Content uploaded by Jenny Dankelman
Author content
All content in this area was uploaded by Jenny Dankelman on May 06, 2015
Content may be subject to copyright.
PLEASE SCROLL DOWN FOR ARTICLE
This article was downloaded by:
[TU University of Technology Delft]
On:
15 September 2008
Access details:
Access Details: [subscription number 787712370]
Publisher
Informa Healthcare
Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House,
37-41 Mortimer Street, London W1T 3JH, UK
Minimally Invasive Therapy and Allied Technologies
Publication details, including instructions for authors and subscription information:
http://www.informaworld.com/smpp/title~content=t713683124
Haptics in minimally invasive surgery - a review
E. P. Westebring - van der Putten
ab
; R. H. M. Goossens
a
; J. J. Jakimowicz
c
; J. Dankelman
b
a
Department of Applied Ergonomics and Design, Faculty of Industrial Design Engineering, Delft University of
Technology, the Netherlands
b
Department of Biomedical Engineering, Faculty of Mechanical, Maritime and
Materials Sciences, Delft University of Technology, The Netherlands
c
Department of Surgery, Catharina-
hospital, Eindhoven, the Netherlands
Online Publication Date: 01 January 2008
To cite this Article van der Putten, E. P. Westebring -, Goossens, R. H. M., Jakimowicz, J. J. and Dankelman, J.(2008)'Haptics in
minimally invasive surgery - a review',Minimally Invasive Therapy and Allied Technologies,17:1,3 — 16
To link to this Article: DOI: 10.1080/13645700701820242
URL: http://dx.doi.org/10.1080/13645700701820242
Full terms and conditions of use: http://www.informaworld.com/terms-and-conditions-of-access.pdf
This article may be used for research, teaching and private study purposes. Any substantial or
systematic reproduction, re-distribution, re-selling, loan or sub-licensing, systematic supply or
distribution in any form to anyone is expressly forbidden.
The publisher does not give any warranty express or implied or make any representation that the contents
will be complete or accurate or up to date. The accuracy of any instructions, formulae and drug doses
should be independently verified with primary sources. The publisher shall not be liable for any loss,
actions, claims, proceedings, demand or costs or damages whatsoever or howsoever caused arising directly
or indirectly in connection with or arising out of the use of this material.
REVIEW ARTICLE
Haptics in minimally invasive surgery – a review
E. P. WESTEBRING – VAN DER PUTTEN
1,3
, R. H. M. GOOSSENS
1
, J. J. JAKIMOWICZ
2
&
J. DANKELMAN
3
1
Department of Applied Ergonomics and Design, Faculty of Industrial Design Engineering, Delft University of Technology, the
Netherlands,
2
Department of Surgery, Catharina-hospital, Eindhoven, the Netherlands, and
3
Department of Biomedical
Engineering, Faculty of Mechanical, Maritime and Materials Sciences, Delft University of Technology, The Netherlands
Abstract
This article gives an overview of research performed in the field of haptic information feedback during minimally invasive
surgery (MIS). Literature has been consulted from 1985 to present. The studies show that currently, haptic information
feedback is rare, but promising, in MIS. Surgeons benefit from additional feedback about force information. When it comes
to grasping forces and perceiving slip, little is known about the advantages additional haptic information can give to prevent
tissue trauma during manipulation. Improvement of haptic perception through augmented haptic information feedback in
MIS might be promising.
Key words: Laparoscopy, tactile perception, force feedback
Introduction
Minimally invasive surgery (MIS), which is surgery
performed with long thin instruments through small
incisions, has been used for more than 25 years. The
main reason for the rapid developments in MIS are
the benefits for the patient, such as less trauma,
shorter hospital stay, and reduced recovery time (1–
5). However, this technique brings severe difficulties
for the surgeon (6), which in turn can lead to a
higher number of errors and complications (7).
The indirect vision through an endoscope (cam-
era), and the indirect manipulation of tissue are the
main causes of perception problems, which can be
divided into disturbed hand-eye coordination,
reduced depth perception, and reduced haptics.
Haptics are here defined as the combination of
tactile perception (through sensory skin receptors)
and kinesthetic perception (through muscle, tendons
and joint sensory receptors). The MIS technique can
endanger the patient’s safety, e.g. when grasped
tissue is damaged by the instruments (8–11). Much
attention has been paid to perception problems due
to reduced hand-eye coordination (12–15) and
depth perception (16–19), but not much research
has been done in the field of reduced haptics.
In MIS the hands manipulate tissue indirectly by
instruments. However, it is not completely under-
stood how the instruments interfere with the sensory
perception of the surgeon. In open surgery there is
semi direct tissue contact (with gloved hands), so the
surgeon can feel the temperature, shape, structure,
and consistency of the tissue touched. Compared to
bare hands, a glove will reduce haptics to some extent,
but the surgeon can still directly feel the amount of
force applied when pinching or feel when the tissue
slips through the fingers. According to this (natural)
haptic feedback, the surgeon can adjust the applied
force in such a way that the tissue is not damaged, but
is still held securely. Basically, what the surgeon can
feel through the instruments is unknown.
Nonetheless, a correct perception of the operation
field is needed to manipulate the tissue safely.
Some handheld instruments currently on the
market do not provide reliable haptic feedback, but
are still used for a variety of MIS tasks. Similarly
most robotic surgery systems do not provide any
haptic feedback, but are still used to perform delicate
Correspondence: E.P. Westebring – van der Putten, Delft University of Technology, Faculty of Industrial Design Engineering, Landbergstraat 15, NL-2628
CE Delft, the Netherlands. E-mail: E.p.westebring-vanderputten@tudelft.nl
Minimally Invasive Therapy. 2008; 17:1; 3–16
ISSN 1364-5706 print/ISSN 1365-2931 online # 2008 Taylor & Francis
DOI: 10.1080/13645700701820242
Downloaded By: [TU University of Technology Delft] At: 12:16 15 September 2008
procedures (20). Despite this ability to work without
haptic feedback, the skilfulness with current instru-
ments is far from optimal in MIS. In a review of 148
cardiac surgeries performed with a robotic surgical
system, the da Vinci telemanipulation system
(Intuitive Surgical, Mountain View, CA, USA).
Mohr et al. felt that the lack of haptics might lead
to identification problems (21). Currently, it is
unclear what haptic feedback systems can do in
MIS to improve the skilfulness of surgeons and
reduce risks for patients. In order to improve these
systems, we have to understand the role of haptic
sensation during MIS. Of course, not all tasks
require the same amount of haptic information.
A note on terminology
Because different terminology is used in the litera-
ture, confusion can occur. Therefore, we explain the
terminology used in this article. Haptic perception (or
haptics) is the combination of tactile perception and
kinesthetic perception. Pain and temperature are
used for haptic perception but are not the main focus
of this research. Tactile perception is the perception of
pressure, vibration, and texture (also called discrimi-
native touch or cutaneous sense), and relies on
different receptors in the skin (cutaneous mechan-
oreceptors). Kinesthetic perception relies on receptors
in muscles, tendons and joints and senses position,
movement and forces. Another common term used
to describe haptics is proprioception. However,
proprioception is the perception of posture and
position of the limbs, body and head in space and its
parts relative to one another, including the vestibular
system, cutaneous sense and kinaesthesia (24). In
Figure 1 simplified models of the types of surgery
can be seen and the role of the sensory system to
perceive information (including open surgery).
To find solutions for the difficulties in haptic
perception during MIS, a research project was
initiated at the Delft University of Technology in
cooperation with the Catharina Hospital in
Eindhoven. As part of the project, an extensive
literature review was carried out. The aim of this
review article is to describe the current knowledge
about haptics in MIS, minimally invasive robotic
surgery (MIRS) (also called tele-operations / robotic
surgery), and virtual reality training for MIS (VRT).
The article ends by identifying several important
research areas.
Methods
The literature review focused on research on haptics
in conventional MIS, MIRS and VRT. At first, a
thorough PUBMED and SCOPUS search was
performed in order to find relevant literature in
Figure 1. Simplified models: (A) open surgery; (B) minimally invasive surgery; (C) minimally invasive robotic surgery: (D) virtual reality
training in minimally invasive surgery (with force feedback).
