Mahatma Gandhi Mission’s

College of Engineering and Technology

Noida, U.P., India

Seminar Report

On

“ROBOTICS IN MEDICAL SCIENCE”

As

Part of B. Tech Curriculum

Submitted By:

PUSHKAR SINGH SANI

Vth Semester

1309540048

Under the Guidance of:

Ms. MANUJA PANDEY

(Asst. Professor)

Submitted to:

(Seminar Coordinator) HOD

Mechanical Engineering Department

MGM’s COET,

Noida.

i

Mahatma Gandhi Mission’s

College of Engineering and Technology

Noida, U.P., India

Department of Mechanical Engineering

CERTIFICATE

This is to certify that Mr. / Ms. PUSHKAR SINGH SANI of B. Tech. Mechanical

Engineering, Class TT-ME Roll No. 1309540048 has delivered seminar on the topic

ROBOTICS IN MEDICAL SCIENCE. His / her seminar presentation and report

during the academic year 2015-2016 as the part of B. Tech Mechanical Engineering

curriculum was poor/fair/good/excellent.

(Seminar Coordinator) (Guide) (Head of the Department)

ii

Acknowledgement

I would like to express my deep sense of gratitude to my supervisor Ms. Manuja

Pandey, Assistant Professor, Mechanical Engineering Department, M.G.M. College of

Engineering and Technology, Noida, U.P., for her guidance, support and

encouragement throughout this seminar report work. Moreover, I would like to

acknowledge the Mechanical Engineering Department, M.G.M. College of

Engineering and Technology, Noida, for providing me all possible help during this

seminar report work. Moreover, I would like to sincerely thank everyone who directly

and indirectly helped me in completing this work.

(Pushkar Singh Sani)

Date:

Place: Noida, Uttar Pradesh

iii

ABSTRACT

This report is based on the robotics technologies used in medical science. It provides a

detailed overview of robotic surgical systems and introduces recent developments in

the integration of synergistic controls such as virtual fixtures, dynamic active

constraints, and perceptual docking.

As we all know that it is very challengeable for surgeons. The level of difficulty of

surgery can be reduce by taking help of robots. Robotic assisted surgery has been

proved boom to medical science. This report gives a description about the types of

medical robots, robotic assisted surgery, their benefit & losses, and its future scope.

iv

CONTENTS

PAGES

Certificate i

Acknowledgement ii

Abstract iii

Contents iv

List of figures vii

CHAPTER 1: INTRODUCTION 1-3

1.1 Robotics 1

1.2 Robotic Surgery 1

CHAPTER 2: History of Medical Robotics 4-7

CHAPTER 3: Features of Medical Robotics 8

CHAPTER 4: Types of Medical Robots 9-11

4.1 Vasteras Giraffe 9

4.2 Aethon Tug 9

4.3 Bestic 10

4.4 CosmoBot 10

4.5 Microbots 10

4.6 Anybots 10

4.7 Swisslog Robocourier 10

4.8 Robots for deaf & blind 11

v

CHAPTER 5: Types of Surgical Systems 12-24

5.1 Da Vinci surgical system 12

5.1.1 Introduction 12

5.1.2 Overview 13

5.1.3 Clinical Uses 14

5.1.4 Advantage 15

5.1.5 Disadvantage 16

5.1.6 Future application 16

5.2 Cyberknife 17

5.2.1 Introduction 17

5.2.2 Overview 18

5.2.3 Robotic mounting 18

5.2.4 6D skull 19

5.2.5 Xsight 20

5.2.6 Fiducial 20

5.2.7 Synchrony 21

5.2.8 RoboCouch 22

5.2.9 Frameless 22

5.2.10 Clinical use 23

5.2.11 Advantage 24

5.2.12 Disadvantage 24

5.2.13 Uses 24

CHAPTER 6: Uses of Robotics in Surgery 26-33

6.1 General uses 26

6.2 Cardiothoracic Surgery 26

6.3 Cardiology and electrophysiology 27

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6.4 Colon and rectal surgery 28

6.5 Gastrointestinal surgery 29

6.6 Gynecology 29

6.7 Neurosurgery 29

6.8 Orthopedics 30

6.9 Pediatrics 30

6.10 Radiosurgery 31

6.11 Transplant surgery 31

6.12 Urology 32

6.13 Vascular surgery 33

CHAPTER 7: Future scope 34

CHAPTER 8: Conclusion 35

REFERENCES 37

vii

List of figures

Figure no. Name of figure Page no.

Fig. 1.1 Robotics arm 3

Fig. 2.1 PUMA 560 5

Fig. 2.2 Probot 7

Fig. 4.1 Microbot 11

Fig. 5.1 Da Vinci Surgical System 14

Fig. 5.2 Cyberknife surgical

system 18

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CHAPTER 1

INTRODUCTION

1.1 Robotics

Robotics is the branch of mechanical engineering, electrical engineering and

computer science that deals with the design, construction, operation, and application

of robots, as well as computer systems for their control, sensory feedback, and

information processing.

1.2 Robotic Surgery

Robotic surgery, computer-assisted surgery, and robotically-assisted surgery are terms

for technological developments that use robotic systems to aid in surgical procedures.

Robotically-assisted surgery was developed to overcome the limitations of pre-

existing minimally-invasive surgical procedures and to enhance the capabilities of

surgeons performing open surgery.

In the case of robotically-assisted minimally-invasive surgery, instead of directly

moving the instruments, the surgeon uses one of two methods to control the

instruments; either a direct telemanipulator or through computer control. A

telemanipulator is a remote manipulator that allows the surgeon to perform the normal

movements associated with the surgery whilst the robotic arms carry out those

movements using end-effectors and manipulators to perform the actual surgery on the

patient. In computer-controlled systems the surgeon uses a computer to control the

robotic arms and its end-effectors, though these systems can also still use

telemanipulator for their input. One advantage of using the computerized method is

that the surgeon does not have to be present, but can be anywhere in the world,

leading to the possibility for remote surgery.

