Chapter 7

A Compact, Simple, and Robust Teleoperated Robotic Surgery System

Ji Ma and Peter Berkelman

Abstract The utility of current commercial teleoperated robotic surgery systems is limited by their high cost, large size, and time-consuming setup procedures. We have developed a prototype system which aims to overcome these obstacles by being much smaller, simpler, and easier to set up and operate, while providing equivalent functionality and performance for executing surgical procedures. The prototype system is modular and each component manipulator is approximately 2.5 kg or less, so that they system is easily portable and each manipulator can be individually positioned and xed in place by hand to a rigid frame above the operating table. All system components and materials are autoclaveable and immersible in uids, so that each manipulator can be sterilized and stored by the standard operating procedures used for any other surgical instrument, and no sterile draping is required. The system is described and results of untrained user trials performing standard laparoscopic surgery skill tasks are given.

7.1

Introduction

The development of minimally invasive surgical techniques has been a great benet to patients due to reduced trauma and risk of infection when compared to open surgical procedures. Minimally invasive surgery is much more difcult for the surgeon, however, as dexterity is reduced when handling long, thin instruments through a keyhole incision, and visibility is reduced by the necessity of using a rigid endoscope and video monitor to display the internal tissues and instruments to the surgeon during the procedure. Teleoperated robotic surgical systems aim to regain and enhance the dextrous capabilities of surgeons to perform minimally invasive procedures by appropriate scaling between motions of the teleoperation masters and slaves, reducing the

P. Berkelman (*) Department of Mechanical Engineering, University of Hawaii-Manoa, 2540 Dole St, Honolulu, HI 96822, USA e-mail: peterb@hawaii.edu

J. Rosen et al. (eds.), Surgical Robotics: Systems Applications and Visions, DOI 10.1007/978-1-4419-1126-1_7, # Springer Science+Business Media, LLC 2011

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Fig. 7.1 Endoscope and instrument manipulators

manual tremor of the surgeon, and enabling direct control of instrument tips by eliminating the reversed motions between manual minimally invasive surgery instrument handles and tips caused by the instruments pivoting about a fulcrum at the incision point. Commercial systems are being used in a steadily increasing number of hospitals, however in practice their use is often limited to specic cases and procedures, due to complex, costly, and time-consuming setup and maintenance procedures. At the University of Hawaii we have developed a compact prototype system which aims to address the shortcomings of the rst generation of robotic surgery systems by being much smaller, simpler, and easier to set up and use than current commercial systems. The manipulators are shown attached to a rigid frame clamped above a table in Fig. 7.1. The most important features of our system are that it is autoclaveable and immersible in uids for sterility and cleaning, its small size for easy setup and use, and its modular design so that any component of the system may be easily added, removed, or replaced at any time during procedures.

7.1.1

Disadvantages of Current Systems

The most widely used teleoperated robotic system for minimally invasive surgery is currently the da Vinci, from Intuitive Surgical Systems [5]. Although it is commercially successful and approved for a number of surgical procedures, it is large and costly, the layout of the operating room must be recongured to accommodate its size,

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and specialized procedures are necessary for the setup and use of the system. The complete system may be difcult to t into standard operating rooms, and typically an entire room must be permanently devoted to robotic system regardless of its frequency of use, as it is too massive to be regularly moved between rooms. All parts of the robotic system within the operating eld must be carefully enclosed in sterile drapes before each procedure, which adds to the setup time. Furthermore, it may be necessary to replan standard procedures so that the external arms carrying the surgical instruments do not collide. The large size of the surgical manipulators partially obstruct the access and view of the patient by the surgical staff. An immersive teleoperation master console with a stereo display provides a high degree of telepresence for operating instruments inside the patient, but peripheral awareness of the exterior condition of the patient is lost due to the physical separation and the immersive display. The ZEUS from Computer Motion [13], which is currently unavailable due to merging with Intuitive Surgical, was smaller than the da Vinci yet its large manipulator bases attached to the operating table and its use of serial jointed robotic arms to manipulate instruments also somewhat reduces free access to the patient from all directions by the surgical staff and may require careful preplanning and positioning to avoid collisions between the arms during a given procedure. The Laprotek from [3] system from Endovia and the RAVEN [8] developed at the University of Washington are also both somewhat smaller and less obtrusive than the da Vinci and ZEUS systems. These two systems mainly rely on actuation by cable tendons, which is a possible source of difculty due to wear, stretching, and variable tension and friction.