4 E.P. Westebring – van der Putten et al.
Downloaded By: [TU University of Technology Delft] At: 12:16 15 September 2008
English. The electronic databases from 1985 to
February 2007 were searched, using the following
search terms: ‘haptics OR haptic OR tactile OR
force AND/OR feedback’ AND ‘Minimally Invasive
Surgery OR MIS OR laparoscopy OR laparoscopic
OR virtual reality OR simulation OR robotic OR
tele-surgery OR tele-operation OR Minimally inva-
sive Robotic Surgery OR MIRS OR master AND
slave’. After the database survey all relevant papers
in the reference lists of the already found papers were
consulted in addition to conference proceedings and
books about the topic. The survey resulted in 118
relevant papers and documents. Two review studies
(22,23) were found that provided some information
about haptics during minimally invasive surgery, but
since they did not focus on this subject their results
were far from complete.
After data collection, the results from the review
were divided into three main groups: Haptic sensa-
tion in conventional minimally invasive surgery,
haptic sensation in minimally invasive robotic
surgery, and haptic sensation in virtual reality
training. The groups are discussed in detail in the
‘‘Results’’ section with each subsection, starting with
an overview of research into what a surgeon can
actually feel through his instruments, followed by a
survey of technical improvement aids that have been
found.
Results
Haptic sensation in conventional minimally
invasive surgery (MIS)
In theory, a surgeon wants to feel the forces, position
and tactile information generated by the instruments
applied on the tissue in order to control them. The
ability to feel texture, shape, size and consistency of
tissue using MIS graspers has been studied (25–29).
These studies show that haptics are considerably
reduced compared to bare hands, except for texture
discrimination, although one is able to distinguish
shape, size and consistency of tissue. Unfortunately,
all these studies used artificial tissue like sandpaper
and plastic cubes and cones.
Bholat et al. (27) showed that the surgeon is
provided with some haptic feedback in laparoscopy
(MIS performed in the belly alcove) (determine
primitive shapes, texture and consistency of springs),
and experts performed better, which means that
surgeons learn to understand and interpret the
haptic information presented. Only experts distin-
guished different textures (abrasive materials) better
with a dissector than with bare hands, probably due
to the experience to sense vibrations along with
amplification by the lever effect of the trocar. Boer et
al. (30) showed that reusable dissectors were eight
times less sensitive than bare hands when trying to
feel a simulated arterial pulse.
In general, interposition of instruments reduces
haptic feedback considerably in minimally invasive
procedures (26,27,29,30).
Interference components of haptic sensation
Items, attributes and techniques establish the link
between the surgeon’s hands and the treated tissue,
thereby interfering with the desired haptic percep-
tion (see Figure 1). These interference factors
consist of the following components (see Figure 2
for an overview of the interference factors in
conventional MIS).
Friction between trocar and instrument shaft. The
trocar placed in the patient’s skin, where the
instruments are inserted, prevents insufflated CO2
gas to come out and protects against skin rupture as
well. During instrument movement, the shaft is in
contact with the airtight wall of the trocar that causes
friction, which works against the movement (1,31).
This friction is different, but constant for each
trocar, and can exceed 3N with some trocars
(29,32).
Figure 2. Interference factors in conventional minimally invasive
surgery. The grip force (Fg) is not equal to the tip force (Ft) due
to the instrument’s mechanism. The hand force (Fh) is not equal
to the organ force (Fo) due to the scaling factor (ideal
Fh5Fo(OA/Ah)) and the resistance of the abdominal wall. The
pull force at the handle (F
pull
h) is not equal to the pull force at the
organ (F
pull
o) due to trocar friction. The torque, applied at the
handle (Th), is influenced by the trocar friction as well.
Haptics in minimally invasive surgery 5
Downloaded By: [TU University of Technology Delft] At: 12:16 15 September 2008
The resistance of the abdominal wall during a lever
movement. When the instruments are levered, the
resistance of the abdominal wall (skin,
subcutaneous fat, facial and muscular layers) can
vary because the biomechanical properties are not
isotropic and differ among individuals. This force
torque, with respect to the abdominal wall, can
range from 0 to 0.7 Nm according to angle and
directionoftilt(29).
Scaling and mirroring of tip forces. Because the
incision point transfers the instrument shaft into a
lever, it scales and mirrors the forces at the tip of the
instrument (perpendicular to the shaft) (16). The
length of the lever arm depends on the insertion
depth of the instrument, the patient’s abdominal
wall thickness, and the target location. Theoretically,
the force felt by the surgeon’s hand can range from
0.2 to 4.5 times the actual force generated by
instrument tissue contact. This induces an
additional distortion of haptic feedback. The
interaction forces of the instrument with organs
applied by the surgeon were measured in the range
of 0 to 10–12 N (Ft) (29,33,34).
Instruments mechanism. Each instrument has a
mechanism, which differs in construction and thus
mechanical properties (28,29,35). During grasping,
the operating force experienced by the surgeon
should be a measure for the grasp force applied to
the tissue. In theory, this force should be transmitted
without distortion and losses. Due to friction in the
mechanism, commercially available MIS graspers
show a mechanical efficiency of less than 50% (35).
The force transmission is not constant during the
grasping movement due to backlash and play in the
mechanism. The relative variation in force
transmission of commercially available graspers is
between 26.1 and + 1.9 (35). This means that with
some instruments, the grasp force increases with an
increasing angle of the handle while with others, the
force decreases under the same circumstances. This
results in a variety of grasp forces with the same
operating force and therefore uncertainty about the
grasp force information delivered to the surgeon’s
hand. An accompanying problem occurs when a
surgeon changes instruments that differ in their
mechanical properties.
Haptic sensation is greatest during low velocity of
translation movement, the smallest angle of tilt, and
an efficient-accurate mechanical mechanism. The
interference properties of haptics can be of the same
order as during contact with the organ. This makes it
difficult for a surgeon to discriminate between
somesthesic information generated by the organ
and information resulting from friction or resistance
of the abdominal wall (29).
Technical improvement aids
The addition of haptic information feedback in MIS
can give the surgeon the ability to sense slip and
applied forces in order to control grasp forces. This
haptic sensation can reduce tissue trauma. There are
two approaches to improve haptics: Improving the
mechanical construction and adding extra informa-
tion feedback (sensory substitution), transmitted
electromechanically.
Mechanical approach
In the Daum-Hand (EndoHand) (36,37) the con-
tact forces on the grasper were detected by mem-
branes and transmitted hydraulically to membranes
connected to the surgeon’s fingers, so an average
grasping force was felt. However, it was shown that
the dexterity (measured by time and errors) of the
grasper was less compared to conventional graspers
(37).
The low-friction forceps of Herder et al. (38,39)
consists of a rolling link mechanisms (40) to
transmit movements and forces with a mechanical
efficiency of 96%. One was able to feel a pulse with
this laparoscopic instrument, but this ability was
still reduced compared to bare hands (2.7 times
less sensitive). However, compared to conventional
MIS instruments, the prototype performed better
(30).
A laparoscopic grasper designed by Bala´zs et al.
(41) and a kidney manipulator designed by Kota et
al. (42) do not contain bolt joints but have elastic
jaws, so friction can be neglected. Unfortunately, no
tests with these instruments could be found.
Mechanically efficient instruments are not always
beneficial. For example, improving mechanical
efficiency did not necessarily lead to decreased pinch
forces, depending on the task. Mechanically efficient
graspers can even increase the maximal excessive
force, compared to normal graspers (90% efficiency
compared with 30%) depending on the task. For
tasks requiring little instrument movement, such as
grasping and holding tissue, a low mechanical
efficiency was sufficient, whereas tasks with repeated
motion (feel tissue) required high mechanical
efficiency. A holding task showed twice as much
force necessary to prevent slip, and no difference
occurred between novices and experts, probably
because no practicing was involved before the start
of the test (28). Additionally, the lack of endoscopic-
visual feedback resulted in more slips (43).
6 E.P. Westebring – van der Putten et al.
Downloaded By: [TU University of Technology Delft] At: 12:16 15 September 2008
Sensory substitution
Sensory substitution was used in most studies, using
the electromechanical approach, to improve haptics.
A thorough overview of different types of available
tactile displays was made by Wall et al. (44). These
different types of displays can be used to improve
haptics during MIRS and VRT as well.
The electromechanical approach uses sensors to
measure forces applied to the tissue, and/or distract
tactile tissue information, to reflect them electronically
to the surgeon using a haptic, auditory or visual
display. Auditory and visual displays depict a force
distribution, or tactile information, using either an
auditory signal or a graphical representation. Several
kinds of haptic displays exist, kinesthetic (force plus
position), vibro-tactile, relief-tactile, stretch-tactile,
and electro-tactile displays. A kinesthetic display uses
an array of forces and positions that counteract the
operator’s manipulation forces and positions. Less
sophisticated are force displays (sometimes only
displaying forces in certain dimensions) and position
displays that are often used instead of a full kinesthetic
display. A vibro-tactile display uses an array of
vibrating pins where the amplitude or the frequency
of vibration becomes bigger with larger measured
forces. A relief-tactile display uses an array of movable
pins placed on the skin: The larger the measured
force, the larger the deflection of the pin. A stretch-
tactile display presents information through spatio-
temporal patterns of mechanical skin stretch. An
electro-tactile (or electro-cutaneous) display uses an
array of electrodes placed on the skin to create touch
sensation (45).
