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Objectives: In the current clinical practice of thermal ablation treatment for liver tumors, achieving consistent and effective clinical outcomes across tumors of varying shapes, sizes and locations remains challenging. The aim of this study was to evaluate the repeatability of a novel robotic approach for configurable ablation of distinct tumor shapes and compare it to the standard ablation technique for creating ellipsoidal ablation volumes., Materials and Methods: The repeatability was evaluated in terms of width variability in created ablation volumes. Using a robotic navigation platform, custom ablation profiles configured with power, time, and distance parameters were designed to create four distinct ablation shapes. The profiles were applied for microwave ablation in a tissue-mimicking liver model. For comparison of ablation shape variability, six standard ellipsoidal shapes were created using the standard ablation technique by configuring power and time parameters. For each sample, the resulting ablation area was segmented, and the resulting shape width and length were calculated at the measurement points. Width variability was calculated as the median of the absolute pairwise differences in width at each measurement point, and configurable versus standard ablation shapes were compared using the Mann-Whitney U test., Results: All tissue-mimicking samples were successfully ablated using both configurable (n = 48) and standard ablation technique (n = 35). Study findings revealed noninferiority regarding repeatability of created ablation shapes using the robotic platform for configurable ablation, compared to created standard ellipsoidal ablation shapes (p < 0.001, 95% CI ≤ -0.05 mm, Δ = -0.22 mm). Median repeatability of created configurable shapes was 1.00 mm, and for standard shapes 1.22 mm. Maximal repeatability for both groups was below 3 mm., Conclusion: The repeatability of configurable ablation shapes was observed to be noninferior to the standard ablation shapes. Achieving configurable ablation volumes underscores the potential to advance personalization of thermal ablation treatment and broaden its applicability to distinct tumor cases. In-vivo validation is needed for evaluation of the clinical implications of this novel treatment technique., Competing Interests: SW and PT are listed as co-inventors in a patent application relevant for this publication Method and System for Pose Controlled Ablation, 16150502.9 - 1659. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be constructed as a potential conflict of interest., (Copyright © 2024 Bulatović, Hermann, Tinguely, Paolucci and Weber.)

The predictive brain hypothesis suggests that perception can be interpreted as the process of minimizing the error between predicted perception tokens generated via an internal world model and actual sensory input tokens. When implementing working examples of this hypothesis in the context of in-air sonar, significant difficulties arise due to the sparse nature of the reflection model that governs ultrasonic sensing. Despite these challenges, creating consistent world models using sonar data is crucial for implementing predictive processing of ultrasound data in robotics. In an effort to enable robust robot behavior using ultrasound as the sole exteroceptive sensor modality, this paper introduces EchoPT (Echo-Predicting Pretrained Transformer), a pretrained transformer architecture designed to predict 2D sonar images from previous sensory data and robot ego-motion information. We detail the transformer architecture that drives EchoPT and compare the performance of our model to several state-of-the-art techniques. In addition to presenting and evaluating our EchoPT model, we demonstrate the effectiveness of this predictive perception approach in two robotic tasks.

Background: Pedicle screw placement during spine fusion is physically and mentally demanding for surgeons. Consequently, spine surgeons can become fatigued, which has implications for both patient safety and surgeon well-being., Purpose: We sought to assess the cognitive workload of surgeons placing pedicle screws using robotic-assisted navigation compared with fluoroscopic and computed tomography (CT)-assisted placement., Methods: We performed a nonrandomized prospective controlled trial to compare the cognitive workload of 3 surgeons performing single-level minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) using robotic, CT, or fluoroscopic navigation on 25 patients (15 in the robotic navigation group and 10 in the nonrobotic group). Immediately after each procedure, surgeons submitted the National Aeronautics and Space Administration-Task Load Index (NASA-TLX), which has 6 subscales: mental demands, physical demands, temporal demands, performance, effort, and frustration. Four tasks associated with pedicle screw placement were assessed independently: (1) screw planning, (2) calibrating robot/obtaining imaging/registration, (3) pedicle cannulation, and (4) screw placement. Patient demographics and surgical characteristics were obtained and reviewed., Results: Surgeons' self-reported cognitive workload was significantly reduced when using robotic-assisted navigation versus CT/fluoroscopic navigation. Workload was reduced for screw planning, pedicle cannulation, and screw placement. In addition, there were significant reductions in each subdomain for these 3 tasks, encompassing mental demand, physical demand, temporal demand, effort, and frustration with improved task performance., Conclusions: This study found significant reductions in mental workload with improved perceived performance for robotic-assisted pedicle screw placement compared with fluoroscopic and CT-navigation techniques. Lowering the cognitive burden associated with screw placement may allow surgeons to address the remainder of the operative case with less decision fatigue, prevent complications, and increase surgeon wellness., Competing Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: KWM reports relationships with NIH, OREF, SRS, Johnson & Johnson, GE Health, and Sustain Surgical. SQ reports relationships with Viseon, Tissue Differentiation Intelligence, HS2, Minimally Invasive Spine Study Group, Stryker, SpineGuard, Globus Medical, Surgalign, Lifelink.com, Spinal Simplicity, Contemporary Spine Surgery, NASS, Annals of Translational Medicine, HSS Journal, Society of Minimally Invasive Spine Surgery (SMISS), Lumbar Spine Research Society (LSRS), Cervical Spine Research Society (CSRS), Association of Bone and Joint Surgeons (ABJS), and International Society for the Advancement of Spine Surgery (ISASS). SI reports relationships with Innovasis, HS2, Stryker, Healthgrades, and Globus Medical. The other authors declare no potential conflicts of interest., (© The Author(s) 2024.)

