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Nicolás Pérez de Olaguer Santamaría Autonomous Surgical Robotics 1 / 29 MIN Faculty Department of Informatics Autonomous Surgical Robotics Nicolás Pérez de Olaguer Santamaría University of Hamburg Faculty of Mathematics, Informatics and Natural Sciences Department of Informatics Technical Aspects of Multimodal Systems 04. December 2017

Nicolás Pérez de Olaguer Santamaría Autonomous Surgical Robotics 2 / 29 Outline 1. Motivation 2. Non-Autonomous Surgical Robots 3. Supervised Autonomous Robots 4. STAR surgical Robot 5. Discussion 6. Conclusions

Motivation Motivation Non-Autonomous Surgical Robots Supervised Autonomous Robots STAR surgical Robot Discussion Conclusions Would you trust on a robot to perform you a surgical intervention? https://youtu.be/hulnz902gwo Nicolás Pérez de Olaguer Santamaría Autonomous Surgical Robotics 3 / 29

Nicolás Pérez de Olaguer Santamaría Autonomous Surgical Robotics 4 / 29 Why use surgical Robots? They provide: Enhanced effectiveness Safety Optimal techniques Minimally invasive surgery

Brief history Motivation I I Supervised Autonomous Robots STAR surgical Robot Discussion Conclusions First surgical robot: Arthrobot, Vancouver 1983. PUMA 560 I I Non-Autonomous Surgical Robots 1985 1st neurosurgical biopsy. ROBODOC, 1992, used to crave a cavity in the femur to perfectly fit a hip prosthesis in the patient. Arthrobot [1] Puma 560 [2] ROBODOC [3] Nicolás Pérez de Olaguer Santamaría Autonomous Surgical Robotics 5 / 29

Brief history (cont.) Motivation Non-Autonomous Surgical Robots Supervised Autonomous Robots STAR surgical Robot Discussion Conclusions Da Vinci Surgical System, 2000 I Minimally invasive surgery. I Teleoperated system. I Four interactive robot arms. I To replace laparoscopic tools. I US 2 million. Da Vinci surgical system[5] Nicolás Pérez de Olaguer Santamaría Autonomous Surgical Robotics Laparoscopic Tools [4] 6 / 29

Nicolás Pérez de Olaguer Santamaría Autonomous Surgical Robotics 7 / 29 Brief history (cont.) No. of operations worldwide by the Da Vinci Surgical System [5].

Nicolás Pérez de Olaguer Santamaría Autonomous Surgical Robotics 8 / 29 Brief history (cont.) Concentric Tube Robots (2005) youtu.be/iug4jco-apc [6]

Nicolás Pérez de Olaguer Santamaría Autonomous Surgical Robotics 9 / 29 Autonomy of surgical robots Level of Autonomy Da Vinci surgical system[5] STAR Robot[7]

Nicolás Pérez de Olaguer Santamaría Autonomous Surgical Robotics 10 / 29 Non-Autonomous Surgical Robots The action is completely performed by the surgeon. Hand-eye coordination. We do not have an intelligent system. Benefits: Reduce human fatigue. Allow high precision. Minimal Invasive Surgery Drawbacks: Relies on the dexterity of the surgeon. Slow learning curve.

Nicolás Pérez de Olaguer Santamaría Autonomous Surgical Robotics 11 / 29 Autonomy an ability to perform intended tasks based on current state and sensing without human intervention (ISO 8373:2012)

Nicolás Pérez de Olaguer Santamaría Autonomous Surgical Robotics 12 / 29 State of the art The robot perform a certain task with the supervision of the doctor. Surgeon asses the automated planning of the robot before implementation. Discrete control of the system. Used in rigid tissues surgeries i.e. bone interventions. Never tested in human soft tissue. Increased complexity by tissue deformation.

Nicolás Pérez de Olaguer Santamaría Autonomous Surgical Robotics 13 / 29 Features Reduce human errors. Deal with different sensory data. Execute predefined motions. Improve safety, consistency and quality of intervention.

Nicolás Pérez de Olaguer Santamaría Autonomous Surgical Robotics 14 / 29 Paper Supervised autonomous robotic soft tissue surgery A. Shademan, R. S. Decker, J. D. Opfermann, S. Leonard, A. Krieger, and P. C. Kim Published 4 May 2016, Sci Transl Med 8 (337), 337ra64337ra64 DOI : 10.1126/scitranslmed.aad9398 Sheikh Zayed Institute for Pediatric Surgical Innovation, Children s National Health System, 111 Michigan Avenue Northwest, Washington, DC 20010, USA. Department of Computer Science, Johns Hopkins University, 3400 North Charles Street, Baltimore, MD 21218, USA.

