ARTÍCULO CLÍNICO

 

Robotic technology in oral and maxillofacial surgery

Tecnología robótica en cirugía oral y maxilofacial

 

 

J.A. Hueto Madrid

Médico Adjunto. Servicio de Cirugía Oral y Maxilofacial.
Director del Grupo de Investigación en Robótica y Cirugía Craneofacial. Hospital Universitario Vall d’Hebrón, Barcelona, España

Correspondence

 

 

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ABSTRACT

The use of robots in surgery as operating room assistants or as surgical agents has attracted interest for decades. Their accuracy, resistance to fatigue and many other features augur a prominent role of this technology in maxillofacial surgery in the future. Nevertheless, experience in this field and other surgical specialities has shown that robotic technology is not yet mature enough to be used routinely in operating rooms. The introduction of new technologies to improve miniaturization, cooperative work, and better interactive behavior may endow robots with the necessary features to make them useful enough to include them in our surgical activities.

Key words: Robots; New technology; Oral maxillofacial surgery.

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RESUMEN

La utilización de robots en cirugía como ayudantes o como cirujanos despierta interés desde hace décadas. Sus características de precisión, incansabilidad y muchas otras ventajas auguran a esta tecnología un papel destacado en la cirugía maxilofacial del futuro. No obstante, las experiencias en nuestro campo y en otras especialidades quirúrgicas han puesto de manifiesto la falta de madurez de la tecnología robótica para incorporarse a corto plazo a los quirófanos. La introducción de tecnologías para una mayor miniaturización, su actuación cooperativa y una mejor interacción con el medio pueden aportar las características que necesitan para ser útiles y definitivamente incorporarse a nuestra actividad.

Palabras clave: Robótica; Nuevas tecnologías; Cirugía oral maxilofacial.

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Introduction

The concept of automatization is attributed to Aristotle, fourth century AD. Aristotle wrote about how he thoughts the robots of his time could be improved: "...if each instrument could do its own work, obeying and anticipating orders... if the loom’s shuttle knew how to weave, if the pick knew how to stroke the lyre without a hand to guide it, then masters would have no need for servants».¹ What Aristotle was proposing went beyond simple robots, which mechanically repeat the movements that they have been programmed to do. He envisioned the need for some sort of intelligence that would govern the movements of the devices, endowing them with capacity to make on-the-spot decisions.

Some sort of judgment or intelligence and a certain degree of perception of the surroundings are necessary for a device to make decisions about its movements by deducing the most advisable action.

Robots existed in ancient Greece, but they had little practical applicability and were used more as for entertainment than as tools. The only robot with a real practical application was the clock.

Automaton type robots have many limitations in surgery due to the variability of the work setting and the combination of elastic, flexible, fluid, viscous, and solid structures that make up living beings. These problems make it difficult to replicate the efficiency of industrial robots, which work economically and untiringly, quickly and precisely, equally capable of painting a car or assembling a television set, in the operating room.

The engineering specifications are extremely high because, in practice, robots are expected to work as well as or better than human beings.

The first robots used in surgery acted as automatons, rigorously executing their programming or the movements of the system operator without interacting with surroundings and making decisions autonomously.

Clinical experiences began to accumulate in the late 1980s in gastrointestinal surgery, urology, and cardiac surgery. Most of these systems have been used in endoscopic surgery or other minimally invasive surgical procedures. ^2-8

AESOP^® Robot was the first robotic system approved for surgical use by the FDA in 1994. This robot bears the camera in laparoscopic surgery. A later version approved in 2000 had a voice recognition system that acted in response to the surgeon’s verbal orders.

ZEUS^® System was developed in Europe and introduced into clinical practice in 1998.

