As mentioned in 1st SMARTsurg newsletter, we have chosen a total of 7 use cases on urology, cardiovascular and orthopaedic surgery. The surgical workflow of these surgical use cases is represented in a graphical format with the components of the surgical activity, for example, “Phases” of the surgery.
To obtain user-specific requirements in minimally invasive robotic surgery, a total of 29 surgeons, of urology, orthopaedic and cardiovascular specialties, are interviewed as shown in the following table:
We used a questionnaire set to conduct the interviews. Two types of questions have been considered in the questionnaire set. Either surgeon expressed their opinions in the expressive form or surgeons gave the answers in the form of Yes/No or surgeons expressed their answers by selecting one or more options. We organised and structured recorded audio data of the interviews into verbatim transcripts for further analysis. The answers of different participant surgeons then were grouped together for each question in the questionnaire.
We analysed data within the specialties (interview data of orthopaedic surgeons, urologists and cardiac surgeons separately), which is called the ‘within-case’ analysis. The ‘within-case analysis’ was used to identify common categories or a theme for the user requirements from each surgical use case. For example, urologists need better ‘image quality’, which is defined as a category. After the ‘within-case’ analysis, we analysed the specialties, i.e. common requirements between different specialties, which is called the ‘across-case’ analysis. During the ‘across-case’ analysis, the identified requirements were prioritised, using the score on the scale of 1 to 5, during the SMARTsurg consortium meeting (Milan, Italy, 10-11 July 2017), where most of the end users were present and gave their contribution in identifying the priorities. We elicited a total of 33 user requirements, out of which 4 requirements (i.e. superimposed preoperative images, active constraints – an anatomical region which is defined preoperatively to stop the robot move outside of this region, articulated instruments, and hand exoskeleton as surgeon’s side master system) were mandatory. The elicited requirements have been put in correspondence with the system hardware. Clinicians' feedbacks were kept into account for the final application scenarios choice.
Hereafter, the three application scenarios synopsis with user requirements is reported:
1. Robot-assisted Partial Lateral Meniscectomy (RaPLM)
A meniscus tear is a common knee joint injury. RaPLM is performed to remove of all or part of a torn meniscus. Smart glasses (for assistants), hand exoskeleton, better image quality and articulated instruments are needed in all the phases of RaPLM. In first phase of RaPLM surgeons need to overview the knee joint, where the three-fingered instrument could be used to see the knee compartments. Then, to evaluate the position of the tear in the meniscus, which is done conventionally by marking the damage by the probe, haptic perception, “a sense of touch”, could be useful. Then, during the RaPLM, first pre-operative images could be superimposed to see the damaged meniscus, which helps to cut it minimally. The three-fingered instrument then could be used to cut the free cartilage pieces where active constraints could also be implemented to prevent the injury to meniscus rim and to cut the minimum meniscus.
2. Robot-assisted Partial Nephrectomy (RAPN)
RAPN is performed to remove a kidney tumour, where a tumorous portion of the kidney is removed. Hand exoskeleton, better image quality, smart glasses (for assistants) and 3D images for visualisation are needed in all the phases of RAPN. During preparation of the kidney, active constraints could be used to prevent the injuries to vasculature such as the aorta or vena cava as well as organs such as liver and spleen. After that, during the excision of the tumour, preoperative images are superimposed to see the renal artery, while incising the renal capsule before clamping the artery. After the preoperative images are superimposed, active constraints could be used to prevent the injury to renal arteries. After that, haptics could be used for the closure of renal breach during suturing and pulling of the thread while doing the suturing of the kidney.
3. Robot-assisted Coronary Artery Bypass Grafting (CABG)
CABG is advised in the patients with significant narrowing or blockage of coronary artery. Hand exoskeleton, better image quality, smart glasses (for assistants), and 3D images are needed in all the phases of CABG. First, during the phase of an artery called LIMA (Left Internal Mammary Artery) takedown, preoperative images could be used to identify LIMA and the thymus gland. Then, active constraints could be used for preventing the injuries to LIMA while cauterising the sternal branches or using the diathermy. Before the LIMA takedown, haptics could be used to assess the calcium deposits, if any, in the coronary artery. Articulated instruments could then be used to take down LIMA and to go posterior side of the heart, e.g. to assess the posterior branch of the coronary artery. During LIMA-LAD (Left Anterior Descending Artery, which is a branch of a coronary artery) anastomosis, haptics could be used during suturing and pulling of the thread, where the three-fingered instrument could be used to cut the sutures.