Schostek et al. (26) developed a tactile sensor,
integrated into a laparoscopic grasper jaw, to obtain
information about shape and consistency of tissue
structures. The tactile data were wirelessly trans-
ferred (Bluetooth) and graphically displayed to the
surgeon. The prototype of the system proved
feasibility (in an experimental environment) and
the tactile data supplemented the haptic feedback
provided by conventional MIS instruments.
However, tissue exploration time was longer com-
pared to a conventional grasper.
Prasad et al. (46) developed a 2-degrees of
freedom (DOF) force-sensing sleeve fitting a variety
of instruments. The sleeve was used passively to
monitor intra-abdominal forces during a retraction
task. An audio display was used relaying force
information to the user. Frequency modulation was
preferred to amplitude information, but surgeons
were concerned about continual noise in an operat-
ing room setting.
Dargahi et al. (47) developed force sensors to fit in
laparoscopic graspers, but the device that provided
visual force feedback on the handle was not tested
with users. Nevertheless, this probably will not work
since surgeons do not look at their hands during a
procedure.
Fischer and Trapp (48) developed a tactile optical
pressure sensor to fit a laparoscopic grasper and a
sensing rod. This optical sensor displayed indura-
tions (spread in the tissue) graphically. The mea-
sured values served to activate a vibro-tactile display-
unit at the surgeon’s fingertip providing tactile
feedback. In a later study they (49) optimized the
vibro-tactile display, but no results were presented.
Yao et al. (50) developed a surgical probe with
tactile and auditory feedback. Tactile and auditory
reproduction was established by detecting and
magnifying the acceleration signal resulting from
instrument-surface interaction. Subjects used the
probe to detect cuts under four conditions: No
amplification, tactile feedback, sound feedback, and
passive touch. Tactile and auditory feedbacks
showed significant improvements in performance.
Unfortunately, the probe was not used through a
trocar, so no interference factors were discounted
for.
Bicchi et al. (51) placed a force and position
sensor in a conventional MIS instrument and
displayed the information graphically (position
versus force), showing that subjects could discrimi-
nate between objects of different materials.
Two experiments were performed by Ottermo et
al. (52): A hardness and size discrimination task
(rubber balls hidden in pig’s intestine) using gloved
fingers, a conventional laparoscopic instrument, or a
laparoscopic instrument with a sensor array. A visual
display provided tactile information (pressure dis-
tribution). Gloved fingers were better at differentiat-
ing hardness and size compared with the
conventional instrument and the instrument with
the sensor. There was no significant difference
between the conventional instrument and the
instrument with the sensor. This indicated that
visual presentation might not be an ideal way of
presenting tactile information. The authors indi-
cated that the presence of the array does not make
the task more difficult.
Fischer at al. (53) studied a totally different
approach of sensory substitution. They used sensors
that could sense tissue oxygenation next to transla-
tional forces. The principle they used was based on
the fact that when tissue oxygenation decreases
below a certain value, trauma will occur. If
oxygenation values are displayed to the user, grip
forces can be controlled.
Several groups developed sensors to implement
into instruments, for example tri-axial force sensors
Haptics in minimally invasive surgery 7
Downloaded By: [TU University of Technology Delft] At: 12:16 15 September 2008
(54), tactile sensors to detect arteries (55), piezo-
electric tactile sensors to detect compliance and total
applied force (56) and vibro-tactile sensors, where
vibration is applied to the tissue, and different tissue
properties are determined by the resonance range
(57). However, how feedback is provided is not
clear.
Haptic sensation in minimally invasive robotic
surgery (MIRS)
In MIRS the instrument (slave) and handgrip
(master) are physically disconnected, called a mas-
ter-slave system (Figure 3). The master is held by
the surgeon and dictates movements to the slave that
controls the instrument via an electromechanical
device. The advantage of this system is that it
compensates for some of the interference factors
described earlier. An example is the simplicity to
neutralize the mirroring effect by software. However,
the mirroring does not seem to be an enormous
problem because it is easy to get used to (12).
When forces are measured, it is relatively easy to
neutralize the scaling disturbance factor by applying
a scaling factor between the master and the slave. In
the same way, the interference from trocar friction
can be neutralized by directly sending the tip force
information to the handle of the master. Research
showed that it is possible to measure forces (grip and
tip force sensors) at the tip of the instrument and
reflect them to the master (48,49). In spite of these
technical possibilities, haptic feedback is still rare in
MIRS (58–62), because adding force feedback is
expensive and technically difficult (changes of
instability). Currently there is no commercially
available robotic system with haptic feedback
(59,63,64). Position feedback is supported, and
forces and positions are bounded to prevent exces-
sive forces. Several research groups have addressed
design issues for ideal kinesthetic control master/
slave-mechanisms (65,66) and listed requirements
for MIRS systems (67).
Technical improvement aids
Because haptic feedback is not yet commercially
available in MIRS, much research focused on evalua-
tion and technical improvement by augmented force
information feedback. Numerous reviewed studies
used the Personal Haptic Interface Mechanism
(PHANToM Sensable Technologies, Inc., Woburn,
MA, USA). The PHANToM was the first commer-
cially available force feedback device that presented
the illusion of contact with a rigid virtual object using
programmable constraint forces supplied to an end-
effector such as a handle or stylus (68).
Tholey et al. (62) researched the capability of
tissue characterization during grasping with a
Master-slave prototype (PHANToM used as a
master device). For both experts and novices,
providing both visual and force feedback led to
better tissue characterization (varied stiffness) than
only visual feedback or only force feedback.
However, based on vision alone, experts were much
better than novices, probably due to their experience
with vision feedback in conventional MIS. The
drawback was that subjects did not activate the
grasper themselves (one of the test leaders was); they
only felt the feedback by the PHANToM.
Wagner et al. (60) analysed advantages of force
feedback during a blunt dissection task (novices used
a laparoscopic hook on a clay tissue model).
Addition of force feedback (using the PHANToM)
resulted in more precise dissection, fewer errors
(factor 3), lower applied peak and average forces
(50% lower) at the instrument tip and shorter
duration of high forces, compared to less or no force
feedback. The addition of force feedback did not
reduce the time required to accomplish the task.
Figure 3. Schematic representation of robotic surgery. The
handgrips (master) are physically disconnected from the special
designed laparoscopic instruments at the slave side. The interac-
tion between master and slave is controlled by a computer. Forces
at the instrument tip are not measured in current systems.
8 E.P. Westebring – van der Putten et al.
Downloaded By: [TU University of Technology Delft] At: 12:16 15 September 2008
Kazi (69) investigated the benefits of force feed-
back (using a modified DISTEL Master-Slave
system) during a catheter insertion task and found
that peak forces were 40% higher without force
feedback than with it.
Hu et al. (61) researched the ability to give
realistic kinesthetic sensation, experienced through
conventional MIS instruments to a master-slave
system. The slave consisted of a commercially
available disposable grasper equipped with position
and force sensors in the handle, operated by a
human slave. The information retrieved from the
sensors transmitted force feedback to the master
(PHANToM-stylus). Experts and novices alike were
able to quantify stiffness of different tissue samples
grasped by the slave with a high degree of accuracy.
(The slave was operated by another human instead
of electronically.)
Rosen et al. (70) developed a master-slave grasper
(force feedback endoscopic grasper; FREG) with
bilateral force feedback. Subjective tests of ranking
stiffness of silicone materials, without visual feed-
back, using the FREG showed significant improve-
ment in the performance compared to a standard
grasper. Moreover, the FREG performance was
closer to performance of the human hand (latex-
gloved) than a standard grasper. There were no
differences in performance between experts and
novices (71).
Demi et al. (72) presented a prototype of a force-
reflecting MIRS system and evaluated the impor-
tance of force feedback. The prototype was actually
suited to reduce unintentional injuries when appro-
priate force feedback was available, although the
operating time increased compared to a manual
intervention. However, for experts in conventional
MIS, skills were not transferred to robotic surgery.
De Gersem et al. (73) described a possibility to
enhance sensitivity of stiffness by optimization of a
control concept for a master-slave system based on
human perception capabilities. Stiffness perception
could be enhanced from 8–12% (revealed in an
earlier study (74)) to 6% JND (just noticeable
difference) compared to a probing task (using a
PHANToM interface).
