Post on 11-Dec-2015
description
Mahatma Gandhi Mission’s
College of Engineering and Technology
Noida, U.P., India
Seminar Report
On
“ROBOTICS IN MEDICAL SCIENCE”
As
Part of B. Tech Curriculum
Submitted By:
PUSHKAR SINGH SANI
Vth Semester
1309540048
Under the Guidance of:
Ms. MANUJA PANDEY
(Asst. Professor)
Submitted to:
(Seminar Coordinator) HOD
Mechanical Engineering Department
MGM’s COET,
Noida.
i
Mahatma Gandhi Mission’s
College of Engineering and Technology
Noida, U.P., India
Department of Mechanical Engineering
CERTIFICATE
This is to certify that Mr. / Ms. PUSHKAR SINGH SANI of B. Tech. Mechanical
Engineering, Class TT-ME Roll No. 1309540048 has delivered seminar on the topic
ROBOTICS IN MEDICAL SCIENCE. His / her seminar presentation and report
during the academic year 2015-2016 as the part of B. Tech Mechanical Engineering
curriculum was poor/fair/good/excellent.
(Seminar Coordinator) (Guide) (Head of the Department)
ii
Acknowledgement
I would like to express my deep sense of gratitude to my supervisor Ms. Manuja
Pandey, Assistant Professor, Mechanical Engineering Department, M.G.M. College of
Engineering and Technology, Noida, U.P., for her guidance, support and
encouragement throughout this seminar report work. Moreover, I would like to
acknowledge the Mechanical Engineering Department, M.G.M. College of
Engineering and Technology, Noida, for providing me all possible help during this
seminar report work. Moreover, I would like to sincerely thank everyone who directly
and indirectly helped me in completing this work.
(Pushkar Singh Sani)
Date:
Place: Noida, Uttar Pradesh
iii
ABSTRACT
This report is based on the robotics technologies used in medical science. It provides a
detailed overview of robotic surgical systems and introduces recent developments in
the integration of synergistic controls such as virtual fixtures, dynamic active
constraints, and perceptual docking.
As we all know that it is very challengeable for surgeons. The level of difficulty of
surgery can be reduce by taking help of robots. Robotic assisted surgery has been
proved boom to medical science. This report gives a description about the types of
medical robots, robotic assisted surgery, their benefit & losses, and its future scope.
iv
CONTENTS
PAGES
Certificate i
Acknowledgement ii
Abstract iii
Contents iv
List of figures vii
CHAPTER 1: INTRODUCTION 1-3
1.1 Robotics 1
1.2 Robotic Surgery 1
CHAPTER 2: History of Medical Robotics 4-7
CHAPTER 3: Features of Medical Robotics 8
CHAPTER 4: Types of Medical Robots 9-11
4.1 Vasteras Giraffe 9
4.2 Aethon Tug 9
4.3 Bestic 10
4.4 CosmoBot 10
4.5 Microbots 10
4.6 Anybots 10
4.7 Swisslog Robocourier 10
4.8 Robots for deaf & blind 11
v
CHAPTER 5: Types of Surgical Systems 12-24
5.1 Da Vinci surgical system 12
5.1.1 Introduction 12
5.1.2 Overview 13
5.1.3 Clinical Uses 14
5.1.4 Advantage 15
5.1.5 Disadvantage 16
5.1.6 Future application 16
5.2 Cyberknife 17
5.2.1 Introduction 17
5.2.2 Overview 18
5.2.3 Robotic mounting 18
5.2.4 6D skull 19
5.2.5 Xsight 20
5.2.6 Fiducial 20
5.2.7 Synchrony 21
5.2.8 RoboCouch 22
5.2.9 Frameless 22
5.2.10 Clinical use 23
5.2.11 Advantage 24
5.2.12 Disadvantage 24
5.2.13 Uses 24
CHAPTER 6: Uses of Robotics in Surgery 26-33
6.1 General uses 26
6.2 Cardiothoracic Surgery 26
6.3 Cardiology and electrophysiology 27
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6.4 Colon and rectal surgery 28
6.5 Gastrointestinal surgery 29
6.6 Gynecology 29
6.7 Neurosurgery 29
6.8 Orthopedics 30
6.9 Pediatrics 30
6.10 Radiosurgery 31
6.11 Transplant surgery 31
6.12 Urology 32
6.13 Vascular surgery 33
CHAPTER 7: Future scope 34
CHAPTER 8: Conclusion 35
REFERENCES 37
vii
List of figures
Figure no. Name of figure Page no.
Fig. 1.1 Robotics arm 3
Fig. 2.1 PUMA 560 5
Fig. 2.2 Probot 7
Fig. 4.1 Microbot 11
Fig. 5.1 Da Vinci Surgical System 14
Fig. 5.2 Cyberknife surgical
system 18
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CHAPTER 1
INTRODUCTION
1.1 Robotics
Robotics is the branch of mechanical engineering, electrical engineering and
computer science that deals with the design, construction, operation, and application
of robots, as well as computer systems for their control, sensory feedback, and
information processing.
1.2 Robotic Surgery
Robotic surgery, computer-assisted surgery, and robotically-assisted surgery are terms
for technological developments that use robotic systems to aid in surgical procedures.
Robotically-assisted surgery was developed to overcome the limitations of pre-
existing minimally-invasive surgical procedures and to enhance the capabilities of
surgeons performing open surgery.
In the case of robotically-assisted minimally-invasive surgery, instead of directly
moving the instruments, the surgeon uses one of two methods to control the
instruments; either a direct telemanipulator or through computer control. A
telemanipulator is a remote manipulator that allows the surgeon to perform the normal
movements associated with the surgery whilst the robotic arms carry out those
movements using end-effectors and manipulators to perform the actual surgery on the
patient. In computer-controlled systems the surgeon uses a computer to control the
robotic arms and its end-effectors, though these systems can also still use
telemanipulator for their input. One advantage of using the computerized method is
that the surgeon does not have to be present, but can be anywhere in the world,
leading to the possibility for remote surgery.