The first experiences with the Da Vinci^® system, consisting of two robotic arms, were published in 1995 (Fig. 1). This system was used in the first robotic experiences in cardiac surgery: valvular repair and coronary artery bypass surgery.¹⁸

The advantages of robots in surgery still are not clear. The high cost of the systems and prolongation of surgical times are not recompensated with enhanced treatment precision and predictability. The strategy for introducing the systems probably was inappropriate because they were presented as a replacement for the intervention of humans in procedures. As we understand, the most important area opened by the introduction of robots is in the development of new techniques that cannot be performed by hand. For instance, minimally invasive techniques with tiny incisions or endoscopic techniques. Techniques requiring extremely high precision (CADCAM surgery), such as implantology and large craniofacial resections, could be performed with the help of robots.

The use of robots in medicine and surgery will expand rapidly when intensive miniaturization becomes possible, which will make it possible to use «clusters» of minirobots that act together, guided by their own intelligence, to perform specific actions.

Robot miniaturization will open the way to new therapeutic options, such as distractor robotization. Intelligent distractors that are completely submerged could respond to instructions from the surgeon to modify their vectors. Another possibility for using robots could be to automate repetitive processes, such as the placement of microsurgical sutures, skin sutures, osteosynthesis plates and screws, etc.

Robots in medicine can adopt different configurations depending on the function for which they are designed:⁹

• Assistant robots: machines that substitute a surgical assistant. The robots used in laparoscopy to separate and carry the video camera are of this type.

• Robotic servants: systems dedicated to helping disabled patients perform common tasks like feeding, taking medications, moving, and others.

• Robotic prostheses: devices connected to the patient that replace the action of lost limbs or extremities.

• Simulators: robotic systems used to simulate surgical operations for training and practice. Simulators have been developed especially for laparoscopic surgery.¹⁰ They include robots designed to reproduce human biomechanics: mandibular,^11,12 foot, wrist, and other movements.

• Diagnostic robots: used in ultrasonography and other radiological techniques to enhance precision. There are also pulse-locating robots for arterial puncture.

• Passive robots: used in surgical navigation systems.

• CAD CAM systems: used in implantology to construct positioning splints. Robots can be divided into three surgical groups:

• Telemanipulators: slave robots without any initiative. Telemanipulators are limited to accurately reproducing the surgeon’s real-time movements from a console in which an image of the operating field is viewed. The console may be located beside the patient in the same operating room or some distance away (telesurgery).

• Preprogrammed robots: these robots execute a series of movements and actions that have been programmed previously using the patient’s preoperative data.

• Preprogrammed intelligent robots: these robots are programmed to execute a task, but they can modify the parameters of execution in response to changes in the intervention conditions, such as patient position, obstacles, temperature, and others.

What qualities must a robotic system have to be useful in surgery? We can summarize these qualities in four parameters:

• Intelligence: When we speak of a robot endowed with «intelligence,»we are referring to its capacity to interpret the surgeon’s orders and to make certain decisions. For example, when we order a robot to «separate the tongue,» the robot has to process a series of parameters and integrate all the information about its surroundings: understand the order, determine its spatial position, identify the tongue visually and determine its position, determine all necessary movements for execution, move the instrument through a safe zone without injuring the patient or interfering with the surgeon, apply sufficient pressure, etc.

• Perception: The robot has to be able to perceive its surroundings to act efficiently. The most important parameters are the robot’s position, its position relative to the patient, surgeon or other elements, and the detection of possible obstacles. The robot’s basic "senses" should be human senses: vision, proprioception, touch, and temperature. The perception of robots can, however, be expanded beyond our own capacities (enhanced perception or reality): pH, infrared, X-rays, electromagnetic waves (radar), spectroscopy, ultrasound, and others. ¹³

• Flexibility: One of the disadvantages of many existing robotic systems is that they have been designed for specific surgical procedures. It is difficult to adapt them for procedures different from those for which they have been designed. Because of the volume of the equipment and its spatial and infrastructure requirements, the operating room often must be constructed around the equipment, which is not transportable.

