Mika Sinanan

University of Washington Seattle, Seattle, Washington, United States

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Publications (34)27.04 Total impact

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    ABSTRACT: Background Laparoscopic psychomotor skills are challenging to learn and objectively evaluate. The Fundamentals of Laparoscopic Skills (FLS) program provides a popular, inexpensive, widely-studied and reported method for evaluating basic laparoscopic skills. With an emphasis on training safety before efficiency, we present data that explores the metrics in the FLS curriculum. Materials and Methods A multi-institutional (n=3) cross-sectional study enrolled subjects (n=98) of all laparoscopic skill levels to perform FLS Tasks in an instrumented box trainer. Recorded task videos were post-evaluated by faculty reviewers (n=2) blinded to subject identity using a modified Objective Structured Assessment of Technical Skills (OSATS) protocol. FLS scores were computed for each completed task and compared to demographically-established skill levels (training level and number of procedures), video review scoring, and objective performance metrics including path length, economy of motion, and peak grasping force. Results Three criteria used to determine expert skill—training and experience level, blinded review of performance by faculty via OSATS, and FLS scores—disagree in establishing concurrent validity for determining “true experts” in FLS tasks. FLS-scoring exhibited near-perfect correlation with task time for all three tasks (Pearson’s R = 0.99, 1.00, 1.00 with p < .00000001). FLS Error penalties had negligible effect on FLS scores. Peak grasping force did not correlate with task time or FLS scores. Conclusions FLS technical skills scores presented negligible benefit beyond the measurement of task time. FLS scoring is weighted more towards speed than precision and may not significantly address poor tissue handling skills, especially regarding excessive grasping force. Categories of experience or training level may not form a suitable basis for establishing proficiency thresholds or for construct validity studies for technical skills.
    No preview · Article · Jan 2014 · Journal of Surgical Research
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    ABSTRACT: The feasibility of video-assisted retroperitoneal debridement (VARD) for infected pancreatic walled-off necrosis is established. We provide prospective data on the safety and efficacy of VARD. Multicenter, prospective, single-arm phase 2 study. Six academic medical centers. We evaluated 40 patients with pancreatic necrosis who had infection determined using Gram stain or culture. Percutaneous drains were placed at enrollment, and computed tomographic scans were repeated at 10 days. Patients who had more than a 75% reduction in collection size were treated with drains. Other patients were treated with VARD. Crossover to open surgery was performed for technical reasons and/or according to surgeon judgment. Efficacy (ie, successful VARD treatment without crossover to open surgery or death) and safety (based on mortality and complication rates). Patients received follow-up care for 6 months. We enrolled 40 patients (24 men and 16 women) during a 51-month period. Median age was 53 years (range, 32-82 years). Mean (SD) Acute Physiology and Chronic Health Evaluation II score at enrollment was 8.0 (5.1), and median computed tomography severity index score was 8. Of the 40 patients, 24 (60%) were treated with minimally invasive intervention (drains with or without VARD). Nine patients (23%) did not require surgery (drains only). For 31 surgical patients, VARD was possible in 60% of patients. Most patients (81%) required 1 operation. In-hospital 30-day mortality was 2.5% (intent-to-treat). Bleeding complications occurred in 7.5% of patients; enteric fistulas occurred in 17.5%. This prospective cohort study supports the safety and efficacy of VARD for infected pancreatic walled-off necrosis. Of the patients, 85% were eligible for a minimally invasive approach. We were able to use VARD in 60% of surgical patients. The low mortality and complication rates compare favorably with open debridement. An unexpected finding was that a reduction in collection size of 75% according to the results of computed tomographic scans at 10 to 14 days predicted the success of percutaneous drainage alone.