Preamble: Robotic magnetic navigation (RMN)-guided catheter ablation (CA) technology has been used for the treatment of cardiac arrhythmias for almost 20 years. Various studies reported that RMN allows for high catheter stability, improved lesion formation and a superior safety profile. So far, no guidelines or recommendations on RMN-guided CA have been published., Purpose: The aim of this consensus paper was to summarize knowledge and provide recommendations on management of arrhythmias using RMN-guided CA as treatment of atrial fibrillation (AF) and ventricular arrhythmias (VA)., Methodology: An expert writing group, performed a detailed review of available literature, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Recommendations on RMN-guided CA are presented in a guideline format with three levels of recommendations to serve as a reference for best practices in RMN procedures. Each recommendation is accompanied by supportive text and references. The various sections cover the practical spectrum from system and patient set-up, EP laboratory staffing, combination of RMN with fluoroscopy and mapping systems, use of automation features and ablation settings and targets, for different cardiac arrhythmias., Conclusion: This manuscript, presenting the combined experience of expert robotic users and knowledge from the available literature, offers a unique resource for providers interested in the use of RMN in the treatment of cardiac arrhythmias., Competing Interests: The Erasmus MC has received research grants from Acutus Medical, Biosense Webster and Stereotaxis. TS-T has received an educational grant from Abbott, a contract for education and advisory activities with Biotronik and consultancy contract with Acutus Medical and Ablacon. SW has received honoraria from Biotronik en Daiichi Sankyo. S-CY has received a research grant from Medtronic and honoraria from Medtronic and Boston Scientific. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2024 Noten, Szili-Torok, Ernst, Burkhardt, Cavaco, Chen, Cheung, de Chillou, Crystal, Cooper, Gasparini, Geczy, Goehl, Hügl, Jin, Kampus, Kazemian, Khan, Kongstad, Magga, Peress, Raatikainen, Romanov, Rossvoll, Singh, Vatasescu, Wijchers, Yamashiro, Yap and Weiss.)

Objective: To investigate the effectiveness of computer-assisted and robot-assisted atlantoaxial pedicle screw implantation for the treatment of reversible atlantoaxial dislocation (AAD)., Methods: The clinical data of 42 patients with reversible AAD admitted between January 2020 and June 2023 and met the selection criteria were retrospectively analyzed, of whom 23 patients were treated with computer-assisted surgery (computer group) and 19 patients were treated with Mazor X spinal robot-assisted surgery (robot group). There was no significant difference in gender, age, T value of bone mineral density, body mass index, etiology, and preoperative Japanese Orthopaedic Association (JOA) score, Neck Dysfunction Index (NDI) between the two groups ( P >0.05). The operation time, screw implantation time, intraoperative blood loss, hand and wrist radiation exposure, and complications were recorded and compared between the two groups. Gertzbein classification was used to evaluate the accuracy of screw implantation. JOA score and NDI were used to evaluate the function before operation, at 3 days after operation, and at last follow-up. At last follow-up, the status of screws and bone fusion were observed by neck three-dimensional CT., Results: The operation time and hand and wrist radiation exposure of the computer group were significantly longer than those of the robot group ( P <0.05), and there was no significant difference in the screw implantation time and intraoperative blood loss between the two groups ( P >0.05). All patients were followed up 11-24 months, with an average of 19.6 months. There was no significant difference in the follow-up time between the two groups ( P >0.05). There was no significant difference in the accuracy of screw implantation between the two groups ( P >0.05). Except for 1 case of incision infection in the computer group, which improved after antibiotic treatment, there was no complication such as nerve and vertebral artery injury, screw loosening, or breakage in the two groups. The JOA score and NDI significantly improved in both groups at 3 days after operation and at last follow-up ( P <0.05) compared to those before operation, but there was no significant difference between the two groups ( P >0.05). At last follow-up, 21 patients (91.3%) in the computer group and 18 patients (94.7%) in the robot group achieved satisfactory atlantoaxial fusion, and there was no significant difference in the fusion rate between the two groups ( P >0.05)., Conclusion: Computer-assisted or robot-assisted atlantoaxial pedicle screw implantation is safe and effective, and robotic navigation shortens operation time and reduces radiation exposure.

Objective: Spinal metastases can significantly affect quality of life in patients with cancer and present complex neurosurgical challenges for surgeons. Surgery with instrumentation is often indicated to alleviate pain, preserve neurological function, and ensure mechanical stability. However, distortions in the bony anatomy due to oncological disease can decrease the accuracy of pedicle screw placement. Robotic-assisted surgery may offer an opportunity to increase screw accuracy and improve navigation of spinal lesions compared to conventional techniques. Therefore, we presented our institutional experience evaluating robotic-assisted surgical fixation for spinal metastases., Methods: Patients undergoing robotic-assisted surgery at a large tertiary care center between January 2019 - January 2023 for the treatment of spinal metastases were identified. Patient characteristics, including demographics, tumor pathology, surgical complications, and post-operative outcomes were extracted. The Gertzbein Robbins classification system (GRS) was used to assess pedicle screw placement accuracy in patients with post-operative computed tomography., Results: Twenty patients were identified, including 7 females (35 %), with an overall median age of 66 years (range: 39-80 years) and median BMI of 25 kg/m 2 (range: 17-34 kg/m 2 ). An average of four spinal levels were instrumented, with metastases located primarily in the thoracic (n=17, 85 %) spine. Common primary tumor types included prostate (n=4), lung (n=2), and plasma cell (n=2) cancers. Most pedicle screws (92 %) were classified as GRS A in patients with postoperative imaging. Post-operative complications were unrelated to the use of the robot, and included pulmonary embolism (n=1), deep vein thrombosis (n=2), and gastric symptoms (n=3). Three patients were readmitted at 30 days, with one reoperation due to tumor recurrence. Four patients were deceased within 6 months of surgery., Conclusions: Despite the inherent high-risk nature of these surgeries, this study underscores the safety and efficacy of robotic-assisted surgery in the management of spinal metastases. Robots can be helpful in ensuring accuracy of pedicle screw placement in patients with metastatic disease., Competing Interests: Conflict of Interest Nicholas Theodore has received royalties from, holds stock ownership in, has consulted for, and has served on the scientific advisory board/other office for Globus Medical. Dr. Lubelski reported serving as a consultant for Icotec, Carbofix, and Mindset Medical. Dr. Lubelski receives research support from Dilon Technologies. The other authors have no conflicts of interest to disclose. No generative artificial intelligence (AI) or AI-assisted technologies were utilized in the writing of this manuscript., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Background: Preoperative computed tomography (CT)-guided localization of small pulmonary nodules (SPNs) is the major approach for accurate intraoperative visualization in video-assisted thoracoscopic surgery (VATS). However, this interventional procedure has certain risks and may challenge to less experienced junior doctors. This study aims to evaluate the feasibility and efficacy of robotic-assisted CT-guided preoperative pulmonary nodules localization with the modified hook-wire needles before VATS., Methods: A total of 599 patients with 654 SPNs who preoperatively accepted robotic-assisted CT-guided percutaneous pulmonary localization were respectively enrolled and compared to 90 patients with 94 SPNs who underwent the conventional CT-guided manual localization. The clinical and imaging data including patients' basic information, pulmonary nodule features, location procedure findings, and operation time were analyzed., Results: The localization success rate was 96.64% (632/654). The mean time required for marking was 22.85±10.27 min. Anchor of dislodgement occurred in 2 cases (0.31%). Localization-related complications included pneumothorax in 163 cases (27.21%), parenchymal hemorrhage in 222 cases (33.94%), pleural reaction in 3 cases (0.50%), and intercostal vascular hemorrhage in 5 cases (0.83%). Localization and VATS were performed within 24 hours. All devices were successfully retrieved in VATS. Histopathological examination revealed 166 (25.38%) benign nodules and 488 (74.62%) malignant nodules. For patients who received localizations, VATS spent a significantly shorter time, especially the segmentectomy group (93.61±35.72 vs. 167.50±40.70 min, P<0.001). The proportion of pneumothorax in the robotic-assisted group significantly decreased compared with the conventional manual group (27.21% vs. 43.33%, P=0.002)., Conclusions: Robotic-assisted CT-guided percutaneous pulmonary nodules hook-wire localization could be effectively helpful for junior less experienced interventional physicians to master the procedure and potentially increase precision., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-198/coif). The authors have no conflicts of interest to declare., (2024 Journal of Thoracic Disease. All rights reserved.)