7.1.2

Advantages of Smaller, Simpler Modular Systems

Reducing the size and complexity of a robotic surgery system provides many complementary advantages. First, small, lightweight instrument and endoscope manipulators permit them to be xed directly above the patient, allowing full access to the patient from all sides and not occupying any oor space in the operating room. Each manipulator can be easily positioned with one hand and clamped in place on a rigid frame, and is small enough to t inside a typical hospital autoclave and stored in a cabinet. Individual manipulators can easily be added, removed, or replaced in the system at any time during surgical procedures, to switch between different types of instruments, to manually operated instruments, or to convert to an open procedure in only minutes. The small size and light weight of the mechanisms also result in reductions in the motor torques required to counteract gravity loads. With lower motor torque requirements, miniature brushless motors may be used, integrated directly into the manipulator mechanism with a minimal amount of gear reduction and drivetrain components. The use of miniature motors further reduces the total mass of the manipulators, and the simplicity of the drivetrains improves the reliability of the manipulators as the number of potential failure points is reduced, no lubrication or

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other maintenance procedures are necessary, and stretching and wear of actuation cables are not a cause for concern. Finally, the reduced mass and motor torque requirements in the manipulators improve the safety of the system. Any unintended collisions between manipulators or impacts with patient anatomy are less likely to cause damage, as the kinetic energy from the moving mass of the manipulators would be more easily dissipated.

7.1.3

University of Hawaii System Components

A schematic diagram of the compact laparoscopic surgery robot system is shown in Fig. 7.2, showing all the components of the system and the communications links between them. The components of the compact surgery robot system include the following: Teleoperation Masters: The masters receive the surgeons hand motions then change these motions into position signals. The masters use PHANToM Omni haptic device which can detect the motion of the surgeons hand. Miniature brushless DC motors are used.1 Instrument Manipulators: The instrument manipulator follows the masters motion signal to realize translation and rotation motion of surgical instrument which is attached on the manipulator. Surgical Instruments: The surgical instruments provide serials of tools for surgery. The surgical instrument can be attached to or detached from the instrument manipulator rapidly during instrument exchange in surgical procedure. Endoscope Manipulator: The structure of endoscope manipulator is same as the instrument manipulator except its lower force/torque requirement for moving endoscope and one less DOF. The endoscope manipulator moves according to voice command or foot pedal input of the surgeon or moves semi-autonomously to trace the object in the surgical site. Motor Controllers: Motor controllers are used to drive the DC brushless motors in the manipulators and the instruments.2 Video Feedback: A video signal is acquired from the endoscope and the video feedback is provided by a monitor for the surgeon and nurses to observe the surgical site. In the current surgery robot protope, an endoscope
1 2

MicroMo Brushless DC. MicroMo MCBL 3003.

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Fig. 7.2 Schematic of communication between modular components of surgical robot system prototype

Endoscope Command:

Central Controller:

and a TV monitor are used to provide the surgeon with a 2-D video feedback. Since the surgeons hands are occupied by two masters, a voice command recognition system and a set of foot switches are used to control the endoscope manipulator. The control software includes hardware device drivers, control software and the user interface, and executes on a PC in a compact enclosure with a touchscreen and running Windows XP. The system control software is described in further detail in [9].

A second enclosure contains additional motor controllers, power supplies, and a multichannel serial port output card to send commands from the high-level PC control to individual motor controllers. The entire system is modular and portable and any of the components may be added, removed, replaced at any time, converting between teleoperated minimally invasive surgery, manual minimally invasive surgery, or to open procedures. Total setup time from packing cases to operation is less than 15 min. The endoscope and instrument manipulators, and the teleoperated instruments described in detail in Sects. 2, 3, and 4.