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In the case of enhanced open surgery, autonomous instruments (in familiar

configurations) replace traditional steel tools, performing certain actions (such as rib

spreading) with much smoother, feedback-controlled motions than could be achieved

by a human hand. The main object of such smart instruments is to reduce or eliminate

the tissue trauma traditionally associated with open surgery without requiring more

than a few minutes' training on the part of surgeons. This approach seeks to improve

open surgeries, particularly cardio-thoracic, that have so far not benefited from

minimally-invasive techniques.

Robotic surgery has been criticized for its expense, by one estimate costing $1,500 to

$2000 more per patient

Medical robotics is a stimulating and modern field in medical science that involves

numerous operations and extensive use of telepresence. The discipline of telepresence

signifies the technologies that permit an individual to sense as if they were at another

location without being actually there. Robots are utilized in the discipline of medicine

to execute operations that are normally performed manually by human beings.

These operations may be extremely professional and facilitated to diagnose and treat

the patients. Though medical robotics may still be in its infancy, the use of medical

robots for numerous operations may increase the quality of medical treatment.

Utilization of telepresence in the medical operations has eliminated the barriers of

distance, due to which professional expertise is readily available. Use of robotics in

the medical field and telepresence minimize individual oversight and brings

specialized knowledge to inaccessible regions without the need of physical travel.

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Fig. 1.1: Robotics arm

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CHAPTER 2

History of Medical Robotics

Medical robotics was introduced in the science of medicine during the early 1980s,

first in the field of urology. Robotic arms were introduced and used for medical

operations. Robotics initially had inferior quality imaging capabilities. During this

period, the National Aeronautics and Space Administration also started exploring

utilization of robotics for telemedicine. Telemedicine comprises the use of robotics by

physicians for the observation and treatment of patients without being actually in the

physical presence of the patient. As telemedicine improved, it started to be used on

battlefields. During the close of the last century, medical robotics was developed for

use in surgery and numerous other disciplines. Continued advancement in medical

robotics is still in progress, and improved techniques are being developed.

The first robot to assist in surgery was the Arthrobot, which was developed and used

for the first time in Vancouver in 1983. Intimately involved were biomedical

engineer, Dr. James McEwen, Geoff Auchinleck, a UBC engineering physics grad,

and Dr. Brian Day as well as a team of engineering students. The robot was used in

an orthopedic surgical procedure on 12 March 1984, at the UBC

Hospital in Vancouver. Over 60 arthroscopic surgical procedures were performed in

the first 12 months, and a 1985 National Geographic video on industrial robots, The

Robotics Revolution, featured the device. Other related robotic devices developed at

the same time included a surgical scrub nurse robot, which handed operative

instruments on voice command, and a medical laboratory robotic arm.

A YouTube video entitled Arthrobot illustrates some of these in operation.

In 1985 a robot, the Unimate PUMA 560, was used to place a needle for a brain

biopsy using CT guidance. In 1992, the PROBOT, developed at Imperial College

London, was used to perform prostatic surgery by Dr. Senthil Nathan at Guy's and

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Fig 2.1: PUMA 560

St Thomas' Hospital, London. This was the first pure robotic surgery in the world.

The ROBODOC from Integrated Surgical Systems (working closely with IBM) was

introduced in 1992 to mill out precise fittings in the femur for hip replacement. The

purpose of the ROBODOC was to replace the previous method of carving out a femur

for an implant, the use of a mallet and broach/rasp.

Further development of robotic systems was carried out by SRI

International and Intuitive Surgical with the introduction of the da Vinci Surgical

System and Computer Motion with the AESOP and the ZEUS robotic surgical

system. The first robotic surgery took place at The Ohio State University Medical

Center in Columbus, Ohio under the direction of Robert E. Michler. Examples of

using ZEUS include a fallopian tube reconnection in July 1998, a beating

heart coronary artery bypass graft in October 1999, and the Lindbergh Operation,

which was a cholecystectomy performed remotely in September 2001.

The original telesurgery robotic system that the da Vinci was based on was developed

at SRI International in Menlo Park with grant support from DARPA and NASA.

Although the telesurgical robot was originally intended to facilitate remotely

performed surgery in battlefield and other remote environments, it turned out to be

more useful for minimally invasive on-site surgery. The patents for the early

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prototype were sold to Intuitive Surgical in Mountain View, California. The da Vinci

senses the surgeon’s hand movements and translates them electronically into scaled-

down micro-movements to manipulate the tiny proprietary instruments. It also detects

and filters out any tremors in the surgeon's hand movements, so that they are not

duplicated robotically. The camera used in the system provides a true stereoscopic

picture transmitted to a surgeon's console. Examples of using the da Vinci system

include the first robotically assisted heart bypass (performed in Germany) in May

1998, and the first performed in the United States in September 1999 and the first all-

robotic-assisted kidney transplant, performed in January 2009. The da Vinci Si was

released in April 2009, and initially sold for $1.75 million.

In May 2006 the first artificial intelligence doctor-conducted unassisted robotic

surgery on a 34 year old male to correct heart arrhythmia. The results were rated as

better than an above-average human surgeon. The machine had a database of 10,000

similar operations, and so, in the words of its designers, was "more than qualified to

operate on any patient". In August 2007, Dr. Sijo Parekattil of the Robotics Institute

and Center for Urology (Winter Haven Hospital and University of Florida) performed

the first robotic assisted microsurgery procedure denervation of the spermatic cord for

chronic testicular pain. In February 2008, Dr. Mohan S. Gundeti of the University of

Chicago Comer Children's Hospital performed the first robotic pediatric neurogenic

bladder reconstruction.

On 12 May 2008, the first image-guided MR-compatible robotic neurosurgical

procedure was performed at University of Calgary by Dr. Garnette Sutherland using

the Neuro Arm. In June 2008, the German Aerospace Centre (DLR) presented a

robotic system for minimally invasive surgery, the Microsurgery. In September 2010,

the Eindhoven University of Technology announced the development of

the Sofie surgical system, the first surgical robot to employ force feedback. In

September 2010, the first robotic operation at the femoral vasculature was performed

at the University Medical Centre Ljubljana by a team led by Borut Geršak.

