Opportunities and challenges in improving surgical work flow

Safe and efficient surgical operations depend on a work environment larger than the individual operating room (OR) and on communications at different levels of the hospital organization. Extensive communication is needed before and during surgery to ensure that surgical rooms, equipment, and supplies; patients; surgeons; supporting personnel; and accompanying documentation are all ready at the appropriate times. In this article, we compile the results of three of our studies of communication activities outside ORs, with the goal of identifying opportunities and challenges in the workflow of surgery. The first study demonstrates the amount of communication work performed by OR coordinators. The second study demonstrates the potential functions of a whiteboard in communication. The third study describes an organizational learning strategy of proactive event reporting. We apply computer-supported cooperative work and organizational learning concepts to the findings and suggest ways in which information technology may improve surgical workflow.     

A hybrid genetic approach for solving an integrated multi-objective operating room planning and scheduling problem

In this paper, we propose a multi-objective integer linear programming model aiming at efficiently planning and managing hospital operating room suites. By effectively exploiting a novel hybrid genetic solution approach, the devised optimization model is able to determine, in an integrated way, (i) the operating room time assigned to each surgical specialty, (ii) the operating room time assigned to each surgical team, (iii) the surgery admission planning and (iv) the surgery scheduling. The resulting Pareto frontiers provide a set of “optimal” solutions able to support hospital managers in efficiently orchestrating the involved resources and planning surgeons and surgeries. On this basis, the proposed solution framework could represent a suitable engine for the development of advanced and effective health care management decision support systems.     

Design and implementation of a PC-based image-guided surgical system

In interactive, image-guided surgery, current physical space position in the operating room is displayed on various sets of medical images used for surgical navigation. We have developed a PC-based surgical guidance system (ORION) which synchronously displays surgical position on up to four image sets and updates them in real time. There are three essential components which must be developed for this system: (1) accurately tracked instruments; (2) accurate registration techniques to map physical space to image space; and (3) methods to display and update the image sets on a computer monitor. For each of these components, we have developed a set of dynamic link libraries in MS Visual C++ 6.0 supporting various hardware tools and software techniques. Surgical instruments are tracked in physical space using an active optical tracking system. Several of the different registration algorithms were developed with a library of robust math kernel functions, and the accuracy of all registration techniques was thoroughly investigated. Our display was developed using the Win32 API for windows management and tomographic visualization, a frame grabber for live video capture, and OpenGL for visualization of surface renderings. We have begun to use this current implementation of our system for several surgical procedures, including open and minimally invasive liver surgery.     

Development of inverse dynamic model for a surgical hybrid parallel robot with equivalent lumped masses

Robotic-assisted surgery is a continuously developing field, as robots have demonstrated clear benefits in the operating room. This paper presents the inverse dynamic model (in the case of using the laparoscope as a surgical instrument) and some characteristics of a 5-DOF hybrid parallel robot designed for minimally invasive surgery. The new inverse dynamic model is obtained using the virtual work method on the basis of dynamically equivalent lumped masses. The simulation and numerical results have been obtained for the experimental model of the developed PARASURG-5M robot, showing that the analytical inverse dynamic model could be used in the control of the robot. Finally, a comparison between the simulation data obtained in Matlab (IDM) with the simulation data through a Multi-body Simulation software (MBS), namely Adams (MBS) has been performed.     

Steps in the development of a robotic scrub nurse

This paper describes how a robotic scrub nurse has been developed to assist human scrub nurses (also called delivery scrub nurses) during surgical interventions. The developed system in this work (nicknamed Quirubot) is equipped with a speech recognition module to recognize the requested surgical instrument; Quirubot locates this element on a storage tray using computer vision and pattern recognition and picks the element from the tray placing it on an interchange tray where the human scrub nurse can finally use this tool. Moreover, to implement the manipulation of surgical instruments, an electromagnetic gripper has been adapted to pick and place them. Fanuc LR Mate 200iB robot has been electrically modified to add a new connector devoted to control the electromagnetic gripper. Nowadays Quirubot can identify up to 27 surgical instruments and more than 82 spoken instructions; the advantages of the system have been demonstrated using a group of experienced and intermediate skilled scrub nurses in a open abdominal aortic aneurysm surgery simulation (experiments performed in a robotics lab and an operating room). After this study, the use of a robotic scrub nurse is justified in an nBio operating room to improve the system up to obtaining a more robust version to be used at the Hospital Universitario de Sant Joan d’Alacant.     

