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Robotic surgeryUsing robots in the operating room to assist the surgeon in performing surgery. The surgeonviews the patient via a terminal and manipulates robotic surgical instruments via a controlpanel. Views of the organs being worked on are transmitted from tiny cameras inserted into

the body.

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

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

Robotic Operation gical.com)

The surgeon on the left is performing a laparoscopic operation on the patient via robotic instruments from IntuitiveSurgical. A traditional operating room procedure would require a much larger incision 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 manufacturing industries formaterial handling, welding, assembly, etc. so robots are designed as helping

hand. They help us in difficult, unsafe task. Machines th at can be programmedto perform a variety of jobs, and they can range from simple machines toohighly complex, computer controlled intelligent system. Robots are used inindustries, warehouse, laboratories, etc. Technocrats and Medical surgeon allover the world have joint hands for developing specialized robotic devices forperforming surgical operations too.This paper presents a robotic system for precise needle insertion under

radiological guidance for surgical interventions. It is compatible with port able

X-ray units and computer tomography scanners. The system presents modularstructure comprising global positioning, miniature robotic and radiolucentneedle driver modules. The system may be operated stand alone underjoystick control making it adaptable to operating rooms, or under full imageguided computer control.This paper will also proved brief classification, operation and practicalapplication in medical science. The R-T Friction transmission with axial loadingfor needle insertion gives the idea which where used in ancient year . Alsothis robot is control by the GPS system, which is far away from the operationroom

Robotic surgery is relatively new, and fundamental concepts are still beingformulated. Various medical robotics and computer aided surgery projectshave been undertaken at Imperial College over the last 10 years, many of which have been clinically applied. One conclusion, that has resulted, is thatthere is much benefit to be gained from the use of a force controlled lever onthe end of the robot, that is held by the surgeon as an input control system.This leads to improved levels of safety as well as clarifying that the surgeon isin charge of the procedure

Robotic surgery make use of Robots to perform surgery. Major potential advantages of roboticsurgery are precision and miniaturization. With our skilled surgeons and the robotic system, we cannow use minimally invasive techniques in even the most complicated 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 science fiction. Their descriptions ranged from the dumbmachine that replaced monotonous work as first describedby the Czech playwright Karel Capek in the classic play"Rossum's Universal Robots. In 1921 to the ultra-intelligentanthropomorphic robots of Isaac Asimov's classic sciencefiction books of the 1950's to the familiar R2D2 and C3PO

of Star Wars films beginning in the1970's to the incredible cyborgs of theTerminator film series. However it was arare exception that the depiction was that of a medical robot

Robots gradually made their way into factories for dangerous repetitive accurate tasks (automobileassembly), handling hazardous wastes in thenuclear industries (figure 1), great dexterity andprecision (computer chip assembly) and asdelivery robots, such as those by Joseph

Engelberger, MD (figure 2).None of these were anthropomorphic, they all were designed toprovide functionality. While many could exceed human performancein a specific dexterous task such as the MIT- Utah Hand (figure 3) or exceed human sensualperception, none achieved even the minimal intelligence of a two year old baby. Many triedto gain expertise in a specific domain, with various recognition capabilities, however theserobots were never able to demonstrate cognitive abilities. This is the background upon whichthe origins of medical robotics arose.

DEVELOPME NT OF CURRE NT SYS T EMS

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

exploration missions of Voyager andothers. At this time Jaron Lanier, whocoined the term "virtual reality" (VR),contributed the DataGlove and objectoriented program (his company VPL, Incwas an abbreviation for VisualProgramming Language), which made itpossible to interact with the threedimensional (3-D) virtual scenes. Scott


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F isher and Joe Rosen integrated these ideas of interactivity of VR and applied them tosurgical robotics. Their earliest concepts (figure 5) envisioned telepresence surgery (a termcoined by Scott F isher, who later started his own company called Telepresence ResearchInc.) using the DataGlove as a method of controlling the remote robotic hands.The NASA-Ames team had expertise in VR, but not robotics. Joe Rosen and Scott F isher took their vision to Phil Green, PhD at Stanford Research Institute (SRI, later changed to SRI

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

interface technology expertise, and was SRI's expert inthe emerging VR field. With Joe Rosen's clinical input,the first direction for development was as an extremelydexterous telemanipulator to greatly enhance vascular and nerve anastomoses for hand surgery. In keeping withthe VR and telepresence concept, the design focusedupon an intuitive interface (figure 6) which was able togive the surgeon the sense that (s)he were operating upona hand directly in front of their eyes, but which was infact located upon the other side of the room. Scott F isher was fond of saying that, although he could not teleport

(as in "Beam me up, Scotty") he could send his presence to a remote site.In 1988-89, the parallel development of laparoscopic cholecystectomy emerged on thesurgical front. Jacques Perrisat, MD of Bordeaux, F rance presented a video tape of alaparoscopic cholecystectomy to the Society of American Gastrointestinal EndoscopicSurgeons (SAGES) annual meeting in Atlanta, GA. The profound effect of the introductionof laparoscopic surgery to the main stream surgical community (in addition to the pioneeringprocedures performed by Joe Eddy Reddick, MD, Douglas Owens, MD, Barry McKearnen,MD and George Berci, MD) caused an explosion in the use of laparoscopic cholecystectomy.It soon became apparent that, although laparoscopic surgery was of great benefit to thepatient, it created an enormous difficulty for the surgeon, since there was the degrading of thesense of touch, the loss of natural 3-D visualization( 2) and impairment of dexterityprincipally due to the fulcrum effect of the instruments.While Joe Rosen was beginning animal and then early clinical trials with the GreenTelepresence Surgery System (as it was being called), Richard Satava, MD began workingfirst with the NASA-Ames group and then was introduced to the SRI telepresence team. As ageneral surgeon and surgical endoscopist, it was immediately evident that the telepresencesystem provided a number of solutions to the laparoscopic surgery problems ( 3). In responseto Rick Satava's suggestions, Phil Green began devoting the telepresence effort towardsmacroscopic surgery ( 4) and specifically to improving upon laparoscopic surgery, in additionto the microscopic surgery for Joe Rosen in hand surgery. A video tape of the telepresencesurgery system was demonstrated to COL Russ Zajtchuck, MD and Donald Jenkins, PhD of

