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International Journal of Applied Engineering Research, ISSN 0973-4562 Volume 11, Number 23 (2016) pp. 11277–11298

© Research India Publications, http://www.ripublication.com/ijaer.htm

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Evolution of Robotics in Medical Surgeries and Health Care Systems

A Review

Royson Dsouza

Manipal University Dubai, UAE.

Catherine Deborah, Vishal Samuel and Aysha Sunaina

Manipal University Dubai, UAE.

Abstract

This paper gives an outlook to the progressive use of Robotics

in medical surgery and health care since its onset in the late

20th century. The introduction of robots in surgery began in

1985 that used a surgical arm to perform a brain biopsy using

a CT scan. Although it has been dilatory to enter the field of

medicine, it is one of the most talked about approach in

surgery today. Robotics have been used in several areas of

surgical work, namely, neurology, cardiology, orthopedics, a

wide range of organ-ectomies, building artificial bones &

muscles (prosthetics), emergency response, laparoscopy,and

so on. The popular surgical instrumentations include the

DaVinci system (pioneered by an American company-

Intuitive Surgicals) and the Zeus system. As of then, they

have revolutionized the medical field by overcoming various

challenges met during human-assisted surgeries. Other

innovative surgical projects are High-Performance-robotic

Muscles, Anthropomorphic Robotic Bones etc.Advantages of

using these are high precision, better dexterity etc.It has also

paved its way in healthcare sciences and are to date used

critically in pharmacy, telehealth etc.

Keywords: Robotics, Surgery, Prosthetics, Healthcare,

Neurosurgery, Cardiac surgery.

AMS subject classification:

1. INTRODUCTION

The word Robot comes from the Czech word robota, which

means forced labor, first introduced by Czech novelist,

journalist and playwright, Karel apek, in his play Rossum’s

Universal Robots. It has changed in its definition from dumb

machines that perform continual, mundane tasks to a highly

intelligent robot of popular culture [1]. The Robotic

Industries Association defined robot as a re-programmable,

multifunctional manipulator fashioned to move material

parts, tools or specialized devices through variety of

programmed motions are done for carrying out unnumbered

tasks [2]. Not only is it safe but robot assisted surgery can be

used on large masses with great convenience. The statistics

illustrate minimal peri-operative time period and morbidity

rates [3].

In 1985, PUMA 560 was the first used robot in a neural

biopsy with great precision. Use of cameras during

laparoscopy, immensely improved accuracy and precision of

the entire procedure. This paved the way for the use of robots

in treatment of the human body. Surgical systems like the da

Vinci system were created in 1999 [2]. It consists of an

advanced master-slave relation and three or four robotic arms

[5] and is most ordinarily utilized for hysterectomies and

prostatectomy. The Zeus (Fig. 1) is another popular system

that possesses remote telemanipulator and robotic arms like

the Da Vinci system, following the same principle [2]. It is

well-acknowledged for scaling large hand movements

performed by the surgeon into short, precise tool motions [2].

The creation of these various systems has given birth to new

robots that have been specifically designed to treat certain

parts of the body such as the brain and heart such as

Neuromate.

For several years prosthetics and orthosis has paved its way

in surgery providing the most beneficial help to the

unfortunate (elderly class, those who went through accidents,

eg., soldiers etc.) [6]. Seeming as almost impossible until a

century ago, the keen part of this kind of system is its

actuation system, which is biologically inspired [7]. Bones

are manufactured using a 3-D printer and ligaments using



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laser rubber sheets. They are controlled by using

electromyographical signals caught at the dermis or by

directly implanting electrodes at the motor cortex [8].

ROBODOC and RARP (Robot assisted radical Prostectomy)

is another example of a robot equipped in orthopedics for hip

replacementand other general purpose surgeries [1, 2, 3].

From the start of 1980s Robotics has discovered its place in

Healthcare [9].

Robots in the healthcare sector has been a recent

development. Real time communication between doctors and

their patients have become effective by using telerobtics. The

method provides access to people in remote areas who lack in

good medical facilities, thus extending services of health care

to more of the population. In this way Robotics itself has

drastically evolved in surgical and healthcare sector. All the

surgical sectors are thoroughly reviewed and presented in this

paper.

2. ROBOTICS IN MEDICAL SURGERY

Areprogrammable manipulator that has an artificial type of

sensing can carry an array of surgical tasks with the aid of a

surgical robot [10]. Surgical robots are classified into three

categories based on robot-surgeon interaction:

1. Supervisory-Controlled Systems: The surgeon

designs the procedure early on and this is

downloaded onto the robot [12]. The robot replicates

the surgeons hand movements during the operation

while being overseen by the surgeon.

2. Telesurgical Systems: Haptic feedback control is

utilized wherein the surgeons motions are replicated

by the console in a real-time environment. It

eliminates the need for the surgeon to be in the

operating room.

3. Shared-Control System: The procedure is fully

controlled by the surgeon and the robot provides a

steady-hand manipulation of the surgical

instrument. Both of these events occur

simultaneously.

Figure 1. The Zeus surgical system with its table-mounted arms (left) and the surgeons console (right) [4].



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Figure 2: Neuromate [12].

Minimally invasive surgery(MIS) is used in various fields

such as lung, heart, gynecologic, head, neck, spine and

general surgeries. It involves using the state of the art

technology in minimizing the damage embedded onto the

skin and tissues of the body during surgery. It has been

implemented in the various fields in medicine since the 1960s

[13]. They are of two types: robot-assisted MIS (RMIS) and

non-robotic assisted which is also known as endoscopic

surgery. Laparoscopy is a type of MIS but is used to describe

MIS in general. Its benefits are numerous such as: less

scarring, reduced bleeding, quicker recovery, low overall cost

and low risk of infection [14]. As a result of these advantages,

the patients duration at the hospital reduces and they can get

return to their daily activities much faster [15, 16]. MIS

utilizes microscopic cameras which are penetrated into the

skin through incisions. These incisions are made prior to the

insertion. The cameras are connected to thin flexible tubes

and can be inserted into areas that are generally difficult to

reach. The output from the camera can be viewed on an image

display. The surgeon performs the surgery using a console.

