mdnoman uddin - [PDF Document] (2024)

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Robotic surgeryUsing robots in the operating room to assist thesurgeon in performing surgery. The surgeonviews the patient via aterminal and manipulates robotic surgical instruments via acontrolpanel. Views of the organs being worked on are transmittedfrom tiny cameras inserted into

the body.

Such robots are considerably less invasive than normal operatingroom procedures becausethe instruments can be inserted into muchsmaller incisions in the human body. This type of "laparoscopic"surgery means less pain and less scarring, and patients recovermuch faster.

Since the patient and surgeon are separated by an electronicconsole, it also enables"telesurgery," which allows the surgeon toperform the operation in a remote location. Seetelesurgery .

Robotic Operation gical.com)

The surgeon on the left is performing a laparoscopic operationon the patient via robotic instruments from IntuitiveSurgical. Atraditional operating room procedure would require a much largerincision in order to accommodate the

surgeon's hands. (Image courtesy of Intuitive Surgical,

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ABSTRACT

Over the years robots have been widely used in manufacturingindustries formaterial handling, welding, assembly, etc. so robotsare designed as helping

hand. They help us in difficult, unsafe task. Machines th at canbe programmedto perform a variety of jobs, and they can range fromsimple machines toohighly complex, computer controlled intelligentsystem. Robots are used inindustries, warehouse, laboratories, etc.Technocrats and Medical surgeon allover the world have joint handsfor developing specialized robotic devices forperforming surgicaloperations too.This paper presents a robotic system for preciseneedle insertion under

radiological guidance for surgical interventions. It iscompatible with port able

X-ray units and computer tomography scanners. The systempresents modularstructure comprising global positioning, miniaturerobotic and radiolucentneedle driver modules. The system may beoperated stand alone underjoystick control making it adaptable tooperating rooms, or under full imageguided computer control.Thispaper will also proved brief classification, operation andpracticalapplication in medical science. The R-T Frictiontransmission with axial loadingfor needle insertion gives the ideawhich where used in ancient year . Alsothis robot is control by theGPS system, which is far away from the operationroom

Robotic surgery is relatively new, and fundamental concepts arestill beingformulated. Various medical robotics and computer aidedsurgery projectshave been undertaken at Imperial College over thelast 10 years, many of which have been clinically applied. Oneconclusion, that has resulted, is thatthere is much benefit to begained from the use of a force controlled lever onthe end of therobot, that is held by the surgeon as an input control system.Thisleads to improved levels of safety as well as clarifying that thesurgeon isin charge of the procedure

Robotic surgery make use of Robots to perform surgery. Majorpotential advantages of roboticsurgery are precision andminiaturization. With our skilled surgeons and the robotic system,we cannow use minimally invasive techniques in even the mostcomplicated procedures like Cardiacsurgery, , Orthopedics, ,Urology etc.

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INT RODUC TI O N

F or about 75 years, robots had been the sole perview of sciencefiction. Their descriptions ranged from the dumbmachine thatreplaced monotonous work as first describedby the Czech playwrightKarel Capek in the classic play"Rossum's Universal Robots. In 1921to the ultra-intelligentanthropomorphic robots of Isaac Asimov'sclassic sciencefiction books of the 1950's to the familiar R2D2 andC3PO

of Star Wars films beginning in the1970's to the incrediblecyborgs of theTerminator film series. However it was arareexception that the depiction was that of a medical robot

Robots gradually made their way into factories for dangerousrepetitive accurate tasks (automobileassembly), handling hazardouswastes in thenuclear industries (figure 1), great dexterityandprecision (computer chip assembly) and asdelivery robots, suchas those by Joseph

Engelberger, MD (figure 2).None of these were anthropomorphic,they all were designed toprovide functionality. While many couldexceed human performancein a specific dexterous task such as theMIT- Utah Hand (figure 3) or exceed human sensualperception, noneachieved even the minimal intelligence of a two year old baby. Manytriedto gain expertise in a specific domain, with variousrecognition capabilities, however theserobots were never able todemonstrate cognitive abilities. This is the background uponwhichthe origins of medical robotics arose.

DEVELOPME NT OF CURRE NT SYS T EMS

The earliest conceptions of surgical robotics came from Scott Fisher,PhD ( 1) (at the National Aeronautics and SpaceAdministration(NASA) Ames Research Center, Palo Alto, CA) andJoseph Rosen,MD (Plastic Surgery, Stanford University, Palo Alto,CA) in the midto late 1980's. At that time the NASA-Ames group leadby MichaelMcGreevy, PhD and Steve Ellis, PhD were working invirtual reality(VR). This group was joined by Scott F isher and JoeRosen as thefirst head mounted display (figure 4) was beingdeveloped as a wayto display the massive amounts of data beingreturned from NASA'splanetary

exploration missions of Voyager andothers. At this time JaronLanier, whocoined the term "virtual reality" (VR),contributed theDataGlove and objectoriented program (his company VPL, Incwas anabbreviation for VisualProgramming Language), which made itpossibleto interact with the threedimensional (3-D) virtual scenes.Scott

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F isher and Joe Rosen integrated these ideas of interactivity ofVR and applied them tosurgical robotics. Their earliest concepts(figure 5) envisioned telepresence surgery (a termcoined by Scott Fisher, who later started his own company called TelepresenceResearchInc.) using the DataGlove as a method of controlling theremote robotic hands.The NASA-Ames team had expertise in VR, butnot robotics. Joe Rosen and Scott F isher took their vision to PhilGreen, PhD at Stanford Research Institute (SRI, later changed toSRI

International after acquiring Sarnoff Research Institute ofPrinceton, NJ). Phil Green washead of the biomechanics section atSRI and was working with other roboticists such as JohnHill, PhD,Joel Jensen, PhD and Ajit Shah, PhD. Tom Piantanida, PhD providedthe human

interface technology expertise, and was SRI's expert intheemerging VR field. With Joe Rosen's clinical input,the firstdirection for development was as an extremelydexteroustelemanipulator to greatly enhance vascular and nerve anastomosesfor hand surgery. In keeping withthe VR and telepresence concept,the design focusedupon an intuitive interface (figure 6) which wasable togive the surgeon the sense that (s)he were operating uponahand directly in front of their eyes, but which was infact locatedupon the other side of the room. Scott F isher was fond of sayingthat, although he could not teleport

(as in "Beam me up, Scotty") he could send his presence to aremote site.In 1988-89, the parallel development of laparoscopiccholecystectomy emerged on thesurgical front. Jacques Perrisat, MDof Bordeaux, F rance presented a video tape of alaparoscopiccholecystectomy to the Society of American GastrointestinalEndoscopicSurgeons (SAGES) annual meeting in Atlanta, GA. Theprofound effect of the introductionof laparoscopic surgery to themain stream surgical community (in addition to thepioneeringprocedures performed by Joe Eddy Reddick, MD, DouglasOwens, MD, Barry McKearnen,MD and George Berci, MD) caused anexplosion in the use of laparoscopic cholecystectomy.It soon becameapparent that, although laparoscopic surgery was of great benefitto thepatient, it created an enormous difficulty for the surgeon,since there was the degrading of thesense of touch, the loss ofnatural 3-D visualization( 2) and impairment ofdexterityprincipally due to the fulcrum effect of theinstruments.While Joe Rosen was beginning animal and then earlyclinical trials with the GreenTelepresence Surgery System (as itwas being called), Richard Satava, MD began workingfirst with theNASA-Ames group and then was introduced to the SRI telepresenceteam. As ageneral surgeon and surgical endoscopist, it wasimmediately evident that the telepresencesystem provided a numberof solutions to the laparoscopic surgery problems ( 3). Inresponseto Rick Satava's suggestions, Phil Green began devoting thetelepresence effort towardsmacroscopic surgery ( 4) andspecifically to improving upon laparoscopic surgery, in additiontothe microscopic surgery for Joe Rosen in hand surgery. A video tapeof the telepresencesurgery system was demonstrated to COL RussZajtchuck, MD and Donald Jenkins, PhD of

the Borden Institute of Walter Reed Army Medical Center. Theybrought this to the attentionof the Surgeon General of the Army,Alcide LaNoue, which resulted in the transfer of Satavafrom F t.Ord, CA to the Pentagon's Advanced Research Projects Agency (ARPA -which wasdeveloping the ARPA-net that later evolved into theInternet). Under the Surgeon General'ssupport, ARPA (later tobecome DARPA in 1993) was requested to begin a program inAdvancedBiomedical Technologies, to include telepresence surgery (as it wasnow beingcalled). Donald Jenkins was requested to be co-programmanager in this effort, which over the next 7 years funded amajority of projects in telepresence and robotic surgery.A thirdeffort was also beginning independently in the early 1990's. Dr.Hap Paul, DVM and

