Rhinological And Otological Society Inc Robotic -PDF Free Download

Rhinological and Otological Society Inc Robotic

2019 | 3 views | 6 Pages | 1.42 MB

robot-assisted surgery has evolved as an adjunct to open and endoscopic techniques. Surgical robots are now approved by the United States Food and Drug Administration for a variety of thoracic and abdomi-nal/pelvic surgical procedures. The purpose of this study is to demonstrate the technical feasibility of robot-assisted microlaryngeal surgery.

Different Combinations of Retractors Scopes and Instruments and Their Results
Retractor Scope Instrument Exposure Instrument Excursion
Lindholm laryngoscope 0 degree 2 D 8 mm HP SG G limited Endoscope movement very limited
view of AC without movement of laryngoscope
instrument movement very limited
except in HP and SG
Lindholm laryngoscope 30 degree 3 D 8 mm HP SG G Endoscope movement very limited
without movement of laryngoscope
instrument movement very limited
except in HP and SG
Lindholm laryngoscope 0 degree 2 D 5 mm HP SG G limited Endoscope movement very limited
view of AC without movement of laryngoscope
instrument movement relatively free
Lindholm laryngoscope 30 degree 3 D 5 mm HP SG G Endoscope movement very limited
without movement of laryngoscope
instrument movement relatively free
McIvor mouthgag 0 degree 2 D 8 mm HP SG G limited Relatively free movement in HP and SG
view of AC without repositioning of mouthgag
limited in G
McIvor mouthgag 30 degree 3 D 8 mm HP SG G Relatively free movement in HP and SG
without repositioning of mouthgag
limited in G
McIvor mouthgag 0 degree 2 D 5 mm HP SG G limited Relatively free movement in HP SG and
view of AC G without repositioning of mouthgag
2 D two dimensional 3 D three dimensional HP hypopharynx SG supraglottis G glottis AC anterior commissure
all adjusted to optimize exposure and instrument range of mo of the instruments With the 5 mm instruments move
tion Both 5 mm two dimensional and 10 mm three dimensional ment was markedly less restricted Because the endoscope
endoscopes of 0 degrees and 30 degrees were utilized Addition passed through the laryngoscope there was no difference
ally 8 mm and 5 mm microinstruments were used for manipula in exposure or instrument excursion with either the two
tion of the different structures of the pharynx and larynx The 5
dimensional or the three dimensional endoscopes
mm and 8 mm measurements refer to the diameter of the instru
ment shaft The grasping or cutting components of the instru
In this same parallel orientation the larynx was ex
ments measure 2 mm to 4 mm Trials of suturing within the posed with a McIvor mouthgag With the mouthgag move
endolarynx were performed using 6 0 prolene sutures Proce ment of the endoscope was not restricted and the entire
dures were performed with and without endotracheal intubation hypopharynx supraglottis and glottis could be visualized
All experiments were photographed and video recorded without repositioning of the mouthgag The anterior com
missure was better visualized with the 30 degree endo
RESULTS scope Trials using the 5 mm two dimensional endoscope
In the initial attempts to introduce the robotic arms and the 10 mm three dimensional endoscope yielded sim
into the pharynx and larynx the airway mannequin was ilar endoscope and instrument excursion but with the 5
placed in parallel to the robot In this setup a patient mm two dimensional endoscope depth perception and
would be required to be in stirrups straddling the base of three dimensionality were lost With the 8 mm instru
the robot while this setup is clinically impractical it ments there was relatively unrestricted movement in the
allows for the greatest degree of movement of the robotic hypopharynx and supraglottis but left and right hand
arms Using a Lindholm laryngoscope with the endoscope instruments could not work in tandem in the glottis due to
passing through the lumen of the laryngoscope the phar sheer space limitations With the 5 mm instruments
ynx and larynx could be well visualized with both the there was relatively free movement throughout the phar
two dimensional and three dimensional 0 degree and 30 ynx and larynx and endolaryngeal suturing between the
degree endoscopes Movement of the endoscope was lim vocal folds was performed without difficulty with 6 0 pro
ited by the lumen of the laryngoscope therefore exposure lene sutures The only limitation in this setup occurred
