Automated knot tying for fixation in minimally invasive, robot-assisted cardiac surgery

Cardiovascular disease (CVD) is perhaps the most significant worldwide health issue. While open-heart surgery remains the predominant treatment, significant advancements have been made in minimally invasive surgery (MIS) and minimally invasive robot-assisted (MIRA) surgery. MIRA techniques offer many advantages over open-heart procedures and have extended the capabilities of MIS. However, these benefits come at the cost of increased operating times due to time spent tying knots. The additional bypass time limits patient access and is the most significant barrier to the adoption of MIRA techniques. This research seeks to overcome this barrier by designing a device for MIRA cardiac procedures that automates the knotting of sutures. If this task can be automated while ensuring the delivery of high-quality knots, great progress can be made in transforming the field. MIRA cardiac procedures can move from novel procedures performed by a select group of surgeons on a limited pool of patients to a viable alternative available to the majority of patients with CVD. In this research we propose a design for a self-contained device that delivers a locking knot. Results suggest that consistent knots can be delivered at a time savings of 12.5% and 26.4% over manual knots for trained and untrained users of a surgical robot, respectively.     

Adverse Events in Robotic Surgery: A Retrospective Study of 14 Years of FDA Data

BackgroundUse of robotic systems for minimally invasive surgery has rapidly increased during the last decade. Understanding the causes of adverse events and their impact on patients in robot-assisted surgery will help improve systems and operational practices to avoid incidents in the future.MethodsBy developing an automated natural language processing tool, we performed a comprehensive analysis of the adverse events reported to the publicly available MAUDE database (maintained by the U.S. Food and Drug Administration) from 2000 to 2013. We determined the number of events reported per procedure and per surgical specialty, the most common types of device malfunctions and their impact on patients, and the potential causes for catastrophic events such as patient injuries and deaths.ResultsDuring the study period, 144 deaths (1.4% of the 10,624 reports), 1,391 patient injuries (13.1%), and 8,061 device malfunctions (75.9%) were reported. The numbers of injury and death events per procedure have stayed relatively constant (mean = 83.4, 95% confidence interval (CI), 74.2–92.7 per 100,000 procedures) over the years. Surgical specialties for which robots are extensively used, such as gynecology and urology, had lower numbers of injuries, deaths, and conversions per procedure than more complex surgeries, such as cardiothoracic and head and neck (106.3 vs. 232.9 per 100,000 procedures, Risk Ratio = 2.2, 95% CI, 1.9–2.6). Device and instrument malfunctions, such as falling of burnt/broken pieces of instruments into the patient (14.7%), electrical arcing of instruments (10.5%), unintended operation of instruments (8.6%), system errors (5%), and video/imaging problems (2.6%), constituted a major part of the reports. Device malfunctions impacted patients in terms of injuries or procedure interruptions. In 1,104 (10.4%) of all the events, the procedure was interrupted to restart the system (3.1%), to convert the procedure to non-robotic techniques (7.3%), or to reschedule it (2.5%).ConclusionsDespite widespread adoption of robotic systems for minimally invasive surgery in the U.S., a non-negligible number of technical difficulties and complications are still being experienced during procedures. Adoption of advanced techniques in design and operation of robotic surgical systems and enhanced mechanisms for adverse event reporting may reduce these preventable incidents in the future.     

Recent developments in pig embryo transfer.

Porcine embryo transfer has been performed for approximately 50 years, and surgical methods have proven to be reliable for collection and transfer of embryos. However, surgical collection and transfer have the disadvantage of being less useful on the farm. Recently, new procedures for both collection and transfer of embryos have been developed to improve usefulness. The surgical procedure has been refined to a minimally invasive procedure, using endoscopy for collection and transfer of embryos. A nonsurgical procedure for embryo collection has also been devised, but is limited to use in sows with surgically shunted (shortened) uterine horns. Nonsurgical embryo transfer procedures have been developed recently and have proven to be successful. The nonsurgical procedures are preferable to surgical procedures from an animal welfare point of view and because these procedures can be performed on farms without the need for special facilities.     

