Applications of Robotics and Computer Aided Surgery in Urology
Pierre Mozer, ISIR-APHP Paris, France

Urology is the medical and surgical specialty that focuses on the urinary tracts (kidneys, ureter, bladder) of males and females, and on the reproductive system of males (prostate and testicle). Urology is probably the most advanced surgical field of « soft tissue » for computer aided surgery and robotics.

In this presentation after a historical introduction, we will focus mainly on prostate and kidney applications from a clinical point of view with a technical perspective. We will introduce the advantages and drawbacks of Direct Image Guided Interventions versus navigation systems and teleoperative system. To conclude, we will describe our experience of the process from « bench to bedside » to develop devices CE marked and FDA approved.

Real-time haptic simulation of medical procedures involving deformations and device-tissue interactions
Christian Duriez, INRIA, Villeneuve d'Ascq, France

In this work, we aim to provide new simulation tools for medical and surgical interventions. These tools have many applications including training of physicians, planning of interventions,  providing assistance during a real intervention or for the control of surgical robots.

However, to obtain a realistic or even predictive simulation of the procedure, we must take into account the deformation of the anatomical structures and the mechanical interactions between devices and tissues. At the same time, the simulation must be interactive and computed in real-time to keep the gesture of the physician in the loop of the simulation. The major challenge of our work is to guarantee a certain level of accuracy in the simulation while keeping a very short computation time, consistent with the real-time.

This lecture will introduce the scientific issues and some recent results: algorithms and models to simulate the deformations of the anatomical structures with finite element method, models for the simulation of the tool-tissues interactions, and the approaches dedicated to haptic rendering of surgical simulation. The open-source SOFA framework ( dedicated to interactive medical simulations will also be presented. Finally, some preliminary work on the use of simulation for helping the robotization of a procedure and for the control of soft-robots will be shown.

Robotics for Image guided Procedures
Andreas Melzer, IMSaT, Dundee, UK

Many different robotic systems have been developed for surgical procedures over the past 25 years. Medical robotics for image guided procedures is an evolving field and the ultimate role of these systems has yet to be determined. This presentation will focus on robotic systems for image guided interventions such as biopsy of suspicious lesions, drainage interstitial tumor treatment or needle placement for pain treatment, spinal blocks and neurolysis. Historian remarks will include the early work on CT guided stereotactic brain procedures XRay and Ultrasound guided robotics and the first MRI compatible mechatronic devices.
Five interventional robotics systems designed to work with MRI, CT, fluoroscopy, and ultrasound imaging will be presented and compared in more detail. The systems include the AcuBot for active needle insertion under CT or fluoroscopy, the B-Rob systems for needle placement using CT or ultrasound, the Innomotion for MRI and CT interventions, the MRBot for MRI guided prostate procedures and ExAblate MR guided Focused Ultrasound . Following the systems descriptions, the issues of imaging system compatibiliy for the kinematics, sensors and drives, registration needs,patient movement and respiration motion compensation, and the potential for force feedback, and control mode will be discussed. Further research and clinical trials requirements will be outlined.

Fixing the Beating Heart: Ultrasound-Guided Robotic Surgery
Robert D. Howe, Harvard University, Cambridge, USA

To treat defects within the heart, surgeons currently use stopped-heart techniques. These procedures are highly invasive and incur a significant risk of neurological impairment. We are developing methods for performing surgery within the heart while it is beating. New real-time 3-D ultrasound imaging allows visualization through the opaque blood pool, but this imaging modality poses difficult image processing challenges, including poor resolution, acoustic artifacts, and data rates of 30 to 40 million voxels per second. To track instruments within the heart we have developed a Radon transform-based algorithm, which is readily implemented in real-time on graphics processor units. For manipulation of rapidly moving cardiac tissue we have created fast robotic catheters that can track the tissue based on ultrasound image features. This allows the surgeon to interact with the heart as if it was stationary. In vivo validation of this technology in atrial septal defect closure and mitral valve annuloplasty procedures demonstrate the potential for improved patient outcomes.

