Supervised autonomous robotic soft tissue surgery
Science Translational Medicine • 4 May 2016 • Vol 8, Issue 337 • p. 337ra64 • DOI: 10.1126/scitranslmed.aad9398
Hands-free
The operating room may someday be run by robots, with surgeons overseeing their moves. Shademan et al. designed a “Smart Tissue Autonomous Robot,” or STAR, which consists of tools for suturing as well as fluorescent and 3D imaging, force sensing, and submillimeter positioning. With all of these components, the authors were able to use STAR for soft tissue surgery—a difficult task for a robot given tissue deformity and mobility. Surgeons tested STAR against manual surgery, laparoscopy, and robot-assisted surgery for porcine intestinal anastomosis, and found that the supervised autonomous surgery offered by the STAR system was superior.
Abstract
The current paradigm of robot-assisted surgeries (RASs) depends entirely on an individual surgeon’s manual capability. Autonomous robotic surgery—removing the surgeon’s hands—promises enhanced efficacy, safety, and improved access to optimized surgical techniques. Surgeries involving soft tissue have not been performed autonomously because of technological limitations, including lack of vision systems that can distinguish and track the target tissues in dynamic surgical environments and lack of intelligent algorithms that can execute complex surgical tasks. We demonstrate in vivo supervised autonomous soft tissue surgery in an open surgical setting, enabled by a plenoptic three-dimensional and near-infrared fluorescent (NIRF) imaging system and an autonomous suturing algorithm. Inspired by the best human surgical practices, a computer program generates a plan to complete complex surgical tasks on deformable soft tissue, such as suturing and intestinal anastomosis. We compared metrics of anastomosis—including the consistency of suturing informed by the average suture spacing, the pressure at which the anastomosis leaked, the number of mistakes that required removing the needle from the tissue, completion time, and lumen reduction in intestinal anastomoses—between our supervised autonomous system, manual laparoscopic surgery, and clinically used RAS approaches. Despite dynamic scene changes and tissue movement during surgery, we demonstrate that the outcome of supervised autonomous procedures is superior to surgery performed by expert surgeons and RAS techniques in ex vivo porcine tissues and in living pigs. These results demonstrate the potential for autonomous robots to improve the efficacy, consistency, functional outcome, and accessibility of surgical techniques.
Get full access to this article
View all available purchase options and get full access to this article.
Already a Subscriber?Sign In
Supplementary Material
Summary
Materials and Methods
Fig. S1. Young’s modulus calculations for pig bowel and human bowel, with geometry and applied forces kept constant.
Fig. S2. Deformation patterns for markers illustrate the uncertain nature of motion propagation in soft tissue.
Fig. S3. Robotic construction of end-to-end anastomosis.
Table S1. Quantitative geometric quality of ex vivo linear suturing.
Table S2. Quantitative geometric quality of ex vivo end-to-end anastomosis.
Movie S1. Supervised autonomous end-to-end intestinal anastomosis.
Resources
REFERENCES AND NOTES
1
Thiel D. D., Winfield H. N., Robotics in urology: Past, present, and future. J. Endourol. 22, 825–830 (2008).
2
Nifong L. W., Chu V. F., Bailey B. M., Maziarz D. M., Sorrell V. L., Holbert D., Chitwood W. R., Robotic mitral valve repair: Experience with the da Vinci system. Ann. Thorac. Surg. 75, 438–443 (2003).
3
B. B. Yarlagadda, M. S. Russell, G. A. Grillone, in Robotic Surgery of the Head and Neck, G. A. Grillone, S. Jalisi, Eds. (Springer, New York, 2015), chap. 1, pp. 1–11.
4
Sutherland G. R., Wolfsberger S., Lama S., Zarei-nia K., The evolution of neuroArm. Neurosurgery 72, A27–A32 (2013).
5
Remacle M., Prasad V. M. N., Lawson G., Plisson L., Bachy V., Van der Vorst S., Transoral robotic surgery (TORS) with the Medrobotics Flex™ System: First surgical application on humans. Eur. Arch. Otorhinolaryngol. 272, 1451–1455 (2015).
