Biorobotics in Medicine 1774694085, 9781774694084

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Biorobotics in Medicine

BIOROBOTICS IN MEDICINE

Edited by: ShivSanjeevi Sripathi

ARCLER

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www.arclerpress.com

Biorobotics in Medicine ShivSanjeevi Sripathi

Arcler Press 224 Shoreacres Road Burlington, ON L7L 2H2 Canada www.arclerpress.com Email: [email protected] e-book Edition 2023 ISBN: 978-1-77469-567-8 (e-book) This book contains information obtained from highly regarded resources. Reprinted material sources are indicated. Copyright for individual articles remains with the authors as indicated and published under Creative Commons License. A Wide variety of references are listed. Reasonable efforts have been made to publish reliable data and views articulated in the chapters are those of the individual contributors, and not necessarily those of the editors or publishers. Editors or publishers are not responsible for the accuracy of the information in the published chapters or consequences of their use. The publisher assumes no responsibility for any damage or grievance to the persons or property arising out of the use of any materials, instructions, methods or thoughts in the book. The editors and the publisher have attempted to trace the copyright holders of all material reproduced in this publication and apologize to copyright holders if permission has not been obtained. If any copyright holder has not been acknowledged, please write to us so we may rectify. Notice: Registered trademark of products or corporate names are used only for explanation and identification without intent of infringement. © 2023 Arcler Press ISBN: 978-1-77469-408-4 (Hardcover) Arcler Press publishes wide variety of books and eBooks. For more information about Arcler Press and its products, visit our website at www.arclerpress.com

DECLARATION Some content or chapters in this book are open access copyright free published research work, which is published under Creative Commons License and are indicated with the citation. We are thankful to the publishers and authors of the content and chapters as without them this book wouldn’t have been possible.

ABOUT THE EDITOR

ShivSanjeevi Sripathi completed his Masters in Biotechnology from Mumbai University in 2008. He was awarded for academic excellence in both his Bachelors and Masters for securing second rank in Mumbai University in 2006 and first rank in his college: Kishinchand chellaram College. For his Masters he secured first rank in his college KET’s V.G.Vaze College. He qualified CSIR and NET and and TOEFL in September 2008. He then worked on a stem cell project at the Specialized Centre for Cell Based Therapy (SCCT),KEM Hospital at Mumbai on a project entitled, : Isolation & detection of stem cells from Human Umbilical cord/ amniotic membrane” following which he worked at Junior Research Fellow at Microbiology & Cell Biology Department, Indian Institute of Science, Bangalore on cloning of cell wall genes and transcription factors in E.coli & M.smegmatis. As a writer, he has authored and co-authored 35 books on various aspects of biology such as bionics, molecular wires, cloning, hypertension, the epidemics of the 21st century, handling depression, camouflage, hygiene, immunology and many more with international publishers. He loves to read and share on interesting aspects of life sciences in books. In his free time he loves to travel and explore and give talks on spirituality, ancient customs and traditions.

TABLE OF CONTENTS



List of Contributors.......................................................................................xiii



List of Abbreviations.................................................................................... xvii

Preface..................................................................................................... ....xxi Chapter 1

Biorobotics in Medicine: A Snapshot.......................................................... 1 1.1 Altering Healthcare............................................................................... 2 1.2 Case Study: Robotic Surgery for Neurosurgery...................................... 5 1.3 Covid-19 and Other Aspects................................................................. 7 1.4 References............................................................................................ 9

Chapter 2

Robots for Surgery................................................................................... 11 2.1 A Snapshot......................................................................................... 12 2.2 Trends................................................................................................. 15 2.3 Case Study: Open Esophagectomy for Esophageal Cancer: Robot-Assisted Vs. Video-Assisted.................................................... 33 2.4 Case Study: Robots For Total Mesorectal Excision (Tme):..................... 38 2.5 Final Points......................................................................................... 41 2.6 References.......................................................................................... 43

Chapter 3

Robots for Surgery Continued.................................................................. 45 3.1 Robotic Systems.................................................................................. 46 3.2 Feasibility of Robotic Surgery for Colorectal Cancer (CRC).................. 54 3.3 Maxillofacial Surgery: What is the Status?........................................... 60 3.4 Robots for Pediatric Surgery: Few Studies:........................................... 62 3.5 Hernia Repairs: A Comparison............................................................ 68 3.6 The Hope for Cerebral Palsy (CP)........................................................ 70 3.7 Final Points......................................................................................... 72 3.8 References.......................................................................................... 75

Chapter 4

Nanobiorobotics...................................................................................... 77 4.1 Concepts............................................................................................ 78 4.2 Case Studies....................................................................................... 80 4.3 References.......................................................................................... 86

Chapter 5

A Brief Review on Challenges in Design and Development of Nanorobots for Medical Applications.................................................. 87 Abstract.................................................................................................... 87 Introduction.............................................................................................. 88 Challenges in the Design and Development of Nanorobots...................... 90 Challenges in the Application of Nanorobots.......................................... 110 Biocompatibility and Toxicity of Nanorobots.......................................... 115 Conclusions............................................................................................ 116 Author Contributions.............................................................................. 117 References.............................................................................................. 118

Chapter 6

Robotic Applications in Orthodontics: Changing the Face of Contemporary Clinical Care.............................................................. 129 Abstract.................................................................................................. 129 Introduction............................................................................................ 130 Methodology.......................................................................................... 133 Results.................................................................................................... 137 Discussion.............................................................................................. 145 Orthodontic Applications of Robotics: Crystal Gazing Into the Future!... 150 Conclusions............................................................................................ 151 References.............................................................................................. 152

Chapter 7

Current Advances in Robotics for Head and Neck Surgery—A Systematic Review............................................................... 169 Simple Summary..................................................................................... 169 Abstract.................................................................................................. 170 Introduction............................................................................................ 170 Methods................................................................................................. 172 Results.................................................................................................... 174 Conclusions............................................................................................ 189 Author Contributions.............................................................................. 190 References.............................................................................................. 191 x

Chapter 8

Gait Training Using a Robotic Hip Exoskeleton Improves Metabolic Gait Efficiency in the Elderly................................................. 199 Abstract.................................................................................................. 199 Introduction............................................................................................ 200 Results.................................................................................................... 202 Discussion.............................................................................................. 206 Materials and Methods........................................................................... 212 Acknowledgements................................................................................ 219 Author Contributions.............................................................................. 219 References.............................................................................................. 220

Chapter 9

Recent Advances in Design and Actuation of Continuum Robots for Medical Applications........................................................................ 227 Abstract.................................................................................................. 227 Introduction............................................................................................ 228 Continuum Robots Inspiration and Design.............................................. 229 Actuation Methods for Continuum Robot................................................ 246 Future Research Challenges and Conclusions......................................... 257 Conclusions............................................................................................ 260 Author Contributions.............................................................................. 261 References.............................................................................................. 262

Chapter 10 Evolving from Laboratory Toys towards Life-Savers: Small-Scale Magnetic Robotic Systems with Medical Imaging Modalities................................................................... 275 Abstract.................................................................................................. 275 Introduction............................................................................................ 276 Conventional Imaging Setup for Small-Scale Magnetic Robots................ 278 Medical Imaging Modalities.................................................................... 281 Integrating Medical Imaging Modalities in Small-Scale Magnetic Robots........................................................................... 282 Outlook.................................................................................................. 293 References.............................................................................................. 295 Index...................................................................................................... 305

xi

LIST OF CONTRIBUTORS

Shiv Sanjeevi Sripathi Gautham Giri Department of Mechanical and Industrial Engineering, Ryerson University, Toronto, ON M5B 2K3, Canada Yaser Maddahi  Department of Research and Development, Tactile Robotics, Winnipeg, MB R3T 6A8, Canada Kourosh Zareinia Department of Mechanical and Industrial Engineering, Ryerson University, Toronto, ON M5B 2K3, Canada Samar Adel Faculty of Dentistry, Alexandria University, Alexandria, Egypt Abbas Zaher Faculty of Dentistry, Alexandria University, Alexandria, Egypt Nadia El Harouni Faculty of Dentistry, Alexandria University, Alexandria, Egypt Adith Venugopal Department of Orthodontics, Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai, India Department of Orthodontics, University of Puthisastra, Phnom Penh, Cambodia Pratik Premjani Swami Vivekananda Subharati University, Meerut, India Nikhilesh Vaid European University College, DHCC, Dubai, UAE

Felix Boehm Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Medical Center, 89075 Ulm, Germany Surgical Oncology Ulm, i2SOUL Consortium, 89075 Ulm, Germany Rene Graesslin Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Medical Center, 89075 Ulm, Germany Surgical Oncology Ulm, i2SOUL Consortium, 89075 Ulm, Germany Marie-Nicole Theodoraki Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Medical Center, 89075 Ulm, Germany Surgical Oncology Ulm, i2SOUL Consortium, 89075 Ulm, Germany Leon Schild Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Medical Center, 89075 Ulm, Germany Surgical Oncology Ulm, i2SOUL Consortium, 89075 Ulm, Germany Jens Greve Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Medical Center, 89075 Ulm, Germany Surgical Oncology Ulm, i2SOUL Consortium, 89075 Ulm, Germany Thomas K. Hoffmann Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Medical Center, 89075 Ulm, Germany Surgical Oncology Ulm, i2SOUL Consortium, 89075 Ulm, Germany Patrick J. Schuler Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Medical Center, 89075 Ulm, Germany Surgical Oncology Ulm, i2SOUL Consortium, 89075 Ulm, Germany Elena Martini The BioRobotics Institute, Scuola Superiore Sant’Anna, Pisa, Italy Simona Crea The BioRobotics Institute, Scuola Superiore Sant’Anna, Pisa, Italy Fondazione Don Carlo Gnocchi, Milan, Italy Andrea Parri The BioRobotics Institute, Scuola Superiore Sant’Anna, Pisa, Italy xiv

Luca Bastiani Institute of Clinical Physiology, National Research Council, Pisa, Italy Ugo Faraguna Institute of Clinical Physiology, National Research Council, Pisa, Italy Zach McKinney The BioRobotics Institute, Scuola Superiore Sant’Anna, Pisa, Italy Raffaello Molino-Lova Fondazione Don Carlo Gnocchi, Milan, Italy Lorenza Pratali Institute of Clinical Physiology, National Research Council, Pisa, Italy Nicola Vitiello The BioRobotics Institute, Scuola Superiore Sant’Anna, Pisa, Italy Fondazione Don Carlo Gnocchi, Milan, Italy Yong Zhong Shien-Ming Wu School of Intelligent Engineering, South China University of Technology, Guangzhou 511442, China Luohua Hu Shien-Ming Wu School of Intelligent Engineering, South China University of Technology, Guangzhou 511442, China Yinsheng Xu Shien-Ming Wu School of Intelligent Engineering, South China University of Technology, Guangzhou 511442, China Jiachen Zhang Department of Biomedical Engineering, City University of Hong Kong, Hong Kong, China

xv

LIST OF ABBREVIATIONS APO

Active Pelvis Orthosis

ATP

Adenosine triphosphate

AI

Artificial intelligence

AT

Assisted Technology

AESOP

Automated Endoscopic System for Optimal Positioning

BiCMOS

Bipolar Complementary metal-oxide-semiconductor

CNTs

Carbon Nano Tubes

CMOS

Complementary metal-oxide-semiconductor

CT

Computed tomography

CR

Continuum robot

COS

Core outcome sets

DOF

Degrees-of-freedom

DLW

Direct laser writing

DFS

Disease-free survival

DCM

Dual continuum mechanism

ETPP

Effective target protrusive position

EAP

Electro-active Polymer

ERF

Electro-rheological fluid

EMADIS

Endoscopy-assisted magnetic actuation with dual imaging system

EBL

Estimated blood loss

FES

Finite Element Simulations

FMSMs

Fluorescence magnetic spore-based microrobots

FTL

Follow-the-leader

GC

Gait cycle

GLAD

Glancing angle deposition

IC

Integrated Circuit

LOS

Length of stay

LCEs

Liquid-crystal elastomers

LCN

Liquid crystal network

LMPA

Low Melting Point Alloy

LN

Lymph nodes

ML

Machine learning

MRI

Magnetic resonance imaging

MVSMs

Mechanism-based variable stiffness methods

MCoT

Metabolic Cost of Transport

METs

Metabolic equivalents

MOSFET

Metal–Oxide–Semiconductor Field-Effect Transistor

MSQC

Michigan Surgical Quality Collaborative

MIS

Minimally invasive surgery

NEMS

Nanoelectromechanical systems

NBI

Narrow-band imaging

NOTES

Natural Orifice Transluminal Endoscopic Surgery

NIRF

Near-infrared fluorescence

NIR

Near-infrared radiation

OSA

Obstructive sleep apnea

OSAS

Obstructive sleep apnea syndrome

OTC

Optical coherence tomography

PASE

Physical Activity Scale for the Elderly

PAD

Precision-aiming device

RF

Radio frequency

ROM

Range of motion

RLN

Recurrent laryngeal nerve

RCMP

Remotely controlled mandibular positioner

RAGT

Robot-assisted gait training

RAS

Robot-assisted surgery

RALP

Robotic-assisted laparoscopic pyeloplasty

RAR

Robotic-assisted repair

RAS

Robotic-assisted surgery

SMA

Shape Memory Alloy

SMP

Shape Memory Polymer

SPL

Single Port Laparoscopy

SWNT

Single-Wall NanoTube xviii

SCI

Spinal cord injury

SOR

Standard open repair

TP

Thermoplastic Polymer

TME

Total mesorectal excision

TLM

Transoral laser microsurgery

TORS

Transoral robot-assisted surgery

VHDL

Very High Speed Integrated Circuit Hardware Description Language

VAMIE

Video-assisted minimally invasive esophagectomy

VPL

Virus protein linear

WHO

World Health Organization

xix

PREFACE

The play Rossom’s Universal Robots written by Czech playwright Karel Capek (1921) was where the word “robot” (robota, meaning forced labor) was born. We have a slew of books and movies whose concepts based on robots range from funny to scary and hopeful. The robots employed today are seeing great progress in terms of their processing and artificial intelligence (AI). Their use has been probed in several unchartered areas like deep-sea exploration, working in dangerous zones and microprocessor assembly for computers. In the field of medicine, their use and entry have been slower. “Whether we are based on carbon or on silicon makes no fundamental difference; we should each be treated with appropriate respect.” ‒ Arthur C. Clarke, ‘2010: Odyssey Two’.