The absence of a haptic feedback in RMIS creates a limiting

factor for the surgeon [17]. Haptic feedback is under

development. It is being implemented using specialized

sensors.

3. CLASSIFICATION OF ROBOTICS SURGERY

Classification of Robotic surgery is done based on parts and

avenue. Based on the parts/organs:

1. Neurosurgery: This deals primarily with the

treatment of diseases associated with the spine and

the brain. It comprises of the various robots for the

treatment.

2. Cardiac Surgery: As the name suggests, it deals with

the treatment of the most vital visceral organ: the

heart. Prosthetics: Involves the invention artificial

limbs and its progression.

Based on Avenue:

1. Radiosurgery: Treatment of cancerous and non-

cancerous cells using different sources and dosage

of radiation.



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2. Nanorobotics: The advent of Nano metric robots and

how they are ingeniously engaged in medical

conduct and combat.

4. NEUROSURGERY

Neurosurgery deals with procedures involving the nervous

system which consists of the brain, nerves and spinal cord.

Brain surgery is focused on the most as the brain is the most

important aspect of the human body, controlling all senses

and movement.

The basic idea of neurosurgery involves the accessing of a

buried target area that is enclosed by delicate tissue. After

which precise motions based on the processed images are

made [2]. Modern day neurosurgery robots showcase image-

guided positioning or orientation of cannula/other tools.A

neurological robot consists of: feedback sensors, a robotic

arm, end effectors, wireless localization system and a data

processing unit. The NeuroMate by Renishaw and Pathfinder

by Prosurgics are precision positioning systems that are

capable of registering pre-operative images and can give

accurate frameless choice for guide positioning [2, 8, 19].

They provide haptic feedback control [20].

These robotic-arm systems having 6-DoF, use reflectors that

are attached to the patient’s head which consists of a camera

system instead of a mechanical, ultrasonographic or

radiological guidance system [10]. Some of these systems are

discussed below.

4.1 Neuromate

NeuroMate consists of a console and a lone robotic arm [18].

The arm ends with a mount designed for holding surgical

instruments. The console processes MRI (magnetic resonance

images) or CT (computed tomography) are used to produce a

3-D map of the brain. Using this information the surgical

instruments are positioned, oriented and guided. As the

surgeon operates it manually, the system is locked in position,

although it is capable of performing more active surgical

procedures [18]. The device is a telesurgery system making it

more convenient for the surgeon to operate. It is capable of

cutting, cauterization, needle insertion and irrigation on a

microscopic scale (microsurgery) while concurrently

obtaining MRI [10]. Along with biopsy, the system can

perform other procedures including neuroendoscopy,

transcranial magnetic simulation, radio surgery, deep brain

stimulation and stereo tactic electroencephalography [2].

4.2. NeuroArm

The NeuroArm is a MRI compatible system which comprises

of a controller, a robot and a workstation. Identical to

Neuromate, it provides a audio, visual and tactile feedback

[21]. It is capable of both microsurgery and image guided

biopsy. It consists of two arms, each having 7 DOF used for

accurate tool positioning and a 1 DOF tool actuated by

piezoelectric motors mechanism for each of the end effectors

[2, 21]. There is an attached microscope which gives a

detailed view for the surgeon to operate. It has a master-slave

configuration where the movement of the stylus hand

controller which is handled by the surgeon, get mimicked by

the tool tip of the surgical tool attached to the end effectors.

The tool length is of 25-30cm which optimizes access to the

deep structures of the body and devoid of compromising the

position of the operating microscope [22]. The end effectors

have a multiaxis force sensing system used to give a haptic

feedback to the surgeon [21]. The surgeon controls the 2 arms

from aworkstation which provides an way to perform

microsurgery and stereotaxy and provide 3-DMRimages [23,

24]. It is capable of performing various operations such as

fine suturing, thermocoagulation and even biopsy [25]. In

2008, the NeuroArm was for the first time used in a 21- year-

old patient for the removal of a brain lesion. Since then,

reports have shown approving results for its work station

[10].

4.3. Pathfinder

The Pathfinder is a surgical system that receives a CT or MRI

during a preoperative stage. It identifies the surgical area by

locating reflectors that are attached on the patients head. This

is performed using a camera that is embedded in its distal arm

[26]. At the entry point the tool holder is then positioned

along a trajectory of a straight line [18]. Subsequent to the

preparation of a burr hole by the surgeon, the surgical tool is

inserted by the robot with a sub millimeter accuracy [2, 18].

It uses guiding needles for biopsy as well as guiding the drills

to form burr holes [2].

4.4. Spinal Fusion

As the name suggests, the robot invented here is for

facilitating surgery involving human spine fusion i.e, aiding

the doctor in cutting in a particular pedicle screw. Spine

fusion has become a notoriously painful task and common for

those with acute and chronic back aches. Chronic LowBack

Pain (CLBP) has become ever so common in elderly and

needs quick recovery strategies [27]. Conventionally,



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physicians used to always abide by using trivial surgical tools

and a set of CT scans to perform the surgery. This procedure

summarized as follows:

Initially the targeted area is studied using graphics from

MRI/CT scan, after which, the surgical plan is discussed.

This targeted area of the operation is thoroughly

sterilized and dissected intra-operatively.

The integral part of the surgery begins when the

surgeon bores holes in the vertebrae as a guide track

to fix screws through them.

Fluoroscopic images are taken to re-ensure these are

in their right position and connecting rod is then

used to firmly fasten them.

Finally, the wound is covered and sutured.