Interventional oncology is routinely tasked with the feat of tumor characterization or destruction, via image-guided biopsy and tumor ablation, which may pose difficulties due to challenging-to-reach structures, target complexity, and proximity to critical structures. Such procedures carry a risk-to-benefit ratio along with measurable radiation exposure. To streamline the complexity and inherent variability of these interventions, various systems, including table-, floor-, gantry-, and patient-mounted (semi-) automatic robotic aiming devices, have been developed to decrease human error and interoperator and intraoperator outcome variability. Their implementation in clinical practice holds promise for enhancing lesion targeting, increasing accuracy and technical success rates, reducing procedure duration and radiation exposure, enhancing standardization of the field, and ultimately improving patient outcomes. This narrative review collates evidence regarding robotic tools and their implementation in interventional oncology, focusing on clinical efficacy and safety for nonhepatic malignancies., Competing Interests: Conflicts of Interest R.B. is a consultant of Interventional Systems (Kitzbühel, Austria). B.J.W. has a research and development agreement with former XAct Robotics, Inc, Philips, Siemens, Varian, Canon, NVIDIA., (Thieme. All rights reserved.)

Eighty consecutive complex spinal robotic cases utilizing intraoperative 3D CT imaging (E3D, Group 2) were compared to 80 age-matched controls using the Excelsius robot alone with C-arm Fluoroscopic registration (Robot Only, Group 1). The demographics between the two groups were similar-severity of deformity, ASA Score for general anesthesia, patient age, gender, number of spinal levels instrumented, number of patients with prior spinal surgery, and amount of neurologic compression. The intraoperative CT scanning added several objective factors improving patient safety. There were significantly fewer complications in the E3D group with only 3 of 80 (4%) patients requiring a return to the operating room compared to 11 of 80 (14%) patients in the Robot Only Group requiring repeat surgery for implant related problems (Chi squared analysis = 5.00, p = 0.025). There was a significant reduction the amount of fluoroscopy time in the E3D Group (36 s, range 4-102 s) compared to Robot only group (51 s, range 15-160 s) (p = 0.0001). There was also shorter mean operative time in the E3D group (257 ± 59.5 min) compared to the robot only group (306 ± 73.8 min) due to much faster registration time (45 s). A longer registration time was required in the Robot only group to register each vertebral level with AP and Lateral fluoroscopy shots. The estimated blood loss was also significantly lower in Group 2 (mean 345 ± 225 ml) vs Group 1 (474 ± 397 ml) (p = 0.012). The mean hospital length of stay was also significantly shorter for Group 2 (3.77 ± 1.86 days) compared to Group 1 (5.16 ± 3.40) (p = 0.022). There was no significant difference in the number of interbody implants nor corrective osteotomies in both groups-Robot only 52 cases vs. 42 cases in E3D group.Level of evidence: IV, Retrospective review., (© 2024. The Author(s).)

Historically, pedicle screw accuracy measurements have relied on CT and expert visual assessment of the position of pedicle screws relative to preoperative plans. Proper pedicle screw placement is necessary to avoid complications, cost and morbidity of revision procedures. The aim of this study was to determine accuracy and precision of pedicle screw insertion via a novel computer vision algorithm using preoperative and postoperative computed tomography (CT) scans. Three cadaveric specimens were utilized. Screw placement planning on preoperative CT was performed according to standard clinical practice. Two experienced surgeons performed bilateral T2-L4 instrumentation using robotic-assisted navigation. Postoperative CT scans of the instrumented levels were obtained. Automated segmentation and computer vision techniques were employed to align each preoperative vertebra with its postoperative counterpart and then compare screw positions along all three axes. Registration accuracy was assessed by preoperatively embedding spherical markers (tantalum beads) to measure discrepancies in landmark alignment. Eighty-eight pedicle screws were placed in 3 cadavers' spines. Automated registrations between pre- and postoperative CT achieved sub-voxel accuracy. For the screw tip and tail, the mean three-dimensional errors were 1.67 mm and 1.78 mm, respectively. Mean angular deviation of screw axes from plan was 1.58°. For screw mid-pedicular accuracy, mean absolute error in the medial-lateral and superior-inferior directions were 0.75 mm and 0.60 mm, respectively. This study introduces automated algorithms for determining accuracy and precision of planned pedicle screws. Our accuracy outcomes are comparable or superior to recent robotic-assisted in vivo and cadaver studies. This computerized workflow establishes a standardized protocol for assessing pedicle screw placement accuracy and precision and provides detailed 3D translational and angular accuracy and precision for baseline comparison., (© 2024. The Author(s).)

