robotics nd simulation system in neurosurgery # ROSA # MAZOR DR SHAMEEJ MUHAMED KV NEUROSURGEON

1. DR SHAMEEJ MUHAMED KV
SENIOR RESIDENT
DEPARTMENT OF NEUROSUREGRY
GMC KOZHIKODE

2. + Neurosurgery is an intrinsically high-risk endeavor in which
even seemingly straightforward cases can be associated with
complications.
+ In those patients with complex brain tumors and other
pathologies, the challenges are even greater.
+ Potential benefits of patient-specific preoperative rehearsal of
complex, high-risk neurosurgery are enormous.

3. + A SURGICAL ROBOT is any reprogrammable –powered manipulator
with artificial sensing that can assist in a variety of surgical tasks
+ Use of robotics in the operating room in neurosurgery has been
increasing in the last few years
+ Robotics is a fast-moving discipline, which- in tandem with
advances in artificial intelligence and machine learning – is
transforming the practice of neurosurgery.
+ There is hope that robotics will eliminate mechanistic errors,
reduce operating times and provide the same or even greater
resective margins with minimal-access surgery

4. + Computerized Neurosurgical Simulation Device
+ A computer device that provides a surgery-like environment,
including a three-dimensional visualization of various surgical
scenarios.
+ User is provided two instruments with adjustable forces, such as
suction and cauterization.
+ Simulators can accurately calculate and display in real time the
deformation of the brain tissues in accordance with the force
applied from the suction and cauterization.
+ At the end of the “surgery,” simulators can also provide feedback
on the surgery.

5. + Haptic Technology
+ Technology that provides tactile feedback to a user by
recreating a sense of touch.
+ Haptic devices can provide users with a sense of objects that
are “hard” or “soft” when force is applied in the simulated
setting.
+ Haptics are typically utilized in tandem with computerized
neurosurgical simulation devices to provide the user with
combined visual and sensory feedback.

6. + Robotic-assisted Surgery
+ Robotic surgical systems that provide intraoperative assistance
to a surgeon during a procedure.
+ A surgeon typically sits at a remote control station, where he
or she is able to guide the motions and actions of the robot’s
arms to perform a given task

7. + TELEMENTORING -when the local surgical team is performing
the operation with an expert mentor watching through the
interface for errors.
+ TELESURGERY- when the mentor performs the surgery directly
with a surgical team watching to learn techniques (and as a
safety precaution should mechanisms fail). Although the
mentors have full control of the robotic arm’s movements
during telesurgery, the surgeons in the remote area could
override the mentor’s control as a safety feature

8. + They can all be broadly classified into three categories.
1. The telesurgical robot (master–slave) /Dependent system
2. The supervisory surgeon controlled robot
3. Handheld shared/controlled systems

9. + In this type of robot, the surgeon remotely controls the actions of
the robot
+ Most popular type of robotic system because surgeon maintains
full control of the system
+ Surgeons controls the robot in real time through the haptic
interface .
+ Robot faithfully replicates the surgeons motions with the interface .
+ Master slave surgeon gets real –time feedback from surgical scene
via the camera and the force feedback from the instruments

11. + Da Vinci system- The most well known system of this kind.
+ Neuroarm - (University of Calgary), It is a MRI-compatible robotic
arm that mimics the movements of a surgeon’s hands
+ NeuRobot ( shinshu university school of medicine , matsumoto ,
Japan)

13. + The NeuroArm (University of Calgary), It is a MRI-compatible
robotic arm that mimics the movements of a surgeon’s hands.
+ It uses piezoelectric motors and has eight degrees of freedom
(DOF)
+ It contain 2 arms , 2 camera & a work station
+ It is the first robot that provides tactile feedback and is controlled
by the neurosurgeon, who works from a remote workstation
outside the operating room.
+ It has been reported to been involved in more than 1,000
neurosurgical procedures.

14. +

15. + Surgeon preforms motion before surgery and robots repeats
motion
+ These largely perform stereotactic tasks with or without a
frame
+ They have progressed from guiding biopsy needles and depth
electrodes to planning and inserting pedicle screws in the
spine

17. + Automated Positioning Systems , as well as Radiosurgery
systems such as Cyber Knife and Gamma knife.
+ Neuromate
+ SurgiScope
+ Pathfinder

18. + Robot used most usually in stereotactic interventions.
+ The system can be used for biopsy planning, and it provides
position feedback from its navigation system (not measured,
but calculated), and can carry out ultrasound and CT
registration

19. + Is mounted on the ceiling and could be controlled manually
or with a touch-screen controller.
+ The system is also very suitable for navigation without a
stereotactic frame, can operate in microsurgery or biopsy
mode.
+ The system was modular and efficient, but time-consuming
and voluminous

20. + is a system with a robotic arm that navigates based on tracking
fiducial markers attached to the patient's skull.
+ Registration is based on CT(for localization) and MRI(for tumor
segmentation) datasets.
+ By attaching markers to the robot and using a camera system,
Pathfinder could be repositioned in the OR room and it would
recalculate the desire path, without the need of a new
configuration.