Adaptive coordination in cardiac anaesthesia: a study of situational changes in coordination patterns using a new observation system

Patient care in hospital settings requires coordinated team performance. Studies in other industries show that successful teams adapt their coordination processes to the situational task requirements. This prospective field study aimed to test a new observation system and investigate patterns of adaptive coordination within operating room teams. A trained observer recorded coordination activities during 24 cardiac surgery procedures. The study tested whether different patterns occur during different phases of and between different types of surgical procedures (two-way multivariate ANOVA with repeated measure). A statistically significant increase was found in clinical and coordination activities in phases of the operation with high task interdependence. The highest level of 'coordination via the work environment' (i.e. an implicit coordination mechanism) was recorded during the actual procedure on the beating heart. These findings prove the sensitivity of the observation system developed and evaluated in this study and provide insight into patterns of adaptive coordination in cardiac anaesthesia. This study furthers our understanding of adaptive coordination as a cornerstone of effective team performance in complex work environments. Using a new observation system, it describes patterns employed by health care professionals in response to changing task demands in an acute patient care setting.     

Optimization of layout and path planning of surgical robotic system

Positioning a surgical robot for optimal operation in a crowded operating room is a challenging task. In the robotic-assisted surgical procedures, the surgical robot’s end-effector must reach the patient’s anatomical targets because repositioning of the patient or surgical robot requires additional time and labor. This paper proposes an optimization algorithm to determine the best layout of the operating room, combined with kinematics criteria and optical constraints applied to the surgical assistant robot system. A new method is also developed for trajectory of robot’s end-effector for path planning of the robot motion. The average deviations obtained from repeatability tests for surgical robot’s layout optimization were 1.4 and 4.2 mm for x and y coordinates, respectively. The results of this study show that the proposed optimization method successfully solves the placement problem and path planning of surgical robotic system in operating room.

     

Improving cardiac surgical care: A work systems approach

Over the past 50 years, significant improvements in cardiac surgical care have been achieved. Nevertheless, surgical errors that significantly impact patient safety continue to occur. In order to further improve surgical outcomes, patient safety programs must focus on rectifying work system factors in the operating room (OR) that negatively impact the delivery of reliable surgical care. The goal of this paper is to provide an integrative review of specific work system factors in the OR that may directly impact surgical care processes, as well as the subsequent recommendations that have been put forth to improve surgical outcomes and patient safety. The important role that surgeons can play in facilitating work system changes in the OR is also discussed. The paper concludes with a discussion of the challenges involved in assessing the impact that interventions have on improving surgical care. Opportunities for future research are also highlighted throughout the paper.     

The road to surgical simulation and surgical navigation

The recent advantage of the power of graphic workstations has made it possible to handle 3D human structures in an interactive way. Real-time imaging of medical 3D or 4D images can be used not only for diagnosis, but also for various novel medical treatments. By elaborating on the history of the establishment of our laboratory, which focuses on medical virtual reality, we describe our experience of developing surgery simulation and surgery navigation systems according to our research results. In the case of surgical simulation, we mention two kinds of virtual surgery simulators that produce the haptic sensation of surgical maneuvers in the user’s fingers. Regarding surgical navigation systems, we explain the necessity of the augmented reality function for the encouragement of the ability of robotic surgery and its trial for clinical case.     

