Today's state of the art in surgical robotics

Abstract

Objective: This paper describes the current level of development of robots for surgery.

Material and Methods: This paper is based on a literature search in Pubmed, IEEExplore, CiteSeer and the abstract volumes of the MICCAI 2002, 2003 and 2004, CARS 2003 and 2004, CAOS 2003 and 2004, CURAC 2003 and 2004 and MRNV 2004 meetings.

Results: Divided into different disciplines (imaging, abdominal and thoracic surgery, ENT, OMS, neurosurgery, orthopaedic surgery, radiosurgery, trauma surgery, urology), 159 robot systems are introduced. Their functionality, deployment, origin and mechanical set-up are described. Additional contacts and internet links are listed.

Conclusions: The systems perform diverse tasks such as milling cavities in bone, harvesting skin, screwing pedicles or irradiating tumors. From a technical perspective the strong specialization of the systems stands out. Most of the systems are being developed in Germany, the United States, Japan or France.

• Robot-aided surgery
• review
• state-of-the-art

Introduction

Computer-aided surgery is in a state of continuous development [1–5]. Research is being done at university research facilities as well as on the part of commercial entities. Recent developments enable single procedures in trauma surgery and urology besides the established applications in neurosurgery, orthopaedics, cardiac and abdominal surgery. Some can be used in MRI, while others are small enough to be hand-held. Industrial robots are being adopted or special robot kinematics with specific mechanical structures are being developed.

The current state of the development of robot-aided surgery, especially of mechanical components, is summarized here, and the individual systems are introduced. They are assigned to specific medical disciplines: imaging, abdominal and thoracic surgery, ENT, OMS, neurosurgery, orthopaedics, radiosurgery, trauma surgery, or urology, according to their field of deployment.

A descriptive statistical evaluation of features, such as clinical readiness for use, kinematics employed, origin (nationality) and degrees of freedom (DOF), is presented.

This work focuses on technicians conducting research and development in the field of computer- and robot-aided surgery, as well as on the interested physician who will find himself in closer contact with this technology in the future. The technician will be able to position his projects within an international context, where the physician will get an overview of existing systems and their clinical readiness for use.

Material and methods

A search of the literature databases Pubmed, IEEExplore and CiteSeer has been carried out; the link lists of institutes working in the field of robot-aided surgery have been sifted through; and finally, a general internet search has been carried out. Additionally, the abstract volumes of the conferences MICCAI 2002, 2003 and 2004, CARS 2003 and 2004, CAOS 2003 and 2004, CURAC 2003 and 2004 and MRNV 2004 have been sifted through. In this context, special emphasis has been placed on developments in the past 4 years.

All systems providing an automated or remote movement of a tool have been included in this inquiry. Motorized platforms for surgical microscopes are excluded as, for example, they do not manipulate tissue.

The evaluation of the gathered data was carried out using Microsoft Excel 2000®.

The citing of systems and projects is sorted according to the earlier mentioned disciplines, and within these in alphabetical order. Citations of unknown project names are placed at the end of sections. Unknown project names are replaced by a code composed of letters corresponding to the country of origin and consecutive numbers.

Results

The results are compiled in Table I.

Table I.  Overview of the robotic systems.

