A survey on actuators-driven surgical robots

Objective Since the first report of transgastric peritoneoscopic surgery in 2004, minimal invasive surgery (MIS) including conventional laparoscopy, natural orifice transluminal endoscopic surgery (NOTES), single incision laparoscopic surgery (SILS), and robotic surgery have gained traction in general and visceral surgery. While laparoscopic surgery is now the gold standard in many institutions, other MIS approaches lag behind in spite of the enthusiasm of few promoters. The present study investigates the current role of NOTES and SILS in Switzerland. Methods All Swiss surgical departments where queried. Heads of department were asked to complete a detailed questionnaire regarding the use of NOTES and SILS techniques, reminders were sent twice. Results Of 93 departments queried, 63 (68%) answered the survey and most were public hospitals (92%). One third of general surgery departments and 46% of visceral surgery departments had the highest accreditation level A and V1, respectively. While up to 27% of the responding hospitals had performed NOTES in the past, only about 9% still use the technique today. Since January 2019, only two departments performed NOTES cholecystectomy, one department NOTES colectomy and three departments NOTES total mesorectal excision. The main reasons for not performing NOTES anymore were lack of perceived benefits, higher costs, increased morbidity in routine procedures, no patient demand, and the lack of surgical expertise. A similar picture was found regarding the use of SILS, with 37% of hospitals having past experience with SILS and only 13% still performing SILS procedures. Yet, significantly more institutions performed a broader range of SILS procedures today: SILS appendectomy (n = 2), SILS cholecystectomy (n = 4), SILS thyroidectomy (n = 1), SILS small bowel resection (n = 2), SILS colonic resection (n = 5), and SILS rectal resection (n = 2). The main reasons for not performing routinely SILS were similar to the rationale against NOTES. Conclusion Due to technical limitations and lack of perceptible benefits, NOTES and SILS are less frequently performed nowadays than they were in the past. Only a minority of departments are still performing NOTES and SILS, including cholecystectomies, appendectomies, thyroidectomies, and bowel resections. Whether the rise in use of robotic techniques correlates with the decrease of NOTES and SILS needs further investigation.

Laparoscopy has become the standard surgery mode of right hemicolectomy, including conventional laparoscopy, hand-assisted laparoscopic surgery (HALS), single-port laparoscopic surgery (SPLS), natural orifices translumenal endoscopic surgery (NOTES) and robotic laparoscopy. How to select reasonable laparoscopic mode could be confusing sometimes. For patients, safety, cost-effectiveness and radical cure of the surgery are very important. For doctors, advance and convenience of the surgery must be considered as well. How do we choose a win-win operation method Conventional laparoscopic surgery is the basis of all the minimally invasive surgeries, and total mesocolon resection with D3 lymphadenectomy is an important technical foundation of right hemicolectomy. HALS has some advantages in patients with obesity, abdominal surgery history, intestinal adhesion or intestinal obstruction. SPLS and NOTES have minimized abdominal trauma leading to faster recovery, but have certain technical difficulties, especially NOTES. Although robotic laparoscopic surgery is advanced, but its high cost limits its popularization. Surgeons should integrate their technical levels, hospital equipment, and conditions of patients, then choose reasonable operation mode of right hemicolectomy.

In the past 30 years surgical practice has changed considerably owing to the advent of minimally invasive surgery (MIS). This paper investigates the changing surgical landscape chronologically and quantitatively, examining the technologies that have played, and are forecast to play, the largest part in this shift in surgical practice. Electronic patent and publication databases were searched over the interval 1980-2011 for ('minimally invasive' OR laparoscopic OR laparoscopy OR 'minimal access' OR 'key hole') AND (surgery OR surgical OR surgeon). The resulting patent codes were allocated into technology clusters. Technology clusters referred to repeatedly in the contemporary surgical literature were also included in the analysis. Growth curves of patents and publications for the resulting technology clusters were then plotted. The initial search revealed 27,920 patents and 95,420 publications meeting the search criteria. The clusters meeting the criteria for in-depth analysis were: instruments, image guidance, surgical robotics, sutures, single-incision laparoscopic surgery (SILS) and natural-orifice transluminal endoscopic surgery (NOTES). Three patterns of growth were observed among these technology clusters: an S-shape (instruments and sutures), a gradual exponential rise (surgical robotics and image guidance), and a rapid contemporaneous exponential rise (NOTES and SILS). Technological innovation in MIS has been largely stagnant since its initial inception nearly 30 years ago, with few novel technologies emerging. The present study adds objective data to the previous claims that SILS, a surgical technique currently adopted by very few, represents an important part of the future of MIS.