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William Barger, MD (orthopedic surgeon) began collaborating withRussell Taylor, PhD of IBM's T.J. Watson Research Center( 5) todevelop a robotic system (based upon the IBMPuma arm) that would beable to be used for hip replacement surgery (many breeds ofdogs,including German shepards and golden retrievers came to HapPaul to have hip replacementfor the fractured and dislocated hips).Theresearch which this team conducted resulted in the

first robotic surgical device, named RoboDoc(figure 7). This wasa modification of the basicprincipals of the Puma Arm which enabledpre-operative planning of the procedure (to includematching theprosthesis exactly with the femur that would accept theprosthesis). RoboDoc wasable to precisely core out the femoralshaft with a96% precision, while standard hand broach was

able to provide an accuracy of only 75%. Dr. Barger then tookthe system to clinical trials in humans after Hap Paul proveditsefficacy (clinically) in his veterinarian practice and RoboDocisnow a commercial product. Subsequently, other orthopedicsurgeonssuch as Dr. Anthony DiGioia, MD( 6), are developingother systemssuch as the HipNav for replacement of the kneeand hip joints.On theother side of the Atlantic at this same earl timeframe,two teamswere producing early prototype surgical roboticsystems, one in eachof the different categories as above. Onesystem by Sir JohnWickham, MD and Brian Davies, PhD of Guy's Hospital in London( 7)was similar to RoboDoc in that itwas used for precise coring; butas a urologist, John Wickhamdeveloped the system to assist intrans-urethral resection of theprostate (TURP). This was amechanically constrained systemwhich used a robotic arm similar tothe Puma and RoboDoc.

However for patient safety, there was a large circular metalring (figure 8) through which the resectioninstrument was passedand which prevented the roboticarm from moving out of the precisefield of the prostate.After successfully proving the accuracy ofthe system onpotatoes and then a few patients in the clinic trial,JohnWickham was given permission to conduct studies onanimals toshow efficacy and safety.The second system being developed inEurope was acollaboration of Hermann Rinnsland, PhD of theForschungszentrum Karlsruhe (Karlsruhe Nuclear Research Center,Karlsruhe, Germany) and

Gerhard Buess, MD of the University of Tuebingen, in Tuebingen,Germany( 8). HermannRinnsland was head of the group which developedGermany's telemanipulation robotics for handling of nuclear waste.This was a highly dexterous system, similar to the SRI system,butwith significant differences, especially in the surgeon'sworkstation. This system, calledAdvanced Robot and TelemanipulatorSystem for Minimally Invasive Surgery (ARTEMIS)(figure 9) hadremote telemanipulators like the SRI system, but the surgeon'sconsole had thehand input devices "over the shoulder" to provideextra manipulation abilities. The systemwas very efficient, howeverafter the first prototype was developed and demonstrated tobeeffective, funding for the F orschungszentrum project was notrenewed and this promising

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system has yet to progress into the commercial phase.Thus thestate of the art in robotics surgery at 1993 was that of thesystems describe above.However the military (through the DARPAprogram) began to dramatically increase attentionin the GreenTelepresence Surgery system in the following years until 1999 withthe close-out of the DARPA program (see below for militarysystem).All during this timeframe (late 1980's - 1993), theneurosurgical and radiological community

were investigating robotics to collaborate with neurosurgeons toprecisely position probes,resection instruments, ablation devicesand other surgical tools, principally for minimallyinvasive brainsurgery. F rank Jolesz, MD of Brigham and Women's Medical CenterandWilliam Lorensen, PhD of General Electric Research Center werepioneers in the open MRIsystem( 9) for real-time updates of brainimages in the initial real-time, image-guidedneurosurgical systems.Neurosurgeon Richard Bucholz, MD of St. Louis UniversityMedicalCenter( 10) was also independently developing a trackingsystem, called the Stealth Station,that could be used duringneurosurgery to provide accurate stereotactic navigationduringsurgery. This effort resulted in an image guided system forreal-time tracking of instrumentsin surgery. In the 1996, DanielKarron, PhD of New York University, New York( 11 )developed anaudio system that provided audio feedback depending upon proximityto theintended target, in essence an audio navigation assistancefor the Stealth Station. This is oneof the only systems which weredesigned to provide synesthesia, the substitution of onesense(audio) for another sense (vision) in order to improveaccuracy.Beginning in July, 1992, Rick Satava and Don Jenkinsdeveloped the Defense AdvancedResearch (DARPA) Advanced BiomedicalTechnologies (ABMT) program. The militaryimperative was to savesoldiers that had been wounded on the battlefield usingadvancedtechnologies. Review of the Wound Data and MunitionsEffectiveness Team (WDMET)database of the casualties of the VietNam war( 12) revealed that although great improvementhad occurredin overall mortality, when examining those soldiers with lifethreateningwounds in the far forward battlefield, there was littlechange from as early as the Civil War.As a rough generalizationone-third died of head or massive injuries, about one thirddiedfrom wounds (principally exsanguinating hemorrhage) which wereestimated to be survivalbased upon today's technology, andone-third survived. A comprehensive program wasinitiated, utilizingadvanced sensor, robotics, telemedicine and virtual realitysystems. One of

the prime concepts was to implement Scott F isher and JoeRosen's idea to "bring the surgeon to thewounded soldier - throughtelepresence". The GreenTelepresence Surgery System was seen as amethodof providing surgical care right on the battlefield tosavethose soldiers which would otherwiseexsanguinate( 13). It wasenvisioned that the roboticmanipulator arms would be mounted in avehicle for Medical F orward Advanced Surgical Treatment(MED FAST). The vehicle chosen was a BradleyF

ighting Vehicle - 577A (figure 10). The surgicalworkstation wasto be placed in the rear echelonMobile Advanced Surgical Hospital(MASH); whena soldier was wounded it was envisioned that themedicwould place him into the MED F AST and

together the surgeon (at the telesurgery unit in the MASH) andthe medic in the MED F ASTwould together perform just enoughsurgery to stop the hemorrhage (the current concept of"damage-control surgery), in order for the casualty to betransported as soon as possible back to the MASH, but now thesoldier was alive instead of exsanguinating before arrival atthe

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MASH. In 1996, a military field test was conducted by SRI,International whichdemonstrated successfully that surgery could beperformed over a 5 kilometer distance with amicrowavetelecommunication link-up between a MASH hospital and the MED FAST.However, the battlefield of the 1990's was changing fromconventional, open battlefields tothe close quarters of urbanterrain, which was ill suited for the MED F AST vehicle.Althoughsuccessfully demonstrated on the animal model, the systemhas not yet been implemented for

battlefield casualty care.A significant number of other roboticsurgery applications were being developed by DARPAto providesolutions for many of the difficult issues. Thomas Sheridan, PhD ofMassachusettsInstitute of Technology (MIT)( 14) was tackling thelatency problem - the time of travel of theelectronic signal fromthe moment the handle of the instrument on the workstationmoveduntil the signal arrived at the tip of the manipulator. It isknown that humans can compensatefor latency (delay) of up to 200milliseconds (msec), after which the delay is too great foraccuracy. Tom Sheridan was attempting to solve the problem bypredictive algorithms, andwas successful in demonstrating toleranceof delay up to 300 msec. Other investigators suchas AlbertoRovetta, PhD of Milan, Italy, have tried to work around the problemby havingidentical software programs at the two remote places, sothe only thing transmitted is thehand signals. In 1993, AlbertoRovetta( 15) was able to successfully perform a liver biopsy onapig liver with the surgeon's station being at the NASA JetPropulsion Lab (JPL) inPasadena, CA and the manipulators and pigliver in his laboratory in Milan. The time lagusing a satellite wasover 1200 msec (1.2 seconds). (Note: it takes about 1.2 sec for asignalto be transmitted to a geosynchronous satellite 22,000milesabove the earth and then return).Other contributions occurringcame from Kenneth Salisbury,PhD, Marc Raibert, PhD, and RobertPlayter, PhD from theMIT Artificial Intelligence and RoboticsLaboratory under the direction of Rodney Brooks, PhD. This groupwasworking upon the haptics (sense of touch) and developedanaccurate force feedback system for the robotic devices( 16).Thisbecame a commercial product called "The Phantom"(figure 11), whichhas become the industry standard for providing haptics to a virtualenvironment and the basics for robotics systems. Other researchersfrom MIT working to improve telepresence surgery inone fashion oranother included Blake Hannaford, PhD and David Brock, PhD.