Several other groups have designed experimental
haptic master-slave devices (75), but they are at a
developmental stage, and no tests of haptic perfor-
mance have been published yet.
Sensory substitution
Morimoto et al. (76) developed a prototype force
sensor system provided as an in-line transducer with
six DOFs to fit current robotic-Babcocks. Force data
were graphically presented. A three phase experi-
mental trial, using a living pig, showed that force
information could be used to minimize tissue trauma
during laparoscopic surgery.
Kitagawa et al. (77,78) studied the effect of
substituting direct haptic feedback with visual and
auditory cues using the da Vinci robotic system
(Intuitive Surgical Inc., Mountain View, CA, USA).
They observed the difference between applied forces
during a knot tying procedure for four different
feedback scenarios: No feedback, auditory feedback,
visual feedback, and a combination of auditory and
visual feedback. Visual feedback, which provided
continuous force information, could improve robot-
assisted performance during complex tasks such as
knot-tying. Discrete auditory feedback gave addi-
tional useful support.
Akinbiyi et al. (79) developed an augmented
reality system (integrated with the da Vinci) pre-
senting force information via a graphic display that
overlays a visual representation of force levels on top
of the moving instrument tips. During a knot-tying
task, the system decreased the number of broken
sutures, decreased the number of loose knots, and
resulted in more consistent application of forces.
Judkins et al. (80) showed that after adding
feedback on grip force information graphically, for
a short training period (ten trials using the da Vinci)
and then removing it, users still used less force
during several tasks (Bimanual carrying, needle
passing and suture tying).
Bethea et al. (81) showed (with a modified da
Vinci) that visual sensory substitution permitted the
surgeon to apply more consistent, precise, and
greater tensions to fine suture materials without
breakage during knot-tying.
Tavakoli et al. (82) developed a prototype of a
master/slave system (haptic interface and end-
effector sensors) with kinesthetic feedback in
5DOFs (described in (83,84)). The Master looked
like a conventional MIS instrument handle. They
compared force information feedback in one direc-
tion with visual and kinesthetic feedback in a (blind)
lump detection task. Visual feedback showed longer
task completion times, but task accuracy was the
same.
Sensor-actuator asymmetry
Due to costs and practical application of force
feedback in MIRS, it may not be possible to match
the number of DOFs of position sensing and control
with the degrees of freedom of force sensing and
feedback. Almost all MIRS systems presented in this
article have more DOFs to manipulate than force
Haptics in minimally invasive surgery 9
Downloaded By: [TU University of Technology Delft] At: 12:16 15 September 2008
sensing and feedback (up to seven DOFs: three
translational forces, three torque forces, and one
pinch force). Verner and Okamura (85) presented
dynamic models of sensor-actuator asymmetries in
master-slave systems and showed that asymmetries
demonstrate challenges in creating practical, force-
reflecting master-slave systems. Some preliminary
research has been conducted to see whether this
sensor-actuator asymmetry affects performance.
Semere et al. (86) determined the effect of such
sensor-actuator asymmetry during bilateral MIRS.
In a task where users had to push a cup through a
series of poses and in a blunt dissection task using
phantom tissues, three different force feedback
conditions were applied to a 3-D master-slave
system: 3-D force feedback, force feedback without
the axial forces measured on the slave tool, and no
force feedback. The tasks were also performed
manually using a hand-held stylus. The absence of
measured axial forces did not create difference in
applied force levels, in comparison with complete 3-
D force feedback. In addition, this partial force
feedback was a significant improvement over MIRS
with no force feedback.
Verner et al. (87) studied the effect of sensor-
actuator asymmetry where users performed standar-
dized tasks with varying force feedback conditions
included: No forces, grip forces only, translational
forces only, or grip and translational forces (sensor-
actuator symmetry). Force feedback lowered error
rates and force rates but full-force feedback was not
always preferable above partial force feedback. In a
later study, Verner and Okamura (88) determined
the effect of grip force feedback in relation to
translational force feedback when users performed
a soft peg-in-hole task with various DOFs of force
feedback: Full force feedback, translational force
feedback only, grip force feedback only, and no force
feedback. The level of force applied in the transla-
tional and gripping DOFs were decoupled by the
subjects. They explain that this is likely due to the
decoupled dynamics of internal and external hand
forces.
Conventional and robotic minimally invasive
surgery compared
Some studies compared MIS and MIRS. For
example, Cao et al. (89) compared a line-drawing
task conducted with MIS (limited haptic feedback)
and MIRS (no haptic feedback). MIS performance
was faster and extra visual force information was
beneficial for both MIS and MIRS task perfor-
mance. The number of errors was bigger in MIS
probably because there were fewer DOFs than in
MIRS. Berguer et al. (90) compared mental and
physical workloads during conventional MIS and
MIRS without augmented haptic feedback. MIRS
appeared slower and less precise than MIS for
simple tasks, but equally fast and possibly less
stressful for complex tasks. Previous experience in
MIS had a complex influence on the physical and
mental adaptation to MIRS.
Research showed that despite reduced haptic
feedback in MIS compared to bare hands, it is
possible to determine the consistency of tissue with a
laparoscopic grasper (25,61). Some new designs,
including force feedback, for master–slave systems
performed better on this task (70).
Haptic sensation in virtual reality training
(VRT)
VRT is used to train surgeons in all kinds of
procedures. A well-designed VRT-system should
provide realistic feelings of real-life surgery. Thus, a
simulator without kinesthetic feedback does not
train the student to cope and master the disturbance
and interference factors that occur during MIS.
Considerable interest exists in developing haptic-
VRT-systems, even though the importance of haptic
feedback remains poorly understood (25,91,92). A
schematic drawing of a VRT system with haptic
feedback is given in Figure 4.
To produce realistic tissue and instrument beha-
viour, it is important to have information on the
mechanical properties of organs. However, this is
difficult to achieve because solid organs (e.g., liver,
spleen and pancreas), hollow organs (e.g., gall-
bladder, stomach, bowel), sick and healthy tissue
behave different when manipulated and have non-
linear stress-strain behaviour (93,94). Some
researchers have tried to obtain these mechanical
properties, for example on bowel tissue (76,94).
Some instruments were developed to obtain in-vivo
Figure 4. Schematic representation of a virtual reality training
simulator with haptic feedback. Forces are generated by a motor
and determined by a computer.
10 E.P. Westebring – van der Putten et al.
Downloaded By: [TU University of Technology Delft] At: 12:16 15 September 2008
linear tissue compliance and geometry change
(92,95), but much is still unknown. This lack of
knowledge in combination with technical difficulties
makes it difficult to realize realistic tissue behaviour
in VRT-systems. Several articles (96,97) gave an
overview about the technical problems and impor-
tant aspects that occur with haptic rendering.
Tissue consistency perception is mainly based on
haptic information (25). Lamanta et al. (25) showed
that by seeing the tissue, experts could recall the
consistency of tissue, because they had a kind of
tactile memory built up. In VRT especially novices
needed haptic information, when consistency infor-
mation had to be delivered (25,62).
Schijven and Jakimowicz (98) gave an overview of
the most important VRT-systems available at that
moment, and concluded that from the 12 systems,
six contained force feedback and three provided an
option to implement force feedback; however, they
were expensive and the quality was not satisfactory.
Performance with augmented haptic
information feedback
Is it possible to improve performance when haptic
information is displayed to the users in a VRT
system? Not much research found answered this
question.
Wagner et al. (99) demonstrated that force feed-
back can provide physical constraints to an opera-
tor’s motion, passively restraining the hand and
reducing error even before the operator could
voluntarily respond to the force stimulus. The
magnitude of unwanted incursions into a virtual
wall were reduced up to 80%, compared to no force
feedback. Feedback through a kinesthetic display
reduced errors within 150 ms of encountering the
virtual wall while feedback using a vibration display
took longer.
Stro¨m et al. (100) analyzed whether the addition
of force feedback in VRT, early in the training phase,
improved performance in a diathermy task. They
concluded that haptic feedback could be important
early in the training phase of skill acquisition.
In a virtual computer movement task, augmented
force feedback presented via a mouse helped to
perform better (101) (the closer the mouse reached
the target the more resistance the user got to move
the mouse).
Technical improvement aids
Some studies have been done in the field of
improvement of haptics in VRT-systems. For
example, Acosta et al. (102) developed a haptic
skill-based laparoscopic simulator called LapSkills
that aimed to provide a quantitative measure of the
surgeon’s skill level and to help improve their
efficiency and precision. It is not clear how haptics
were displayed to the user and if more than
translational force feedback was displayed.