of different elements of the larynx required repositioning when working at the extremes of the exposed operative
of the laryngoscope rather than just movement of the field In these far lateral anterior and posterior locations
endoscope Exposure of the pharynx supraglottis and movement was restricted when the back of the instrument
glottis could be achieved with both the 0 degree and 30 arms contacted the ring of the mouthgag
degree endoscopes but the view of the anterior commis Attempts to visualize the pharynx and larynx using
sure was superior with the 30 degree endoscope The only a 10 mm standard abdominal trocar Ethicon Endo
movement of the 8 mm robotic instruments was restricted Surgery Cincinnati OH and the endoscope were largely
by either the lips or the laryngoscope except in the hypo unsuccessful Endoscope movement without another de
pharynx and supraglottis where there was good excursion vice on which to suspend the larynx resulted in movement
Laryngoscope 115 May 2005 Hockstein et al Robotic Microlaryngeal Surgery
of the entire head and neck and seemed to be dangerous room table and the robot The ideal set up would place the
Additionally the proximity of the tip of the endoscope to patient perpendicular to the robot as is done for thoracic
the surgical field made for a very narrow field of view and abdominal procedures but this severely limited
Having identified the optimal configuration to in movement of the endoscope and the far robot arm Rotat
clude suspension with the McIvor mouthgag combined ing the bed to an angle of 30 degrees to 45 degrees allowed
with the three dimensional 30 degree endoscope and the 5 for freedom of movement of the endoscope and both robotic
mm instruments for work at the glottic level and either arms but the far arm was slightly more restricted at the
the 5 mm or the 8 mm instruments for work in the hypo extremes of the operative field Fig 1 Using this config
pharynx or at the level of the supraglottis attempts were uration manipulation of the mannequin s epiglottis ary
made to identify the best angle between the operating tenoids cartilages and vocal folds was performed Fig 2
Fig 1 A Operating room table rotated
30 degrees relative to the base of the
robot allows for introduction of three ro
botic arms through the mouth into the
larynx in an airway mannequin The man
nequin is suspended with a McIvor
mouthgag Note the videotower to the
side displaying an endoscopic view of
the instruments at the level of the glottis
A forth robotic arm is not being used B
Surgeon working from remote console
Laryngoscope 115 May 2005 Hockstein et al Robotic Microlaryngeal Surgery
Fig 2 Endoscopic view of the mannequin s larynx suspended with Fig 3 A B Endolaryngeal suturing and knot tying with 6 0 prolene
a McIvor mouthgag viewed with a 30 degree endoscope and 5 mm suture in the intubated mannequin is performed with 5 mm instru
instruments A The 5 mm instruments grasping the epiglottis B ments Knot tying is performed after removal of the needle
The 5 mm instruments grasping the right arytenoid
vision This is accomplished with dual endoscopes feeding
Endolaryngeal suturing and knot tying between the man separate video cameras and eyepieces The endoscopes are
nequin s vocal folds was also successfully performed using configured to converge on a focal point in the same way in
the 5 mm instruments and 6 0 prolene sutures Fig 3 which our eyes do and this provides the surgeon with true
Finally having identified an operating room setup depth perception Fig 4 Second surgical robots allow
that would enable robotic assisted microlaryngeal surgery increased freedom of movement of endoscopic instru
in a patient without an endotracheal tube instrument ments including simulated flexion extension pronation
manipulation was performed after endotracheal intuba and supination of instruments at their distal tips Fig 5
tion with a standard 6 0 endotracheal tube The tube did Third surgical robots allow for scaling of movement
not significantly interfere with instrument excursion in translating large movements of the hands into small
the hypopharynx or the supraglottis and in the glottis movements of the instruments Additionally surgical ro
the tube was easily manipulated with the robotic arms bots can filter tremor 5
Only its space occupying effect in the glottis interfered These assets are particularly useful for microlaryn
