Minimally invasive surgery (MIS) has been an essential tool in the surgical sector for many years due to its crucial advantages compared to open surgery. To overcome remaining limitations, teleoperated MIS experienced a strong emergence. However, the widespread usage of such systems is hindered by the enormous financial hurdle. The use of standard components and conventional tools for teleoperated MIS can facilitate integration into existing hospital workflows and can be a cost-efficient and versatile approach for research purposes. To compensate for the lack of haptic feedback, some teleoperation setups inherit a sensor system allowing them to record interaction forces and display them at the user interface. In research and in commercially available systems, different positions for the sensor can be found. In this paper, mechanical interfaces for the guidance and actuation of non-wristed and wristed standard instruments are presented. Furthermore, a method for the extracorporeal measurement of interaction forces is presented, characterized, and discussed. The overall mean relative error of the magnitude of the interaction force is 9.4%, while the overall mean absolute error of the force vector is 14.4$^{\circ }$, both below the respective human differential perception threshold. The presented measurement method is a simple, yet sufficiently accurate approach to measure interaction forces in surgical telemanipulation.

In this study, we present a new approach to improving vocal fold access to perform phonomicrosurgery. It is done by shooting the laser through a mirror to reach the vocal fold hidden parts. A geometrical study of laser shooting path was conducted for vocal fold anatomical constraints, followed by devising a laser-shooting system conceptual design. Control laws were developed and tested by simulation and validated experimentally on a test bench in a monocular and stereoscopic configuration. Simulation and experimental results are provided to demonstrate the effectiveness of the developed approach.

In minimally invasive surgery, surgical instruments with a wrist joint have better flexibility. However, the bending motion of the wrist joint causes a coupling motion between the end-effector and wrist joint, affecting the accuracy of the movement of the surgical instrument. Aiming at this problem, a new gear train decoupling method is proposed in the paper, which can automatically compensate for the coupled motion in real-time. Based on the performance tests of the instrument prototype, a series of decoupling effects tests are carried out. The test results show that the surgical instrument has excellent decoupling ability and stable performance.

This paper introduces a novel kinematic of a four degrees of freedom (DoFs) device based on Delta architecture. This new device is expected to be used as a haptic device for tele-operation applications. The challenging task was to obtain orientation DoFs from the Delta structure. A fourth leg is added to the Delta structure to convert translations into rotations and to provide translation of the handle. The fourth leg is linked to the base and to the moving platform by two universal joints. The architecture as well as the kinematic model of the new structure, called 4haptic, are presented. Comparisons in terms of kinematic behavior between the 4haptic device and the existing device developed based on spherical parallel manipulator architecture are presented. The results prove the improved behavior of the 4haptic device offering a singularity-free useful workspace, which makes it a suitable candidate to tele-operated system for Minimally Invasive Surgery. The dimensions of the 4haptic device, having the smallest workspace containing a prespecified region in space, are identified based on an optimal dimensional synthesis method.

Serial spherical linkages have been used in the design of a number of robots for minimally invasive surgery, in order to mechanically constrain the surgical instrument with respect to the incision. However, the typical serial spherical mechanism suffers from conflicting design objectives, resulting in an unsuitable compromise between avoiding collision with the patient and producing good kinematic and workspace characteristics. In this paper, we propose a multi-robot system composed of two redundant serial spherical linkages to achieve this purpose. A multi-objective optimization for achieving the aforementioned design goals is presented first for a single redundant robot and then for a multi-robot system. The problem of mounting multiple robots on the operating table as well as the way cooperative actions can be performed is addressed. The sensitivity of each optimal solution (single-robot and multi-robot) to uncertainties in the design parameters is investigated.