the Borden Institute of Walter Reed Army Medical Center. They brought 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 the Internet). Under the Surgeon General'ssupport, ARPA (later to become DARPA in 1993) was requested to begin a program inAdvanced Biomedical Technologies, to include telepresence surgery (as it was now beingcalled). Donald Jenkins was requested to be co-program manager in this effort, which over the next 7 years funded a majority of projects in telepresence and robotic surgery.A third effort 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 with Russell Taylor, PhD of IBM's T.J. Watson Research Center( 5) to develop a robotic system (based upon the IBMPuma arm) that would be able to be used for hip replacement surgery (many breeds of dogs,including German shepards and golden retrievers came to Hap Paul 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 was a modification of the basicprincipals of the Puma Arm which enabled pre-operative planning of the procedure (to includematching the prosthesis exactly with the femur that would accept the prosthesis). RoboDoc wasable to precisely core out the femoral shaft with a96% precision, while standard hand broach was

able to provide an accuracy of only 75%. Dr. Barger then took the system to clinical trials in humans after Hap Paul proved itsefficacy (clinically) in his veterinarian practice and RoboDocis now a commercial product. Subsequently, other orthopedicsurgeons such as Dr. Anthony DiGioia, MD( 6), are developingother systems such as the HipNav for replacement of the kneeand hip joints.On the other side of the Atlantic at this same earl timeframe,two teams were producing early prototype surgical roboticsystems, one in each of the different categories as above. Onesystem by Sir John Wickham, MD and Brian Davies, PhD of Guy's Hospital in London( 7) was similar to RoboDoc in that itwas used for precise coring; but as a urologist, John Wickhamdeveloped the system to assist in trans-urethral resection of theprostate (TURP). This was a mechanically constrained systemwhich used a robotic arm similar to the Puma and RoboDoc.

However for patient safety, there was a large circular metal ring (figure 8) through which the resectioninstrument was passed and which prevented the roboticarm from moving out of the precise field of the prostate.After successfully proving the accuracy of the system onpotatoes and then a few patients in the clinic trial, JohnWickham was given permission to conduct studies onanimals to show efficacy and safety.The second system being developed in Europe was acollaboration of Hermann Rinnsland, PhD of theF orschungszentrum 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 developed Germany'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's workstation. This system, calledAdvanced Robot and Telemanipulator System for Minimally Invasive Surgery (ARTEMIS)(figure 9) had remote telemanipulators like the SRI system, but the surgeon's console had thehand input devices "over the shoulder" to provide extra manipulation abilities. The systemwas very efficient, however after the first prototype was developed and demonstrated to beeffective, funding for the F orschungszentrum project was not renewed and this promising


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

were investigating robotics to collaborate with neurosurgeons to precisely position probes,resection instruments, ablation devices and other surgical tools, principally for minimallyinvasive brain surgery. F rank Jolesz, MD of Brigham and Women's Medical Center andWilliam Lorensen, PhD of General Electric Research Center were pioneers in the open MRIsystem( 9) for real-time updates of brain images in the initial real-time, image-guidedneurosurgical systems. Neurosurgeon Richard Bucholz, MD of St. Louis University MedicalCenter( 10) was also independently developing a tracking system, called the Stealth Station,that could be used during neurosurgery to provide accurate stereotactic navigation duringsurgery. This effort resulted in an image guided system for real-time tracking of instrumentsin surgery. In the 1996, Daniel Karron, PhD of New York University, New York( 11 )developed an audio system that provided audio feedback depending upon proximity to theintended target, in essence an audio navigation assistance for the Stealth Station. This is oneof the only systems which were designed to provide synesthesia, the substitution of one sense(audio) for another sense (vision) in order to improve accuracy.Beginning in July, 1992, Rick Satava and Don Jenkins developed the Defense AdvancedResearch (DARPA) Advanced Biomedical Technologies (ABMT) program. The militaryimperative was to save soldiers that had been wounded on the battlefield using advancedtechnologies. Review of the Wound Data and Munitions Effectiveness Team (WDMET)database of the casualties of the Viet Nam war( 12) revealed that although great improvementhad occurred in overall mortality, when examining those soldiers with life threateningwounds in the far forward battlefield, there was little change from as early as the Civil War.As a rough generalization one-third died of head or massive injuries, about one third diedfrom wounds (principally exsanguinating hemorrhage) which were estimated to be survivalbased upon today's technology, and one-third survived. A comprehensive program wasinitiated, utilizing advanced sensor, robotics, telemedicine and virtual reality systems. One of

the prime concepts was to implement Scott F isher and Joe Rosen's idea to "bring the surgeon to thewounded soldier - through telepresence". The GreenTelepresence Surgery System was seen as a methodof providing surgical care right on the battlefield tosave those soldiers which would otherwiseexsanguinate( 13). It was envisioned that the roboticmanipulator arms would be mounted in a vehicle for Medical F orward Advanced Surgical Treatment(MED F AST). The vehicle chosen was a BradleyF

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

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


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MASH. In 1996, a military field test was conducted by SRI, International whichdemonstrated successfully that surgery could be performed over a 5 kilometer distance with amicrowave telecommunication link-up between a MASH hospital and the MED F AST.However, the battlefield of the 1990's was changing from conventional, open battlefields tothe close quarters of urban terrain, which was ill suited for the MED F AST vehicle. Althoughsuccessfully demonstrated on the animal model, the system has not yet been implemented for