Some groups have developed haptic interfaces for
VRT systems, but no literature could be found about
user test. Chou and Wang (103) developed a VRT-
system for MIRS neurosurgery, which included
collision detection, deformation of soft tissue and
kinesthetic rendering. During needle insertion, the
brain was displayed, and the resistance force
between the needle and organs were reflected to
the surgeon by a 3-DOFs force feedback device.
Maass at al. (104) developed a flexible interface that
could control several different force-feedback hard-
ware systems, including the PHANToM, the
Laparoscopic Impulse Engines from Immersion,
and the VS-One virtual endoscopic surgery trainer.
Several groups have developed VRT-systems with
force feedback displays (92,105,106)
Sensory substitution
In VRT-systems the image of the surgery field often
serves as a sensory substitution device itself. In a
VRT needle task, force feedback in combination
with visual feedback of needle position resulted in
better performance than one of the two feedback
systems alone (107).
Sensor-actuator asymmetry
The same perception problems that occur with
sensor-actuator asymmetry in MIRS are applicable
for VRT. For example, sensor-actuator asymmetry
can cause non realistic feedback in VR, especially
when one of the three translational forces is not
displayed to the user (108).
Discussion
The purpose of this review was to give an overview of
the current knowledge of haptics in MIS. MIS
instruments do, in fact, provide surgeons with haptic
feedback. Although bare hands performed better,
texture, shape, and consistency of objects can be
perceived. Research showed that when using mini-
mally invasive techniques haptics are reduced con-
siderably. But sensitivity qualities are highly variable,
depending on the instrument. Perceived haptics are
interfered by indirect tissue contact, trocar friction,
resistance of the abdominal wall, scaling and
mirroring of tip forces, and friction in the system
Haptics in minimally invasive surgery 11
Downloaded By: [TU University of Technology Delft] At: 12:16 15 September 2008
mechanics. These interference components of haptic
sensation during MIS can be as big as the interaction
forces with the organs themselves. Currently, there
are no commercially available MIS instruments,
MIRS systems, and VRT-systems with adequate
haptic information feedback. However, haptic feed-
back during MIS is needed (109).
Many research groups claim to have developed
haptic information feedback systems, but in fact they
mean force information feedback. Commercially
available MIRS systems only provide position feed-
back because of high cost and instability problems
that still exist with the implementation of force and
tactile information feedback in these complicated
systems. Surgeons have to estimate applied contact
forces by visual observation of tissue deformation
and color change during MIRS. Especially when
there are a lot of instruments inserted during a
complex procedure, it is possible that some of them
are out of sight while holding tissue. In such a case,
force feedback could be helpful to control the grasp.
The available VRT-systems provide no or non-
realistic haptics because, next to technical difficulties
and render realistic haptics, not much is known
about the mechanical properties of living tissue.
Surgeons will benefit from extra information
regarding the levels of force applied to tissues.
Although reasonable research has been done on the
displaying of translational forces, studies about
information feedback of grip forces and slips are
rare. Many high-degree-of-freedom haptic devices
and master-slave systems either do not have grippers
or do not provide force feedback in the gripper
DOF. Ideally, MIS instruments should have full
haptic feedback, meaning that force feedback is
provided in all DOFs of manipulation, and slippage
and texture information is presented to the operator.
Thus the surgeons can feel as though they are
directly manipulating the tissue. Full-haptic feed-
back as described above is not available because it is
technologically not yet possible. A solution might be
to provide partly haptic information feedback, but
this will result in a sensor-actuator asymmetry that
might be a problem. However, it has been shown
that information on grip force and translational
forces do not interfere with each other, so they can
be displayed separately without causing confusion.
Reducing the interference factors using mechani-
cally more efficient instruments is not always
preferred, depending on the task. An augmented
haptic information display seems a better approach.
However, additional feedback signals are only
desirable when no extra mental workload is added.
Force feedback reduced errors without requiring the
cognitive attention of the user in a cannulation task
(99). In the non-medical field, force feedback can
indeed reduce mental workload in master-slave tasks
(110–112). Haptic displays, even if they do not
present information in all DOFs, can enable passive
strategies that would not be possible with only force
information, such as with sensory substitution.
However, a haptic information display that uses
sensory substitution is much cheaper and easier to
implement. When it is implemented correctly, haptic
information displayed by sensory substitution is able
to improve the surgeon’s performance compared to
no haptic information feedback at all. In non-medical
fields, force information, displayed by sensory sub-
stitution, aids performance, for example combined
auditory and vibro-tactile displays (113,114), or only
vibro-tactile display (115). Sensory substitution can
only partly improve haptic feedback, because it is very
difficult or even impossible to provide ‘‘full’’ haptic
information feedback (force in all DOFs and tactile
information on slips) without adding unwanted extra
mental workload.
Further, haptic feedback alone might not be
enough to prevent unnecessary tissue trauma.
Different sensing modalities, or multi-modal sensory
input, may be required to prevent tissue trauma.
Complementary studies in a non-surgical VR task
(116) showed that multi-modal feedback of force
information (auditory combined with force feed-
back) performed better than no force feedback and
the two modalities on their own. In an additional
study (117) (in a VR manipulation task), it was
shown that in addition to kinesthetic feedback,
auditory or visually displayed force information
performed even better than kinesthetically displayed
force information alone.
Augmented feedback of force information is
beneficial for both experts and novices, even though
experienced users are trained to cope with little
haptic feedback. They are trained to use visual
feedback to constrain their movements and avoid
large forces. However, the aid of augmented force
feedback can decrease errors even for experts.
Almost all reviewed studies were performed in a
non-clinical setting. To give the surgeon extra haptic
information, not only during simulated training
settings, but also during clinical surgery, the avail-
ability of this information is a prerequisite.
Therefore, sensors must be applicable in wet and
warm environments, and be able to be sterilized.
During experimental surgery on animals some
studies have shown that it is possible to get this
information from living tissue with sensors imple-
mented in the instruments (29,76,91,118). Because
of this, our research group (at TU Delft) will focus
on improvements of haptic perception in conven-
12 E.P. Westebring – van der Putten et al.
Downloaded By: [TU University of Technology Delft] At: 12:16 15 September 2008
tional MIS, especially on the perception of slips and
applied excessive forces during grasping, in order to
prevent tissue trauma and improve patient safety
during MIS.
Conclusion
Augmented force information can aid performance in
all fields of minimally invasive surgery, and surgeons
benefit from the additional feedback of force informa-
tion. This information should be presented by a haptic
display because of its intuitive nature, but a multi-
sensory display might be preferable. In general, little
research has been done in the field of augmented
haptics during MIS. Especially when it comes to
grasping forces and the perception of slips, little is
known about the advantages additional haptic infor-
mation can give to prevent tissue trauma during
manipulation. Improvement of haptic perception by
means of augmenting haptic information feedback to
MIS might be promising for patient safety.
References
1. Cuschieri A. Whither Minimal Access Surgery: Tribulations
and Expectations. American Journal of Surgery.
1995;169:9–19.
2. Moreno-Egea A, Torralba J, Morales G, Fernandez T, et al.
Laparoscopic Repair of Secondary Lumbar Hernias: Open
Vs. Laparoscopic Surgery. A Prospective, Nonrandomized
Study. Cirugia Espanola. 2005;77:159–62.
3. Dedemadi G, Sgourakis G, Karaliotas C, Christofides T,
et al. Comparison of Laparoscopic and Open Tension-Free
Repair of Recurrent Inguinal Hernias: A Prospective
Randomized Study. Surgical Endoscopy. 2006;20:
1099–104.
4. Roumm A, Pizzi L, Goldfarb N, Cohn H. Minimally
Invasive: Minimally Reimbursed? An Examination of Six
Laparoscopic Surgical Procedures. Surgical Innovations.
2005;12:261–87.
5. Stefanoni M, Casciola L, Ceccarelli G, Spaziani A, et al. The
Biliopancreatic Diversion. A Comparison of Laparoscopic
and Laparotomic Techniques. Minerva Chirurgica.
2006;61:205–13.
6. Stassen HG, Dankelman J, Grimbergen KA, Meijer DW.
Man-Machine Aspects of Minimally Invasive Surgery.
Annual Reviews in Control. 2001;25:111–22.
7. Dankelman J, Wentink M, Stassen HG. Human Reliability
and Training in Minimally Invasive Surgery. Min Invas Ther
& Allied Technol. 2003;12:129–35.
8. van der Voort M, Heijnsdijk EA, Gouma DJ. Bowel Injury as
a Complication of Laparoscopy. British Journal of Surgery.
2004;91:1253–8.