Minimally invasive surgery. Future developments.

The rapid development of minimally invasive surgery means that there will be fundamental changes in interventional treatment. Technological advances will allow new minimally invasive procedures to be developed. Application of robotics will allow some procedures to be done automatically, and coupling of slave robotic instruments with virtual reality images will allow surgeons to perform operations by remote control. Miniature motors and instruments designed by microengineering could be introduced into body cavities to perform operations that are currently impossible. New materials will allow changes in instrument construction, such as use of memory metals to make heat activated scissors or forceps. With the reduced trauma associated with minimally invasive surgery, fewer operations will require long hospital stays. Traditional surgical wards will become largely redundant, and hospitals will need to cope with increased through-put of patients. Operating theatres will have to be equipped with complex high technology equipment, and hospital staff will need to be trained to manage it. Conventional nursing care will be carried out more in the community. Many traditional specialties will be merged, and surgical training will need fundamental revision to ensure that surgeons are competent to carry out the new procedures.     

Expression of matrix metalloproteinase-1 (MMP-1) in Wistar rat's intervertebral disc after experimentally induced scoliotic deformity

Minimally invasive spine surgery is becoming more common in the treatment of adult lumbar degenerative disorders. Minimally invasive techniques have been utilized for multilevel pathology, including adult lumbar degenerative scoliosis. The next logical step is to apply minimally invasive surgical techniques to the treatment of adolescent idiopathic scoliosis (AIS). However, there are significant technical challenges of performing minimally invasive surgery on this patient population. For more than two years, we have been utilizing minimally invasive spine surgery techniques in patients with adolescent idiopathic scoliosis. We have developed the present technique to allow for utilization of all standard reduction maneuvers through three small midline skin incisions. Our technique allows easy passage of contoured rods, placement of pedicle screws without image guidance, and allows adequate facet osteotomy to enable fusion. There are multiple potential advantages of this technique, including: less blood loss, shorter hospital stay, earlier mobilization, and relatively less pain and need for pain medication. The operative time needed to complete this surgery is longer. We feel that a minimally invasive approach, although technically challenging, is a feasible option in patients with adolescent idiopathic scoliosis. Although there are multiple perceived benefits, long term data is needed before it can be recommended for routine use.     

Biomechanical properties of abdominal organs in vivo and postmortem under compression loads

Accurate knowledge of biomechanical characteristics of tissues is essential for developing realistic computer-based surgical simulators incorporating haptic feedback, as well as for the design of surgical robots and tools. As simulation technologies continue to be capable of modeling more complex behavior, an in vivo tissue property database is needed. Most past and current biomechanical research is focused on soft and hard anatomical structures that are subject to physiological loading, testing the organs in situ. Internal organs are different in that respect since they are not subject to extensive loads as part of their regular physiological function. However, during surgery, a different set of loading conditions are imposed on these organs as a result of the interaction with the surgical tools. Following previous research studying the kinematics and dynamics of tool/tissue interaction in real surgical procedures, the focus of the current study was to obtain the structural biomechanical properties (engineering stress-strain and stress relaxation) of seven abdominal organs, including bladder, gallbladder, large and small intestines, liver, spleen, and stomach, using a porcine animal model. The organs were tested in vivo, in situ, and ex corpus (the latter two conditions being postmortem) under cyclical and step strain compressions using a motorized endoscopic grasper and a universal-testing machine. The tissues were tested with the same loading conditions commonly applied by surgeons during minimally invasive surgical procedures. Phenomenological models were developed for the various organs, testing conditions, and experimental devices. A property database-unique to the literature-has been created that contains the average elastic and relaxation model parameters measured for these tissues in vivo and postmortem. The results quantitatively indicate the significant differences between tissue properties measured in vivo and postmortem. A quantitative understanding of how the unconditioned tissue properties and model parameters are influenced by time postmortem and loading condition has been obtained. The results provide the material property foundations for developing science-based haptic surgical simulators, as well as surgical tools for manual and robotic systems.     