with manipulation of the glottic structures geal surgery The potential for increased precision with
robotic surgery with a very favorable learning curve will
DISCUSSION allow surgeons more rapid mastery of technically difficult
Currently surgical robots are used in abdominopel surgical procedures Endolaryngeal suturing a very chal
vic and thoracic surgery Cardiac procedures are being lenging task with conventional endoscopic instruments is
performed without thoracotomy and abdominal proce made relatively easy for the robotic surgeon Additionally
dures with significantly reduced blood loss and decreased the tremor filtration offers potentially much more gentle
operating time 3 4 These improvements are the result of handling of tissues
several features of robotic surgery First surgical robots The currently available technology which has been
offer the advantage of true three dimensional endoscopic developed for use in the abdomen and the chest lends
Laryngoscope 115 May 2005 Hockstein et al Robotic Microlaryngeal Surgery
Fig 4 A Three dimensional vision is provided by two in line rigid
telescopes B The two telescopes feed different cameras and are
viewed in two eyepieces
itself reasonably well to use in the pharynx and larynx in
that all of these surgical fields involve primarily muscle Fig 5 An 8 mm instrument with simulated flexion extension
gland and connective tissues Scissors tissue grasping pronation and supination mimics movements of the human wrist
forceps cautery and needle holders the instruments re
quired for microlaryngeal surgery are all commercially
available and in clinical use other fields have handled the issues of bleeding in the
The primary hurdle to the application of the daVinci surgical field in a variety of ways Primarily the use of
surgical robot for microlaryngeal surgery is the means of bipolar cautery forceps combined with the excellent optic
introducing large robotic arms into the narrow funnel technology allows for the prevention of bleeding by iden
created by the mouth Traditional means of laryngeal tification and cauterization of small vessels and the iden
exposure with laryngoscopes is not adequate for robot tification and ligation of larger vessels In laparoscopic
assisted microlaryngeal surgery Most laryngoscopes are and thoracoscopic cases an assistant surgeon can use a
closed tubes which severely limit endoscope movement rigid nonrobotic suction catheter to assist the robotic sur
Even with modification of the laryngoscopes to open the geon A novel approach to the problem of suctioning could
lumen the mouth is not kept widely open With use of a be the placement of a flexible suction catheter in the
mouthgag with a long tongue blade and a 30 degree en surgical field which could be grasped and manipulated by
doscope both laryngeal exposure and oral aperture are the robotically controlled instruments depending on the
improved A potential improvement on the McIvor mouth surgeon s needs Finally if none of these strategies work
gag may be the Dingman mouthgag with its integrated the development of instruments with integrated suction
cheek retractors With the use of the wristed instruments could alleviate these problems For maintenance of hemo
and a 30 degree endoscope issues of line of sight required stasis a variety of monopolar cautery bipolar cautery
for CO2 laser surgery are obviated For procedures in ultrasonic shears and clip appliers are commercially
which laser surgery is the current standard of care the available Animal modeling will be valuable in studying
benefits of robotic assistance are unknown Robotic sur the ability to maintain hemostasis in the excision of larger
gery may offer speed advantages over laser surgery and lesions
with angled endoscopes and wristed instruments allow
for improved exposure and the ability to work around CONCLUSIONS
corners Microlaryngeal and pharyngeal surgery is the most
Another potential obstacle to the performance of fitting otorhinolaryngologic application of robotic surgery
robotic assisted microlaryngeal surgery is the lack of at the present time The application of surgical robotics to
availability of suction instruments Robotic surgeons in other areas of the head and neck paranasal sinuses tem
Laryngoscope 115 May 2005 Hockstein et al Robotic Microlaryngeal Surgery

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