Objective: Computed tomography is considered the gold-standard imaging tool to evaluate spinal implant accuracy. However, there are no studies that evaluate the accuracy of robotic sacroiliac joint (SIJ) implant placement using CT to date. The aim of this study was to compare the accuracy of implant placement on CT between robotic and fluoroscopic navigation for SIJ fusion and the subsequent complications and clinical outcomes of suboptimally placed screws., Methods: A retrospective analysis of SIJ fusions utilizing either robotic or fluoroscopic guidance at a single institution was conducted from 2014 to 2023. Implant placement accuracy was evaluated on intra- or postoperative CT. Primary endpoints were SIJ screw placement accuracy and complications. Secondary endpoints were pain status at the first and second follow-ups and rates of 2-year revision surgery. Statistical analysis was performed using chi-square tests., Results: Sixty-nine patients who underwent 78 SIJ fusions were included, of which 63 were robotic and 15 were fluoroscopic. The mean age of the cohort at the time of surgery was 55.9 ± 14.2 years, and 35 patients (50.7%) were female. There were 135 robotically placed and 34 fluoroscopically placed implants. A significant difference was found in implant placement accuracy between robotic and fluoroscopic fusion (97.8% vs 76.5%, p < 0.001). When comparing optimal versus suboptimal implant placement, no difference was found in the presence of 30-day complications (p = 0.98). No intraoperative complications were present in this cohort. No difference was found in subjective pain status at the first (p = 0.69) and second (p = 0.45) follow-ups between optimal and suboptimal implant placement. No patients underwent 2-year revision surgery., Conclusions: Use of robotic navigation was significantly more accurate than the use of fluoroscopic navigation for SIJ implant placement. Complications overall were low and not different between optimally and suboptimally placed implants. Suboptimally placed implants did not differ in degree of subjective pain improvement or rates of revision surgery postoperatively.

Osteochondral lesion of the talus (OLT) is a localized cartilage and subchondral bone injury of the talus trochlea. OLT is caused by trauma and other reasons, including osteochondritis dissecans of the talus (OCD) and talus osteochondral tangential fracture. OLT can develop from being asymptomatic to subchondral bone cysts accompanied by deep ankle pain. OLT tends to occur on the medial and lateral sides of the talar vault. OLT seriously affects the patients' life and work and may even lead to disability. Herein, we reviewed advances in the treatment of OLT and the strengths and weaknesses of various treatments. Different treatment methods, including conservative treatments and surgical treatments, can be adopted according to the different subtypes or clinical symptoms of OLT. Conservative treatments mostly relieve symptoms in the short term and only slow down the disease. In recent years, it has been discovered that platelet-rich plasma injection, microfracture, periosteal bone grafting, talar cartilage transplantation, allograft bone transplantation, reverse drilling under robotic navigation, and other methods can achieve considerable benefits when each of these treatment methods is applied. Furthermore, microfracture combined with platelet-rich plasma injections, microfracture combined with cartilage transplantation, and various other treatment methods combined with anterior talofibular ligament repair have all led to good treatment outcomes., Competing Interests: 利益冲突　所有作者均声明不存在利益冲突, (© 2024《四川大学学报（医学版）》编辑部 版权所有Copyright ©2024 Editorial Board of Journal of Sichuan University (Medical Sciences).)

Study Design: Human Cadaveric Study., Objective: This study aims to explore the feasibility of using preoperative magnetic resonance imaging (MRI), zero-time-echo (ZTE) and spoiled gradient echo (SPGR), as source data for robotic-assisted spine surgery and assess the accuracy of pedicle screws., Methods: Zero-time-echo and SPGR MRI scans were conducted on a human cadaver. These images were manually post-processed, producing a computed tomography (CT)-like contrast. The Mazor X robot was used for lumbar pedicle screw-place navigating of MRI. The cadaver underwent a postoperative CT scan to determine the actual position of the navigated screws., Results: Ten lumbar pedicle screws were robotically navigated of MRI (4 ZTE; 6 SPGR). All MR-navigated screws were graded A on the Gertzbein-Robbins scale. Comparing preoperative robotic planning to postoperative CT scan trajectories: The screws showed a median deviation of overall 0.25 mm (0.0; 1.3), in the axial plane 0.27 mm (0.0; 1.3), and in the sagittal plane 0.24 mm (0.0; 0.7)., Conclusion: This study demonstrates the first successful registration of MRI sequences, ZTE and SPGR, in robotic spine surgery here used for intraoperative navigation of lumbar pedicle screws achieving sufficient accuracy, showcasing potential progress toward radiation-free spine surgery., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Robotic navigation has been shown to increase precision, accuracy, and safety during spinal reconstructive procedures. There is a paucity of literature describing the best techniques for robotic-assisted spine surgery for complex, multilevel cases or in cases of significant deformity correction. We present a case series of 100 consecutive multilevel posterior spinal fusion procedures performed for multilevel spinal disease and/or deformity correction. 100 consecutive posterior spinal fusions were performed for multilevel disease and/or deformity correction utilizing robotic-assisted placement of pedicle screws. The primary outcome was surgery-related failure, which was defined as hardware breakage or reoperation with removal of hardware. A total of 100 consecutive patients met inclusion criteria. Among cases included, 31 were revision surgeries with existing hardware in place. The mean number of levels fused was 5.6, the mean operative time was 303 min, and the mean estimated blood loss was 469 mL. 28 cases included robotic-assisted placement of S2 alar-iliac (S2AI) screws. In total, 1043 pedicle screws and 53 S2AI screws were placed with robotic-assistance. The failure rate using survivorship analysis was 18/1043 (1.7%) and the failure rate of S2AI screws using survivorship analysis was 3/53 (5.7%). Four patients developed postoperative wound infections requiring irrigation and debridement procedures. None of the 1043 pedicle screws nor the 53 S2AI screws required reoperation due to malpositioning or suboptimal placement. This case series of 100 multilevel posterior spinal fusion procedures demonstrates promising results with low failure rates. With 1043 pedicle screws and 53 S2AI screws, we report low failure rates of 1.7% and 5.7%, respectively with zero cases of screw malpositioning. Robotic screw placement allows for accurate screw placement with no increased rate of postoperative infection compared to historical controls. Level of evidence: IV, Retrospective review., (© 2023. The Author(s), under exclusive licence to Springer-Verlag London Ltd., part of Springer Nature.)