A new minimally invasive surgical (MIS) robot consisting of a spherical remote center motion (RCM) mechanism with modular design is proposed. A multi-objective dimensional synthesis model is presented to obtain the excellent performance indices. There are four objectives: a global kinematic index, a compactness index, a global comprehensive stiffness index, and a global dynamic index. Other indices characterizing the design requirement, such as workspace, mechanical parameter, and mass, are chosen as constraints. A new decoupled mechanism is raised to solve the coupled motion between the linear platform and the four degrees of freedom (DoF) of surgical instrument as a result of post-driving motors. Another new mechanical decoupled method is proposed to eliminate the coupled motion between the wrist and the forceps, enhance the dexterity of surgical instrument, and improve the independence of each motor. Then, a 7-DoF MIS robotic prototype based on optimization results has been built up. Experiment results validate the effectiveness of the two mechanical decoupled methods. The position change of the RCM point, accuracy, and repeatability of the MIS robot meet the requirements of MIS. Successful animal experiments validate the effectiveness of the novel MIS robot.

Robotic-assisted surgery is a continuously developing field because robots have demonstrated clear benefits in operating rooms. Until now, vast majority of robots used in surgery had serial structures. This paper presents the kinematic modelling of a 5-degree of freedom hybrid parallel architecture in two slightly different variants. The kinematics of this structure is determined, and following the analysis of singularities, the best variant is chosen. The robot workspace is computed and finally the experimental model and some simulation results are presented.

Developed minimally invasive surgical (MIS) robots are large multi-arm, multipurpose systems requiring significant investments that limit their availability in hospitals. A larger distribution of MIS robots with benefit for patients might be achieved improving their modularity and scalability so that smaller hospitals or medical centers could decide for a simpler and lower cost setup for a limited number of treatments only, while centers with higher funding could have more systems dedicated to different classes of operations. In line with this statement the paper proposes the paradigm of lean MIS system comprising a scalable set of modular, agile, small size single-instrument robots with limited life cycle cost. Miniaturization of instruments can further reduce invasiveness of procedures and one promising research direction is needle laparoscopic surgery, which can be applied to classes of operations on small regions requiring small force interaction with the patient. In the paper the development of a lean single-instrument manipulator for needlescopic surgery is presented and a new master concept for accurate restitution of surgical force proposed and discussed.

Persistent patency of the arterial duct represents one of the most common lesions in the field of congenital cardiac disease. The strategies for management continue to evolve. In this review, we focus on management beyond the neonatal period. We review the temporal evolution of strategies for management, illustrate the currently available the techniques for permanent closure of the patent arterial duct, review the expected outcomes after closure, discuss the current controversy over the appropriate treatment of the so-called “silent” duct, and provide recommendations for the current state of management of patients with persistent patency of the arterial duct outside of the neonatal period.

At the Congenital Heart Institute of Florida, we now recommend closure of all patent arterial ducts, regardless of their size. Before selecting and performing the type of procedure, we explain the natural history of the persistently patent arterial duct to the parents or legal guardian of the child. Particular emphasis is placed on the risks of endocarditis, including the recognition that many cases of endocarditis may not be preventable.

The devastating effects of endocarditis, coupled with the perception of more anecdotal reports of endocarditis with the silent duct, as well as the low risk of interventions, has led us to recommend closure of the patent arterial duct in these situations. We now recommend intervention, after informed consent, for all patients with a patent arterial duct regardless of size, including those in which the patent duct is “silent”. We recognize, however, that this remains a controversial topic, especially given the new recommendations for endocarditis prophylaxis from American Heart Association.

Since 2003, our strategy for closure of the patent arterial duct has changed subsequent to the availability of the Amplatzer occluder. This new device has allowed significantly larger patent arterial ducts to be closed with interventional catheterization procedures that in the past would have been closed at surgery. During the interval between 2002 and 2006 inclusive, the overall surgical volume at our Institute has been stable. Over this period, the number of patients undergoing surgical ligation of the patent arterial duct has decreased, with this decline in volume most notable for the subgroup of patients weighing more than five kilograms. This decrease has been especially notable in thoracoscopic procedures and is attributable to the increased ability to close larger ducts using the Amplatzer occluder.