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Fig. 2.2: Probot

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CHAPTER 3

Features of Medical Robotics

Medical robotics is managed by physicians through computerized consoles. The

consoles may be near the patients, or at an external site. Consoles include single or

multiple arms being in the control of the physicians who perform operations on

patients. The shape and dimensions of these arms depend upon the type of surgery

being performed. The medical data and requirement is fed in the robotics before start

of surgery, including the X-rays, and other diagnostic examinations. This information

facilitates the medical robotics to traverse the human body correctly.

The purpose of utilizing medical robotics is the provision of enhanced diagnostic

capabilities, increased patient comfort, and less hazardous and more meticulous

interventions. Robots are being used for multiple operations, including replacement of

joints, kidneys, and open heart surgery. The patient images are visible to the

physician, and he can accordingly control the robot by a computer. He may not be

required to be present in the patient room. The robots have enabled the physicians to

perform operations on patients who are located at long distances. Therefore, the

environment produced is friendly where the physicians experience less fatigue. (Some

surgeries may be performed for long durations causing extensive fatigue to the

physicians.) The use of robotics in the medical field makes many medical procedures

much more smooth and comfortable.

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CHAPTER 4

Types of Medical Robots

o Vasteras Giraffe

o Aethon Tug

o Bestic

o CosmoBot

o Microbots

o AnyBots

o Swisslog Robocourier

o Robots for Paralyzed patient

4.1 Vasteras Giraffe

The Vasteras Giraffe is a mobile communication tool that enables the elderly to

communicate with the outside world. It is remote controlled, and it has wheels, a

camera and a monitor.

4.2 Aethon Tug

The Aethon Tug is an automated system that allows a facility to move supplies such

as medication, linens and food from one space to another. End users can attach the

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system to a variety of hospital carts to transport supplies and it can be employed for a

variety of applications.

4.3 Bestic

Bestic is a small robotic arm with a spoon on the end. The arm can be easily

maneuvered, and a user can independently control the spoon's movement on a plate to

choose what and when to eat.

4.4 CosmoBot

Doctors use CosmoBot to enhance the therapy of developmentally disabled children

between 5 and 12 years old.

4.5 Microbots

An assortment of free-roaming robots that carry out precise, delicate tasks inside the

human body. Its power sources are external electromagnetic coils, and it uses

magnetic field gradients as a steering mechanism.

4.6 Anybots

AnyBots provides a type of immersive telepresence, meaning instead of focusing

merely on audio and video communications, the AnyBots robot allows for movement

controlled by a remote.

4.7 Swisslog Robocourier

The Swisslog Robocourier is an autonomous mobile robot. The tool dispatches and

delivers specimens, medications and supplies throughout the hospital.

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4.8 Robots for deaf & blind

o Dexter, a robotic hand communication aid for people who are both deaf and

blind.

o Uses finger spelling to communicate information typed on a keyboard stored

in a computer or received from a special telephone.

Fig. 4.1: Microbot

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CHAPTER 5

Types of Surgical Systems

1. Da Vinci Surgical System

2. Cyberknife

5.1 Da Vinci surgical system

5.1.1 Introduction

The Da Vinci Surgical System is a robotic surgical system made by the

American company Intuitive Surgical. Approved by the Food and Drug

Administration (FDA) in 2000, it is designed to facilitate

complex surgery using a minimally approach, and is controlled by a surgeon

from a console. The system is commonly used for prostatectomies, and

increasingly for cardiac valve repair and gynecologic surgical procedures.

According to the manufacturer, the da Vinci System is called "da Vinci" in

part because Leonardo da Vinci's "study of human anatomy eventually led to

the design of the first known robot in history.

Da Vinci robots operate in hospitals worldwide, with an estimated 200,000

surgeries conducted in 2012, most commonly

for hysterectomies and prostate removals. As of June 30, 2014, there was an

installed base of 3,102 units worldwide, up from 2,000 units at the same time

the previous year. The location of these units are as follows: 2,153 in the

United States, 499 in Europe, 183 in Japan, and 267 in the rest of the world.

The "Si" version of the system costs on average slightly under US$2 million,

in addition to several hundred thousand dollars of annual maintenance fees.

The da Vinci system has been criticized for its cost and for a number of issues

with its surgical performance.

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5.1.2 Overview

The da Vinci System consists of a surgeon’s console that is typically in the

same room as the patient, and a patient-side cart with four interactive robotic

arms controlled from the console. Three of the arms are for tools that hold

objects, and can also act as scalpels, scissors, bodies, or unipolar or hi. The

surgeon uses the console’s master controls to maneuver the patient-side cart’s

three or four robotic arms (depending on the model). The instruments’ jointed-

wrist design exceeds the natural range of motion of the human hand; motion

scaling and tremor reduction further interpret and refine the surgeon’s hand

movements. The da Vinci System always requires a human operator, and

incorporates multiple redundant safety features designed to minimize

opportunities for human error when compared with traditional approaches.

The da Vinci System has been designed to improve upon

conventional laparoscopy, in which the surgeon operates while standing, using

hand-held, long-shafted instruments, which have no wrists. With conventional

laparoscopy, the surgeon must look up and away from the instruments, to a

nearby 2D video monitor to see an image of the target anatomy. The surgeon

must also rely on a patient-side assistant to position the camera correctly. In

contrast, the da Vinci System’s design allows the surgeon to operate from a

seated position at the console, with eyes and hands positioned in line with the

instruments and using controls at the console to move the instruments and

camera.

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Fig. 5.1: Da Vinci Surgical System

By providing surgeons with superior visualization, enhanced dexterity, greater

precision and ergonomic comfort, the da Vinci Surgical System makes it

possible for more surgeons to perform minimally invasive procedures

involving complex dissection or reconstruction. For the patient, a da Vinci

procedure can offer all the potential benefits of a minimally invasive

procedure, including less pain, less blood loss and less need for blood

transfusions. Moreover, the da Vinci System can enable a shorter hospital stay,

a quicker recovery and faster return to normal daily activities.