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7.2

Endoscope Manipulator

Early development and testing of the endoscope manipulator used in our teleoperated system was carried out at the TIMC-IMAG laboratory of Grenoble, France, and is described in detail in [2]. The current version has been commercialized by EndoControl S.A. of Grenoble as the ViKY (Vision Kontrol EndoscopY) [6] and is shown in Fig. 7.3. The ViKY system has undergone extensive human trials with over 300 procedures performed as a robotic assistant to position and hold an endoscope during minimally invasive surgical procedures performed manually. The device has received CE marking for use in Europe, and was approved by the FDA in December 2008 for use in the United States. The endoscope manipulator consists of an annular base placed on the abdomen, a clamp to hold the endoscope trocar, and two joints which enable azimuth rotation and inclination of the endoscope about a pivot point centered on the incision. A compression spring around a telescoping shaft with an internal cable which is wound around a motorized spool control the insertion depth of the endoscope. Control of the robot is simple and straightforward, as the motion of each motor directly corresponds to the horizontal and vertical motion and zoom of the endoscope camera image. As a result, no kinematic calculations, initialization procedures, or homing sequences need to be performed to operate the robot. No calibration procedure is necessary and the manipulator is ready to be used immediately after being powered on. The endoscope can be quickly removed at any time for cleaning or replacement, and the robot can be removed while leaving the trocar in place in the abdomen. A set of foot switches and a voice command recognition system are available as user control interfaces to enable the surgeon to control the endoscope manipulator motions while holding surgical instruments in both hands.

Fig. 7.3 ViKY endoscope manipulator

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The manipulator is approximately 800 g. Rigid laparoscopic endoscopes with video cameras are typically 300500 g. The base diameter is 110 mm and the minimum height is approximately 100 mm. To meet the sterility and hygiene requirements of the operating room without using sterile drapes, all components are autoclaveable and waterproof. In addition, the surfaces of all moving parts must be accessible to cleaning brushes for rapid cleaning after procedures without using tools for disassembly. To satisfy this requirement, the rotating ring in the base of the manipulator is supported on a set of smooth, rotating pinions rather than a ball bearing. Earlier commercial endoscope manipulators include the Aesop [4] from Computer Motion Inc., and the EndoAssist [1] from Prosurgics, formerly Armstrong Healthcare. Both of these manipulators are serial jointed robotic arms, with large massive bases and passive gimbal joints where the endoscope is attached, to allow the endoscope to pivot about the incision point.

7.3

Instrument Manipulation

The basic structure and design of the instrument manipulators in the system are similar to the endoscope manipulator described in the previous section. However the performance requirements of instrument manipulators are more demanding with respect to accuracy, sensitivity, response time, stiffness, and forces generated, and an additional actuated degree of freedom is required to rotate the instrument shaft. The instrument manipulators move a platform to which various different surgical instruments may be attached. Teleoperation masters control the motions of the instrument manipulators and instruments together. The instrument manipulators and teleoperation masters are described in this section and the articulated robotic surgical instruments developed for the instrument manipulators are described in the next section.

7.3.1

Instrument Manipulators

An instrument manipulator is shown in Fig. 7.4 holding a manual minimally invasive surgical instrument. Figure 7.5 shows a manipulator with no attached instrument. A rack-and-pinion drive is used in the instrument manipulators to control the instrument insertion depth instead of the cable-and-spring mechanism of the endoscope manipulator due to the greater precision and forces required in the instrument manipulators. The rack-and-pinion motor and a fourth motor to rotate the instrument shaft are both built into the upper platform of the instrument manipulators. The base of the instrument manipulators is smaller in diameter than the endoscope

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Fig. 7.4 Instrument manipulator holding manual instrument

Fig. 7.5 Instrument manipulator without instrument

manipulator in order to more easily place multiple robots next to each other on the abdomen of the patient. If the motors are disabled or powered off, their motions are backdriveable, which is useful during initial device setup or in case of a motor failure. Each manipulator is particularly compact and lightweight at 1.8 kg, 100 mm in diameter and 360 mm in height. A pair of commercial haptic interfaces as teleoperation masters [11] A grasper handle with gripping force feedback, shown in Fig. 7.6, is used in place of the original stylus to provide the user a more ergonomic operation of the wrist and more precise and delicate gripper force control which can avoid tissue trauma caused by large forces from the gripper. In the initial development, the two buttons on the handle of the haptic device were used to control the gripper to open and close. But

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Fig. 7.6 Teleoperation master console

we found induced motions in the system are caused by the forces required to press the buttons. Precise opening and closing of a gripper or scissors is difcult to control precisely using these on/off buttons only.