9. Barbosa Barros M, Lozano FS, Queral L. Vascular Injuries
During Gynecological Laparoscopy – the Vascular Surgeon’s
Advice. Sao Paulo Medical Journal. 2005;123:38–41.
10. Marucci DD, Cartmill JA, Walsh WR, Martin CJ. Patterns
of Failure at the Instrument-Tissue Interface. Journal of
Surgery Research. 2000;93:16–20.
11. Marucci DD, Shakeshaft AJ, Cartmill JA, Cox MR, et al.
Grasper Trauma During Laparoscopic Cholecystectomy.
Australian and New Zeeland Journal of Surgery.
2000;70:578–81.
12. Tendick F, Cavusoglu MC. Human Machine Interfaces for
Minimally Invasive Surgery. Proceedings – 19th Annual
International Conference of the IEEE Engineering in
Medicine and Biology Society; 1997 October 30 –
November 2, Chicago, IL, 1997: 2771–6.
13. Dutkiewicz P, Kielczewski M, Kowalski M. Visual Tracking
of Surgical Tools for Laparoscopic Surgery. InKozlowski K,
editor. Proceedings – Fourth International Workshop on
Robot Motion and Control, RoMoCo’04; Puszczykowo;
2004:23–8.
14. Wentink M. Hand-Eye Coordination in Minimally Invasive
Surgery [PhD-thesis]. Delft: Technical University Delft; 2003.
15. DeLucia P, Mather R, Griswold J, Mitra S. Toward the
Improvement of Image-Guided Interventions for Minimally
Invasive Surgery: Three Factors That Affect Performance.
Human Factors. 2006;48:23–38.
16. Tendick F, Jennings RW, Tharp G, Stark L. Sensing and
Manipulation Problems in Endoscopic Surgery: Experiment,
Analysis and Observation. Presence. 1993;2:66–81.
17. Breedveld P, Stassen HG, Meijer DW, Jakimowicz JJ.
Observation in Laparoscopic Surgery: Overview of
Impeding Effects and Supporting Aids. Journal of
Laparoendoscopic and Advanced Surgical Technics. 2000
Oct;10(5): 231–41.
18. Breedveld P, Hirose S. Design of Steerable Endoscopes to
Improve the Visual Perception of Depth During
Laparoscopic Surgery. Journal of mechanical design.
2004;126:2–5.
19. Voorhorst FA. Affording Action, Implementing Perception-
Action Coupling for Endoscopy [PhD-Thesis]. Delft:
Technical University Delft; 1998.
20. Stephenson ER, Jr., Sankholkar S, Ducko CT, Damiano RJ,
Jr. Robotically Assisted Microsurgery for Endoscopic
Coronary Artery Bypass Grafting. Annals of Thoracic
Surgery. 1998;66:1064–7.
21. Mohr FW, Falk V, Diegeler A, Walther T, et al. Computer-
Enhanced ‘‘Robotic’’ Cardiac Surgery: Experience in 148
Patients. Journal of Thoracic Cardiovascular Surgery.
2001;121:842–53.
22. Breedveld P, Stassen HG, Meijer DW, Jakimowicz JJ.
Manipulation in Laparoscopic Surgery: Overview of
Impeding Effects and Supporting Aids. Journal of
Laparoendoscopic and Advanced Surgical Technics.
1999;9:469–80.
23. Dario P, Hannaford B, Menciassi A. Smart Surgical Tools
and Augmenting Devices. IEEE Transactions on Robotics
and Automation. 2003;19:782–92.
24. Widmaier EP, Hershel R, Strang KT. Vander, Sherman,
and Lucano’s Human Physiology, the Mechanisms of Body
Function. 9th Ed. 9 ed., Boston: McGraw-Hill; 2004.
25. Lamata P, Gomez EJ, Sanchez-Margallo FM, Lamata F,
et al. Tissue Consistency Perception in Laparoscopy to
Define the Level of Fidelity in Virtual Reality Simulation.
Surgical Endoscopy. 2006;20:1368–75.
26. Schostek S, Ho CN, Kalanovic D, Schurr MO. Artificial
Tactile Sensing in Minimally Invasive Surgery – a New
Technical Approach. Minimally Invasive Therapy and Allied
Technologies. 2006;15:296–304.
27. Bholat OS, Haluck RS, Murray WB, Gorman PJ, et al.
Tactile Feedback Is Present During Minimally Invasive
Surgery. Journal of the American College of Surgeons.
1999;189:349–55.
28. Heijnsdijk EA, Pasdeloup A, van der Pijl AJ, Dankelman J,
et al. The Influence of Force Feedback and Visual Feedback
Haptics in minimally invasive surgery 13
Downloaded By: [TU University of Technology Delft] At: 12:16 15 September 2008
in Grasping Tissue Laparoscopically. Surgical Endoscopy.
2004;18:980–5.
29. Picod G, Jambon AC, Vinatier D, Dubois P. What Can the
Operator Actually Feel When Performing a Laparoscopy?
Surgical Endoscopy. 2005;19:95–100.
30. den Boer KT, Herder JL, Sjoerdsma W, Meijer DW, et al.
Sensitivity of Laparoscopic Dissectors, What Can You Feel?
Surgical Endoscopy. 1999;13:869–73.
31. Salle D, Gosselin F, Bidaud P, Gravez P. Analysis of Haptic
Feedback Performances in Telesurgery Robotic Systems.
Proceedings – IEEE International Workshop – Robot and
Human Communication 2001; Bordeaux-Paris; 2001:618–23.
32. van den Dobbelsteen JJ, Schooleman A, Dankelman J.
Friction Dynamics of Trocars. Surgical Endoscopy.
2006;13:6.
33. Toledo L, Gossot D, Fritsch S, Revillon Y, et al. [Study of
Sustained Forces and the Working Space of Endoscopic
Surgery Instruments]. Annales de chirurgie.
1999;53:587–97.
34. Rosen J, MacFarlane M, Richards C, Hannaford B, et al.
Surgeon-Tool Force/Torque Signatures–Evaluation of
Surgical Skills in Minimally Invasive Surgery. Studies in
Health Technology and Informatics. 1999;62:290–6.
35. Sjoerdsma W, Herder JL, Horward MJ, Jansen A, et al.
Force Transmission of Laparoscopic Grasping Instruments.
Minimally Invasive Therapy and Allied Technologies.
1997;6:274–8.
36. Melzer A, Kipfmuller K, Halfar B. Deflectable Endoscopic
Instrument System Denis. Surgical Endoscopy.
1997;11:1045–51.
37. Jackman SV, Jarzemski PA, Listopadzki SM, Lee BR, et al.
The Endohand: Comparison with Standard Laparoscopic
Instrumentation. Journal of Laparoendoscopic & Advanced
Surgical Techniques. 1999;9:253–8.
38. van der Pijl AJ, Herder JL. Development of 5mm-Trocar
Laparoscopic Forceps with Mechanical Force Feedback.
Proceedings – ASME Design Engineering Technical
Conference; 2001; Pittsburgh, PA; 2001:579–85.
39. Herder JL, Horward MJ, Sjoerdsma W. A Laparoscopic
Grasper with Force Perception. Minimally Invasive Therapy
and Allied Technologies. 1997;6:279–86.
40. Kuntz JP. Rolling Link Mechanisms [Phd]. Delft: Delft
Technical University; 1995.
41. Bala´zs M, Feussner H, Hirzinger G, Omote K, et al.
Replacing Mechanical Joints in Laparoscopic Forceps with
Elastic Beams for Improved Pressure Control and
Sensitivity: A New Tool for Minor-Access Surgery. IEEE
Engineering in Medicine and Biology Magazine.
1998;17:45–8.
42. Kota S, Lu KJ, Kreiner K, Trease B, et al. Design and
Application of Compliant Mechanisms for Surgical Tools.
Journal of biomechanical engineering. 2005;127:981–9.
43. Heijnsdijk EA, Pasdeloup A, Dankelman J, Gouma DJ. The
Optimal Mechanical Efficiency of Laparoscopic Forceps.
Surgical Endoscopy. 2004;18:1766–70.
44. Wall SA, Brewster S. Sensory Substitution Using Tactile Pin
Arrays: Human Factors, Technology and Applications.
Signal Processing. 2006;86:3674–95.
45. Lundborg G, Rosen B, Lindstrom K, Lindberg S. Artificial
Sensibility Based on the Use of Piezoresistive Sensors.
Preliminary Observations. Journal of Hand Surgery [Br].
1998;23:620–6.