Purpose: To assess the feasibility and safety of a robotic system for percutaneous needle insertion during thermal ablation of liver tumors., Materials and Methods: This study analyzed the CT-guided percutaneous needle insertion using the EPIONE robotic device (Quantum Surgical, Montpellier, France) for radiofrequency or microwave liver ablation. The main criteria of the study were feasibility (possibility to perform the thermal ablation after needle insertion), the number of needle adjustments (reiteration of robotically assisted needle insertion when initial needle positioning is considered insufficient to perform ablation), and robotic-guided procedure safety (complications related to the needle insertion). Patients were followed up at 6 months post-intervention to assess local tumor control., Results: Twenty-one patients with 24 tumors, including 6 HCC and 18 metastases measuring 15.6 ± 7.2 mm, were enrolled. One patient (with one tumor) was excluded for protocol deviation. Robotic assisted thermal ablation was feasible for 22/23 lesions (95.7%) and 19/20 patients (95.0%), as validated by a data safety monitoring Board (95% CI [76.39%; 99.11%]) for the per-protocol population. The mean number of needle adjustments per tumor treated was 0.4 (SD: 0.7), with 70.8% of tumors requiring no adjustment. No adverse events were depicted. Rate of local tumor control was 83.3% for patients and 85.7% for tumors, at 6 months., Conclusion: This bicentric first-in-human pilot study suggests both feasibility and safety of a stereotactic CT-guided EPIONE device for the percutaneous needle insertion during liver tumor thermal ablation., (© 2022. The Author(s).)

Background: In recent years, there has been increasing interest in outpatient spine surgery. Minimally invasive techniques have created an opportunity for ambulatory lumbar fusion, and these techniques increasingly involve advanced technologies such as navigation and robotics., Objective: To explore the barriers, advantages, and future predictions for such technology in the context of outpatient lumbar fusions., Methods: This is a narrative review of studies examining the advantages, limitations, and cost-effectiveness of navigation and spinal robotics in conjunction with the outcomes and costs of outpatient lumbar fusion., Results: Outpatient lumbar fusion is a growing trend with ample evidence of its safety, favorable patient outcomes, and cost savings. Navigation and spinal robotics are associated with improved instrumentation accuracy and fewer complications, and the long-term cost savings can make these technologies financially practical in the outpatient setting. Future capabilities with robotics will only increase their value., Conclusions: Advanced technologies such as navigation and robotics are strategic long-term investments in the context of outpatient lumbar fusion., Clinical Relevance: The favorable outcomes and costs associated with navigation and robotics will be relevant to any spine surgeon interested in developing an outpatient lumbar fusion program., Competing Interests: Declaration of Conflicting Interests: The authors report no conflicts of interest in this work., (This manuscript is generously published free of charge by ISASS, the International Society for the Advancement of Spine Surgery. Copyright © 2022 ISASS. To see more or order reprints or permissions, see http://ijssurgery.com.)

We present an implantable brain-computer interface surgical case assisted by robotic navigation system in an elderly patient with tetraplegia caused by cervical spinal cord injury. Left primary motor cortex was selected for implantation of microelectrode arrays based on fMRI location of motor imagery. Robotic navigation system was used during this procedure for precise and stable manipulation. A design of bipartite incision was made to reduce the risk of surgery-related infection and facilitate BCI training. At 1-year follow-up, the neural signals were robust, and this patient was able to control three-dimensional movement of a prosthetic limb without any complications., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Austria, part of Springer Nature.)

Aims: Robotic magnetic navigation (RMN) provides increased catheter precision and stability. Formerly, only the CARTO 3 mapping system was integrated with the RMN system (CARTO-RMN). Recently, a novel high-resolution non-contact mapping system (AcQMap) has been integrated with the RMN system (AcQMap-RMN) for the treatment of atrial fibrillation (AF) and atrial tachycardias (AT). We aim to compare the safety, efficiency, and efficacy of AcQMap-RMN with CARTO-RMN guided catheter ablation (CA) procedures., Material and Methods: In this prospective registry, procedural safety efficiency and outcome data from total of 238 consecutive patients (147 AcQMap-RMN and 91 CARTO-RMN patients) were compared., Results: AcQMap-RMN is non-inferior in the primary endpoint of safety as compared to CARTO-RMN across the whole group (overall procedural complications in 5 (3.4%) vs. 3 (3.3%) patients, p = 1.0). Overall procedure durations were longer and associated with more fluoroscopy use with AcQMap-RMN (172.5 vs. 129.6 min, p < 0.01; 181.0 vs. 131.0 mGy, p = 0.02, respectively). Procedure duration and fluoroscopy use decreased significantly between the first 30 and the last 30 AcQMap-RMN procedures. The AcQMap-RMN system had fewer recurrences after persistent AF ablations and was non-inferior in paroxysmal AF patients compared to CARTO-RMN at 12 months (36.6% vs. 75.0%, p = 0.04, PAF 6.6% vs. 12.5%, p = 0.58; respectively). CA of AT outcomes were better using the AcQMap-RMN system (1 year recurrence 17.1% vs. 38.7%, p < 0.05)., Conclusion: AcQMap-RMN integration has no negative impact on the excellent safety profile of RMN guided ablations. It improves outcomes of CA procedures for persAF and AT but requires longer procedure times and higher fluoroscopy use during the initial learning phase., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2022 The Author(s).)