    No preview · Article · Sep 2010 · Archives of surgery (Chicago, Ill.: 1960)
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    ABSTRACT: A teleoperated surgical robotic system allows surgical procedures to be conducted across long distances while utilizing wired and wireless communication with a wide spectrum of performance that may affect the outcome. An open architecture portable surgical robotic system (Raven) was developed for both open and minimally invasive surgery. The system has been the subject of an intensive telesurgical experimental protocol aimed at exploring the boundaries of the system and surgeon performance during a series of field experiments in extreme environments (desert and underwater) teleportation between US, Europe, and Japan as well as lab experiments under synthetic fixed time delay. One standard task (block transfer emulating tissue manipulation) of the Fundamentals of Laparoscopic Surgery (FLS) training kit was used for the experimental protocol. Network characterization indicated a typical time delay in the range of 16-172 ms in field experiments. The results of the lab experiments showed that the completion time of the task as well as the length of the tool tip trajectory significantly increased (alpha< 0.02) as time delay increased in the range of 0-0.5 sec increased. For teleoperation with a time delay of 0.25s and 0.5s the task completion time was lengthened by a factor of 1.45 and 2.04 with respect to no time delay, whereas the length of the tools' trajectory was increased by a factor of 1.28 and 1.53 with respect to no time delay. There were no statistical differences between experienced surgeons and non-surgeons in the number of errors (block drooping) as well as the completion time and the tool tip path length at different time delays.
    Full-text · Article · Sep 2009 · Conference proceedings: ... Annual International Conference of the IEEE Engineering in Medicine and Biology Society. IEEE Engineering in Medicine and Biology Society. Conference
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    ABSTRACT: The collaborative effort between fundamental science, engineering and medicine provides physicians with improved tools and techniques for delivering effective health care. Minimally invasive surgery (MIS) techniques have revolutionized the way a number of surgical proce- dures are performed. Recent advances in surgical robotics are once again revolutionizing MIS interventions and open surgery. In an ear- lier research endeavor, 30 surgeons performed 7 different MIS tasks using the Blue Dragon system to collect measurements of position, force, and torque on a porcine model. This data served as the foun- dation for a kinematic optimizatio no f as pherical surgical robotic
    Full-text · Article · Aug 2009 · The International Journal of Robotics Research
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    ABSTRACT: In the area of surgical robotics no standard means of performance evaluation has been established. Thousands of surgeons have gone through the SAGES FLS Program, and the psychomotor skill portion of the program is considered the gold standard in laparoscopic skills evaluation. This research describes the use of the FLS block transfer task to evaluate the performance of both surgeons and non-surgeons teleoperating under different time delay conditions on the University of Washington RAVEN Surgical Robot. Time delays of 0 ms, 250 ms, and 500 ms were used and a statistically significant difference in mean block transfer time as well as mean tool tip path length were shown. For this task no significant difference was shown between the surgeon and non-surgeon groups. Clearly surgeon input and feedback is key to surgical robotic system development, but this result implies that non-surgeon subjects can be tested for simple usability evaluations.
    Full-text · Conference Paper · May 2009
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    ABSTRACT: Robotic assisted surgery generates the possibility of remote operation between surgeon and patient. We need better understanding of the engineering issues involved in operating a surgical robot in remote locations and through novel communication links between surgeon and surgery site. This paper describes two recent experiments in which we tested the RAVEN, a new prototype surgical robot manipulation system, in field and laboratory conditions. In the first experiment, the RAVEN was deployed in a pasture and ran on generator power. Telecommunication with the surgical control station was provided by a novel airborne radio link supported by an unmanned aerial vehicle. In the second experiment, the RAVEN was teleoperated via Internet between Imperial College in London and the BioRobotics Lab at the University of Washington in Seattle. Data are reported on surgeon completion times for basic tasks and on network latency experience. The results are a small step towards teleoperated surgical robots which can be rapidly deployed in emergency situations in the field.