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In the case of enhanced open surgery, autonomous instruments (in familiar
configurations) replace traditional steel tools, performing certain actions (such as rib
spreading) with much smoother, feedback-controlled motions than could be achieved
by a human hand. The main object of such smart instruments is to reduce or eliminate
the tissue trauma traditionally associated with open surgery without requiring more
than a few minutes' training on the part of surgeons. This approach seeks to improve
open surgeries, particularly cardio-thoracic, that have so far not benefited from
minimally-invasive techniques.
Robotic surgery has been criticized for its expense, by one estimate costing $1,500 to
$2000 more per patient
Medical robotics is a stimulating and modern field in medical science that involves
numerous operations and extensive use of telepresence. The discipline of telepresence
signifies the technologies that permit an individual to sense as if they were at another
location without being actually there. Robots are utilized in the discipline of medicine
to execute operations that are normally performed manually by human beings.
These operations may be extremely professional and facilitated to diagnose and treat
the patients. Though medical robotics may still be in its infancy, the use of medical
robots for numerous operations may increase the quality of medical treatment.
Utilization of telepresence in the medical operations has eliminated the barriers of
distance, due to which professional expertise is readily available. Use of robotics in
the medical field and telepresence minimize individual oversight and brings
specialized knowledge to inaccessible regions without the need of physical travel.
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Fig. 1.1: Robotics arm
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CHAPTER 2
History of Medical Robotics
Medical robotics was introduced in the science of medicine during the early 1980s,
first in the field of urology. Robotic arms were introduced and used for medical
operations. Robotics initially had inferior quality imaging capabilities. During this
period, the National Aeronautics and Space Administration also started exploring
utilization of robotics for telemedicine. Telemedicine comprises the use of robotics by
physicians for the observation and treatment of patients without being actually in the
physical presence of the patient. As telemedicine improved, it started to be used on
battlefields. During the close of the last century, medical robotics was developed for
use in surgery and numerous other disciplines. Continued advancement in medical
robotics is still in progress, and improved techniques are being developed.
The first robot to assist in surgery was the Arthrobot, which was developed and used
for the first time in Vancouver in 1983. Intimately involved were biomedical
engineer, Dr. James McEwen, Geoff Auchinleck, a UBC engineering physics grad,
and Dr. Brian Day as well as a team of engineering students. The robot was used in
an orthopedic surgical procedure on 12 March 1984, at the UBC
Hospital in Vancouver. Over 60 arthroscopic surgical procedures were performed in
the first 12 months, and a 1985 National Geographic video on industrial robots, The
Robotics Revolution, featured the device. Other related robotic devices developed at
the same time included a surgical scrub nurse robot, which handed operative
instruments on voice command, and a medical laboratory robotic arm.
A YouTube video entitled Arthrobot illustrates some of these in operation.
In 1985 a robot, the Unimate PUMA 560, was used to place a needle for a brain
biopsy using CT guidance. In 1992, the PROBOT, developed at Imperial College
London, was used to perform prostatic surgery by Dr. Senthil Nathan at Guy's and
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Fig 2.1: PUMA 560
St Thomas' Hospital, London. This was the first pure robotic surgery in the world.
The ROBODOC from Integrated Surgical Systems (working closely with IBM) was
introduced in 1992 to mill out precise fittings in the femur for hip replacement. The
purpose of the ROBODOC was to replace the previous method of carving out a femur
for an implant, the use of a mallet and broach/rasp.
Further development of robotic systems was carried out by SRI
International and Intuitive Surgical with the introduction of the da Vinci Surgical
System and Computer Motion with the AESOP and the ZEUS robotic surgical
system. The first robotic surgery took place at The Ohio State University Medical
Center in Columbus, Ohio under the direction of Robert E. Michler. Examples of
using ZEUS include a fallopian tube reconnection in July 1998, a beating
heart coronary artery bypass graft in October 1999, and the Lindbergh Operation,
which was a cholecystectomy performed remotely in September 2001.
The original telesurgery robotic system that the da Vinci was based on was developed
at SRI International in Menlo Park with grant support from DARPA and NASA.
Although the telesurgical robot was originally intended to facilitate remotely
performed surgery in battlefield and other remote environments, it turned out to be
more useful for minimally invasive on-site surgery. The patents for the early
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prototype were sold to Intuitive Surgical in Mountain View, California. The da Vinci
senses the surgeon’s hand movements and translates them electronically into scaled-
down micro-movements to manipulate the tiny proprietary instruments. It also detects
and filters out any tremors in the surgeon's hand movements, so that they are not
duplicated robotically. The camera used in the system provides a true stereoscopic
picture transmitted to a surgeon's console. Examples of using the da Vinci system
include the first robotically assisted heart bypass (performed in Germany) in May
1998, and the first performed in the United States in September 1999 and the first all-
robotic-assisted kidney transplant, performed in January 2009. The da Vinci Si was
released in April 2009, and initially sold for $1.75 million.
In May 2006 the first artificial intelligence doctor-conducted unassisted robotic
surgery on a 34 year old male to correct heart arrhythmia. The results were rated as
better than an above-average human surgeon. The machine had a database of 10,000
similar operations, and so, in the words of its designers, was "more than qualified to
operate on any patient". In August 2007, Dr. Sijo Parekattil of the Robotics Institute
and Center for Urology (Winter Haven Hospital and University of Florida) performed
the first robotic assisted microsurgery procedure denervation of the spermatic cord for
chronic testicular pain. In February 2008, Dr. Mohan S. Gundeti of the University of
Chicago Comer Children's Hospital performed the first robotic pediatric neurogenic
bladder reconstruction.
On 12 May 2008, the first image-guided MR-compatible robotic neurosurgical
procedure was performed at University of Calgary by Dr. Garnette Sutherland using
the Neuro Arm. In June 2008, the German Aerospace Centre (DLR) presented a
robotic system for minimally invasive surgery, the Microsurgery. In September 2010,
the Eindhoven University of Technology announced the development of
the Sofie surgical system, the first surgical robot to employ force feedback. In
September 2010, the first robotic operation at the femoral vasculature was performed
at the University Medical Centre Ljubljana by a team led by Borut Geršak.