This book presents research-backed examples of how robots are being employed to assist healthcare procedures. This becomes pertinent with repeated pandemic outbreaks. The COVID-19 pandemic has necessitated “social distancing” with robust sterilization and cleaning procedures: robots have been probed in these aspects. For example, Swingobot 2000 from Taski looks at autonomous cleaning and eXtremeDisinfection roBOT (XDBOT) from researchers at Nanyang Technological University (NTU), Singapore is controlled wirelessly and can clean switches and under the beds making it a fit for cleaning hospitals. As far as social distancing is concerned the COVID-robot (Sathyamoorthy et al, arXiv, 2020) monitors the “6 feet distance”. Robots have also been developed for oropharyngeal swab testing. While more research is warranted to corroborate the logistics, cost and safety aspects for large-scale use of these robots, the idea and initial research hold promise. The book starts with examples of robots in healthcare followed by two chapters on surgical robots or case studies and examples of the potential of these machines in surgery. The discovery of something of small proportions such as the “microscope” paved the way for the vast field of microbiology. Similarly, the concepts of nano and micro have been extended to robots with the development of “nanobots”. Research is ongoing in this field aimed at employing these robots to target specific cells or deliver appropriate cargo to alter the face of drug delivery. While the field looks exciting, there are points that warrant deep analyses: one is the cost entailed of these robots that has been reported by many research teams and the second is the ethical aspects. While we have seen reports of robots greeting patients and recording their temperature, there are questions like “can they accidentally harm us”? Further, whether the ailing and the elderly would be comfortable with a “digital” doctor

or system given that most humans yearn for other human connections is another aspect that still remains unclear. The impact of robots in medical science cannot be ignored: perhaps appropriate usage and realizing that these instruments are aimed at assisting doctors and surgeons and not replacing them. “Don’t think of robots as replacements for humans -- think of them as things that will help make us better at tackling many of the problems we face” -EOIN TREACY

CHAPTER

1

Biorobotics in Medicine: A Snapshot

“By using human ova and hormone control, one can grow human flesh and skin over a skeleton of porous silicone plastics that would defy external examination.” – Dr. Alfred Lanning, ‘I, Robot’.

Contents 1.1 Altering Healthcare............................................................................... 2 1.2 Case Study: Robotic Surgery for Neurosurgery...................................... 5 1.3 Covid-19 and Other Aspects................................................................. 7 1.4 References............................................................................................ 9

2

Biorobotics in Medicine

1.1 ALTERING HEALTHCARE “Clocks, artificial fountains, mills, and other such machines which, although only man-made, have the power to move of their own accord in many different ways” (Descartes, 1664/1985)-this line summarizes the concept of automation in biology. The use of robots in life sciences has long captured researchers. To illustrate this, Holland and team (2021) reviewed the use of robots in telehealth that is documented in table 1.1 below (Holland J, Kingston L, McCarthy C, Armstrong E, O’Dwyer P, Merz F, McConnell M, 2021: © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license: http://creativecommons. org/licenses/by/4.0/): Application

Ref.

Year of Make Dev.

Robot Name

Service Area

Specifications

Patient Monitoring

[56]

2016

Academic / Research based

iWard

remote physical condition monitoring for patients.

RGB camera, 3D laser sensor, 3D sensor for object detection, and EQ01 sensor unit with monitoring belt and sensor electronics module.

[57]

2014

Academic/ Research based

Carebot

Screening of patients in healthcare facilities and measuring vital signs.

Based on Yujin Robot’s Charlie [58]: 120 cm tall. Tiltable touch screen, microphones, ultrasonic sensors, bumper sensors, and a laser range finder.

[59]

2017

Academic/ Research based

Telemedical Assistant

Record patient’s vitals, dispense medications and act as a virtual presence to communicate with physicians/family.

HD camera, speakers, medicine and keyboard trays, ultrasonic sensors, solar sensors, and LCD display.

Biorobotics in Medicine: A Snapshot

Mass Monitoring

3

[60]

2017

Temi

Temi Robot

Telepresence for the evaluation, monitoring and treatment of patients.

100 × 35 × 45 (cm). 8 h of operation, moves up to 1 m/s. LiDAR, two depth cameras, RGB camera, five proximity sensors, IMU sensor, six Time of Flight linear sensors, and LCD screen.

[61]

2019

PAL Robotics

ARI

Interact with patients for COVID-19.

53 × 75 × 165 (cm). Maximum payload of 0.5 kg, operates for 8–12 h, Touch screen, Three cameras, two speakers, and four microphones.

[62]

2020

Academic/ Research based

Teleoperation Robot System

Daily remote check-ups, remote auscultation and monitoring emotional states.

Dual arm manipulators (YuMi IRB14000), camera, medical storage box, omnidirectional chassis, wifi transmission modules, tablet for remote consultation.

[63]

2020

Academic/ Research based

Cough Detection Robot

COVID-19 screening, recording temperature and any coughing events.

[64]

2020

Academic/ Research based

Social Distance Robot

Detection of individuals not complying to social distance measures.

2D LiDAR, RGBD camera and thermal camera.

[65]

2019

UBTECH

AIMBOT

temperature measurement, public address system, mask detection, automatic disinfectant.

HD camera, infrared camera, thermal camera, LiDAR, speaker, and disinfection unit with spray nozzle

4

Remote Surgery

Biorobotics in Medicine [66]

2017

UBTECH

CRUZR

Point of contact in quarantine areas, remote consultation, mask detection, broadcast health recommendations and vocalize reminders.

LiDAR, sonar sensors, infrared, depth-perception camera, HD camera, speaker, omnidirectional wheels, and touchscreen.

[67]

2020

Academic/ Research based

SHUYU

Temperature screening for drivers and passengers.

Translational parallel manipulator with a closed passive limb, four high accuracy thermometers, two cameras, ultrasonic sensors, voice broadcast system and dual IR camera.

[67]

2020

Academic/ Research based

SHUYUmini

Temperature screening for pedestrians.

Parallelogram manipulator, high accuracy thermometer, three laser ranging sensors, ultrasonic sensor, and IR camera.

[68]

2020

Misty Robotics

Misty II

Temperature screening.

25.4 × 20.32 (cm). Thermal camera, 4K camera, three microphone arrays, speakers LCD display, bump sensors.

[69]

1999

Intuitive Surgical

DaVinci

Minimally invasive surgery.

91.59 × 127 × 175.3 (cm). Optical and magnetic encoders, hall sensor, IR sensor, and four arm manipulators (as of 2003)

[70]

1995

Computer Motion

ZEUS

Cardiac, abdominal, gynecology and urology surgeries with a surgeon present.

Three arm manipulators for instrument manipulation and control of a endoscopic camera, and two monitors.

Biorobotics in Medicine: A Snapshot

5

[71]

2020

Academic/ Research based

MELODY

Remote ultrasounds.

Three DOF robotic arm manipulator, ultrasound probe, fictive probe and electronic control.

[72]

2019

MGI Tech

MGIUS-R3 Tele-echography Robot System

Remote diagnosis of pneumonia.

108 × 140 × 83 (cm). Two imaging monitors, a fictive transducer, arm manipulator, force sensor with convex and linear array transducers.

1.2 CASE STUDY: ROBOTIC SURGERY FOR NEUROSURGERY Researchers Vakharia, Rodionov, Miserocchi et al (2021) probed the use of robotic surgery for stereoelectroencephalography (SEEG: a process involving the stereotactic implantation of 7–16 electrodes within predefined regions of the brain for locating the sites of drug-resistant focal epilepsy). This “single-centre, single-blinded, randomized controlled trial” published in Scientific Reports (Trial registration: ISRCTN17209025: https://doi. org/10.1186/ISRCTN17209025) scrutinized the performance of a novel robotic trajectory guidance device, the iSYS1 (Medizintechnik GmbH) vs. that of the conventional frameless approach of precision-aiming device (PAD) in 32 patients with 16 patients assigned to each of these two groups. Figure 1.1 below illustrates the protocol with iSYS1: (A) Insertion of the Vertek probe (for navigation in real-world) into the working channel of the iSYS1 device (B) Automatic alignment of the working channel to the trajectory by the system (C) Replacement of the probe with a reduction tube followed by skin incision (D) Defining the entry point (E) The reduction tube drills the skull (F) Screwing the skull anchor bolt (G) Removal of the reduction (H) Placing the other bolts (I) Placing of the electrodes through the bolts (Vakharia, Rodionov, Miserocchi et al, 2021: Open Access: This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not

6

Biorobotics in Medicine

included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/):

An average lowering of 30% was documented by the researchers for the individual bolt insertion implantation time per electrode for the iSYS group vs. that of the PAD group: 6.36 min (95% CI 5.72–7.07) versus 9.06 min (95% CI 8.16–10.06), p = 0.0001, respectively. The target accuracy was better for the PAD group, however: 1.58 mm (95% CI 1.38–1.82) versus 1.16 mm (95% CI 1.01–1.33), p = 0.004, respectively for the PAD and iSYS group. Other outcomes assayed documented no differences paving the way for further fine-tuning of the system for incorporation in medical care. Table 1.2 below documents the post-operative measures for the manual vs. robotic SEEG (Vakharia, Rodionov, Miserocchi et al, 2021: Open Access: This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/):

Biorobotics in Medicine: A Snapshot iSYS1 group

PAD group

Ratio of median estimate (iSYS1/PAD groups) (95% CI)

P-value**

Electrode insertion time (mins) Median (95% CI)

6.36 (5.72– 9.06 (8.16– 7.07) 10.06)

0.70 (0.61–0.81)

0.0001

Total operative time (mins)* Median (95% CI)

176.4 (153.7– 202.6)

0.92 (0.78–1.08)

0.293

Entry point accuracy (mm) Median (95% CI)

1.09 (0.99– 1.17 (1.06– 1.20) 1.29)

0.93 (0.81–1.07)

0.334

Target point ac1.58 (1.38– 1.16 (1.01– curacy (mm) Median 1.82) 1.33) (95% CI)

1.37 (1.12–1.67)

0.004

Error of angle of implantation (degrees) Median (95% CI)

1.24 (1.04–1.48)

0.023

201.5 (175.5– 231.3)

2.13 (1.87– 1.71 (1.51– 2.41) 1.94)

Post-operative haem- 1/16 orrhage (6.25%)

2/16 (12.5%)

Post-operative infection

0/16 (0%)

0/16 (0%)

Post-operative neurological deficit

0/16 (0%)

0/16 (0%)

7

1.3 COVID-19 AND OTHER ASPECTS Given the COVID-19 pandemic, “social distancing” and “testing” have now penetrated our lives. This has led to robots being probed for COVID-19 testing to minimize the risk to healthcare workers. Table 1.3 below documents robots in COVID-19 testing as documented by Holland and team (2021) in Robotics (Holland J, Kingston L, McCarthy C, Armstrong E, O’Dwyer P, Merz F, McConnell M, 2021: © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license: http://creativecommons.org/licenses/by/4.0/):

8

Biorobotics in Medicine

Ref.

Year of Dev.

Make

Robot Name

Service Area Success Rate

Specifications

[27]

2020

Academic/ Research based

Nasopharyngeal Sampling Robot

Upper throat swabbing

[28]

2020

Lifeline Robotics

Commercial Middle Throat Swab- throat swabbing Robot bing

Gentle and consistent. Swabbing takes 25 s.

UR3 manipulator arm, 3D-printed end-effector, headrest.

[29]

2020

Academic/ Research based

Semi-automatic Oropharyngeal Swab Robot

Middle throat swabbing

No congestion or injury. If sampling force >40 g, evidence of sore throat.

Binocular endoscope serpentine robot arm manipulator, wireless transmission, and human–robot interaction terminal.

[30]

2020

Academic/ Research based

Telerobotic system swab robot

Upper respiratory swabbing

N/A—Pre- Two wide-angle liminary cameras, two testing. microphones, force sensor, wireless transmission, parallel kinematic manipulator, end-effector and Stewart platform.

N/A—Pre- 15 × 6 × 4 (cm). liminary Swab gripper, 2 testing. DOF end-effector for actuating swab, and a 6 DOF passive arm for positioning.

Further, robots have also been employed for sterilization, cleaning and also for social care (for augmenting social communication in autism and personal care). The subsequent chapters present further reports on how robots are being employed in the medical industry. “Helena: Will they be happier when they can feel pain? Dr. Gall: On the contrary. But they will be technically more perfect.” – Karel Čapek, ‘R.U.R.’.

Biorobotics in Medicine: A Snapshot

9

1.4 REFERENCES 1.

2.