TH E COMMERC IA L IZATI O N YE A RSThe commercialization ofrobotic surgery started with the RoboDoc system in 1992-93 asindicatedabove. In spite of the exceptional performance of RoboDoc,the system went through a prolongedapproval process with the Foodand Drug Administration (FDA). However for directsurgicalmanipulation in laparoscopic surgery, the first applicationwas to control the camera in laparoscopicsurgery. With initial seedfunding from DARPA, Yulun Wang, PhD began developing theAutomated

Endoscopic System for Optimal Positioning (AESOP)( 17) inhisnewly formed company, Computer Motion, Incorporated.Thisprovided acceptance by the medical and surgicalcommunity ofrobotics as an effective assistive device. Thissystem was the firstrobotic device to receive FDA approvaland launched the robotics ingeneral surgery movement.During this timeframe, image guidedsurgery systems began

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commercialization with both the NeuroMate in Switzerland (figure12), and Richard Bucholz's Stealthsystem. These systems werespecifically developed for neurosurgery, as was the GeneralElectricopen magnetic resonance imaging (MRI) that waspopularizedby Ference Jolesz and Ron Kikinis of Brigham Women's Hospital(8).

While AESOP was being marketed to the surgicalcommunity,Fredrick Moll, MD licensed the SRI GreenTelepresence Surgery rightsand started IntuitiveSurgical, Inc. After extensive redesigningfrom the

ground up, thedaVinci surgicalsystem (figure13) was produced andintroduced. In April, 1997, the firstrobotic surgical(tele-operation) procedure on a patient wasperformed in BrusselsBelgium by Jacques Himpens, MD andGuy Cardiere, MD( 18). Within ayear, Computer Motion had

put their system, Zeus (figure 14), into production. Bothsystemsare similar, in that they have remote manipulators which arecontrolled by a surgical workstation. One major difference is inthe surgical workstations. The daVinci system has stereoscopicimagewhich is displayed just above the surgeon's hands so it appears asif the surgical instrumenttips are an extension of the handles -this gives the impression that the patient is actually rightinfront of the surgeon (or conversely, that the surgeon's presencehas been transported to right nextto the patient - hence the termtele-presence). The Zeus system is ergonomically designed withthemonitor comfortably in front of the surgeon's chair and theinstrument handles in the correct eye-hand axis for maximumdexterity. There is no illusion of being at the patient's side,rather there isthe sense of an operation at distant site but withenhanced capabilities. Initially, the daVinci systemwas the onlyone with an additional degree of freedom, a "wrist"; howeverrecently the Zeus systemhas introduced instruments with a wrist.Theconcept of dexterity enhancement was suitable for the emerginglaparoscopic surgery field, andespecially for minimally invasivecardiac surgery applications. Although the originalGreenTelepresence Surgery system was designed for remote traumasurgery on the battlefield, thecommercial telepresence systems wereenvisioned fordelicate cardiac surgery, specifically coronaryartery bypassgrafting. It was believed that the robotic systemswould allowminimally access surgery on the beating heart. This isto beachieved by first blocking and then overpacing the heartandgating the motion of the robotic system to the heart rate.

While the minimally access approach has been achieved,the"virtual stillness" of the gating method is still indevelopment.The challenge of extremely accurate and dexterousrobotics was chosen for ophthalmologic surgery,and specifically forlaser retinal surgery. The blood vessels on the retina are 25microns apart.Human performance limits are an accuracy ofapproximately 200 microns. Stephen Charles, MD of Baptist Hospitaland MicroDexterity Systems, Inc (MDS) in Memphis, TN collaboratedwith a brilliantteam at NASA Jet Propulsion Laboratory (JPL), whichincluded Paul Schenker, Hari Das, EdwardBarlow and othersa todevelop the Robot Assisted MicroSurgery (RAMS) system (figure 15).This

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system included 3 basic innovations: 1) eye tracking of thesaccades of the eye (200 Hz) so the videoimage was perfectly stillon the video monitor, 2) scaling of 100 to 1, giving the system 10micronaccuracy, and 3) tremor reduction (between 8 - 14 Hz),removing any tremor or inaccuracy. Today,any surgeon could sit downat the microdexterity system and perform laser surgery with 10micronaccuracy, that is 20 times beyond the accuracy of the unaidedhuman hand.

The issue of remote surgery using robotics was limited to shortdistances because of the latencyissue. It was only recently (2001)that the Zeus system was used for a trans-Atlantic roboticsurgeryoperation between New York City and Strasbourg, France byJacques Marescaux and MicheleGagner. The limitation to longdistance surgery is the latency or delay, which cannot exceed200msec. At longer delays, the time from the hand motion of thesurgeon until the action of the robot'send effector (instrument) isso great that the tissue could move and the surgeon would cutthewrong structure. In addition with delays greater than 200 msecthere is conflict within system suchthat the robotic system becomesunstable. However, Marescaux and Gagner employed adedicatedhigh-bandwidth Asynchornous Transfer Mode (ATM)terrestrial fiberoptic cable and were able toconduct the surgerywith a delay of only 155 msec. Thus, with very broadband,terrestrial fiber opticcable connection, it is possible to performremote surgery over thousands of miles. When the Next

Generation Internet, with the 45 Mbyte/sec fiber optic cabling,becomes universally available, suchremote surgery can become areality to many places in the world

C HA LLE NG ES AN D FU T URE SYS T EMS

The current systems are just the beginning of the roboticsrevolution. All of the systems havein common a central workstationfrom which the surgeon conducts the surgery.

This workstation (see figures 13,14) is the central point whichintegrates the entire spectrumof surgery (figure 16). Patientspecific pre-operative images can be imported into thesurgicalworkstation for pre-operative planning and rehearsal of acomplicated surgical procedure, asis being developed by JacquesMarescaux, MD ( 19).F igure 17 illustrates a patient's liver with amalignantlesion, and the methods of visualizing,pre-operativeplanning and procedure rehearsal. At the time ofsurgery, this image can be imported into theworkstation forintra-operative navigation. It can also

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be used as a stand alone workstation for surgical simulation fortraining of surgical skills andoperative techniques. Thus, on aninvisible level, the challenge is going to be to performtheintegration of the software of all the different elements, suchas importing images, pre-operative planning tools, automaticsegmentation and registration for data fusion and imageguidance andsophisticated decision and analysis tools to provide automaticoutcomesanalysis of the surgical procedure.