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Fig. 2.2: Probot
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CHAPTER 3
Features of Medical Robotics
Medical robotics is managed by physicians through computerized consoles. The
consoles may be near the patients, or at an external site. Consoles include single or
multiple arms being in the control of the physicians who perform operations on
patients. The shape and dimensions of these arms depend upon the type of surgery
being performed. The medical data and requirement is fed in the robotics before start
of surgery, including the X-rays, and other diagnostic examinations. This information
facilitates the medical robotics to traverse the human body correctly.
The purpose of utilizing medical robotics is the provision of enhanced diagnostic
capabilities, increased patient comfort, and less hazardous and more meticulous
interventions. Robots are being used for multiple operations, including replacement of
joints, kidneys, and open heart surgery. The patient images are visible to the
physician, and he can accordingly control the robot by a computer. He may not be
required to be present in the patient room. The robots have enabled the physicians to
perform operations on patients who are located at long distances. Therefore, the
environment produced is friendly where the physicians experience less fatigue. (Some
surgeries may be performed for long durations causing extensive fatigue to the
physicians.) The use of robotics in the medical field makes many medical procedures
much more smooth and comfortable.
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CHAPTER 4
Types of Medical Robots
o Vasteras Giraffe
o Aethon Tug
o Bestic
o CosmoBot
o Microbots
o AnyBots
o Swisslog Robocourier
o Robots for Paralyzed patient
4.1 Vasteras Giraffe
The Vasteras Giraffe is a mobile communication tool that enables the elderly to
communicate with the outside world. It is remote controlled, and it has wheels, a
camera and a monitor.
4.2 Aethon Tug
The Aethon Tug is an automated system that allows a facility to move supplies such
as medication, linens and food from one space to another. End users can attach the
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system to a variety of hospital carts to transport supplies and it can be employed for a
variety of applications.
4.3 Bestic
Bestic is a small robotic arm with a spoon on the end. The arm can be easily
maneuvered, and a user can independently control the spoon's movement on a plate to
choose what and when to eat.
4.4 CosmoBot
Doctors use CosmoBot to enhance the therapy of developmentally disabled children
between 5 and 12 years old.
4.5 Microbots
An assortment of free-roaming robots that carry out precise, delicate tasks inside the
human body. Its power sources are external electromagnetic coils, and it uses
magnetic field gradients as a steering mechanism.
4.6 Anybots
AnyBots provides a type of immersive telepresence, meaning instead of focusing
merely on audio and video communications, the AnyBots robot allows for movement
controlled by a remote.
4.7 Swisslog Robocourier
The Swisslog Robocourier is an autonomous mobile robot. The tool dispatches and
delivers specimens, medications and supplies throughout the hospital.
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4.8 Robots for deaf & blind
o Dexter, a robotic hand communication aid for people who are both deaf and
blind.
o Uses finger spelling to communicate information typed on a keyboard stored
in a computer or received from a special telephone.
Fig. 4.1: Microbot
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CHAPTER 5
Types of Surgical Systems
1. Da Vinci Surgical System
2. Cyberknife
5.1 Da Vinci surgical system
5.1.1 Introduction
The Da Vinci Surgical System is a robotic surgical system made by the
American company Intuitive Surgical. Approved by the Food and Drug
Administration (FDA) in 2000, it is designed to facilitate
complex surgery using a minimally approach, and is controlled by a surgeon
from a console. The system is commonly used for prostatectomies, and
increasingly for cardiac valve repair and gynecologic surgical procedures.
According to the manufacturer, the da Vinci System is called "da Vinci" in
part because Leonardo da Vinci's "study of human anatomy eventually led to
the design of the first known robot in history.
Da Vinci robots operate in hospitals worldwide, with an estimated 200,000
surgeries conducted in 2012, most commonly
for hysterectomies and prostate removals. As of June 30, 2014, there was an
installed base of 3,102 units worldwide, up from 2,000 units at the same time
the previous year. The location of these units are as follows: 2,153 in the
United States, 499 in Europe, 183 in Japan, and 267 in the rest of the world.
The "Si" version of the system costs on average slightly under US$2 million,
in addition to several hundred thousand dollars of annual maintenance fees.
The da Vinci system has been criticized for its cost and for a number of issues
with its surgical performance.
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5.1.2 Overview
The da Vinci System consists of a surgeon’s console that is typically in the
same room as the patient, and a patient-side cart with four interactive robotic
arms controlled from the console. Three of the arms are for tools that hold
objects, and can also act as scalpels, scissors, bodies, or unipolar or hi. The
surgeon uses the console’s master controls to maneuver the patient-side cart’s
three or four robotic arms (depending on the model). The instruments’ jointed-
wrist design exceeds the natural range of motion of the human hand; motion
scaling and tremor reduction further interpret and refine the surgeon’s hand
movements. The da Vinci System always requires a human operator, and
incorporates multiple redundant safety features designed to minimize
opportunities for human error when compared with traditional approaches.
The da Vinci System has been designed to improve upon
conventional laparoscopy, in which the surgeon operates while standing, using
hand-held, long-shafted instruments, which have no wrists. With conventional
laparoscopy, the surgeon must look up and away from the instruments, to a
nearby 2D video monitor to see an image of the target anatomy. The surgeon
must also rely on a patient-side assistant to position the camera correctly. In
contrast, the da Vinci System’s design allows the surgeon to operate from a
seated position at the console, with eyes and hands positioned in line with the
instruments and using controls at the console to move the instruments and
camera.
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Fig. 5.1: Da Vinci Surgical System
By providing surgeons with superior visualization, enhanced dexterity, greater
precision and ergonomic comfort, the da Vinci Surgical System makes it
possible for more surgeons to perform minimally invasive procedures
involving complex dissection or reconstruction. For the patient, a da Vinci
procedure can offer all the potential benefits of a minimally invasive
procedure, including less pain, less blood loss and less need for blood
transfusions. Moreover, the da Vinci System can enable a shorter hospital stay,
a quicker recovery and faster return to normal daily activities.