21. + Are hybrid between the dependent and autonomous system
+ Surgeon remains in control of the procedure while the robot
provides steady hand manipulation of the instrument.
+ For example , this system involve a passive arm hooked up to a
surgeon’s hand that moves only when permitted , but still filter
unwanted motions such as hand tremors

23. + SteadyHands
+ Evolution 1

24. + SteadyHands, developed by Josh Hopkins Institute.
+ The aim of this system is to remove the tremor of the
surgeon's hands

25. + Surgical simulation has been limited to cadaveric and animal
courses, training models, or devices that test basic skills.
+ These programs have enabled surgeons to practice surgical
procedures in a risk-free environment.
+ Within the past decade, computerized surgical simulation has
progressively increased in sophistication.
+ Computerized surgical simulation with haptic feedback in certain
systems, coupled with the increased utilization of robotic-assisted
microsurgery, has led to the development of a new era in the
training and skill set

26. + The world's first surgical robot was the 'Heartthrob', which was
developed and used for the first time in Vancouver, BC, Canada
in 1983.
+ It was used in an orthopedic surgical procedure on March 12,
1983, at the UBC Hospital in Vancouver.
+ 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

27. + The first robot robot used in neurosurgery was the PUMA 200
in 1985
+ PUMA (Programmable Universal Machine for Assembly)
industrial robot (Advanced Research & Robotics, Oxford, CT)
was used to place a needle for a brain biopsy using CT
guidance
+ The surgeon inputs X-Y coordinates and uses programs which
calculated the stereotactic coordinates in frame based
surgeries in PUMA

28. + 1987-Neuromate (Integrated Surgical Systems, Sacramento, CA)
+ 1991-Minerva (University of Lausanne, Lausanne, Switzerland)
Used real time images from a CT scan allowing the surgeon to
change markings during the procedure
+ 1995-The Steady Hand System (John Hopkins University, Baltimore,
MD)
+ System detects the amount of pressure a surgeon uses
+ 2000s- Neuropath (Shinto University School of Medicine,
Matsumoto, Japan)

29. + IMRIS Inc.'s SYMBIS(TM) Surgical System also known as NeuroArm
is the world’s first MRI-compatible surgical robot.
+ Medtech's ROSA is being used by several institutions, including the
Cleveland Clinic in the U.S, and in Canada at Sherbrook 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 completed robotized stereotaxic,
including in the placement of depth electrodes in the treatment of
epilepsy, selective resections, and stereotaxic biopsies

30. + ROSA Robotic Device
+ Lefranc and associates demonstrated the utility of robotic surgery
in performing stereotactic biopsies.
+ They employed the ROSA robotic device (Medtech, Montpellier,
France), containing a planning station and a robotic arm with 6
degrees of freedom containing haptic abilities.
+ These investigators conducted a retrospective analysis of the first
100 frameless stereotactic biopsies utilizing the ROSA robotic
device.

32. + Rosanna (Medtech), the robot’s planning software, was utilized for
trajectory planning and to target the biopsy needle.
+ Once the trajectory was determined, the robotic arm was positioned.
+ In this study, Lefranc and associates did not utilize the haptic abilities of the
robot, but rather employed it as an instrument holder whereby
instruments were positioned and used through an adapted reducer held
over the planned target and trajectory by the robotic arm.
+ Histologic diagnosis was achieved in 97 of 100 patients with no deaths or
permanent morbidity.

34. + There were six cases of postoperative hemorrhage within the lesion or
along the biopsy tract on postoperative CT scan, but only two cases
developed transient neurological symptoms.
+ Rates of histologic diagnosis and complications are similar to those of
traditional frame-based and frameless stereotactic biopsy procedures.
+ Importantly for cost-benefit analysis, as the surgeons gained experience,
the last 50 cases, including positioning, robot installation, draping, and
performing the surgical procedure, took less than 1 hour.

35. + Spine Assist (Mazor Robotics, Orlando, FL) is a computer- assisted
robotic navigation device for pedicle screw placement.
+ This robotic system uses a cylindrical device with 6 degrees of
freedom coupled to a workstation.
+ It employs the Renaissance Guidance System software (Maor
Robotics) for preoperative planning, intraoperative image
acquisition and registration, and robot motion control.
+ Once the trajectory is planned, a disposable clamp kit is used to
bone-mount the robot, thereby allowing localization of the correct
coordinates and guidance for each pedicle screw placement

36. + Hu and associates conducted a retrospective analysis of 102
patients during lumbar pedicle screw placement.
+ In their study, they successfully used this system in 95 of 102
patients.
+ They implanted 960 pedicle screws employing the robot; 949 were
accurately placed (98.9%).
+ This rate was very similar to a prior retrospective, multicenter study
that had a 98.3% accurate placement rate.