5.1.3 Clinical Uses

The da Vinci System has been successfully used in the following procedures:

o Radical prostatectomy, pyeloplasty, cystectomy, nephrectomy and

ureteral replantation.

o Hysterectomy, myomectomy and sacrocolpopexy;

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o Hiatal hernia repair;

o Spleen-sparing distal pancreatectomy, cholecystectomy, Nissen

fundoplication, Heller myotomy, gastric bypass,

donor nephrectomy, adrenalectomy,splenectomy and bowel resection;

o Internal mammary artery mobilization and cardiac tissue ablation;

o Mitral valve repair and endoscopic atrial septal defect closure;

o Mammary to left anterior descending coronary

artery anastomosis for cardiac revascularization with

adjunctive mediastinotomy.

o Transoral resection of tumors of the upper aerodigestive tract

(tonsil, tongue base, larynx) and transaxillary thyroidectomy

o Resection of spindle cell tumors originating in the lung.

5.1.4 Advantage

o Simpler procedure

o Minimally invasive

o Better technique

o Reduced bleeding

o Less painful

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o Smaller scar

o Faster healing

o Decreased hospital stay

5.1.5 Disadvantage

o Longer learning period

o High cost of the equipment and thereby the procedure

o Reduction in space for assistants

o Lack of tactile sensation for the surgeon

5.1.6 Future application

Although the general term "robotic surgery" is often used to refer to the

technology, this term can give the impression that the da Vinci System is

performing the surgery autonomously. In contrast, the current da Vinci

Surgical System cannot – in any manner – function on its own, as it was not

designed as an autonomous system and lacks decision making software.

Instead, it relies on a human operator for all input; however, all operations –

including vision and motor functions— are performed through remote human-

computer interaction, and thus with the appropriate weak AI software, the

system could in principle perform partially or completely autonomously. The

difficulty with creating an autonomous system of this kind is not trivial; a

major obstacle is that surgery per se is not an engineered process – a

requirement for weak AI. The current system is designed merely to replicate

seamlessly the movement of the surgeon's hands with the tips of micro-

instruments, not to make decisions or move without the surgeon’s direct input.

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The possibility of long-distance operations depends on the patient having

access to a da Vinci System, but technically the system could allow a doctor to

perform telesurgery on a patient in another country. In 2001, Dr. Marescaux

and a team from IRCAD used a combination of high-speed fiber-optic

connection with an average delay of 155 ms with advanced asynchronous

transfer mode (ATM) and a Zeus telemanipulator to successfully perform the

first transatlantic surgical procedure, covering the distance between New York

and Strasbourg. The event was considered a milestone of global telesurgery,

and was dubbed “Operation Lindbergh”

5.2 Cyberknife

5.2.1 Introduction

The CyberKnife Robotic Radiosurgery System is a non-invasive alternative

to surgery for the treatment of both cancerous and non-cancerous tumors

anywhere in the body, including the prostate, lung, brain, spine, liver,

pancreas and kidney. The treatment – which delivers beams of high dose

radiation to tumors with extreme accuracy – offers new hope to patients

worldwide.

Though its name may conjure images of scalpels and surgery, the

CyberKnife treatment involves no cutting. In fact, the CyberKnife System

is the world’s first and only robotic radiosurgery system designed to treat

tumors throughout the body non-invasively. It provides a pain-free, non-

surgical option for patients who have inoperable or surgically complex

tumors, or who may be looking for an alternative to surgery.

The CyberKnife is a frameless robotic radiosurgery system used for

treating benign tumors, malignant tumors and other medical conditions.

The system was invented by John R. Adler, a Stanford University professor

of neurosurgery and radiation oncology, and Peter and Russell Schonberg

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of Schonberg Research Corporation. It is made by the Accuracy company

headquartered in Sunnyvale, California.

The CyberKnife system is a method of delivering radiotherapy, with the

intention of targeting treatment more accurately than standard radiotherapy.

The two main elements of the CyberKnife are the radiation produced from

a small linear particle accelerator and a robotic arm which allows the

energy to be directed at any part of the body from any direction.

5.2.2 Overview

Several generations of the CyberKnife system have been developed since its

initial inception in 1990. There are two major features of the CyberKnife

system that are different from other stereotactic therapy methods.

Fig. 5.2: Cyberknife Surgical System

5.2.3 Robotic mounting

The first is that the radiation source is mounted on a general purpose industrial

robot. The original CyberKnife used a Japanese Fanuc robot, however the

more modern systems use a German KUKA KR 240. Mounted on the Robot is

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a compact X-band linac that produces 6MV X-ray radiation. The linac is

capable of delivering approximately 600 cGy of radiation each minute – a new

800 cGy / minute model was announced at ASTRO 2007. The radiation is

collimated using fixed tungsten collimators (also referred to as "cones") which

produce circular radiation fields. At present the radiation field sizes are: 5, 7.5,

10, 12.5, 15, 20, 25, 30, 35, 40, 50 and 60 mm. ASTRO 2007 also saw the

launch of the IRIS variable-aperture collimator which uses two offset banks of

six prismatic tungsten segments to form a blurred regular dodecagon field of

variable size which eliminates the need for changing the fixed collimators.

Mounting the radiation source on the robot allows near-complete freedom to

position the source within a space about the patient. The robotic mounting

allows very fast repositioning of the source, which enables the system to

deliver radiation from many different directions without the need to move both

the patient and source as required by current gantry configurations.The

CyberKnife system uses an image guidance system. X-ray imaging cameras

are located on supports around the patient allowing instantaneous X-ray

images to be obtained.

5.2.4 6D skull

The original (and still utilized) method is called 6D or skull based tracking.

The X-ray camera images are compared to a library of computer generated

images of the patient anatomy. Digitally Reconstructed Radiographs (or

DRR's) and a computer algorithm determines what motion corrections have to

be given to the robot because of patient movement. This imaging system

allows the CyberKnife to deliver radiation with an accuracy of 0.5mm without

using mechanical clamps attached to the patient's skull. The use of the image-

guided technique is referred to as frameless stereotactic radiosurgery. This

method is referred to as 6D because corrections are made for the 3

translational motions (X,Y and Z) and three rotational motions. It should be

noted that it is necessary to use some anatomical or artificial feature to orient

the robot to deliver X-ray radiation, since the tumor is never sufficiently well

defined (if visible at all) on the X-ray camera images.

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5.2.5 Xsight

Additional image guidance methods are available for spinal tumors and for

tumors located in the lung. For a tumor located in the spine, a variant of the

image guidance called Xsight-Spine is used. The major difference here is that

instead of taking images of the skull, images of the spinal processes are used.