5.1.3 Clinical Uses
The da Vinci System has been successfully used in the following procedures:
o Radical prostatectomy, pyeloplasty, cystectomy, nephrectomy and
ureteral replantation.
o Hysterectomy, myomectomy and sacrocolpopexy;
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o Hiatal hernia repair;
o Spleen-sparing distal pancreatectomy, cholecystectomy, Nissen
fundoplication, Heller myotomy, gastric bypass,
donor nephrectomy, adrenalectomy,splenectomy and bowel resection;
o Internal mammary artery mobilization and cardiac tissue ablation;
o Mitral valve repair and endoscopic atrial septal defect closure;
o Mammary to left anterior descending coronary
artery anastomosis for cardiac revascularization with
adjunctive mediastinotomy.
o Transoral resection of tumors of the upper aerodigestive tract
(tonsil, tongue base, larynx) and transaxillary thyroidectomy
o Resection of spindle cell tumors originating in the lung.
5.1.4 Advantage
o Simpler procedure
o Minimally invasive
o Better technique
o Reduced bleeding
o Less painful
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o Smaller scar
o Faster healing
o Decreased hospital stay
5.1.5 Disadvantage
o Longer learning period
o High cost of the equipment and thereby the procedure
o Reduction in space for assistants
o Lack of tactile sensation for the surgeon
5.1.6 Future application
Although the general term "robotic surgery" is often used to refer to the
technology, this term can give the impression that the da Vinci System is
performing the surgery autonomously. In contrast, the current da Vinci
Surgical System cannot – in any manner – function on its own, as it was not
designed as an autonomous system and lacks decision making software.
Instead, it relies on a human operator for all input; however, all operations –
including vision and motor functions— are performed through remote human-
computer interaction, and thus with the appropriate weak AI software, the
system could in principle perform partially or completely autonomously. The
difficulty with creating an autonomous system of this kind is not trivial; a
major obstacle is that surgery per se is not an engineered process – a
requirement for weak AI. The current system is designed merely to replicate
seamlessly the movement of the surgeon's hands with the tips of micro-
instruments, not to make decisions or move without the surgeon’s direct input.
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The possibility of long-distance operations depends on the patient having
access to a da Vinci System, but technically the system could allow a doctor to
perform telesurgery on a patient in another country. In 2001, Dr. Marescaux
and a team from IRCAD used a combination of high-speed fiber-optic
connection with an average delay of 155 ms with advanced asynchronous
transfer mode (ATM) and a Zeus telemanipulator to successfully perform the
first transatlantic surgical procedure, covering the distance between New York
and Strasbourg. The event was considered a milestone of global telesurgery,
and was dubbed “Operation Lindbergh”
5.2 Cyberknife
5.2.1 Introduction
The CyberKnife Robotic Radiosurgery System is a non-invasive alternative
to surgery for the treatment of both cancerous and non-cancerous tumors
anywhere in the body, including the prostate, lung, brain, spine, liver,
pancreas and kidney. The treatment – which delivers beams of high dose
radiation to tumors with extreme accuracy – offers new hope to patients
worldwide.
Though its name may conjure images of scalpels and surgery, the
CyberKnife treatment involves no cutting. In fact, the CyberKnife System
is the world’s first and only robotic radiosurgery system designed to treat
tumors throughout the body non-invasively. It provides a pain-free, non-
surgical option for patients who have inoperable or surgically complex
tumors, or who may be looking for an alternative to surgery.
The CyberKnife is a frameless robotic radiosurgery system used for
treating benign tumors, malignant tumors and other medical conditions.
The system was invented by John R. Adler, a Stanford University professor
of neurosurgery and radiation oncology, and Peter and Russell Schonberg
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of Schonberg Research Corporation. It is made by the Accuracy company
headquartered in Sunnyvale, California.
The CyberKnife system is a method of delivering radiotherapy, with the
intention of targeting treatment more accurately than standard radiotherapy.
The two main elements of the CyberKnife are the radiation produced from
a small linear particle accelerator and a robotic arm which allows the
energy to be directed at any part of the body from any direction.
5.2.2 Overview
Several generations of the CyberKnife system have been developed since its
initial inception in 1990. There are two major features of the CyberKnife
system that are different from other stereotactic therapy methods.
Fig. 5.2: Cyberknife Surgical System
5.2.3 Robotic mounting
The first is that the radiation source is mounted on a general purpose industrial
robot. The original CyberKnife used a Japanese Fanuc robot, however the
more modern systems use a German KUKA KR 240. Mounted on the Robot is
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a compact X-band linac that produces 6MV X-ray radiation. The linac is
capable of delivering approximately 600 cGy of radiation each minute – a new
800 cGy / minute model was announced at ASTRO 2007. The radiation is
collimated using fixed tungsten collimators (also referred to as "cones") which
produce circular radiation fields. At present the radiation field sizes are: 5, 7.5,
10, 12.5, 15, 20, 25, 30, 35, 40, 50 and 60 mm. ASTRO 2007 also saw the
launch of the IRIS variable-aperture collimator which uses two offset banks of
six prismatic tungsten segments to form a blurred regular dodecagon field of
variable size which eliminates the need for changing the fixed collimators.
Mounting the radiation source on the robot allows near-complete freedom to
position the source within a space about the patient. The robotic mounting
allows very fast repositioning of the source, which enables the system to
deliver radiation from many different directions without the need to move both
the patient and source as required by current gantry configurations.The
CyberKnife system uses an image guidance system. X-ray imaging cameras
are located on supports around the patient allowing instantaneous X-ray
images to be obtained.
5.2.4 6D skull
The original (and still utilized) method is called 6D or skull based tracking.
The X-ray camera images are compared to a library of computer generated
images of the patient anatomy. Digitally Reconstructed Radiographs (or
DRR's) and a computer algorithm determines what motion corrections have to
be given to the robot because of patient movement. This imaging system
allows the CyberKnife to deliver radiation with an accuracy of 0.5mm without
using mechanical clamps attached to the patient's skull. The use of the image-
guided technique is referred to as frameless stereotactic radiosurgery. This
method is referred to as 6D because corrections are made for the 3
translational motions (X,Y and Z) and three rotational motions. It should be
noted that it is necessary to use some anatomical or artificial feature to orient
the robot to deliver X-ray radiation, since the tumor is never sufficiently well
defined (if visible at all) on the X-ray camera images.
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5.2.5 Xsight
Additional image guidance methods are available for spinal tumors and for
tumors located in the lung. For a tumor located in the spine, a variant of the
image guidance called Xsight-Spine is used. The major difference here is that
instead of taking images of the skull, images of the spinal processes are used.