Figure 3: The experimental layout of SPINEBOT [28]

Issue with such a method is that its tedious and surgeon is

bound to bump into inaccuracy while guiding the screws in

its right track. This is where robotics comes to the picture.

The essential components of this robot are the basic surgery

assisting system and the much required navigation control.

Ethernet is also used to share data when necessary. An optical

tracker is present to detect the surgical area by tracking the

point of a probe attached to the area. The robot simply

positions and directs drills, needles and other instruments and

thereby conducts self-actuated screwing and boring

operations in the lumbar. The trajectory that makes the most

of the insertion of the pedicle screw is chosen carefully as to

increase the strength between the transpedicular screw-

vertebra boundaries [28]. Not just this, but during respiration,

it is also able to successfully compensates the movement of

the patient. The surgeons are able to accomplish higher

precision and minimal invasion through this method due to

the presence of robot that equips image processing. One

popular model developed for this purpose is the Spinebot,

which performs drilling and other useful tasks. It consists of

a Cartesian type 3-DOF positioner, a 2-DOF gimbals and a 2-

DOF drilling instrument. Depending on the task, it operates

in two modes, namely, passive mode and active mode. The

passive mode is mostly used to navigate the spot, later used

by the surgeon to undertake the surgery. Hence, the robot

doesn’t really perform the surgery.Wider range of operation

is provided by the active mode. The robot directly bores a

hole on a lumbar and automatically fixes a screw through it.



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5. CARDIAC SURGERY

Robotic cardiac surgery involves making minute incisions on

the chest and using specially designed instruments to perform

the surgery. The incisions are precise and improve the overall

efficiency. Incisions or ports are first made in the chest, in the

gap between the ribs. A camera along with surgical

instruments are embedded into the ports. The instruments

have motion sensors to give the surgeon control over its

movements. At the console, there is a pair of lens through

which the surgeon can see images produced from the camera.

From this, a 3-D image of the area being operated is produced

for the surgeon. Foot pedals are used to control the zoom of

the camera. A study in the treatment of certain heart diseases

is discussed below:

5.1. Photo Chemotherapy

These compromise frameworks and gadgets to treat and cure

heart arrhythmias- a condition that is subjected to the rise and

fall in cardiovascular tissues that leads to inactivity of the

electrical pulses normally generated by the heart. The

frameworks integrates the utilization of photo chemotherapy,

(or photodynamic treatment, a non-warm system to obliterate

the tissues and blood pathways from which show inefficiency

regulated [29].

5.1.1. Field of invention

The present change identifies with the treatment of

cardiovascular arrhythmias and, all the more especially,

frameworks and gadgets to treat and cure heart arrhythmias

utilizing photo chemotherapy (i.e. photodynamic treatment)

[34, 35].

5.1.2. Background of invention

The sinus focus point (SA focus) is known as the heart’s

“trademark pacemaker”. Under normal function, electrical

incitation spreads from the SA, through the atria (the

insignificant, upper chambers of the heart), and into the

ventricles (the expansive, principle pumping chambers of the

heart). This electrical wave acts as the trigger before the heart

starts pumping. 60–100 is the normal pulse rate for any

normally beating heart. Therefore these electrical signals are

vital for active and normal pumping of blood.

In two or three arrhythmias, for event, the typical instance of

electrical excitation is attenuated leads to strange pathways.

In a different issue, these cardiac cells might be auto

arrhythmicž, expecting control over the pacemaker activity

from the SA focus point. By emptying certain cardiovascular

tissue, a considerable piece of these arrhythmias can be

eliminated.

Radiofrequency is another such approach for this treatment.

Under this, a corresponding catheter test is embedded onto

the endocardiac surface (most prone to arrhythmia). This

framework has met with limited success nowand again of

heart arrhythmias. The procedure is enhanced when

connected with atrial fibrillation, the largest saw and

weakening kind of maintained heart arrhythmia known.

Atrial fibrillation affects more than 2 million individuals in

the United States alone and is responsible for roughly 75,000

strokes yearly [36]. Atrial fibrillation (AF) is a brisk, sporadic

heart musicality brought on by malfunctioning electrical

signals especially at the upper part of the heart [37, 38, 39].

AF may build the heart rate to a tremendous rate of 100 to

175 pulses per second. Instead contracting regularly, they

tremble, which can lead to pooling of blood at one area alone

and this accumulation leads to strokes. In the most recent

couple of years, it has been found that different patients with

paroxysmal atrial fibrillation may have hints of arrhythmia

instituted by a central wellspring of expedient ectopic action.

Intracardiac mapping has shown that these ectopic foci are

routinely organized in the pneumonic veins, especially the

dominating aspiratory veins, which are known not

myocardial sleeves that may open up a few centimeters from

the left atrial insertions of these veins [40, 41]. These foci can

comparably be an adjoining wellspring of kept up atrial

fibrillation [42, 43]. New methods, for occurrence, for case,

inflatable ultrasound catheters, inflatable laser catheters, and

deployable RF catheters, have been proposed to electrically

bind the chamber and aspiratory veins in patients with central

atrial fibrillation. Central ejection of the aspiratory veins

utilizing these carrier ports, in any case, has encountered as

of minimal use and success [44]. The cryptic nature of the

pneumonic vein ostia utilizing x-shaft fluoroscopy, [45]

perplexities, for example, progression of systemic

embolization, [46] hole of the myocardial divider and [47]

pericardial spreads and aspiratory vein stenosis brought on by

the intense post-clearing combustible reaction to abnormal

state ostial warms and cell neorosis.

5.1.3. Summary of invention

The present change highlights non-warm techniques and

gadgets for the treatment and/or cure of cardiovascular

arrhythmias. The present creation identifies with the

treatment and cure of cardiovascular arrhythmias utilizing



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photo chemotherapy or photodynamic treatment which can be

used for the following:

To wreck the tissues and pathways from which

unusual signs, affecting cardiovascular arrhythmias,

rise.