7.4

Articulated Wrist Instruments

We have produced instruments with articulated, motorized wrists at the active ends to improve surgical dexterity compared to standard manual instruments in minimally invasive surgery. The ability to bend an instrument tip up to 90 in any direction, teleoperated from the master console, enables the tip to approach and contact tissues from a wide range of angles, can avoid occlusions and obstructions, and provides better access for gripping and cutting, and especially suturing, in which the tip of a needle must follow a helical path. The use of articulated wrists in our system provides the full teleoperated robotic surgical assistance functionality equivalent to current commercial systems. Although the current prototype instrument wrists in development have not yet been tested to withstand repeated autoclave cycles, all the motors and materials used in the instrument wrists are commercially available in autoclaveable versions.

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7.4.1

Wire-Driven Flexible Spines

Instead of using cable-driven rotational joints in the instrument wrists, our instruments use a wire-driven exible spine for bending, in an approach similar to Van Meer [12]. This actuation method is easier to fabricate, does not require small bending radii in actuation cables, and is free from kinematic singularities. The articulated instruments provide an additional two degrees of freedom in wrist motion to increase dexterity and a single degree of freedom for tool actuation. In Fig. 7.7, four wrist plates (1.8 mm height and 6 mm diameter) and three spheres (3mm diameter) are stacked together with each sphere between two plates. The wrist plates have drilled holes for eight Nitinol wires (0.33 mm diameter) to pass through. Four Nitinol wires, actuated in antagonistic pairs, are used for driving the wrist rotations and the other four wires are passive to provide the wrist more axial rigidity. Figure 7.8 shows the fabricated wrist with a gripper tip. The total length of the exible part of the wrist is 12 mm. A conventional manual surgical tool tip (5 mm diameter) is attached to the end of the wrist. The opening and closing of the gripper is driven by a ninth superelastic Nitinol alloy wire (0.43 mm diameter) which passes through the pierced spheres and wrist plates. The wrist bending motion range is 90 degrees in all directions. The diameter of the instrument is 6 mm. The materials of the wrist are biocompatible, low cost, and autoclaveable. During instrument exchange in a surgery procedure, different instruments can be detached from and attached to the instrument manipulator quickly. In the current prototype as shown in Fig. 7.9, the driving motors and the instrument are assemble together. The total length of the modular surgical instrument prototype is 450 mm and the weight is 380 g. Miniature brushless DC are used for actuation of the two perpendicular wrist bending directions and for the instrument gripper or scissor. To convert the motor shaft rotations to the linear motions required for wire actuation and increase their force capabilities, miniature worm gear assemblies are used for the antagonistic

Fig. 7.7 Flexible spine structure for articulated instrument wrist

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Fig. 7.8 Surgical instrument wrist and gripper

Fig. 7.9 Complete surgical instrument

actuation of wrist bending and a miniature lead screw is used for the gripper/scissor actuation. The motors and gear reductions at the top of a robotic instrument are shown in Fig. 7.10.

7.4.2

Grip Force Feedback

In typical manual laparoscopic surgery, surgeons can feel approximate contact, gripping, and cutting forces from instrument and tissue interactions, but the force sensations are masked by friction and backlash in the manual instrument handle and the trocar. In current robotic surgery without force feedback, the surgeons have no contact sensation from their hand and must judge the forces applied to tissue based on the tissue deformation seen in the video feedback and their surgical experience.

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Fig. 7.10 Actuation motors and reduction mechanisms at head of instrument

Aside from the force information from instrument and tissue interaction, the grasping force of the gripper is also important because too much grasping force will damage tissue and it is difcult to judge the grasping force from tissue deformation. It is difcult to sense forces at the tip of the surgical instrument due to the miniature size, the harsh environment inside the body, and biocompatibility and sterility requirements. In the design of our surgery instrument, we installed a load sensor between the gripper motor lead screw and the actuation wire to indirectly measure grasping force. This measure is approximate, however, as the measured friction between the driving wire and the wrist varies from 0.5 N to 2 N as the wrist bends from 0 to 90 . A miniature voice coil,3 linear bearing, and linear potentiometer were added to the gripper control mechanism on the handles of the teleoperation masters, as shown in Fig. 7.11. The voice coil can provide a continuous force of 2.3 N and peak forces up to 7.4 N. Due to the friction and hysteresis in the motion gripper actuation wire, it is difcult to provide user force feedback which is both stable and useful to the user for gripping tasks. Further investigation and testing is necessary to lter the sensed force signal and compensate for friction to stably provide realistic grip force feedback to the teleoperator.