37. + Hu and associates demonstrated a 1.1% rate of malpositioning (11
screws). They postulated the misplacement of the 11 screws was
due to “skiving” of the drill bit or trocar off the facet.
+ They had to abort the robotic guidance in 110 screws (10.1%)
because of poor registration or technical trajectory issues.
+ In 7 patients, the robot was not used because of severe deformity,
high body mass index, extremely poor bone quality, registration
difficulty resulting from previous hardware that had loosened,
difficulty with bone-mounting, and device technical issues

38. + The ability to perform surgery on a smaller scale
(microsurgery).
+ Increased accuracy and precision (stereotactic surgery).
+ Access to small corridors (minimally invasive surgery).
+ Ability to process large amounts of data (image- guided
surgery).
+ The ability for telesurgery.
+ Deducing the surgeon’s physiological tremor by 10- folds.
+ Eliminates fatigue.

39. HUMANS ROBOTS
STRENGTHS STRENGTHS
Strong hand-eye coordination Good geometric accuracy
Dexterous (at human scale ) Stable and untiring
Flexible and adaptable Can be designed for wide range of scales
Can integrate extensive and diverse information May be sterilized
Able to use qualitative information Resistant to radiation &b infection
Good judgment Can use diverse sensors ( chemical , force, acoustic
etc.) in control

40. LIMITATIONS LIMITATIONS
Limited dexterity outside natural scale Poor judjegement
Prone to tremor & fatigue Limited dexterity & hand- eye coordination
Limited geometric accuracy Limited to relatively simple procedures
Limited ability to use quantitative information Technology in flux
Large operating room space requirement Difficult to construct and debug
Limited sterility
Susceptible to radiation & infection

42. + Benefits of virtual simulation devices in the hands- on training
of surgical residents have been well established.
+ Although the primary application of these devices has been to
enhance laparoscopic training of general surgery residents,
there has been growing interest to utilize them in
neurosurgery.
+ This is driven in part by the diversity and complexity of
neurosurgical procedures coupled with reduced resident work
hours.

43. + 1. NeuroTouch simulator with Touch X and ARTHRO Mentor
+ 2. SuRgical Planner (SRP) and Surgical Navigation Advanced
Platform
+ 3. Immersive Touch Simulation System

44. + Although there are overlaps between the graphical user interface
and device haptics of these simulators, each offers a unique user
experience.
+ These devices utilize a pair of handheld instruments to re- create
various neurosurgery-specific scenarios.
+ They also provide performance feedback to a user that can be
tracked over time to monitor variables such as progress, learning,
and speed.

45. + NeuroTouch simulator was developed and released in 2012 by the National
Research Council Canada (Ottawa, ON).
+ NeuroTouch is a virtual reality training simulator that employs task-specific,
pre developed scenarios offering a relatively wide spectrum of user
practice tasks.
+ Depending on the specific training module a user selects, there are several
different performance variables that will generate data based on a specific
task
+ The variable of “force” is measured through the utilization of haptic
feedback, driven by the integrated Touch X haptic device (Geomagic, Cary,
NC) and the Simbionix ARTHRO Mentor (3D Systems, Rock Hill, SC).

47. + Unlike the NeuroTouch system, which utilizes task-specific, pre developed
training scenarios, the SuRgical Planner (SRP) allows a user to upload a
patient’s CT/MRI DIACOM sequences for patient-specific practice.
+ This enables a user to practice complex patient-specific surgical
procedures.
+ SNAP is an FDA-approved neurosurgical device that imports a 3D plan from
the SRP, allowing surgeons to establish multiple views with rotation, and
permits interaction with the navigation image to see behind pathology and
vital structures.
+ Tumors, vessels, and tissues can be rendered partially transparent to
improve visualization.
+ Used in more than 600 cranial tumors and vascular surgeries.

49. + THE Immersive Touch stimulation system developed at the university of
Illinois , Chicago
+ Combines the elements of both Neuro Touch and SRP
+ System provides several neurosurgical rehearsal scenarios such as
ventriculostomy placement, bipolar electro cautery, and spine pedicle
screw placement.
+ In addition to pre developed rehearsal scenarios, the Immersive Touch
Mission Rehearsal simulator provides for patient-specific rehearsal by
allowing a surgeon to upload CT/MRI data to the device
+ A user is provided a set of 3D glasses for visualization, a PHANTOM Omni
handheld device (Sensable, Wilmington, MA) and an iPad (Apple,
Cupertino, CA) for instrument utilization, and a foot pedal for instrument
activation.

51. + The future of neurosurgery will include systems which can
perform a wide spectrum of neurosurgical procedures, an
increasing usage of telementoring and telesurgery,
improvements in artificial intelligence, and virtual reality.
+ The future of neurorobotics will see robots with ambidextrous
abilities, more degrees of freedom, kinesthetic feedback, and a
more user-friendly interface.
+ Greater integration of artificial intelligence and
nanotechnology will soon create surgical procedures that
cannot be done without it

52. + Thank you

53. + YOUMAN & WINN
+ Robotics in neurosurgery Veejay Bagga , Dev Bhattacharyya
Consultant Neurosurgery, Sheffield Teaching Hospitals NHS
Foundation Trust-Annals of the Royal College of Surgeons of
England
+ Robotics in neurosurgery; evolution ,current challenes and
compromises doulgeris jj et al . Cancer control 2015

54. + THANK YOU