battlefield casualty care.A significant number of other robotic surgery applications were being developed by DARPAto provide solutions for many of the difficult issues. Thomas Sheridan, PhD of MassachusettsInstitute of Technology (MIT)( 14) was tackling the latency problem - the time of travel of theelectronic signal from the moment the handle of the instrument on the workstation moveduntil the signal arrived at the tip of the manipulator. It is known that humans can compensatefor latency (delay) of up to 200 milliseconds (msec), after which the delay is too great for accuracy. Tom Sheridan was attempting to solve the problem by predictive algorithms, andwas successful in demonstrating tolerance of delay up to 300 msec. Other investigators suchas Alberto Rovetta, PhD of Milan, Italy, have tried to work around the problem by havingidentical software programs at the two remote places, so the only thing transmitted is thehand signals. In 1993, Alberto Rovetta( 15) was able to successfully perform a liver biopsy ona pig liver with the surgeon's station being at the NASA Jet Propulsion Lab (JPL) inPasadena, CA and the manipulators and pig liver in his laboratory in Milan. The time lagusing a satellite was over 1200 msec (1.2 seconds). (Note: it takes about 1.2 sec for a signalto be transmitted to a geosynchronous satellite 22,000 milesabove the earth and then return).Other contributions occurring came from Kenneth Salisbury,PhD, Marc Raibert, PhD, and Robert Playter, PhD from theMIT Artificial Intelligence and Robotics Laboratory under the direction of Rodney Brooks, PhD. This group wasworking upon the haptics (sense of touch) and developed anaccurate force feedback system for the robotic devices( 16).This became a commercial product called "The Phantom"(figure 11), which has become the industry standard for providing haptics to a virtual environment and the basics for robotics systems. Other researchers from MIT working to improve telepresence surgery inone fashion or another included Blake Hannaford, PhD and David Brock, PhD.

TH E COMMERC IA L IZATI O N YE A RSThe commercialization of robotic surgery started with the RoboDoc system in 1992-93 as indicatedabove. In spite of the exceptional performance of RoboDoc, the system went through a prolongedapproval process with the Food and Drug Administration (FDA). However for direct surgicalmanipulation in laparoscopic surgery, the first application was to control the camera in laparoscopicsurgery. With initial seed funding from DARPA, Yulun Wang, PhD began developing the Automated

Endoscopic System for Optimal Positioning (AESOP)( 17) in hisnewly formed company, Computer Motion, Incorporated.This provided acceptance by the medical and surgicalcommunity of robotics as an effective assistive device. Thissystem was the first robotic device to receive FDA approvaland launched the robotics in general surgery movement.During this timeframe, image guided surgery systems began


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commercialization with both the NeuroMate in Switzerland (figure 12), and Richard Bucholz's Stealthsystem. These systems were specifically developed for neurosurgery, as was the General Electricopen magnetic resonance imaging (MRI) that waspopularized by 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 rights and started IntuitiveSurgical, Inc. After extensive redesigning from the

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

put their system, Zeus (figure 14), into production. Bothsystems are similar, in that they have remote manipulators which are controlled by a surgical workstation. One major difference is in the surgical workstations. The daVinci system has stereoscopicimage which is displayed just above the surgeon's hands so it appears as if the surgical instrumenttips are an extension of the handles - this gives the impression that the patient is actually right infront of the surgeon (or conversely, that the surgeon's presence has been transported to right nextto the patient - hence the term tele-presence). The Zeus system is ergonomically designed with themonitor comfortably in front of the surgeon's chair and the instrument handles in the correct eye-hand axis for maximum dexterity. There is no illusion of being at the patient's side, rather there isthe sense of an operation at distant site but with enhanced capabilities. Initially, the daVinci systemwas the only one with an additional degree of freedom, a "wrist"; however recently the Zeus systemhas introduced instruments with a wrist.The concept of dexterity enhancement was suitable for the emerging laparoscopic surgery field, andespecially for minimally invasive cardiac surgery applications. Although the original GreenTelepresence Surgery system was designed for remote trauma surgery on the battlefield, thecommercial telepresence systems were envisioned fordelicate cardiac surgery, specifically coronary artery bypassgrafting. It was believed that the robotic systems would allowminimally access surgery on the beating heart. This is to beachieved by first blocking and then overpacing the heart andgating 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 in development.The challenge of extremely accurate and dexterous robotics was chosen for ophthalmologic surgery,and specifically for laser retinal surgery. The blood vessels on the retina are 25 microns apart.Human performance limits are an accuracy of approximately 200 microns. Stephen Charles, MD of Baptist Hospital and MicroDexterity Systems, Inc (MDS) in Memphis, TN collaborated with a brilliantteam at NASA Jet Propulsion Laboratory (JPL), which included Paul Schenker, Hari Das, EdwardBarlow and othersa to develop the Robot Assisted MicroSurgery (RAMS) system (figure 15). This


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

The issue of remote surgery using robotics was limited to short distances because of the latencyissue. It was only recently (2001) that the Zeus system was used for a trans-Atlantic robotic surgeryoperation between New York City and Strasbourg, France by Jacques Marescaux and MicheleGagner. The limitation to long distance surgery is the latency or delay, which cannot exceed 200msec. At longer delays, the time from the hand motion of the surgeon until the action of the robot'send effector (instrument) is so great that the tissue could move and the surgeon would cut thewrong structure. In addition with delays greater than 200 msec there is conflict within system suchthat the robotic system becomes unstable. However, Marescaux and Gagner employed a dedicatedhigh-bandwidth Asynchornous Transfer Mode (ATM) terrestrial fiberoptic cable and were able toconduct the surgery with a delay of only 155 msec. Thus, with very broadband, terrestrial fiber opticcable connection, it is possible to perform remote 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 a reality 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 robotics revolution. All of the systems havein common a central workstation from which the surgeon conducts the surgery.

This workstation (see figures 13,14) is the central point which integrates the entire spectrumof surgery (figure 16). Patient specific pre-operative images can be imported into the surgicalworkstation for pre-operative planning and rehearsal of a complicated surgical procedure, asis being developed by Jacques Marescaux, MD ( 19).F igure 17 illustrates a patient's liver with a malignantlesion, and the methods of visualizing, pre-operativeplanning and procedure rehearsal. At the time of surgery, this image can be imported into theworkstation for intra-operative navigation. It can also


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be used as a stand alone workstation for surgical simulation for training of surgical skills andoperative techniques. Thus, on an invisible level, the challenge is going to be to perform theintegration of the software of all the different elements, such as importing images, pre-operative planning tools, automatic segmentation and registration for data fusion and imageguidance and sophisticated decision and analysis tools to provide automatic outcomesanalysis of the surgical procedure.

