In a first, a robotic system makes four-arm laparoscopy feasible for surgeons

A new robotic system promises to bring the best out of human surgeons by allowing them to use their feet along with their hands during a laparoscopic operation.
Rupendra Brahambhatt
The robotic system developed by the EPFL team.
The robotic system developed by the EPFL team.


Some surgeries are so complex and tiresome that while performing them doctors may wish they could have four arms. Laparoscopy is one such operation, it is used to diagnose and treat various problems in the abdomen and pelvis region.

Every year more than 13 million laparoscopic surgeries are conducted across the globe and it's one of those medical procedures that put a lot of mental and physical load on surgeons.

A team of researchers at the Swiss Federal Institute of Technology Lausanne (EPFL) has developed a robotic system that can solve this problem.

Their system will allow surgeons to easily perform multiple tasks at once using both their hands and feet during a laparoscopy. The EPFL team claims that it’s the world’s first robotic setup that can facilitate four-arm laparoscopic operations.

"Our system opens up new possibilities for surgeons to perform 4-handed laparoscopic procedures, allowing a single person to do a task that is usually performed by two, sometimes three people,” said Mohamed Bouri, one of the researchers and head of EPFL’s REHAssist research group, in an official release.

Four-arm laparoscopy offers better control

We previously reported about the da Vinci Xi surgical system that is currently used by many surgeons in the US to perform minimally invasive but complicated surgeries like laparoscopy with great precision. 

Using da Vinci doctors can make the best use of their hands but the new EPFL robot takes it one step further as it provides surgeons with two additional robotic arms that can be controlled using haptic foot interfaces.

This reduces the workload on hands and allows doctors to do more in less time and that too in a hassle-free manner. 

The robotic setup comprises four robot units in total; hands can control the two robotic arms supposed to perform manipulative surgical tasks, one foot can be used to control an actuated gripper, and the other foot can be used to govern the robotic arm equipped with a camera.

Bauri explained, “Actuators in the foot pedals give haptic feedback to the user, guiding the foot towards the target as if following an invisible field of forces, and also limit force and movement to ensure that erroneous feet movements do not endanger the patient.”

You may wonder wouldn’t it be more tiresome for a surgeon to constantly and simultaneously use their hands and feet during a surgery? Well, not if the robots could predict the action of the surgeons and coordinate their movements in advance according to the need of their users.

The EPFL team claims that they have designed the control framework of their system in such a way that it allows doctors and robots to exercise “shared control,” meaning that it’s not always the surgeon or user who is leading a step in the surgery, sometimes it could also be the robot who has already predicted and planned for the next step. 

“To reduce the complexity of the control, the robots actively assist the surgeon by coordinating their movements with the surgeons through active prediction of the surgeon’s intent and adaptive visual tracking of laparoscopic instruments with the camera. Additionally, assistance is offered for more accurate grasping of the tissues,” said Aude Billard, one of the study authors and a professor at EPFL’s School of Engineering.

This is how the shared control feature reduces the burden on the human surgeon and enhances the safety and precision of laparoscopic operations. The researchers also trained 12 surgeons and successfully tested the feasibility of their system.

Dr. Enrico Broennimann, one of the doctors who tested the system, said, “The idea to actively use one’s feet to perform robotic-assisted surgery is a good idea, and it’s definitely a learnable skill. I’d like to see it implemented in the operating room, perhaps as a cockpit well away from the patient to increase ergonomics.”  

Currently, the EPFL team is conducting clinical trials in Geneva and if everything works out well, we soon might see these robot assistants in our hospitals. 

The study is published in The International Journal of Robotics Research.

Study Abstract:

Robotic surgery is a promising direction to improve surgeons and assistants’ daily life with respect to conventional surgery. In this work, we propose solo laparoscopic surgery in which two robotic arms, controlled via haptic foot interfaces, assist the task of the hands. Such a system opens the door for simultaneous control of four laparoscopic tools by the same user. Each hand controls a manipulative tool while a foot controls an endoscope/camera and another controls an actuated gripper. In this scenario, the surgeon and robots need to work collaboratively within a concurrent workspace, while meeting the precision demands of surgery. To this end, we propose a control framework for the robotic arms that deals with all the task- and safety-related constraints. Furthermore, to ease the control through the feet, two assistance modalities are proposed: adaptive visual tracking of the laparoscopic instruments with the camera and grasping assistance for the gripper. A user study is conducted on twelve subjects to highlight the ease of use of the system and to evaluate the relevance of the proposed shared control strategies. The results confirm the feasibility of four-arm surgical-like tasks without extensive training in tasks that involve visual-tracking and manipulation goals for the feet, as well as coordination with both hands. Moreover, our study characterizes and motivates the use of robotic assistance for reducing task load, improving performance, increasing fluency, and eliciting higher coordination during four-arm laparoscopic tasks.

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