Development of an optical 3-D position measuring system for simultaneous detection of 6 degrees of freedom]

A few years ago it became possible to carry out complicated surgical procedures in humans with the required precision by combining medical imaging (MRI, CT) with minimally invasive surgery. The confined space within these imaging systems and the resulting inaccuracies associated with the manual use of instruments increasingly make necessary the help of aids ranging from positioning systems to robotic devices, which themselves must be position controlled. A position sensor has been developed for a medical robotic system allowing the image-controlled insertion of injection needles and the simultaneous administration of different drugs. The 3D position coordinates are determined by a noncontact optical principle, which also enables simultaneous determination of all 6 basic degrees of freedom of the robotic system (3 translational, 3 rotational). On the basis of an area image sensor and the measurement of a geometrically defined structure in the path of the rays between sensor and light source, the position coordinates are calculated almost real time. Special emphasis was placed on designing the sensor system to cover a sufficiently large workspace to enable it to cover the entire intervention area. The sensor described herein determines the position coordinates in a volume of 10 x 10 x 10 cm at a resolution of up to 1 mm for translations and 1 degree for rotations.     

Taking the example of computer systems engineering for the analysis of biological cell systems

In this paper, we discuss the potential for the use of engineering methods that were originally developed for the design of embedded computer systems, to analyse biological cell systems. For embedded systems as well as for biological cell systems, design is a feature that defines their identity. The assembly of different components in designs of both systems can vary widely. In contrast to the biology domain, the computer engineering domain has the opportunity to quickly evaluate design options and consequences of its systems by methods for computer aided design and in particular design space exploration. We argue that there are enough concrete similarities between the two systems to assume that the engineering methodology from the computer systems domain, and in particular that related to embedded systems, can be applied to the domain of cellular systems. This will help to understand the myriad of different design options cellular systems have. First we compare computer systems with cellular systems. Then, we discuss exactly what features of engineering methods could aid researchers with the analysis of cellular systems, and what benefits could be gained.     

Taking the example of computer systems engineering for the analysis of biological cell systems

In this paper, we discuss the potential for the use of engineering methods that were originally developed for the design of embedded computer systems, to analyse biological cell systems. For embedded systems as well as for biological cell systems, design is a feature that defines their identity. The assembly of different components in designs of both systems can vary widely. In contrast to the biology domain, the computer engineering domain has the opportunity to quickly evaluate design options and consequences of its systems by methods for computer aided design and in particular design space exploration. We argue that there are enough concrete similarities between the two systems to assume that the engineering methodology from the computer systems domain, and in particular that related to embedded systems, can be applied to the domain of cellular systems. This will help to understand the myriad of different design options cellular systems have. First we compare computer systems with cellular systems. Then, we discuss exactly what features of engineering methods could aid researchers with the analysis of cellular systems, and what benefits could be gained.     

Simultaneous robotic-assisted mitral valve repair and percutaneous coronary intervention

We present a case report of a robotic-assisted mitral valve repair with simultaneous percutaneous coronary intervention. A 58-year-old man presented with New York Heart Association class III symptoms from severe mitral regurgitation and significant stenosis of the right coronary artery. In a hybrid operating theater, the patient underwent placement of a bare metal stent in the right coronary artery followed immediately by robotic-assisted mitral valve repair. Both procedures were successful and occurred in a timely fashion. The patient experienced no immediate postoperative complications and was discharged home on postoperative day 5. At 2-week follow-up, he had returned to his normal activities of daily living and at 1 year remained asymptomatic. This case report demonstrates the benefits of minimally invasive robotic mitral valve repair in allowing for successful repair, early postoperative return to activity, minimal incision pain, and high patient satisfaction. It further highlights the potential benefit of a hybrid operating theater in allowing surgical and percutaneous coronary intervention procedures to be delivered in a safe and efficient manner.     