On a technical side, few if any of the systems include the full range of sensory input (eg.sound, haptics or touch) and there are but a few simple instruments (end effectors). The nextgeneration systems will add the sense of touch, and improved instruments. The instrumentswill need to be both standard mechanical instruments as well as energy directed instrumentssuch as electrocoagulation, high intensity focused ultrasound, radio-therapy, desiccation,ablation etc. In addition advanced diagnostic systems, such as ultrasound, near infra-red, andconfocal microscopy can be mounted on the robotic systems and used for minimally invasivediagnosis. The systems will become smaller, more robust (not require a full time technician)and less expensive. They will adapt for the requirements of the other surgical subspecialties.In the evolution of the robotics, the systems will become more intelligent, eventuallyperforming most, if not all, of an operative procedure. In current systems such as RoboDocand NeuroMate, the surgeon preplans the operation on patient specific CT scans. This plan isthen programmed into the surgical robot, and the robot performs precisely what the surgeonwould have done if (s)he were performing the operation, but with precision and dexterityabove human limitations. This is a trend which will continue, with the surgeon planning moreand more of the operation which the robot can effectively and efficiently carry out. The robotmust be under complete control of the surgeon, in case something unexpected were to occur and the surgeon would take over. It is conceivable that in the distant future under specialcircumstances such as remote expeditions or the NASA Mission to Mars, that robots wouldbe performing the entire surgical procedure. However in the near future there will bedevelopment of hybrid hardware-software systems that will perform complete portions of anoperation, such as an anastomosis, nerve grafting, etc.These systems will require a complicated infrastructure, and the operation room (OR) of the

F uture will have to accommodate them. The uniquerequirements for 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 an evolution of the OR to resemble more of a "controlroom" because of the large number of electronics whichneed to be controlled. An interesting product involved

with patient monitoring and control is the Life Support for Trauma and Transport (LSTAT)(figure 18), which is in essence an entire intensive care unit (ICU). Although the LSTAT wasdeveloped by the military as an evacuation system

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


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maintaining continuous monitoring.There has been speculation about the use of nanotechnology to inject miniscule robots intothe blood stream to migrate or be navigated to the target. Numerous concept diagrams showmechanical types of systems that either are controlled by a surgeon or are autonomous. Whileinteresting conceptually, there is little practical understanding of how to actually 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 to the eye, will probably bemanufactured chemically by the billions, and will not be controlled but rather, like drugdesign, be programmed to recognize certain cell or tissue types to deliver medication or causeablation.F requently micro-electro-mechanical systems (MEMS) are discussed in conjunction withnanotechnology, however these systems are one thousand times larger (1.0 x 10-6meters)than nanotechnology (1.0 x 10-9meters). Such systems would be visible as very tiny robots

which could be directly controlled by a surgeon. However as the technology scales down in size, it also scales downin power or force which can be generated, making itextremely difficult to actually conduct work at this scale.While there are a number of MEMS robots (figure 20),none are actually performing any significant work, let aloneany activity resembling a surgical procedure. Nevertheless,MEMS and nanotechnology are areas for future potential

surgical robotics which will take decades to develop and perfect. It is essential for surgeons tobe aware of these technologies, and others such as quantum mechanics, biomimetic materialsand 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 and miniaturization. Further advantages are articulation beyond normalmanipulation and three-dimensional magnification. At present, surgical robots are not autonomous,

but are always under the control of a surgeon. They are used as tools to extend the surgical skills of atrained surgeon.Robotic surgery is different from minimally invasive surgery. Minimally invasive surgery (sometimescalled laparoscopic surgery) is a general term for procedures that reduce trauma by performingoperations through small ports rather than large incisions. Minimally invasive surgery is nowcommonplace for certain procedures. But until now, we haven't been able to use minimally invasivetechniques for more complex operations. With our skilled surgeons and the robotic system, we cannow use minimally invasive techniques in even the most complicated procedures like Cardiacsurgery, 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 a hip replacement Intuitive SurgicalSystem introduce the da Vinci Robot in 1995 and Computer Motion, AESOP and the ZEUS roboticsurgical system.. In 1988, the PROBOT was used to perform prostatic surgery in England. TheROBODOC from Integrated Surgical Systems was introduced in 1992, and is a robot to mill out

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

Robot-assisted surgery is the latest development in the larger movement of endoscopy, a typeof minimally invasive surgery the idea being that less invasive procedures translate intoless trauma and pain for patients. Surgery through smaller incisions typically results in lessscarring and faster recovery. It's not that robots are changing the basics of surgery. Surgeonsare still cutting and sewing like they have been for decades. Robots represent a newcomputer-assisted tool that provides another way for surgeons to work.

Rather than cutting patients open, endoscopy allows surgeons to operate through smallincisions by using an endoscope. This fiber optic instrument has a small video camera thatgives doctors a magnified internal view of a surgical site on a television screen.

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

With robotic surgical systems, surgeons don't move endoscopic instruments directly withtheir hands. Instead, surgeons sit at a console several feet from the operating table and usejoysticks similar to those used in video games. They perform surgical tasks by guiding themovement of the robotic arms in a process known as tele-manipulation.

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

and hardware and requires manufacturers to implement training programs for surgeons. The FDAalso monitors experimental uses for robotic applications, including clinical trials for robotic heartsurgery. It's too soon to say for sure how far and how fast robotic surgery will grow, but experts saythe future looks promising

Robot's hands. A surgical robot is a computer controlled and self powered device whichcan be programmed to manipulate various surgical instruments. Robotic Surgery Da Vinci can be used for numerous different procedures including Coronary Artery Bypass, Blood Vessels, Nerves, Kidney Removal and Transplant, Tubal Ligation, Mitral Valve Repair,Gallbladder Robotic Surgery is a microsurgery which is performed by surgeons bymanipulating removal and Hip Replacement etc.

Robotic Surgery is a microsurgery which is performed by surgeons by manipulating Robot'shands. A surgical robot is a computer controlled and self powered device which can beprogrammed to manipulate various surgical instruments. Robotic Surgery Da Vinci can beused for numerous different procedures including Coronary Artery Bypass, Blood Vessels,Nerves, Kidney Removal and Transplant, Tubal Ligation, Mitral Valve Repair, Gallbladder removal and Hip Replacement etc.