Holland J, Kingston L, McCarthy C, Armstrong E, O’Dwyer P, Merz F, McConnell M. Service Robots in the Healthcare Sector. Robotics. 2021; 10(1):47. https://doi.org/10.3390/robotics10010047 Vakharia, V.N., Rodionov, R., Miserocchi, A. et al. Comparison of robotic and manual implantation of intracerebral electrodes: a singlecentre, single-blinded, randomised controlled trial. Sci Rep 11, 17127 (2021). https://doi.org/10.1038/s41598-021-96662-4

CHAPTER

2

Robots for Surgery

“The machine has no feelings, it feels no fear and no hope ... it operates according to the pure logic of probability. For this reason I assert that the robot perceives more accurately than man” -MAX FRISCH

Contents 2.1 A Snapshot......................................................................................... 12 2.2 Trends................................................................................................. 15 2.3 Case Study: Open Esophagectomy for Esophageal Cancer: Robot-Assisted Vs. Video-Assisted.................................................... 33 2.4 Case Study: Robots For Total Mesorectal Excision (Tme):..................... 38 2.5 Final Points......................................................................................... 41 2.6 References.......................................................................................... 43

12

Biorobotics in Medicine

2.1 A SNAPSHOT The medical field has witnessed advancements many of which are attributed to technology-whether in imaging or design and other novel approaches. A robot is “a reprogrammable, multifunctional manipulator designed to move materials, parts, tools, or other specialized devices through various programmed motions for the performance of a variety of tasks”, as put forth by the Robot Institute of America (1979). While the probing of robots in surgery is still receiving the limelight, the lowering of hospital stay and diminishing of patient trauma have been documented (Beasley, 2012). An early report traces how a robot was employed in a brain biopsy procedure in 1985 that paved the way for robots entering the stage. Figure 2.1 illustrates the systems reported over time from the 1990s (Tirth Ginoya, Yaser Maddahi, Kourosh Zareinia, 2021: Copyright © 2021 Tirth Ginoya et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited):

No

Robotic system

Company

Year

Regulatory status

Procedures

1

NeuroMate®

Currently–Renishaw plc, UK

1987

FDA–1997 (First model) CE mark–1997

Deep brain stimulation (DBS), stereoelectroencephalography (SEEG) [1, 2, 11, 17]

2

ROBODOC® Surgical System

Current–Think Surgical, USA

1992

CE mark–1996 FDA–1998 (THA) FDA–2009 (TKA)

Total hip arthroplasty, Total knee arthroplasty [1, 7, 14, 15]

3

AESOP™ Robotic Surgical System

Computer Motion Inc., USA

1993

FDA–1994 (first model)

MIS–urologic, thoracic, cardiac, etc. fields [8, 17]

Robots for Surgery

13

4

CyberKnife®

Accuray Inc, USA

1994

FDA–2001

Radiosurgery, SBRT, Hypothalamic hamartomas [1, 18, 19, 21]

5

Zeus® Robotic Surgical System

Computer Motion Inc., USA

1995

FDA–2001

MIS, cardiac procedures [1, 8]

6

CASPAR®

OrtoManquet/U.R.S, Germany

1997

N/A

TKA, THA, anterior crucial ligament repair [1, 14, 22]

7

Da Vinci® Surgical System

Intuitive Surgical, USA

1999

FDA–2000 (first model)

MIS [1, 2, 4, 8, 24]

No

Robotic system

Company

Year

Regulatory Procedures status

1

AcuBot

Urobotics Lab, USA

2001

NA

Percutaneous access, radiological percutaneous interventions [25, 26]

2

PathFinder™

Current–Prosurgics, UK

2001

FDA–2004

Stereotactic neurosurgery, brain tumors, Parkinson’s disease, and epilepsy [27, 28]

3

InnoMotion

Current–DePuy Initial modSynthesis Inc., el–2001 USA

CE mark 2005

MRI-guided percutaneous interventions [25, 31, 32]

4

Niobe™ ES Magnetic Navigation System

Stereotaxis, USA

CE mark– 2008 FDA–2009

Treatment of cardiac arrhythmias, catheter interventions, endoscopy [33, 35]

2003

14

Biorobotics in Medicine

5

Raven Surgical System

Universities of Washington and California, USA

2005

NA

MIS [36, 37]

6

Sensei®

Current–Auris Health, USA

Initial Experiment–2005

FDA–2007

Catheter interventions, atrial fibrillation [33, 38]

7

NeuroArm™

Current–IMRIS Inc., Canada

2006

FDA–2008

Microsurgery, stereotaxy, neurosurgery, treatment of glioma, [2, 5, 6, 39]

8

FreeHand® v1.2

Free hand 2010 2008 ltd, UK

FDA–2009

Laparoscopy, MIS [1, 24]

9

Telelap ALF-X

Current–TransEtrix Surgical Inc., USA

2008

CE mark– 2011

Gynecological surgery [42], endoscopy, [43]

10

ROSA® Brain

Zimmer Biomet, France

2008

CE mark– 2008 (from website) FDA–2012

Keyhole procedures, open skull operations, deep brain stimulation [1, 3, 4, 46]

11

Novalis® powered by TrueBeam™ STx

BrainLab Inc., Germany and Varian Medical System, USA

2010

NA

Radiosurgery, radiotherapy [1, 45]

No

Robotic system Company

Year

Regulatory status

Procedures

1

Renaissance®

2011

FDA and CE mark 2011, FDA–2012 (neuro procedure)

Biopsies, osteotomies, spinal deformities [1, 3, 4]

Current Medtronic, Ireland

Robots for Surgery

15

2

ROSA® spine

Zimmer Biomet, 2012 France

FDA–2016 CE mark–2014 (from website)

Biopsies, planning, [3, 4, 17, 46]

3

Flex® robotic system

Medrobotics Corp., USA

2013

CE mark–2014 FDA–2015 (ENT), 2017 (colorectal surgery)

Laparoendoscopic single-port surgery (LESS), transoral surgery [24, 50, 51, 65]

4

MAKO™

Stryker

2015

FDA–2015 (TKA), 2015 (THA)

Total Hip arthroplasty, Total knee arthroplasty, unicompartmental knee arthroplasty [15, 53]

5

Senhance™ TransEtrix Sur- 2015 Surgical System gical Inc., USA

FDA–2017

Laparoscopy, gynecological procedures, hysterectomy [24, 54, 55]

6

Preceyes Surgi- Preceyes BV, cal System Netherlands

2016

CE mark–2019

Retina surgery, intraocular procedures [56]

7

Versius® CMR Surgical, Surgical System UK

2016 CE mark–2019 (cadaveric trials) reveal–2018

Minimal access surgery, colorectal procedures [57, 58, 65]

8

Navio™ Surgi- Current–Smith 2017 cal System and Nephew, UK

FDA–2016 (TKR)

Knee prosthesis positioning, unicompartmental knee arthroplasty [59]

9

SPORT™ Sur- Titan Medical gical System Inc., Canada

2017

FDA–to be applied in 2020

MIS, single-incision laparoscopic surgery (SIL), LESS [17, 24, 61, 65]

10

Ion™ roboticassisted platform

Intuitive surgical, USA

2017

FDA–2019

Minimal invasive biopsy, MIS

11

Monarch™ Platform

Aruis Health, USA

2018

FDA–2018

Peripheral bronchoscopy, endoscopy, [63]

12

Mazor X– Stealth™ Edition

Medtronic Plc., 2019 Ireland

FDA–2018

Spine surgery, Pedicle Instrumentation, MIS [46, 47]

2.2 TRENDS The usage of robotic surgery with time was scrutinized on general surgical procedures with data from the Michigan Surgical Quality Collaborative

16

Biorobotics in Medicine

(MSQC): constituted by 73 Michigan hospitals and the Blue Cross/Blue Shield of Michigan based on 169404 patient data for January 1, 2012, through June 30, 2018. The researchers Sheetz, Claflin and Dimick (2020) reported a “dramatic increase” in the use of robotic surgery for the time span: at 2.1% per year from 1.8% to 15.1%. While this trend was on similar lines for most surgeries, robotic surgery in inguinal hernia repair rose from 0.7% to 28.8% over this time. Figure 2.2 below illustrates the findings of employing robotic surgery in 169404 patient data from 73 Michigan hospitals (2012-2018) (Sheetz KH, Claflin J, Dimick JB, 2020: This is an open access article distributed under the terms of the CC-BY license, which permits unrestricted use, distribution, and reproduction in any medium. You are not required to obtain permission to reuse this article content, provided that you credit the author and journal):

Trends in usage of the surgical approaches:

Procedure

Proportional Use, % Year 2012

Year 2018

Fold Difference Annual Slope (95% CI), %

All

1.8

15.1

8.4

2.1 (1.9-2.3)

Inguinal hernia repair

0.7

28.8

41.1

5.4 (5.1-5.7)

Ventral hernia repair

0.5

22.4

44.8

3.7 (3.5-3.9)

Colectomy

2.5

16.3

6.5

2.1 (1.8-2.4)

Reflux surgery

5.4

26.0

4.8

2.8 (2.3-3.2)

Proctectomy

3.1

26.7

8.6

4.0 (3.2-4.9)

Cholecystectomy

2.5

7.5

3.0

0.4 (0.3-0.5)

Complex cancer resec- 2.1 tions

3.9

1.9

0.4 (0.1-0.7)

Robots for Surgery

17

In conclusion, the rapid diffusion of robotic surgery for general surgeries was documented by the researchers. This rise was associated with a dip in the commonly used minimally invasive approaches, like laparoscopy. This paves the way for efficiently oversee this approach to ensure its use safely and effectively. A more detailed table of the above research is depicted below in table 2.1 (Sheetz KH, Claflin J, Dimick JB, 2020: This is an open access article distributed under the terms of the CC-BY license, which permits unrestricted use, distribution, and reproduction in any medium. You are not required to obtain permission to reuse this article content, provided that you credit the author and journal): Procedure

Surgical Approacha Laparoscopic

Open

Robotic

Before After Difference Before After Difference Before After Differ(95% CI) (95% CI) ence (95% CI) All Proportional use, %

53.2

Annual slope, 1.3 %

51.3

−1.9 (−2.2 44.8 to −1.6)

40.6

−4.2 (−4.5 NA to −3.9)

8.8

8.8 (8.7 to 8.9)

−0.3

−1.6 (−1.7 −1.6 to −1.5)

−0.4

1.2 (1.1 to NA 1.3)

2.8

2.8 (2.7 to 2.9)

17.5

4.7 (3.7 to 74.0 5.7)

60.4

−13.6 (−15.1 to −12.2)

19.2

19.2 (18.7 to 19.7)

0.5

1.5 (1.1 to −1.0 1.9)

−1.1

−0.1 (−0.6 NA to 0.3)

5.4

5.4 (5.1 to 5.6)

26.7

−0.8 (−1.8 73.0 to 0.2)

64.2

−8.8 (−9.8 NA to −7.9)

9.0

9.0 (8.6 to 9.3)

−0.2

−1.8 (−2.2 −1.6 to −1.5)

−0.8

0.8 (0.4 to NA 1.1)

4.0

4.0 (3.8 to 4.2)

37.7

5.0 (4.0 to 64.1 6.0)

52.5

−11.7 (−12.7 to −10.6)

NA

9.6

9.6 (9.2 to 10.0)

0.4

−1.5 (−1.8 −2.2 to −1.1)

−1.1

1.1 (0.8 to NA 1.5)

3.1

3.1 (2.8 to 3.4)

Inguinal hernia repair Proportional use, %

12.8

Annual slope, −1.0 %

NA

Ventral hernia repair Proportional use, %

27.4

Annual slope, 1.7 % Colectomy Proportional use, %

32.7

Annual slope, 1.9 %

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Biorobotics in Medicine

Reflux surgery Proportional use, %

69.1

Annual slope, −0.5 %

75.6

6.5 (4.2 to 24.2 8.9)

8.4

−15.8 (−18.3 to −13.3)

0.6

1.1 (0.6 to −0.4 1.6)

−1.1

15.0

−1.9 (−5.4 79.3 to 1.5)

−0.2

NA

14.2

14.2 (13.3 to 15.1)

−0.7 (−1.0 NA to −0.4)

3.8

3.8 (3.4 to 4.2)

66.8

−12.5 (−16.1 to −8.9)

18.7

18.7 (16.9 to 20.5)

−0.8 (−1.2 −1.0 to −0.2)

−1.2

−0.2 (−1.6 NA to 1.1)

5.8

5.8 (4.8 to 6.9)

87.1

−0.2 (−1.0 14.9 to 0.5)

13.1

−1.7 (−4.4 NA to 1.0)

5.9

5.9 (5.7 to 6.1)

0.1

1.1 (0.9 to 0.1 1.2)

−0.2

−0.1 (−0.2 NA to 0.1)

1.4

1.4 (1.3 to 1.5)

21.7

2.6 (−0.1 to 5.2)

78.2

74.7

−3.5 (−6.2 NA to −0.7)

3.5

3.5 (2.9 to 4.1)

0.2

−2.2 (−3.2 −2.8 to 1.1)

−0.3

2.4 (1.4 to NA 3.6)

0.6

0.6 (0.2 to 1.1)

Proctectomy Proportional use, %

16.9

Annual slope, 0.6 %

NA

Cholecystectomy Proportional use, %

87.4

Annual slope, −1.0 % Complex cancer resections Proportional use, %

19.1

Annual slope, 2.4 %

A systematic review published in Frontiers in Surgery of the employing of robotic assistance in plastic and reconstructive surgery documented the promise of this approach in terms of boosted access and dexterity albeit presenting the challenge of costs. In terms of microsurgery, table 2.2 below documents the feasibility of robotic assistance (© 2017 Dobbs, Cundy, Samarendra, Khan and Whitaker. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms):

Robots for Surgery Reference

Year Study design

Operations performed

19

Outcomes reported

Preclinical studies Katz et al. (10)

2005 Animal model

Arterial and venous anasto- All anastomoses grossly moses and free-flap trans- patent, confirmed by auplantation (N = 1 pig) dible Doppler signals, visibly adequate perfusion of tissues, and arterial bleeding seen after incision distal to the anastomoses 4 h after the procedure

Knight et al. 2005 Animal model Arterial end-to-end anas(11) Case controlled tomoses (N = 31 vs N = 30 controls)

Karama2006 Animal tissue noukian et al. samples (12)

A remarkable degree of tremor filtration, but significantly slower operative time. All anastomoses were patent and nonleaking

Slit arteriotomy and end-to- The Zeus robotic system end arterial anastomoses in is a viable tool for procine hearts microsurgical vascular reconstruction. It allows for precise movement, lack of hand tremor, enhanced microvascularisation and improved ergonomics, compared to conventional human assistance. The major advantage is the ability of the robot to scale down the surgeon’s movements to a microscopic level

Katz et al. (13)