    Full-text · Chapter · Jun 2008
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    ABSTRACT: Accurate knowledge of biomechanical characteristics of tissues is essential for developing realistic computer-based surgical simulators incorporating haptic feedback, as well as for the design of surgical robots and tools. As simulation technologies continue to be capable of modeling more complex behavior, an in vivo tissue property database is needed. Most past and current biomechanical research is focused on soft and hard anatomical structures that are subject to physiological loading, testing the organs in situ. Internal organs are different in that respect since they are not subject to extensive loads as part of their regular physiological function. However, during surgery, a different set of loading conditions are imposed on these organs as a result of the interaction with the surgical tools. Following previous research studying the kinematics and dynamics of tool/tissue interaction in real surgical procedures, the focus of the current study was to obtain the structural biomechanical properties (engineering stress-strain and stress relaxation) of seven abdominal organs, including bladder, gallbladder, large and small intestines, liver, spleen, and stomach, using a porcine animal model. The organs were tested in vivo, in situ, and ex corpus (the latter two conditions being postmortem) under cyclical and step strain compressions using a motorized endoscopic grasper and a universal-testing machine. The tissues were tested with the same loading conditions commonly applied by surgeons during minimally invasive surgical procedures. Phenomenological models were developed for the various organs, testing conditions, and experimental devices. A property database-unique to the literature-has been created that contains the average elastic and relaxation model parameters measured for these tissues in vivo and postmortem. The results quantitatively indicate the significant differences between tissue properties measured in vivo and postmortem. A quantitative understanding of how the unconditioned tissue properties and model parameters are influenced by time postmortem and loading condition has been obtained. The results provide the material property foundations for developing science-based haptic surgical simulators, as well as surgical tools for manual and robotic systems.
    Preview · Article · May 2008 · Journal of Biomechanical Engineering
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    ABSTRACT: The Society of American Gastrointestinal Endoscopic Surgeons (SAGES) Fundamentals of Laparoscopic Surgery (FLS) program contains curriculum that includes both a cognitive and psychomotor skills. In this research the use of FLS Block Transfer task is used to evaluate the performance of surgeons' teleoperating the University of Washington Surgical robot. The use of the FLS Trainer Box and accessories kit provides a well-defined series of tasks that can be repeated by any researchers working in the field of surgical robotics so that systems can be evaluated using a common method.
    Full-text · Article · Feb 2008 · Studies in health technology and informatics
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    ABSTRACT: Within the area of telerobotic surgery no standardized means of surgically relevant performance evaluation has been established. The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Fundamentals of Laparoscopic Surgery (FLS) program provides a set of standardized tasks that are considered the 'gold standard' in surgical skill assessment. We present a methodology for using one of the SAGES FLS tasks for surgical robotic performance evaluation. The TeleRobotic FLS methodology is extendable to two other FLS tasks. Time delay in teleoperation in general and telesurgery in particular is one of the fundamental effects that limits performance in telerobotic surgery. In this pilot study the effect of time delay on the Block Transfer task performance was investigated. The RAVEN Surgical Robot was used in a master/slave configuration in which time delays of 0, 250, 500, and 1000 ms were introduced by a network emulator between the master (Surgeon Site) and the slave (Patient Site). The study included three subjects, each of whom was presented with three of the four conditions. The results show that one subject had a lower error rate with increasing time delay, whereas the other subjects had a higher error rate with increased delay. The subject with the longest average completion time suffered the least performance decrease under time delay.
    Full-text · Article · Feb 2008 · Conference proceedings: ... Annual International Conference of the IEEE Engineering in Medicine and Biology Society. IEEE Engineering in Medicine and Biology Society. Conference
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    ABSTRACT: .Abstract-While there are many benefits to minimally invasive surgery, force feedback, or touch sensation, is lacking in the currently available MIS tools, including surgical robots, creating the potential for excessive force application during surgery. The goal of this work was to develop a methodology with which to identify stress magnitudes and durations that can be safely applied with a grasper to different tissues, helping to improve MIS device design and reduce potential for clinically relevant consequences. Using the porcine model, stresses typically applied in MIS were applied to liver, ureter, and small bowel using a motorized endoscopic grasper. Acute indicators of tissue damage including cellular death, activation of the coagulation cascade, and infiltration of inflammatory cells were measured using histological and image analysis techniques. ANOVA and post-hoc analyses were used to detect stress magnitudes and durations that caused significantly increased tissue damage with the goal to ultimately identify safe stress'thresholds'during grasping of the studied tissues. Preliminary data suggests a graded non-linear response between applied stress magnitude and apoptosis in liver and small bowel as well as granulocyte infiltration in small bowel.