Design and control of collaborative robots for assistance to gesture
Guillaume Morel, ISIR, Paris, France

This talk will focus on the concept of comanipulation and its applications to medical robotics. A  comanipulation system is a robotic device that does not perform tasks autonomously but is rather  aimed at assisting a human operator to perform a task. Potential assistive functions cover a very  wide range that includes:
• Guidance, which can be provided by applying geometrical constraints to a tool.
• Tremor cancelling, which can be obtained by appropriately filtering the user motion.
• Force scaling, which may be brought by dual port force control.
• Augmented tactile perception, which consists of imposing extra force to the interface in the  aim of coding information.
• Augmented dexterity, which covers the fields of handheld dexterous instruments.

A common feature of these applications is that a human operator is definitely part of the loop. For these reasons, a key issue in this field is to study the properties of human motion and motor control characteristics.

The talk will emphasize some of the theoretical questions that are raised by this growing field, as well as applications for surgery (handheld instruments for eye surgery, for laparoscopic surgery, assistive devices for orthopedic surgery, for neurosurgery, assistance to ultrasound examination, etc.).

Vision-based control of robots and applications in medical robotics
Florent Nageotte, ICube, Strasbourg, France

Vision-based control of robots consists in using an imaging device as an external sensor for controlling robots. It is attractive because of its similarity with the way human-beings control their hands for reaching and moving objects. The interest for this kind of control has begun in the 1980's and a uniform framework has been given at the end of the 1980's and during the 90's. Since then, visual servoing has become an important field of robotics and has generated thousands of papers with the goal to improve features such as trajectories, stability or robustness. Vision-based control is used in different medical robotics applications and it has probably an important role to play in this field where visual sensors are usually the main available sensors.

In this lecture I will first present the two main ways to control robots with visual sensors, namely Position-based visual servoing and Image-based visual servoing. I will try to emphasize practical limitations and problems for standard cameras as well as for imaging devices used in medical applications.

Then I will give a quick overview of some of the existing improvements on different interesting aspects, such as the use of complex image features or of general and unknown targets. Finally, we will look at some of the existing applications in the field of medical robotics (laparoscopic surgery, heart surgery, ultrasonography, flexible endoscopy) and discuss the current limitations.

Steerable Scopes, Manipulators, and Needles: Modeling and Design of Curved Surgical Robots
Robert J. Webster III, Vanderbilt University, USA

If you want to create a new endoscope-like robot or steerable needle, where do you start?  This talk will describe some basic modeling strategies for flexible curved robots, and some examples of how such robots can be designed.  It will also provide some examples of applying flexible curved robots in a variety of surgical and interventional scenarios.

Image-Guided Hybrid Minimally Invasive Surgery
Luc Soler, IRCAD, Strasbourg, France

A new surgery of soft tissues is about to rise: The Image-Guided Hybrid Minimally Invasive Surgery. It consists in combining technologies of conventional minimally invasive surgery using rigid endoscopes, gastroenterology using flexible endoscopes and interventional radiology using intraoperative medical imaging. The development of computer-assisted surgery is here mandatory to obtain efficient clinical results demonstrating benefits for the patient, reducing pain and post-operative complications. This computer-assisted surgery can be summarized in four major steps. The first one consists in automated 3D modelling of patients from their medical images. The second one consists in using this modelling in surgical planning and simulation software offering then the opportunity to train the surgical gesture before carrying it out. The third step consists in intraoperatively superimposing preoperative data onto the real view of patients. This Augmented Reality provides surgeons a view in transparency of their patient allowing to track instruments and improve pathology targeting. The last one consists in robotizing the procedure by replacing human gesture by a robotic gesture that can be automated. We will present the concept and existing applications of this Image-Guided Hybrid Minimally Invasive Surgery, and future perspectives in this domain.

Robotic compensation of physiological motion for enhanced surgical accuracy
Cameron Riviere, Carnegie Mellon University, USA

Involuntary quasi-periodic physiological motion hinders accurate manipulation during surgery. The problem in some cases is motion of the patient (e.g., heartbeat, respiration), in others, motion of the surgeon (e.g., hand tremor). Accuracy can be improved by robotic compensation of the physiological motion. This talk will describe active and passive techniques for compensation of all of the above disturbances, enabling more accurate tool positioning and thereby reduced collateral damage to tissue.