The ability to navigate the anterior lumbar disc space may improve clinical outcomes and implant longevity. However, no robotic navigation systems are presently authorized by the U.S. Food and Drug Administration to assist with anterior retroperitoneal lumbar interbody surgery. Furthermore, no studies to date have investigated such an application of this technology. This study examines the application of robotic navigation to anterior lumbar total disc replacement surgery to improve retroperitoneal exposure and orientation of the anterior lumbar spine, enhance coronal plane centralization of the implant, optimize surgical trajectory, and mitigate radiologic exposure. Postoperative outcomes of a small cohort of patients undergoing anterior lumbar total disc replacement surgery using robotic navigation were analyzed. The results of the study revealed that a modified use of the aforementioned robot-assisted surgical technology enhances coronal plane centralization and trajectory, all while mitigating radiologic exposure, resulting in more accurate placement of the implant within the intervertebral space at each level., Competing Interests: The authors declare no conflict of interest., (© 2021 The Author(s).)

Objective: Several approaches have been studied for internal fixation of the spine using pedicle screws (PSs), including CT navigation, 2D and 3D fluoroscopy, freehand, and robotic assistance. Robot-assisted PS placement has been controversial because training requirements, cost, and previously unclear benefits. This meta-analysis compares screw placement accuracy, operative time, intraoperative blood loss, and overall complications of PS insertion using traditional freehand, navigated, and robot-assisted methods., Methods: A systematic review was performed of peer-reviewed articles indexed in several databases between January 2000 and August 2021 comparing ≥ 2 PS insertion methods with ≥ 10 screws per treatment arm. Data were extracted for patient outcomes, including PS placement, misplacement, and accuracy; operative time, overall complications, intraoperative blood loss, postoperative hospital length of stay, postoperative Oswestry Disability Index (ODI) score, and postoperative visual analog scale (VAS) score for back pain. Risk of bias was assessed using the Newcastle-Ottawa score and Cochrane tool. A network meta-analysis (NMA) was performed to estimate PS placement accuracy as the primary outcome., Results: Overall, 78 studies consisting of 6262 patients and > 31,909 PSs were included. NMA results showed that robot-assisted and 3D-fluoroscopy PS insertion had the greatest accuracy compared with freehand (p < 0.01 and p < 0.001, respectively), CT navigation (p = 0.02 and p = 0.04, respectively), and 2D fluoroscopy (p < 0.01 and p < 0.01, respectively). The surface under the cumulative ranking (SUCRA) curve method further demonstrated that robot-assisted PS insertion accuracy was superior (S = 0.937). Optimal screw placement was greatest in robot-assisted (S = 0.995) placement, and misplacement was greatest with freehand (S = 0.069) approaches. Robot-assisted placement was favorable for minimizing complications (S = 0.876), while freehand placement had greater odds of complication than robot-assisted (OR 2.49, p < 0.01) and CT-navigation (OR 2.15, p = 0.03) placement., Conclusions: The results of this NMA suggest that robot-assisted PS insertion has advantages, including improved accuracy, optimal placement, and minimized surgical complications, compared with other PS insertion methods. Limitations included overgeneralization of categories and time-dependent effects.

Pedicle screw fixation in pediatric spine surgery has become common practice given the fixation stability and improved curve correction. However, due to proximity to vital structures, accuracy is paramount. Literature has reported accuracy rates from 87.5 to 90% using traditional freehand techniques. This study presents our initial experience with pedicle screw placement using the newest generation of spinal robotics for treatment of pediatric spinal deformity. A cohort of patients, aged 8-21 years, undergoing spinal fusion surgery using robotic-assisted technology was reviewed. Diagnoses, Cobb angles, surgical time, robot time, number of screws placed, and complications were recorded. Accuracy of screw placement was assessed based on analysis of successful screw execution, evaluation screw position using intraoperative fluoroscopy and post-operative radiographs, and clinical evaluation. The average age was 14.5 years. Prevalent diagnoses included idiopathic (65%) and neuromuscular scoliosis (13%). Mean preoperative curve measured 66.8°. The median time for operation was 235 minutes with medians of 8 levels fused and 5 screws placed per patient. Of the 314 screws placed, we recorded a 98.7% accuracy rate. Lateral deviation was the most common cause of malpositioning. Post-operative plain films revealed no grossly misplaced screws. There were no perioperative neurologic deficits or malpositioned screws requiring reoperation. This is the first reported series of navigated spinal robotics used for pedicle screw placement in children. Our clinical success rate was 98.7% and there were no clinically relevant screw related complications. The study shows promising initial results of combined robotic-navigation techniques in pediatric patients., (© 2020. Springer-Verlag London Ltd., part of Springer Nature.)

As robotics in spine surgery has progressed over the past 2 decades, studies have shown mixed results on its clinical outcomes and economic impact. In this review, we highlight the evolution of robotic technology over the past 30 years, discussing early limitations and failures. We provide an overview of the history and evolution of currently available spinal robotic platforms and compare and contrast the available features of each. We conclude by summarizing the literature on robotic instrumentation accuracy in pedicle screw placement and clinical outcomes such as complication rates and briefly discuss the future of robotic spine surgery., Competing Interests: Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Darren R. Lebl, MD, reports relationships with Medtronic, Nuvasive, Stryker, Depuy Synthes, Guidepoint, Remedy Logic, ISPH II, Vestia Ventures, MiRUS, Woven Orthopedic Technologies, Integrity Implants, and HS2. Sheeraz A. Qureshi, MD, MBA, reports relationships with Stryker K2M, Globus Medical, Paradigm Spine, AMOpportunities, RTI Surgical, Integrity Implants, Medical Device Business Services, Medtronic USA, Nuvasive, Avaz Surgical, Simplify Medical, Tissue Differentiation Intelligence, Vital 5, Spinal Simplicity, LifeLink.com, Healthgrades, Society of Minimally Invasive Spine Surgery, Simplify Medical, North American Spine Society, Minimally Invasive Spine Study Group, Lumbar Spine Research Society, International Society for the Advancement of Spine Surgery, Contemporary Spine Surgery, Cervical Spine Research Society, Association of Bone and Joint Surgeons, and Annals of Translational Medicine. Ram K. Alluri, MD, Fedan Avrumova, BS, Ahilan Sivaganesan, MD, and Avani S. Vaishnav, MBBS, declare no potential conflicts of interest., (© The Author(s) 2021.)

