IEEE Robotics & Automation Magazine - March 2022 - 69

the standard da Vinci (DV) grasper. The motion of the tools
were controlled using commercial inertial measurement unit
(IMU) sensor-based devices attached to the user's arms and
hands. This article summarizes results obtained from three
studies with similar features but different levels of
complexity, taken with both lay users with no experience in
surgery or teleoperation and surgeons experienced in
RAMIS. The results showed that more than 70% of users
achieved better results using articulated tools but required
more physical and mental effort for teleoperation.
Introduction
Minimally invasive surgery (MIS) and its noticeable benefits
for patients in terms of fast recovery makes it a popular choice
for a wide range of surgeries. Open surgery has always been
invasive, causing high stress and pain for the patient, a prolonged
recovery and exposure to higher risks of infections [1].
MIS, on the other hand, requires small incisions to allow
instrument shafts to enter the surgical site through trocars
plus additional holes to insert lights and cameras. The small
incisions cause less postoperative pain and leave smaller scars
with overall better physical and psychological recovery [1],
[2]. Even though benefits for the patient have been established,
MIS brings some challenges to the operator, including
vision, dexterity, and ergonomy [3].
RAMIS has overcome several identified MIS issues, such
as fulcrum effect, surgeon's physical tremor due to muscular
fatigue, and hand-eye coordination. These improvements
have made some types of surgery, previously impossible, routinely
performed in hospitals [4]. Robotic surgeries are widely
used but come with high costs to the system, a lack of haptic
feedback, and a steep learning curve for junior surgeons. The
DV EndoWrist, with its three-axis joint resembling the dexterity
of the human wrist, allows surgeons to perform dexterous
tasks, otherwise difficult with rigid laparoscopic tools [5].
Laparoscopy has seen the addition of an elbow joint to secure
surgical triangulation and positioning of the tools in singleincision
laparoscopic surgery [6], [7]. Despite the progress
made using rigid instruments with dexterous wrists in particular
tasks, [8], there is continued demand for dexterity-motivated
developments of more articulated tools. The number of
DoF with more articulated and flexible tools as in [9] and
[10], and a number of different research platforms for flexible
access surgery have recently been developed, including highly
articulated robotic probes [11], the multitasking platform
[12], and two-module soft endoscopes [13] as well as other
instruments for surgeries performed in particularly constrained
areas, such as the throat [14]. However, increased the
dexterity of the surgical tools increases teleoperation complexity.
With a provision of increased instrument articulation,
a more sophisticated primary controller is needed to meet the
high number of DoF, as in [13].
High-DoF Master Controllers
In spite of some efforts to gain intuitive control of complex
devices [15], [16], the difficulties associated with
teleoperation are still impediments to the deployment of
effective and usable dexterous secondary instruments. Examples
of anthropomorphic control of robotic arms and optimized
human-robot arm/hand mapping can be found in
[17] and [18] using Kinect sensors and deep neural networks,
respectively. Wearable approaches of arm/hand tracking
based on commercially available sensors (Xsens
products) [19], [20], although not developed specifically for
surgeries, implemented the idea of using human body
motion to control human-like robotic arms.
In the Horizon 2020 SMart weArable Robotic Teleoperated
Surgery (SMARTsurg) project [21], funded by the European
Commission, we explored how to enable more complex
minimally invasive surgical operations by developing a wearable
primary concept to reduce cognitive load by allowing
greater teleoperation dexterity. In this direction, we conducted
a large requirement-elicitation study with a group of surgeons
from different surgical backgrounds [22], which
highlighted potential benefits of the surgical wearable primary
concept. For this purpose, we set up three user studies with
the aim to assess advantages and limitations of an intuitive,
anthropomorphic teleoperation system in simulated surgical
scenarios. We investigated the efficacy of tools with an
extended number of DoF, mapped and teleoperated by a
commercial anthropomorphic tracking device.
Purpose
The purpose of this study was to evaluate dexterous, surgical
robotic platforms adaptable to arm/hand anthropomorphic
master controllers using a set of wearable sensors to control a
high degree of dexterity patient side manipulators in immersive,
virtual surgical environments. The instruments used in
the simulations feature a different number of joints on the
instrument shaft and various types of the surgical end effector.
Materials and Methods
We performed three user studies of increasing complexity on
diverse occasions with three different user groups. In each
study, different surgical instruments or primary control systems
were used to execute the same set of tasks. All the virtual
surgical tasks were built in Unity, a software for game
design and graphic applications. Two different end effectors
were tested: the DV standard grasper and the three-fingered
tool (3 F), an anthropomorphic grasper proposed and developed
in the SMARTsurg project. The length of the DV
grasper is 28 mm. The 3 F tool has three articulated digits,
each with two DoF. The first and second phalanx of each
digit is 24.64- and 19.84-mm long, respectively. The 3 F tool
is designed to have a powerful grasp and permit more dexterous
manipulations. The surgical tasks were inspired by the
DV training simulator, which features different single or
bimanual tasks, including peg transfer, suturing, and so on.
The virtual surgical tasks, aimed at testing instrument dexterity,
intuitiveness, and ease of the primary controller, were
co-designed with a surgeon experienced in using the DV
surgical system. The tasks were not designed to be overly
MARCH 2022 * IEEE ROBOTICS & AUTOMATION MAGAZINE *
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IEEE Robotics & Automation Magazine - March 2022

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