This Review explores the challenges and the opportunities for robotics to tackle infectious diseases such as COVID-19.

The evolution of medical technologies—such as surgical devices and imaging techniques—has transformed all aspects of surgery. A key area of development is robot-assisted minimally invasive surgery (MIS). This review paper provides an overview of the evolution of robotic MIS, from its infancy to our days, and envisioned future challenges. It provides an outlook of breakthrough surgical robotic platforms, their clinical applications, and their evolution over the years. It discusses how the integration of robotic, imaging, and sensing technologies has contributed to create novel surgical platforms that can provide the surgeons with enhanced dexterity, precision, and surgical navigation while reducing the invasiveness and efficacy of the intervention. Finally, this review provides an outlook on the future of robotic MIS discussing opportunities and challenges that the scientific community will have to address in the coming decade. We hope that this review serves to provide a quick and accessible way to introduce the readers to this exciting and fast-evolving area of research, and to inspire future research in this field.

Complex joint fractures often require an open surgical procedure, which is associated with extensive soft tissue damages and longer hospitalization and rehabilitation time. Percutaneous techniques can potentially mitigate these risks but their application to joint fractures is limited by the current sub-optimal 2D intra-operative imaging (fluoroscopy) and by the high forces involved in the fragment manipulation (due to the presence of soft tissue, e.g., muscles) which might result in fracture malreduction. Integration of robotic assistance and 3D image guidance can potentially overcome these issues. The authors propose an image-guided surgical robotic system for the percutaneous treatment of knee joint fractures, i.e., the robot-assisted fracture surgery (RAFS) system. It allows simultaneous manipulation of two bone fragments, safer robot-bone fixation system, and a traction performing robotic manipulator. This system has led to a novel clinical workflow and has been tested both in laboratory and in clinically relevant cadaveric trials. The RAFS system was tested on 9 cadaver specimens and was able to reduce 7 out of 9 distal femur fractures (T- and Y-shape 33-C1) with acceptable accuracy (≈1 mm, ≈5°), demonstrating its applicability to fix knee joint fractures. This study paved the way to develop novel technologies for percutaneous treatment of complex fractures including hip, ankle, and shoulder, thus representing a step toward minimally-invasive fracture surgeries.

Vascular diseases are the most common precursors to ischemic heart disease and stroke, which are two of the leading causes of death worldwide. Endovascular intervention is a minimally invasive surgical approach to treat such diseases. Compared to open surgery, it has the advantages of faster recovery, reduced need for general anesthesia, reduced blood loss and significantly lower mortality. Endovascular procedures require high surgical skills to minimize contacts between the manipulated instruments (catheters and guidewires) and the vessel wall, which represent one of the major risks for the patient. Robotic assistance can potentially improve the precision and stability of instruments manipulation. One key limitation of current commercial robotic platforms is the lack of haptic feedback, preventing their acceptance and limiting the clinical usability. This paper proposes to bring the benefit of haptic feedback to robot-assisted endovascular intervention. Here we hypothesize that the introduction of 3D haptic guidance during robot-assisted endovascular procedure can further improve the surgical performance and safety while overcoming the limitations of currently available technology. The proposed 3D haptic guidance allows the surgeon to sense the vasculature while controlling a catheter through a robotic haptic manipulator. Validation of the system is performed through end-user experiments with vascular surgeons on a bespoke surgical simulator. The obtained results demonstrate that 3D haptic guidance has the potential of improving effectiveness, precision, and safety of endovascular intervention. Furthermore, vascular surgeons found the proposed technology safe and overall easy to use, indicating its potential on real surgical procedures.

Objective: In-vivo validation on animal setting of a pneumatically propelled robot for endovascular intervention, to determine safety and clinical advantage of robotic cannulations compared to manual operation. Methods: Robotic assistance and image-guided intervention are increasingly used for improving endovascular procedures with enhanced navigation dexterity and accuracy. However, most platforms developed in the past decade still present inherent limitations in terms of altered clinical workflow, counterintuitive human-robot interaction, and a lack of versatility. We have created a versatile, highly integrated platform for robot-assisted endovascular intervention aimed at addressing such limitations, and here we demonstrate its clinical usability through in-vivo animal trials. A detailed in-vivo study on four porcine models conducted with our robotic platform is reported, involving cannulation and balloon angioplasty of five target arteries. Results: The trials showed a 100% success rate, and post-mortem histopathological assessment demonstrated a reduction in the incidence and severity of vessel trauma with robotic navigation versus manual manipulation. Conclusion: In-vivo experiments demonstrated that the applicability of our robotic system within the context of this study was well tolerated, with good feasibility, and low risk profile. Comparable results were observed with robotics and manual cannulation, with clinical outcome potentially in favor of robotics. Significance: This study showed that the proposed robotic platform can potentially improve the execution of endovascular procedures, paving the way for clinical translation.

Purpose Joint fractures must be accurately reduced minimising soft tissue damages to avoid negative surgical outcomes. To this regard, we have developed the RAFS surgical system, which allows the percutaneous reduction of intra-articular fractures and provides intra-operative real-time 3D image guidance to the surgeon. Earlier experiments showed the effectiveness of the RAFS system on phantoms, but also key issues which precluded its use in a clinical application. This work proposes a redesign of the RAFS’s navigation system overcoming the earlier version’s issues, aiming to move the RAFS system into a surgical environment. Methods The navigation system is improved through an image registration framework allowing the intra-operative registration between pre-operative CT images and intra-operative fluoroscopic images of a fractured bone using a custom-made fiducial marker. The objective of the registration is to estimate the relative pose between a bone fragment and an orthopaedic manipulation pin inserted into it intra-operatively. The actual pose of the bone fragment can be updated in real time using an optical tracker, enabling the image guidance. Results Experiments on phantom and cadavers demonstrated the accuracy and reliability of the registration framework, showing a reduction accuracy (sTRE) of about \(0.88~\pm 0.2\,\hbox {mm}\) (phantom) and \(1.15\pm 0.8\,\hbox {mm}\) (cadavers). Four distal femur fractures were successfully reduced in cadaveric specimens using the improved navigation system and the RAFS system following the new clinical workflow (reduction error \(1.2\pm 0.3\,\hbox {mm}\), \(2\pm 1{^{\circ }})\). Conclusion Experiments showed the feasibility of the image registration framework. It was successfully integrated into the navigation system, allowing the use of the RAFS system in a realistic surgical application.