Sacroiliac joint (SIJ) pathology is a common cause of significant pain and disability, and operative treatment consisting of SIJ fusion can be performed in cases where non-operative measures fail to provide sustained relief. Through the years, SIJ fusion has evolved from an open invasive procedure, to more recently, being performed through minimally invasive techniques. Intraoperative navigation systems and robotic guidance are becoming popularized for SIJ fusion, as well as other routine and complex spinal cases. The utility of navigation and robotics is the enhanced ability of the surgeon to place instrumentation more accurately, with less dissection, blood less, and overall operative time. We present a technique guide for robotic instrumented SIJ fusion with intraoperative navigation that we have put into practice at our institution and found to be very beneficial to patients for the above reasons. We describe the setup and utilization of these technologies intraoperatively, and provide specific case examples to highlight our technique. The described methods have been found to be effective and reproducible, allowing for minimally invasive SIJ screw placement with high accuracy and safety. We emphasize that utilizing intraoperative navigation and robotics is not meant to substitute for surgeon knowledge of case steps or anatomy, but rather to enhance safety and efficacy. To our knowledge, robotic SIJ fusion has not been previously described in the literature., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/jss-20-681). Dr. RDP reports personal fees and other from Globus, outside the submitted work; Dr. ISA reports grants from Orthofix, outside the submitted work. The other authors have no conflicts of interest to declare., (2021 Journal of Spine Surgery. All rights reserved.)

Background: Robot-assisted surgery was developed to improve accuracy and outcomes in total knee arthroplasty (TKA). One important determinant of TKA success is a well-balanced knee throughout the range of motion. The purpose of this study is to determine if robot-assisted TKA (RA-TKA) results in improved intracompartmental ligament balance compared with conventional jig-based instrumentation (CM-TKA)., Methods: This retrospective cohort study included 2 cohorts-a CM-TKA (n = 49) vs RA-TKA (n = 37) cohort. Demographic and intraoperative data, including intraoperative compartment loads, were measured after final implant implantation in extension (10°), mid-flexion (45°), and full flexion (90°), using an intraoperative compartment pressure sensor. An a priori power analysis revealed our study exhibited >80% power in detecting a 5-pound (lb) difference in compartment loads in the 2 cohorts., Results: There was no difference between medial and lateral compartment loads in extension, mid-flexion, and full flexion for the conventional (15.1 lbs, 15.9 lbs, and 13.4 lbs, respectively) vs RA-TKA (14.2 lbs, 15.1 lbs, and 10.3 lbs, respectively). The percentage of patients with high load compartment pressure in flexion (>40 lbs) by the conclusion of the surgery was significantly greater for the conventional (18%) vs the robotic TKA cohort (3%, P  = .025). The percentage of patients with unbalanced knees (>20 lbs differential between medial and lateral compartments) in flexion was significantly greater in the conventional (24%) vs robotic TKA cohort (5%, P  = .018)., Conclusions: In this series, RA-TKA resulted in improved intraoperative compartment balancing in flexion with no observed difference in mid-flexion and extension compared with CM-TKA., (© 2020 The Authors.)

Background: The quality of catheter-tissue contact is one of the most important determinants of catheter ablation (CA) success. The absence of catheter-tissue contact feedback has been regarded a major limitation of remote magnetic navigation (RMN)-guided CA. The e-Contact module (ECM) is a novel feature designed for RMN that measures the quality of catheter-tissue contact., Objective: The purpose of this study was to describe the first clinical experience with this feature and to test its effect on procedural parameters and interference with other ablation equipment during CA procedures as well as its safety., Methods: This was a prospective, single-center, 2-phase study investigating ECM use during complex RMN procedures in 30 patients. Impact of ECM on procedural parameters was evaluated in the feasibility phase (FP), and its interference with other equipment was tested in the interference phase (IP) using pacing maneuvers at 3 randomly selected right atrial sites. Intracardiac electrograms were evaluated for disturbances by 2 independent electrophysiologists., Results: For FP, mean procedural time was 162 ± 66 minutes, fluoroscopy time 21 ± 9 minutes, and ablation time 34 ± 21 minutes. For IP, no significant differences in pacing capture or thresholds were found (ECM- vs ECM+: site 1: 2.05 vs 2.21 mA; P = .320; site 2: 2.15 vs 2.12 mA; P = .873; site 3: 2.51 vs 2.50 mA; P = .976). Electrogram disturbances did not significantly differ between ECM- and ECM+. No adverse events were reported., Conclusion: The ECM is a novel catheter-tissue contact technology designed for RMN-guided CA. Our study suggests that this feature is feasible and does not interfere with other electrophysiology equipment while maintaining an excellent safety profile., (© 2020 Heart Rhythm Society. Published by Elsevier Inc.)

Robot-assisted spine surgery has recently emerged as a viable tool to enable less invasive and higher precision surgery. The first-ever spine robot, the SpineAssist (Mazor Robotics Ltd., Caesarea, Israel), gained FDA approval in 2004. With its ability to provide real-time intraoperative navigation and rigid stereotaxy, robotic-assisted surgery has the potential to increase accuracy while decreasing radiation exposure, complication rates, operative time, and recovery time. Currently, robotic assistance is mainly restricted to spinal fusion and instrumentation procedures, but recent studies have demonstrated its use in increasingly complex procedures such as spinal tumor resections and ablations, vertebroplasties, and deformity correction. However, robots do require high initial costs and training, and thus, require justification for their incorporation into common practice. In this review, we discuss the history of spinal robots along as well as currently available systems. We then examine the literature to evaluate accuracy, operative time, complications, radiation exposure, and costs - comparing robotic-assisted to traditional fluoroscopy-assisted freehand approaches. Finally, we consider future applications for robots in spine surgery., Competing Interests: The authors report no conflicts of interest in this work., (© 2019 D’Souza et al.)

This paper proposes an architecture that explores a gap in the spectrum of existing strategies for robot control mode switching in adjustable autonomy. In situations where the environment is reasonably known and/or predictable, pre-planning these control changes could relieve robot operators of the additional task of deciding when and how to switch. Such a strategy provides a clear division of labour between the automation and the human operator(s) before the job even begins, allowing for individual responsibilities to be known ahead of time, limiting confusion and allowing rest breaks to be planned. Assigned Responsibility is a new form of adjustable autonomy-based teleoperation that allows the selective inclusion of automated control elements at key stages of a robot operation plan's execution. Progression through these stages is controlled by automatic goal accomplishment tracking. An implementation is evaluated through engineering tests and a usability study, demonstrating the viability of this approach and offering insight into its potential applications.