To pound enough customary tissue so that an

arrhythmia cannot be administered.

To wreck the tissues and pathways from which

unmissable signs rise and/or to destroy other heart

tissue such that sporadic electrical rhythms cannot

be kept up.

Figure 4. Electroanatomic mapping. (A) The catheter (composed of tip and ring electrodes and a location sensor). (B) A location

pad with three coils producing magnetic fields. (C) Real time display of catheter position (D) Activation charts [42].

A procedure for treating and/or curing cardiovascular

arrhythmias incorporates dealing with a restoratively

persuading measure regarding photosensitizing directors by

acquainting the patient with light fit for prompting the

photosensitizing specialists. Particularly, the photosensitizing

powers is gone on to the cardiovascular tissue, wherein the

photosensitizing directors is exceptionally eaten up by the

tissues and pathways from which eccentric signs bringing on

the arrhythmias rise and/or by routine tissues that help with

supporting the heart arrhythmias. An illuminating system is

utilized to organize the photosensitizing experts. The fiber

optic catheter may wait till it would go on laser recognition

with a blend of light cases. Here are two examples:



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Example 5.1.

In one encapsulation, the fiber optic catheter

goes on light in a discrete point.

In another, the fiber optic catheter goes on light

in a quick specimen by utilizing a fiber optic

diffuser with the fiber optic catheter.

The fiber optic catheter goes on light in

annular/ring shaped outline by putting an

angioplasty sort inflatable or for all intents and

purposes indistinguishable structure over the

fiber optic.

Example 5.2. The contraption for photo chemotherapy or

photodynamic treatment of cardiovascular arrhythmias

contains a catheter having an inflatable/storage facility at its

distal end and a light source, for example, a fiber optic

catheter, inside the inflatable or store. In one case, the catheter

is embedded to the searched for treatment site (e.g. the

aspiratory vein ostia) and a photosensitizing experts is

saturated into the inflatable or storage facility. The

photosensitizing directors is then put through the inflatable or

vault to the treatment site, for event, through one or more

pores in the inflatable or supply, or through a semi vulnerable

material encompassing inaccurately a piece of the inflatable

or store. The light source then goes on right through the

inflatable to the treatment site, in this manner beginning the

photosensitizing overseers.

5.2. Cardiovascular Surgery

Cardiovascular surgery is a high-danger methodology paying

little mind to paramount declines in related severity and

mortality throughout the most recent 30 years [44]. Each year,

28000 of 357000 patients encountering a coronary supply

course avoid joining or valve technique in the USA

experience a hostile occasion, around half of these are likely

preventable. Besides, 33% of passings after taking an

alternate route, join surgery which may be preventable [46].

Tenacious security tries have seen little change over the span

of the latest decade towards more secure consideration.

Likely deterrents are less intensive or thorough systems to

recognize wellbeing risks and execute convincing solutions.

In the scope of surgical wellbeing, investigation is result

driven and surveyed, confining our appreciation of structure

and process variables that impact understanding results [45].

To grasp these variables in the cardiovascular working room

(COR), we ought to augment our examination methodologies

and conduct arranged studies, including observational field

ponders. It has been recognized specific wellbeing dangers in

the midst of cardiovascular surgery, however only few have

used an interdisciplinary approach to manage amidst these

perils. However, tolerant security is actually interdisciplinary

and each control will “see” different risks in a thought

structure. All things considered, experts from various

requests could give a more complete picture of hazards and

opportunities to improve them.

While patients may suspect that their experts will act to their

most prominent point of interest, there is confirmation that

clinical judgements in, for example, cardiology may be

influenced by the sociodemographic characteristics of the

patient, stereotyping, and moreover restorative

administrations resource limitations. Patients, particularly

more prepared people, may not be given the extent of

treatment decisions fitting for the treatment of their condition

[45]. There is some verification that more prepared people

guide their authorities later than more young people with

reactions of wiped out wellbeing, frequently show in an

atypical way, and they in like manner experience an

aggregate addition in demonstrative, referral, and treatment

delays differentiated and more energetic people [48]. These

are among the likely explanations behind the reported

additions in emergency systems in more prepared people with

cardiovascular disease, with their extended risks and

expenses. More established people with extraordinary

myocardial confined rot are furthermore routinely denied

access to ace workplaces, for instance, admission to coronary

thought and heart recuperation administrations [47]. They are

more unwilling to get lifesaving thrombolysis where

illustrated, and are less disposed to get convincing solutions,

for instance, beta blockers on mending office discharge that

patients developed under 60.9 Documented age sways in the

written work are self-sufficient of sex, and research moreover

shows that women of all ages are less disposed to get capable

cardiovascular medications when required than men [45].

This is particularly exasperating given that coronary ailment

is the essential driver of death around the globe. It is moreover

a paramount purpose behind death and failure among more

prepared people, particularly in the UK.

The confirmation on treatment plans by age and sex suggests

that patients are excluded in the fundamental authority

process. It is ethically charming to make note of patients’

points of view before settling on system or individual

treatment decisions. Where individual fulfillment and future

issues are crucial, patients’informed slants should be as basic

in therapeutic administrations decisions as the collection of

affirmation on the clinical feasibility and costs of a

framework [46].



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The dynamic speculation of patients in shared fundamental

administration about their social protection is in like manner

a crucial estimation of contemporary models of patient

centered thought and of authority patient essential initiative,

disregarding the way that these models are unreliable and

various acknowledge that patients are unequipped for, or

reluctant to, participate. This is a region where test data are

still required and our examination arrangements to address

this. The Locating Errors through Networked Surveillance

(LENS) study was a bit of the Flawless Operative

Cardiovascular Unified Systems action, and financed by the

Society of Cardiovascular Anesthesiologists Foundation. The

LENS study was coordinated by professionals from the Johns

Hopkins Armstrong Institute for Patient Safety and Quality,

and used various reviews and anticipated strategies and an

interdisciplinary gathering to recognize tolerant wellbeing

dangers in heart surgery. This paper depicts the categorization

of data probably accumulated in the LENS study to recognize

dangers in the COR.