Whereas the skull is effectively rigid and non-deforming, the spinal vertebrae

can move relative to each other, this means that image warping algorithms

must be used to correct for the distortion of the X-ray camera images.

A recent enhancement to Xsight is Xsight-Lung which allows tracking of some

lung tumors without the need to implantfiducial markers.

5.2.6 Fiducial

For soft tissue tumors, a method known as fiducial tracking can be utilized.

Small metal markers (fiducials) made out of gold for bio-compatibility and

high density to give good contrast on X-ray images are surgically implanted in

the patient. This is carried out by an interventional radiologist, or

neurosurgeon. The placement of the fiducials is a critical step if the fiducial

tracking is to be used. If the fiducials are too far from the location of the

tumor, or are not sufficiently spread out from each other it will not be possible

to accurately deliver the radiation. Once these markers have been placed, they

are located on a CT scan and the image guidance system is programmed with

their position. When X-ray camera images are taken, the location of the tumor

relative to the fiducials is determined, and the radiation can be delivered to any

part of the body. Thus the fiducial tracking does not require any bony anatomy

to position the radiation. Fiducials are known however to migrate and this can

limit the accuracy of the treatment if sufficient time is not allowed between

implantation and treatment for the fiducials to stabilize.

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5.2.7 Synchrony

The final technology of image guidance that the CyberKnife system can use is

called the Synchrony system or Synchrony method. The synchrony method

uses a combination of surgically placed internal fiducials (typically small gold

markers, well visible in x-ray imaging), and light emitting optical fibers (LED

markers) mounted on the patient skin. LED markers are tracked by an infrared

tracking camera. Since the tumor is moving continuously, to continuously

image its location using X-ray cameras would require prohibitive amounts of

radiation to be delivered to the patient's skin. The Synchrony system

overcomes this by periodically taking images of the internal fiducials, and

computing a correlation model between the motion of the external LED

markers and the internal fiducials. Time stamps from the two sensors (x-ray

and infrared LED) are needed to synchronize the two data streams, hence the

name Synchrony.

Motion prediction is used to overcome the motion latency of the robot and the

latency of image acquisition. Before treatment, a computer algorithm creates a

correlation model that represents how the internal fiducial markers are moving

compared to the external markers. During treatment, the system continuously

infers the motion of the internal fiducials, and therefore the tumor, based on

the motion of the skin markers. The correlation model is updated at fixed time

steps during treatment. Thus, the Synchrony tracking method makes no

assumptions about the regularity or reproducibility of the patient breathing

pattern.

To function properly, the Synchrony system requires that for any given

correlation model there is a functional relationship between the markers and

the internal fiducials. The external marker placement is also important, and the

markers are usually placed on the patient abdomen so that their motion will

reflect the internal motion of the diaphragm and the lungs. The synchrony

method was invented in 1998. The first patients were treated at Cleveland

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Clinic in 2002. Synchrony is utilized primarily for tumors that are in motion

while being treated, such as lung tumors and pancreatic tumors.

5.2.8 RoboCouch

A robotic six degree of freedom patient treatment couch called

RoboCouchimproves patient positioning options for treatment.

5.2.9 Frameless

The frameless nature of the CyberKnife also increases the clinical efficiency.

In conventional frame-based radiosurgery, the accuracy of treatment delivery

is determined solely by connecting a rigid frame to the patient which is

anchored to the patient’s skull with invasive aluminum or titanium screws.

The CyberKnife is the only radiosurgery device that does not require such a

frame for precise targeting. Once the frame is connected, the relative position

of the patient anatomy must be determined by making a CT or MRI scan.

After the CT or MRI scan has been made, a radiation oncologist must plan the

delivery of the radiation using a dedicated computer program, after which the

treatment can be delivered, and the frame removed. The use of the frame

therefore requires a linear sequence of events that must be carried out

sequentially before another patient can be treated. Staged CyberKnife

radiosurgery is of particular benefit to patients who have previously received

large doses of conventional radiation therapy and patients with gliomas

located near critical areas of the brain. Unlike whole brain radiotherapy, which

must be administered daily over several weeks, radiosurgery treatment can

usually be completed in 1–5 treatment sessions. Radiosurgery can be used

alone to treat brain metastases, or in conjunction with surgery or whole brain

radiotherapy, depending on the specific clinical circumstances.

By comparison, using a frameless system, a CT scan can be carried out on any

day prior to treatment that is convenient. The treatment planning can also be

carried out at any time prior to treatment. During the treatment the patient

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need only be positioned on a treatment table and the predetermined plan

delivered. This allows the clinical staff to plan many patients at the same time,

devoting as much time as is necessary for complicated cases without slowing

down the treatment delivery. While a patient is being treated, another clinician

can be considering treatment options and plans, and another can be conducting

CT scans.

In addition, very young patients (pediatric cases) or patients with fragile heads

because of prior brain surgery cannot be treated using a frame based system.

Also, by being frameless the CyberKnife can efficiently re-treat the same

patient without repeating the preparation steps that a frame-based system

would require.

The delivery of a radiation treatment over several days or even weeks (referred

to as fractionation) can also be beneficial from a therapeutic point of view.

Tumor cells typically have poor repair mechanisms compared to healthy

tissue, so by dividing the radiation dose into fractions the healthy tissue has

time to repair itself between treatments. This can allow a larger dose to be

delivered to the tumor compared to a single treatment.

5.2.10 Clinical use

Since August 2001, the CyberKnife system has FDA clearance for treatment

of tumors in any location of the body. Some of the tumors treated

include: pancreas, liver, prostate, spinal lesions, head and neck cancers,

and benign tumors.

None of these studies have shown any general survival benefit over

conventional treatment methods. By increasing the accuracy with which

treatment is delivered there is a potential for dose escalation, and potentially a

subsequent increase in effectiveness, particularly in local control rates.

However the studies cited are so far limited in scope, and more extensive

research will need to be completed in order to show any effects on survival.

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In 2008 actor Patrick Swayze was among the people to be treated with

CyberKnife radiosurgery.