膝关节镜手术仿真训练系统设计

利用虚拟现实技术建立的手术仿真训练系统,可以大大减少内窥镜等疑难手术的培训时间并节约昂贵的动物实验费用.为满足膝关节镜手术训练的需要,针对虚拟手术仿真的技术特点,提出了关于虚拟现实技术的膝关节镜手术仿真训练系统的设计,主要对系统体系结构、软件结构、功能模块和系统界面的设计和技术实现进行了研究,最终实现了一个支持双手操作的手术仿真训练系统.实践证明,系统能逼真地模拟手术的流程,取得了良好的训练效果.     

Robotic surgery setup simulation with the integration of inverse-kinematics computation and medical imaging

At present, there are representative robot operation systems such as da Vinci and ZEUS which have realized minimally invasive surgery by the use of dexterous manipulators. In the operating room, medical staff must prepare and set up an environment in which the robot has optimal freedom of motion and its functions can be fully demonstrated for every case. The range of motion in which the robot can reach and be maneuvered is restricted by the fixed point of the trocar site. We have developed a preoperative planning system with the function of volume rendering of medical images and automatic positioning by applying an inverse-kinematics computation of surgical robot. The motion of a surgical robot can be simulated in advance with the intuitive interface and kinematics computation program running in the background of the system. If robotic surgery planning with volume rendering of DICOM images is possible, the discussion of a surgical plan can be directly made just after the diagnosis considering the patient-specific structure. This kind of setup platform would be essential for the future introduction of surgical robotics into an operating room.     

“What are We Missing?” Usability’s Indexical Ground

In this paper, we describe how usability provides the indexical ground upon which design work in a surgery is achieved. Indexical and deictic referential practices are used (1) to constitute participation frameworks and work sites in an instructional surgery and (2) to encode and manage participants’ differential access to the relevancies and background knowledge required for the achievement of a successful surgical outcome. As a site for both learning and work, the operating room afforded us the opportunity to examine how usability, which is a critical design consideration, can be used as a resource for learning in interaction. In our detailed analysis of the interaction among participants (both co-present and projected) we sought to describe a particular case of how usability was produced as a relevant consideration for surgical education in the operating room. In doing so, we demonstrate a set of members’ methods by which actors worked to establish and provide for the relevance of the anticipated needs of projected users as part of developing an understanding of their current activity.

腹腔镜机器人控制系统的设计及实现

根据机器人辅助微创手术任务的特点设计了腹腔镜机器人控制系统．研究了基于运动控制卡的 开放式机器人控制器结构,设计了机器人伺服系统及相应控制器硬件接口,采用面向对象的技术和模块化思 想开发了系统控制软件,应用灵活度和可操作度概念建立了腹腔镜机器人的手术规划和控制平台．通过调试 伺服参数提高了系统控制性能．实验表明,该腹腔镜机器人控制系统具有稳定性、高可靠性和多任务适应性, 满足微创手术需求．     

Video-as-data: Technical and social aspects of a collaborative multimedia application

We studied the use of a collaborative multimedia system for coordinating teamwork among members of a neurosurgical team. We analyze the use of video within the operating room and the use of broadcast audio and video to other locations in the hospital to enable remote neurophysiological monitoring. We describe how the multimedia system was used in a real world work context, including its benefits and problems. We argue that video can be useful as more than just pictures of people talking to one another; video can be a rich tool to enable analysis and problem solving. We discuss privacy problems inherent in collaborative multimedia technology and describe how they played out in the hospital during the course of our study.     

User interface evaluation of a multimedia CD-ROM for teaching minor skin surgery

Expert operative information is a prerequisite for any form of surgical training. However, the shortening of working hours has reduced surgical training time and learning opportunities. As a potential solution to this problem, multimedia programs have been designed to provide computer-based assistance to surgical trainees outside of the operating theatre. Few studies, however, have focused on the interface features of surgical multimedia programs, the successful design of which could be conducive to the evaluation of the effectiveness of learning. This study evaluated a multimedia CD-ROM designed for teaching minor skin surgery. A questionnaire, based on an existing user interface rating tool, was administered to 20 trainees (both junior and senior) in plastic surgery. Findings from the study revealed trainees' high rating of the CD-ROM on a scale of 1–10 (mean = 8); the analysis of which contributes towards an understanding of both the characteristics of the learning material and the learners in the evaluation of the user interface.     