6. AN INSIGHT TO PROSTHESIS AND ORTHESIS

There are various technologies that have encouraged doctors

and surgeons to adopt the use of prosthetics and orthotics.

These are nothing but the collaborative use of machine and

human limbs considering actuator technologies that act like

our muscles and exploit rules of actual biological locomotion

[49]. They have given hope to the physically challenged

(suffering from traumatic injury, cerebral palsy or multiple

sclerosis etc.). While it is highly difficult to mimic human

hands and legs with its n number of joints and bones, it is

important to match them as much as possible for robust and

easy locomotion. Crude materials such as leather and wood

were initially used in making primal devices [49]. However

due to its non adaptive and hefty nature the were proven

impotent. Recent designs comprise of sophisticated electrical

motors, sensors, polymer based artificial muscle or carbon

composite leaf springs that are not only nimble, strong, light

and swift but also mimic the muscle property such as

absorption and release of energy. Later trends incorporated

use of SCP (Super Coiled Polymers) which more or less

upgraded the frontier for Robotic Arms [50]. One thing

researchers understood was that O & P should be able to

control motive force and joint impedance in order for

artificial appendages to match that of natural ones. Since

natural muscles are basically polymers, it is an added

advantage that these polymer synthesized artificial muscles

mostly behave as biological muscles. Infact, polymer

actuators are often pronounced interchangeably with the word

artificial muscle. The most rapidly developing technology

and the easies one for modelling is 3-D printing, also known

as rapid proto-typing. Physical models are easily created with

the help of softwares (CAD etc). The object is resolved into a

series of slices while under the production process. The 3-D

printer may use ink or varying other materials. Few among

the umpteen no.of things that are popularly manufactured

bones, exoskeletons , dental prosthetics, ears etc. [52]. One

such actuation technique, EMG or electromyography, has

been extensively analyzed as a way of controlling prosthetic

devices as it provides a noninvasive way of measuring muscle

activity [51].

Mechanical sensors are used as an indirect way of knowing

user intent in these actuators. External sensors such as

capacitive and potentiometer sensors are basically used for

measuring postures of our ankle joint. Ankle position during

the swing period of walking and ankle impedance while at

stand still are powered after retrieving corresponding sensory

information [49].

In later years the strength space of the interphalengeal

muscles in the human arm were studied experimentally.

These include the Flexor Digitorum Profundus(FDP) and the

Flexor Digitorum Superficialis (FDS) muscles. The design of

the robotic arms thus built took in mind the detachment of

these strength areas into a lighter (strength) area where finer

handling and general work were executed and a higher area

where the more rigid grasps were executed [7]. A relationship

was hence created between EMG signal of forearm and

actuation system, which was all along the main goal of this

project. Observations that were made were: (i) FDP muscle is

shown to reach its maximal force execution at more at 35%

of the total flexural effort but naturally continues to exert

more pressure (ii) Different actuator mechanisms are taken

into consideration in its design I.e, hydraulic, pneumatic,

ultrasonic etc.(iii) DC motors are used for

abduction/adduction movements [7]. After such inventories

the pace of robotics in prosthetics have progressed and many

brands, applying the same principle has been promoted.

These include the Shadow hand, I-Limb hand, Fluid hand etc.

Cons of using these artificial limbs are: Balance, Cost

(Magneto-strictive materials, shape memory alloys,

piezoelectric are used conservatively where large material is

required), meeting certain parameters (Output power,

elasticity stroke, and damping) of natural muscle, dexterity,

appearance, weight and durability.



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Figure 5: 1. Foot and Ankle orthoses., 2a. Elastic actuator comprising ball-screw and motor, 2b. Series elasticity, 3. Potentiometer

Angle Sensor, 4. Capacitive force sensor [49].

6.1. 3-D printed prosthetics

Is also known as rapid proto-typing, is a rapidly developing

technology in medical as well as other engineering fields.

Physical models are easily created with the help of softwares

(CAD etc).

The object is resolved into a series of slices while under the

production process. The 3-D printer may use ink or varying

other materials. Few among the umpteen no.of things that are

popularly manufactured bones, exoskeletons, dental

prosthetics, ears etc. [52].

6.2. Exoskeletons

An exoskeleton is another type of prosthetic device that is

anthromorphic in its appearance and is used by the

handicapped just as one would wear their garment [53]. It

basically acts as an extension to augment leg and hand

motion. The development progressed from the lower

extremities of the human body up to the torso of the patient

[54]. The first type invention was the kinematic walker that

was introduced half a decade ago, constituting a hydraulic

actuator for motioning various body parts. The closest

human-like ankle built in these exoskeletons is the bleex

ankle that has three d.o.f. just as ours. Some speacialised

exoskeletons were invented bearing in mind the tiniest of

operations like pinch or grasping by human phalanges. The

key is to build minimum no.of actuation modes and include a

controllable D.O.F. [55] These possess feedback sensors (for

accuracy purposes) and force sensing resistors on the palmar

and dorsal side of the hand as a way to provide input to a

microcontroller that activates pneumatic pistons [56]. A few

well-known exoskeletons built hydraulically powered are:

1. The ReWalk: Is a light-weight, independent suit that

is best used for 50 m–100 m continuous waking with

a speed of approximately 0.21 m/s. It comprises DC



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motors, cyclic batteries, a programmable system and

a huge set of sensors [57].

2. Exoskeleton Lower Extremity Gait System or

eLEGS: Uses up-to forty sensors and four motors

and is assisted with crutch or walker. An additional

carbon frame is used as a substitute for bone

strength. Speed limited to two mph and uses battery

that lasts for six hours.