46. Prasad SK, Kitagawa M, Fischer GS, Zand J, et al. A
Modular 2-Dof Force-Sensing Instrument for Laparoscopic
Surgery. In: Ellis RE, Peters TM, editors. Lecture Notes in
Computer Science; 2003; Montreal, Que.; 2003:279–86.
47. Dargahi J, Najarian S. An Integrated Force-Position Tactile
Sensor for Improving Diagnostic and Therapeutic Endoscopic
Surgery. Biomedical Material Engineering. 2004;14:151–66.
48. Fischer H, Trapp R. Tactile Optical Sensor for Use in
Minimal Invasive Surgery. Studies in Health Technology
and Informatics. 1996;29:623–9.
49. Fischer H, Trapp R, Schule L, Hoffmann B. Actuator Array
for Use in Minimally Invasive Surgery. Journal De Physique
IV : JP. 1998;7.
50. Yao H-Y, Hayward V, Ellis RE. A Tactile Enhancement
Instrument for Minimally Invasive Surgery. Computer
Aided Surgery. 2005;10:233–9.
51. Bicchi A, Canepa G, De Rossi D, Iacconi P, et al.
Sensorized Minimally Invasive Surgery Tool for Detecting
Tissutal Elastic Properties. Proceedings – IEEE
International Conference on Robotics and Automation;
1996; Minneapolis, MN, USA: IEEE; 1996:884–8.
52. Ottermo MV, Øvstedal M, Langø T, Stavdahl Ø, et al. The
Role of Tactile Feedback in Laparoscopic Surgery. Surgical
Laparoscopy, Endoscopy and Percutaneous Techniques.
2006;16:390–400.
53. Fischer GS, Akinbiyi T, Saha S, Zand J, et al. Ischemia and
Force Sensing Surgical Instruments for Augmenting
Available Surgeon Information. Proceedings – IEEE/RAS-
EMBS International Conference on Biomedical Robotics
and Biomechatronics, BioRob 2006; Pisa; 2006:1030–5.
54. Valdastri P, Harada K, Menciassi A, Beccai L, et al.
Integration of a Miniaturised Triaxial Force Sensor in a
Minimally Invasive Surgical Tool. IEEE transactions on bio-
medical engineering. 2006;53:2397–400.
55. Beasley RA, Howe RD. Tactile Tracking of Arteries in
Robotic Surgery. Proceedings – IEEE International
Conference on Robotics and Automation; 2002;
Washington, DC; 2002:3801–6.
56. Sedaghati R, Dargahi J, Singh H. Design and Modeling of
an Endoscopic Piezoelectric Tactile Sensor. International
Journal of Solids and Structures. 2005;42:5872–86.
57. Plinkert PK, Baumann I, Flemming E. Tactile Sensor for
Tissue Differentiation in Minimally Invasive Ent Surgery.
Laryngorhinootologie. 1997;76:543–9.
58. Okamura AM. Methods for Haptic Feedback in
Teleoperated Robot-Assisted Surgery. Industrial Robotics.
2004;31:499–508.
59. Wagner CR. Force Feedback in Surgery, Physical
Constraints and Haptic Information [Phd thesis].
Cambridge: Harvard University; 2006.
60. Wagner CR, Stylopoulos N, Howe RD. The Role of Force
Feedback in Surgery: Analysis of Blunt Dissection.
Proceedings – 10th Symposium on Haptic Interfaces for
Virtual Environment and Teleoperator Systems, HAPTICS
2002; 2002:68–74.
61. Hu T, Tholey G, Desai JP, Castellanos AE. Evaluation of a
Laparoscopic Grasper with Force Feedback. Surgical
Endoscopy. 2004;18:863–7.
62. Tholey G, Desai JP, Castellanos AE. Force Feedback Plays a
Significant Role in Minimally Invasive Surgery: Results and
Analysis. Annals of surgery. 2005;241:102–9.
63. Sim HG, Yip SK, Cheng CW. Equipment and Technology
in Surgical Robotics. World journal of urology.
2006;24:128–35.
64. Grimbergen CA, Jaspers JEN. Robotics in Minimally
Invasive Surgery. Proceedings – IEEE International
Conference on Systems, Man and Cybernetics; 2004; The
Hague; 2004:2486–91.
65. Tavakoli M, Patel RV, Moallem M. Design Issues in a
Haptics-Based Master-Slave System for Minimally Invasive
14 E.P. Westebring – van der Putten et al.
Downloaded By: [TU University of Technology Delft] At: 12:16 15 September 2008
Surgery. Proceedings – IEEE International Conference on
Robotics and Automation; 2004; New Orleans, LA;
2004:371–6.
66. Yokokohji Y, Yoshikawa T. Bilateral Control of Master-
Slave Manipulators for Ideal Kinesthetic Coupling –
Formulation and Experiment. IEEE Transactions on
Robotics and Automation. 1994;10:605–19.
67. Brooks TL. Telerobotic Response Requirements.
Proceedings – IEEE International Conference on Systems,
Man and Cybernetics; 1990; Los Angeles, CA, USA: Publ
by IEEE; 1990:113–20.
68. Massie T, Salisbury K. The Phantom Haptic Interface: A
Device for Probing Virtual Object. Proceedings – ASME
Winter Annual Meeting, Symposium on Haptic Interfaces
for Virtual Environment and Teleoperator Systems; 1994;
Chicago, IL; 1994.
69. Kazi A. Operator Performance in Surgical
Telemanipulation. Presence: Teleoperators and Virtual
Environments. 2001;10:495–510.
70. Rosen J, Hannaford B, MacFarlane MP, Sinanan MN.
Force Controlled and Teleoperated Endoscopic Grasper for
Minimally Invasive Surgery-Experimental Performance
Evaluation. IEEE Transactions on Biomedical
Engineering. 1999;46:1212–21.
71. MacFarlane M, Rosen J, Hannaford B, Pellegrini C, et al.
Force-Feedback Grasper Helps Restore Sense of Touch in
Minimally Invasive Surgery. Journal of Gastrointestinal
Surgery. 1999;3:278–85.
72. Demi B, Ortmaier T, Seibold U. The Touch and Feel in
Minimally Invasive Surgery. Proceedings – IEEE International
Workshop on Haptic Audio Visual Environments and their
Applications; 2005; Ottawa, ON; 2005:33–8.
73. de Gersem G, van Brussel H, Tendick F. Reliable and
Enhanced Stiffness Perception in Soft-Tissue
Telemanipulation. The International Journal of Robotics
Research. 2005;24:805–22.
74. de Gersem G, van Brussel H, Tendick F. A New
Optimization Function for Force Feedback in
Teleoperation. Proceedings – International conference on
computer assisted radiology and surgery (CARS); 2003
june; London UK; 2003:1354.
75. Fritz E, GCaRQvdL. Haptic Gripper with Adjustable
Inherent Passive Properties Eurohaptics; 2004; Munich
Germany; 2004.
76. Morimoto A, Foral R, Kuhlman J, Zucker K, et al. Force
Sensor for Laparoscopic Babcock. Studies in Health
Technology and Informatics. 1997;39:354–61.
77. Kitagawa M, Dokko D, Okamura AM, Yuh DD. Effect of
Sensory Substitution on Suture-Manipulation Forces for
Robotic Surgical Systems. Journal of Thoracic and
Cardiovascular Surgery. 2005;129:151–8.
78. Kitagawa M, Dokko D, Okamura AM, Bethea BT, et al.
Effect of Sensory Substitution on Suture Manipulation
Forces for Surgical Teleoperation. Studies in Health
Technology and Informatics. 2004;98:157–63.
79. Akinbiyi T, Okamura AM, Yuh DD. Dynamic Augmented
Reality for Haptic Display in Robot – Assisted Surgical
Systems. Proceedings – Medicine Meets Virtual Reality.
2005; 567–70.
80. Judkins T, Oleynikov D, Stergiou N. Real-Time Augmented
Feedback Benefits Robotic Laparoscopic Training. Studies
in Health Technology and Informatics. 2006;119:243–8.
81. Bethea BT, Okamura AM, Kitagawa M, Fitton TP, et al.
Application of Haptic Feedback to Robotic Surgery. Journal
of Laparoendoscopic and Advanced Surgical Technics.
2004;14:191–5.
82. Tavakoli M, Aziminejad A, Patel RV, Moallem M. Methods
and Mechanisms for Contact Feedback in a Robot-Assisted
Minimally Invasive Environment. Surgical Endoscopy.
2006;20:1570–9.
83. Tavakoli M, Patel RV, Moallem M. A Haptic Interface for
Computer-Integrated Endoscopic Surgery and Training.
Virtual Reality. 2006;9:160–76.