2006 Animal cadavers Microvascular anastomoses All anastomoses were of tarsal and superficial successful and patent femoral vessels (N = 2 dog postoperatively cadavers)

Taleb et al. (14)

2008 Animal cadaver Microvascular anastomoses Immediate and delayed (1 in rat tail transplantation (N h postoperation) patency = 2) of the arterial anastomoses

20

Biorobotics in Medicine

Ramdhian et 2011 Animal tissue al. (15) samples

Earthworm segment anasto- The high quality 3D moses (N = 15) vision allowed by the robotic system was excellent and compensated for loss of tactile feedback. The robotic system eliminated physiological tremor. Motion scaling by the robot improved precision of the surgical gesture

Lee et al. (16) 2012 Live animal models

Femoral artery end-to-end anastomoses (N = 20)

Generation of learning curves for robot-assisted microvascular anastomosis. Important aspects of learning identified included starting level, learning plateau and learning rate

Robert et al. 2013 Human cadaver Radial/ulnar artery dissec- Successful anastomoses (17) tion and microvascular anas- The assembling and tomoses (N = 2 cadavers, 4 disassembling of the anastomoses) vascular clamp were time consuming

In both cases (radial and ulnar arteries), the 10/0 needle was bent and a second suture had to be used Alrasheed et 2014 Synthetic vessel Microvascular anastomoses Successful validation of al. (18) models (N = 50) microsurgical assessment tool and characterization of learning curve Proficiency gained by operators over 5 learning sessions Selber and Alrasheed (19)

2014 Synthetic models Microvascular anastomoses Definition of a learning (N = 5 per surgeon) curve in microsurgery and the development of a structured assessment of robotic microsurgical skills

Robots for Surgery

21

Willems et al. 2016 Synthetic miMicrovascular anastomoses Manual surgery was supe(20) crovessel models (N = 80, vs 80 control) rior to robotically assisted microsurgery in techniCase controlled cally easy exposures. In difficult exposures (greater depth and lower sidewall angles), however, robotically assisted microsurgery had a shorter surgery time and a higher comfort rating. Objective Structured Assessment of Technical Skills scores were similar to those assessing traditional microsurgery Clinical studies Boyd et al. (21)

2006 Case cohort, retrospective

Van der Hulst 2006 Case report et al. (22)

Robotic vessel harvest of internal mammary vessels for use in free-flap breast reconstructive procedures (11 muscle-sparing transverse rectus abdominis musculocutaneous (TRAM) flaps, six superior gluteal artery (SGA) flaps, four superficial inferior epigastric artery flaps, and one superior gluteal arterial perforator flap) (N = 22 free-flaps, in 20 patients)

Pedicle was harvested with robot-assisted technique

Breast reconstruction with muscle-sparing free TRAMflap, using robotic arterial anastomosis (N = 1)

The time to perform this anastomosis was about 40 min and significantly longer than the standard technique (around 15 min)

Microvascular anastomosis via standard technique An average pedicle length of 6.7 cm is long enough to allow anastomosis without vein graft

The number of procedures carried out in each study is documented and represented as N number. Robots have also been employed for muscle flap harvest as documented in table 2.3 below (© 2017 Dobbs, Cundy, Samarendra, Khan and Whitaker. This is an open-access article distributed under the terms of the

22

Biorobotics in Medicine

Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms): Reference

Year

Study design

Operations performed

Outcomes reported

2011

Human cadaver

Latissimus dorsi muscle harvest (N = 10 in 8 cadavers)

Successful harvest of all muscles

Patel and Ped- 2012 ersen (26)

Human cadaver

Rectus abdominis muscle No postoperative comdissection and harvest (N plications or surgical= 2) site morbidity

Selber et al. (27)

Human cadaver

Latissimus dorsi muscle harvest and transfer (N = 8)

Successful harvest and transfer of all flaps that left no visible incisions, with no major complications

Patel et al. (28) 2012

Case report

Pedicled myocutaneous latissimus dorsi flap for shoulder reconstruction after sarcoma resection (N = 1)

No objective outcomes reported-flap successfully raised robotically One of the limitations is the time/learning curve

Lazzaro et al. 2013 (29)

Case report

Intercostal muscle flap after lobectomy (done in conjunction with VATS) (N = 1)

Success of surgery— no conversion to open procedures and both patients returned home 5 days postop

Preclinical studies Selber (25)

2012

Clinical studies

Robots for Surgery

23

Ibrahim et al. (30)

2014

Case series

Rectus abdominus Less tissue violation, muscle flap harvest (N not compared to open reported) technique, resulting in reduced postoperative pain, shorter duration of hospital stay, and more rapid functional recovery

Chung et al. (31)

2015

Case series

Transaxillary gasless robot-assisted latissimus dorsi muscle harvest (3 delayed reconstructions, 4 immediate after nipple sparing mastectomy, 5 corrections of deformity in Poland syndrome) (N = 12)

Operating time, general satisfaction, cosmetic satisfaction, scar, and symmetry satisfaction were all outcomes measured via survey given to all patients with followup longer than months Robotic time decreases with experience

Singh et al. (32)

2015

Case series and retrospective review

Extralevator abdomino- An incisionless roperineal excision with botic flap harvest with robotic rectus abdominis preservation of the flap harvest, for reconanterior rectus sheath struction after resection of obviates the risk of distal rectal adenocarci- ventral hernia while noma (N = 3) providing robust tissue closure of the radiated abdominoperineal excision wound

The number of procedures carried out in each study is documented and represented as N number. The suitability of robots in assisting nerve repair was also demonstrated in preclinical and clinical systems as in table 2.4 below (© 2017 Dobbs, Cundy, Samarendra, Khan and Whitaker. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms):

24

Biorobotics in Medicine

Reference

Year Study design

Operations performed Outcomes reported

Preclinical studies Latif et al. (34) 2008 Animal model Intercostal nerve Successful anastomosis grafting for reversal of with no apparent complithoracic sympathectomy cations (N = 1) Nectoux et al. (35)

2009 Animal and human tissue samples

Extrafascicular neurolysis, donor nerve dissection and subsequent repair of peripheral nerve (N not reported)

The robot removed physiological tremor There was some technical difficulty with the choice and manipulation of the three-dimensional stereoscopic vision enabled a better view and safe and accurate repair of peripheral nerve lesions

Mantovani et al. 2011 Human cadaver Supraclavicular brachial (36) plexus exploration and nerve graft anastomosis and reconstruction (N = 2)

The robot allowed microsurgery to be performed in a very small space with telemanipulation and minimally invasive techniques

Garcia et al. (37)

2012 Human cadaver Sural nerve graft and The goals of the opneurotisation using the eration were achieved accessory nerve (N = 3) without conversion to open surgery. There were no complications

de Melo et al. (38)

2013 Human cadaver Microsurgical nerve Dissection and transfer transfer of the branches achieved successfully of the axillary nerve onto the nerve of the long head of the triceps brachii (N = 1)

Facca et al. (39) 2014 Human cadaver Sural nerge graft between C5 root or spinal nerve, and the musculocutaneous nerve (N = 8)

Porto de Melo et al. (40)

Endoscopic treatment of supraclavicular nerve palsy is feasible, however, both sural nerve grafts and C5-6 avulsions were converted to open

2014 Animal model Phrenic nerve harvest Successful nerve harvest and application in brachial plexus surgery (N = 1)

Robots for Surgery

25

Miyamoto et al. 2016 Animal model Intercostal nerve harvest Physiological tremor was (41) for brachial plexus re- eliminated and there were construction (N = 3) no major complications Clinical studies Latif et al. (42) 2011 Case study

Intercostal nerve graft harvesting and grafting into sympathetic chain using tension free nerve anastomoses (N = 1)

Successful operation, patient discharged one day postoperatively and no sign of Horner’s syndrome on short term follow-up

Coveliers et al. 2013 Case cohort, (43) retrospective

Selective postganglionic thoracic sympathectomy for patients with palmar or axillary hyperhidrosis (N = 110 operations in 55 patients)

Of the 55 patients, 53 (96%) had sustained relief of their hyperhidrosis at a median follow-up of 24 months (range, 3 to 36 months), and compensatory sweating was seen in four patients (7.2%)

Naito et al. (44) 2012 Case cohort

The Oberlin procedure of nerve transfer for restoration of elbow flexion (N = 4)

At 12 months’ mean follow-up, all patients had recovered to useful elbow flexion, with no sensory/ motor deficit in the ulnar nerve territory

Berner (45) 2013 Case series (book chapter)

Repair of brachial plexus injury (N = 12)

Considering the microsurgical gesture, all nerve repairs were achieved under excellent conditions Need to convert to open surgery in nine cases

Tigan et al. (46) 2014 Case cohort

Nerve grafting after excision of benign peripheral nerve tumors (N = 7)

In postoperative surveys, neuropathic pain halved from 6/10 to 3/10 postop, with no worsening of sensory deficits

The number of procedures carried out in each study is documented and represented as N number.

26

Biorobotics in Medicine

Procedures related to upper limb surgeries are documented in table 2.5 below (© 2017 Dobbs, Cundy, Samarendra, Khan and Whitaker. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms): Reference

Year

Study design

Operations performed

Outcomes reported

Animal cadaver

Humeral cross-section, amputation, and replantation of the left forelimb. Stages done with surgical robot were soft tissue repair and vessel patency tests during limb replantation (not any microvascular procedures) (N = 1)

Patency tests were all positive. Venous bleeding demonstrated vascular success of replantation

Preclinical studies Taleb et al. (47)

2009

The robot removed physiological tremor and allowed for a smaller operating field

Huart et al. (48)

2012

Human cadaver

Kite flap hand surgery (N = 1)

Operating time was longer with the robot, but kite flap transfer was successful

Maire et al. (49)

2012

Human cadaver

Removal of left hallux medial hemipulp (with sensory nerve, collateral artery and dorsal vein) and transfer to left thumb radial hemipulp (N = 1)

Successful free hallux hemipulp transfer, however, operating time was increased by non-microsurgical moments which could be improved by instrumentation improvement

2010

Case report

Robotic anastomosis of No postoperative probvein grafts for hypothenar lems of note hammer syndrome (N = 1) Successful cure of vasomotor disorder

Clinical studies Facca and Liverneaux (50)

Robots for Surgery

27

The number of procedures carried out in each study is documented and represented as N number. A lot of studies have been documented for Trans-Oral Robotic Surgery (TORS) with literature demonstrative of the promise of surgical robots (© 2017 Dobbs, Cundy, Samarendra, Khan and Whitaker. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms): Reference

Year Study design

Operations performed

Outcomes reported

Preclinical studies Selber et al. (54) 2010 Coffee cup models, TORS free radial forearm pig cadavers, hu- flap reconstruction of man cadavers oropharyngeal defect (N = 2) Robotic microvascular anastomosis Smartt et al. (55) 2013 Human cadaver

Superiorly based posterior pharyngeal flap transfer (N = 3)

Successful reconstruction of the oropharynx by trans-oral robotic flap inset and microvascular anastomosis

Successful transfer of posterior pharyngeal flaps, with mean surgical time of 113 min. Technically, the learning curve for using the robot telemanipulator was steep There was no damage to adjacent structures

Clinical studies Desai et al. (56) 2008 Case cohort, retro- Mucosal flap and No intra- or postopspective analysis pyriform sinus flap recon- erative complications, structions (N = 7) one patient required tracheostomy

28

Biorobotics in Medicine

Mukhija et al. (57)

2009 Case series

Radial forearm fasciocutaneous free-flap harvest and reconstruction of oral cavity (N = 2)

Successful positioning of the flap, shorter operating time compared to conventional techniques, shorter hospital stay compared to mandibulotomy approach

Selber (58)

2010 Case series

Free-flap reconstruction of oropharynx (radial forearm free-flap, anterolateral thigh flap, facial artery, myomucosal flap), primary closure after tumor resection, and microvascular anastomosis (N = 5)

Better access and improved precision within the oropharynx, compared to conventional tecnhiques

Radial forearm flap for reconstruction of the tounge base, vallecula and pre-epiglotic space, due to soft tissue and hyoid radionecrosis (N = 1)

The patient passed a swallow evaluation after 1 week, and started an oral diet 8 days after the operation

Free-flap reconstruction of oropharynx—sternocleidomastoid free-flap, mucosal mulscular flaps and pharyngoplasty (N = 30)

Equivalent rates of loco-regional and distant control of malignancy and better short-term eating ability, compared to conventional techniques

Garfein et al. (59)

Genden et al. (60)

2011 Case report

2011 Prospective nonrandomized case– control study

Successful microvascular anastomosis

There was good function showed by video oesophagram 6 week postoperatively

No major long term sequelae

Robots for Surgery

29

Genden et al. (61)

2011 Prospective nonrandomized case– control study

Musculomucosal adPostoperatively, vancement flap pharyngo- patients regained explasty (N = 30) cellent function, with Radial forearm free-flap near-normal scores on the Functional Oral reconstruction Intake Scale and Performance Status Scale for Head and Neck Cancer Patients at 1 year after surgery

Bonawitz and Duvvuri (62)

2012 Case cohort, retro- Free-flap oropharyngeal No major complicaspective reconstruction, with tions and no flap loss microvascular anastomoses in the tongue base and soft palate (N not reported)

Longfield et al. 2012 Case series (63)

Robotic reconstruction after resection squamous cell carcinoma of the oropharynx using local and distant free-flaps, with microvascular anastomoses (N not reported)

Bonawitz and Duvvuri (64)

Local random transposi- No major complication flaps from buccal tions mucosa, the hard palate or the pharyngeal wall (N not reported)

2013 Case series

Patients can be safely reconstructed (locally or with free tissue transfer) robotically after TORS

Facial artery musculomucosal (FAMM) flap for larger defects of the soft palate Bonawitz and Duvvuri (65)

2013 Case cohort, retro- FAMM flap reconstrucspective tion after removal of malignant tumors of the soft palate (N = 5)

No major complications, no flap loss

30

Biorobotics in Medicine

Duvvuri et al. (66)