Whereas the skull is effectively rigid and non-deforming, the spinal vertebrae
can move relative to each other, this means that image warping algorithms
must be used to correct for the distortion of the X-ray camera images.
A recent enhancement to Xsight is Xsight-Lung which allows tracking of some
lung tumors without the need to implantfiducial markers.
5.2.6 Fiducial
For soft tissue tumors, a method known as fiducial tracking can be utilized.
Small metal markers (fiducials) made out of gold for bio-compatibility and
high density to give good contrast on X-ray images are surgically implanted in
the patient. This is carried out by an interventional radiologist, or
neurosurgeon. The placement of the fiducials is a critical step if the fiducial
tracking is to be used. If the fiducials are too far from the location of the
tumor, or are not sufficiently spread out from each other it will not be possible
to accurately deliver the radiation. Once these markers have been placed, they
are located on a CT scan and the image guidance system is programmed with
their position. When X-ray camera images are taken, the location of the tumor
relative to the fiducials is determined, and the radiation can be delivered to any
part of the body. Thus the fiducial tracking does not require any bony anatomy
to position the radiation. Fiducials are known however to migrate and this can
limit the accuracy of the treatment if sufficient time is not allowed between
implantation and treatment for the fiducials to stabilize.
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5.2.7 Synchrony
The final technology of image guidance that the CyberKnife system can use is
called the Synchrony system or Synchrony method. The synchrony method
uses a combination of surgically placed internal fiducials (typically small gold
markers, well visible in x-ray imaging), and light emitting optical fibers (LED
markers) mounted on the patient skin. LED markers are tracked by an infrared
tracking camera. Since the tumor is moving continuously, to continuously
image its location using X-ray cameras would require prohibitive amounts of
radiation to be delivered to the patient's skin. The Synchrony system
overcomes this by periodically taking images of the internal fiducials, and
computing a correlation model between the motion of the external LED
markers and the internal fiducials. Time stamps from the two sensors (x-ray
and infrared LED) are needed to synchronize the two data streams, hence the
name Synchrony.
Motion prediction is used to overcome the motion latency of the robot and the
latency of image acquisition. Before treatment, a computer algorithm creates a
correlation model that represents how the internal fiducial markers are moving
compared to the external markers. During treatment, the system continuously
infers the motion of the internal fiducials, and therefore the tumor, based on
the motion of the skin markers. The correlation model is updated at fixed time
steps during treatment. Thus, the Synchrony tracking method makes no
assumptions about the regularity or reproducibility of the patient breathing
pattern.
To function properly, the Synchrony system requires that for any given
correlation model there is a functional relationship between the markers and
the internal fiducials. The external marker placement is also important, and the
markers are usually placed on the patient abdomen so that their motion will
reflect the internal motion of the diaphragm and the lungs. The synchrony
method was invented in 1998. The first patients were treated at Cleveland
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Clinic in 2002. Synchrony is utilized primarily for tumors that are in motion
while being treated, such as lung tumors and pancreatic tumors.
5.2.8 RoboCouch
A robotic six degree of freedom patient treatment couch called
RoboCouchimproves patient positioning options for treatment.
5.2.9 Frameless
The frameless nature of the CyberKnife also increases the clinical efficiency.
In conventional frame-based radiosurgery, the accuracy of treatment delivery
is determined solely by connecting a rigid frame to the patient which is
anchored to the patient’s skull with invasive aluminum or titanium screws.
The CyberKnife is the only radiosurgery device that does not require such a
frame for precise targeting. Once the frame is connected, the relative position
of the patient anatomy must be determined by making a CT or MRI scan.
After the CT or MRI scan has been made, a radiation oncologist must plan the
delivery of the radiation using a dedicated computer program, after which the
treatment can be delivered, and the frame removed. The use of the frame
therefore requires a linear sequence of events that must be carried out
sequentially before another patient can be treated. Staged CyberKnife
radiosurgery is of particular benefit to patients who have previously received
large doses of conventional radiation therapy and patients with gliomas
located near critical areas of the brain. Unlike whole brain radiotherapy, which
must be administered daily over several weeks, radiosurgery treatment can
usually be completed in 1–5 treatment sessions. Radiosurgery can be used
alone to treat brain metastases, or in conjunction with surgery or whole brain
radiotherapy, depending on the specific clinical circumstances.
By comparison, using a frameless system, a CT scan can be carried out on any
day prior to treatment that is convenient. The treatment planning can also be
carried out at any time prior to treatment. During the treatment the patient
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need only be positioned on a treatment table and the predetermined plan
delivered. This allows the clinical staff to plan many patients at the same time,
devoting as much time as is necessary for complicated cases without slowing
down the treatment delivery. While a patient is being treated, another clinician
can be considering treatment options and plans, and another can be conducting
CT scans.
In addition, very young patients (pediatric cases) or patients with fragile heads
because of prior brain surgery cannot be treated using a frame based system.
Also, by being frameless the CyberKnife can efficiently re-treat the same
patient without repeating the preparation steps that a frame-based system
would require.
The delivery of a radiation treatment over several days or even weeks (referred
to as fractionation) can also be beneficial from a therapeutic point of view.
Tumor cells typically have poor repair mechanisms compared to healthy
tissue, so by dividing the radiation dose into fractions the healthy tissue has
time to repair itself between treatments. This can allow a larger dose to be
delivered to the tumor compared to a single treatment.
5.2.10 Clinical use
Since August 2001, the CyberKnife system has FDA clearance for treatment
of tumors in any location of the body. Some of the tumors treated
include: pancreas, liver, prostate, spinal lesions, head and neck cancers,
and benign tumors.
None of these studies have shown any general survival benefit over
conventional treatment methods. By increasing the accuracy with which
treatment is delivered there is a potential for dose escalation, and potentially a
subsequent increase in effectiveness, particularly in local control rates.
However the studies cited are so far limited in scope, and more extensive
research will need to be completed in order to show any effects on survival.
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In 2008 actor Patrick Swayze was among the people to be treated with
CyberKnife radiosurgery.