3. Master-Slave Exoskeleton: This consists of an

upper-limb exoskeleton that gets instructions for

basic motion. The EMG signals are basically sent

from 16 muscles in correspondence to motions of

the human arm. These signals are reflected in detail

by sketching FFT graphs. Seven motors are

equipped (using pulse width modulation technique)

for seven DOF. Accelerometers are mounted on this

exoskeleton to foresee the action of the user and

calculate angle of rotation [58].

4. NTUH-ARM (or National Taiwan University

Hospital-ARM): A rehabilitation robot that is

capable of 7-DOF [59].

7. RADIOSURGERY

Radiosurgery involves treating of cancer by utilizing

radiation in large amounts and concentrating them on the

tumor infested areas. When the beams are used to treat tumors

in the brain and spine it is called Stereotactic radiosurgery

(SRS) and when used to treat tumors on other parts of the

body outside the brain and spine area, it is called Stereotactic

body radiation therapy (SBRT) [60, 61]. Radiosurgery is also

known as CyberKnife or Gamma Knife which is named after

the machines being used. CT scans and MRI give the precise

location of a tumor which is in relation to skeletal landmarks

or fiducial markers that are implanted [62]. Establishing the

exact location of the landmarks is crucial and challenging.A

stereotactic frame is attached to the skeleton of a patient and

is used for identifying the landmarks. It is locked in position

with respect to the treatment device [62]. This method

enables the tumor to be centered inside a sphere of multiple

radiation sources [62]. This increases the dosage of radiation

and reduces its impact on the surrounding tissue. A frameless

system uses Stereo X ray Imaging for locating the landmarks

in respect to the treatment device [62].

7.1. Gamma Knife

The Gamma Knife is a minimally invasive SRS device that

focuses on the treatment of cancerous and non-cancerous

tumors which was developed in 1969 by Elekta AB. It

provides a painless alternative to the conventional surgery. It

consists of a lightweight stereotactic head frame which has a

3-D coordinate system and is fixed onto the patients head. A

collimator helmet consisting of 201 holes is fitted onto the

head frame. The treatment begins with the patient undergoing

a CT, MRI or angiography scan in order to locate the lesions.

Locating the tumors is a crucial step [63]. The results are sent

over to the planning computer system which give the 3-D

coordinates of the tumor. The identified location is then

exposed to 201 individual gamma beams of cobalt-60 [63, 65,

66]. These beams are focused onto the centre of a collimator

helmet to deliver a high concentration of radiation with low

irradiation of proximal structures. The beam is selected based

on the shape of the tumor and its intensity is chosen on the

duration of exposure. Treatment is performed in a single

session which can extend from 20 minutes up to 2 hours [67].

Its accuracy is up to 0.3 mm [68]. Upon completion of the

treatment, the head frame gets removed and the patient is

moved out of the machine automatically. The whole

procedure is painless. The main limitation of this device is

that cancer is treated in the brain, head and neck. Some of the

lesions that are treatable include: brain metastases, gliomas,

arteriovenous malformations of the brain, meningioma,

chondrosarcoma, Optic nerve sheath meningioma and

trigeminal neuralgia. In addition to the treatment of tumors,

brain disorders like Parkinsons disease and obsessive

compulsive disorder can also be treated.



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Figure 6: CyberKnife [75].

7.2. CyberKnife

Developed by Accuray, it is utilized to treat both non-

cancerous as well as cancerous tumors in any part of the body

including the brain, spine, kidney, pancreas, prostate and

liver. It initially was developed as a frameless alternative to

the already existing SRS systems like Gamma Knife which is

equipped with stereotactic beam collimator and a head frame.

In the following papers, its initial development has been

discussed [69, 70, 71, 72, 73]. The radiation beams are

delivered with high accuracy of less than one millimeter. It

treats the tumors non-invasively and gives a painless and non-

surgical option for patients having complex tumors. It is

equipped to discharge radiation from practically any direction

so as to conform to tumors of any shape. During the set-up a

soft mesh mask is fitted to the patient during which the CT

scan is performed. This scan is used to extract the shape, size

and location of the tumor [74]. Treatment is done in one to

five sessions. The latest advancement is the addition of VSI

system. This has shown an increase in the radiation delivery

and variable beam apertures thereby reducing the treatment

time.

It is comprised of a robotic arm that holds a linear accelerator

(LINAC), a 6 DOF robotic patient table known as The Robo-

Couch and an X-ray imaging system that is capable of taking

in two orthogonal orientations concurrently [2]. The robotic

arm provides a radiation dosage that has been initially

planned and is executed in an array of orientations [2]. If any

movement of the target occurs during the treatment, a motion

tracking system known as Synchrony System tracks the tissue

surface optically and correlates its motion to movements of

the radio-opaque fiducials placed near the target, thus

enabling it to predict the target motion continuously [2].



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Surgeons are capable of utilizing more than 1200 different

angles and positions for targeting the tumors.

When the treatment begins, an automatic DRR (digitally

reconstructed radiograph) registration is performed which

gives a 3-dimentional model of the patient while

simultaneously giving a live feed of images which are

obtained from the X-ray imaging system located inside the

treatment room. The alignment of the beams is based on the

DRRs [76]. Two individual transformations, one for

theDRRpairs and one for the live images are united [76].

They are then changed to a 3-dimentional transformation

using geometric back projection which allows a room and

target space transformation [76]. The geometries of the

robotic manipulator and the Robocouch are known and this

gives control over the dosage of each treatment beam with

respect to the target volume. Using the the Image guidance

system, the treatment table can be manipulated to align the

patient at the beginning of each treatment. The LINAC is

repositioned whenever there is any movement of the patient

during the treatment thereby ensuring the delivery of the

beam at each target node. Target localization, alignment

corrections and image acquisition are continuously repeated

during each treatment delivery, usually every 30–60s [76].

