Using this system, tremor filtering, movement scaling, increased range of motion, and improved ergonomics could be achieved. The input manipulators allow for seven DOFs, i.e., the surgeon can roll; pitch; yaw; move in x, y, z direction; and grip using the laparoscopic tools. The imaging system provides the surgeon with a high-definition, 3D magnified image of the operative field with the use of two independent cameras in the dual-channel endoscopes [6].
Around the same time of the introduction of the da Vinci robot, Computer Motion (merged with Intuitive Surgical Inc. in 2003) revealed the AESOP (Automated Endoscopic System for Optimal Positioning) as the first laparoscopic camera holder, while voice activation was added later [12]. After that, Computer Motion produced an integrated robotic system termed the ZEUS surgical system [11, 12]. ZEUS has three robotic arms that are mounted on the operating table [14]. One robotic arm is AESOP, which helps the surgeon with a better vision from inside the patient’s body. The other two arms of ZEUS are the extension of the left and right arms of the surgeon to support precise incisions and extractions. Similar to the da Vinci system, surgeons sit at a console and wear special glasses to see a three-dimensional image. However, ZEUS differs from the da Vinci system because its AESOP part can respond to voice commands. The FDA cleared AESOP and ZEUS in 1994 and 2001, respectively.
Historically, robotic have contributed to and impacted surgery areas such as neurosurgery, orthopedics, maxillofacial, ophthalmology, urology, gastrointestinal surgery, and cardiac surgery [12]. The da Vinci robot has been used in many different procedures such as cardiothoracic surgery, general surgery, gynecology, and urology [15]. For example, in glottis cancer, the adaptation of laser cutters to the suite of da Vinci robotic instruments has made a robotic approach practical [16]. What’s more, the design of flexible robots advances robotic surgery further by addressing the limitations related to rigid endoscopy [16]. Recently, intraoperative image-based techniques have also been shown to help surgeons to more accurately localize and to reach desired structures without violating neighboring critical structures [17–19].
17.4 Advantages and Disadvantages of Robotics in the Medical Field
Compared to conventional open surgery, robots have been purported to provide many advantages. A list of these advantages, paramount in otologic surgery, is summarized below [6]:
- 1.
Increased accuracy and surgical precision
- 2.
Improved three-dimensional visualization and magnification relative to binocular microscopy
- 3.
Less invasive access with the potential for minimizing recovery time and downstream surgical costs
- 4.
Improved stability through scaling of surgical maneuvers
- 5.
Improved ergonomics for the surgeon
- 6.
Better access due to afforded higher degree of freedom
- 7.
Articulation beyond normal manipulation
- 8.
Ability to perform operations from a distance (telesurgery)
In spite of the main advantages acquired by a surgical robot, some limitations have been reported as well [6]:
- 1.
High initial and subsequent maintenance costs
- 2.
Need to train surgeon and staffs
- 3.
Prolonged learning curve
- 4.
Lack of haptic feedback to the operator
- 5.
Need to get FDA approval, which is expensive and time consuming
17.5 Robotics in Otologic Surgery
Robotic systems in otologic surgery can be categorized in three classes: (1) telerobotic, (2) cooperative, and (3) autonomous robotic system. Each category is described below.
Previous efforts incorporating robotics into otologic surgery are summarized in Table 17.1 and will be further discussed below.