2013 Case cohort, retro- Oropharyngeal reconspective struction with FAMM free-flaps, ALT free-flaps, radial forearm flaps and uvular flaps (N = 12)

No major complications, some minor flap dehiscence, two revision procedures needed (one fistula, one bulky flap)

Hans et al. (67) 2013 Case series

Radial forearm free-flap A complication of a reconstruction after resec- neck hematoma retion of hypopharyngeal quiring draining under carcinoma (N = 2) general anesthesia, no fistulae

Park et al. (68)

Radial forearm muscle No surgery-related free-flap reconstruction of complications of oropharynx (N = 7) infections, viable and functioning free-flaps in all patients, one hundred percent of patients happy with postoperative appearance and could tolerate an oral diet

2013 Case series, prospective study

Song et al. (69) 2013 Case series

De Almeida et al. (70)

Robotic ablation surgery, Flap insetting and mifree-flap reconstruction croanastomoses were (radial forearm free-flaps, achieved using a speanterolateral thigh flap), cially manufactured and microvascular anasto- robotic instrument mosis (N = 5) No complications

2014 Case cohort, retro- Velopharyngoplasty Good swallowing spective reconstructinos with local outcomes, no carotid flaps alone, regional and artery ruptures free-flaps, and secondary healing (N = 92)

Byeon et al. (71) 2015 Case series

Reconstruction and Good cosmetic outlymph node dissection for comes and no major head and neck maligcomplications nancy (N = 37)

Robots for Surgery Perrenot et al. (72)

2014 Case series

Infra-hyoid myocutaneous flap reconstructions (N = 8)

31

Good esthetic results One case required re-operating due to hemostasis No other complications Seven out of eight patients tolerated oral feeding postoperatively

Lai et al. (73)

2015 Case cohort

Free radial forearm fasciocutaneous flap reconstruction after resection of oropharyngeal cancer (N = 5)

All reconstructive surgeries were successful, with no flap failure or take-backs, no wound infections and no fistulae

Meccariello et al. (74)

2016 Case report

Resection and reconstruc- Restoration of a comtion, with temporalis petent velopharyngeal muscle flap, of squamous sphincter, with watercell carcinoma of the tight seal between lateral oropharyngeal wall pharynx and neck extending into the soft Timely healing and palate (N = 1) enhanced postoperative functional results

Gorphe et al. (75)

2017 Non-randomized FAMM and free ALT flap Robotic surgery phase II muti-center reconstructions of the proved feasible, and prospective trial oropharynx (N = 9) further technological progress in developing robotic systems specifically for transoral surgery will be of benefit to patients

Biron et al. (76) 2017 Case–control series Radial forearm free-flap reconstruction after excision of oropharyngeal squamous cell carcinoma (N = 18)

Significantly shorter admission duration and fewer postoperative complications

The number of procedures carried out in each study is documented and represented as N number.

32

Biorobotics in Medicine

Reference

Year

Study design Operations performed

Outcomes reported

Preclinical studies Khan et al. (77)

2016

Airway manikin and human cadaver

The Hynes With each variation, a subjective pharyngoplasty assessment (rated as poor, fair, (N = 1) good or excellent) was made for vision and access to either the posterior pharynx or palate, and it was validated by two of the authors for each set-up

Podolsky et al. (78)

2017

Cleft palate simulator test bed

The von Langenbeck cleft palate repair procedure (N = 1)

Excellent close up visualization of the anatomy, the ability to articulate the wrist intra-orally (not possible with standard instruments), tremor reduction, better ambidexterity and more precise dissection and tissue manipulation, compared to conventional open techniques

Controlled cohort study

The robot was used to dissection and repair the palatine muscles in 10 patients with a cleft of the palate (N = 10, 30 controls)

Increased dexterity and operative view using the robot

Clinical studies Nadjmi (79)

Reference

2015

Year

Study design Operations performed

Overall operative time was longer using the robot compared to the control group in which the traditional method was used

Outcomes reported

Microvascular surgery Dombre et al. (80)

2003

Live animal Skin graft (N not Robotically harvested skin samples model were of the same quality as manureported) ally harvested ones

Robots for Surgery

33

Taghizadeh et al. 2014 (81)

Human cadaver

“Necklift” Successful necklift procedures, platysmaplasty— with certain areas for improvement a short incision in surgical methodology suggested facelift with when using robotic systems (hard concomitant to interpret) robot-assisted neck lift (N = 6)

Shi et al. (82)

2017

Live animal Mandibular bone The robotically assisted drilling model drilling ostedemonstrated more accurate drill otomy (N = 1) positioning, increased stability and accuracy, and relieved surgeon fatigue so as to reduce facial trauma

2016

Case-report

Clinical studies Ciudad et al. (83)

Tight gastroepi- Successful flap harvest, but no ploic lymph node postoperative surgical outcomes flap (RGE-LNF) reported for the treatment of lymphedema of the extremities (N = 1) Microvascular procedures performed with standard technique

The number of procedures carried out in each study is documented and represented as N number.

2.3 CASE STUDY: OPEN ESOPHAGECTOMY FOR ESOPHAGEAL CANCER: ROBOT-ASSISTED VS. VIDEO-ASSISTED Mederos and team (2021) scrutinized the clinical outcomes in literature for robot-assisted minimally invasive esophagectomy (RAMIE) vs. video-assisted minimally invasive esophagectomy (VAMIE) and open

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Biorobotics in Medicine

esophagectomy (OE). Esophageal cancer treatment often entails esophagectomy; the researchers probed for articles on robotic surgery or esophagectomy or cancer between January 1, 2013, and May 6, 2020, to narrow down on 21 studies with 9355 patients. The results of these analyses are documented in figure 2.3 below (Mederos MA, de Virgilio MJ, Shenoy R, et al, 2021: This is an open access article distributed under the terms of the CC-BY license, which permits unrestricted use, distribution, and reproduction in any medium. You are not required to obtain permission to reuse this article content, provided that you credit the author and journal):

Robots for Surgery

35

36

Biorobotics in Medicine

While a modest lowering in pulmonary complications was demonstrated with RAMIE as opposed to VAMIE, there were no variations between the two approaches for estimated blood loss (EBL), the number of lymph nodes (LN) harvested, anastomotic leak, recurrent laryngeal nerve (RLN) palsy, total complications, hospital length of stay (LOS) and the 90-day mortality. When examined against OE, the operative time and lymph node harvest were more for RAMIE while the EBL, pulmonary and overall complications were lower in RAMIE. Overall, the authors concluded that RAMIE and VAMIE are on similar lines with RAMIE however documenting lesser pulmonary complications as opposed to VAMIE and OE necessitates more detailed analyses. Table 2.6 below summarizes the findings (Mederos MA, de Virgilio MJ, Shenoy R, et al, 2021: This is an open access article distributed under the terms of the CC-BY license, which permits unrestricted use, distribution, and reproduction in any medium. You are not required to obtain permission to reuse this article content, provided that you credit the author and journal):

Robots for Surgery Outcome

Study limitations

Consistency

37

Directness Precision Certainty of evidence

Intraoperative outcomes Operating room time Greater for RAMIE than VAMIE Greater for RAMIE than OE

•

RCT: low; • Inconsistent Direct matched observational studies: moderate; Consistent Direct unmatched observational studies: high

Imprecise Low

Precise

High

Lymph node harvest Greater for RAMIE than VAMIE

RCT: low; matched observational studies: moderate; unmatched observational Greater for RA- studies: high MIE than OE

Inconsistent

Direct

Imprecise Low

Consistent

Direct

Imprecise Moderate

Consistent

Direct

Imprecise Moderate

Inconsistent

Direct

Precise

High

Consistent

Direct

Precise

High

Consistent

Direct

Imprecise Moderate

Inconsistent

Direct

Precise

Low

Consistent

Direct

Precise

Moderate

Estimated blood loss Less for RAMIE than VAMIE Less for than RAMIE than OE

RCT: low; matched observational studies: moderate; unmatched observational studies: high

Short-term postoperative outcomes Anastomotic leak RAMIE equiva- RCT: low; matched obserlent to VAMIE vational studies: moderate; RAMIE equiva- unmatched observational studies: high lent to OE Recurrent laryngeal nerve injury RAMIE equiva- RCT: low; matched oblent to VAMIE servational studies: low; RAMIE equiva- unmatched observational studies: moderate lent to OE Pulmonary complications

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Biorobotics in Medicine

Fewer for RAMIE than VAMIE

RCT: low; matched observational studies: moderate; unmatched observational Fewer for RA- studies: high MIE than OE

Inconsistent

Direct

Precise

Moderate

Consistent

Direct

Impreci- Moderate sion

Direct

Imprecise Moderate

Direct

Imprecise Very low

Consistent

Direct

Imprecise Moderate

Consistent

Direct

Imprecise Moderate

Consistent

Direct

Imprecise High

Inconsistent

Direct

Imprecise Very low

Inconsistent

Direct

Imprecise Very low

Inconsistent

Direct

Imprecise Very low

Inconsistent

Direct

Imprecise Very low

Consistent

Direct

Imprecise Very low

Length of stay RAMIE equiva- Matched observational stud- Inconsistent lent to VAMIE ies: moderate; unmatched observational studies: high Inconsistent Less for RAMIE than OE Total complications Greater for RAMIE than VAMIE

RCT: low; matched observational studies: moderate; unmatched observational Fewer for RA- studies: high MIE than OE Mortality RAMIE equiva- RCT: low; matched obserlent to VAMIE vational studies: moderate; RAMIE equiva- unmatched observational studies: high lent to OE Long-term and oncologic outcomes Recurrence Less for RAMIE than VAMIE

RCT: low; matched observational studies: moderate; unmatched observational RAMIE equiva- studies: high lent to OE Cancer-free survival Greater for RAMIE than VAMIE

RCT: low; matched observational studies: high; unmatched observational RAMIE equiva- studies: high lent to OE

Abbreviations: OE, open esophagectomy; RAMIE, robot-assisted minimally invasive esophagectomy; RCT, randomized clinical trial; VAMIE, video-assisted minimally invasive esophagectomy.

2.4 CASE STUDY: ROBOTS FOR TOTAL MESORECTAL EXCISION (TME): A 2021-published report by Zeng, Wang, Li, Lin, Zhu and Yi in Frontiers in Surgery probed the suitability of Micro Hand S surgical robot (independently

Robots for Surgery

39

developed system produced by Shandong Wego Surgical Robot Co., LTD) and the da Vinci surgical robot (produced by Intuitive Surgical Co., LTD) (ClinicalTrials.gov: NCT02752698). Figure 2.4 below illustrates the robotic system, the incision points and the surgery (© 2021 Zeng, Wang, Li, Lin, Zhu and Yi. This is an openaccess article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms):

(A) The patient’s console (B) The doctor’s console

Incision sites:

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Biorobotics in Medicine

Operating scenario:

Of 54 patients, enrolled, 15 patients were operated by the Micro Hand S system and 39 patients by the da Vinci system. No perioperative death or anastomotic leak was observed and both systems documented no difference for hospital stay, time or blood loss. The time taken differed between the systems: 24.2 ± 9.4 min for the Micro Hand S robot and 17.1 ± 5.1 min for the da Vinci system with the total surgery and hospital costs lower for the Micro Hand S group. These findings of the use of robotic surgery are documented in table 2.7 below (© 2021 Zeng, Wang, Li, Lin, Zhu and Yi. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms): p

Micro Hand S

da Vinci

(n = 14)

(n = 14)

Total operation time (min)

260.6 (45.4)

256 (42.9)

0.783

Robotic installation time (min)

24.2 (9.4)

17.1 (5.1)

0.021*

Robotic operation time (min)

143.29 (36.0)

137.9 (27.4)

0.662

Blood loss (ml)

123.6 (60.2)

127.1 (105.5)

0.913

Anastomotic leak, n (%)

0/14 (0)

0/14 (0)

1.000

Perioperative death, n (%)

0/14 (0)

0/14 (0)

1.000

Hospital stay (d)

13.2 (6.3)

12.6 (4.2)

0.753

Time to first liquid diet (d)

2.4 (0.5)

2.4 (0.6)

0.746

Time of getting out of bed (d)

2.1 (0.3)

2.2 (0.4)

0.297

Total hospital costs (yuan)

87,040.1 (24,676.9) 125,292.3 (17,706.7) 0.000**

Surgery costs (yuan)

25,772.3 (4,117.0)

46,940.9 (10,199.7)

0.000**

Robots for Surgery

41

Values are presented as mean (SD). *

P < 0.05, P < 0.001.

**

Micro Hand S (n = 14)

da Vinci (n = 14)

p

Number of lymph nodes harvested (n)

15.8 (3.0)

15.5 (3.6)

0.776

Distance to PRM (cm)

8.2 (3.1)

9.5 (4.2)

0.919

Distance to DRM (cm)

2.3 (1.1)

2.3 (1.1)

0.374

Positive rate of CRM, n (%)

0/14 (0)

0/14 (0)

1.000

Macroscopical mesorectum integrity, n (%)

1.000

Complete

14 (100)

13 (92.9)

Nearly complete

0 (0)

1 (7.1)

Incomplete

0 (0)

0 (0)

Values are presented as mean (SD) or number with percentage. PRM, proximal resection margin; DRM, distal resection margin; CRM, circumferential resection margin.

2.5 FINAL POINTS Robotics in surgery has evinced augmented interest as evidenced by “an exponential increase” (from 168 in the year 2000 to more than 2000 in 2014) in publications according to a research article that probed PubMed for “robot” and “surgery”. This boost in research linked to robotic surgeries is depicted in figure 2.5 below (© 2017 Dobbs, Cundy, Samarendra, Khan and Whitaker. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms):

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Biorobotics in Medicine

What started off as Arthrobot that assisted patient positioning in an orthopedic surgery and orientation of a biopsy needle by Unimation Puma 200 has led now to the ZEUS robotic system that performed a long-distance cholecystectomy on a patient in France and the surgeon in New York as well as the Da Vinci robotic system that has been employed extensively (Zemmar, Lozano and Nelson, 2020). Further studies are ongoing to augment the accuracy during surgeries. “Here I come Cryogenic heart, skin a polished silver One thing I am glad of For this I thank my builder I can never rust” -LOUIS SHALAKO

Robots for Surgery

43

2.6 REFERENCES 1.

2.