5.2.11 Advantage
o The fatigue factor is considerably reduced as the surgeon is seated
and does not have to constantly hold onto the instruments.
o Robotic surgeries are minimally invasive
o Incisions are smaller
o Less risk of infection
o Hospital stays are generally shorter
o Patients recuperate faster
5.2.12 Disadvantage
o These Specific machines can be very expensive to own and operate
o Surgeons and nurses have to be specially trained to know how to use
them
o There is not much data out there about come procedures
5.2.13 Uses
The CyberKnife® Robotic Radiosurgery System is a non-invasive alternative
to surgery for the treatment of both cancerous and non-cancerous tumors
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anywhere in the body, including the prostate, lung, brain, spine, liver,
pancreas and kidney. The treatment – which delivers high doses of radiation to
tumors with extreme accuracy – offers new hope to patients who have
inoperable or surgically complex tumors, or who may be looking for a non-
surgical option.
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CHAPTER 6
Uses of robotics in surgery
6.1 General uses
In early 2000 the field of general surgical interventions with the da Vinci device was
explored by surgeons at Ohio State University. Reports were published in esophageal
and pancreatic surgery for the first time in the world and further data was
subsequently published by Horgan and his group at the University of Illinois and then
later at the same institution by others. In 2007, the University of Illinois at
Chicago medical team, led by Prof. Pier Cristoforo Giulianotti, reported
apancreatectomy and also the Midwest's first fully robotic Whipple surgery. In April
2008, the same team of surgeons performed the world's first fully minimally
invasive liver resection for living donor transplantation, removing 60% of the patient's
liver, yet allowing him to leave the hospital just a couple of days after the procedure,
in very good condition. Furthermore the patient can also leave with less pain than a
usual surgery due to the four puncture holes and not a scar by a surgeon.
6.2 Cardiothoracic Surgery
Robot-assisted MIDCAB and Endoscopic coronary artery bypass (TECAB)
operations are being performed with the Da Vinci system. Mitral valve repairs and
replacements have been performed. The Ohio State University, Columbus has
performed CABG, mitral valve, esophagectomy, lung resection, tumor resections,
among other robotic assisted procedures and serves as a training site for other
surgeons. In 2002, surgeons at the Cleveland Clinic in Florida reported and published
their preliminary experience with minimally invasive "hybrid" procedures. These
procedures combined robotic revascularization and coronary stenting and further
expanded the role of robots in coronary bypass to patients with disease in multiple
vessels. Ongoing research on the outcomes of robotic assisted CABG and hybrid
CABG is being done.
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6.3 Cardiology and electrophysiology
The Stereotaxic Magnetic Navigation System (MNS) has been developed to increase precision and
safety in ablation procedures for arrhythmias and atrial fibrillation while reducing radiation
exposure for the patient and physician, and the system utilizes two magnets to remotely steerable
catheters. The system allows for automated 3-D mapping of the heart and vasculature, and MNS
has also been used in interventional cardiology for guiding stents and leads in PCI and CTO
procedures, proven to reduce contrast usage and access tortuous anatomy unreachable by manual
navigation. Dr. Andrea Natale has referred to the new Stereotaxic procedures with the magnetic
irrigated catheters as "revolutionary."
The Hansen Medical Sensei robotic catheter system uses a remotely operated system
of pulleys to navigate a steerable sheath for catheter guidance. It allows precise and
more forceful positioning of catheters used for 3-D mapping of the heart and
vasculature. The system provides doctors with estimated force feedback information
and feasible manipulation within the left atrium of the heart. The Sensei has been
associated with mixed acute success rates compared to manual, commensurate with
higher procedural complications, longer procedure times but
lower fluoroscopy dosage to the patient.
At present, three types of heart surgery are being performed on a routine basis using
robotic surgery systems. These three surgery types are:
Atrial septal defect repair – the repair of a hole between the two upper
chambers of the heart,
Mitral valve repair – the repair of the valve that prevents blood from
regurgitating back into the upper heart chambers during contractions of the heart,
Coronary artery bypass – rerouting of blood supply by bypassing blocked
arteries that provide blood to the heart.
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As surgical experience and robotic technology develop, it is expected that the
applications of robots in cardiovascular surgery will expand.
6.4 Colon and rectal surgery
Many studies have been undertaken in order to examine the role of robotic procedures
in the field of colorectal surgery.
Results to date indicate that robotic-assisted colorectal procedures outcomes are "no
worse" than the results in the now "traditional" laparoscopic colorectal operations.
Robotic-assisted colorectal surgery appears to be safe as well. Most of the procedures
have been performed for malignant colon and rectal lesions. However, surgeons are
now moving into resections for diverticulitis and non-resective rectopexies (attaching
the colon to the sacrum in order to treat rectal prolapse.)
When evaluated for several variables, robotic-assisted procedures fare equally well
when compared with laparoscopic, or open abdominal operations. Study parameters
have looked at intraoperative patient preparation time, length of time to perform the
operation, adequacy of the removed surgical specimen with respect to clear surgical
margins and number of lymph nodes removed, blood loss, operative or postoperative
complications and long-term results.
More difficult to evaluate are issues related to the view of the operative field, the
types of procedures that should be performed using robotic assistance and the
potential added cost for a robotic operation.
Many surgeons feel that the optics of the 3-dimensional, two camera stereo optic
robotic system are superior to the optical system used in laparoscopic procedures. The
pelvic nerves are clearly visualized during robotic-assisted procedures. Less clear
however is whether or not these supposedly improved optics and visualization
improve patient outcomes with respect to postoperative impotence or incontinence,
and whether long-term patient survival is improved by using the 3-dimensional optic
system. Additionally, there is often a need for a wider, or "larger" view of the
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operative field than is routinely provided during robotic operations. The close-up view
of the area under dissection may hamper visualization of the "bigger view", especially
with respect to ureteral protection.
Questions remain unanswered, even after many years of experience with robotic-
assisted colorectal operations. Ongoing studies may help clarify many of the issues of
confusion associated with this novel surgical approach.
6.5 Gastrointestinal surgery
Multiple types of procedures have been performed with either the 'Zeus' or da
Vinci robot systems, including bariatric surgery and gastrectomy for cancer. Surgeons
at various universities initially published case series demonstrating different
techniques and the feasibility of GI surgery using the robotic devices.[9]Specific
procedures have been more fully evaluated, specifically esophageal fundoplication for
the treatment of gastroesophageal refluxand Heller myotomy for the treatment of
achalasia.