On a technical side, few if any of the systems include the fullrange of sensory input (eg.sound, haptics or touch) and there arebut a few simple instruments (end effectors). The nextgenerationsystems will add the sense of touch, and improved instruments. Theinstrumentswill need to be both standard mechanical instruments aswell as energy directed instrumentssuch as electrocoagulation, highintensity focused ultrasound, radio-therapy, desiccation,ablationetc. In addition advanced diagnostic systems, such as ultrasound,near infra-red, andconfocal microscopy can be mounted on therobotic systems and used for minimally invasivediagnosis. Thesystems will become smaller, more robust (not require a full timetechnician)and less expensive. They will adapt for the requirementsof the other surgical subspecialties.In the evolution of therobotics, the systems will become more intelligent,eventuallyperforming most, if not all, of an operative procedure.In current systems such as RoboDocand NeuroMate, the surgeonpreplans the operation on patient specific CT scans. This planisthen programmed into the surgical robot, and the robot performsprecisely what the surgeonwould have done if (s)he were performingthe operation, but with precision and dexterityabove humanlimitations. This is a trend which will continue, with the surgeonplanning moreand more of the operation which the robot caneffectively and efficiently carry out. The robotmust be undercomplete control of the surgeon, in case something unexpected wereto occur and the surgeon would take over. It is conceivable that inthe distant future under specialcirc*mstances such as remoteexpeditions or the NASA Mission to Mars, that robots wouldbeperforming the entire surgical procedure. However in the nearfuture there will bedevelopment of hybrid hardware-software systemsthat will perform complete portions of anoperation, such as ananastomosis, nerve grafting, etc.These systems will require acomplicated infrastructure, and the operation room (OR) of the

F uture will have to accommodate them. The uniquerequirementsfor these systems include a very robustinformation infrastructure,access to information fromthe outside (such as xrays, images,consultation), voicecontrol of the system by the surgeon,andmicrominiaturization of the systems. Perhaps there willbe anevolution of the OR to resemble more of a "controlroom" because ofthe large number of electronics whichneed to be controlled. Aninteresting product involved

with patient monitoring and control is the Life Support forTrauma and Transport (LSTAT)(figure 18), which is in essence anentire intensive care unit (ICU). Although the LSTAT wasdevelopedby the military as an evacuation system

for the battlefield (the "trauma pod" from RobertHeinlein's"Starship Troopers"), it contains completemonitoring andadministration systems, telemedicinecapability and can be dockedand undocked withoutremoving the patient and is fully compatiblewithcurrent tele-robotic systems.A system similar to this may beincorporated into theOR of the F uture (figure 19) to facilitatepatientanesthesia, surgery and transportation while

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maintaining continuous monitoring.There has been speculationabout the use of nanotechnology to inject miniscule robots intotheblood stream to migrate or be navigated to the target. Numerousconcept diagrams showmechanical types of systems that either arecontrolled by a surgeon or are autonomous. Whileinterestingconceptually, there is little practical understanding of how toactually constructsuch total, complex systems on a molecular level,and more importantly how to control them.

The first generations of these systems will not be visible tothe eye, will probably bemanufactured chemically by the billions,and will not be controlled but rather, like drugdesign, beprogrammed to recognize certain cell or tissue types to delivermedication or causeablation.F requently micro-electro-mechanicalsystems (MEMS) are discussed in conjunction withnanotechnology,however these systems are one thousand times larger (1.0 x10-6meters)than nanotechnology (1.0 x 10-9meters). Such systemswould be visible as very tiny robots

which could be directly controlled by a surgeon. However as thetechnology scales down in size, it also scales downin power orforce which can be generated, making itextremely difficult toactually conduct work at this scale.While there are a number ofMEMS robots (figure 20),none are actually performing anysignificant work, let aloneany activity resembling a surgicalprocedure. Nevertheless,MEMS and nanotechnology are areas forfuture potential

surgical robotics which will take decades to develop andperfect. It is essential for surgeons tobe aware of thesetechnologies, and others such as quantum mechanics, biomimeticmaterialsand systems, tissue engineering and genetic programming,in order to anticipate the greatrevolution that is developing.

Robotic surgery is the use of robots in performing surgery.Major potential advantages of roboticsurgery are precision andminiaturization. Further advantages are articulation beyondnormalmanipulation and three-dimensional magnification. At present,surgical robots are not autonomous,

but are always under the control of a surgeon. They are used astools to extend the surgical skills of atrained surgeon.Roboticsurgery is different from minimally invasive surgery. Minimallyinvasive surgery (sometimescalled laparoscopic surgery) is ageneral term for procedures that reduce trauma byperformingoperations through small ports rather than largeincisions. Minimally invasive surgery is nowcommonplace for certainprocedures. But until now, we haven't been able to use minimallyinvasivetechniques for more complex operations. With our skilledsurgeons and the robotic system, we cannow use minimally invasivetechniques in even the most complicated procedures likeCardiacsurgery, Gastrointestinal surgery, Gynecology, Neurosurgery,Orthopedics, , Urology etc

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HI STORY

In 1985 a robot, the PUMA 560, was used to place a needle for ahip replacement Intuitive SurgicalSystem introduce the da VinciRobot in 1995 and Computer Motion, AESOP and the ZEUSroboticsurgical system.. In 1988, the PROBOT was used to performprostatic surgery in England. TheROBODOC from Integrated SurgicalSystems was introduced in 1992, and is a robot to mill out

precise fittings in the surgery. In 2001, Marescaux used theZeus robot to perform a surgery.

Robot-assisted surgery is the latest development in the largermovement of endoscopy, a typeof minimally invasive surgery the ideabeing that less invasive procedures translate intoless trauma andpain for patients. Surgery through smaller incisions typicallyresults in lessscarring and faster recovery. It's not that robotsare changing the basics of surgery. Surgeonsare still cutting andsewing like they have been for decades. Robots represent anewcomputer-assisted tool that provides another way for surgeons towork.

Rather than cutting patients open, endoscopy allows surgeons tooperate through smallincisions by using an endoscope. This fiberoptic instrument has a small video camera thatgives doctors amagnified internal view of a surgical site on a televisionscreen.

In abdominal endoscopy, known as laparoscopy, surgeons threadthe fiber optic instrumentinto the abdomen. F irst performed in thelate 1980s, laparoscopy is now routine for manyprocedures, such assurgery on the gallbladder and on female organs.

With robotic surgical systems, surgeons don't move endoscopicinstruments directly withtheir hands. Instead, surgeons sit at aconsole several feet from the operating table and usejoystickssimilar to those used in video games. They perform surgical tasksby guiding themovement of the robotic arms in a process known astele-manipulation.

The Food and Drug Administration reviews data on the safety andeffectiveness of robotic software

and hardware and requires manufacturers to implement trainingprograms for surgeons. The FDAalso monitors experimental uses forrobotic applications, including clinical trials for roboticheartsurgery. It's too soon to say for sure how far and how fastrobotic surgery will grow, but experts saythe future lookspromising

Robot's hands. A surgical robot is a computer controlled andself powered device whichcan be programmed to manipulate varioussurgical instruments. Robotic Surgery Da Vinci can be used fornumerous different procedures including Coronary Artery Bypass,Blood Vessels, Nerves, Kidney Removal and Transplant, TubalLigation, Mitral Valve Repair,Gallbladder Robotic Surgery is amicrosurgery which is performed by surgeons bymanipulating removaland Hip Replacement etc.

Robotic Surgery is a microsurgery which is performed by surgeonsby manipulating Robot'shands. A surgical robot is a computercontrolled and self powered device which can beprogrammed tomanipulate various surgical instruments. Robotic Surgery Da Vincican beused for numerous different procedures including CoronaryArtery Bypass, Blood Vessels,Nerves, Kidney Removal and Transplant,Tubal Ligation, Mitral Valve Repair, Gallbladder removal and HipReplacement etc.

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SURGICAL PLANNING

Surgical planning consists of three main parts. T hese areimaging the patient, creating asatisfactory three-dimensional (3D)model of the imaging data, and planning/rehearsingtheoperation.