3.

4.

5.

6.

7.

Ryan A. Beasley, “Medical Robots: Current Systems and Research Directions”, Journal of Robotics, vol. 2012, Article ID 401613, 14 pages, 2012. https://doi.org/10.1155/2012/401613 Tirth Ginoya, Yaser Maddahi, Kourosh Zareinia, “A Historical Review of Medical Robotic Platforms”, Journal of Robotics, vol. 2021, Article ID 6640031, 13 pages, 2021. https://doi.org/10.1155/2021/6640031 Sheetz KH, Claflin J, Dimick JB. Trends in the Adoption of Robotic Surgery for Common Surgical Procedures. JAMA Netw Open. 2020;3(1):e1918911. doi:10.1001/jamanetworkopen.2019.18911 Dobbs TD, Cundy O, Samarendra H, Khan K and Whitaker IS (2017) A Systematic Review of the Role of Robotics in Plastic and Reconstructive Surgery—From Inception to the Future. Front. Surg. 4:66. doi: 10.3389/fsurg.2017.00066 Mederos MA, de Virgilio MJ, Shenoy R, et al. Comparison of Clinical Outcomes of Robot-Assisted, Video-Assisted, and Open Esophagectomy for Esophageal Cancer: A Systematic Review and Meta-analysis. JAMA Netw Open. 2021;4(11):e2129228. doi:10.1001/ jamanetworkopen.2021.29228 Zeng Y, Wang G, Li Z, Lin H, Zhu S and Yi B (2021) The Micro Hand S vs. da Vinci Surgical Robot-Assisted Surgery on Total Mesorectal Excision: Short-Term Outcomes Using Propensity Score Matching Analysis. Front. Surg. 8:656270. doi: 10.3389/fsurg.2021.656270 Zemmar, A., Lozano, A.M. & Nelson, B.J. The rise of robots in surgical environments during COVID-19. Nat Mach Intell 2, 566–572 (2020). https://doi.org/10.1038/s42256-020-00238-2

CHAPTER

3

Robots for Surgery Continued

“The Three Laws of Robotics: 1: A robot may not injure a human being or, through inaction, allow a human being to come to harm; 2: A robot must obey the orders given it by human beings except where such orders would conflict with the First Law; 3: A robot must protect its own existence as long as such protection does not conflict with the First or Second Law; The Zeroth Law: A robot may not harm humanity, or, by inaction, allow humanity to come to harm.” ― Isaac Asimov, I, Robot

Contents 3.1 Robotic Systems.................................................................................. 46 3.2 Feasibility of Robotic Surgery for Colorectal Cancer (CRC).................. 54 3.3 Maxillofacial Surgery: What is the Status?........................................... 60 3.4 Robots for Pediatric Surgery: Few Studies:........................................... 62 3.5 Hernia Repairs: A Comparison............................................................ 68 3.6 The Hope for Cerebral Palsy (CP)........................................................ 70 3.7 Final Points......................................................................................... 72 3.8 References.......................................................................................... 75

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Biorobotics in Medicine

3.1 ROBOTIC SYSTEMS A major roadblock in employing the gold standard laparoscopy notwithstanding its extensive use and advantages is the “fulcrum effect” i.e movement of the tip in a direction opposite to that of the operating surgeon. Another challenge is the adjustment of the 3D knowledge of anatomy necessitated by the surgeon into the 2D video feed presented by the system. Figure 3.1 below documents the fulcrum effect of laparoscopy (Gangemi A, Chang B, Bernante P, Poggioli G, 2021: © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license: https://creativecommons.org/licenses/by/4.0/):

This has facilitated the entry of a slew of robotic-assisted surgery (RAS) approaches being explored for various arenas of medicine as depicted below in figure 3.2 (Kawashima, Kanno, and Tadano, 2019: Open Access: This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated):

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47

The first generation was inclusive of the voice-controlled Automated Endoscopic System for Optimal Positioning (AESOP) that circumvented an extra surgical assistant. Notwithstanding its extensive usage in urology and cardiology, a challenge was its inability to fit the operations of the surgeon. This led to the second-generation system like Zeus that possessed two additional manipulators facilitating the holding of the operating instruments along with an AESOP robotic scope. Subsequently, the da Vinci surgical system (third-generation) encompassed a patient’s cart with a surgeon’s console and a high-definition 3-dimensional visualization system that transmitted true-to-life stereoscopic images of the actual anatomy (Liu, Li, Shi et al, 2017). Figure 3.3 below illustrates a scheme of the setup in robotic surgery (Liu, HH, Li, LJ, Shi, B. et al, 2017: This work is licensed under a Creative Commons Attribution 4.0 International License. The images or other third party material in this article are included in the article’s Creative Commons license, unless indicated otherwise in the credit line; if the material is not included under the Creative Commons license, users will need to obtain permission from the license holder to reproduce the material. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/):

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Biorobotics in Medicine

As an example, traditional laparoscopic approaches entail the surgeon operating the system in a standing position. In RAS, there is an option of a seated console also. Figure 3.4 below illustrates surgeon consoles in RAS: (A) da Vinci, (B) MiroSurge, (C) Revo-I (D) Senhence, (E) Versius seated and (F) standing (Longmore SK, Naik G, Gargiulo, 2020: © 2020 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license: http://creativecommons.org/licenses/by/4.0/):

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Laparoscopy entails two types of robots: master-slave type and handheld forceps. There are 6-degrees-of-freedom (DOF) of motion in the master-slave surgical robot with a 2-DOF at the tip of the wrist joint and a 4-DOF arm. The master console facilitates the operation of the remote slave arms with the wrist tip to allow intuitive surgeries on the lines of the 6-DOF of the operating surgeon. An example of such a system is illustrated in figure 3.5 below. The system being worked upon by Riverfield Inc. entails a pneumatic drive on the slave-side to circumvent the cleaning and sterilization of electric sensors (Kawashima, Kanno, and Tadano, 2019: Open Access: This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/ by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated):

Examples of such systems that have received FDA approval are the da Vinci surgical system (patent expired) and Zeus. Challenges are being worked on developing systems with haptics (Greek for “to touch”) and lower costs. Table 3.1 below documents a few master-slave surgical robots (Kawashima, Kanno, and Tadano, 2019: Open Access: This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http:// creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative

50

Biorobotics in Medicine

Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/ publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated): Company

Target Disease Mechanism and Drive

Configuration

Status

Intuitive Surgical da MIS Multi-port Vinci Xi (USA)

Link + Electri- Master console and FDA approved cal motor slave patient cart Clinical use with four arms worldwide

TransEnterix Senhanse (USA)

Link + Electri- Master console FDA approved cal motor and separated slave robot arms

MIS Multi-port

CMR surgical Veri- MIS Multi-port sus (UK)

Link + Electri- Master console and Under developcal motor separated slave hu- ment man like robot arms

Meere Revo-I (Korea)

MIS Multi-port

Link + Electri- Master console and Clinical use in cal motor slave patient cart Korea with four arms

RiverField (Japan)

MIS Multi-port

Flexible joint + Master console and Under developPneumatic slave patient cart ment with arms

Intuitive Surgical da MIS Single-port Flexible joint + Master console and FDA approved Vinci Sp (USA) Electrical motor slave patient cart with single arm Titan Medical SPORT (Canada)

MIS Single-port Flexible joint + Master console and Under developElectrical motor slave patient cart ment with single arm

EndoMaster (Singa- NOTES Tranpore) soral surgery

Flexible joint + Master console and Clinical trial Electrical motor slave patient cart with single arm

Auris, Monarch Platform (USA)

Flexible joint + Master console and Clinical trial Electrical motor slave patient cart with single arm

NOTES Lung cancer

Hand-held robotic forceps are controlled with an interface on the forcep wrist joint at its tip and function on the same lines as that of traditional forceps. These systems are smaller than the master-slave robot due to the absence of a master console. An integrated robot has been developed with pneumatic actuators for 2-DOF robotic forceps supported by a 4-DOF passive holder. This system is depicted in figure 3.6 below (Kawashima, Kanno, and Tadano, 2019: Open Access: This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http:// creativecommons.org/licenses/by/4.0/), which permits unrestricted use,

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51

distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/ publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated):

Looking at the patient arms and carts, there is a single integrated cart with all instrument arms (SPRINT, da Vinci and Avatera systems, to name a few) and individual carts for each instrument arm (Versius, MiroSurge and Hugo systems, to name a few). These carts are summarized in table 3.2 below (Longmore SK, Naik G, Gargiulo, 2020: © 2020 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license: http://creativecommons.org/licenses/by/4.0/): Key: Single = all arms attached to a single cart; Individual = each arm with a cart; N/A = information not available at time of writing; DOF = degrees of freedom; A = arms are mounted to the surgical table; B = one arm in each robot is used for the endoscope; E = under trocar column refers to the port size for the endoscope, where as other trocar sizes are for the instruments; S under trocar column refers to single port systems where the instruments and endoscope are inserted through the same trocar

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Biorobotics in Medicine

Robot

No. Arms

Instrument Arms B

DOF

Trocar

Cart Type

References

Avatera

4

3

6

5 mm

Single

[15,25,26]

da Vinci (except SP)

4

3

7

8 mm

Single

[16,18,49]

da Vinci SP

1

2

7

S 25 mm

Single

[20]

Hugo

4

3

N/A

N/A

Individual

[38]

MiroSurge

3

2

7

N/A

Individual A [29,63,82,101]

Revo-I

4

3

7

12 mm

Single

[17,21,22,23,24]

Senhence

4

3

7

I 5 mm E 10 mm

Individual

[8,11,12,13,14,37]

SPORT Surgical System

1

2

N/A

S 25 mm

Single

[42,44,45]

SPRINT

1

2

6

S 30 mm

Single

[40,41]

Versius

5

4

7

5 mm

Individual

[6,12,22,37,39,43]

Few carts have been depicted in figure 3.7 below: (A) da Vinci Xi B) da Vinci SP (C) Senhence (D) MiroSurge (E) Versius and (F) Revo-I (Longmore SK, Naik G, Gargiulo, 2020: © 2020 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license: http://creativecommons.org/licenses/by/4.0/):

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53

A handle (serving as the surgeon’s interface of the device), a shaft and a tip all constitute traditional laparoscopic instruments. As outlined above, a fulcrum effect is created with the DOF lowered due to the insertion of the instrument into a patient via a trocar. Wrist-like robotic instruments can form a curved arc upon deflection and the others with the jaws within the wrist. Figure 3.8 below illustrates TOP: (A) Conventional laparoscopic instrument; (B) DOF of 5 in this instrument; (C) 6th degree of freedom derived from a curved instrument: F = fulcrum effect of trocars (Parente G, Thomas E, Cravano S, Di Mitri M, Vastano M, Gargano T, Cerasoli T, Ruspi F, Libri M, Lima M, 2021: © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license: https://creativecommons.org/licenses/by/4.0/):

BOTTOM: Robotic devices: A) Radius Surgical System® (Tuebingen Scientific), (B) FlexDex® (FlexDex Surgical Inc.), (C) LaproFlex® (DEAM), (D) Intuitool® (UneMed), (E) ArtiSential® (LIVSMED) (Parente G, Thomas E, Cravano S, Di Mitri M, Vastano M, Gargano T, Cerasoli T, Ruspi F, Libri M, Lima M, 2021: © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license: https://creativecommons.org/licenses/by/4.0/):

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3.2 FEASIBILITY OF ROBOTIC SURGERY FOR COLORECTAL CANCER (CRC) Researchers Peng, Li, Tang, Li, Li, Wu, Lu, Lin and Pan reported retrospective analyses of the treatment, complications and survival of 109 CRC patients (diagnosed as per the 8th edition American Joint Committee on Cancer (AJCC) staging) who underwent robotic surgery between June 2016 and May 2019 at Sun Yat-sen University Cancer Center (Guangzhou, China).