Optoelectronic display system for minimal invasive laparoscopic operations: initial experiences with new face-mounted display video eyeglasses]

A major aspect of efforts to improve minimally invasive surgery is the optimization of visualization, which is currently unsatisfactory due to the limited number of pixels in the monitors used, and inadequate alignment of the optical axis. Optical systems provided with commercially available head-mounted displays have failed to improve optical quality and significantly facilitate or improve laparoscopic surgery [2,3]. Innovations in the field of consumer video using a new optical prism and a high-resolution matrix (180,000 pixels) are the core elements of a new face-mounted display (FMD-Eye-Trek 700, Olympus Optical Co, Europe GmbH, Hamburg, Germany) that provides high image quality. This device has now been tested for the first time during laparoscopic procedures (n = 14) and combined laparoscopic-endoscopic procedures (n = 7) under clinical conditions. Impressive optical, ergonomic and surgeon-related benefits were established.     

混合痔手术治疗技术新进展

：痔(Haemorrhoids)是直肠末端黏膜、肛管皮肤下痔静脉丛屈曲或扩张而形成的柔软静脉团,是外科常见的疾病。尽管保守治 疗适用于大部分患者人群,但是手术治疗却适用于大部分严重病人,比如外剥内扎术就被视为治疗IV 度痔的金标准。痔的手术 治疗有传统手术和微创手术,为了减轻患者的痛苦、加速恢复、减少并发症的发生,PPH 和TST 等新型手术方式也逐渐被应用于 III痔的治疗中,这些手术方法的目的是纠正痔疮的病因及病理生理基础,具有微创、痛苦小的特点,但往往复发率较高。随着手术 方式的改进以及操作技术的成熟,痔的外科治疗效果也取得了长足的进步。本文对混合痔的外科手术技术作一综述,为临床治疗 提供理论依据。     

痔治疗的临床进展研究

痔是肛肠外科最常见的疾病之一,其治疗方式多种多样,尚无统一治疗标准。虽然,痔在临床上以保守治疗为主,但是对于II度以上有症状的痔,手术仍是目前最主要的治疗方式。关于有症状痔最佳治疗方式的争论仍在继续,无论是非手术治疗、传统的痔切除术还是痔的微创手术,都处于不断的改进和探索之中。临床医生总希望能够找到一项理想的具有复发率低、安全可靠、可早期恢复正常活动、术后疼痛轻微甚至无痛的手术方式。随着手术方式的改进和医疗技术的进步,痔的治疗效果也取得了很大的进步。本文就痔的非手术治疗、有创手术治疗以及微创手术治疗作一综述,为痔的临床治疗提供一定的理论依据。     

Image-guided simulation of tissue deformation using a mechanical model on a surgical application

This paper presents a method for localizing the position of a liver and a tumor within the tissue during a minimally invasive liver operation. From pre-operative CT scans, the liver volume and its internal structures are segmented using image-processing techniques. Based on these segmentations, a three-dimensional mechanical model is built to compute the liver volume and internal structure displacement under boundary conditions such as external forces from the surgical instrument. This can help the surgeon understand the motion of internal structures when manipulating the liver. To validate our method, an experiment on a porcine liver explant was performed to assess the difference between actual tissue motion and the mechanical model.     

Technological advances in minimally invasive radiofrequency ablation of cardiac tissues

Ablative techniques have been sought in many circumstances as alternatives to surgical resection/incision. Besides being minimally invasive, potential benefits of ablation include greater speed and improved access to target tissue compared with other surgical techniques. There is a wide variety of ablation technologies currently in use for medical treatment. These include but are not limited to tissue heating by radiofrequency (RF) current, microwaves, laser, and high intensity ultrasound. RF is among the most heavily used because of its relatively low complexity and cost. Ablative techniques have proven to be viable alternatives to surgical resection/incision of tissue. Although there are other means of tissue heating besides RF, RF is the most commonly used technique in operating rooms because of the reliability of transmural lesions and the low complexity of the system. Optimal systems account for the heterogeneous nature of tissue and variations in tissue property through the ablation cycle. It is important to monitor and assure adequate energy delivery by selecting the appropriate configuration of devices. Energy delivery varies between the various generators and systems, some more responsive than others with relative to changes in tissue impedance that will affect the end results of the operation.     

