Dale J. Podolsky

Infant Robotic Cleft Palate Surgery: A Feasibility Assessment Using a Realistic Cleft Palate Simulator

Background: A surgical robot offers enhanced precision, visualization, and access and the potential to improve outcomes in cleft palate surgery. The goal of this study was to investigate the feasibility of using the da Vinci robot for cleft palate repair in infants using a cleft palate simulator test bed. Methods: A high-fidelity cleft palate simulator was developed that allows performance of a robotic cleft palate repair procedure. A complete cleft palate repair was performed with the da Vinci Si with 5-mm instruments and the da Vinci Xi with 8-mm instruments. The advantages of the robotic approach were assessed in comparison with using standard instruments. For each system, arm repositioning, collisions, instrument and endoscope excursion, wrist orientation, and vision were compared for 12 steps of the repair. Results: The cleft palate simulator provided a reproducible platform for testing robotic cleft palate surgery. The advantages of the robotic approach were the ability to articulate a miniature wrist intraorally with superior visualization, increased ambidexterity, and improved ergonomics compared with using standard instruments. Cleft palate repair with the Xi was superior to the Si with respect to arm repositioning, instrument collisions and excursion, and wrist orientation. However, Xi performance remained suboptimal because of the larger instruments. Conclusions: Robotic cleft palate repair using the da Vinci system offers advantages compared with the traditional approach. Cleft palate repair is more feasible with the Xi and 8-mm instruments. However, performance is limited by the instrumentation, which requires modification to ensure safety and efficacy. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Evaluation and Implementation of a High-Fidelity Cleft Palate Simulator.

Background: Cleft palate repair is a challenging procedure to learn because of the delicate tissue handling required and the small confines of the infant oral cavity. As a result, cleft palate simulators have previously been described to augment cleft palate repair training. Although valuable, they lack the fidelity for this complex procedure. Methods: A high-fidelity cleft palate simulator was evaluated by staff and fellows in pediatric plastic surgery who provided feedback on its realism, anatomical accuracy, and effectiveness as a training tool. The simulator was implemented within a training workshop following a didactic session on cleft palate repair and anatomy. A test was administered to each participant before and immediately after the workshop to assess knowledge transfer. Perceived confidence of performing a repair following the workshop was also assessed, as was the workshop’s effectiveness. Results: Overall, participants agreed that the simulator is anatomically accurate and realistic and strongly agreed that the simulator is a valuable training tool. The average test score increased from 25 percent before the workshop to 77.27 percent after the workshop. Overall, participants of the workshop felt more confident performing a repair and strongly agreed that the workshop was valuable and effective. Conclusions: A high-fidelity cleft palate simulator has been evaluated as realistic, anatomically accurate, and valuable as a training tool. The simulator was successfully integrated into a training workshop, which resulted in significant knowledge increase on anatomy and the procedure and perceived confidence and comfort in performing a cleft palate repair.

Miniaturized Instruments for the da Vinci Research Kit: Design and Implementation of Custom Continuum Tools

The da Vinci Surgical System is a commercially available surgical robotics platform used to perform more than 450,000 surgeries annually, primarily for gynecological and urological procedures [1]. This technology enhances the surgeons dexterity through the use of a multiarm robot with wristed instruments that enter a patients body through small incisions. However, the size of existing instruments (5-8 mm in shaft diameter) has prevented the adoption of the da Vinci system in areas such as neurosurgery, head and neck surgery, and pediatrics [2], [3]. These applications require high dexterity in small, confined workspaces, and, therefore, new miniaturized tools are needed [4].

Economy of Hand Motion During Cleft Palate Surgery Using a High-Fidelity Cleft Palate Simulator.

Objective: The objectives of this study were to assess economy of hand motion of residents, fellows, and staff surgeons using a high-fidelity cleft palate simulator to (1) stratify performance for the purpose of simulator validation and (2) to estimate the learning curve. Design: Two residents, 2 fellows, and 2 staff surgeons performed cleft palate surgery on a high-fidelity cleft palate simulator while their hand motion was tracked using an electromagnetic hand sensor. The time, number of hand movements, and path length of their hands were determined for 10 steps of the procedure. The magnitude of these metrics was compared among the 3 groups of participants and utilized to estimate the learning curve using curve-fitting analysis. Results: The residents required the most time, number of hand movements, and path length to complete the procedure. Although the number of hand movements was closely matched between the fellows and staff, the overall total path length was shorter for the staff. Inverse curves were fit to the data to represent the learning curve and 25 and 113 simulation sessions are required to reach within 5% and 1% of the expert level, respectively. Conclusion: The simulator successfully stratified performance using economy of hand motion. Path length is better matched to previous level of experience compared to time or number of hand movements.

Utilization of a robotic mount to determine the force required to cut palatal tissue

Determination of the material properties of soft tissue is a growing area of interest that aids in the development of new surgical tools and surgical simulators. This study first aims to develop a robot-operated tissue testing system for determination of tissue cutting forces. Second, this system was used to ascertain the cutting properties of the hard and soft palate mucosa and soft palate musculature for the purpose of developing a robotic instrument for cleft palate surgery and a cleft-specific surgical simulator. The palate tissue was cut with a 15 blade mounted to the robot with varying angles (30°, 60°, 90°) and speeds (1.5, 2.5, 3.5 cm/s) of cutting to imitate typical operative tasks. The cutting force range for hard palate mucosa, soft palate mucosa and soft palate muscle were 0.98-3.30, 0.34-1.74 and 0.71-2.71 N, respectively. The break-in force of the cut (i.e. force required for the blade to penetrate the tissue) is significantly impacted by the angle of the blade relative to the tissue rather than the cutting speed. Furthermore, the total surface area of the tissue in contact with the blade during the cut has a significant impact on the total force expended on the tissue.