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55

Figure 3.9 below illustrates TOP: the total mesorectal excision (TME) surgeries conducted by five surgeons employing the da Vinci Surgical System (Intuitive Surgical Inc., Sunnyvale, CA, USA) (A) Operation room setup (B) Inferior mesenteric nerve (in white arrow) preservation (C) Hypogastric nerves (in black arrow) preservation (D) Pelvic plexus preservation (in blue arrow) (© 2021 Peng, Li, Tang, Li, Li, Wu, Lu, Lin and Pan. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms):

BOTTOM: Patient details (© 2021 Peng, Li, Tang, Li, Li, Wu, Lu, Lin and Pan. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms):

Biorobotics in Medicine

56

Variables

Total (n = 109) Sigmoid cancer Rectal cancer (n (n = 35) = 74)

Age [median (range), years] 59 (31–82)

60 (34–82)

57 (31–73)

Age > 65 years (n,%)

30 (27.5)

10 (28.6)

20 (27.0)

Male gender (n,%)

75 (68.8)

25 (71.4)

50 (67.6)

BMI (mean ± SD, kg/m2)

22.8 ± 3.0

22.7 ± 2.8

22.9 ± 3.2

15

35 (32.1)

35 (100)

0

11–15

13 (11.9)

0

13 (17.6)

Robots for Surgery Continued 6–10

35 (32.1)

0

35 (47.3)

≤5

26 (23.9)

0

26 (35.1)

I

17 (15.6)

4 (11.4)

13 (17.6)

II

43 (39.4)

15 (42.9)

28 (37.8)

III

45 (41.3)

15 (42.9)

30 (40.5)

IV

4 (3.7)

1 (2.9)

3 (4.1)

Neoadjuvant CRT (n,%)

37 (33.9)

0

37 (50.0)

Neoadjuvant chemotherapy (n,%)

4 (3.7)

0

4 (5.4)

57

Preoperative TNM stage (n,%)

BMI, body mass index; ASA, American Society of anesthesiologists; SD, standard deviation; DAV, inferior tumor margin from the anal verge; TNM stage, tumor-node-metastasis classification; CRT, chemoradiotherapy. Looking at the outcomes, there was no intraoperative ureteral injury or conversion to open or laparoscopic procedure. Post-operative mortality was not documented for 30 days and complications were seen in 10.1% with recovery in all following relevant intervention. These details post-robotic surgery are documented in table 3.3 below (© 2021 Peng, Li, Tang, Li, Li, Wu, Lu, Lin and Pan. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms):

Male

Female

Female

Male

Male

Male

Male

Male

Female

3

4

5

6

7

8

9

10

11

59

49

68

50

43

69

37

54

47

59

Rectum 6

Rectum 10

Sigmoid 28 colon

Rectum 1

Rectum 3

Rectum 5

Sigmoid 25 colon

Rectum 7

Rectum 6

Rectum 10

Yes

No

No

Yes

Yes

Yes

No

No

Yes

No

T3N0M1

T3N1M0

T3N2M0

T4N0M0

pCR

T3N0M0

T3N0M0

T3N0M0

pCR

T3N1M0

LAR

LAR

Sigmoidectomy

APR

APR

LAR

HAR

LAR

LAR

LAR

Male

T2N0M0

2

Yes

LAR

Rectum 4

Female

1

37

Types of operation

Order Gender Age Tumor DAV NA- Pathological (years) location (cm) CRT stage

Complication detected on POD (days)

3

6

3

3

5

5

Anastomotic 5 leakage

Anastomotic 6 leakage

Anastomotic 1 bleeding

Delay wound 8 healing

Intestinal obstruction

Chylous leakage

Chylous leakage

Intestinal obstruction

Intestinal obstruction

Pelvic hemorrhage

Anastomotic 2 leakage, Intestinal obstruction

Complication

Invention LOS after suroutcome gery (day)

Recovery 24

Operation

Recovery 11

Conservative treat- Recovery 24 ment

Conservative treat- Recovery 10 ment

Conservative treat- Recovery 30 ment

Operation

Conservative treat- Recovery 9 ment

Conservative treat- Recovery 10 ment

Conservative treat- Recovery 12 ment

Conservative treat- Recovery 12 ment

Conservative treat- Recovery 14 ment

Conservative treat- Recovery 12 ment

Invention

Alive with tumor

Alive (NED)

Alive (NED)

Alive (NED)

Alive (NED)

Alive (NED)

Alive (NED)

Alive (NED)

Alive (NED)

Alive (NED)

Alive (NED)

Survial status

58 Biorobotics in Medicine

Robots for Surgery Continued Variables

Total (n = 109 ,%)

Sigmoidectomy + HAR (n = 48,%)

LAR (n = 45,%)

APR (n = 16,%)

LOS after surgery [median (range), days]

7 (4–30)

7 (4–12)

7 (4–24)

8 (6–30)

30 day mortality

0

0

0

0

Postoperative complication

11 (10.1)

2 (4.2)

7 (15.6)

2 (12.5)

Anastomotic leakage

3 (2.8)

0

3 (6.7)

0

Anastomotic bleeding

1 (0.9)

1 (2.1)

0

0

Pelvic hemorrhage

1 (0.9)

0

1 (2.2)

0

Intestinal obstruction

4 (3.7)

0

3 (6.7)

1 (6.3)

Chylous leakage

2 (1.8)

1 (2.1)

1 (2.2)

0

Delay wound healing

1 (0.9)

0

0

1 (6.3)

Defecated dysfunction

38 (34.9)

9 (18.8)

29 (64.4)

0

Urinary dysfunction

5 (4.6)

0

1 (2.2)

4 (25.0)

Sexual dysfunction

8 (7.3)

0

4 (8.9)

4 (25.0)

Alive (NED)

102 (93.6)

45 (93.8)

41 (91.1)

16 (100)

Alive with tumor

6 (5.5)

2 (4.2)

4 (8.9)

0

Death due to tumor

1 (0.9)

1 (2.1)

0

0

Local recurrence

1 (0.9)

1 (2.1)

0

0

Distant metastasis

5 (4.6)

2 (4.2)

3 (6.7)

0

59

HAR, high anterior resection; LAR, low anterior resection; APR, abdominoperineal resection; LOS, length of stay; NED, no evidence of disease. 93.6% of the patients were alive over the median follow-up of 17 months (1–37 months) with overall survival of 97.2% and disease-free survival (DFS) of 92.9% in non-metastatic patients (n = 104). Overall, the researchers presented the “remarkable surgical advantages of robotic surgery” in CRC given the increased magnification within mesorectal edema for resection facilitating more efficient surgeries. The survival data are depicted in figure 3.10 below (A) Net 2-year overall survival (B) 2-year disease-free survival in non-metastatic patients. (C) 2-year disease-free survival as per the pathologic stage (© 2021 Peng, Li, Tang, Li, Li, Wu, Lu, Lin and Pan. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No

60

Biorobotics in Medicine

use, distribution or reproduction is permitted which does not comply with these terms):

3.3 MAXILLOFACIAL SURGERY: WHAT IS THE STATUS? A quest is on to facilitate minimally invasive surgery (MIS) in maxillofacial surgery given the impact of transmandibular or a transpharyngeal incisions in conventional approaches for this part of the body such as impaired speech and disfigurement. Early work in 2005 first reported vallecular cyst excision employing transoral robotic surgery (TORS) in maxillofacial surgery by McLeod and Melder to later receive FDA approval for oropharyngeal cancer (T1 and T2 stages). Given the promise of lowered tremor, precise movements and lower cosmetic disfigurement, robotic assistance is being probed for maxillofacial surgery. Table 3.4 below documents the status and potential of robotic surgery for head and neck malignancies as documented by Liu HH., Li LJ and Shi B. et al, Int J Oral Sci, 2017(This work is licensed under a Creative Commons Attribution 4.0 International License. The images or other third party material in this article are included in the article’s Creative Commons license, unless indicated otherwise in the credit line; if the material is not

Robots for Surgery Continued

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included under the Creative Commons license, users will need to obtain permission from the license holder to reproduce the material. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/): Patients

Advantages

Limitations

Future

Head and neck neoplasms resection Upper aerodigestive tract tumor 16–65

In common: decreased damage to surrounding tissues; superior function recovery, better oncologic control and lower morbidity than conventional open surgery as well as radiochemical therapy; excellent aesthetics

In common: long surgical duration; lack of specific instruments (sharp instrumentation); lack of haptic feedback, and expensive

In common: realization of haptic feedback; bimanual operation and improvement of sharp instruments

Parapharyngeal spcae tumor 36, 61, 73–75 Thyroid gland tumor and mediastinal parathyroid77–89

Upper aerodigestive tract tumor: high effectiveness in detection of unknown primary tumors

Thyroidectomy: long hospitalization and considerable duration of drainage

Thyroidectomy: modified surgical approach to reduce the extent of the flap

Salivary glands tumor 90–95 Neck dissection 96–106

Thyroidectomy: easy to ligate the tract after carefully tracing it

Flap reconstruction: combination of robotic surgery and virtual surgical planning

Post-ablative defect Neck dissection: low reconstruction 17, 40, risk of lymph-edema and 60, 62, 107–109 lymph node recurrence Flap reconstruction: high survival rate

Table 3.5 below documents the status and potential of robotic surgery for other surgeries of the head and neck as documented by Liu HH., Li LJ and Shi B. et al, Int J Oral Sci, 2017(This work is licensed under a Creative Commons Attribution 4.0 International License. The images or other third party material in this article are included in the article’s Creative Commons license, unless indicated otherwise in the credit line; if the material is not included under the Creative Commons license, users will need to obtain permission from the license holder to reproduce the material. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/):

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Biorobotics in Medicine

Patients

Advantages

Limitations

Future

Lip and palate cleft 110–111

Low damage to the vascularization and related innervation of surrounding muscles, quick function recovery

Long surgical duration

More high-quality clinical investigation

Maxillofacial fracture

Insufficient data

Insufficient data Specific design of related robotic surgical system

Craniofacial asymmetry 114–115

Insufficient data

Insufficient data Transition from theoretical feasibility to clinical application

OSAS: obstructive sleep apnea syndrome 117–128

Low intropetative bleeding and tracheotomy, decreased postoperative pain, hospital stay as well as incidence of dysphagia

Unstable cure rate varies from 45% to 90%, significant postoperative lingual oedema and transient hypogeusia

Combination of robotic resection of BOT and conventional surgery like uvulopalatopharyngoplasty or sphincter pharyngoplasty

In common; minimal damage to surrounding normal tissues as well as speech and swallow function; excellent aesthetics

Laryngeal lefts: unsatisfactory cure rate

Laryngeal lefts: application of specific miniaturized instruments to obtain enough surgical space

Others Laryngeal clefts 129

Laryngocele 130 Laryngocele: short operative time Ectopic lingual thyroid 131–133

Ectopic lingual thyroid: short operative time and low recurrence

Ptyalolithiasis 134–135

Ptyalolithiasis: high cure rate and low lingual nerve damage rate

3.4 ROBOTS FOR PEDIATRIC SURGERY: FEW STUDIES: 0Preliminary usage of ArtiSential®, an articulated device produced by Livsmed in two case studies at Pediatric Surgery Department, IRCCS Sant’Orsola-Malpighi University Hospital and Minimally Invasive and Robotic Pediatric Surgery Center (MISCBO), Alma Mater Studiorum— University of Bologna, Italy was documented in the Children journal by Parente and team (2021). The first was thoracoscopic thymectomy on a 14-year-old boy with Myasthenia Gravis. The authors reported minimal

Robots for Surgery Continued

63

bleeding and no complications in the use of ArtiSential® that was employed to address the limited space of the hemithorax. The second example was hepatic lymphangioma debulking in a 9-year-old boy aimed at augmented maneuvering in the confined space of the liver employing the robotic system. Figure 3.11 below illustrates the use of a robotic system in pediatric surgery for thoracoscopic thymectomy (A to C documenting the augmented DOFs in the limited space) and hepatic lymphangioma debulking (D-E with indocyanine green) (Parente G, Thomas E, Cravano S, Di Mitri M, Vastano M, Gargano T, Cerasoli T, Ruspi F, Libri M, Lima M, 2021: © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license: https://creativecommons.org/licenses/by/4.0/):

Looking at urology, Sheth and Koh (2019) have documented robotic platforms for potential usage in pediatric patients (Copyright © 2019 Sheth and Koh. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms):

64

Biorobotics in Medicine

Company

Location

Robotic system Approach

Intuitive surgical

Sunnyvale, CA

Da Vinci Surgical Laparoscopic System LESS

TransEnterix

Morrisville, NC

SenhanceTM

Laparoscopy

Medrobotics Corp

Raynham, MA

Flex ®

Transoral

Cambridge Medical Robotics Ltd.

Cambridge, UK

Versius

Titan Medical Inc.

Toronto, ON

TransEnterix

Morrisville, NC

Status

Camera

Robotic segments

DOF

Haptic Additional features feedback

Commercially available

2 HD-3D

4

7

None

Tremor filtration

FDA anticipated

HD-3D (eye-tracking) 3

7

Present

Navigation, eye-tracking camera control system, individual robotic carts

Commercially available

HD-2D (semirigid or flexible)

2

180◦

None

Core flexible, steerable scope that becomes rigid once positioned

Laparoscopic

FDA validation

HD-3D

Up to 5 (modular)

7

Present

Force and position measurements > 1000x/second, up to 5 arms, lightweight

SPORTTM

LESS

FDA pending

HD-3D

1

Multiple None

Singe incisions, multi-articulated instruments, single arm mobile cart

SurgiBotTM

LESS

FDA denied, marketing in China

HD-3D

2

6

Internal triangulation

None

4

German Aeurospace Center (DLR)

Oberpfaffenhogen-Weßling Mirosurge

Laparoscopy

Commercially available (not US)

HD-3D

3–5

7

Present

Easy adaptation of MIRO arms

Medtronic

Minneapolis, MN

Hugo

Laparoscopic

Development

–

–

–

–

Flexible use—mass utilization to decrease cost

Nanyang Technological University

Singapore

MASTER

NOTES

Clinical Trial

2D endoscope

2

9

Present

For NOTES allows smaller instruments with larger forces, reconstruction navigation

BIOTRONIK

Berlin, Germany

9

NOTES

Commercially available (not US)

N/A

1

None

Use in ureteroscopy and endovascular procedures

HominisTM

Laparoscopic LESS NOTES

Development

–

Humanoid 360◦ shaped arms

–

Humanoid shaped robotics arms

Virtual Incision and CAST Omaha, NA (Omaha, NA)

Miniature in vivo Advanced robot (MIVR)

Development

HD—flexible tip

2

6

None

Miniaturized unit artificial intelligence + machine learning

J&J/Alphabet

Verb Surgical

Advanced

Development

–

–

–

-

“Surgery 4.0”—digital surgery combining robotics with data-driven machine learning

Mountain View, CA

Morales-López, Pérez-Marchán and Pérez Brayfield (2019) reviewed the potential of robotic-assisted laparoscopic pyeloplasty (RALP): considered as the most ubiquitously reported robotic procedure in children as of now. While its acceptance and safety have been the plus points, the elevated costs and increased hospital stays warrant further fine-tuning. Table 3.6 below documents the literature on robotic-assisted laparoscopic pyeloplasty (Copyright © 2019 Morales-López, Pérez-Marchán and Pérez Brayfield. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms):

Robotic Surgery Evolution in Pediatric Urology

July 2019 | Volume 7 | Article 259

ViaCath

Memic Innovative Surgery Israel

Sheth and Koh

Frontiers in Pediatrics | www.frontiersin.org

TABLE 1 | Comparison of da Vinci surgical and new robotic systems.

Morales-López et al. Morales-López et al.

