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Research Papers

The Role of Tissue Slip Feedback in Robot-Assisted Surgery

[+] Author and Article Information
Natalie T. Burkhard

Department of Mechanical Engineering,
Stanford University,
Stanford, CA 94305
e-mail: ntb@stanford.edu

J. Ryan Steger

Advanced Product Development,
Intuitive, Inc.,
Sunnyvale, CA 94086

Mark R. Cutkosky

Fellow ASME
Department of Mechanical Engineering,
Stanford University,
Stanford, CA 94305

Manuscript received November 5, 2018; final manuscript received February 22, 2019; published online March 21, 2019. Assoc. Editor: Carl Nelson.

J. Med. Devices 13(2), 021003 (Mar 21, 2019) (9 pages) Paper No: MED-18-1202; doi: 10.1115/1.4043018 History: Received November 05, 2018; Revised February 22, 2019

Slip, or accidental loss, of grasped biological tissue can have negative consequences in all types of surgery (open, laparoscopic, robot-assisted). This work focuses on slip in robot-assisted surgery (RAS) with the goal of improving the quality of grasping and tool–tissue interactions. We report on a survey of 112 RAS surgeons, the results of which support the value of detecting and reducing slip in a variety of procedures. We conducted validation tests using a thermal slip sensor in a surgical grasper on tissue in vivo and ex vivo. The results of the survey and validation informed a user study to assess whether tissue slip feedback can improve performance and reduce effort in a phantom tissue manipulation task. With slip feedback, experienced subjects were significantly faster to complete the task, dropped tissue less (3% versus 38%), and experienced decreased mental demands and situational stress. These results provide motivation to further develop the sensor technology and incorporate it in robotic surgical equipment.

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References

Mabrouk, M. , Frumovitz, M. , Greer, M. , Sharma, S. , Schmeler, K. M. , Soliman, P. T. , and Ramirez, P. T. , 2009, “ Trends in Laparoscopic and Robotic Surgery Among Gynecologic Oncologists: A Survey Update,” Gynecol. Oncol., 112(3), pp. 501–505. [CrossRef] [PubMed]
Rosen, J. , Hannaford, B. , and Satava, R. M. , 2011, Surgical Robotics: Systems Applications and Visions, Springer Science & Business Media, Berlin, Germany.
Cartmill, J. A. , Shakeshaft, A. J. , Walsh, W. R. , and Martin, C. J. , 1999, “ High Pressures are Generated at the Tip of Laparoscopic Graspers,” Aust. N. Z. J. Surg., 69(2), pp. 127–130. [CrossRef] [PubMed]
De, S. , 2008, “ The Grasper-Tissue Interface in Minimally Invasive Surgery: Stress and Acute Indicators of Injury,” Doctor of philosophy, University of Washington, Seattle, WA.
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Childers, C. P. , and Maggard-Gibbons, M. , 2018, “ Understanding Costs of Care in the Operating Room,” JAMA Surg., 153(4), p. e176233. [CrossRef] [PubMed]
Burkhard, N. T. , Cutkosky, M. R. , and Steger, J. R. , 2018, “ Slip Sensing for Intelligent, Improved Grasping and Retraction in Robot-Assisted Surgery,” IEEE Rob. Autom. Lett., 3(4), pp. 4148–4155. [CrossRef]
IT'IS Foundation, 2010–2018, “ Database: Thermal Conductivity,” Zurich, Switzerland, accessed Nov. 16, 2017, https://itis.swiss/virtual-population/
Burkhard, N. , Steger, R. , and Cutkosky, M. , 2017, “ Sensing Slip of Grasped Wet, Conformable Objects,” IEEE/RSJ International Conference on In Intelligent Robots and Systems (IROS), Vancouver, BC, Canada, Sept. 24–28, pp. 5744–5749.
Hedrick, T. L. , 2008, “ Software Techniques for Two and Three-Dimensional Kinematic Measurements of Biological and Biomimetic Systems,” Bioinspiration Biomimetics, 3(3), p. 034001. [CrossRef] [PubMed]
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Wilson, M. R. , Poolton, J. M. , Malhotra, N. , Ngo, K. , Bright, E. , and Masters, R. S. , 2011, “ Development and Validation of a Surgical Workload Measure: The Surgery Task Load Index (SURG-TLX),” World J. Surg., 35(9), pp. 1961–1969. [CrossRef] [PubMed]