Natural Orifice Transluminal Endoscopic Surgery (NOTES) is a potential paradigm shift of Minimally Invasive Surgery that makes use of natural orifices to access the peritoneum for surgery without leaving visible scars. With NOTES, there are various benefits for patients such as fewer complications, improved precision, and faster recovery. In NOTES, the endoscope needs to be sufficiently flexible to go through the tortuous paths inside the human body to reach the target therapeutic site; once at the target site, the endoscope needs to be stiff enough to withstand external payloads as a stable platform during tissue manipulation without unwanted bending of the endoscope tip. Thus, an endoscope whose stiffness can be adjusted on command is desired. This thesis presents a novel variable-stiffness manipulator/endoscope and its application in NOTES. Two main objectives are identified: (𝑖) design, testing, and modeling of a novel approach for variable-stiffness manipulators, for proof of concepts, using a thermoplastic material whose stiffness is tunable through temperature. The temperature is adjusted through the joule heat generated by applying electric current into flexible metal coils inside the manipulator. A model that represents the relationship between the stiffness and the variables like dimensions of the design, heating time, and applied current will be studied and verified with experiments; and (𝑖𝑖) design, testing, and modeling of a variable-stiffness manipulator by considering critical requirements on sizes, and efficiency of real surgeries in flexible endoscopy and NOTES. Driven by 8 tendons, the robot has two bending sections and can be bent into “S” shapes. The active cooling mechanism is designed to shorten the activation time. The thermal insulation is also included to keep the temperature of the outer surface in the safe range. The comparisons in terms of the stiffness changing ratio and stiffness itself between the proposed design and the commercial endoscopes are shown along with extensive experiments. In particular, the manipulator has a high stiffness-changing ratio (22) between rigid and flexible states while that of its commercial Olympus counterpart is only 1.59. Heating and cooling mathematical models are also derived and evaluated using the experimental data. The cooling time with the active cooling mechanism is 11.9s while that of passive ambient cooling is 100.3s. The thermal insulation layer keeps the temperature of the outer surface within the safe range (below 41˚C) during operation. The results confirm the feasibility of developing a compact variable-stiffness endoscopic manipulator with significantly high stiffness-changing ratio (low stiffness in the flexile mode and high stiffness in the rigid mode), shortened time for switching the modes, and safe thermal insulation. The proposed manipulator may be used as a stable endoscopic platform in general flexible endoscopy and key-hole surgery.

Objective: The aim of this research was to compare two new hysterectomy techniques by robotic vaginal natural orifice transluminal endoscopic surgery and to demonstrate that transvaginal robotic hysterectomy can be performed in nulliparous patients by natural orifice transluminal endoscopic surgery (NOTES). Materials and Methods: This research was conducted in a case series format. Previous experience with total vaginal NOTES hysterectomy (TVNH) and with transvaginal robotic surgery for robotic vaginally assisted NOTES hysterectomy (RVANH), led to the decision to combine these techniques to perform robotic TVNH (RTVNH) in nulliparous patients. Twenty patients were included in this study. In 10 nulliparous patients, RTVNH was performed. A gloveport was inserted into the vagina to create a pneumovagina. A Da Vinci Xi surgical robot was side-docked between the legs of each patient. The hysterectomy was performed via transvaginal NOTES using the surgical robot. Once the hysterectomy was completed, the robot and gloveport were removed. The colpotomy was closed as in classical vaginal surgery. The data of these patients were compared to that of 10 parous patients who underwent RVANH. Results: All procedures were completed without conversion to transabdominal laparoscopy or laparotomy. Mean patient data and results for RTVNH/RVANH were: age, 49–63; body mass index, 26.4–27.8; total operating time, 90–118 minutes; hemoglobin drop, 1.2–1.3 g/dL; uterus weight, 149–213 g; pain scores at day 1, 2–2, and at day 2, 2–2. There was one complication in the RVANH group: superficial thrombophlebitis. Conclusions: This cohort study confirmed that robotic transvaginal surgery is feasible and can be used to perform total hysterectomy. RTVNH enabled hysterectomies to be performed without any abdominal incisions in nulliparous patients, who had been determined as unsuitable candidates for classical vaginal hysterectomy. RTVNH and RVANH are novel techniques and require further validation. Further developments in robotic technology will help overcome the practical problem of arm collision and will increase the time efficiency of the procedure. (J GYNECOL SURG 32:270)

Transvaginal natural orifice transluminal endoscopic surgery (v-NOTES) offers several unique advantages including reduced postoperative pain and improved cosmetic outcomes. This study aimed to evaluate the effectiveness of v-NOTES in the treatment of tubal pregnancy, with a focus on patient outcomes and cost-effectiveness. A retrospective analysis was conducted on 40 cases of tubal pregnancy treated surgically between December 1, 2020 and May 31, 2022. Patients were divided into 2 groups: the v-NOTES group (n = 20), who underwent transvaginal natural orifice transluminal endoscopic surgery, and the control group (n = 20), who underwent laparoscopic single-site surgery (LESS). Key variables including age, body mass index, operative time, intraoperative blood loss, postoperative pain, recovery time, and total costs were evaluated and compared between the 2 groups. Operative time and intraoperative blood loss were comparable between the 2 groups, patients in the v-NOTES group reported significantly lower postoperative pain scores and shorter hospital stays (P < .05). Additionally, the time return to normal activity was markedly shorter in the v-NOTES group compared to the LESS group (16 hours vs 25 hours, respectively). Both procedures demonstrated similar safety profiles; but v-NOTES was associated with a faster recovery and higher patient satisfaction. V-NOTES is a safe and effective minimally invasive surgical option for tubal pregnancy, providing enhanced recovery and improved patient experience compared to LESS.