T he imaging of the patient may be accomplished via variousmeans. T he main method isthat of computer tomography (C T ). C Tis the process whereby a stack of cross-sectionalviews of thepatient are taken using magnetic-resonance-imaging or x-raymethods. T hiskind of imaging is necessary for all types ofoperative procedure and, as such, does notdiffer from traditionalsurgical techniques. T his two-dimensional (2D) data must thenbeconverted into a 3D model of the patient (or, more usually, of thearea of interest ).T he reasons for this transformation aretwofold. Firstly, the 2D data, by its very nature,is lacking ininformation. T he patient is, obviously, a 3D object and, as such,occupies aspatial volume. 2D data is just that - two-dimensional;hence it cannot easily provideinformation pertaining to such issuesas volume (of, for instance, a tumour) or, position(with respect todistances perpendicular to the cross-sectional data). Secondly, itis more

accurate and intuitive for a surgeon, when planning a procedure,to view the data in theform that it actually exists.

T he actual transformation into a 3D model is readilyaccomplishable through volumegraphics methods (see Volume Graphics: T he road to interactive medical imaging?).T hese methodsproduce computer-graphics-based models that possess such featuresasthe ability to rotate the model, view its interior, zoom in, andso on. T hat is, all thecapabilities of currentcomputer-aided-design (C A D) systems. A s may be expected,however,the processing requirements of these modelling systems are ratherlarge, asare the costs of the hardware necessary. I t should benoted, however, that the speed of said hardware is increasing allthe time and the price will decrease too, as thetechnology involvedbecomes more commonplace. T his means that the process will be

more cost-efficient and increasingly routine in the future.

T he third phase of the planning is the actual development ofthe plan itself. T hisinvolves determining the movements and forcesof the robot in a process called 'pathplanning' - literallyplanning the paths that the robot will follow.

I t is here that the 3D patient model comes into play, as it iswhere all the measurementsand paths are taken from. T hisemphasises the importance of the accuracy of the model,as anyerrors will be interpreted as absolute fact by the surgeons (andhence the robot)in their determination of the plan. H ere, surgeonsare reliant upon the engineeringbehind the system that is beingused - thus the need for reliable systems (discussed inthe sectionon safety).

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What is robotic surgery?

Robotic surgery is an extension of laparoscopic surgery. Mostpeople are familiar withlaparoscopy. Surgery is performed bymanipulating straight instruments while viewing theinstruments on amonitor. Robotic surgery is the evolution of laparoscopy thataddresses thedrawbacks of laparoscopy.

One obstacle of laparoscopy is the loss of 3-D spatialrelationshipssince the 2-D monitor is used to operate. The da VinciSurgicalSystem uses a laparoscope that is comprised of 2 camerasand lensesto provide the surgeon with a true minimally invasive 3-Dview of thesurgical field including depth of field, magnificationand highresolution.

Laparoscopic instruments have the feel of "chop sticks". TheDaVinci Surgical Cart includes the EndoWrist Instruments. TheEndoWristInstruments are designed to mimic the movement of thehumanhands, wrists and fingers. The extensive range of motionallowsprecision that is not available in standard minimallyinvasiveprocedures.

Laparoscopic surgery places the surgeon in an uncomfortableposition that can lead to ahigher rate of surgical errors. TheDaVinci Surgeon Console contains

the master controls that the surgeon uses to manipulate theEndoWristinstruments. The handles or Masters translate thesurgeon's naturalhand and wrist movements into corresponding,precise and scaledmovements. The EndoWrist Instruments are onlyable to move whencommanded by the surgeon. There is a clutch thatdeactivates theinstruments and allows the surgeon to maintain acomfortable position at all times.

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THE SURGE RY

Robotic surgery is the process whereby a robot actually carriesout a surgical procedureunder the control of nothing other than itscomputer program. A lthough a surgeonalmost certainly will beinvolved in the planning of the procedure to be performed andwillalso observe the implementation of that plan, the execution of theplan will not beaccomplished by them - but by the robot.

A robot's motions can be precisely controlled and constrainedthrough its programmingT his results in undeviating trajectories,high accuracies with predictable velocities andaccelerations withno overshoot. A s expected when dealing with automatedprocesses,the benefits of repeatability and reliability areinherent.

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W hat are the components of the robot?

The da Vinci Surgical System is an integral part of theoperating room and supports theentire surgical team. The Systemconsists of a surgeon console, patient-side cart, instrumentsandimage processing equipment.

y The Surgeon ConsoleUsing the da Vinci Surgical System, thesurgeon operates while seatedcomfortably at a console viewing a 3-Dimage of the surgical field.The surgeon's fingers grasp the mastercontrols below the display withhands and wrists naturallypositioned relative to his or her eyes. Thetechnology seamlesslytranslates the surgeon's hand, wrist and finger movements intoprecise, real-time movements of our surgicalinstruments inside thepatient.

y Patient-side CartProvides the four robotic arms two or threeinstrument arms andone endoscope arm that execute the surgeon'scommands. Thelaparoscopic arms pivot at the 1-cm operating portseliminating theuse of the patient's body wall for leverage andminimizing tissuedamage. Supporting surgical team members assist ininstalling theproper instruments, prepare the 1-cm port in thepatient, as well assupervise the laparoscopic arms and tools beingutilized.

y EndoWrist InstrumentsA full range of instruments are providedto support the surgeon whileoperating. The instruments are designedwith seven degrees of motionthat mimic the dexterity of the humanhand and wrist. Each instrumenthas a specific surgical mission suchas clamping, suturing and tissuemanipulation. Quick-release leversspeed instrument changes duringsurgical procedures.

InSite Vision System with high resolution 3-D Endoscope andImage ProcessingEquipmentProvides the true to life 3-D images ofthe operative field. Operatingimages are enhanced, refined andoptimized using image synchronizers,high-intensity illuminators andcamera control units

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3D HD VISION

The vision system of the da Vinci Si delivers high resolutionvideo into the viewer located atthe surgeon console. This providessurgeons with visual sharpness that is greater thananythingpreviously available.

As the surgeon operates, the da Vinci vision system displayshigh definition video in 3D for true perception of depth. Theimmersive quality of the 3D vision provides a virtual extensionofthe surgeons hands and eyes into the patients body.

The digital zoom feature provides a highly magnified view oftissue. Increased surgeonconfidence results from this superior viewof tissue planes and the target anatomy.

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DIFFE R EN T TYP E S O F ROBOT IC SYST EM S Computer Motion ofSanta Barbara California has become the leading producer of medicalrobotics.Different types of robots are da Vinci, Aesop and Zeus.Theda Vinci Surgical System was the first operative surgical robot.Products like Aesop, Hermes, andZeus are the next generation ofsurgical equipment and are used together to create a highly

networked and efficient operating room.

3.1. da Vinci Surgical SystemIncorporating the latestadvancements in robotics and computer technology, the da VinciSurgicalSystem was the first operative surgical robot deemed safeand effective by the United States Foodand Drug Administration foractually performing surgery.The da Vinci system was developed byIntuitive Surgical system, which was established in 1995.Itsfounders used robotic surgery technology that had been developedat SRI International, previouslyknown as Stanford ResearchInstitute. The FDA approved da Vinci in May 2001The da Vinci is asurgical robot enabling surgeons to perform complex surgeries in aminimally

invasive way, in a manner never before experienced to enhancehealing and promote well-being. Itis used in over 300 hospitals inthe America and Europe.