    Preview · Article · Nov 2007 · The International Journal of Robotics Research
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    ABSTRACT: The Global Operative Assessment of Laparoscopic Skills (GOALS) is a valid assessment tool for objectively evaluating the technical performance of laparoscopic skills in surgery residents. We hypothesized that GOALS would reliably differentiate between an experienced (expert) and an inexperienced (novice) laparoscopic surgeon (construct validity) based on a blinded videotape review of a laparoscopic cholecystectomy procedure. Ten board-certified surgeons actively engaged in the practice and teaching of laparoscopy reviewed and evaluated the videotaped operative performance of one novice and one expert laparoscopic surgeon using GOALS. Each reviewer recorded a score for both the expert and the novice videotape reviews in each of the 5 domains in GOALS (depth perception, bimanual dexterity, efficiency, tissue handling, and overall competence). The scores for the expert and the novice were compared and statistically analyzed using single-factor analysis of variance (ANOVA). The expert scored significantly higher than the novice did in the domains of depth perception (p = .005), bimanual dexterity (p = .001), efficiency (p = .001), and overall competence ( p = .001). Interrater reliability for the reviewers of the novice tape was Cronbach alpha = .93 and the expert tape was Cronbach alpha = .87. There was no difference between the two for tissue handling. The Global Operative Assessment of Laparoscopic Skills is a valid, objective assessment tool for evaluating technical surgical performance when used to blindly evaluate an intraoperative videotape recording of a laparoscopic procedure.
    No preview · Article · Jul 2007 · Surgical Innovation
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    Mika N. Sinanan · Jacob Rosen · Richard Satava · Alice Acker
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    ABSTRACT: With patient safety and improved outcomes as its focus, the Institute for Surgical and Interventional Simulation (ISIS), is dedicated to the training of medical professionals in technical and procedural skills, and research and development of emerging simulation technologies and educational strategies. ISIS is a collaborative institute of the University of Washington School of Medicine. It connects fifteen departments within the School of Medicine, the School of Nursing, the School of Dentistry, the Biorobotics Laboratory, the Human Interface Technology Lab, and the Center for Videoendoscopic Surgery. ISIS has active MOUs with other simulation centers at University of British Columbia, Oregon Health and Sciences University, and Madigan Army Medical Center, and a presence in Washington, Wyoming, Alaska, Montana, and Idaho. This model has applicability in civilian and military settings, as the collaboration with Madigan Army Medical Center (Andersen Simulation Center) demonstrates.
    Full-text · Article · May 2007
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    ABSTRACT: Surgical simulators are excellent training tools for minimally invasive procedures but are currently lacking in realistic tissue rendering and tissue responses to manipulation. Accurate color representation of tissues may add realism to simulators and provide medically relevant information. The goal of this study was to determine feasible methods for measuring color of in vivo tissue, specifically liver, in a standardized color space. Several compressions were applied to in vivo porcine liver. Three methods were then used to determine the CIELab and/or sRGB colors of normal and damaged liver. Results suggest that there are significant differences between normal and damaged liver color.
    Preview · Article · Feb 2007 · Studies in health technology and informatics
  • Scott Gunther · Jacob Rosen · Blake Hannaford · Mika Sinanan
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    ABSTRACT: With the development of new technologies in surgery, minimally invasive surgery (MIS) has drastically improved the way conventional medical procedures are performed. However, a new learning curve has resulted requiring an expertise in integrating visual information with the kinematics and dynamics of the surgical tools. The Red DRAGON is a multi-modal simulator for teaching and training MIS procedures allowing one to use it with several modalities including: simulator (physical objects and virtual objects) and an animal model. The Red DRAGON system is based on a serial spherical mechanism in which all the rotation axes intersect at a single point (remote center) allowing the endoscopic tools to pivot around the MIS port. The system includes two mechanisms that incorporate two interchangeable MIS tools. Sensors are incorporated into the mechanism and the tools measure the positions and orientations of the surgical tools as well as forces and torques applied on the tools by the surgeon. The design is based on a mechanism optimization to maximize the manipulability of the mechanism in the MIS workspace. As part of a preliminary experimental protocol, five expert level surgeons performed three laparoscopic tasks--a subset of the Fundamental Laparoscopic Skill (FLS) set as a baseline for skill assessment protocols. The results provide an insight into the kinematics and dynamics of the endoscopic tools, as the underlying measures for objectively assessing MIS skills.