6
Centers for Disease Control and Prevention, Number of all-listed procedures for discharges from short-stay hospitals, by procedure category and age (2010).
7
Reiley C. E., Plaku E., Hager G. D., Motion generation of robotic surgical tasks: Learning from expert demonstrations. Conf. Proc. IEEE Eng. Med. Biol. Soc. 2010, 967–970 (2010).
8
A. Murali, S. Sen, B. Kehoe, A. Garg, S. McFarland, S. Patil, W. D. Boyd, S. Lim, P. Abbeel, K. Goldberg, Learning by observation for surgical subtasks: Multilateral cutting of 3D viscoelastic and 2D Orthotropic Tissue Phantoms, IEEE International Conference on Robotics and Automation (ICRA), Seattle, WA, 26 to 30 May 2015.
9
D. Hu, Y. Gong, B. Hannaford, E. J. Seibel, Semi-autonomous simulated brain tumor ablation with RAVENII Surgical Robot using behavior tree, IEEE International Conference on Robotics and Automation (ICRA), Seattle, WA, 26 to 30 May 2015.
10
T. B. Sheridan, Telrerobotics, Automation, and Human Supervisory Control, (MIT Press, Cambridge, 1992), p. 14.
11
Pearle A. D., Kendoff D., Stueber V., Musahl V., Repicci J. A., Perioperative management of unicompartmental knee arthroplasty using the MAKO robotic arm system (MAKOplasty). Am. J. Orthop. 38 (Suppl. 2), 16–19 (2009).
12
Lunsford L. D., Flickinger J., Lindner G., Maitz A., Stereotactic radiosurgery of the brain using the first United States 201 cobalt-60 source gamma knife. Neurosurgery 24, 151–159 (1989).
13
Adler J. R., Chang S. D., Murphy M. J., Doty J., Geis P., Hancock S. L., The Cyberknife: A frameless robotic system for radiosurgery. Stereotact. Funct. Neurosurg. 69 (1–4 Pt. 2), 124–128 (1997).
14
Pitcher J. D., Wilson J. T., Tsao T.-C., Schwartz S. D., Hubschman J. P., Robotic eye surgery: Past, present, and future. J. Comput. Sci. Syst. Biol. 3, 1–4 (2012).
15
Moustris G. P., Hiridis S. C., Deliparaschos K. M., Konstantinidis K. M., Evolution of autonomous and semi-autonomous robotic surgical systems: A review of the literature. Int. J. Med. Robot. 7, 375–392 (2011).
16
Leonard S., Wu K. L., Kim Y., Krieger A., Kim P. C. W., Smart tissue anastomosis robot (STAR): A vision-guided robotics system for laparoscopic suturing. IEEE Trans. Biomed. Eng. 61, 1305–1317 (2014).
17
S. Leonard, A. Shademan, Y. Kim, A. Krieger, P. C. W. Kim, Smart Tissue Anastomosis Robot (STAR): Accuracy evaluation for supervisory suturing using near- infrared fluorescent markers, IEEE International Conference on Robotics and Automation (ICRA), Hong Kong, 31 May to 7 June 2014.
18
R. Decker, A. Shademan, J. Opfermann, S. Leonard, P. C. W. Kim, A. Krieger, Performance evaluation and clinical applications of 3D plenoptic cameras, Proceedings SPIE, 9494, 18 June 2015.
19
A. Shademan, M. F. Dumont, S. Leonard, A. Krieger, and P. C. W. Kim, Feasibility of near- infrared markers for guiding surgical robots, Proceedings SPIE, 8840, 27 September 2013.
20
M. Kitagawa, A. M. Okamura, B. T. Bethea, V. L. Gott, W. A. Baumgartner, Analysis of suture manipulation forces for teleoperation with force feedback, in Medical Image Computing and Computer-Assisted Intervention (Springer, Berlin, Heidelberg, 2002), pp. 155–162.
21
H. M. Mehdorn, G. H. Müller, Microsurgical Exercises: Basic Techniques, Anastomoses, Refertilization, Transplantation (Stuttgar, Thieme, NY, 1989).