The target positions stability is responsible for the imaging

interval. The manipulator compensates for all the rotations

and small translations during imaging and repositioning of

the LINAC [76]. During the commencement of the treatment,

the robot moves in an order through the various nodes that

have been selected during the treatment planning [76]. The

manipulator can only travel between nodes at which one or

many treatment beams are programmed to be delivered due

to the optimized path traversal algorithm [76].

8. OTHER SURGERIES

Robot assisted surgeries have also benefited other organ

surgeries such as in the case of Abdominal Surgery

(Peritoneum and retro-peritoneum).These were able to

counter act ovarian tumors and fibroid in the female

population with post operative period of only 7 days. Initially,

installation is done in the umbilical zone, maintaining

distance between ports.A visual image is sent to the surgical

department using Multidetector Computer Tomography

(MDCT). Only drawback being, limited instrument dexterity.

Other surgical operations carried out widely with robots are

cystectomy, Vasovasostomy, renal transplant etc [77].

9. DAWN OF NANOROBOTICS

Nano robot is a micro device that uses technology based on

Nano-material science and robotics with advanced biological

knowledge. The introduction of bio-bots has been one of the

most promising and effective upturn in medical history to

combat diseases, without having to dissect the body organs.

Under this technique the physician can continuously examine

the progress of the micro-bot from outside once it is

suspended into the target area (bloodstream, affected tissue

etc.). Just as any other normal robot, the design architecture

of nanorobots include onboard sensors, motors, manipulators,

power supplies but molecular sized computers [78].

Biological sensors that incorporate tissues, cells or enzymes

which are capable of electrical activation are employed as

away of analyzing the fluid [79]. The entire process is

minimally invasive, pre-programmed and can be trusted to

give the most accurate report [80, 81]. Role in distinct fields:

1. Central Nervous System: They are able to repair

damaged neurons by acting as an implant. For patients

who suffer from paralysis, these bots once injected, can

relocate themselves into a corresponding section of their

brain and take in electrical impulses. These are then

signaled to bodys motor neuron (which are defective) to

trigger the robotic arm etc [80]. Other inventions in this

field is the supermagnetic nano capsules. As the

capillaries of the CNS are structurally distinct from those

of the other tissues, the differences affects permeability

barrier between the blood of the cerebral capillaries and

the extracellular fluid in its tissue. The capsules are

thereby invented to get through this blood-brain-barrier

(or BBB) with help of magnetic forces. The bio-

engineers took care of 3 parameters in creating it i.e.,

geometrical, biophysical and biological properties.

Smeared on its surface are exclusive ligandsspecific

receptor systems that acts as a recognition site for the cell

membrane and thereby attracts the functionalized CNT

(Carbon Nano-tube). Then the capsule repositions itself

to the corresponding configuration. To boost the

penetration of these capsules into the endothelial layer,

they are shaped spherically or in a rod like fashion

(single-wall CNT) [82].

2. Cancer Treatment: The chemotherapy used today is

difficult to control as it tends to affect other healthy

tissues located at its vicinity, causing hair loss, weakness,

nausea, depression, and a mass of other symptoms [79].

This is overcome using Nano robotics [83]. Under the

machine gun approach, a set of primary nanobots are sent

to the cancer cells to inflame it. After which a second set

is again sent to sense the inflamed tissue and discharge a



11290

particular chemotherapy drug. Only the area of attack

becomes concentrated with the drug as a result [80]. A

similar tactic could be taken to enable nanobots to supply

anti-HIV drugs [81].

MC-1 bacterium was first found in 1993, in a

River in Rhode Island. These are magnetic in

nature and have the special ability of orienting

themselves with Earths magnetic field. Their

strain is now cultivated in labs (model microbot).

It has a globular body that provides abundant

surface area (for attaching anticancer drug

molecules), a pair of spinning, whip like tail-

powered by molecular rotary motors ž that whizz

it through water at extreme speed.A weak

magnetic field pointing toward the tumor is

generated to maneuver the microbot [84].

Another alternative approach is using Nano shells

that keep circulating in the bloodstream until it

meets the tumor cells. Subsequently an IR laser is

dispatched. The shells take in the selective

frequencies and melt the polymer to release the

drug at the infected area. Furthermore, this

practice is used by diabetic patients wherein a

ballpoint- pen size IR laser is used for heating the

skin at the site where the shell is present. This time

an array of insulin is released. The Nano shell

polymer can remain inside the body for a long

period of time [85].

3. Circulatory system: To clear blockages from the various

blood vessels. Other inventions are:

Respirocytes: Aclass of synthetic and

mechanicalRBCs that are are excited by endogenous

serum glucose for active pumping. A quantity is

these mixed in the bloodstream of a man prone to

heart attacks can keep him alive for nearly four

hours after the event. Semi-treatment of anemia are

one among its many applications [85].

Microbivores: A class of synthetic and mechanical

WBCs. It functions to eliminate pathogens using a

digest and discharge protocol [85].

4. Swarm intelligence: After experimenting on macro

robots, this approach is installed in body-nanobots. They

basically communicate among themselves to come to a

common decision (acting as a single unit) and avoid

toxins [80].

5. Surgical benefits: Delicate surgeries like the fetal surgery

(with major mortality rates) and eye surgeries are

accomplished with perfect accuracy due to the robots

better access. The pros of dealing with this science is that

a lot of the parts required to run the robot are naturally

available. For example, the protein, rhodopsin, instilled

in the bot has a quality to trap solar energy and use this

in the form of ATP to rotate nano-scopic shafts. The

amount of research going on in this field is paramount.

The future goals are to develop better actuating

mechanisms to successfully shield diseases [86].

10. ROBOTICS IN HEALTHCARE SYSTEMS

Service robot is a type of robot that is used to perform

specific tasks outside the industrial field. These include

health care robots, robots for sewers, electric tunnel

inspection, harvesting and construction robots [9]. Among

their varied range of services, aid to the handicapped and the

elderly are the most prominent [9].