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SURGICAL PLANNING

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

T he imaging of the patient may be accomplished via various means. T he main method isthat of computer tomography (C T ). C T is the process whereby a stack of cross-sectionalviews of the patient are taken using magnetic-resonance-imaging or x-ray methods. T hiskind of imaging is necessary for all types of operative procedure and, as such, does notdiffer from traditional surgical techniques. T his two-dimensional (2D) data must thenbe converted into a 3D model of the patient (or, more usually, of the area of interest ).T he reasons for this transformation are twofold. Firstly, the 2D data, by its very nature,is lacking in information. 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 issues as volume (of, for instance, a tumour) or, position(with respect to distances perpendicular to the cross-sectional data). Secondly, it is 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 readily accomplishable through volumegraphics methods (see Volume G raphics: T he road to interactive medical imaging?).T hese methods produce computer-graphics-based models that possess such features asthe ability to rotate the model, view its interior, zoom in, and so on. T hat is, all thecapabilities of current computer-aided-design (C A D) systems. A s may be expected,however, the processing requirements of these modelling systems are rather large, asare the costs of the hardware necessary. I t should be noted, however, that the speed of said hardware is increasing all the time and the price will decrease too, as thetechnology involved becomes 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 of the plan itself. T hisinvolves determining the movements and forces of the robot in a process called 'pathplanning' - literally planning the paths that the robot will follow.

I t is here that the 3D patient model comes into play, as it is where all the measurementsand paths are taken from. T his emphasises the importance of the accuracy of the model,as any errors will be interpreted as absolute fact by the surgeons (and hence the robot)in their determination of the plan. H ere, surgeons are reliant upon the engineeringbehind the system that is being used - thus the need for reliable systems (discussed inthe section on safety).


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What is robotic surgery?

Robotic surgery is an extension of laparoscopic surgery. Most people are familiar withlaparoscopy. Surgery is performed by manipulating straight instruments while viewing theinstruments on a monitor. Robotic surgery is the evolution of laparoscopy that addresses thedrawbacks of laparoscopy.

One obstacle of laparoscopy is the loss of 3-D spatial relationshipssince the 2-D monitor is used to operate. The da Vinci SurgicalSystem uses a laparoscope that is comprised of 2 cameras and lensesto provide the surgeon with a true minimally invasive 3-D view of thesurgical field including depth of field, magnification and highresolution.

Laparoscopic instruments have the feel of "chop sticks". The DaVinci Surgical Cart includes the EndoWrist Instruments. The EndoWristInstruments are designed to mimic the movement of the humanhands, wrists and fingers. The extensive range of motion allowsprecision that is not available in standard minimally invasiveprocedures.

Laparoscopic surgery places the surgeon in an uncomfortable position that can lead to ahigher rate of surgical errors. The DaVinci Surgeon Console contains

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


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THE SURGE RY

Robotic surgery is the process whereby a robot actually carries out a surgical procedureunder the control of nothing other than its computer program. A lthough a surgeonalmost certainly will be involved in the planning of the procedure to be performed andwill also observe the implementation of that plan, the execution of the plan will not beaccomplished by them - but by the robot.

A robot's motions can be precisely controlled and constrained through its programmingT his results in undeviating trajectories, high accuracies with predictable velocities andaccelerations with no overshoot. A s expected when dealing with automated processes,the benefits of repeatability and reliability are inherent.


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W hat are the components of the robot?

The da Vinci Surgical System is an integral part of the operating room and supports theentire surgical team. The System consists of a surgeon console, patient-side cart, instrumentsand image processing equipment.

y The Surgeon ConsoleUsing the da Vinci Surgical System, the surgeon operates while seatedcomfortably at a console viewing a 3-D image of the surgical field.The surgeon's fingers grasp the master controls below the display withhands and wrists naturally positioned relative to his or her eyes. Thetechnology seamlessly translates the surgeon's hand, wrist and finger movements into precise, real-time movements of our surgicalinstruments inside the patient.

y Patient-side CartProvides the four robotic arms two or three instrument arms andone endoscope arm that execute the surgeon's commands. Thelaparoscopic arms pivot at the 1-cm operating ports eliminating theuse of the patient's body wall for leverage and minimizing tissuedamage. Supporting surgical team members assist in installing theproper instruments, prepare the 1-cm port in the patient, as well assupervise the laparoscopic arms and tools being utilized.

y EndoWrist InstrumentsA full range of instruments are provided to support the surgeon whileoperating. The instruments are designed with seven degrees of motionthat mimic the dexterity of the human hand and wrist. Each instrumenthas a specific surgical mission such as clamping, suturing and tissuemanipulation. Quick-release levers speed instrument changes duringsurgical procedures.

InSite Vision System with high resolution 3-D Endoscope and Image ProcessingEquipmentProvides the true to life 3-D images of the operative field. Operatingimages are enhanced, refined and optimized using image synchronizers,high-intensity illuminators and camera control units


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3D HD VISION

The vision system of the da Vinci Si delivers high resolution video into the viewer located atthe surgeon console. This provides surgeons with visual sharpness that is greater thananything previously available.

As the surgeon operates, the da Vinci vision system displays high definition video in 3D for true perception of depth. The immersive quality of the 3D vision provides a virtual extensionof the surgeons hands and eyes into the patients body.

The digital zoom feature provides a highly magnified view of tissue. Increased surgeonconfidence results from this superior view of 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 of Santa Barbara California has become the leading producer of medical robotics.Different types of robots are da Vinci, Aesop and Zeus.The da Vinci Surgical System was the first operative surgical robot. Products like Aesop, Hermes, andZeus are the next generation of surgical equipment and are used together to create a highly

networked and efficient operating room.

3.1. da Vinci Surgical SystemIncorporating the latest advancements in robotics and computer technology, the da Vinci SurgicalSystem was the first operative surgical robot deemed safe and effective by the United States Foodand Drug Administration for actually performing surgery.The da Vinci system was developed by Intuitive Surgical system, which was established in 1995. Itsfounders used robotic surgery technology that had been developed at SRI International, previouslyknown as Stanford Research Institute. The FDA approved da Vinci in May 2001The da Vinci is a surgical robot enabling surgeons to perform complex surgeries in a minimally