Pediatric Robotic Assisted Pyeloplasty

Pediatric Robotic Assisted Pyeloplasty Robots for Surgery Continued 65

TABLE 1 | Series of reported robotic-assisted laparoscopic pyeloplasty cases. TABLE 1 | Series of reported robotic-assisted laparoscopic pyeloplasty cases. Author Author

Procedure Procedure

Kutikov et al. (15) Kutikov et al. (15) Avery et al. (16) Avery et al. (16) Asensio et al. (17) Asensio et al. (17) Olsen et al. (18) Olsen et al. (18) Minnillo et al. (19) Minnillo et al. (19) Singh et al. (20) Singh et al. (20) Atug et al. (21) Atug et al. (21) Franco et al. (22) Franco et al. (22) Perez-Brayfield Perez-Brayfield

RALP RALP RALP RALP RALP RALP RALP RALP RALP RALP RALP RALP RALP RALP RALP RALP RALP RALP

# of pts # of pts

Mean age Mean age (yrs) (yrs)

Laterality Laterality UPJ UPJ

Approach Approach

9 9 60 60 5 5 65 65 155 155 34 34 7 7 15 15 41 41

0.47 0.47 0.61 0.61 10.59 10.59 7.9 7.9 10.5 10.5 12 12 13 13 11.9 11.9 10.2 10.2

n/a n/a Bilateral (2) Bilateral (2) n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a Right (14), Right (14), Left (27) Left (27)

Transperitoneal Transperitoneal Transperitoneal Transperitoneal Transperitoneal Transperitoneal Retroperitoneal Retroperitoneal n/a n/a n/a n/a Transperitoneal Transperitoneal Transperitoneal Transperitoneal Trans Trans

Mean op Mean op time (min) time (min)

Hospital Hospital stay (days) stay (days)

Complications Complications

Success Success rate (%) rate (%)

122.8 122.8 232 232 144 144 146 146 198.5 198.5 105 105 184 184 223 223 135 135

1.4 1.4 1 1 2.6 2.6 2 2 1.9 1.9 n/a n/a 1.2 1.2 n/a n/a 1.5 1.5

n/a n/a 7 7 n/a n/a 11 11 17 17 2 2 1 1 4 4 5 5

78 78 91 91 100 100 100 100 96 96 97 97 100 100 n/a n/a 95% 95%

Complications Complications

Success Success rate (%) rate (%)

TABLE 2 | Series of reported cases comparing open pyeloplasty, laparoscopic pyeloplasty, and robotic-assisted laparoscopic pyeloplasty. TABLE 2 | Series of reported cases comparing open pyeloplasty, laparoscopic pyeloplasty, and robotic-assisted laparoscopic pyeloplasty. Author Author

Procedure Procedure (OP, LAP, (OP, LAP, RALP) RALP)

Barbosa et al. (23) Barbosa et al. (23) Yee et al. (24) Yee et al. (24) Subotic et al. (25) Subotic et(26) al. (25) Lee et al. Lee et al. (26) Song et al. (27) Song et al. (27)

Cundy et al. (28) Cundy et al. (28)

Salö et al. (29) Salö et al. (29)

# of # of patients patients

Mean age Mean (yrs)age (yrs)

RALP RALP

58 58

7.2 7.2

OP OP RALP

154 154 8

1.2 1.2 11.5

RALP OP OP OP OP RALP

88 88

11.5 9.8 9.8 9.8

8 33 33 33

9.8 7.9 7.9 7.6

OP

33 30 30

7.6 8.5 8.5

LP LP

30 30

10.5 10.5

RALP OP OP OP

Laterality Laterality UPJ UPJ

Approach Approach

Bilateral Bilateral (10) (10) n/a

n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a (8), Right Right (8), Left (22) Left (22) Right (6), Right (6), Left (24) Left (24) Right (3),

Mean Mean operative operative time (min) time (min)

Hospital Hospital stay (days) stay (days)

Transperitoneal Transperitoneal

n/a n/a

n/a n/a

1

n/a n/a n/a

n/a n/a 363

n/a n/a 2.4

7

n/a n/a n/a n/a

363 248 248 248

2.4 3.3 3.3 3.3

n/a n/a n/a n/a

248 219 219 181

3.3 2.3 2.3 3.5

n/a Transperitoneal Transperitoneal

181 192.5 192.5

3.5 6.6 6.6

Transperitoneal Transperitoneal

197.4 197.4

5.8 5.8

RALP RALP

10 10

11 11

OP vs. OP vs. RALP RALP LP vs.

157,166 157,166

7, 8.1 7, 8.1

Right Left (7)(3), Left (7) n/a n/a

n/a n/a

97, 151 97, 151

6.5, 10 6.5, 10

n/a n/a

n/a n/a

Right (38), Left (54) Right (38), Left (54) Right (10), Left (21) Right (10), Left (21)

Retro (15), Trans Retro(16) (15), Trans (16)

RALP LP vs. RALP OP

OP

92 92

6.2 6.2

RALP RALP

31 31

8.3 8.3

Transperitoneal Transperitoneal

n/a n/a

1 17 01 00 10 01 40

254.1 254.1

3.2 3.2 RALP (shorter RALP HS)(shorter HS) RALP (shorter

diff. no significant diff. 167

HS)(shorter RALP HS) 4.4

167

4.4

249 249

3.4 3.4

67.9 67.9 100

100 87.5 87.5 87.5 87.5 94 10094 100 96.7

4

96.7

4

89.7 89.7

4

RALP (Longer RALP OT)(Longer OT) no significant

76.9 76.9

1

1

100 100

5, 9 5, 9

88.5, 87.3 88.5, 87.3

10, 10 10, 10

96.9, 99.3 96.9, 99.3

25 25

92 92

9

94 94

9

COSTS AND CONSIDERATIONS TheAND utility of pediatric COSTS CONSIDERATIONS

supplies being the largest contributor to the rising cost. For surgery with indocyanine greenvs.to(ICG)-guided supplies being comparing the largestlaparoscopic contributor the rising cost. For example, when robotic approaches example, when comparing vs.$3,000. robotic approaches there was an average increase laparoscopic in costs of over near-infrared fluorescence (NIRF) wasthere documented by Esposito and team was an average increase in costs of over $3,000. In another study, Varda et al. again demonstrated an increased In another study, Varda et al. again an increased utilization of the RALP in children (33).demonstrated They showed that within (2020) in Frontiers in pediatrics. The researchers probed the results of autilization 12-year period a persistent cost when of thethere RALPwas in children (33).higher They showed thatRALP within a 12-year period there waspyeloplasty. a persistent The higher cost when was compared with open increased costRALP in 76 various laparoscopic and/or roboticRALP procedures on persisted pediatric patients to was compared open pyeloplasty. increased cost in over open with pyeloplasty as The the cost of operating RALPequipment over openin pyeloplasty persisted as thehigh cost even of operating room for robotic cases remained when suggest the utility of this combined approach excising tumors, partial considering the costfor associated hospital stays related room equipment robotic with caseslonger remained high even when open Highassociated volumes with of RALP be required for considering the cost longermay hospital stays related nephrectomy, difficult cholecystectomytoinstitutions andsurgery. varicocele. to profit from the procedures as total investment Several studies have delved into the evaluation of costs of the Several studies have thestudies evaluation of costs of the treatment options fordelved UPJO.into Some have even suggested treatment forin UPJO. studies even suggested a 2.7 timeoptions increase cost Some in RALP as have compared to other amodalities 2.7 time ofincrease in cost in RALP to other UPJO (30). In 2017 Jacobsasetcompared al. (31) published modalities of UPJO In 2017 Jacobsshowing et al. (31) a cost analysis study(30). in adult patients fairlypublished similar acosts costfor analysis study in adult patients showing fairly similar open pyeloplasty ($22,421) as compared to minimally costs for pyeloplasty open pyeloplasty ($22,421) compared to minimally invasive ($22,843). Vardaasand colleagues evaluated invasive pyeloplasty ($22,843). Varda and colleagues the national trends of UPJO treatment modalities in evaluated children the national trends of of the UPJO treatment in children including analysis available datamodalities on cost (32). They reported evidence of including analysis ofofantheincreasing availabletrend data toward on costutilization (32). They minimallyevidence invasiveofpyeloplasty overtrend opentoward pyeloplasty. In the reported an increasing utilization of study, minimally invasive modalities an increased costInwith minimally invasive pyeloplasty overhad open pyeloplasty. the a significant increase in price related had to RALP. Operating study, minimally invasive modalities an increased costroom with were byincrease far the in greatest contributor to costs, with robotic acosts significant price related to RALP. Operating room costs were by far the greatest contributor to costs, with robotic

to open surgery. High volumes of RALP may be required for

cost is divided between increased number of procedures institutions to profit the procedures as total investment Figure 3.12 below illustrates the utility offromanrobotic surgery with performed. An estimated to five robotic cases week cost is divided between three an increased number of per procedures are necessaryAn to estimated profit fromthree robotic surgery, which a clear performed. to five robotic casesis per week indocyanine green (ICG)-guided near-infrared fluorescence (NIRF) for limitation for pediatric centers mattersurgery, their sizewhich (34). Reaching are necessary to profit fromno robotic is a clear limitation for pediatric centers no matter their size (34). Reaching augmented discernment and ease: TOP: robot-assisted removal of five ovarian tumors in 11-16-year-old patient: the time taken was 78 ± 12 min and no complications were documented A) tumor mass identified B) resection edges C) uterus vascularization post-resection (Copyright © 2020 Esposito, Settimi, Del Conte, Cerulo, Coppola, Farina, Crocetto, Ricciardi, Esposito and Escolino. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No Frontiers in Pediatrics | www.frontiersin.org

Frontiers in Pediatrics | www.frontiersin.org

4

4

January 2019 | Volume 7 | Article 4

January 2019 | Volume 7 | Article 4

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Biorobotics in Medicine

use, distribution or reproduction is permitted which does not comply with these terms):

BOTTOM: Varicocele repair in 8-18-year-olds by laparoscopic (n = 37) and robot-assisted (n = 3) left varicocelectomy with no adverse effects up to 24 months (Copyright © 2020 Esposito, Settimi, Del Conte, Cerulo, Coppola, Farina, Crocetto, Ricciardi, Esposito and Escolino. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms):

Navarrete Arellano and Garibay González (2019) presented the impact of robot-assisted laparoscopic and thoracoscopic surgery (RALTS) in pediatric surgery between March 2015 and March 2018 in a prospective, observational, and longitudinal study in Frontiers in Pediatrics. Of 186 RALTS approaches (41 different surgical techniques) on 147 pediatric patients, the safety

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and effectiveness for even complex surgeries like thoracic/ hepatobiliary procedures emerged with the authors documenting the promise of more robust robotic assistance programs. The details of the approaches entailed in this work are documented in table 3.7 below (Copyright © 2019 Navarrete Arellano and Garibay González. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms): Area

n (%)

Procedures

UROLOGICAL Pyeloplasty

19

Nephrectomy

18

Ureteral reimplantation

17

Mitrofanoff

6

Nephroureterectomy

6

Varicocelectomy

5

Release of extrinsic obstruction UP union

3

Inguinal hernia repair

3

Desderivation of ureterostomy and ureteral reimplantation

2

Cystolithotomy

2

Various*

10

Subtotal

91 (48.92)

Primary fundoplication

38

Redo fundoplication

13

Cholecystectomy

11

Gastrostomy

9

GI-HB

Biliodigestive

6

Operation of malone

2

Various

5

Subtotal

84 (45.16)

**

***

THORACIC

68

Biorobotics in Medicine Diaphragmatic plication

3

Lobectomy

2

Bronchogenic cyst excision

1

Subtotal

6 (3.23)

Oncological Mediastinal teratoma

1

Resection of carcinoid in stomach

1 (adult)

Left radical nephrectomy

1

Retroperitoneal lipoma

1

Left adrenalectomy (pheochromocytoma)

1

Subtotal

5 (2.69)

Ureteroureterostomy, augmentation cystoplasty, bladder neck closure, heminephrectomy with ureterectomy, perirenal abscess drainage, colostomy closure, enterovesical fistula closure, review of Mitrofanoff, ureterostomy, and ureteropyelography. *

Roux-en-Y hepaticojejuno reconstruction. **

(5)

or

portojejuno

(1)

anastomosis

Duodenoplasty with adherensiolysis, extraction of gastric trichobezoar, drainage, and debridement of recurrent retrohepatic abscess postappendectomy, gastrojejunoanastomosis with Roux-en-Y and splenectomy. ***

3.5 HERNIA REPAIRS: A COMPARISON Nguyen, David, Shiozaki et al (2021) compared standard open repair (SOR) or robotic-assisted repair (RAR) for hernia repairs between September 2016 and February 2017 on 43 patients (16 SOR versus 27 RAR) whose BMI, age, gender, diabetes and hernia size were comparable. While the RAR group documented lowered estimated blood loss (EBL) and hospital stay, the operative times were longer as opposed to the OAR group. Despite this prolonging of the operative time, patient outcomes were improved for complex ventral hernia repairs, according to the authors. The results of standard open repair (SOR) or robotic-assisted repair (RAR) for hernia repairs are documented in table 3.8 below (Nguyen, B., David, B., Shiozaki, T. et al, 2021: Open Access: This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if

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69

changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/): Key: SOR standard open repair, RAR robotic assisted repair, BMI body mass index, DVT deep vein thrombosis, UTI urinary tract infection, SSI surgical site infection SOR n = 16

RAR n = 27

P-Value

55.4 ± 12.4

58.6 ± 10.4

0.367

Male

4 (25%)

13 (48%)

0.133

Female

12 (75%)

14 (52%)

Caucasian

16 (100%)

24 (89%)

African American

0 (0%)

3 (11%)

BMI

32.2 ± 6.4

33.3 ± 5.5

0.558

Diabetes

3 (19%)

7 (26%)

0.719

Operative time

206.5

272.1

0.001

Estimated blood loss

146.9 ± 75.8

43.0 ± 85.1