Figures

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Fig. 1

(a) Slip sensor board mounted on a modified EndoWrist® instrument, (b) in vivo testing of slip sensor on porcine mesentery, and (c) user study to explore utility of slip feedback for a nonactive tool

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Fig. 2

Questions #3–11: Rated frequency of slip, risk of slip, and frustration due to slip during RAS retraction, setup of critical view, and handling of fragile tissue (μ + 1σ shown). For clinical risk, see Table 4 for rating description. Although the rated clinical risk of slip is overall low (the chosen category describes no harm to the patient), frustration and frequency of slip are significant.

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Fig. 3

Top: Questions #12–14: Typical responses to slip during RAS retraction, setup of critical view, and handling of fragile tissue. Bottom: Questions #15–17: Mean time to recover prior operating pose during RAS retraction, setup of critical view, and handling of fragile tissue.

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Fig. 4

In vivo porcine testing via laparotomy and da Vinci Xi Surgical System with prototype grasper (left hand) and Fenestrated Bipolar Forceps (right hand)

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Fig. 5

Slip signal S˙mag22 and tissue slip versus time for each of the four tested in vivo tissues. Representative trials are shown.

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Fig. 6

In vivo versus ex vivo data (dot-dash in black) from Ref. [7]. The in vivo data shown are the mean signals produced from 3 to 7 trials per tissue type. The ex vivo tissues shown are esophagus, bowel, fallopian tube, lung, and ovary and are the mean signals produced over 30–50 trials per tissue type. Slip in all cases is detectable well within the 3 mm specification to provide timely information to surgeons [7]. The detectable slips ranged from 0.32 to 2.99 mm.

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Fig. 7

Onset slip velocity versus detectable slip for 4 in vivo tissues and ex vivo porcine tissues (ex vivo data reproduced from Ref. [7]). Catching slip in the white region is desirable; slip is detected within 3 mm. The yellow region denotes that tissue has slipped > 3 mm but not yet a jaw width. The red region is undesirable.

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Fig. 8

(a) and (b) Motivation. Tools 1, 2, and 3 may be used to tension the tissue, but only tools 1 and 2 are actively controlled. A surgeon may use tools 1 and 3 to initially tension the tissue, release control of tool 3, while it retracts the tissue, and resume work using 1 and 2. Slip at 3 can go unnoticed and result in loss of traction and exposure. (c) Study setup. Subjects must use the slip sensing tool 3 to retract the “tissue” (chamois) behind the wall. Then, the subject releases control of 3 and uses the ProGrasps 1 and 2 to hook the chamois over the target posts. Meanwhile, external slips applied to the control strings may cause slip to occur in 3.

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Fig. 9

State machine describing transitions between slip detection states. We start in the idle state until the slip sensing tool grasps tissue. When the grasp is maintained for 1 s and the tool is nonactive, we transition to checking for Slip unless we detect tissue release or activation of the tool. The 1 s wait time helps avoid false positives generated during grasping, as contact can be uneven.

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Fig. 10

User study task. The circled insets show what the subject sees through the endoscope at each stage.

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Fig. 11

Demographics and experience levels of participants

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Fig. 12

Participant responses to slip during user study, without and with auditory slip feedback (FB). In the no FB case, unnoticed/ignored slip indicates that the user either never noticed slip occurring or chose to not respond to it. In the FB case, users were notified of every slip.

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Fig. 13

Perceived workload results as measured by the SURGTLX [12]. The six rating scales are mental demands, physical demands, temporal demands, task complexity, situational stress, and distractions. The only significant differences (*) were decreased mental and temporal demands and situational stress in the presence of auditory slip feedback.

Tables

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