Robotic assisted vaginal natural orifice transluminal endoscopic surgery high uterosacral ligament suspension (NOTES-HUS) for uterine prolapse with and without uterine preservation

9 - Robotics for minimally invasive surgery (MIS) and natural orifice transluminal endoscopic surgery (NOTES)

Natural Orifice Transluminal Endoscopic Surgery(NOTES) is a new concept that has no scar at abdominal skin because the surgical instruments are inserted through stomach, colon, vaginal or urinary bladder through natural entry port. But, it is technically difficult because of the limit of the conventional endoscopic surgical instruments. A robot technique can be a best solution for the NOTES. In robotic surgery, intuitive and safe control of robot arms is most important factor for successive surgery. For intuitive control, the motion of surgeon’s hand and robot arm must be same or similar. A master console for intuitive control for NOTES robot was developed. A simulator of surgical robot for NOTES was developed to estimate master manipulator, research control algorithm.

Laparoscopic transumbilical sleeve gastrectomy without visible abdominal scars

224 - Natural Orifice Transluminal Endoscopic Surgery (NOTES) of Hysterectomy and Bilateral Salpingo-Oophrectomy for Female to Male Transgender Men

Robotic Transvaginal Natural Orifice Transluminal Endoscopic Surgery for Resection of Parametrial and Bowel Deeply Infiltrated Endometriosis

Endoscopic transesophageal access techniques

In recent decades, surgical specialties have experienced numerous changes and developments, and minimally invasive surgical techniques have been adopted to reduce patient morbidity (Branco et al., 2008a). Laparoscopy has a well-established role in the modern era of surgery. Despite the difficulties in terms of learning curve early in the clinical implementation of this method, almost all surgical specialties have adopted the minimally invasive surgical approach as the gold standard. This results in less postoperative pain, shorter hospital stay, faster recovery and better aesthetic results (Jin et al., 2009; Keus et al., 2010; Kondo et al., 2006). Recently, a new minimally invasive surgical approach has been increasingly described in the literature as NOTES (Natural Orifice Transluminal Endoscopic Surgery). This is an access to the abdominal cavity without any incisions in the abdominal wall (scarless surgery), and the natural orifices serve as the gateway to the peritoneal cavity. Thus, an endoscope is inserted into the abdominal cavity through the stomach, vagina, bladder or colon (de la Fuente et al., 2007). The first report of this surgical technique was described by Gettman et al. (2002), at The University of Texas in 2002, which demonstrated that transvaginal nephrectomy in an experimental animal model was feasible. Two years later, Kalloo et al. (2004) performed transgastric liver biopsies at the Johns Hopkins University. After these initial reports, several researchers have demonstrated the safety of the transgastric access to perform tubal ligation (Jagannath et al., 2005), cholecystectomy (Park et al., 2005), gastrojejunostomy (Kantsevoy et al., 2005), subtotal hysterectomy with oophorectomy (Wagh et al, 2005; Wagh et al, 2006), splenectomy (Kantsevoy et al., 2006), gastric bypass (Kantsevoy et al., 2007), nephrectomy (Lima et al., 2007) and pancreatectomy (Matthes et al., 2007), all based on experimental studies in the porcine model. Since 2007, reports of cholecystectomy (Branco Filho et al., 2007; Marescaux et al., 2007; Zorron et al., 2007), nephrectomy (Branco et al., 2008b) and tubal ligation (Kondo et al., 2009)

The application of flexible endoscopy tools for Natural Orifice Translumenal Endoscopic Surgery (NOTES) is constrained due to limitations in dexterity, instrument insertion, navigation, visualization, and retraction. Miniature endolumenal robots can mitigate these constraints by providing a stable platform for visualization and dexterous manipulation. This video demonstrates the feasibility of using an endolumenal miniature robot to improve vision and to apply off-axis forces for task assistance in NOTES procedures. A two-armed miniature in vivo robot has been developed for NOTES. The robot is remotely controlled, has on-board cameras for guidance, and grasper and cautery end effectors for manipulation. Two basic configurations of the robot allow for flexibility during insertion and rigidity for visualization and tissue manipulation. Embedded magnets in the body of the robot and in an exterior surgical console are used for attaching the robot to the interior abdominal wall. This enables the surgeon to arbitrarily position the robot throughout a procedure. The visualization and task assistance capabilities of the miniature robot were demonstrated in a nonsurvivable NOTES procedure in a porcine model. An endoscope was used to create a transgastric incision and advance an overtube into the peritoneal cavity. The robot was then inserted through the overtube and into the peritoneal cavity using an endoscope. The surgeon successfully used the robot to explore the peritoneum and perform small-bowel dissection. This study has demonstrated the feasibility of inserting an endolumenal robot per os. Once deployed, the robot provided visualization and dexterous capabilities from multiple orientations. Further miniaturization and increased dexterity will enhance future capabilities.