NEUROLOGY
perform minimally invasive surgery, while providing a 3D HD view, ergonomic design and wristed instruments that can bend and rotate more than the human hand. Surgeons have used this system in over three million surgeries since it received FDA approval in 2000. Autonomous systems are less common, but surgeons currently use this equipment in stereotactic neurosurgery, a sector where robotic systems are growing in popularity.
Stereotactic surgery
Stereotactic neurosurgery is a technique used by neurosurgeons to locate surgical targets within the brain using 3D imaging data and either an external frame or imaging markers attached to the scalp as a reference point. This technique enables surgeons to reach targets that are deep in the brain in a minimally invasive way. Surgeons would most commonly use this technique in procedures including deep brain stimulation (DBS), stereoelectroencephalography (SEEG), biopsy and endoscopy, or to deliver devices or instruments to a small target in the brain. Traditionally, in frame-based stereotactic
surgery, the surgeon would attach a frame to the patient’s head and use an imaging technique to identify the best routes to the target area. The frame provides a fixed support to accurately position surgical instruments according to 3D co-ordinates. Surgeons must use the imaging information to identify the most suitable angle at which to enter the brain in order to minimise the risk of damaging vital tissue. In a brain biopsy, the target co-ordinates help to position and pass a probe through a small hole in the skull. In another example, in the main type of procedure to treat the symptoms of Parkinson’s, electrodes are
placed deep in the brain to deliver high frequency stimulation.
Robotics in stereotactic neurosurgery
The first commercially available neurorobotic device was the neuromate for neurosurgical procedures. The neuromate can decrease procedure time and increase safety in stereotactic neurosurgery in frame and frameless procedures. The robot has five degrees of freedom, can be mounted with surgical instruments and can be used in a number of procedures. Surgeons have used the neuromate in thousands of electrode implantation procedures for DBS, SEEG, neuroendoscopy and biopsies and it is now used in many hospitals around the world with several installed in the UK.
Thanks to developments in medical IT, there is now easy to use procedure planning software such as Renishaw’s neuroinspire for stereotactic procedures. Surgeons can integrate the software with the robot to help devise and programme the device in order to place instruments and/or devices into the correct location. This is effective in reducing human errors and operating times.
Training surgeons in robotics
One of the challenges to the widespread acceptance of robotics in the neurosurgical operating theatre, once they have been proven effective and safe, is the ability to train neurosurgeons to use the innovative technologies.
In the neurosurgical field, there is room for improvement in speed, tactile ability and human robot interfaces, but work is underway to resolve the limitations.
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Simulation techniques are continually improving and the more lifelike the simulation the better, as simulation is a good alternative to cadavers. A benefit of a simulation is that it can be specific to an individual patient if generated using pre-operative imaging, so a surgeon can prepare and practise an exact patient specific procedure using the technology as a dry run. Improvements in virtual reality techniques will prove useful in training surgeons to use the technology of the future. It is extremely important that surgeons have a familiar and comfortable environment in which to practise using Renishaw’s technology. This is one of the reasons that Renishaw has set up a Healthcare Centre of Excellence in Miskin, near Cardiff in Wales. Within this centre, there is a mock operating theatre suite that mimics the real-life hospital setting, but without the complication of a sterile environment. In the state-of-the-art suite, surgeons can be trained to perform highly complex stereotactic procedures using the Renishaw range of neurological products. Another technology making its mark on surgical training is live streaming. The first virtual reality streamed surgery was broadcast in April 2016 to medical students as well as other interested parties. Live streaming has broken geographical barriers so that experienced surgeons can demonstrate surgical techniques and procedures in real time, which is why the Healthcare Centre of Excellence has provided this very technology in its operating theatre. As engineering expertise continues to
grow, so too will the demand for precision. In the neurosurgical field, there is room for improvement in speed, tactile ability and human robot interfaces, but work is underway to resolve the limitations. Completely autonomous surgery is still a long way off, but robotics is already changing the face of neurosurgery forever, although in a slower, more progressive way than the explosion that affected poor Phineas Gage.
CSJ MARCH 2017
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