84. Tavakoli M, Patel R, Moallem M. Haptic Interaction in
Robot-Assisted Endoscopic Surgery: A Sensorized End
Effector. International Journal of Medical Robotics and
Computer Assisted Surgery. 2005;1:53–63.
85. Verner LN, Okamura AM. Sensor/Actuator Asymmetries in
Telemanipulators: Implications of Partial Force Feedback.
Proceedings – 14th Symposium on Haptics Interfaces for
Virtual Environment and Teleoperator Systems 2006;
Alexandria, VA; 2006:309–14.
86. Semere W, Kitagawa M, Okamura AM. Teleoperation with
Sensor/Actuator Asymmetry: Task Performance with Partial
Force Feedback. Proceedings – 12th International
Symposium on Haptic Interfaces for Virtual Environment
and Teleoperator Systems, HAPTICS; 2004; Chicago, IL;
2004:121–7.
87. Verner LN, Jeung K, Okamura AM. The Effects of Gripping
and Translational Forces on Teleoperation. Springer Tracks
in Advanced Robotics. 2005;18:231–42.
88. Verner LN, Okamura A. Effects of Translational and
Gripping Force Feedback Are Decoupled in a 4-Degree-
of-Freedom Telemanipulator Proceedings – Second Joint
EuroHaptics – Haptic Interfaces for Virtual Environment
and Teleoperator Systems (WHC’07) 2007; Tsukuba
(Japan); 2007:286–91.
89. Cao CGL, Webster JL, Perreault JO, Schwaitzberg SD, et al.
Visually Perceived Force Feedback in Simulated Robotic
Surgery. Proceedings – 47th Annual Meeting of the Human
Factors and Ergonomics Society; 2003:1466–70.
90. Berguer R, Smith W. An Ergonomic Comparison of Robotic
and Laparoscopic Technique: The Influence of Surgeon
Experience and Task Complexity. Journal of Surgical
Research. 2006;134:87–92.
91. Dubois P, Thommen Q, Jambon AC. In Vivo Measurement
of Surgical Gestures. IEEE Transactions on Biomedical
Engineering. 2002;49:49–54.
92. Ottensmeyer MP, Ben-Ur E, Salisbury JK. Input and
Output for Surgical Simulation: Devices to Measure
Tissue Properties in Vivo and a Haptic Interface for
Laparoscopy Simulators. Studies in Health Technology
and Informatics. 2000;70:236–42.
93. Carter TJ, Sermesant M, Cash DM, Barratt DC, et al.
Application of Soft Tissue Modelling to Image-Guided
Surgery. Medical Engineering and Physics.
2005;27:893–909.
94. Carter FJ, Frank TG, Davies PJ, McLean D, et al.
Measurements and Modelling of the Compliance of
Human and Porcine Organs. Medical Image Analysis.
2001;5:231–6.
95. Brouwer I, Ustin J, Bentley L, Sherman A, et al. Measuring
in Vivo Animal Soft Tissue Properties for Haptic Modeling
in Surgical Simulation. Studies in Health Technology and
Informatics. 2001;81:69–74.
96. Basdogan C, De S, Kim J, Muniyandi M, Kim H, et al.
Haptics in Minimally Invasive Surgical Simulation and
Training. Proceedings – Haptic rendering – Beyond visual
computing; 2004 march april: IEEE Computer Society; 2004.
97. Cavusoglu MC, Tendick F. Multirate Simulation for High
Fidelity Haptic Interaction with Deformable Objects in
Virtual Environments. Proceedings – IEEE International
Haptics in minimally invasive surgery 15
Downloaded By: [TU University of Technology Delft] At: 12:16 15 September 2008
Conference on Robotics and Automation (ICRA 2000);
2000 April 24–28, 2000; San Francisco, CA; 2000:2458–65.
98. Schijven M, Jakimowicz J. Virtual Reality Surgical
Laparoscopic Simulators. Surgical Endoscopy. 2003;17:
1943–50.
99. Wagner CR, Howe RD. Mechanisms of Performance
Enhancement with Force Feedback. First Joint
EuroHaptics Conference and Symposium on Haptic
Interfaces for Virtual Environment and Teleoperator
Systems. 2005; 21–9.
100. Stro¨m P, Hedman L, Sarna L, Kjellin A, et al. Early
Exposure to Haptic Feedback Enhances Performance in
Surgical Simulator Training: A Prospective Randomized
Crossover Study in Surgical Residents. Surgical Endoscopy.
2006;20:1383–8.
101. Houtsma A, Keuning H. Can Augmented Force Feedback
Facilitate Virtual Target Acquisition Tasks? Studies in
Health Technology and Informatics. 2006;119:207–12.
102. Acosta E, Temkin B. Haptic Laparoscopic Skills Trainer
with Practical User Evaluation Metrics. Studies in Health
Technology and Informatics. 2005;111:8–11.
103. Chou W, Wang T. Human-Computer Interactive
Simulation for the Training of Minimally Invasive
Neurosurgery. Proceedings – IEEE International
Conference on Systems, Man and Cybernetics; 2003;
Washington, DC; 2003:1110–5.
104. Maass H, Chantier BB, Cakmak HK, Trantakis C, et al.
Fundamentals of Force Feedback and Application to a
Surgery Simulator. Computer Aided Surgery.
2003;8:283–91.
105. Wu H, Hourie C, Eagleson R, Patel R. A Haptics Based
Simulator for Laparoscopic Pyeloplasty. Studies in Health
Technology and Informatics. 2006;119:583–5.
106. Aschwanden C, Sherstyuk A, Burgess L, Montgomery K. A
Surgical and Fine-Motor Skills Trainer for Everyone? Touch
and Force-Feedback in a Virtual Reality Environment for
Surgical Training. Studies in Health Technology and
Informatics. 2005;119:19–21.
107. Gerovich O, Marayong P, Okamura AM. The Effect of
Visual and Haptic Feedback on Computer-Assisted Needle
Insertion. Computer Aided Surgery. 2004;9:243–9.
108. Barbagli F, Salisbury K. The Effect of Sensor/Actuator
Asymmetries in Haptic Interfaces. Proceedings – 11th Symp
Haptic Interfaces for Virtual Environment and Teleoperator
Systems; 2003:140–7.
109. den Boer KT, de Jong T, Dankelman J, Gouma DJ.
Problems with Laparoscopic Instruments: Opinions of
Experts. Journal of Laparoendoscopic & Advanced
Surgical Techniques. 2001;11:149–55.
110. Oakley I, McGee MR, Brewster S, Gray P. Putting the Feel
in ‘Look and Feel’. Proceedings – Conference on Human
Factors in Computing Systems 2000; The Hague, Neth:
ACM; 2000:415–22.
111. Lessard J, Robert J-M, Rondot P. Evaluaton of Working
Techniques Using Teleoperation for Power Line
Maintenance. Proceedings – SPIE – The International
Society for Optical Engineering; 1995; Boston, MA, USA:
Society of Photo-Optical Instrumentation Engineers;
1995:88–98.
112. Chou W, Wang T. The Design of Multimodal Human-
Machine Interface for Teleoperation. Proceedings – IEEE
International Conference on Systems, Man and
Cybernetics; 2001; Tucson, AZ; 2001:3187–92.
113. Massimino MJ. Improved Force Perception through
Sensory Substitution. Control Engineering Practice.
1995;3:215–22.
114. Massimino MJ, Sheridan TB. Sensory Substitution for
Force Feedback in Teleoperation. In: Stassen HG, editor.
Proceedings – IFAC Symposia Series; 1993; Hague, Neth:
Publ by Pergamon Press Inc; 1993:109–14.
115. Debus T, Jang TJ, Dupont P, Howe R. Multi-Channel
Vibrotactile Display for Teleoperated Assembly.
International Journal of Control, Automation and Systems.
2004;2:390–7.
116. Richard P, Coiffet P. Human Perceptual Issues in Virtual
Environments: Sensory Substitution and Information
Redundancy. Proceedings – IEEE International Workshop
Robot and Human Communication – 1995; Tokyo, Jpn;
1995:301–6.
117. Richard P, Coiffet P. Dextrous Haptic Interaction in Virtual
Environments: Human Performance Evaluations.
Proceedings – IEEE International Workshop Robot and
Human Communication 1999; Pisa; 1999:315–20.
118. Lamata P, Gomez EJ, Sanchez-Margallo FM, Lamata F,
et al. Study of Laparoscopic Forces Perception for Defining
Simulation Fidelity. Studies in Health Technology and
Informatics. 2006;119:288–92.
16 E.P. Westebring – van der Putten et al.
Downloaded By: [TU University of Technology Delft] At: 12:16 15 September 2008
