulate neural elements and a steady hand while doing so, often exploiting small working corridors utilizing exposures that minimize collateral damage. Additionally, the procedures may be long and arduous, predisposing the surgeon to both mental and physical fatigue. In light of these characteristics, spine surgery may actually be an ideal candidate for the integration of navigation and robotic-assisted procedures.With this paper, we aim to critically evaluate the current literature and explore the options available for intraoperative navigation and robotic-assisted spine surgery.

Navigation and robotics in spinal surgery: Where are we now?

This paper presents an overview of the surgical robotics field, highlighting significant milestones and grouping the various propositions into cohorts. The review does not aim to be exhaustive but rather to highlight how surgical robotics is acting as an enabling technology for minimally invasive surgery. As such, there is a focus on robotic surgical solutions which are commercially available; research efforts which have not gained regulatory approval or entered clinical use are mostly omitted. The practice of robotic surgery is currently largely dominated by the da Vinci system of Intuitive Surgical (Sunnyvale, CA, USA) but other commercial players have now entered the market with surgical robotic products or are appearing in 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, lower cost, possibly disposable robots rather than the current large, versatile and capital expensive systems. As the trend towards minimally invasive surgery (MIS) increases, surgery becomes more technically demanding for surgeons and more challenging for medical device technologists and it is clear that surgical robotics has now an established foothold in medicine as an enabling technology of MIS.

Surgical robotics: Reviewing the past, analysing the present, imagining the future

This paper presents a new approach to robot-assisted spine and trauma surgery in which a miniature robot is directly mounted on the patient's bony structure near the surgical site. The robot is designed to operate in a semiactive mode to precisely position and orient a drill or a needle in various surgical procedures. Since the robot forms a single rigid body with the anatomy, there is no need for immobilization or motion tracking, which greatly enhances and simplifies the robot's registration to the target anatomy. To demonstrate this concept, we developed the MiniAture Robot for Surgical procedures (MARS), a cylindrical 5/spl times/7 cm/sup 3/, 200-g, six-degree-of-freedom parallel manipulator. We are currently developing two clinical applications to demonstrate the concept: 1) surgical tools guiding for spinal pedicle screws placement; and 2) drill guiding for distal locking screws in intramedullary nailing. In both cases, a tool guide attached to the robot is positioned at a planned location with a few intraoperative fluoroscopic X-ray images. Preliminary in-vitro experiments demonstrate the feasibility of this concept.

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Y. Kunicher

Papers

Bone-mounted miniature robot for surgical procedures: Concept and clinical applications