Presented at the 2006 SAGES Meeting
NATURAL ORIFICE SURGERY WITH AN ENDOLUMINAL MOBILE ROBOT Mark E. Rentschler1, Jason Dumpert1, Stephen R. Platt1, Shane M. Farritor1, Dmitry Oleynikov2 1
University of Nebraska - Lincoln, N104 Walter Scott Engineering Center P.O. Box 880656 Lincoln, NE 68588-0656 Phone: (402) 472-5805 2
University of Nebraska Medical Center, 983280 Nebraska Medical Center Omaha, NE 68198-3280 Phone: (402) 559-5508 Fax: (402) 559-6749 E-mail:
[email protected]
Abstract: Natural orifice surgery promises to eliminate skin incisions and reduce post operative pain and discomfort. Such an approach provides a distinct benefit compared to conventional laparoscopy where multiple entry incisions are required for tools and camera. Endoscopy is currently the only way to perform procedures through the gastrointestinal tract and is limited by instrumentation and the need to pass the entire scope into the patient. In contrast an untethered miniature robot that is inserted through the mouth would then be able to enter the abdominal cavity through a gastrotomy, and explore the entire peritoneal cavity. In this study we developed an endoluminal robot capable of transgastric abdominal exploration under esophagogastroduodenoscopic (EGD) control. Under EGD control a gastrotomy was created and the miniature robot was deployed into the abdominal cavity under remote control. Ultimately, future procedures will include a family of robots working together inside the gastric and abdominal cavities after insertion through the esophagus. Such technology will help reduce patient trauma while providing surgical flexibility. Keywords: Endoluminal, Transgastric, Laparoscopy, In vivo, Mobile, Robots
Introduction The use of robotics is currently recognized as a major driving force for advancing Minimally Invasive Surgery (MIS) [1-3]. However, current surgical robots, such as the da Vinci system made by Intuitive Surgical, have several significant limitations. Although one recent report concluded that robotic surgery can enhance dexterity compared to traditional laparoscopy [4], most studies suggest that current robotic systems offer little or no improvement over standard laparoscopic instruments in the performance of basic skills [5-7]. Current systems are also not available in most hospitals and remain constrained by limited sensory and mobility capabilities, and high cost. Much effort is focused on developing next generation robots that improve mobility and sensing while reducing complexity and cost. The Carnegie Mellon Robotics Institute is developing intelligent microsurgical instruments to electronically cancel tremor in handheld surgical tools [8-10]. A full prototype has been completed and preliminary tests indicate tremor oscillations can be reduced by as much as 50%. Prototypes of new endoscopic tools with force and tactile feedback and smaller and less expensive robotic systems are being created at the Bio-Robotics Laboratory at the University of Washington [11-13]. All of the above systems are implemented from outside the body and will therefore always be constrained to some degree by the limitations of working through small incisions. Research has been done to develop medical robots in which all (or most) of the device enters the body. The simplest such mechanisms have been maneuverable endoscopes for colonoscopy [14-15] and laparoscopy [16]. These devices
have actuators that can turn the endoscope tip after it enters the body. However, support equipment such as power and control (and often the actuators) remain outside the body. More advanced in vivo robots have been developed to explore hollow cavities such as the colon or esophagus with locomotion systems based on ‘inch-worm’ motion that use a series of grippers and extensors [17-18], rolling tracks [19], or rolling stents [20]. These devices all use external power in the form of electricity and/or vacuum sources for locomotion. In the abdominal cavity in vivo robots have been shown to be very useful for providing visual feedback and task assistance. A mobile camera robot was shown to be capable of providing the sole visual feedback to the surgeon during a porcine cholecystectomy [21]. A mobile camera and biopsy robot was also shown to be capable of taking a biopsy of liver during a porcine surgery [22]. Natural orifice surgery, specifically peroral endoscopic transgastric abdominal surgery, is being very actively investigated in both animals and humans. This technique aims to replace traditional laparoscopic surgery. Several animal studies have shown the feasibility and effectiveness of this surgical approach. A pilot animal study has shown that endoscopic transgastric gastrojejunostomy is technically feasible [23]. Another study used a peroral endoscopic transgastric approach for ligation of the Fallopian tubes. Long-term post-operative survival showed that this procedure is technically feasible and safe in a porcine model [24]. Yet another study demonstrated the successful removal of gallbladders from 8 pigs using a transgastric approach [25]. Finally, Reddy and Rao used a transgastric approach to successfully remove a patient’s spleen [26, 27], although results have not yet been published as a full paper.
These early studies suggest that a transgastric approach to endoscopy is both possible and effective. Previous work by the authors has shown in vivo robots can be used in traditional laparoscopy to provide vision [21] and task assistance [22]. This paper combines trasgastric approaches with in vivo robots and shows the potential of this combined approach to facilitate far more complex natural orifice procedures.