    No preview · Article · Feb 2007 · Studies in health technology and informatics
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    Mitchell J H Lum · Jacob Rosen · Mika N Sinanan · Blake Hannaford
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    ABSTRACT: With a focus on design methodology for developing a compact and lightweight minimally invasive surgery (MIS) robot manipulator, the goal of this study is progress toward a next-generation surgical robot system that will help surgeons deliver healthcare more effectively. Based on an extensive database of in-vivo surgical measurements, the workspace requirements were clearly defined. The pivot point constraint in MIS makes the spherical manipulator a natural candidate. An experimental evaluation process helped to more clearly understand the application and limitations of the spherical mechanism as an MIS robot manipulator. The best configuration consists of two serial manipulators in order to avoid collision problems. A complete kinematic analysis and optimization incorporating the requirements for MIS was performed to find the optimal link lengths of the manipulator. The results show that for the serial spherical 2-link manipulator used to guide the surgical tool, the optimal link lengths (angles) are (60 degrees, 50 degrees). A prototype 6-DOF surgical robot has been developed and will be the subject of further study.
    Preview · Article · Aug 2006 · IEEE Transactions on Biomedical Engineering
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    ABSTRACT: Minimally invasive surgery (MIS) involves a multidimensional series of tasks requiring a synthesis between visual information and the kinematics and dynamics of the surgical tools. Analysis of these sources of information is a key step in defining objective criteria for characterizing surgical performance. The Blue DRAGON is a new system for acquiring the kinematics and the dynamics of two endoscopic tools synchronized with the endoscopic view of the surgical scene. Modeling the process of MIS using a finite state model [Markov model (MM)] reveals the internal structure of the surgical task and is utilized as one of the key steps in objectively assessing surgical performance. The experimental protocol includes tying an intracorporeal knot in a MIS setup performed on an animal model (pig) by 30 surgeons at different levels of training including expert surgeons. An objective learning curve was defined based on measuring quantitative statistical distance (similarity) between MM of experts and MM of residents at different levels of training. The objective learning curve was similar to that of the subjective performance analysis. The MM proved to be a powerful and compact mathematical model for decomposing a complex task such as laparoscopic suturing. Systems like surgical robots or virtual reality simulators in which the kinematics and the dynamics of the surgical tool are inherently measured may benefit from incorporation of the proposed methodology.
    Preview · Article · Apr 2006 · IEEE Transactions on Biomedical Engineering
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    ABSTRACT: As the field of surgical robotics continues to evolve, it is important to keep patient safety in mind. This paper describes a safety control architecture aimed at moving an experimental system in the direction of intrinsically safe operation. The system includes safety features such as: a small number of states, Programmable Logic Controller (PLC) state transition control, active enable, brakes, E-STOP, and a surgeon foot pedal.
    Full-text · Article · Feb 2006 · Studies in health technology and informatics
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    ABSTRACT: Several criteria exist for determining the optimal design for a surgical robot. This paper considers kinematic performance metrics, which reward good kinematic performance, and dynamic performance metrics, which penalize poor dynamic performance. Kinematic and dynamic metrics are considered independently, and then combined to produce hybrid metrics. For each metric, the optimal design is the one that maximizes the performance metric over a specific design space. In the case of a 2-DOF spherical mechanism for a surgical robot, the optimal design determined by kinematic metrics is a robot arm with link angles (alpha(12)=90 degrees , alpha(23)=90 degrees ). The large link angles are the most dextrous, but have the greatest risk of robot-robot or robot-patient collisions and require the largest actuators. The link lengths determined by the dynamic metrics are much shorter, which reduces the risk of collisions, but tend to place the robot in singularities much more frequently. When the hybrid metrics are used, and a restriction that the arm must be able to reach a human's entire abdomen, the optimal design is around (alpha(12)=51 degrees, alpha(23)=54 degrees). The hybrid design provides a compromise between dexterity and compactness.