7.5

User Trials

The system has undergone sets of preliminary trials in the laboratory to compare its performance to manual laparoscopic surgery and published results from other systems when operated by untrained users. Student volunteers were recruited to perform standardized surgical skills tasks including placing rings on pegs with a single instrument, tracing motion trajectories, peg transfers with two instruments,

MotiCont Inc.

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Fig. 7.11 Grip force feedback actuator assembly in teleoperation handle

suturing with knot tying, and precision cutting. The two tasks Sect. 5.1 were performed with instruments with xed straight wrists, to simplify the teleoperation interface and reduce the training and familiarization period for the operators, and the tasks in Sect. 5.2 were performed with the articulated wrists as described in Sect. 4.

7.5.1

Comparison to Manual Instruments

In order to compare the performance of our surgical robotic system with typical manual MIS instrument operation, user testing experiments were designed and performed. Two tasks were performed by participants using both the manual MIS instrument and the teleoperated robotic system. The positions of the instrument incision point, the task object, the monitor and the user were arranged to be the same for both the manual and robot instrument operations. An optical motion capture system4 was used to capture the motions of the surgical instrument tips for both the manual and the robot task operations. Further detail regarding these comparative user experiments is provided in [10]. Four infrared LEDs were afxed to the handle of each surgical instrument to enable tracking of the instrument tip position at a 30 Hz sample rate. This motion tracking technique accounts for all motion from hysteresis, vibration, and deformation in the manipulator support clamps, support frame, and mechanism, except for exing of the instrument shaft between the handle and tip.
4

Optotrak Certus, Northern Digital Inc.

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Before the experiments, each participant was allowed 215 min to practice until the participant felt that he or she was familiar with the operations. In the experiments, the novice participants preferred to spend much more time practicing the manual surgical instrument operation than in the robotic teleoperation. The practice time for participants in manual operation was about 510 min while the practice time in robotic operation was only about 12 min. Two tasks were used to compare manual laparoscopic instrument operation and teleoperated robotic operation. Each task required one hand only. Task 1: Pick and Place Use the gripper instrument to pick up nine rings and place them on pegs. The pegs are arranged in a grid with 20 mm separation and the rings were lined up against the edge of the tray containing the pegs before each task. The execution time results are shown in Fig. 7.12, indicating that manual instrument operation takes more time than robot teleoperation except for subjects 5 and 6. It was observed that in teleoperation, the motion of the instrument tips paused while grasping the rings, but in manual operation rings could be easily grasped while moving the instrument. The average grasping time was approximately 21% of total robot teleoperation time. Task 2: Trajectory Following Use the gripper instrument to follow the given trajectory indicated on a horizontal plane. A 20 mm square was plotted on graph paper as the given trajectory. The participants were asked to control the tip of the surgical gripper instrument to move along the square trajectory. Each participant was asked to follow the trajectory in the clockwise direction for ve circuits. Figures 7.13 and 7.14 are sample instrument tip trajectories for manual and

Fig. 7.12 Manual and teleoperated ring placement task completion times

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Fig. 7.13 Manual instrument tip trajectory

Fig. 7.14 Teleoperated instrument tip trajectory

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teleoperated instruments. The trajectory of the manual operation is much coarser due to hand tremors and vibrations. In the teleoperation data, although there are some tremors from the teleoperation master device, the trajectory is much more accurate and smoother than manual instrument operation.