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

Until very recently surgeons options included traditional surgery with a large open incision orlaparoscopy, which uses small incisions but is typically limited to very simple procedures. The daVinci Surgical System provides surgeons with an alternative to both traditional open surgery andconventional laparoscopy, putting asurgeon's hands at the controls ofa state-of-the-art robotic platform. The da Vinci System enablessurgeons to perform even the most complex and delicate procedures through very small incisionswith unmatched precision. It is important to know that surgery with da Vinci does not place a robotat the controls; surgeon is controlling every aspect of the surgery with the assistance of the da Vincirobotic platform. Thus da Vinci is changing the experience of surgery for the surgeon, the hospitaland most importantly for the patient.3.2. AesopAesop's function is quite simple merely to maneuver a tiny video camera inside the patientaccording to voice controls provided by the surgeon. By doing so, Aesop has eliminated the need fora member of the surgical team to hold the endoscope in order for a surgeon to view his operativefield in a closed chest procedure. This advance marked a major development in closed chest or port-access bypass techniques, as surgeons could now directly and precisely control their operative fieldof view. Today about 1/3 of all minimally invasive procedures use Aesop to control an endoscope.Considering each Aesop machine can handle 240 cases a year, only 17,000 machines are needed to

handle all minimally invasive procedures a relatively small number considering the benefits of thistechnology.3.3. ZeusZeus is the youngest and most technically advanced robotic aid. Zeus contains robotic arms thatmimic conventional surgical equipment and a viewing monitor that gives the surgeon a view of hisoperative field. More importantly, Zeus enables a surgeon to operate on a patient using joystick likehandles which translate the surgeon's hand movements into precise micro-movements inside thepatient. For example a 1-cm movement by a surgeon's hand is translated into a .1 cm movement of


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the surgical tip held by a robotic arm. Zeus also has the unique capability of reducing human handtremor and greatly increasing the dexterity of the surgeon. Zeus allows surgeons to go beyond thelimits of MIS enabling a new class of delicate procedures currently impossible to perform. The maindisadvantage is high machine cost. It is around 1 million dollars. Its FDA approval is pending.

A lternative N ames of Robotic Surgery

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

Categories of Robotic Surgery

Robotic Surgery is further sub divided into three categories named as Supervisory ControlledSystem, Telesurgical System and Shared Control System.

Supervisory Controlled System: - This procedure is only executed by robot which performsaccording to the surgeon inputs already given in a computer program.Telesurgical System: - It is also called remote surgery that requires the surgeon who willmanipulate the arms of robotic throughout the procedure. It is called remote surgery becausesurgeon can operate this type of surgery from remote location by using sensor data of robot.The primary device that is used for this type of surgery is da Vinvi surgical system.Shared Control System: - This type of procedure is performed by maximum involvement of surgeon.

All these procedures can be used to perform robotic surgery that use computer imaging tomake a diagnosis and to perform various operations. These computer imaging modalitiesproduce 3D Images through Magnetic Resonance Imaging (MRI) and ComputedTomography (CT). It also produces 2D imaging through X-Ray Radiography, F luoroscopyand Ultrasonography. Computer Tomography (CT) is main method used for computer imaging out of all these Registration ? It is the process of coordinating the imaging data withthe patient.Navigation - In this step, actual surgery is performed. The surgeon firstly positions the robotas well patient and then surgeon starts the robot to follow the computer programmed


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Medical Robots and T elepresence

SRIs telepresence capabilities leverage our comprehensive portfolio of expertise, whichincludes stereo imaging, telerobotics, sensory devices, video, speech recognition, andtelecommunications, to perform monitoring, actual operations, and assistance-relatedactivities from remote locations in real-time.

Learn about our leading capabilities for life-changingapplications in:

Telepresence surgery Medical automation robots : Trauma Pod and M7Telerobotics 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 about recentdevelopments.

T elepresence Surgery(1993 - present)

SRI's novel approach to minimally

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

SRIs telepresence surgical system allowssurgeons to remotely perform minimallyinvasive surgical procedures from aseparately located operating theater. In1995, SRI spin-off company IntuitiveSurgical, Inc., licensed the technology andis now the global market leader in surgicalrobotics. Throughout the U.S., Europe,and Asia, surgeons use the technology to

help patients recover faster, with less painand fewer complications.

Telepresence surgery carries some uniquebenefits because it provides the right feedback and immersive environment to allow for thesurgeon to effectively use tools in a natural way with the sameor even betterdexteritythan are possible when operating directly.

M7's robotic arms in a modular surgical platform.

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


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

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

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

y Enhanced high-definition 3 D v ision for superior clinical capability

y A n updated user interface for streamlined setup and OR turnover

y Ex tensibility for digital OR integration

The da Vinci S HD Surgical System integrates 3D HD endoscopy and state-of-the-art robotictechnology to virtually extend the surgeons eyes and hands into the surgical field. Only theda Vinci System enables new, minimally invasive options for complex surgical procedures.

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 and electronics that createsurgical immersion. The Surgeon's Console gives doctors the control and ability to navigateinside the patient. The InSite Vision System immerses surgeons in a true-to-life 3-D image.The Navigator TM Camera Control allows the surgeon to easily change, move, zoom and rotatehis or her field of vision. The camera can be repositioned quickly and smoothly within thesurgical opening without disrupting the procedure. The EndoWrist Instruments transformmovement of the doctor's wrists, hands and fingers into movement of the tiny instruments.

The da Vinci Surgical System is the only commercially available technology that can providethe surgeon with the intuitive control, range of motion, fine tissue manipulation capabilityand 3-D visualization characteristic of open surgery, while simultaneously allowing thesurgeon to work through small ports of minimally invasive surgery.

Using the da Vinci System, surgeons can operate with the look and feel of open surgery,performing complex surgical maneuvers through 1-cm ports.

W ORK ING O F ROBOT IC SYST EM

Today's robotics devices typically have a computer software component that controls the movementof mechanical parts of the device as it acts on something in its environment The software is"command central" for the device's operation.Surgeon sits in the console of the surgical system several feet from the patient. He looks through thevision system - like a pair of binoculars - and gets a huge, 3-D view of inside the patient's body andarea of the operation.The surgeon, while watching through the vision system, moves the handles on the console in thedirections he wants to move the surgical instruments. The handles make it easier for the surgeon tomake precise movements and operate for long periods of time without getting tired.The robotic system translates and transmits these precise hand and wrist movements to tinyinstruments that have been inserted into the patient through small access incisions.This combination of increased view and tireless dexterity is helping us overcome some of thelimitations of other types of less invasive surgery. It's also allowing us to finally use minimallyinvasive surgery for more complex operation

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


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Orthopedic Surgeon

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

Navitrack Navigation System (OrthoSoft)

Computer- A ssisted Robotic Surgery

Robotics: Through computer-assisted surgery, surgeon obtains 3-D visualization allowinggreater visibility, corrective alignment and balance of the implant joint.