    Full-text · Article · Feb 2006 · Studies in health technology and informatics
  • Vishal Kapoor · Jana Cole · F Frank Isik · Mika Sinanan · David Flum
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    ABSTRACT: We hypothesized that the use of muscle flaps, known as tissue transfer (TT), at the time of abdominoperineal resection (APR) reduces perineal wound complications. A restrospective review of patients undergoing an APR at the University of Washington (1984-2003) was conducted. Perineal wound complications and eventual wound healing were compared in patients with and without TT. Ninety-two patients (mean age, 56.6 years) underwent APR; 23.9 per cent (n = 22) had concurrent TT. Patients undergoing TT were more likely to have cancer (91% vs. 77%, P = 0.05) and radiation therapy (86% vs. 52%, P < 0.01). Operative times were nearly 2 hours longer in patients having TT (7.4 hours +/- 2.5 hours vs. 5.6 hours +/- 1.8 hours, P = 0.03), but lengths of stay were similar (13 +/- 5.9 days vs. 12 +/- 7.6 days, P = 0.5). Patients undergoing TT had a higher rate of all wound-healing complications (59% vs. 40%, P = 0.1) and major wound-healing complications (32% vs. 26%, P = 0.6). However, these differences were not statistically significant. No differences in major complications were identified in patients with and without preoperative radiation therapy (26% vs. 28%, P = 0.8). Fifteen per cent (n = 14) of all patients failed to heal wounds at 6 months, but only 9 per cent (n = 2) of patients undergoing TT failed to heal their wounds at 6 months compared with 17 per cent (n = 12) in the non-TT group (P = 0.3). After controlling for important covariates, patients undergoing TT during an APR did not have a significantly lower rate of wound complications. The impact of TT on wound healing in patients with recurrent cancer and preoperative radiation therapy is suggestive of a benefit but requires prospective investigation.
    No preview · Article · Feb 2005 · The American surgeon
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    ABSTRACT: Recent advances in technology have led to the fusion of MIS techniques and robot devices. However, current systems are large and cumbersome. Optimizing the surgical robot mechanism will eventually lead to its integration into the operating room (OR) of the future becoming the extended presence of the surgeon and nurses in a room occupied by the patient alone. By optimizing a spherical mechanism using data collected in-vivo during MIS procedures, this study is focused on a bottom-up approach to developing a new class of surgical robotic arms while maximizing their performance and minimizing their size. The spherical mechanism is a rotational manipulator with all axes intersecting at the center of the sphere. Locating the rotation center of the mechanism at the MIS port makes this class of mechanism a suitable candidate for the first two links of a surgical robot for MIS. The required dexterous workspace (DWS) is defined as the region in which 95% of the tool motions are contained based on in-vivo measurements. The extended dexterous workspace (EDWS) is defined as the entire abdominal cavity reachable by a MIS instruments. The DWS is defined by a right circular cone with a vertex angle of 60 degrees and the EDWS is defined by a cone with an elliptical cross section created by two orthogonal vertex angles of 60 degrees and 90 degrees. A compound function based on the mechanism's isotropy and the mechanism stiffness was considered as the performance metric cost function. Optimization across both the DWS and the EDWS lead to a serial mechanism configuration with link length angles of 74 degrees and 60 degrees for a serial configuration. This mechanism configuration maximized the kinematic performance in the DWS while keeping the EDWS as its reachable workspace. Surgeons, using a mockup of two mechanisms in a MIS setup, validated these results experimentally. From these experiments the serial configuration was deemed most applicable for MIS robotic applications compared to a parallel mechanism configuration. The mechanical design of a cable actuated surgical robot was based on optimized link length angles. The system is currently being integrated into a fully operated two-arm system. Small form-factor surgical robotic arms with optimized dexterous workspaces will facilitate the integration of multiple arms while avoiding self-collision in the OR of the future.
    Full-text · Article · Feb 2005 · Studies in health technology and informatics