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Robotics in Keyhole Transcranial Endoscope-Assisted Microsurgery: A Critical Review of Existing Systems and Proposed Specifications for New Robotic Platforms

Marcus, Hani J. MRCS*,‡; Seneci, Carlo A. MEng*; Payne, Christopher J. MEng*; Nandi, Dipankar DPhil; Darzi, Ara FRS*; Yang, Guang-Zhong FREng*

doi: 10.1227/NEU.0000000000000123
Technique Assessment

BACKGROUND: Over the past decade, advances in image guidance, endoscopy, and tube-shaft instruments have allowed for the further development of keyhole transcranial endoscope-assisted microsurgery, utilizing smaller craniotomies and minimizing exposure and manipulation of unaffected brain tissue. Although such approaches offer the possibility of shorter operating times, reduced morbidity and mortality, and improved long-term outcomes, the technical skills required to perform such surgery are inevitably greater than for traditional open surgical techniques, and they have not been widely adopted by neurosurgeons. Surgical robotics, which has the ability to improve visualization and increase dexterity, therefore has the potential to enhance surgical performance.

OBJECTIVE: To evaluate the role of surgical robots in keyhole transcranial endoscope-assisted microsurgery.

METHODS: The technical challenges faced by surgeons utilizing keyhole craniotomies were reviewed, and a thorough appraisal of presently available robotic systems was performed.

RESULTS: Surgical robotic systems have the potential to incorporate advances in augmented reality, stereoendoscopy, and jointed-wrist instruments, and therefore to significantly impact the field of keyhole neurosurgery. To date, over 30 robotic systems have been applied to neurosurgical procedures. The vast majority of these robots are best described as supervisory controlled, and are designed for stereotactic or image-guided surgery. Few telesurgical robots are suitable for keyhole neurosurgical approaches, and none are in widespread clinical use in the field.

CONCLUSION: New robotic platforms in minimally invasive neurosurgery must possess clear and unambiguous advantages over conventional approaches if they are to achieve significant clinical penetration.

ABBREVIATIONS: DOF, degrees of freedom

RAMS, robot-assisted microsurgery

*The Hamlyn Centre for Robotic Surgery, Institute of Global Health Innovation, Imperial College London, London, United Kingdom;

Department of Neurosurgery, Imperial College Healthcare NHS Trust, London, United Kingdom

Correspondence: Hani J. Marcus, MRCS, Clinical Fellow and Specialty Registrar in Neurosurgery, Imperial College London and Imperial College Healthcare NHS Trust, Hamlyn Centre, Paterson Building (Level 3), Praed St, London W2 1NY, UK. E-mail:

Received January 04, 2013

Accepted July 23, 2013

Copyright © by the Congress of Neurological Surgeons