The application of robotics to keyhole transcranial endoscopic microsurgery

Abstract

Over the last decade, there has been a resurgence of clinical interest in keyhole transcranial endoscopic microsurgery as an alternative to conventional microsurgery in carefully selected cases. The supraorbital approach through an eyebrow incision may be considered one of the best examples of the keyhole concept. Although keyhole neurosurgery offers the possibility of reduced approach-related morbidity, it can also present substantial technical challenges. This thesis investigates the potential for robotic platforms to improve the safety and effectiveness of such keyhole approaches. A qualitative survey of neurosurgeons was performed to identify the major technical challenges of keyhole neurosurgery, and a quantitative study of patents and publications performed to determine the technological innovations that might overcome these barriers. Three clear themes emerged: first, surgical approach and better integration with image guidance systems; second, intra-operative visualisation and improvements in endoscopes; and third, surgical manipulation and improvements in instruments. A community survey suggested that robotic platforms incorporating these technologies would be acceptable to patients and their relatives.

Existing robotic platforms were reviewed against the aforementioned requirements for keyhole neurosurgery. In a cadaver study, it was demonstrated that most frequently used surgical robot today, the da VinciTM platform, was neither safe nor feasible to use in keyhole neurosurgery, providing justification for further research.

Technological innovations were sought to address each of the identified barriers to keyhole neurosurgery, including: an on-demand augmented reality system; a 3- Dimensional and High-Definition endoscope; and articulated robotic instruments. In a series of laboratory studies, each proposed technological innovation was compared against the current gold standard using a validated model. These technologies were then integrated into a robotic platform for image guided endoscopic microsurgery. Subsequent preclinical and clinical studies have shown promise, but further work is necessary to evaluate safety and effectiveness.