Until very recently surgeons options included traditionalsurgery with a large open incision orlaparoscopy, which uses smallincisions but is typically limited to very simple procedures. ThedaVinci Surgical System provides surgeons with an alternative toboth traditional open surgery andconventional laparoscopy, puttingasurgeon's hands at the controls ofa state-of-the-art roboticplatform. The da Vinci System enablessurgeons to perform even themost complex and delicate procedures through very smallincisionswith unmatched precision. It is important to know thatsurgery with da Vinci does not place a robotat the controls;surgeon is controlling every aspect of the surgery with theassistance of the da Vincirobotic platform. Thus da Vinci ischanging the experience of surgery for the surgeon, the hospitalandmost importantly for the patient.3.2. AesopAesop's function isquite simple merely to maneuver a tiny video camera inside thepatientaccording to voice controls provided by the surgeon. Bydoing so, Aesop has eliminated the need fora member of the surgicalteam to hold the endoscope in order for a surgeon to view hisoperativefield in a closed chest procedure. This advance marked amajor development in closed chest or port-access bypass techniques,as surgeons could now directly and precisely control theiroperative fieldof view. Today about 1/3 of all minimally invasiveprocedures use Aesop to control an endoscope.Considering each Aesopmachine can handle 240 cases a year, only 17,000 machines areneeded to

handle all minimally invasive procedures a relatively smallnumber considering the benefits of thistechnology.3.3. ZeusZeus isthe youngest and most technically advanced robotic aid. Zeuscontains robotic arms thatmimic conventional surgical equipment anda viewing monitor that gives the surgeon a view of hisoperativefield. More importantly, Zeus enables a surgeon to operate on apatient using joystick likehandles which translate the surgeon'shand movements into precise micro-movements inside thepatient. Forexample a 1-cm movement by a surgeon's hand is translated into a .1cm movement of

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the surgical tip held by a robotic arm. Zeus also has the uniquecapability of reducing human handtremor and greatly increasing thedexterity of the surgeon. Zeus allows surgeons to go beyondthelimits of MIS enabling a new class of delicate procedurescurrently impossible to perform. The maindisadvantage is highmachine cost. It is around 1 million dollars. Its FDA approval ispending.

A lternative N ames of Robotic Surgery

The alternative names given to Robotic Surgery are LaparoscopicSurgery, Robot AssistedSurgery and Robotic Assisted LaparoscopicSurgery.

Categories of Robotic Surgery

Robotic Surgery is further sub divided into three categoriesnamed as Supervisory ControlledSystem, Telesurgical System andShared Control System.

Supervisory Controlled System: - This procedure is only executedby robot which performsaccording to the surgeon inputs alreadygiven in a computer program.Telesurgical System: - It is alsocalled remote surgery that requires the surgeon who willmanipulatethe arms of robotic throughout the procedure. It is called remotesurgery becausesurgeon can operate this type of surgery from remotelocation by using sensor data of robot.The primary device that isused for this type of surgery is da Vinvi surgical system.SharedControl System: - This type of procedure is performed by maximuminvolvement of surgeon.

All these procedures can be used to perform robotic surgery thatuse computer imaging tomake a diagnosis and to perform variousoperations. These computer imaging modalitiesproduce 3D Imagesthrough Magnetic Resonance Imaging (MRI) and ComputedTomography(CT). It also produces 2D imaging through X-Ray Radiography, Fluoroscopyand Ultrasonography. Computer Tomography (CT) is mainmethod used for computer imaging out of all these Registration ? Itis the process of coordinating the imaging data withthepatient.Navigation - In this step, actual surgery is performed. Thesurgeon firstly positions the robotas well patient and then surgeonstarts the robot to follow the computer programmed

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Medical Robots and T elepresence

SRIs telepresence capabilities leverage our comprehensiveportfolio of expertise, whichincludes stereo imaging, telerobotics,sensory devices, video, speech recognition, andtelecommunications,to perform monitoring, actual operations, andassistance-relatedactivities from remote locations inreal-time.

Learn about our leading capabilities forlife-changingapplications in:

Telepresence surgery Medical automation robots : Trauma Pod andM7Telerobotics assistance for the elderly and disabled

Visit SRI's Medical Automation and RoboticsLaboratory (MARLab)to see the technology that

powers our life-saving solutions, and read aboutrecentdevelopments.

T elepresence Surgery(1993 - present)

SRI's novel approach to minimally

invasive surgery led to the first U.S. F DA-approved teleroboticsurgical system.

SRIs telepresence surgical system allowssurgeons to remotelyperform minimallyinvasive surgical procedures from aseparatelylocated operating theater. In1995, SRI spin-off companyIntuitiveSurgical, Inc., licensed the technology andis now theglobal market leader in surgicalrobotics. Throughout the U.S.,Europe,and Asia, surgeons use the technology to

help patients recover faster, with less painand fewercomplications.

Telepresence surgery carries some uniquebenefits because itprovides the right feedback and immersive environment to allow forthesurgeon to effectively use tools in a natural way with thesameor even betterdexteritythan are possible when operatingdirectly.

M7's robotic arms in a modular surgical platform.

Intuitive Surgical's da Vinci Surgical Systemphoto 2008Intuitive Surgical, Inc.

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The newly refined da Vinci Si Surgical System is the latestaddition to the da Vinci productline.

. Launched in April 2009, the da Vinci Si introduces severalenabling features , including:

y Dual-console capability to support training and collaborationduring minimally invasivesurgery.

y Enhanced high-definition 3 D v ision for superior clinicalcapability

y A n updated user interface for streamlined setup and ORturnover

y Ex tensibility for digital OR integration

The da Vinci S HD Surgical System integrates 3D HD endoscopy andstate-of-the-art robotictechnology to virtually extend the surgeonseyes and hands into the surgical field. Only theda Vinci Systemenables new, minimally invasive options for complex surgicalprocedures.

y F ast foolproof setupy

Rapid instrument exchangey Multi-quadrant access

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How does the robot work?

The da Vinci Surgical System combines proprietary software andelectronics that createsurgical immersion. The Surgeon's Consolegives doctors the control and ability to navigateinside thepatient. The InSite Vision System immerses surgeons in atrue-to-life 3-D image.The Navigator TM Camera Control allows thesurgeon to easily change, move, zoom and rotatehis or her field ofvision. The camera can be repositioned quickly and smoothly withinthesurgical opening without disrupting the procedure. The EndoWristInstruments transformmovement of the doctor's wrists, hands andfingers into movement of the tiny instruments.

The da Vinci Surgical System is the only commercially availabletechnology that can providethe surgeon with the intuitive control,range of motion, fine tissue manipulation capabilityand 3-Dvisualization characteristic of open surgery, while simultaneouslyallowing thesurgeon to work through small ports of minimallyinvasive surgery.

Using the da Vinci System, surgeons can operate with the lookand feel of open surgery,performing complex surgical maneuversthrough 1-cm ports.

W ORK ING O F ROBOT IC SYST EM

Today's robotics devices typically have a computer softwarecomponent that controls the movementof mechanical parts of thedevice as it acts on something in its environment The softwareis"command central" for the device's operation.Surgeon sits in theconsole of the surgical system several feet from the patient. Helooks through thevision system - like a pair of binoculars - andgets a huge, 3-D view of inside the patient's body andarea of theoperation.The surgeon, while watching through the vision system,moves the handles on the console in thedirections he wants to movethe surgical instruments. The handles make it easier for thesurgeon tomake precise movements and operate for long periods oftime without getting tired.The robotic system translates andtransmits these precise hand and wrist movements to tinyinstrumentsthat have been inserted into the patient through small accessincisions.This combination of increased view and tireless dexterityis helping us overcome some of thelimitations of other types ofless invasive surgery. It's also allowing us to finally useminimallyinvasive surgery for more complex operation

S urgeon Console The surgeon is situated at this console severalfeet away from the patient operating table. Thesurgeon has his headtilted forward and his hands inside the system's master interface.The surgeonsits viewing a magnified three- dimensional image of thesurgical field with a real-time progressionof the instruments as heoperates. The instrument controls enable the surgeon to move withina onecubic foot area of workspace.

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Orthopedic Surgeon

Robotics, Computer A ssisted Surgery (C A S), Minimally Invasive Surgery(M I S)

Navitrack Navigation System (OrthoSoft)

Computer- A ssisted Robotic Surgery

Robotics: Through computer-assisted surgery, surgeon obtains 3-Dvisualization allowinggreater visibility, corrective alignment andbalance of the implant joint.