Other gastrointestinal procedures including colon resection, pancreatectomy,
esophagectomy and robotic approaches to pelvic disease have also been reported.
6.6 Gynecology
Robotic surgery in gynecology is of uncertain benefit with it being unclear if it affects
rates of complications. Gynecologic procedures may take longer with robot-assisted
surgery but may be associated with a shorter hospital stay following hysterectomy. In
the United States, robotic-assisted hysterectomy for benign conditions has been
shown to be more expensive than conventional laparoscopic hysterectomy, with no
difference in overall rates of complications.
This includes the use of the da Vinci surgical system in benign gynecology and
gynecologic oncology. Robotic surgery can be used to treat fibroids, abnormal
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periods, endometriosis, ovarian tumors, uterine prolapse, and female cancers. Using
the robotic system, gynecologists can perform hysterectomies, myomectomies, and
lymph node biopsies.
6.7 Neurosurgery
Several systems for stereotactic intervention are currently on the market. The
NeuroMate was the first neurosurgical robot, commercially available in 1997.
Originally developed in Grenoble by Alim-Louis_Benabid’s team, it is now owned
by Renishaw. With installations in the United States, Europe and Japan, the system
has been used in 8000 stereotactic brain surgeries by 2009. IMRIS Inc.'s
SYMBIS(TM) Surgical System will be the version of NeuroArm, the world’s
first MRI-compatible surgical robot, developed for world-wide commercialization.
Medtech's Rosa is being used by several institutions, including the Cleveland Clinic in
the U.S, and in Canada at Sherbrooke University and the Montreal Neurological
Institute and Hospital in Montreal (MNI/H). Between June 2011 and September 2012,
over 150 neurosurgical procedures at the MNI/H have been completed robotized
stereotaxy, including in the placement of depth electrodes in the treatment of epilepsy,
selective resections, and stereotaxic biopsies.
6.8 Orthopedics
The ROBODOC system was released in 1992 by Integrated Surgical Systems,
Inc. which merged into CUREXO Technology Corporation. Also, The Acrobot
Company Ltd. developed the "Acrobot Sculptor", a robot that constrained
a bone cutting tool to a pre-defined volume. The "Acrobot Sculptor" was sold to
Stanmore Implants in August 2010. Stanmore received FDA clearance in February
2013 for US surgeries but sold the Sculptor to Mako Surgical in June 2013 to resolve
a patent infringement lawsuit. Another example is the CASPAR robot produced by
U.R.S.-Ortho GmbH & Co. KG, which is used for total hip replacement, total knee
replacement and anterior cruciate ligament reconstruction. MAKO Surgical Corp
(founded 2004) produces the RIO (Robotic Arm Interactive Orthopedic System)
which combines robotics, navigation, and haptics for both partial knee and total hip
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replacement surgery. Blue Belt Technologies received FDA clearance in November
2012 for the Navio™ Surgical System. The Navio System is a navigated, robotics-
assisted surgical system that uses a CT free approach to assist in partial knee
replacement surgery.
6.9 Pediatrics
Surgical robotics has been used in many types of pediatric surgical procedures
including: tracheoesophageal fistula repair, cholecystectomy, nissen fundoplication,
morgagni's hernia repair, kasai portoenterostomy, congenital diaphragmatic
hernia repair, and others. On 17 January 2002, surgeons at Children's Hospital of
Michigan in Detroit performed the nation's first advanced computer-assisted robot-
enhanced surgical procedure at a children's hospital.
The Center for Robotic Surgery at Children's Hospital Boston provides a high level of
expertise in pediatric robotic surgery. Specially-trained surgeons use a high-tech robot
to perform complex and delicate operations through very small surgical openings. The
results are less pain, faster recoveries, shorter hospital stays, smaller scars, and
happier patients and families.
In 2001, Children's Hospital Boston was the first pediatric hospital to acquire a
surgical robot. Today, surgeons use the technology for many procedures and perform
more pediatric robotic operations than any other hospital in the world. Children's
Hospital physicians have developed a number of new applications to expand the use
of the robot, and train surgeons from around the world on its use.[33]
6.10 Radiosurgery
The CyberKnife Robotic Radiosurgery System uses image guidance and computer
controlled robotics to treat tumors throughout the body by delivering multiple beams
of high-energy radiation to the tumor from virtually any direction. The system uses a
German KUKA KR 240. Mounted on the robot is a compact X-band linacthat
produces 6MV X-ray radiation. Mounting the radiation source on the robot allows
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very fast repositioning of the source, which enables the system to deliver radiation
from many different directions without the need to move both the patient and source
as required by current gantry configurations.
6.11 Transplant surgery
Transplant surgery (organ transplantation) has been considered as highly technically
demanding and virtually unobtainable by means of conventional laparoscopy. For
many years, transplant patients were unable to benefit from the advantages of
minimally invasive surgery. The development of robotic technology and its associated
high resolution capabilities, three dimensional visual system, wrist type motion and
fine instruments, gave opportunity for highly complex procedures to be completed in
a minimally invasive fashion. Subsequently, the first fully robotic kidney
transplantations were performed in the late 2000s. After the procedure was proven to
be feasible and safe, the main emerging challenge was to determine which patients
would benefit most from this robotic technique. As a result, recognition of the
increasing prevalence of obesity amongst patients with kidney failure on hemodialysis
posed a significant problem. Due to the abundantly higher risk of complications after
traditional open kidney transplantation, obese patients were frequently denied access
to transplantation, which is the premium treatment for end stage kidney disease. The
use of the robotic-assisted approach has allowed kidneys to be transplanted with
minimal incisions, which has virtually alleviated wound complications and
significantly shortened the recovery period. The University of Illinois Medical
Center reported the largest series of 104 robotic-assisted kidney transplants for obese
recipients (mean body mass index > 42). Amongst this group of patients, no wound
infections were observed and the function of transplanted kidneys was excellent. In
this way, robotic kidney transplantation could be considered as the biggest advance in
surgical technique for this procedure since its creation more than half a century ago.