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

y More exact implant placementy Extended life of the implanty Optimal joint positioning which restores mobilityy Decreased possibility of a revision surgeryy F aster recoveryy Improvement in your quality of lifey Advanced computer-assisted surgical solutions that greatly enhance the precision and

accuracy of hip and knee replacement surgeries.y Think of a Navigational System as an assistant to surgery, providing your surgeon

with extra support and guidance. The System helps your surgeon more precisely alignyour knee implant with computer imaging. Most importantly, with a NavigationalSystem your surgeon is able to better optimize the implants alignment according tothe structure of your body.

y Computer-Assisted Surgery also facilitates Minimally Invasive Surgery (MIS)because it acts as an extension of the surgeons eyes and hands. It helps surgeonsoperate more effectively through a smaller incision

Robotic Assistance and Partial Knee Replacement


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Recently, the F DA has approved the use of robotic guidance systems to assist your surgeonwith removing and resurfacing only the arthritic part of a knee without sacrificing your entireknee joint. This minimally invasive procedure is performed through a 2-3 inch incision andallows your surgeon to preserve as much of your natural 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 cancer as well as a range of non-cancerous (benign)conditions. When lifestyle changes, medication or other less invasive treatments do not helpyour condition, surgery is often recommended. If your doctor suggests surgery, learningabout all available treatment options can help you to make the best decision for your situationand ease any anxiety you may feel about surgery. You may also want to find a doctor whospecializes in the procedure and approach for your specific condition.

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

(sternotomy) which is associated with pain, trauma, a long recovery and risk of infection.F ortunately, less invasive surgical options are often available. The most common isconventional laparoscopic surgery. With this approach, your surgeon uses small incisions toinsert long-shafted instruments to operate on the targeted organ or tissue. Laparoscopy iseffective for many routine procedures, but has limits when the procedure, patients anatomyor condition is challenging or complex.

If you need surgery to treat your cardiothoracic condition, you may be a candidate for daVinci Surgery a safe, effective and minimally invasive procedure. Using the mostadvanced technology available today, the da Vinci Surgical System allows your doctor toperform delicate and complex operations through a few tiny incisions with increased vision,precision, dexterity and control.


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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. When lifestyle changes, medication or other less invasive treatmentsdo not help your condition, surgery is often recommended. If your doctor suggests surgery,learning about all available treatment options can help you to make the best decision for your situation and ease any anxiety you may feel about surgery. You may also want to find adoctor who specializes in the procedure and approach for your specific condition.

All surgeries carry risk, but traditional open surgery with a large incision has significantdrawbacks pain, trauma, a long recovery and risk of infection. F ortunately, less invasivesurgical options are often available. The most common is conventional endoscopic surgery.With this approach, your surgeon uses small incisions to insert long-shafted instruments tooperate on the targeted organ or tissue. Endoscopic surgery is effective for many routineprocedures, but has limits when the procedure, patients anatomy or condition is challengingor complex.

If you need surgery to treat your condition, you may be a candidate for da Vinci Surgery asafe, effective and minimally invasive procedure. Using the most advanced technologyavailable today, the da Vinci Surgical System allows your doctor to perform delicate andcomplex operations through a few tiny incisions with increased vision, precision, dexterityand control.

The da Vinci Surgical System provides patients with a minimally invasive treatment optionfor complex conditions affecting the head and 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 surgeon to more easily identify vitalanatomy such as the delicate nerves and blood vessels surrounding specific anatomy. TheEndoWrist Instruments provide the surgeon with the dexterity not available usingconventional laparoscopic instruments to perform a delicate and precise surgical dissection ,reconstruction or removal of specific tissue. The da Vinci Surgical System isgroundbreaking technology that extends the surgeon's capabilities in the following ways:

y Enhanced 3-D Visualization: Provides the surgeon with a true 3-dimensional view of the operating field. This direct and natural hand-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 instinctive operative controls thatmake complex MIS procedures feel more like open surgery than laparoscopic surgery.

y Greater Surgical Precision: Permits the surgeon to move instruments with suchaccuracy that the current definition of surgical precision is exceeded.

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

eliminating the need for large traumatic incisions.y Increased Range of Motion: EndoWrist Instruments restore full range of motion andability to rotate instruments more than 360 degrees through tiny incisions.

y Reproducibility: Enhances the surgeon's ability to repetitively perform technicallyprecise maneuvers such as endoscopic suturing and dissection.


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B enefits of Robotic Surgery

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

Less P ain Patient feels less pain and feels less uncomfortable.

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

Short Stay Patient who gets operated by Robotic Surgery do not need to stay in the hospitalsfor longer duration.

Quick Recovery This surgical process provides quick recovery time to the patient.Low B leeding The patient has low bleeding while he gets operated through Robotic Surgery

Da Vinci system.

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


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LIMITATIONS

Current equipment is expensive to obtain, maintain, and operate.

Surgeons and staff need special training.

Data collection of procedures and their outcomes remains limited.

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 of procedures and their outcomes remains limited


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A pplicationsCardiac surgery

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

G astrointestinal surgery

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

G ynecology

R obotic surgery in gynecology is one of the fastest growing fields of robotic surgery. This includes theuse of the da Vinci surgical system in benign gynecology and gynecologic oncology. R obotic 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 abdominal incisions is virtually eliminated.

N eurosurgery

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

Orthopedics

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

Pediatrics

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

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

R adiosurgery

The CyberKnife R obotic R adiosurgery S ystem uses image-guidance and computer controlled roboticsto treat tumors throughout the body by delivering multiple beams of high-energy radiation to the tumor from virtually any direction.

U rology

The da Vinci robot is commonly used to remove the prostate gland for cancer, repair obstructedkidneys, repair bladder abnormalities and remove diseased kidneys.