5.2.11 Advantage

o The fatigue factor is considerably reduced as the surgeon is seated

and does not have to constantly hold onto the instruments.

o Robotic surgeries are minimally invasive

o Incisions are smaller

o Less risk of infection

o Hospital stays are generally shorter

o Patients recuperate faster

5.2.12 Disadvantage

o These Specific machines can be very expensive to own and operate

o Surgeons and nurses have to be specially trained to know how to use

them

o There is not much data out there about come procedures

5.2.13 Uses

The CyberKnife® Robotic Radiosurgery System is a non-invasive alternative

to surgery for the treatment of both cancerous and non-cancerous tumors

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anywhere in the body, including the prostate, lung, brain, spine, liver,

pancreas and kidney. The treatment – which delivers high doses of radiation to

tumors with extreme accuracy – offers new hope to patients who have

inoperable or surgically complex tumors, or who may be looking for a non-

surgical option.

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CHAPTER 6

Uses of robotics in surgery

6.1 General uses

In early 2000 the field of general surgical interventions with the da Vinci device was

explored by surgeons at Ohio State University. Reports were published in esophageal

and pancreatic surgery for the first time in the world and further data was

subsequently published by Horgan and his group at the University of Illinois and then

later at the same institution by others. In 2007, the University of Illinois at

Chicago medical team, led by Prof. Pier Cristoforo Giulianotti, reported

apancreatectomy and also the Midwest's first fully robotic Whipple surgery. In April

2008, the same team of surgeons performed the world's first fully minimally

invasive liver resection for living donor transplantation, removing 60% of the patient's

liver, yet allowing him to leave the hospital just a couple of days after the procedure,

in very good condition. Furthermore the patient can also leave with less pain than a

usual surgery due to the four puncture holes and not a scar by a surgeon.

6.2 Cardiothoracic Surgery

Robot-assisted MIDCAB and Endoscopic coronary artery bypass (TECAB)

operations are being performed with the Da Vinci system. Mitral valve repairs and

replacements have been performed. The Ohio State University, Columbus has

performed CABG, mitral valve, esophagectomy, lung resection, tumor resections,

among other robotic assisted procedures and serves as a training site for other

surgeons. In 2002, surgeons at the Cleveland Clinic in Florida reported and published

their preliminary experience with minimally invasive "hybrid" procedures. These

procedures combined robotic revascularization and coronary stenting and further

expanded the role of robots in coronary bypass to patients with disease in multiple

vessels. Ongoing research on the outcomes of robotic assisted CABG and hybrid

CABG is being done.

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6.3 Cardiology and electrophysiology

The Stereotaxic Magnetic Navigation System (MNS) has been developed to increase precision and

safety in ablation procedures for arrhythmias and atrial fibrillation while reducing radiation

exposure for the patient and physician, and the system utilizes two magnets to remotely steerable

catheters. The system allows for automated 3-D mapping of the heart and vasculature, and MNS

has also been used in interventional cardiology for guiding stents and leads in PCI and CTO

procedures, proven to reduce contrast usage and access tortuous anatomy unreachable by manual

navigation. Dr. Andrea Natale has referred to the new Stereotaxic procedures with the magnetic

irrigated catheters as "revolutionary."

The Hansen Medical Sensei robotic catheter system uses a remotely operated system

of pulleys to navigate a steerable sheath for catheter guidance. It allows precise and

more forceful positioning of catheters used for 3-D mapping of the heart and

vasculature. The system provides doctors with estimated force feedback information

and feasible manipulation within the left atrium of the heart. The Sensei has been

associated with mixed acute success rates compared to manual, commensurate with

higher procedural complications, longer procedure times but

lower fluoroscopy dosage to the patient.

At present, three types of heart surgery are being performed on a routine basis using

robotic surgery systems. These three surgery types are:

Atrial septal defect repair – the repair of a hole between the two upper

chambers of the heart,

Mitral valve repair – the repair of the valve that prevents blood from

regurgitating back into the upper heart chambers during contractions of the heart,

Coronary artery bypass – rerouting of blood supply by bypassing blocked

arteries that provide blood to the heart.

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As surgical experience and robotic technology develop, it is expected that the

applications of robots in cardiovascular surgery will expand.

6.4 Colon and rectal surgery

Many studies have been undertaken in order to examine the role of robotic procedures

in the field of colorectal surgery.

Results to date indicate that robotic-assisted colorectal procedures outcomes are "no

worse" than the results in the now "traditional" laparoscopic colorectal operations.

Robotic-assisted colorectal surgery appears to be safe as well. Most of the procedures

have been performed for malignant colon and rectal lesions. However, surgeons are

now moving into resections for diverticulitis and non-resective rectopexies (attaching

the colon to the sacrum in order to treat rectal prolapse.)

When evaluated for several variables, robotic-assisted procedures fare equally well

when compared with laparoscopic, or open abdominal operations. Study parameters

have looked at intraoperative patient preparation time, length of time to perform the

operation, adequacy of the removed surgical specimen with respect to clear surgical

margins and number of lymph nodes removed, blood loss, operative or postoperative

complications and long-term results.

More difficult to evaluate are issues related to the view of the operative field, the

types of procedures that should be performed using robotic assistance and the

potential added cost for a robotic operation.

Many surgeons feel that the optics of the 3-dimensional, two camera stereo optic

robotic system are superior to the optical system used in laparoscopic procedures. The

pelvic nerves are clearly visualized during robotic-assisted procedures. Less clear

however is whether or not these supposedly improved optics and visualization

improve patient outcomes with respect to postoperative impotence or incontinence,

and whether long-term patient survival is improved by using the 3-dimensional optic

system. Additionally, there is often a need for a wider, or "larger" view of the

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operative field than is routinely provided during robotic operations. The close-up view

of the area under dissection may hamper visualization of the "bigger view", especially

with respect to ureteral protection.

Questions remain unanswered, even after many years of experience with robotic-

assisted colorectal operations. Ongoing studies may help clarify many of the issues of

confusion associated with this novel surgical approach.

6.5 Gastrointestinal surgery

Multiple types of procedures have been performed with either the 'Zeus' or da

Vinci robot systems, including bariatric surgery and gastrectomy for cancer. Surgeons

at various universities initially published case series demonstrating different

techniques and the feasibility of GI surgery using the robotic devices.[9]Specific

procedures have been more fully evaluated, specifically esophageal fundoplication for

the treatment of gastroesophageal refluxand Heller myotomy for the treatment of

achalasia.

