Dombre Etienne Gauthier Michael Andreff Nicolas - Nanorobotics

First published 2014 in Great Britain and the United States by ISTE Ltd and John Wiley & Sons, Inc.

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The rights of Michal Gauthier, Nicolas Andreff and Etienne Dombre to be identified as the author of this work have been asserted by them in accordance with the Copyright, Designs and Patents Act 1988.

Library of Congress Control Number: 2013957115

British Library Cataloguing-in-Publication Data
A CIP record for this book is available from the British Library
ISBN 978-1-84821-371-5

Introduction

For almost 30 years, research in medical robotics has led to many prototypes that have been validated technically, and some clinically. There are many specialties in this regard. Orthopedics, neurosurgery, endoscopic microsurgery (mainly gynecology, urology, fetal surgery, etc.), cardiac, thoracic and vascular surgery, ear, nose and throat (ENT) surgery, etc., are a few among others.

It is clear that robotics may facilitate surgical approaches such as minimally invasive surgery (MIS), natural orifice transluminal endoscopic surgery (NOTES), single port access (SPA) surgery and interventional radiology, and it is very promising in microsurgery. We list in some benefits for the patient and the surgeon of robots in the operating room (OR). To summarize, surgical robotics may contribute to less invasive and more accurate surgical gestures. It may also be useful in transcending human limitations.

Considering the benefits, it is surprising that only a few prototypes have managed to find their way into OR or medical offices. Several reasons are generally raised of which a few of the most important are given below:

The cost issue: the cost effectiveness of robotic systems has not yet been proved. Several factors worked against it: the cost of the OR is increased; a technical team is required; the surgical team has to be trained; the setup and skin-to-skin times are longer than conventional procedure. The compatibility with the cluttered environment of the OR should also be improved: the robots are still too bulky; quite often, the weight, dimension and footprint of the robot are out of proportion with respect to the force it has to exert and the workspace it has to cover during an operation.

The clinical added value: as noted in the report of the IARP Workshop on Medical Robotics, the medical added value has to be improved: Medical robotics suffers from a chicken and egg phenomenon in the sense that systems need to be developed before they can be tested clinically, but only through the latter will their true effectiveness and utility be proven [].

Safety issues: a medical robot is a complex system that consists of (1) an articulated and motorized mechanical structure, (2) a humanmachine interface, (3) electronic components and (4) a software controller. These components are used to perform operations in a constrained and not fully structured environment, inside and/or outside of the patients body, in cooperation with the surgeon, and in the presence of the medical staff. Thus, it is easy to understand that a system failure or dysfunction can be extremely critical [SAN 13b].

This analysis pushes for the development of a new generation of robotic systems along three major challenges [DOM 12b]:

Cost: they will be less bulky and less expensive than the current systems.

Ergonomics: they will be of plug and play-type like most tools and equipment in the OR in order to minimize the installation time. They will also be easy to use in order not to require special technical skills of the staff. Moreover, the sensors will be sterilizable, otherwise disposable, and highly integrated into the architecture of these systems.

Safety and medical added value: they will be increasingly less invasive and will not significantly extend the duration of the intervention. Moreover, the doctor/robot interfaces will be specifically designed to facilitate the implementation while ensuring that the level of operational safety is as high as possible.

.Medical robots: benefits for the surgeons and patients

Fields of application	Potential benefits to the surgeon	Potential benefits to the patient
Orthopedic surgery	Precision Possibility of carrying out complex cutting, drilling, milling Integration of multimodal preoperative and intraoperative information (vision, force) safety (virtual fixture)	Less revision surgery Expected longer lifetime of prostheses
Minimally invasive endoscopic surgery	3rd hand Greater comfort Elimination of the fulcrum effect Additional internal mobilities Compensation of physiological movements	Toward an increasingly less invasive surgery and without visible scars
Neurosurgery Interventional radiology Radiotherapy	Precision Safety (avoidance of vital structures) Compensation of physiological movements Exposure to radiations Precise spatial tracking of the dosimetric planning	Invasiveness Early treatment of increasingly smaller tumors Exposure to radiations of healthy tissues
Microsurgery	Downscaling of the forces and displacements Surgeons tremor filtering	Development of innovative procedures beyond the accuracy limits of the surgeon

The above specifications (cost, ergonomics and safety) imply that the future surgical robots should be smaller and dedicated to a limited number of functionalities with a certain level of autonomy appropriate for the complexity of the task they are supposed to achieve. In any case, the surgeon must maintain control of the gesture no matter what, at any time of the operative or exploratory procedure. From this observation, we understand that for many surgical applications, it makes sense to integrate the mobilities and the sensors inside the body rather than outside. In other words, rather than manipulating a multimillennial rigid instrument (like scissors or clamps) with an extracorporeal robot, the idea is to develop intracorporeal robots, offering at least the same performance of movement quality, safety and interaction with the doctor.