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AuTonomous intraLuminAl Surgery

Periodic Reporting for period 1 - ATLAS (AuTonomous intraLuminAl Surgery)

Reporting period: 2019-04-01 to 2021-03-31

Minimal invasive surgical interventions are growing in popularity due to the benefits they offer to patients. Treatment in a minimally invasive way typically comes with less blood loss, smaller scars, earlier release from the hospital, and faster recovery. An increasingly growing branch of minimally invasive intervention makes use of natural human lumens to access deeply seated anatomic sites. Such lumens can be accessed through natural orifices such as the mouth, the nose, ears, anus, or urethra. The vasculature or lymphatic system or examples where via small incisions lumens can be accessed to reach the heart or circulatory system. Instruments that want to take benefit of these speedy routes into the body better be flexible such that the traveled lumens remain intact and do not rupture. Controlling such flexible instruments is however close to art. It takes many years of experience and even then remains stressful and challenging. Robotic technology could be of help here.

The main problem is that robotics is quite complex. Robotics is a highly multi-disciplinary field that spans mechanics, electronics, sensing, software, and control. For surgical robotics (SR) human factors, anatomy, physiology, biocompatibility, and regulatory aspects add to that. When talking about flexible surgical robots each of these disciplines becomes even more challenging. For being successful in this field a Ph.D. may come in handy, but current doctoral training programs in engineering and SR fail to deliver sufficient broadly educated researchers, as they focus too much on single specific excellences. Companies that are active in the field need to restrict them to one single clinical discipline if they want to be successful in managing all the separate aspects. Because of that, they may fail in exploiting the commonalities that exist across intraluminal procedures. Techniques to navigate a vessel may turn useful when aiming to pass through the colon. Sensors that have been developed to visualize the kidney could find great use to observe the sinus and so on. Understanding and improving approaches to sense, model, control, navigate flexible instruments could impact an entire spectrum of surgical/interventional fields.

The main ambition of ATLAS, which stands for “AuTonomous intraLuminAl Surgery”, consists of the development of a state-of-the-art training program to educate highly talented early-stage researchers (ESRs) in the broad set of techniques that are needed to control flexible surgical robotic systems. By targeting three surgical scenarios namely ureteroscopy, colonoscopy, and endovascular navigation, ATLAS forces its ESRs to consider the commonalities and differences across these fields. ATLAS aims to develop three platforms that allow autonomous navigation through the respective lumens. By engaging in these ambitious research topics, participants will be exposed to all aspects of robotics. While contributing to the state of the art they will become proficient in building, modeling, testing, interfacing in short in integrating basic building blocks into systems that display sophisticated behaviour. While maintaining close collaborations with industry and healthcare institutes the ATLAS ESRs will be pushed to keep both clinical and commercial needs and constraints into account.

The creation of a European-wide doctoral program on SR, where participants receive the most recent know-how on intraluminal surgery and robotics, is urgently needed to create a bigger impact on healthcare and advance minimally invasive surgery. While ATLAS will deliver 15 PhDs with unmatched expertise ready to reshape the field, their scientific publications will proceed them. Through our dissemination, ATLAS will already alter the state-of-the-art showing how more sophisticated ways of steering medical instruments are within reach and how improved treatment may be soon a reality.
During the first year of the project, the ATLAS Beneficiaries hired the 15 ESRs, that started activities at the respective host institutions.

So far, 7 Network-wide Training Activities have been organised by the consortium:
NTA9 (Annual Bioengineering School “Advanced bioengineering methods, technologies and tools in surgery and therapy”) 9-12 September in Bressanone, Italy,
NTA2 (Sensing and actuation for soft robotics): 23-25 January 2020, in Delft, the Netherlands
NTA3 (Best integration practices and robotic middle-ware): 24-28 February 2020, in Leuven, Belgium.
NTA4 (3D tissue segmentation, modelling and deformation): 20-24 July 2020, in Verona & Milan, Italy.
NTA5 (CRAS Workshop): 28-30 September 2020, Barcelona, Spain (online).
NTA1 (Medical device development and translation): 27-30 April 2021, Strassbourg, France (online).
NTA7 (Soft skills for soft robotics): 24 March 2021 to 22 April 2021, Barcelona, Spain (online).

Aside from above network-wide training activities, ESRs are organising journal clubs, where they can discuss a paper; ESRs are also engaged in local training activities, organised by the host institution, and attend international PhD schools (Summer School on Surgical Robotics (Montpellier, France), and Hamlyn Winter School (London, UK).

The scientific outcome has been solid with at the moment, 6 journal articles and 4 conference papers, 10 conference abstracts that have been published.
Also, a first patent application has been submitted. In addition, a total of 20 more scientific papers are currently under evaluation or under preparation.

Advances have been made in terms of
* manufacturing and actuation of steerable surgical instruments where especially 3D printing and magnetic actuation have been progressed
* shape sensing and distributed contact sensing based on novel sensing technologies
* real-time reconstruction of luminal structures or classification of anatomic features within such lumens
* new methods for path-planning and distributed control of flexible structures in deformalbe tubular surroundings
* new models to predict the behaviour of flexible instruments or interacting tissue as well as
* new ways to interact with this information as a user or as an autonomous agent responsible of controlling flexible robots in intraluminal settings
* 3 setups in progress to navigate autonomously through a colon, an ureter or the vasculature.
The current scientific progress achieved by all ESRs can be summarised in steps forward in the automation of catheters for 3 main applications (Endovascular catheterization, Colonoscopy, and Ureteroscopy), by tackling challenges that require different specializations: mechanical design, actuation principles, sensing, and estimation, and control and path-planning. Thanks to the collaboration and the emphasis given to integration, ESRs focusing on different fields have a broader perspective, and the possibility of taking advantage of other ESRs results. ATLAS expects to produce 3 integrated systems, each for one medical scenario, that incorporates the work of a subgroup of five ESRs, and that allows for a partially autonomous or supervised navigation of the flexible instrument. Depending on the medical field, the automatization of a part of the procedure can reduce fatigue and the possibility of errors of surgeons. Thanks to the local sensing ad actuation, reduce negative effects on the patient.
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