For infants with symptomatic pulmonary overcirculation weighing less than 5 kilograms, our preference is for the surgical approach. For patients who have ductal calcification, significant pleural scarring, or “window-like” arterial ducts, video-assisted ligation is not an option and open surgical techniques are used. When video-assisted ligation is possible, the approach is based on family and surgeon preference. When open thoracotomy is selected, we usually use a muscle-sparing left posterolateral thoracotomy.

For patients weighing more than 5 kilograms, we currently recommend percutaneous closure for all patent arterial ducts as the first intervention, reserving surgical treatment for those cases that are not amenable to the percutaneous approach. For symptomatic infants weighing greater than 5 kilogram with large ducts, we prefer to use the Amplatzer occluder. In rare instances, the size of the required ductal occluder is so large that either encroachment into the aorta or pulmonary arteries is noted, and the device is removed. The child is then referred for surgical closure. We can now often predict via echocardiography that a duct is too large for transcatheter closure, even with the Amplatzer occluder, and refer these patients directly to surgery.

For patients with an asymptomatic patent arterial duct, we prefer to wait until the weight is from 10 to 12 kilograms, or they are closer to 2 years of age. If the patent arterial duct is greater than 2.0 to 2.5 millimetres in diameter, our preference is to use the Amplatzer occluder. For smaller ducts, we typically use stainless steel coils. Using this strategy, we close all patent arterial ducts, regardless of their size.

Introduction: Inverted papillomas are relatively rare, benign epithelial tumours of the nasal cavity which generate considerable interest because they are locally aggressive, have a tendency to recur and are associated with malignancy.

Aims: To review our experience of the management of inverted papillomas, and to review the literature in order to evaluate recurrence rates, rates of synchronous and metachronous carcinoma, and outcomes of treatment, both endoscopic and conventional.

Methods: We retrospectively reviewed all cases of inverted papilloma that presented to our unit, a tertiary referral centre, over a 20-year period from 1985 to 2005. A Medline review of the literature was performed to identify published case series of inverted papillomas. We undertook a critical analysis of the literature.

Results: We treated 65 patients with inverted papilloma over the 20-year period, with a mean follow up of five years (range one to 20 years). Fifty-eight patients initially underwent nasal biopsy, often with polypectomy. Thirty-six had endoscopic surgery, with five (14 per cent) suffering recurrence, whilst 16 had a lateral rhinotomy and medial maxillectomy, of which four (25 per cent) suffered a recurrence. Seven septal inverted papillomas required local resection, with no subsequent recurrences. There were seven (11 per cent) synchronous and two metachronous malignancies.

Sixty-three case series with adequate data were identified from the literature. There were 163 (7.1 per cent) cases of synchronous carcinoma, out of 2297 cases. Metachronous carcinomas were reported in 74 out of 2047 cases, representing a transformation rate of 3.6 per cent. However, the true population base for these figures is uncertain, given that many series were reported from tertiary centres, where recurrent and problematic cases are likely to be over-represented. The recurrence rates were 12.8 per cent for endoscopic procedures, 17.0 per cent for lateral rhinotomy with medial maxillectomy, and 34.2 per cent for limited resections such as nasal polypectomy and Caldwell–Luc approaches. No significant association between atypia or dysplasia and recurrence or malignant transformation was found. The mean time taken to develop a metachronous carcinoma was 52 months (range six to 180 months). The estimated malignant potential for recurrent disease was up to 11 per cent.

Conclusion: Patients with inverted papilloma should undergo thorough surgery to remove all mucosal disease, most probably by the endoscopic, endonasal route when complete resection is possible. Cases demonstrating atypia or dysplasia may be treated by the endoscopic route. Recurrent disease and metachronous carcinoma can develop after a prolonged period of time. Long-term follow up is recommended to detect recurrence, as disease can become quite extensive before it becomes symptomatic.