Robot registration
Jocelyne Troccaz, TIMC, Grenoble, France

The general problem of registration consists in determining the geometrical relationship between different reference frames where some information is represented. In the context of computer-assisted surgery, this term is most often used when fusing imaging data coming from multi-modality sensors and acquired in different places or at different times. When a robot is introduced, this device also needs to be registered to the data. Indeed, in order to enable the robot to execute a pre-defined plan, or to assist the surgeon in this execution, the relationship between patient data where the planning is defined and the robot reference frame has to be determined. In this talk we present this general context and describe how this problem has been solved for different categories of systems. We distinguish four main intraoperative

Situations: robot alone, robot plus tracking device, robot plus imaging sensor, robot plus imaging sensor plus tracking device. Several examples are detailed and discussed.

Technical I: Urology applications
Jocelyne Troccaz, TIMC, Grenoble, France

Urology concerns the uro-genital apparatus of men and the urinary apparatus of women. Over the last decade, many attention has been given to the development of computer-assistance to this clinical domain. In this talk, we will focus mainly on prostate and kidney applications and will give example of systems developed and work in progress. Prostate applications include trans-urethral resection, radical prostatectomy, biopsy and brachytherapy - both diagnostic and therapeutic interventions. Kidney applications mostly concern percutaneous access to the kidney. As will be seen in the examples coming from the large literature, most robots are connected to imaging (very often ultrasound but also MRI and CT imaging).

Is there a future in robot assisted minimally invasive surgery?
Paolo Fiorini, University of Verona, Italy

In the last year or so, a number of meetings, papers, and discussions have taken place on the subject of clinical and economical effectiveness of robot-assisted minimally invasive procedures. Last February, an influential paper argued that the net effect of robotic surgery, on a specific gynecological procedure, was a significant cost increase of the procedure. Previously, several European National Health systems, and prominent European surgeons, argued whether National Health systems could afford the cost increase due to robotic surgery. As a consequence, on one side the sales of surgical robots have dropped significantly in the first half of this year and, on the other side, the robot manufacturer has been on a "spin campaign" defending its approach and the results achieved with its robotic devices.

Of course there is some truth on both sides of the argument: robots bring a number of advantages to  surgery and to surgeons, however their cost is justified only by the monopolistic situation of current robotic surgery market.

In this talk I will try to review the merits of both arguments and examine the almost invisible efforts of other companies that try to enter the market of robotic surgery. Furthermore, I will argue that these efforts, started a few years ago, are already obsolete and will not bring any benefit neither to patients nor to the National Health systems. Thus there is ample room for innovative approaches that do learn from the experience of ten years of robotic surgery instead of copying what is currently done.

Control in medical and surgical robotics
Nabil Zemiti, LIRMM, Montpellier, France

Medical robots require high performances and robustness for achieving accurate task in interaction with patient such as knee surgery, resection of brain tumors, skin harvesting, MIS…. The capability to handle interaction between manipulator and patient or surgeon is one of the fundamental requirements of medical robots. High performances or interaction are ensured by specific controllers. In the lecture, we will first introduce the basic schemes for free space control (joint space and output space). Then we will focus on interaction control. We will present the classical concepts developed for force regulation. Finally we will exhibit the hybrid external force/position control scheme. The advantages and the efficiency of this scheme will be illustrated on recent applications in reconstructive surgery performed with the SCALPP robot developed at the LIRMM.

Introduction to surgical robotics
Philippe Poignet, LIRMM, Montpellier, France

In order to give an overview of the domains covered by Medical robotics, I will first present some R&D projects in assistive technologies and rehabilitation robotics, before focusing on surgical robotics. Then, I will analyze some classical surgical functions ("machining", constrained manipulation, constrained targeting, surface tracking, microsurgery), from the viewpoint of the engineer, in order to illustrate the limitations of the manual procedures. This analysis will serve to justify the introduction of robotics in surgery. The added-values and limitations of computer & robot aided surgery will be discussed. A state of the art will present the main prototypes and commercial systems. Finally, I will list some future directions of R&D and technical challenges.

Medical Imaging
Guang-Zhong Yang, Imperial College, London, UK


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