手术床控制系统的电磁兼容性设计

在手术室环境下,电磁干扰比较严重,各种医疗设备的正常工作较容易受到影响;针对手术室中常用的医疗设备———电动手术床,对其控制系统进行电磁兼容性(Electromagnetic Compatibility,EMC)设计,提高其EMC性能;首先采用故障树分析法对手术床控制系统进行EMC风险评估,找出导致控制系统EMC性能不良的原因;然后利用CAN总线、隔离、滤波等技术来完成本控制系统的EMC设计,软件方面采用抗干扰技术来保证程序的正确执行;经过测试表明,采用CAN总线设计的手术床控制系统具有较好的电磁兼容性,抗干扰性能较好,EMC风险评估方法和EMC设计方法具有参考价值。     

Haptic feedback and control of a flexible surgical endoscopic robot

A flexible endoscope could reach the potential surgical site via a single small incision on the patient or even through natural orifices, making it a very promising platform for surgical procedures. However, endoscopic surgery has strict spatial constraints on both tool-channel size and surgical site volume. It is therefore very challenging to deploy and control dexterous robotic instruments to conduct surgical procedures endoscopically. Pioneering endoscopic surgical robots have already been introduced, but the performance is limited by the flexible neck of the robot that passes through the endoscope tool channel. In this article we present a series of new developments to improve the performance of the robot: a force transmission model to address flexibility, elongation study for precise position control, and tissue property modeling for haptic feedback. Validation experiment results are presented for each sector. An integrated control architecture of the robot system is given in the end.     

Optimization of thermal fly-height control slider geometry for Tbit/in2 recording

Magnetic storage advances including thermal fly-height control (TFC) technology were able to reduce the clearance between the read/write elements of the slider and the disk surface to increase the recording density of hard disk drives without compromising the stability of the head–disk interface (HDI). Sliders employing TFC technology are designed for flying recording and can yield clearances of few nanometers. However, it is estimated that TFC technology alone cannot provide the even smaller clearances necessary to achieve Tbit/in² recording densities primarily due to the presence of instability-inducing vibrations at the HDI. In this work we perform optimization of the geometry of TFC technology sliders to achieve extremely high-density recording. We propose a flyability parameter coupled with a dynamic, contact mechanics-based friction model of the HDI that accounts for TFC geometry and its influence on the HDI dynamics. Optimization results are analyzed and an operating actuation range is identified that can yield Tbit/in² recording densities with Angstrom-level clearance and minimized vibrations while also accounting for manufacturing and operational tolerances. This allows for light (lubricant) contact or ‘surfing’ recording. The proposed methodology can be used to reduce wear at the interface and investigate the feasibility of contact recoding.     

Embedding robotic surgery into routine practice and impacts on communication and decision making: a review of the experience of surgical teams

While an increasing number of healthcare providers are purchasing surgical robots because of anticipated improvements in patient outcomes, their implementation into practice is highly variable. In robotic surgery, the surgeon is physically separated from the patient and the rest of the team with the potential to impact communication and decision making in the operating theatre and subsequently patient safety. Drawing on the approach of realist evaluation, in this article we review reports of the experience of surgical teams that have introduced robotic surgery to identify how and in what contexts robotic surgery is successfully integrated into practice and how and in what contexts it affects communication and decision making. Our analysis indicates that, while robotic surgery might bring about a number of benefits, it also creates new challenges. Robotic surgery is associated with increased operation duration, which has implications for patient safety, but strategies to reduce it can be effective with appropriate support from hospital administration and nursing management. The separation of the surgeon from the team can compromise communication but may be overcome through use of standardised communication. While surgeon situation awareness may be affected by the separation, the ergonomic benefits of robotic surgery may reduce stress and tiredness and enhance surgeon decision making. Our review adds to the existing literature by revealing strategies to support the introduction of robotic surgery and contextual factors that need to be in place for these to be effective.