6.12 Urology
Robotic surgery in the field of urology has become very popular, especially in the
United States. It has been most extensively applied for excision of prostate cancer
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because of difficult anatomical access. It is also utilized for kidney cancer surgeries
and to lesser extent surgeries of the bladder.
As of 2014, there is little evidence of increased benefits compared to standard surgery
to justify the increased costs.[38] Some have found tentative evidence of more
complete removal of cancer and less side effects from surgery for prostatectomy.[39]
In 2000, the first robot-assisted laparoscopic radical prostatectomy was performed.[5]
6.13 Vascular surgery
In September 2010, the first robotic operations with Hansen Medical's Magellan
Robotic System at the femoral vasculature were performed at theUniversity Medical
Centre Ljubljana (UMC Ljubljana), Slovenia. The research was led by Borut Geršak,
the head of the Department of Cardiovascular Surgery at the centre. Geršak explained
that the robot used was the first true robot in the history of robotic surgery, meaning
the user interface was not resembling surgical instruments and the robot was not
simply imitating the movement of human hands but was guided by pressing buttons,
just like one would play a video game. The robot was imported to Slovenia from the
United States.
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CHAPTER 8
Future scope
What's most remarkable about robotic surgery is what the future might hold.
Doctors are anticipating the growth of tele-medicine and long-distance
operations, where a doctor could conceivably operate on a patient in another city,
state, or even a different continent. Practically, this would mean that surgical centers
would be set up in different parts of the world and a doctor could go to a surgical
center and sit in a control console while a patient in a different surgical center would
be operated on by a robot controlled by that doctor.
Already a long-distance operation was performed via robotic surgery between New
York and Strasbourg, France, in 2001. The surgery, which was dubbed "Operation
Lindbergh" for its pioneering qualities, was performed successfully, but there was a
delayed lag time that made this long-distance surgery impractical. However, as the
internet becomes faster and bandwidth becomes cheaper, this will undoubtedly
change.
In the future there will be tele-medicine, where you can operate on someone
somewhere else in the world.
The other possibility that we could see in the future is the single-incision port, where a
doctor could make a tiny incision, perhaps through a patient's bellybutton, and then
insert the snake-like arms of the robot through that incision. Currently, the robot
makes a few small incisions, through which its arms are inserted.
The next generation of this technology will mean that you put one little hole in the
patient and then put snake-like arms through that hole.
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CHAPTER 8
Conclusion
Medical robotics, and particularly autonomous surgical robotics, are still in an
embryonic stage. Concentrating on surgical robots, the reasons for their not gaining
immediate enthusiasm and acceptance in the medical community are twofold.
Issues of safety have been highlighted, in particular, as hurdles to research and
development taking place. Safety issues have traditionally not been addressed and
there is an urgent need for a consensus on what is 'safe practice' concerning both
human-guided and autonomous robots.
The other main obstacle has been the misconceptions that abound concerning robots.
Surgeons do not like to see clumsy-looking industrial arms in the operating theatre,
they also do not like the idea of being replaced as superfluous equipment.
The first matter (that of safety) is a definite problem. Industrial robots operate in a
confined 'cell of activity' that is separate from their human counterparts - this
obviously cannot be the case with surgical robots. This will require immediate action
if it is not to further hinder the development of a field that can provide great benefits
to society. Considering the fact that increased complexity, both in the program of an
autonomous robot and in the design of a guided (or autonomous) robot, increases the
problem of defining safety standards, it is the opinion of the authors' that the way
forward in surgical robotics should be one that uses human-guided robots and/or
powered robots that are extremely task specific. A robot that has all the skills of a
human surgeon would be extremely complex; it is perhaps better to limit the abilities
that the robot has and, in doing so, limit the possible damage it could do if it were to
malfunction.
The second matter is one of education and social conditioning; it should also be eased
through the solving of the safety predicament. A good point to observe, for worried
surgeons, is the fact that, at best, robots can (at the moment) provide a crude substitute
to an expert surgeon. The human hand has twenty degrees of freedom, while the most
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advanced robots can only provide eight or nine. In addition, in robotic surgery, the
ability to image and model anatomical structures has outperformed the ability to
perform physical, robotic intervention. There have only been three research groups
that have devised specific powered systems that have an autonomous cutting function
(ISS - hip surgery, EPFL - neurosurgery, Imperial College - prostrate surgery). In the
vast majority of robotic surgeries, the surgeon has control of tool-holders or
positioning robots to improve their accuracy and performance.
To conclude, there are several steps that must be taken in order to further the use and
development of robots in surgery (and in medicine in general). These are:
the development, and international adoption, of safety standards
the aim of task-specific, as opposed to general-purpose, robots
the education of the medical community in the acceptance and integration of
robots
The economic and social advantages to be gained from the mass-use of robotics in
medicine (and particularly surgery), as already expounded, are enormous. If all of the
above steps are taken, then the full potential of robotics can be exploited in the
medical sector, as it has been in industrial applications, for the improved welfare of
society everywhere.
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REFERENCES
O'Toole, M. D.; Bouazza-Marouf, K.; Kerr, D.; Gooroochurn, M.; Vloeberghs,
M. (2009). "A methodology for design and appraisal of surgical robotic
systems".Robotica 28 (2)
Kolata, Gina (13 February 2010). "Results Unproven, Robotic Surgery Wins
Converts". The New York Times Retrieved 11 March 2010.
Barnebei et al., Lahey Clinic, presented at HRS 2009: PO04-35 – Robotic
versus Manual Catheter Ablation for Atrial Fibrillation
"Robotics in Medicine", P.Dario, E.Guglielmelli, B.Allotta, IROS '94.
Proceedings of the IEEE/RSJ/GI International Conference on Intelligent
Robots and Systems. Advanced Robotic Systems and the Real World
(Cat.No.94CH3447-0), Sept.1994, Vol.2, pp.739-52
https://en.wikipedia.org/wiki/Robot-assisted_surgery
https://en.wikipedia.org/wiki/Medical_robot
http://www.brighthubengineering.com/robotics/95856-use-of-robotics-in-the-
medical-field/
http://www.davincisurgery.com/
http://www.cyberknife.com/