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A DVA N TA GE S Robotic surgery offers many benefits over traditional surgery. The Robotic Surgical System is greatfor patients and for surgeons. Robotic surgery gives us even greater vision, dexterity and precisionthan possible with standard minimally invasive surgery, so we can now use minimally invasivetechniques for a wider range of procedures. The patient side benefits include,

Reduced painFewer complicationsLess blood loss and need for transfusions

Less post-operative pain and discomfortLess risk of infectionShorter hospital stay

Faster recovery and return to workLess scarring and improved appearance

In today's operating rooms, you'll find two or three surgeons, an anesthesiologist and severalnurses, all needed for even the simplest of surgeries. Most surgeries require nearly a dozenpeople in the room. As with all automation, surgical robots will eventually eliminate the needfor some personnel. Taking a glimpse into the future, surgery may require only one surgeon,an anesthesiologist and one or two nurses. In this nearly empty operating room, the doctor sits at a computer console, either in or outside the operating room, using the surgical robot toaccomplish what it once took a crowd of people to perform.

The use of a computer console to perform operations from a distance opens up the idea of telesurgery , which would involve a doctor performing delicate surgery miles away from thepatient. If the doctor doesn't have to stand over the patient to perform the surgery, and cancontrol the robotic arms from a computer station just a few feet away from the patient, thenext step would be performing surgery from locations that are even farther away. If it werepossible to use the computer console to move the robotic arms in real-time, then it would bepossible for a doctor in California to 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 is now. If you haven't noticed,robotic surgery has come long ways and it was only a dream for doctors and engineers tohave something that you no longer had to make big, hideous scars that would mess upsomebody's body for the rest of their lives. Doctors, before robotic surgery, worked onmaking minimally invasive surgery that would take hours of surgery time. Now, surgery isstill made in hours, but shorter hours are now in check with the robotic surgery. So you can'treally say there is a future of robotic surgery, but you can say that this has been the future for doctors long ago so all 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, spurred on by remarkable recent advances in surgical and computer technology. Computer-controlled diagnostic

instruments have been used in the operating room for years to help provide vitalinformation through ultrasound, computer-aided tomography and other imagingtechnologies. Only recently have robotic systems made their way into the operatingroom as dexterity-enhancing surgical assistants and surgical planners, in answer tosurgeons' demands for ways to overcome the surgical limitations of minimally invasivelaparoscopic surgery, a technique developed 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 perform other general surgical procedures while seated at a computer console and 3-D video imaging system across the room from the patient. The surgeonsoperate controls with their hands and fingers to direct a robotically controlled laparoscope. Atthe end of the laparoscope are advanced, articulating surgical instruments and miniaturecameras that allow surgeons to peer into the body and perform the procedures.

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

NANOTECHNOLOG

Some robots can be as small as or smaller than human cells. T his is the field of nanotechnology. T he use of microscopic robots is emerging as the next technologicalrevolution. I t looks at building materials and devices with atomic precision. I magine thebroad 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 most effective choice in eradicating the malignant tumors without thepainful side effects of chemotherapy and radiation treatment. Among the most serious risks

associated with surgical treatments is the possibility of infection at the point(s) of incision. Suchinfections are often the primary causes of serious complications which may hamper your ability toquickly and properly recover from your procedure. The da Vinci system greatly mitigates that risk of infection in a number of ways. First, the size of incision(s) made is significantly smaller with roboticsurgery than with the traditional procedure. A standard non-robotic prostatectomy typicallyrequires the surgeon to make a six to eight inch vertical incision into the patient s lower abdomen.Such a relatively large incision subjects the patient to a number of operative and post-operativeinfectious agents. That is to say that not only is the open incision site susceptible to any infectiousagents during the procedure, but also the closed but unhealed wound left from the incision may beat risk of contracting harmful infections. Post-operative infections are the more common of the twoinfection risk categories, as hospital rooms cannot be maintained at the extremely high level of sterility which operating rooms are kept. The da Vinci robotic surgical system, however, utilizes amuch less invasive technique which requires four to five incisions smaller than two inches each.Each of these smaller incisions will heal significantly faster than the six to eight inch incision neededfor traditional surgery. Fewer sutures are needed to close the robotic system s incisions. Thisquickens recovery time as well as being less painful to you as the patent.

Quicker Recovery Period

When your physician determines surgery is your best treatment option and refers you to anontological surgeon, you can rest assured that Dr. Samadi and the da Vinci system offer you the bestchance of a full and expedient recovery. Da Vinci s robotic surgical technology optimizes yourchances of experiencing a quicker recovery time opposed to traditional surgical prostatectomy. The

smaller incisions required to maneuver the operating arms heal much faster, require less suturesand are less vulnerable to tearing or infection. The highly precise movements of the robotic armsallow for cleaner removals of malignant tissue. Such precision also produces a more targetedapproach which reduces damage to healthy tissue during the operation. The design of the roboticoperating arms allow for the entire procedure to be conducted without having to leverage operatingtools against the walls of the incision. All of these advantages translate to a speedier and lessworrisome recovery period.


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Minimize Scarring

The sheer size of the incision needed to perform a traditional prostatectomy produces significantscarring of the patient s lower abdomen. The robotic prostatectomy procedure allows for incisionswhich can heal with little to no visible scarring. In addition to the obvious aesthetic value,minimizing scar tissue on the interior walls of the incision can promote better healing of theprostate. Excess scar tissue build up can sometimes interfere with the proper function of theprostate. Although such a complication is typically considered rare, it is worth considering whenexploring treatment options. The precision of robotic surgery offers an inherent solution to thispotential difficulty. By minimizing the total size of the incision needed to remove cancerous tissuethis risk of scar tissue related complications is greatly mitigated.

Surgeon Console

Robotic Assisted SurgeryThe surgeon operates while seated comfortably at the da Vinci Robotic System console viewing a 3-Dimage of the operation. The surgeon s hand, wrist, and finger movements are translated to thesurgical instruments inside the patient while completing the robotic prostatectomy.


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Patient-side Cart

This part of the robot provides the instrument arms that are completely under the control of thesurgeon. The laparoscopic arms pivot at the 1-cm operating ports eliminating the use of the patient sbody wall for leverage and minimizing tissue damage. Supporting surgical team members assist ininstalling the proper instruments, preparing the 1-cm port in the patient, as well as supervise thelaparoscopic arms and tools being utilized whenever a robotic 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 image synchronizers, high intensity illuminators and camera controlunits during 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 standard minimally invasivesurgery, so we can now use minimally invasive techniques for a wider range of procedures. for the future .

mdnoman uddin

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