7.5.2

Comparison to Results of Other Robotic Surgery Systems

The Fundamentals of Laparoscopic Surgery (FLS) curriculum is a standard surgery teaching and training curriculum which was created in the late 1990s by the Society of American Gastointestinal Endoscopic (SAGES). The FLS curriculum includes both cognitive as well as psychomotor skills. The FLS tasks have been used to teach, practice and evaluate the skills of thousands of surgeons. The FLS curriculum provides a structured and repeatable means to evaluate surgical skills, and the use of the FLS tasks in the eld of surgical robotics can allow researchers from different groups to have a common basis for objective evaluation and comparison of their systems. Sample FLS tasks were performed by volunteers to evaluate our surgery robot system. There are ve tasks in the FLS curriculum: peg transfer, precision cutting, placement and securing of ligating loop, simple suture with extracorporeal knot, and simple suture with intracorporeal knot. Two of the tasks, placement/securing of a ligating loop and extracorporeal knot tying, require special tools and therefore these two tasks are not included in the current evaluation. The other three FLS tasks are the peg transfer, precision cutting, and simple suture with intracorporeal knot tasks. Standard commercial surgical training task kits were used.5 In the main study, only the peg transfer task is used because the task is relatively easy for untrained novice users. The precision cutting and suture task were performed by the rst author who has some experience in teleoperating the surgical robot system. In the peg transfer task as shown in Fig. 7.15, a peg board with 12 pegs and 6 rings are manipulated by two gripper instruments. The user is asked to use the left gripper to grasp a ring from the left peg board, transfer the ring to the right gripper in midair, then place the object on the right peg board. After all six rings are transferred to the right peg board, the process is reversed, and the user transfers all the rings to the left peg board. In this task, the total number of object transfers is twelve, including six transfers from left to right and six transfers from right to left. In the suturing and knot tying task, a Penrose drain is attached on a foam block as shown in Fig. 7.16. The instruments required in this task are two needle drivers. The user is required to place a suture precisely through two marks on the Penrose drain. At least three throws including one double throw and two single throws must be
5

Simulab Inc.

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Fig. 7.15 FLS peg transfer task

Fig. 7.16 FLS suturing task

placed on the suture. The task requires needle placement, needle transferring, suturing and knot tying skills. Figure 7.17 shows the cutting task. The tools needed for this task are one gripper and one scissors. A 100 100 mm gauze piece with a circle pattern is secured in view of the endoscope. The user is asked to cut out the circle along the line precisely. The gripper is used to hold the gauze and to place the gauze the best angle for cutting. This task is designed to use hands in a complimentary manner.

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Fig. 7.17 FLS precision cutting task

Fig. 7.18 Manual and teleoperated peg transfer task completion times

The results of the peg transfer task executed by volunteer subjects are shown in Fig. 7.18. Each user performed three repetitions of the peg transfer task, and the task times for right-to-left and left-to-right transfers were recorded separately. The cutting and suture with knot tasks have been performed by the rst author. The average task completion tasks for each of the three tasks are given in Table 7.1 and compared with published results from the da Vinci system from Intuitive Surgical Systems and the RAVEN system from the University of Washington [7]. As the number of users is small in each case and variations in experience levels are

7 A Compact, Simple, and Robust Teleoperated Robotic Surgery System Table 7.1 Comparison with other robotic FLS task completion times Robot system Peg transfer task Suture task da Vinci, Intuitive Surgical Systems 126 s 169 s RAVEN, University of Washington 443 s 578 s University of Hawaii 279 s 214 s

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Cutting task 208 s 280 s

not accounted for, these comparisons are not necessarily indicative of the relative performance or ease of use of each system, however.

7.6

Conclusion

The prototype system is currently complete and fully functional. The endoscope manipulator is the most mature component of our system, in that it has been separately commercialized, has undergone human trials for use with manual instruments, and has obtained CE marking for use in Europe and FDA approval for use in the United States. The instrument manipulators were fabricated with a similar design, components, and materials, so that they are also autoclaveable and immersible in uids. The teleoperated instruments currently carried by the instrument manipulators can be made to be autoclaveable and waterproof by encapsulating the actuation mechanism and substituting autoclaveable versions of the motors, wiring insulation, and connectors. The system is modular and portable, it is regularly transported for demonstrations and testing and can be set up completely in less than 15 min. Preliminary user testing using the complete system has been carried out to validate the utility of the system in a laboratory setting. Further testing and validation remains to be done, by users with surgical training performing more realistic and detailed surgical procedures.
Acknowledgements We are grateful for the assistance of Alpes Instruments SA of Meylan, France for the fabrication of the instrument manipulators, and to EndoControl SA of Grenoble, France, for supplying the endoscope manipulator used in the system. Research support has been provided by the NIH under grant #5R21EB006073, Development of Compact Teleoperated Robotic Minimally Invasive Surgery and by the University of Hawaii-Manoa College of Engineering and Department of Mechanical Engineering.

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