Realistic finite element-based stent design: the impact of balloon folding

At present, the deployment of an intravascular stent has become a common and widely used minimally invasive treatment for coronary heart disease. To improve these coronary revascularization procedures (e.g. reduce in-stent restenosis rates) the optimal strategy lies in the further development of stent design, material and coatings. In the context of optimizing the stent design, computational models can provide an excellent research tool. In this study, the hypothesis that the free expansion of a stent is determined by the unfolding and expansion of the balloon is examined. Different expansion modeling strategies are studied and compared for a new generation balloon-expandable coronary stent. The trifolded balloon methodology presented in this paper shows very good qualitative and quantitative agreement with both manufacturer's data and experiments. Therefore, the proposed numerical expansion strategy appears to be a very promising optimization methodology in stent design.     

微创技术：药理动物模型的新选择

传统药理学动物模型存在创伤过大、精确度低等一系列问题,严重制约着药理学的发展。而医学微创技术的进步为解决这一问题提供了新的选择。已有学者利用微创技术成功地建立了局灶脑梗塞、脊髓缺血及损伤、可复梗阻性黄疸模型、急性心肌梗死模型、慢性心力衰竭等系列动物疾病模型,虽然微创药理学作为一个新兴学科还有待完善,但它的发展必将促进药理学研究达到新的高度.本文通过查阅近年来有关微创技术的国内外文献,对微创技术在药理学中的应用和探索等方面进行了探讨。     

Thoracoscopic lobectomy with the da vinci surgical system

Thoracoscopic upper lobectomy has been performed with the da Vinci surgical system in human cadavers. A minithoracotomy and two additional thoraco ports provided access to the thoracic cavity. An auxiliary port was used for both retraction of the lung and suction. The pulmonary vessels were ligated by robotic instruments, and the bronchi were divided after suturing robotically or with automatic staplers. A standard lymph node dissection was performed. The current da Vinci surgical system provided superior optics and enhanced dexterity. The application of the system for minimally invasive lobectomy may add benefits for both surgeon and patients.     

臀肌筋膜挛缩症的外科手术治疗

臀肌筋膜挛缩症(Gluteal Muscle Contracture,GMC)是指由于各种原因引起的臀肌及其筋膜挛缩,导致髋关节功能受限,表现出特殊的症状、体征的临床综合征。GMC多发生于青少年和儿童患者,目前普遍认为一旦确诊GMC,应尽早手术治疗。随着临床技术的发展,GMC的手术方式也在不断创新、不断发展,其大致分为开放式手术和微创手术两大类,两者虽各具优缺点,但针对不同的患者都取得了不错的治疗效果。本文现对GMC的外科手术治疗的进展作一简要综述。     

Ultrasound-guided Transthoracic Intramyocardial Injection in Mice

Murine models of cardiovascular disease are important for investigating pathophysiological mechanisms and exploring potential regenerative therapies. Experiments involving myocardial injection are currently performed by direct surgical access through a thoracotomy. While convenient when performed at the time of another experimental manipulation such as coronary artery ligation, the need for an invasive procedure for intramyocardial delivery limits potential experimental designs. With ever improving ultrasound resolution and advanced noninvasive imaging modalities, it is now feasible to routinely perform ultrasound-guided, percutaneous intramyocardial injection. This modality efficiently and reliably delivers agents to a targeted region of myocardium. Advantages of this technique include the avoidance of surgical morbidity, the facility to target regions of myocardium selectively under ultrasound guidance, and the opportunity to deliver injectate to the myocardium at multiple, predetermined time intervals. With practiced technique, complications from intramyocardial injection are rare, and mice quickly return to normal activity on recovery from anesthetic. Following the steps outlined in this protocol, the operator with basic echocardiography experience can quickly become competent in this versatile, minimally invasive technique.