Other gastrointestinal procedures including colon resection, pancreatectomy,

esophagectomy and robotic approaches to pelvic disease have also been reported.

6.6 Gynecology

Robotic surgery in gynecology is of uncertain benefit with it being unclear if it affects

rates of complications. Gynecologic procedures may take longer with robot-assisted

surgery but may be associated with a shorter hospital stay following hysterectomy. In

the United States, robotic-assisted hysterectomy for benign conditions has been

shown to be more expensive than conventional laparoscopic hysterectomy, with no

difference in overall rates of complications.

This includes the use of the da Vinci surgical system in benign gynecology and

gynecologic oncology. Robotic surgery can be used to treat fibroids, abnormal

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periods, endometriosis, ovarian tumors, uterine prolapse, and female cancers. Using

the robotic system, gynecologists can perform hysterectomies, myomectomies, and

lymph node biopsies.

6.7 Neurosurgery

Several systems for stereotactic intervention are currently on the market. The

NeuroMate was the first neurosurgical robot, commercially available in 1997.

Originally developed in Grenoble by Alim-Louis_Benabid’s team, it is now owned

by Renishaw. With installations in the United States, Europe and Japan, the system

has been used in 8000 stereotactic brain surgeries by 2009. IMRIS Inc.'s

SYMBIS(TM) Surgical System will be the version of NeuroArm, the world’s

first MRI-compatible surgical robot, developed for world-wide commercialization.

Medtech's Rosa is being used by several institutions, including the Cleveland Clinic in

the U.S, and in Canada at Sherbrooke University and the Montreal Neurological

Institute and Hospital in Montreal (MNI/H). Between June 2011 and September 2012,

over 150 neurosurgical procedures at the MNI/H have been completed robotized

stereotaxy, including in the placement of depth electrodes in the treatment of epilepsy,

selective resections, and stereotaxic biopsies.

6.8 Orthopedics

The ROBODOC system was released in 1992 by Integrated Surgical Systems,

Inc. which merged into CUREXO Technology Corporation. Also, The Acrobot

Company Ltd. developed the "Acrobot Sculptor", a robot that constrained

a bone cutting tool to a pre-defined volume. The "Acrobot Sculptor" was sold to

Stanmore Implants in August 2010. Stanmore received FDA clearance in February

2013 for US surgeries but sold the Sculptor to Mako Surgical in June 2013 to resolve

a patent infringement lawsuit. Another example is the CASPAR robot produced by

U.R.S.-Ortho GmbH & Co. KG, which is used for total hip replacement, total knee

replacement and anterior cruciate ligament reconstruction. MAKO Surgical Corp

(founded 2004) produces the RIO (Robotic Arm Interactive Orthopedic System)

which combines robotics, navigation, and haptics for both partial knee and total hip

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replacement surgery. Blue Belt Technologies received FDA clearance in November

2012 for the Navio™ Surgical System. The Navio System is a navigated, robotics-

assisted surgical system that uses a CT free approach to assist in partial knee

replacement surgery.

6.9 Pediatrics

Surgical robotics has been used in many types of pediatric surgical procedures

including: tracheoesophageal fistula repair, cholecystectomy, nissen fundoplication,

morgagni's hernia repair, kasai portoenterostomy, congenital diaphragmatic

hernia repair, and others. On 17 January 2002, surgeons at Children's Hospital of

Michigan in Detroit performed the nation's first advanced computer-assisted robot-

enhanced surgical procedure at a children's hospital.

The Center for Robotic Surgery at Children's Hospital Boston provides a high level of

expertise in pediatric robotic surgery. Specially-trained surgeons use a high-tech robot

to perform complex and delicate operations through very small surgical openings. The

results are less pain, faster recoveries, shorter hospital stays, smaller scars, and

happier patients and families.

In 2001, Children's Hospital Boston was the first pediatric hospital to acquire a

surgical robot. Today, surgeons use the technology for many procedures and perform

more pediatric robotic operations than any other hospital in the world. Children's

Hospital physicians have developed a number of new applications to expand the use

of the robot, and train surgeons from around the world on its use.[33]

6.10 Radiosurgery

The CyberKnife Robotic Radiosurgery System uses image guidance and computer

controlled robotics to treat tumors throughout the body by delivering multiple beams

of high-energy radiation to the tumor from virtually any direction. The system uses a

German KUKA KR 240. Mounted on the robot is a compact X-band linacthat

produces 6MV X-ray radiation. Mounting the radiation source on the robot allows

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very fast repositioning of the source, which enables the system to deliver radiation

from many different directions without the need to move both the patient and source

as required by current gantry configurations.

6.11 Transplant surgery

Transplant surgery (organ transplantation) has been considered as highly technically

demanding and virtually unobtainable by means of conventional laparoscopy. For

many years, transplant patients were unable to benefit from the advantages of

minimally invasive surgery. The development of robotic technology and its associated

high resolution capabilities, three dimensional visual system, wrist type motion and

fine instruments, gave opportunity for highly complex procedures to be completed in

a minimally invasive fashion. Subsequently, the first fully robotic kidney

transplantations were performed in the late 2000s. After the procedure was proven to

be feasible and safe, the main emerging challenge was to determine which patients

would benefit most from this robotic technique. As a result, recognition of the

increasing prevalence of obesity amongst patients with kidney failure on hemodialysis

posed a significant problem. Due to the abundantly higher risk of complications after

traditional open kidney transplantation, obese patients were frequently denied access

to transplantation, which is the premium treatment for end stage kidney disease. The

use of the robotic-assisted approach has allowed kidneys to be transplanted with

minimal incisions, which has virtually alleviated wound complications and

significantly shortened the recovery period. The University of Illinois Medical

Center reported the largest series of 104 robotic-assisted kidney transplants for obese

recipients (mean body mass index > 42). Amongst this group of patients, no wound

infections were observed and the function of transplanted kidneys was excellent. In

this way, robotic kidney transplantation could be considered as the biggest advance in

surgical technique for this procedure since its creation more than half a century ago.