Joint replacement surgery with the aid of a Navigation Systemhelps improve the results of your procedure. The System empowerssurgeons to accurately fit new implant componentsspecifically tothe anatomy of the body, potentially giving you:

y More exact implant placementy Extended life of the implantyOptimal joint positioning which restores mobilityy Decreasedpossibility of a revision surgeryy F aster recoveryy Improvement inyour quality of lifey Advanced computer-assisted surgical solutionsthat greatly enhance the precision and

accuracy of hip and knee replacement surgeries.y Think of aNavigational System as an assistant to surgery, providing yoursurgeon

with extra support and guidance. The System helps your surgeonmore precisely alignyour knee implant with computer imaging. Mostimportantly, with a NavigationalSystem your surgeon is able tobetter optimize the implants alignment according tothe structure ofyour body.

y Computer-Assisted Surgery also facilitates Minimally InvasiveSurgery (MIS)because it acts as an extension of the surgeons eyesand hands. It helps surgeonsoperate more effectively through asmaller incision

Robotic Assistance and Partial Knee Replacement

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Recently, the F DA has approved the use of robotic guidancesystems to assist your surgeonwith removing and resurfacing onlythe arthritic part of a knee without sacrificing your entirekneejoint. This minimally invasive procedure is performed through a 2-3inch incision andallows your surgeon to preserve as much of yournatural bone and tissue as possible.

C ardiothoracic surgery

Cardiothoracic surgery refers to surgery performed on the heart,lungs and esophagus.Cardiothoracic surgery is performed for canceras well as a range of non-cancerous (benign)conditions. Whenlifestyle changes, medication or other less invasive treatments donot helpyour condition, surgery is often recommended. If yourdoctor suggests surgery, learningabout all available treatmentoptions can help you to make the best decision for yoursituationand ease any anxiety you may feel about surgery. You mayalso want to find a doctor whospecializes in the procedure andapproach for your specific condition.

All surgeries carry risk, but traditional open surgery forcertain cardiothoracic conditionshave specific drawbacks such as along incision and rib-spreading to access the chest cavity

(sternotomy) which is associated with pain, trauma, a longrecovery and risk of infection.F ortunately, less invasive surgicaloptions are often available. The most common isconventionallaparoscopic surgery. With this approach, your surgeon uses smallincisions toinsert long-shafted instruments to operate on thetargeted organ or tissue. Laparoscopy iseffective for many routineprocedures, but has limits when the procedure, patients anatomyorcondition is challenging or complex.

If you need surgery to treat your cardiothoracic condition, youmay be a candidate for daVinci Surgery a safe, effective andminimally invasive procedure. Using the mostadvanced technologyavailable today, the da Vinci Surgical System allows your doctortoperform delicate and complex operations through a few tinyincisions with increased vision,precision, dexterity andcontrol.

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H ead and neck surgery

Head and neck surgery is performed for a range of conditions,including cancer, that affects apatients head and neck. Whenlifestyle changes, medication or other less invasive treatmentsdonot help your condition, surgery is often recommended. If yourdoctor suggests surgery,learning about all available treatmentoptions can help you to make the best decision for your situationand ease any anxiety you may feel about surgery. You may also wantto find adoctor who specializes in the procedure and approach foryour specific condition.

All surgeries carry risk, but traditional open surgery with alarge incision has significantdrawbacks pain, trauma, a longrecovery and risk of infection. F ortunately, less invasivesurgicaloptions are often available. The most common is conventionalendoscopic surgery.With this approach, your surgeon uses smallincisions to insert long-shafted instruments tooperate on thetargeted organ or tissue. Endoscopic surgery is effective for manyroutineprocedures, but has limits when the procedure, patientsanatomy or condition is challengingor complex.

If you need surgery to treat your condition, you may be acandidate for da Vinci Surgery asafe, effective and minimallyinvasive procedure. Using the most advanced technologyavailabletoday, the da Vinci Surgical System allows your doctor to performdelicate andcomplex operations through a few tiny incisions withincreased vision, precision, dexterityand control.

The da Vinci Surgical System provides patients with a minimallyinvasive treatment optionfor complex conditions affecting the headand neck, including:

y Throat Cancer

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What makes robotic surgery better?

With its 3-D view, the da Vinci Surgical System aids the surgeonto more easily identify vitalanatomy such as the delicate nervesand blood vessels surrounding specific anatomy. TheEndoWristInstruments provide the surgeon with the dexterity not availableusingconventional laparoscopic instruments to perform a delicateand precise surgical dissection ,reconstruction or removal ofspecific tissue. The da Vinci Surgical System isgroundbreakingtechnology that extends the surgeon's capabilities in the followingways:

y Enhanced 3-D Visualization: Provides the surgeon with a true3-dimensional view of the operating field. This direct and naturalhand-eye instrument alignment is similar toopen surgery with"all-around" vision and the ability to zoom-in and zoom-out.

y Improved Dexterity: Provides the surgeon with instinctiveoperative controls thatmake complex MIS procedures feel more likeopen surgery than laparoscopic surgery.

y Greater Surgical Precision: Permits the surgeon to moveinstruments with suchaccuracy that the current definition ofsurgical precision is exceeded.

y Improved Access: Surgeons perform complex surgical maneuversthrough 1-cm ports,

eliminating the need for large traumatic incisions.y IncreasedRange of Motion: EndoWrist Instruments restore full range of motionandability to rotate instruments more than 360 degrees through tinyincisions.

y Reproducibility: Enhances the surgeon's ability torepetitively perform technicallyprecise maneuvers such asendoscopic suturing and dissection.

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B enefits of Robotic Surgery

Robotic Surgery Da Vinci system gives the benefits to patient aswell as surgeon in many differentways. This type of technologyprovides comfortable position to be seated for surgeon,bettercontrol, and precision. It provides the following benefits tothe patient as well.

Less P ain Patient feels less pain and feels lessuncomfortable.

Less Marks This is a major benefit for the patient as less scarsare left on the body.Less Infection There are few chances ofpatient getting any kind of infection with thistreatment.

Short Stay Patient who gets operated by Robotic Surgery do notneed to stay in the hospitalsfor longer duration.

Quick Recovery This surgical process provides quick recoverytime to the patient.Low B leeding The patient has low bleedingwhile he gets operated through Robotic Surgery

Da Vinci system.

All those who feel that they are not left with much options toget their diseases cured instead of going for traditionalprocedures, need to give a thought to robotic surgery.

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LIMITATIONS

Current equipment is expensive to obtain, maintain, andoperate.

Surgeons and staff need special training.

Data collection of procedures and their outcomes remainslimited.

Current equipment is expensive to obtain, maintain and operate.If oneof the older model non-autonomous robots is being used,surgeons andstaff need special training. Data collection ofprocedures and their outcomes remains limited

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A pplicationsCardiac surgery

E ndoscopic coronary artery bypass surgery and mitral valvereplacement have been performed.Totally closed chest, endoscopicmitral valve surgeries are being performed now with the robot.

G astrointestinal surgery

M ultiple types of procedures have been performed with eitherthe Zeus or da Vinci robot systems,including bariatric surgery.

G ynecology

R obotic surgery in gynecology is one of the fastest growingfields of robotic surgery. This includes theuse of the da Vincisurgical system in benign gynecology and gynecologic oncology. Robotic surgerycan be used to treat f ibroids, abnormal periods,endometriosis, ovarian tumors, pelvic prolapse, andfemale cancers.Using the robotic system, gynecologists can perform hysterectomies,myomectomies,and lymph node biopsies. The need for large abdominalincisions is virtually eliminated.

N eurosurgery

S everal systems for stereotactic intervention are currently onthe market. M D R obotic's Neuro A rm isthe world first MRI-compatible surgical robot.

Orthopedics

The R OBODOC system was released in 1992 by the Integrated Surgical S ystems

Pediatrics

S urgical robotics has been used in many types of pediatricsurgical procedures including:

tracheoesophageal fistula repair, cholecystectomy, nissenfundoplication, morgagni hernia repair,kasai portoenterostomy,congenital diaphragmatic hernia repair, and others. On January 17,2002,surgeons at Children's Hospital of M ichigan in Detroitperformed the nation's first advanced computer-assistedrobot-enhanced surgical procedure at a children's hospital.

R adiosurgery

The CyberKnife R obotic R adiosurgery S ystem usesimage-guidance and computer controlled roboticsto treat tumorsthroughout the body by delivering multiple beams of high-energyradiation to the tumor from virtually any direction.

