1. Advances in Telesurgery and Surgical Robotics Dr Sanjoy Sanyal MBBS, MS (Surgery), ADPHA, ADHRD Presented at 9 thNational Medical Dental Conference in Seychelles, February 2006

2. Preface (added 2009)

This PPT represents developments in the field during late 90s and early 2000s, in:

• Stanford University School of Medicine

• University of California Berkeley (UCB)

• UC San Francisco (UCSF)

• Massachusetts Inst. of Technology (MIT)

• Escort Heart Institute Research Centre (EHIRC), New Delhi, India

Telesurgery / surgical robotics has advanced considerably now.

3. The research pioneers

Stanford Research Institute (SRI) @ Stanford University School of Medicine

Human Machine Systems Lab (HMSL) @ MIT

Robotic Intelligent Machines Laboratory (RIML)@ UC Berkeley

Robotic Telesurgical Workstation for Laparoscopy (RTWL) @ UCSF

4. Worlds first telesurgery

September 2001 : Tele- chole

Prof Jacques Marescaux , New York & European Institute of Telesurgery, Strasbourg

Round distance =14,000 km

Round Trip Time= 200 msec; video and hi-speed fibre-optic link

June 2001 : Johns Hopkins University, Baltimore & Rome Policlinico Casilino University

http://news.bbc.co.uk/2/hi/science/nature/1552211.stm

5. Background

Traditional surgery

Tri-dimensional

Cognitive input

Tactile feedback

Stereoscopic vision with depth perception

Time lag -ve

Telesurgery

Two-dimensional

Cognitive feedback limited

Tactile feedback ve

Binocular vision without depth perception

Time lag +ve

6. Definitions

Telepresence surgery : Computerized interface @ surgical workstationremote operative site; force feedback (haptic)

Cooperative telesurgery : tele-surgeon / local (remote) assistant cooperation

http://www2.telemedtoday.com/articles/telesurgery.shtml

http:// web.mit.edu/hmsl/www/Telesurgery /

7. Definitions contd

Telerobotics : Remote control with a robotic arm, in conjunction with a laparoscope

http://www2.telemedtoday.com/articles/telesurgery.shtml

8. Definitions contd

Telementoring : Experienced surgeon acts as tutor / instructor ( preceptor ) for remote surgeon via interactive video

Teleproctoring( proctor=supervisor of exams ): Documentation of performance for privileging purposes

http://www2.telemedtoday.com/articles/telesurgery.shtml

9. Technical aspects

Image transmission : T1 transmission (H-320 compression standard)

• Fibre-optic cable

• Microwave

• Satellite

Lag time : should be 1mm

Haptic : Force feedback

10. Haptic

Force reflection / feedback; Graduated tactile input

• resistance at remote site is transmitted to near site by servo motors @ both sites

11. Robotic vs. human arm

DOF : Number of ways an arm can move

Human arm : 7-DOF

Human hand : >20-DOF

Robotic arm : Like human hand, arm and moveable elbow - butwith a fused wrist

Robotic arm : 4-6 DOF

12. Telesurg dynamics @ MIT

Surgeons fingers placed in rings of instruments

Rings are connected tomotors ,gearsandbelts

Precisely translate surgeons hand / finger motions into digital signals

Transmitted through computer- telecomm link

To robotic arms @ remote surgical station

Visual input : 2 remote CCD cameras (15 fps each-> 3-D effect )-> Surgeons monitor -> Mirror -> Optical3-D glasses (stereoscopic vision)

http:// web.mit.edu/hmsl/www/Telesurgery 13. Telesurg components @ MIT 14. Surgeons master tool handle @ MIT 15. Surgeons master tool handle @ MIT 16. Master phantom haptic interface arm 17. Slave phantom haptic interface arm 18. Tele-operation slave tool 19. Tele-operation slave tool 20. Tele-operational details Tool 21. Tele-operational details Interchangeable tool tips 22. Experimental task - grasp / transfer 23. Experimental task - Grasp and transfer with orientation 24. Experimental task - Clip application 25. Experimental task grasper / gripper and shear / scissors 26. Lap experiment box @ MIT 27. Lap simulator-1 @ MIT 28. Lap simulator-2 @ MIT 29. Dynamics of robotics @ UC

Surgeon remote location TV console set of handheld controls ~ videogame joysticks

Joystick :Pencil-sized; 1 for each hand

Computer : Program translates surgeons movements

End-effectors : Robotic instruments enter body to perform actual operation

• Early models : 3-fingered hand

• Present : Hydraulic-powered, single-digit, 3-4 x , 4-jointed (rotate, swivel, to-fro), 2-pronged end grasper