22
Marecik S. J., Chaudhry V., Jan A., Pearl R. K., Park J. J., Prasad L. M., A comparison of robotic, laparoscopic, and hand-sewn intestinal sutured anastomoses performed by residents. Am. J. Surg. 193, 349–355 (2007).
23
Morel P., Alexander-Williams J., Rohner A., Relation between flow-pressure-diameter studies in experimental stenosis of rabbit and human small bowel. Gut 31, 875–878 (1990).
24
J. W. Fleshman Jr., E. H. Birnbaum, S. R. Hunt, M. G. Mutch, I. J. Kodner, B. Safar, Atlas of Surgical Techniques for Colon, Rectum and Anus: A Volume in the Surgical Techniques Atlas Series (Elsevier Health Sciences, Philadelphia PA, 2012).
25
Hoznek A., Salomon L., Rabii R., Slama M.-R., Cicco A., Antiphon P., Abbou C.-C., Techniques in endourology vesicourethral anastomosis during laparoscopic radical prostatectomy: The running suture method. J. Endourol. 14, 749–753 (2000).
26
Dion Y.-M., Hartung O., Gracia C., Doillon C., Experimental laparoscopic aortobifemoral bypass with end-to-side aortic anastomosis. Surg. Laparosc. Endosc. 9, 35–38 (1999).
27
Hollands C. M., Dixey L. N., Torma M. J., Technical assessment of porcine enteroenterostomy performed with ZEUS™ robotic technology. J. Pediatr. Surg. 36, 1231–1233 (2001).
28
Weiser T. G., Regenbogen S. E., Thompson K. D., Haynes A. B., Lipsitz S. R., Berry W. R., Gawande A. A., An estimation of the global volume of surgery: A modelling strategy based on available data. Lancet 372, 139–144 (2008).
29
Tsui C., Klein R., Garabrant M., Minimally invasive surgery: National trends in adoption and future directions for hospital strategy. Surg. Endosc. 27, 2253–2257 (2013).
30
Seo S. H., Kim K. H., Kim M. C., Choi H. J., Jung G. J., Comparative study of hand-sutured versus circular stapled anastomosis for gastrojejunostomy in laparoscopy assisted distal gastrectomy. J. Gastric Cancer 12, 120–125 (2012).
31
Gonzalez R., Lin E., Venkatesh K. R., Bowers S. P., Smith C. D., Gastrojejunostomy during laparoscopic gastric bypass: Analysis of 3 techniques. Arch. Surg. 138, 181–184 (2003).
32
Nguyen N. T., Wolfe B. M., Hypopharyngeal perforation during laparoscopic Roux-en-Y gastric bypass. Obes. Surg. 10, 64–67 (2000).
33
de la Torre R. A., Scott J. S., Laparoscopic Roux-en-Y gastric bypass: A totally intra-abdominal approach–technique and preliminary report. Obes. Surg. 9, 492–498, (1999).
34
Kawasaki K., Fujino Y., Kanemitsu K., Goto T., Kamigaki T., Kuroda D., Kuroda Y., Experimental evaluation of the mechanical strength of stapling techniques. Surg. Endosc., 21, 1796–1799 (2007).
35
Cha J., Shademan A., Le H. N. D., Decker R., Kim P. C. W., Kang J. U., Krieger A., Multispectral tissue characterization for intestinal anastomosis optimization. J. Biomed. Opt. 20, 106001 (2015).
36
M. S. Macsai, Ophthalmic Microsurgical Suturing Techniques (Springer Science & Business Media, New York, 2007).
37
Rho J. Y., Ashman R. B., Turner C. H., Young’s modulus of trabecular and cortical bone material: Ultrasonic and microtensile measurements. J. Biomech. 26, 111–119 (1993).
38
Marchand E., Spindler F., Chaumette F., ViSP for visual servoing: A generic software platform with a wide class of robot control skills. IEEE Robot. Autom. Mag. 12, 40–52 (2005).
39
Christensen M. B., Oberg K., Wolchok J. C., Tensile properties of the rectal and sigmoid colon: A comparative analysis of human and porcine tissue. Springerplus 4, 142 (2015).
Information & Authors
Information
Published In
Science Translational Medicine
Volume 8 | Issue 337
May 2016
May 2016
Copyright
Copyright © 2016, American Association for the Advancement of Science.