Objectives: Circumferential pulmonary vein isolation (CPVI) using irrigated radiofrequency is the most frequently used ablation technique for the treatment of atrial fibrillation worldwide., Background: To date, no large randomized multicenter trials have evaluated the efficacy and safety of CPVI using robotic navigation (RN) systems compared with the current gold standard of manual ablation (MN)., Methods: In this prospective, international multicenter noninferiority trial, 258 patients with paroxysmal or persistent atrial fibrillation were randomized for CPVI using either RN (RN group, n = 131) or manual ablation (MN group, n = 127). In all patients, CPVI was performed using irrigated radiofrequency ablation in combination with a 3-dimensional mapping system. The primary endpoint was the absence of atrial arrhythmia recurrence on or off antiarrhythmic drugs during a 12-month follow-up period. Secondary endpoints were the evaluation of periprocedural complications and procedural data such as procedure time, fluoroscopy time, and incidence of esophageal injury., Results: Baseline characteristics were comparable between the RN group and MN group. Procedure time was significantly shorter in the MN group (129.3 ± 43.1 min vs. 140.9 ± 36.5 min; p = 0.026). 247 patients completed the 12-month follow-up (RN group, n = 123; MN group, n = 124). Recurrence rate was comparable between the RN and MN groups (n = 29 of 123 [23.6%] vs. 25 of 124 [20.2%]). The incidence of procedure-related major complications did not differ significantly between ablation arms (RN group, n = 8 [6.1%] vs. MN group, n = 6 [4.7%]; p = 0.62). One patient from the RN group developed a fatal atrioesophageal fistula., Conclusions: This study demonstrated that robotic ablation is noninferior to the current gold standard of manual ablation for CPVI with respect to success and complication rates. Procedure times were significantly longer in the RN group. (Alster Man and Machine: Comparison of Manual and Mechanical Remote Robotic Catheter Ablation for Drug-Refractory Atrial Fibrillation; NCT00982475)., (Copyright © 2017 American College of Cardiology Foundation. All rights reserved.)

Background: Long-term results after circumferential pulmonary vein isolation (CPVI) for the treatment of paroxysmal atrial fibrillation (PAF) using a robotic navigation system (RNS) have not yet been reported., Objective: To evaluate long-term results of patients with PAF after CPVI using RNS., Methods: In this study, 200 patients (n = 151 (75.5%) male; median age 62.2 (54.7-67.7) years) with PAF were evaluated. In 100 patients, RNS (RN-group) was used for CPVI and compared to 100 manually ablated control patients (MN-group). Radiofrequency was used in conjunction with 3D electroanatomic mapping. Power was limited to 30 watts (W) at the posterior left atrial (LA) wall in the first 49 RNS patients (RN-group-a). After esophageal perforation occurred in one RN-group-a patient, maximum power was reduced to 20 W for the subsequent 51 patients (RN-group-b)., Results: After a median follow-up of 2 years, single (77/100 vs 77/100, p = 0.89) and multiple (90/100 vs 93/100, p = 0.29) procedure success rates were comparable between RN-group and MN-group. Single procedure success rate was significantly lower in RN-group-a as compared to RN-group-b (65.3 vs 88.2%, p = 0.047). In RN-group-a patients, procedural times [200 (170-230) vs 152 (132-200) minutes, p < 0.01] and fluoroscopy times [16.6 (12.9-21.6) minutes vs 13.7 (9.5-19) minutes, p = 0.043] were significantly longer compared to RN-group-b patients., Conclusion: Long-term success rate after CPVI using RNS was comparable to manual ablation. Despite a lower power limit of 20 W at the posterior LA wall, single procedure success rate was higher in RN-group-b as compared to RN-group-a. Procedure time and fluoroscopy time decreased, whilst success rate increased with increasing experience in the RN-group.

The challenge is to accurately guide the surgical tool within the three-dimensional (3D) surgical field for robotically-assisted operations such as tumor margin removal from a debulked brain tumor cavity. The proposed technique is 3D image-guided surgical navigation based on matching intraoperative video frames to a 3D virtual model of the surgical field. A small laser-scanning endoscopic camera was attached to a mock minimally-invasive surgical tool that was manipulated toward a region of interest (residual tumor) within a phantom of a debulked brain tumor. Video frames from the endoscope provided features that were matched to the 3D virtual model, which were reconstructed earlier by raster scanning over the surgical field. Camera pose (position and orientation) is recovered by implementing a constrained bundle adjustment algorithm. Navigational error during the approach to fluorescence target (residual tumor) is determined by comparing the calculated camera pose to the measured camera pose using a micro-positioning stage. From these preliminary results, computation efficiency of the algorithm in MATLAB code is near real-time (2.5 sec for each estimation of pose), which can be improved by implementation in C++. Error analysis produced 3-mm distance error and 2.5 degree of orientation error on average. The sources of these errors come from 1) inaccuracy of the 3D virtual model, generated on a calibrated RAVEN robotic platform with stereo tracking; 2) inaccuracy of endoscope intrinsic parameters, such as focal length; and 3) any endoscopic image distortion from scanning irregularities. This work demonstrates feasibility of micro-camera 3D guidance of a robotic surgical tool.

Background: Time-of-flight (TOF) cameras can guide surgical robots or provide soft tissue information for augmented reality in the medical field. In this study, a method to automatically track the soft tissue envelope of a minimally invasive hip approach in a cadaver study is described., Methods: An algorithm for the TOF camera was developed and 30 measurements on 8 surgical situs (direct anterior approach) were carried out. The results were compared to a manual measurement of the soft tissue envelope., Results: The TOF camera showed an overall recognition rate of the soft tissue envelope of 75%. On comparing the results from the algorithm with the manual measurements, a significant difference was found (P > .005)., Conclusions: In this preliminary study, we have presented a method for automatically recognizing the soft tissue envelope of the surgical field in a real-time application. Further improvements could result in a robotic navigation device for minimally invasive hip surgery., (© The Author(s) 2014.)