• Safety: Aside from the technical requirements of any electromedical device for clinical use, robots must satisfy additional safety requirements. They must be capable of stopping and withdrawing from the field quickly if an emergency arises. They must be designed so that they cannot injure the patient or operating room personnel. They must not interfere with life support devices and anesthesia. They have to be fully sterilizable using conventional systems (heat, gases, and other).

 

Robots in oral and maxillofacial surgery

Only anecdotal experiences exist with robots in oral and maxillofacial surgery. There have been few experiences in our specialty, most of which have centered on surgery of the bone because it is the tissue most accurately visualized by CAT scan. Most published prototypes have not been used in operating rooms with real patients.¹⁸ One reason for this is that most commercial systems have been developed for endoscopic surgery, which still has only limited applications in our specialty. The cost of the equipment and our limited catalogue of minimally invasive procedures make it difficult to develop this technology. The introduction of endoscopy in facial traumatology, temporomandibular joint and salivary gland procedures is opening up possibilities for using these tools in our field. At the AAOMS Research Summit held in Chicago in 2005, the AAOMS cited robotic technologies, minimally invasive surgery, nanotechnology, and miniaturization as emergent techno logies with potential to be used more in our specialty. In Europe there is muchinterest in this field, although investigative efforts have concentrated on navigation techniques. Prototypes of robotic maxillofacial surgery have been developed in Germany, Austria, and France.¹⁷

 

Experiences in Spain

In Spain, the group of Vall d’Hebrón Hospital and Universitat Politècnica de Catalunya designed a robotic system for osteotomy. The system was equipped with a robotic arm that controlled the movements of a handpiece with a shank or Lindeman drill (Fig. 2).

The system had four different modules. The first module is the imaging module, which captures and manipulates the computed tomography image, generating a three-dimensional model from tomographic DICOM files (Fig. 3).

The second module identifies coordinates. It coordinates the spatial position of the virtual model with reality in real time. It uses computerized vision technology. The real patient has targets adhered to the surface and the computer sees the real object using three cameras. The system identifies the targets with mathematical algorithms and determines the spatial position of the real model by triangulation. The system captures the position of the real head and orients the virtual model visible on screen. As the patient’s head turns, the on-screen model turns at the same time.

The third module is used for planning. It allows us to move, turn, enlarge, and visualize our virtual model. We can design the osteotomy that we want to perform on the model, or plan how to protect structures like vessels or nerves to avoid injury when using the cutting tool (Fig. 4).

Finally, the fourth module is execution. This part of the system governs the robot, integrating imaging, coordinates and planning information.

Osteotomies can be executed in three ways:

1. Automatic execution: the robot performs the procedure independently, just like cutting robots work in industrial applications.

2. Semiautomatic execution: the surgeon guides cutting, but the robot defines the plane along which cutting proceeds, acting as a guide for cutting.

3. Guided execution: a volume is defined during planning and the cutting tool cannot proceed beyond this space. We can work manually in this planned space.

A similar prototype without a real-time patient positioning system, called Surgicobot, was developed in Amiens (France).¹⁷

Other prototypes use different positioning systems, e.g., infrared, hertzian waves, and others.

 

Conclusions

Robotic technology has interested surgeons for decades. Although robotics has been successfully incorporated in industrial processes, this has not been the case in surgery and general health sciences. Questions like cost, the operating room setting, and variability of the characteristics of living beings and their tissues make it difficult to incorporate these machines into surgical activity.

The development of new robotic technologies, including miniaturized devices that can work cooperatively and have physicochemical and spatial perception of their surroundings, generates new expectations that will be assessed with time.

Spain occupies a noteworthy position in robotics research and development, despite a chronic lack of industrial support and venture capital.

 

 

Correspondence:
J.A. Hueto Madrid
Servicio de Cirugía Oral y Maxilofacial
Hospital Universitario Vall d’Hebron.
Paseo Vall d’Hebron, 119
08006 Barcelona, España

Recibido: 29.10.07
Aceptado: 31.11.07

 

 

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