Submission history
Received: 24 November 2015
Accepted: 25 March 2016
Acknowledgments
We acknowledge C. Cochenour for technical assistance and R. McCarter for help in statistical analysis. Funding: This work was supported by the Sheikh Zayed Institute for Pediatric Surgical Innovation and Joseph E. Robert Jr. Endowment Awards. Author contributions: A.S., A.K., and P.C.W.K. created the study design. A.S., R.S.D., and S.L. developed the software. A.S., R.S.D., A.K., and J.D.O. carried out deformability experiments and analyzed the data. P.C.W.K. performed the in vivo OPEN procedure. A.S., R.S.D., J.D.O., A.K., S.L., and P.C.W.K. performed the STAR in vivo procedures. A.K. and J.D.O. provided animal care oversight. J.D.O. performed the statistical analysis. P.C.W.K. and J.D.O. performed histology analysis. A.S., R.S.D., J.D.O., S.L., A.K., and P.C.W.K. reviewed some or all of the primary data. A.S., P.C.W.K., A.K., R.S.D., and J.D.O. wrote the manuscript. All authors reviewed the manuscript. Competing interests: P.C.W.K., A.K., A.S., S.L., J.D.O., and R.S.D. are on the following related patents: 61/705,875; 13/863954; US-2014-0005684-A1; 14/038,192; 14/172,502; 61/909,604; 62088545; and 14625425. P.C.W.K. is a founder of Omniboros Inc., which develops smart automated and soft robots. Data and materials availability: There are no material transfer agreements or restrictive patents.
Authors
Metrics & Citations
Metrics
Article Usage
Altmetrics
Citations
Export citation
Select the format you want to export the citation of this publication.
Cited by
- The Cognitive Revolution, Digital Surgery, (1-9), (2021).https://doi.org/10.1007/978-3-030-49100-0
- Vision-Based Framework of Single Master Dual Slave Semi-Autonomous Surgical Robot System, IRBM, 42, 1, (55-64), (2021).https://doi.org/10.1016/j.irbm.2020.06.005
- Physical human–robot interaction for clinical care in infectious environments, Nature Machine Intelligence, 3, 3, (184-186), (2021).https://doi.org/10.1038/s42256-021-00324-z
- Accelerating Psychometric Screening Tests with Prior Information, Explainable AI in Healthcare and Medicine, (305-311), (2021).https://doi.org/10.1007/978-3-030-53352-6_29
- Artificial intelligence in urological oncology: An update and future applications, Urologic Oncology: Seminars and Original Investigations, 39, 7, (379-399), (2021).https://doi.org/10.1016/j.urolonc.2021.03.012
- Three-Dimensional Force Perception of Robotic Bipolar Forceps for Brain Tumor Resection, Journal of Medical Devices, 15, 3, (2021).https://doi.org/10.1115/1.4051361
- Needle Driver Control for a Robotic MIS Suturing System, IFAC-PapersOnLine, 54, 9, (527-532), (2021).https://doi.org/10.1016/j.ifacol.2021.06.112
- Deep learning-based computer vision to recognize and classify suturing gestures in robot-assisted surgery, Surgery, 169, 5, (1240-1244), (2021).https://doi.org/10.1016/j.surg.2020.08.016
- La chirurgie est un vieux métier plein d’avenir, Journal de Chirurgie Viscérale, 158, 3, (S1-S3), (2021).https://doi.org/10.1016/j.jchirv.2021.01.004
- Artificial Intelligence and Machine Learning: Implications for Surgery, Digital Surgery, (311-317), (2021).https://doi.org/10.1007/978-3-030-49100-0
- See more
Loading...
View Options
Get Access
Log in to view the full text
AAAS login provides access to Science for AAAS members, and access to other journals in the Science family to users who have purchased individual subscriptions.
- Become a AAAS Member
- Activate your Account
- Purchase Access to Other Journals in the Science Family
- Account Help
Log in via OpenAthens.
Log in via Shibboleth.
More options
Register for free to read this article
As a service to the community, this article is available for free. Login or register for free to read this article.
View options
PDF format
Download this article as a PDF file
Download PDF