11291

Figure 7: Nano Robots descend on a tumor infected area [83].

Figure 8: Parts of Nano Robot [84].



11292

10.1. Robotics in Pharmacy

The predictability of a robot has potential benefits in the

administration of medication [86]. Due to population growth,

the working hours of workers in hospitals has increased

during outpatient and inpatient care. As a result automated

pharmacy has been introduced to reduce the time and improve

the overall efficiency. It is comprised mainly of a medicine

dispenser, medicine sorter, medicine supplier, database,

prescription information processor and interface with the

hospital HIS(hospital information system) [87]. All these

systems are fully automated and systems like the medicine

dispenser are PLC controlled [87, 88]. In some places robots

are used where the robots arm gathers the required amount of

vial, acquire the medication, and label each of the vials along

with scanning the barcodes and verifying the medication [86].

These bots also store, package and dispense the medications

to the patients [86]. ScriptPro is one of the companies

manufacturing these robots. Their robots have a high

accuracy and are safe with a prescription filling rate of 40–

70% of daily volume. The prescription processing occurs at a

rate of 150 prescriptions per hour.

10.2. Robotics in Tele-health

In telemedicine, we employ tele-health robots are used for

various applications such as recording, patient monitoring,

medical consultation, real-time on scene paramedic support

and telediagnosis [89]. Moreover, this protects patient

confidentiality. This gives a major adavantage for villagers

who have poor access to communicate with specialized

doctors staying far away [90].

10.3. Use for the Elderly

The robots don’t just limit their application for patient care

but its greatly and best used among the elderly. Sebastin

Thrun, invented the NuRSEROBOT [86], is able remind the

elderly to take their medicines on time and is also able to aid

them to the toilets etc, behaving as a typical nurse. After an

agreement between JPL and RWI, manufacturers of mobile

robots, who manufactured a multi-model operator interface

robot, built for similar purpose. This robot has a mobile

platform. It is equipped with a color camera mounted on a

pan-tilt head. For carrying out autonomous navigation, it is

provided with an array sensors. These being, ultrasound,

infrared and other tactile sensors. It is able to operate for at

least quarter of a day in continuous fashion making it highly

dependable. Two layers of programs controls its motion. The

lower level is called the Base Server and the upper layer is the

Rhino package. Both respectively consists of a collection of

device drivers and optimal trajectory control and obstacle

avoidance capabilities. It also programmed to accept

messages in its own machine language from other

surrounding devices. After which a command is signalled to

the Base Server for execution. The manipulator arm used has

six DOF. Video images from the mounted camera on robot,

sonars readings, position of the robot on environment map,

and user voice commands are some of the many user interface

provided by the robot [9]. Certain robots are designed to

provide control methodology for medication intake and

prevention from adverse drug usage for the elderly like the

iRobiQ [91].

10.4. Helping Autistic Children

The Roball robot was invented during the 90s to aid autistic

children and it proved highly developmental for their external

experiences and upbringing. It consists of a spherical ball that

encases various sensors and processing elements. This built

up enables the robot to navigate obstacles in a particular

playroom environment for about one whole minute or so,

after which the robot would provide options to be wheeled,

jolted, or thrusted in order to move again. It can also signal

whether it should repeat any task or feels dizzy [86].A robot

called Keepon was made to interact for 1.5 years with

children having PDD, autism, downs syndrome, Aspergers

syndrome and other developmental disorders [92]. The

results showed that the children who had difficulty with

interpersonal communication were capable of approaching

the robot with security and curiosity [92].



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11. CONCLUSION

The advancement in technology has enabled us to use robots

to perform various operations on the human body and

enhance our well-being. Something that was once considered

as fiction has nowturned into a reality, where robots assist in

surgeries and help combat the various diseases like cancer,

physical impairment, atherosclerosis etc. Robotic Systems

are being evolved significantly to enhance the capabilities of

the surgeon towork in a very confined space and



11295

simultaneously performing extremely complex tasks. Current

clinically available surgical robots have been designed to

mimic the surgeons maneuvers. Advanced Imaging Systems

are used alongside theses robots to get a real time live feed of

the events taking place in the patients body during the

surgery. They are used to detect upcoming diseases and help

protect the patient from further damage to their body. The

invention of prosthetic devices has been proved critically

essential for all the victims of war or accidents that have

culminated in the losing their limbs. The stages in which these

robotic extensions of arms and legs have progressed is

impressive and has been a trusted equipment in their lives.

Nano robots are used to help navigate places in human body

which a surgeon could never access. It gives the advantage of

being able to operate large parts of the body with just a small

incision on the skin thereby preventing major injury to the

patient and minimizing the loss of blood as well as making

the whole operation less painful.

Robots in health care has helped to combat the working hours

required by those in the medical field. In pharmacy, they are

used in packaging medicines and are used as a

communication medium between patient and doctor, thereby

reducing the communication gap between the two and

spreading better health care to majority of the population.

The future holds great promise for the growth of

telemedicine, artificial intelligence and virtual reality. It is an

ongoing study and engineers are routing for ready and

painless strategy to perform the operation. One such tactic is

the use of single incision port that is implemented in order to

maneuver the robot into the human body while presently we

use multiple incisions. Further research is going on to replace

the tactile sensing feedback (prominently used). The Da Vinci

Surgical Systems are already being introduced into hospitals

and it would only be a matter of time when surgeries would

be completely machine controlled. If we conquer this, we

conquer half the medical world!

COMPLIANCE WITH ETHICAL STANDARDS

Disclosure of potential conflicts of interest

Author Royson Dsouza declares that he has no conflict of

interest.

Authors Catherine Debora,Aysha Sunaina andVishal Samuel

declare that they have no conflict of interest.

Ethical Approval

This article does not contain any studies with human

participants or animals performed by any of the authors.

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