Nicolás Pérez de Olaguer Santamaría Autonomous Surgical Robotics 15 / 29 Hypothesis Smart Tissue Autonomous Robot (STAR). Defined in [7] Designed to perform anastomosis of soft tissue (suture). Hypothesis posed: Can this complex intervention be done autonomously and perform better than other surgical techniques? [7]

Tests Tested in: In-vivo and ex-vivo pig intestine. Against: manual surgery (OPEN), laparoscopy (LAP) and robot-assisted surgery (RAS). [7] Nicolás Pérez de Olaguer Santamaría Autonomous Surgical Robotics 16 / 29

Nicolás Pérez de Olaguer Santamaría Autonomous Surgical Robotics 17 / 29 Technologies Actuated suturing tools. Fluorescent and 3D imaging. Force sensing. Submilimiter positioning. [7]

Nicolás Pérez de Olaguer Santamaría Autonomous Surgical Robotics 18 / 29 Robot Arm, Suturing Tool and Force Sensor Seven-DOF KUKA LBR4 robotic arm + one-dof suturing tool. Suturing tool designed for manual actuation. Repeatable 0.05 mm positioning. Force sensor placed in between the last link of the robot arm and the suturing tool ideally should be on the end of the suturing tool. Threshold of 1N.

Nicolás Pérez de Olaguer Santamaría Autonomous Surgical Robotics 19 / 29 Imaging and 3D tracking Near-Infrared fluorescent (NIRF) Imaging. Chemical solution. NIRF markers manually placed by the surgeons. Real-time positioning information.

Nicolás Pérez de Olaguer Santamaría Autonomous Surgical Robotics 20 / 29 Imaging and 3D tracking (cont.) Plenoptic 3D surface reconstruction (1.14mm). 3D visual tracking to the markers. Combination of both avoid problem of occlusion and recognition of the tissue targets. [7]

Nicolás Pérez de Olaguer Santamaría Autonomous Surgical Robotics 21 / 29 Suture Planning Model the deformation of the tissue showed unpredictable behaviour from 0 to 6.5mm. Lead to real-time detection and plan adjusting using the imaging technologies. Algorithm of suture plan computed regarding cut length and thickness (manual or sensor input).

Nicolás Pérez de Olaguer Santamaría Autonomous Surgical Robotics 22 / 29 Suture Planning (Algorithm) Polyline fitted through the NIRF markers. Tissue thickness T, bite depth H, spacing between consecutive sutures S, lumen diameter D and circumference C = πd. Leak-free suture achieved with S < H/1.25 Optimal number of sutures is: N = C/S = ceil(1.25c/h) = ceil(1.25πd/3t ) With T = 1.3mm and D = 1.5mm, N = 16 with suture spacing S = C/N = 2.95mm. [7]

Nicolás Pérez de Olaguer Santamaría Autonomous Surgical Robotics 23 / 29 [7]

Nicolás Pérez de Olaguer Santamaría Autonomous Surgical Robotics 24 / 29 Benefits Optimized techniques. Better performance Proof of their hypothesis. Liberation of the surgeon to only supervise the work. Reduced recovery time.

Nicolás Pérez de Olaguer Santamaría Autonomous Surgical Robotics 25 / 29 Problems Higher expenses. Longer anaesthesia exposure. Only valid for this specific problem. Moreover, this problem can be solved easily by staples. Lots of ethical issues. Hard to implement soon.

Nicolás Pérez de Olaguer Santamaría Autonomous Surgical Robotics 26 / 29 Conclusions It is a first step on the field of robotic autonomy in the OR. Highly risky environment leads to slow down the introduction of the technology. Change the role of the doctors to decision-making rather than actuating.

Nicolás Pérez de Olaguer Santamaría Autonomous Surgical Robotics 27 / 29 Conclusions Are we going to accept the increase of risk in health care as we did in other fields i.e. self driving cars?

Nicolás Pérez de Olaguer Santamaría Autonomous Surgical Robotics 28 / 29 References 1 The Medical Post, Volume 21, No. 23, 12/11/1985 2 30 Years of Robotic Surgery Past, Present and Future, Trevor Hackman, MD, FACS Department of Otolaryngology / Head and Neck Surgery University of North Carolina at Chapel Hill, 2015 IEEE RoboResearch Seminar, 3 ROBODOC - surgical robot success story, Joanne Pransky, Industrial Robot: An International Journal 1997 4 Wikimedia foundation Inc., 2017-11-29, Laparoscopic Surgery, https://en.wikipedia.org/wiki/laparoscopic_surgery/, Wikipedia, Accessed 2017-12-01

Nicolás Pérez de Olaguer Santamaría Autonomous Surgical Robotics 29 / 29 References 5 Surgical Robotics: The Next 25 Years, UK-RAS White papers, 2016 6 Burgner, J., Gilbert, H. B., & Webster, R. J. (2013, May). On the computational design of concentric tube robots: Incorporating volume-based objectives. In Robotics and Automation (ICRA), 2013 IEEE International Conference on (pp. 1193-1198). IEEE. 7 A. Shademan, R. S. Decker, J. D. Opfermann, S. Leonard, A. Krieger, and P. C. Kim, Supervised autonomous robotic soft tissue surgery, Science translational medicine. 8 (337), 337ra64337ra64, (2016)