Materials and Methods The goal of the current study is to demonstrate the capability of introducing a mobile robot into the abdominal cavity through the esophageal opening. Such an approach provides a distinct benefit compared to conventional laparoscopy where multiple external entry incisions are required for tools and cameras. A miniature robot that is inserted through the mouth can enter the abdominal cavity through a gastrotomy, thereby obviating the need for any skin incisions. In this study we developed an endoluminal robot (Figure 1) capable of transgastric exploration under esophagogastroduodenoscopic (EGD) control. The robot is 12 mm in diameter and 35 mm long. The helical wheel profile provides sufficient traction for mobility without causing tissue damage. Two independent motors control the wheels, thereby providing forward, backward, and turning capability. The robot tail prevents the counter-rotation of the robot’s body when the wheels are turning. The entire length of the robot is 75 mm. This prototype endoluminal mobile robot was tethered for power during the porcine surgery, but a wireless in vivo mobile robot has also been developed. This wireless mobile robot has been used successfully in the abdominal environment and will soon be tested in natural orifice endoluminal surgery.
An anesthetized pig was used as the animal model. The 60 lb pig was fed Gatorade and water for 36 hours prior to the procedure. A sterile overtube was advanced into the pig’s stomach with a standard upper endoscope. The stomach was irrigated with antibiotic solution. The robot was inserted into the gastric cavity through the overtube. The robot explored the gastric cavity (Figure 2) and was then inserted into the abdominal cavity through a transgastric incision. The gastric incision was performed with an endoscopic needle-knife (Figure 3). The incision was just large enough to allow the 12 mm diameter robot to pass through. After the robot entered the abdominal cavity, the endoscope was also advanced to view the mobile robot as it explored the abdominal environment. After exploration of the abdominal cavity (Figure 4, 5), the robot was retracted into the gastric cavity. Endoscopic closure of the transgastric incision was successful using two endoclips and one endoloop (Figure 6). The robot was then retracted back through the esophagus (Figure 7).
Results After insertion into the gastric cavity, the mobile robot successfully maneuvered throughout the cavity under EGD control (using visual feedback from the endoscope) (Figure 2). The robot’s size did not hinder its motion and the wheel design provided sufficient traction to traverse throughout the cavity. After gastric exploration, the miniature robot was deployed into the abdominal cavity and maneuvered by remote control. This maneuver provided a challenge to the surgical team, but through careful planning and robot control the robot successfully cleared the gastric cavity.
The mobile robot was capable of traversing the entire abdominal cavity, including the liver (Figure 4) and the small bowel (Figure 5). This exploration was monitored by the endoscope. Future endoluminal robots will provide visual feedback through onboard cameras, much like the laparoscopic mobile camera robots currently under development [21]. Equipped with a camera and a manipulator, this robot could assist with abdominal surgical procedures. In the near future a family of these robots, each with different features, could be capable of performing simple procedures while being remotely controlled. After successfully exploring the abdominal cavity, the mobile robot was retracted into the gastric cavity. Closing the gastrotomy was successfully accomplished using endoclips and one endoloop. Retrieval of the miniature robot was accomplished without difficulty with an Endoscopic snare.
Discussion We performed endoscopic transgastric abdominal exploration with a miniature mobile in vivo robot. This work demonstrated the ability to perform natural orifice surgery in the abdominal cavity using in vivo robotics. The ability to perform abdominal surgery without skin incisions can reduce patient trauma. However, the difficulties lie in performing these procedures using only EGD video feedback, and introducing sufficiently capable tools into the abdominal cavity. The ability to provide transgastric robotic assistance inside the abdominal cavity may help solve some of these problems. As the robot is not restricted by the length or the angle of the endoscope insertion it will by definition have a greater number of
degrees of freedom. The working channel of the endoscope also limits the size and type of instrumentation available to the surgeon. Although it is unlikely that the miniature robot could be used by itself to perform procedures such an appendectomy, it could be used in conjunction with the endoscope to achieve better visualization and greater mobility in the peritoneal cavity. These endoluminal robots would be equipped with cameras and manipulators. In the short term these robots will be able to provide surgical assistance, but ultimately, future procedures will include a family of robots working together inside the gastric and abdominal cavities after insertion through the esophagus. Such technology will help reduce patient trauma while providing surgical flexibility. Future developments of these endoluminal robots include the addition of camera and biopsy capability, much like the successful camera and biopsy robots that have been developed for laparoscopic surgery [22, 23]. Next generation robots will also be wireless as this technology is already being used for the laparoscopic in vivo robots.
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Legends for all Figures
Figure 1:
The 12mm diameter mobile endoluminal robot showed the ability to traverse the stomach and abdominal cavity without causing tissue damage.
Figure 2:
The mobile endoluminal robot while maneuvering inside the stomach.
Figure 3:
A gastrotomy was created to allow the robot to move from the stomach to the abdominal cavity.
Figure 4:
The mobile robot traversing the liver under EGD control.
Figure 5:
The mobile robot was also able to traverse the small bowel.
Figure 6:
After abdominal exploration, the mobile robot was retracted from the abdominal cavity and the gastrotomy was closed.
Figure 7:
The mobile robot was retracted through the esophagus.
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