Anthropomorphicmovements

http:// robotics.eecs.berkeley.edu /medical/ 30. Details of robots

Robo-doc : 2 robots working in concert

• Holding robots

• Companion robots / milli-robots / robotic manipulators

31. Holding robots

Pair of large robotic arms

Hydraulic-actuated

Sits on moveable platform

Driven remotely by surgeons joysticks

Performs like a surgeons shoulder, allowing positioning of its hydraulic arms

32. Holding robots contd

Holds 2 ndrobot, wheels instruments into position by patients side

Guides them through dexterity-requiring surgical procedures (suturing, dissection)

Holds instruments steady while surgeon sutures and ties knots

33. Companion / Milli-robots / Robotic manipulators

Sterile, disposable, steel, mm-scale, fingertip-sized

Slender, jointed, finger-like tools

Connected by wires and tubes to larger robot

Pair of gripping forceps at one end to carry surgical tools

Contains miniscule video-camera

34. Companion robot contd

Inserted into body for actual surgical tasks (cutting, suturing) 10-20 mm incisions

Inserts cameras

Provide tactile feedback though force-deflecting joysticks

Provides 7 DOF

35. Setup @ UC Berkeley 36. Equipment @ UCB 37. Robotic manipulator @ UCB 38. Mini robot controls @ UCB Roll-pitch-roll wrist, gripper and multi-fingered manipulators 39. Robotic endo-manipulator Endo-platform with biopsy forceps 40. Minute threading 41. Threaded robotic instruments knot tying 42. 2-G RTWL @ UCSF In a joint project betweenRIMLofUCBandDepartment of SurgeryofUniversity of California San Francisco( UCSF ), aRobotic Telesurgical Workstation for Laparoscopy (RTWL) was developed 43. Lap interface @ UCSF 44. 4-DOF lap haptic interface 45. Robotic Cardiac Surgery @ EHIRC

Escort Heart Inst. Research Centre in New Delhi, India

Implemented da Vinci Tele-manipulationsystem

Intuitive Surgical Inc., Mountain View, CA, USA

Computer enhanced system

• Surgeons console

• Cart-mounted robotic manipulators

• http://www.ehirc.com/individuals/services/treatment/robotic_surgery.html#

46. Surgeons console @ EHIRC

Display system : 3-D pictures of chest cavity

Surgeonsits at console and gets 3-D view of chest interior

Hand motions are captured, transformed and transmitted to tiny robotic manipulators

47. Robotic manipulators @ EHIRC

Robot is not autonomous; surgeon-controlled

Hold tiny instruments, which go inside the patient's chest.

Surgeon's hand movements transmitted to these instruments

CABG, mitral valve repair, ASD closure

48. IMA LAD CABG 49. Totally endoscopic CABG

Advantages

• Only 3-incisions, each 1 cm on the side and lower chest

• Less pain

• Faster healing and recovery

• Short hospital stay

50. Technical innovations

Teletactation (Tactile feedback)

CyberGlove with CyberTouch

Dextrous master glove

Spatial cognition Hand assist

Surgical simulations / Virtual reality

Dextrous mini-robots

51. Teletactation Tactile feedback

Sensing tactile information throughtactile sensorsthat transmit feel of tissue to surgeons finger

52. CyberTouch CyberGlove

Vibro-tactile, thermal simulators on eachfingerandpalm

Tactile feedback optionenables feelof virtual object

53. CyberGlove

Flexible sensorsmeasure position/movementoffingersandwrist

54. Dextrous master glove

Thumb ,index ,wristflexion sensors and wrist rotation sensor

Senses positionsof surgeon's fingers/wrist

Used as master to drive slave robotic hand

55. Spatial cognition Hand assist in telesurgery Non-dominant hand in-vivo possibly enhances spatial skills through tactile cues, which generate a more accurate 3-D representation of anatomy 56. Lap chole simulation Simulated fat and fascia Dissected away; cystic duct clipped 57. Lap chole simulation contd Cystic artery and duct divided successfully in simulated conditions 58. Karlsruhe Gynec endo surgery simulations 59. Gynec surgery simulations contd http://www- kismet.iai.fzk.de/VRTRAIN/phD_main.html http://www- kismet.iai.fzk.de/VRTRAIN/GIF/PHD/surgSim.jpg 60. Dextrous mini robots

1 Camera attachment

2 Equipped with a needle for biopsy

3 Moves around abdominal cavity spiral pattern moves without slipping

http://news.bbc.co.uk/1/hi/health/4647258.stm

61. Summary

Technically demanding, labor intensive, time consuming, expensive research

Learning curve with similar characteristics

Expensive installation, maintenance and infrastructure

62. Future applications

Emergency trauma care

• 1 stGolden Hour

Battlefield surgery

Remote area assistance

One-to-many telementoring

Space station surgery

63. Cutting edge research today, surgical technology tomorrow 64. Conclusion

Science knows no country, because knowledge belongs to humanity, and is the torch which illuminates the world . Louis Pasteur

Don't be afraid to take a big step. You can't cross a chasm in two small jumps .

• • • • David Lloyd George