6.12 Urology

Robotic surgery in the field of urology has become very popular, especially in the

United States. It has been most extensively applied for excision of prostate cancer

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because of difficult anatomical access. It is also utilized for kidney cancer surgeries

and to lesser extent surgeries of the bladder.

As of 2014, there is little evidence of increased benefits compared to standard surgery

to justify the increased costs.[38] Some have found tentative evidence of more

complete removal of cancer and less side effects from surgery for prostatectomy.[39]

In 2000, the first robot-assisted laparoscopic radical prostatectomy was performed.[5]

6.13 Vascular surgery

In September 2010, the first robotic operations with Hansen Medical's Magellan

Robotic System at the femoral vasculature were performed at theUniversity Medical

Centre Ljubljana (UMC Ljubljana), Slovenia. The research was led by Borut Geršak,

the head of the Department of Cardiovascular Surgery at the centre. Geršak explained

that the robot used was the first true robot in the history of robotic surgery, meaning

the user interface was not resembling surgical instruments and the robot was not

simply imitating the movement of human hands but was guided by pressing buttons,

just like one would play a video game. The robot was imported to Slovenia from the

United States.

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CHAPTER 8

Future scope

What's most remarkable about robotic surgery is what the future might hold.

Doctors are anticipating the growth of tele-medicine and long-distance

operations, where a doctor could conceivably operate on a patient in another city,

state, or even a different continent. Practically, this would mean that surgical centers

would be set up in different parts of the world and a doctor could go to a surgical

center and sit in a control console while a patient in a different surgical center would

be operated on by a robot controlled by that doctor.

Already a long-distance operation was performed via robotic surgery between New

York and Strasbourg, France, in 2001. The surgery, which was dubbed "Operation

Lindbergh" for its pioneering qualities, was performed successfully, but there was a

delayed lag time that made this long-distance surgery impractical. However, as the

internet becomes faster and bandwidth becomes cheaper, this will undoubtedly

change.

In the future there will be tele-medicine, where you can operate on someone

somewhere else in the world.

The other possibility that we could see in the future is the single-incision port, where a

doctor could make a tiny incision, perhaps through a patient's bellybutton, and then

insert the snake-like arms of the robot through that incision. Currently, the robot

makes a few small incisions, through which its arms are inserted.

The next generation of this technology will mean that you put one little hole in the

patient and then put snake-like arms through that hole.

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CHAPTER 8

Conclusion

Medical robotics, and particularly autonomous surgical robotics, are still in an

embryonic stage. Concentrating on surgical robots, the reasons for their not gaining

immediate enthusiasm and acceptance in the medical community are twofold.

Issues of safety have been highlighted, in particular, as hurdles to research and

development taking place. Safety issues have traditionally not been addressed and

there is an urgent need for a consensus on what is 'safe practice' concerning both

human-guided and autonomous robots.

The other main obstacle has been the misconceptions that abound concerning robots.

Surgeons do not like to see clumsy-looking industrial arms in the operating theatre,

they also do not like the idea of being replaced as superfluous equipment.

The first matter (that of safety) is a definite problem. Industrial robots operate in a

confined 'cell of activity' that is separate from their human counterparts - this

obviously cannot be the case with surgical robots. This will require immediate action

if it is not to further hinder the development of a field that can provide great benefits

to society. Considering the fact that increased complexity, both in the program of an

autonomous robot and in the design of a guided (or autonomous) robot, increases the

problem of defining safety standards, it is the opinion of the authors' that the way

forward in surgical robotics should be one that uses human-guided robots and/or

powered robots that are extremely task specific. A robot that has all the skills of a

human surgeon would be extremely complex; it is perhaps better to limit the abilities

that the robot has and, in doing so, limit the possible damage it could do if it were to

malfunction.

The second matter is one of education and social conditioning; it should also be eased

through the solving of the safety predicament. A good point to observe, for worried

surgeons, is the fact that, at best, robots can (at the moment) provide a crude substitute

to an expert surgeon. The human hand has twenty degrees of freedom, while the most

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advanced robots can only provide eight or nine. In addition, in robotic surgery, the

ability to image and model anatomical structures has outperformed the ability to

perform physical, robotic intervention. There have only been three research groups

that have devised specific powered systems that have an autonomous cutting function

(ISS - hip surgery, EPFL - neurosurgery, Imperial College - prostrate surgery). In the

vast majority of robotic surgeries, the surgeon has control of tool-holders or

positioning robots to improve their accuracy and performance.

To conclude, there are several steps that must be taken in order to further the use and

development of robots in surgery (and in medicine in general). These are:

the development, and international adoption, of safety standards

the aim of task-specific, as opposed to general-purpose, robots

the education of the medical community in the acceptance and integration of

robots

The economic and social advantages to be gained from the mass-use of robotics in

medicine (and particularly surgery), as already expounded, are enormous. If all of the

above steps are taken, then the full potential of robotics can be exploited in the

medical sector, as it has been in industrial applications, for the improved welfare of

society everywhere.

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REFERENCES

O'Toole, M. D.; Bouazza-Marouf, K.; Kerr, D.; Gooroochurn, M.; Vloeberghs,

M. (2009). "A methodology for design and appraisal of surgical robotic

systems".Robotica 28 (2)

Kolata, Gina (13 February 2010). "Results Unproven, Robotic Surgery Wins

Converts". The New York Times Retrieved 11 March 2010.

Barnebei et al., Lahey Clinic, presented at HRS 2009: PO04-35 – Robotic

versus Manual Catheter Ablation for Atrial Fibrillation

"Robotics in Medicine", P.Dario, E.Guglielmelli, B.Allotta, IROS '94.

Proceedings of the IEEE/RSJ/GI International Conference on Intelligent

Robots and Systems. Advanced Robotic Systems and the Real World

(Cat.No.94CH3447-0), Sept.1994, Vol.2, pp.739-52

https://en.wikipedia.org/wiki/Robot-assisted_surgery

https://en.wikipedia.org/wiki/Medical_robot

http://www.brighthubengineering.com/robotics/95856-use-of-robotics-in-the-

medical-field/

http://www.davincisurgery.com/

http://www.cyberknife.com/