U rology

The da Vinci robot is commonly used to remove the prostate glandfor cancer, repair obstructedkidneys, repair bladder abnormalitiesand remove diseased kidneys.

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A DVA N TA GE S Robotic surgery offers many benefits overtraditional surgery. The Robotic Surgical System is greatforpatients and for surgeons. Robotic surgery gives us even greatervision, dexterity and precisionthan possible with standardminimally invasive surgery, so we can now use minimallyinvasivetechniques for a wider range of procedures. The patientside benefits include,

Reduced painFewer complicationsLess blood loss and need fortransfusions

Less post-operative pain and discomfortLess risk ofinfectionShorter hospital stay

Faster recovery and return to workLess scarring and improvedappearance

In today's operating rooms, you'll find two or three surgeons,an anesthesiologist and severalnurses, all needed for even thesimplest of surgeries. Most surgeries require nearly a dozenpeoplein the room. As with all automation, surgical robots willeventually eliminate the needfor some personnel. Taking a glimpseinto the future, surgery may require only one surgeon,ananesthesiologist and one or two nurses. In this nearly emptyoperating room, the doctor sits at a computer console, either in oroutside the operating room, using the surgical robot toaccomplishwhat it once took a crowd of people to perform.

The use of a computer console to perform operations from adistance opens up the idea of telesurgery , which would involve adoctor performing delicate surgery miles away from thepatient. Ifthe doctor doesn't have to stand over the patient to perform thesurgery, and cancontrol the robotic arms from a computer stationjust a few feet away from the patient, thenext step would beperforming surgery from locations that are even farther away. If itwerepossible to use the computer console to move the robotic armsin real-time, then it would bepossible for a doctor in Californiato operate on a patient in New York.

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The F uture of Robotic Surgery

The future of robotic surgery is hard to believe but ....it isnow. If you haven't noticed,robotic surgery has come long ways andit was only a dream for doctors and engineers tohave something thatyou no longer had to make big, hideous scars that would messupsomebody's body for the rest of their lives. Doctors, beforerobotic surgery, worked onmaking minimally invasive surgery thatwould take hours of surgery time. Now, surgery isstill made inhours, but shorter hours are now in check with the robotic surgery.So you can'treally say there is a future of robotic surgery, butyou can say that this has been the future for doctors long ago soall you can say is...the future is now!!

Robotic Surgery: Th e Future Is Now

The field of surgery is entering a time of great change, spurredon by remarkable recent advances in surgical and computertechnology. Computer-controlled diagnostic

instruments have been used in the operating room for years tohelp provide vitalinformation through ultrasound, computer-aidedtomography and other imagingtechnologies. Only recently haverobotic systems made their way into the operatingroom asdexterity-enhancing surgical assistants and surgical planners, inanswer tosurgeons' demands for ways to overcome the surgicallimitations of minimally invasivelaparoscopic surgery, a techniquedeveloped in the 1980s.

On July 11, 2000, the first completely robotic surgery device,the daVinci surgical systemfrom Intuitive Surgical (Mountain View,CA). The system enables surgeons to removegallbladders and performother general surgical procedures while seated at a computerconsole and 3-D video imaging system across the room from thepatient. The surgeonsoperate controls with their hands and fingersto direct a robotically controlled laparoscope. Atthe end of thelaparoscope are advanced, articulating surgical instruments andminiaturecameras that allow surgeons to peer into the body andperform the procedures.

They provide surgeons with the precision and dexterity necessaryto perform complex,minimally invasive surgical (MIS) procedures,such as beating-heart single- or double-vesselbypass andneurological, orthopedic, and plastic surgery, among many otherfutureapplications.

NANOTECHNOLOG

Some robots can be as small as or smaller than human cells. This is the field of nanotechnology. T he use of microscopic robotsis emerging as the next technologicalrevolution. I t looks atbuilding materials and devices with atomic precision. I maginethebroad implications for the future of medicine.

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Reduced Risk of Complications

Surgery is always an inherent risky medical procedure. However,for the treatment of cancer,surgical options can be the mosteffective choice in eradicating the malignant tumors withoutthepainful side effects of chemotherapy and radiation treatment.Among the most serious risks

associated with surgical treatments is the possibility ofinfection at the point(s) of incision. Suchinfections are often theprimary causes of serious complications which may hamper yourability toquickly and properly recover from your procedure. The daVinci system greatly mitigates that risk of infection in a numberof ways. First, the size of incision(s) made is significantlysmaller with roboticsurgery than with the traditional procedure. Astandard non-robotic prostatectomy typicallyrequires the surgeon tomake a six to eight inch vertical incision into the patient s lowerabdomen.Such a relatively large incision subjects the patient to anumber of operative and post-operativeinfectious agents. That is tosay that not only is the open incision site susceptible to anyinfectiousagents during the procedure, but also the closed butunhealed wound left from the incision may beat risk of contractingharmful infections. Post-operative infections are the more commonof the twoinfection risk categories, as hospital rooms cannot bemaintained at the extremely high level of sterility which operatingrooms are kept. The da Vinci robotic surgical system, however,utilizes amuch less invasive technique which requires four to fiveincisions smaller than two inches each.Each of these smallerincisions will heal significantly faster than the six to eight inchincision neededfor traditional surgery. Fewer sutures are needed toclose the robotic system s incisions. Thisquickens recovery time aswell as being less painful to you as the patent.

Quicker Recovery Period

When your physician determines surgery is your best treatmentoption and refers you to anontological surgeon, you can restassured that Dr. Samadi and the da Vinci system offer you thebestchance of a full and expedient recovery. Da Vinci s roboticsurgical technology optimizes yourchances of experiencing a quickerrecovery time opposed to traditional surgical prostatectomy.The

smaller incisions required to maneuver the operating arms healmuch faster, require less suturesand are less vulnerable to tearingor infection. The highly precise movements of the robotic armsallowfor cleaner removals of malignant tissue. Such precision alsoproduces a more targetedapproach which reduces damage to healthytissue during the operation. The design of the roboticoperatingarms allow for the entire procedure to be conducted without havingto leverage operatingtools against the walls of the incision. Allof these advantages translate to a speedier and lessworrisomerecovery period.

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Minimize Scarring

The sheer size of the incision needed to perform a traditionalprostatectomy produces significantscarring of the patient s lowerabdomen. The robotic prostatectomy procedure allows forincisionswhich can heal with little to no visible scarring. Inaddition to the obvious aesthetic value,minimizing scar tissue onthe interior walls of the incision can promote better healing oftheprostate. Excess scar tissue build up can sometimes interferewith the proper function of theprostate. Although such acomplication is typically considered rare, it is worth consideringwhenexploring treatment options. The precision of robotic surgeryoffers an inherent solution to thispotential difficulty. Byminimizing the total size of the incision needed to removecancerous tissuethis risk of scar tissue related complications isgreatly mitigated.

Surgeon Console

Robotic Assisted SurgeryThe surgeon operates while seatedcomfortably at the da Vinci Robotic System console viewing a3-Dimage of the operation. The surgeon s hand, wrist, and fingermovements are translated to thesurgical instruments inside thepatient while completing the robotic prostatectomy.

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Patient-side Cart

This part of the robot provides the instrument arms that arecompletely under the control of thesurgeon. The laparoscopic armspivot at the 1-cm operating ports eliminating the use of thepatient sbody wall for leverage and minimizing tissue damage.Supporting surgical team members assist ininstalling the properinstruments, preparing the 1-cm port in the patient, as well assupervise thelaparoscopic arms and tools being utilized whenever arobotic prostatectomy is underway.

InSite Vision System with high resolution 3-D Endoscope

This component provides true 3-D images of the operative field.Operative images are enhanced,refined and optimized using imagesynchronizers, high intensity illuminators and camera controlunitsduring the course of the robotic assisted su

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CONCLUSION

Robotic surgery is an emerging technology in the medical field.It gives us even

greater vision and precision than possible with standardminimally invasivesurgery, so we can now use minimally invasivetechniques for a wider range of procedures. for the future .