Table 17.1
Summary of reported robotic system studies in otologic surgery
Author name and year of publication | Type of robot | Study type | Clinical application | Figure number |
|---|---|---|---|---|
Nguyen et al. [20] (2011) | Telerobotic system 6 DOF | Phantom | Stapedectomy | 2 |
Liu et al. [21] (2014) | Telerobotic system 7 DOF | Cadaveric (* N = 1) | Cochlear implant | 3 |
ROTHBAUM et al. [23] (2002) | Cooperative robotic system 6 DOF | Phantom | Stapedectomy | 4 |
Majdani et al. [27] (2009) | Autonomous robotic system | Phantom | Cochlear implant electrode insertion | 5 |
Schurzig et al. [26] (2010) | 1 DOF | |||
Bell et al. [17] (2012) | Autonomous robotic system 5 DOF | Cadaveric (N = 15) | Cochlear electrode insertion | 6 |
Dillon et al. [18] (2014) | Autonomous robotic system 4 DOF | Phantom | Temporal bone milling | 7 |
Danilchenko et al. [19] (2011) | Autonomous robotic system 6 DOF | Cadaveric (N = 3) | Mastoidectomy | 8 |
17.5.1 Telerobotic Systems
This type of robotic system consists of a master and a slave component with a surgeon included in the control loop. In other words, the surgeon uses a master robot or a joystick to send commands to the slave robot to perform a task on a patient. Telerobotic systems consist of two different types: (1) unilateral telerobotic system and (2) bilateral telerobotic systems. Unilateral telerobotic system does not provide force feedback on the master side, while bilateral telerobotic systems provide force feedback on the master side. For example, the da Vinci robot is a unilateral telerobotic system. Otologic surgery is exceedingly delicate as Nguyen et al. [20] showed that a 5 μm positional resolution and an angular resolution of 0.3° are required. This degree of accuracy is quite difficult to achieve for even the most skilled surgeon. However, a telerobotic system which supports position scaling could possibly make this level of accuracy more universally attainable. Improved visualization within the middle ear could also be achieved by powerful high-definition endoscopic systems, held distally in the surgical field, thus preserving the field of vision.
17.5.1.1 Examples in Otologic Surgery
RobOtol [20]: Nguyen et al. developed a telerobotic system including a master robot and a slave robot. The slave robot’s kinematic chain was composed of three perpendicular linear links at the base and three rotary links at the distal part of the arm, as shown in Fig. 17.2. During otologic surgery, the field of view is quite limited. The vision axis and the approach are almost collinear. The tools have to be very thin and are held far from the tip to avoid blocking of the target. To reduce the visual impairment, a cable transmission mechanism was used to allow for the placement of the two last actuators at the base of the robot arm. The master robot consists of the surgeon controlling the arm remotely using by a pen-like interface with six degrees of freedom (Phantom Omni, Sensable Technologies, Inc., Woburn, MA). Otosclerosis surgery was considered as a model to define the specifications of this robot for a tele-operated otologic surgery. The prototype was tested in human temporal bone specimens by otologists. Duration of procedure, distance covered by the tool, and the number of times the emergency button was pressed were three measures that were considered during the evaluation of the system performance in both position mode and velocity control mode. The operator was able to reach all four target points on the tympanic membrane, the stapes footplate, and the round window in all three temporal bones in velocity command mode. Incus-stapes disjunction and stapes removal were performed successfully under the microscope and with the endoscope in two temporal bones. All participants were able to complete placement of the piston prosthesis in the stapedotomy in both velocity-to-position and position-to-position command modes.
Modified tool for the da Vinci robot [21]: Liu et al. reported on a cadaveric feasibility study of usage of the da Vinci system for cochlear implantation. For this purpose, the group developed an attachment which allowed for a pneumatic-powered drill to be coupled to one of the working arms of the da Vinci robot, as shown in Fig. 17.3. For this study, integration of augmented reality through segmentation of cone-beam high-resolution CT scans of the temporal bones was incorporated into the surgeon’s 3D endoscopic view. Successful completion of the entire surgery was completed in two bones, and the authors noted many possible advantages, afforded by a telerobotic system, which are listed below. However, the authors also reported several disadvantages, when comparing the da Vinci approach to conventional microscopy, with limitations that can possibly preclude the system from clinical implementation. First, the magnification of the robotic 3D endoscope for improved visualization through the posterior tympanostomy was felt to be noticeably inferior. Second, the study reported that the existing robotic arm surgical tools, such as the suction irrigator, were found to be too large for dissection through the posterior tympanostomy approach to the cochlea. However, though the lack of haptic feedback is an undesired effect, it was actually found to be not a significant limitation through sensory substitution through auditory feedback of the high rpm drill.
Fig. 17.2
Telerobotic system. (a) Phantom Omni interface (Master robot), (b) the RobOtol prototype (Slave robot) [20]
Fig. 17.3
Operating room with the da Vinci Si for otologic surgery. Inset is a close-up of the initial position of the endoscope, suction/irrigator, and drill attached with the custom tool adapter (With permission) [21]
Advantages and disadvantages of telerobotic system for ear surgery are listed next.
Advantages
Force scaling
Position scaling
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