Excessive tool-tissue interaction forces often result in tissue damage and intraoperative complications, while insufficient forces prevent the completion of the task. This review sought to explore the tool-tissue interaction forces exerted by instruments during surgery across different specialities, tissues, manoeuvres and experience levels. A PRISMA-guided systematic review was carried out using Embase, Medline and Web of Science databases. Of 462 articles screened, 45 studies discussing surgical tool-tissue forces were included. The studies were categorized into 9 different specialities with the mean of average forces lowest for ophthalmology (0.04N) and highest for orthopaedic surgery (210N). Nervous tissue required the least amount of force to manipulate (mean of average: 0.4N), whilst connective tissue (including bone) required the most (mean of average: 45.8). For manoeuvres, drilling recorded the highest forces (mean of average: 14N), whilst sharp dissection recorded the lowest (mean of average: 0.03N). When comparing differences in the mean of average forces between groups, novices exerted 22.7% more force than experts, and presence of a feedback mechanism (e.g. audio) reduced exerted forces by 47.9%. The measurement of tool-tissue forces is a novel but rapidly expanding field. The range of forces applied varies according to surgical speciality, tissue, manoeuvre, operator experience and feedback provided. Knowledge of the safe range of surgical forces will improve surgical safety whilst maintaining effectiveness. Measuring forces during surgery may provide an objective metric for training and assessment. Development of smart instruments, robotics and integrated feedback systems will facilitate this.

A cable-driven segmented manipulator (CDSM) has superior dexterity for operations in confined space due to its light-slender body and redundant degree of freedoms (DOFs). However, its inverse kinematics resolving and configuration planning are very challenging due to the complex structure and strict constraints. In this article, we propose a two-layer geometric iteration (TLGI) method for inverse kinematics resolving and configuration-constrained Cartesian path planning. The computation efficiency is largely improved and singularities are avoided. First, the end-effector attitude is decomposed into a direction vector and a rotation angle. The former and the end-effector position are combined into state variables of the inner layer, and the latter is treated separately as the state variable of the outer layer. Then, the TLGI method enables to rapidly reach the desired 6-DOF pose by two-layer iterations, i.e., the inner and outer loop iteration. Second, during the inner loop iteration, the CDSM is modeled as an equivalent articulated arm whose end-effector position and direction is the same as that of CDSM, but its links length and joint angles depend on the current configuration of CDSM. Then, the efficient forward and backward reaching inverse kinematics (FABRIKs) method is extended to apply on CDSM so that it can fast reach the inner state variables. During the outer loop iteration, three different rotation cases, i.e., the rotating around the end, root, and both end and root, are designed to switch automatically to reach the outer state variable iteratively. Moreover, by parameterizing geometric constraints of the environment, a TLGI-based configuration-pose simultaneous planning method is also put forward to efficiently achieve additional configuration constraints for operations of CDSM in confined space. Finally, the proposed method is verified by both the simulations and experiments.