Task	Project name	Institute/Company	Country	Status	References
Imaging
Guidance of endoscopic camera	AESOP	Intuitive Surgical Inc., Sunnyvale, CA	USA	Commercially available	www.intuitivesurgical.com [6–8]
Guidance of endoscopic camera	CLEM	Laboratoire TIMC, Grenoble	France	Experimental use	www-timc.imag.fr/ [9], [10]
Guidance of endoscopic instruments	COPRIN	Institut national de recherche en informatique et en automation, Le Chesnay	France	Experimental set-up	www.sop.inria.fr/coprin/index.html
Intestinal endoscope	CROBOT, ENDO-CRAWLER	Computer Integrated Medical Intervention Laboratory, Singapore	Singapore	Experimental set-up	http://mrcas.mpe.ntu.edu.sg/research/crobot/index.htm
Telesonography	EDR	Department of Medical Informatics, Ehime	Japan	Experimental use	www.medinfo.m.ehime-u.ac.jp [11], [12]
Intestinal endoscope	EMIL	ARTS Lab, Scuola Superiore Sant'Anna, Pisa	Italy	Experimental set-up	http://www-crim.sssup.it/research/projects/emil/default.htm [13]
Guidance of endoscopic camera	ENDOASSIST	Armstrong Healthcare Ltd., High Wycombe	UK	Commercially available	www.armstrong.healthcare.com [14]
Guidance of endoscopic camera	ENDOSISTA	Armstrong Healthcare Ltd., High Wycombe	UK	Experimental set-up	www.armstrong.healthcare.com
Guidance of endoscopic camera	FIPS	Forschungszentrum Karlsruhe	Germany	Experimental set-up	http://hbksun17.fzk.de:8080/imb/de/home.html?med/systeme/fips.html∼top.main [15]
Minimally invasive telesonography	GABIE	LIRMM, LRP, TIMC, CEA, Groupe Hospitalier Pitié-Salpêtrière, CHU de Grenoble	France	Experimental set-up	www.lirmm.fr
Telesonography	HIPPOCRATE	Sinters SA, Toulouse	France	Experimental set-up	www.lirmm.fr/∼duchemin/Hippo.htm [16]
Intestinal endoscope	HYPER ENDOSCOPE	Biomedical Micromechanics Laboratory, Nagoya	Japan	Experimental set-up	www.bmse.mech.nagoya-u.ac.jp/index-e.html
Guidance of endoscopic camera	LAPARO-NAVIGATOR, NAVIOT	Biomedical Precision Engineering Laboratory, University of Tokyo	Japan	Experimental set-up	http://bme.pe.u-tokyo.ac.jp/index_e.html [17]
Guidance of endoscopic camera	LER	Laboratoire TIMC, Grenoble	France	Experimental use	www.timc.imag.fr/ [18]
Exoscope	MINOP2	RWTH-Aachen/Lehrstuhl für Biomedizinische Technik	Germany	Experimental set-up	www.minop.de/ [19]
Intestinal endoscope and biopsy	MUSYC	ARTS Lab, Scuola Superiore Sant'Anna, Pisa	Italy	Experimental use	www-arts.sssup.it/research/projects.htm [20], [21]
Telesonography	OTELO	Sinters SA, Toulouse	France	Experimental set-up	www.bourges.univ-orleans.fr/otelo/home.htm [16]
Guidance of endoscopic camera	PAROMIS	RWTH-Aachen/Lehrstuhl für Biomedizinische Technik	Germany	Experimental set-up	www.hia.rwth-aachen.de/research/cht/paromis.html [22]
Telesonography	TER	Laboratoire TIMC, Grenoble	France	Experimental set-up	http://www-timc.imag.fr/gmcao/index.htm [23]
Telesonography	ULTRASOUND ROBOT	Mobile Robotics Sweden AB	Sweden	Experimental set-up	www.mobile-robotics.com/medical
Telesonography	Project name unknown: CAN1	School of Computing and Department of Electrical and Computer Engineering, Queen's University, Kingston, Ontario	Canada	Experimental set-up	www.cs.queensu.ca/∼purang/projects.html [24], [25]
Robot-aided fluoroscopy	Project name unknown: DEU10	Institut für Robotik und Kognitive Systeme, Universität Lübeck	Germany	Experimental set-up	www.rob.uni-luebeck.de/∼binder/c-arm/index.php?lang=en [26]
Guidance of endoscopic camera	Project name unknown: SPA1	Instituto de Automática y Robótica Avanzada de Andalucía, Universidad de Málaga	Spain	Experimental set-up	[27]
Intestinal endoscope	Project name unknown: USA2	Department of Mechanical Engineering, Caltech, Pasadena, CA	USA	Experimental set-up	http://robotics.caltech.edu/∼jwb/medical.html [28]
Drop-in endoscopic cameras	Project name unknown: USA5	Department of Surgery, University of Nebraska Medical Center	USA	Experimental use	[29]
Abdominal and thoracic surgery
Remote-controlled surgery	ACTIVE TROCAR	Department of Mechano-Informatics, Uni Tokyo, Japan	Japan	Experimental set-up	www.ynl.t.u-tokyo.ac.jp/index.html [30]
Remote-controlled surgery	AKTORMED	MITI, TU München	Germany	Experimental set-up	www.aktormed.com [31]
Remote-controlled surgery	ARTEMIS	Institut für angewandte Informatik, Forschungszentrum Karlsruhe	Germany	Experimental set-up	www.iai.fzk.de/medtech/medrob/artemis/welcome.html [32]
Breast biopsy	BBA	Robarts Research Institute, London, ON	Canada	Experimental use	www.imaging.robarts.ca/∼kath [33]
Remote-controlled surgery	BLACK FALCON	Lemelson-MIT, Cambridge, MA	USA	Experimental set-up	www.ai.mit.edu/people/madhani/robots.html [34]
Remote-controlled surgery	BLUE DRAGON	Biorobotics Laboratory, University of Washington, Seattle	USA	Experimental use	http://brl.ee.washington.edu/Research_Active/Surgery/Device_BlueDRAGON/BlueDRAGON.html [35], [36]
Biopsy under image control	B-ROB1	Austrian Research Centers, Seibersdorf	Austria	Experimental set-up	www.arcs.ac.at [37]
Biopsy under image control	B-ROB2	Austrian Research Centers, Seibersdorf	Austria	Experimental set-up	www.arcs.ac.at [38]
Remote-controlled surgery	CT-BOT	l'Equipe AVR; LSIIT, Université Louis Pasteur, Illkirch	France	Experimental set-up	http://hp2gra.u-strasbg.fr/ [39]
Endoscopic surgery	D2M2	LIRMM, Illkirch	France	Experimental set-up	www.lirmm.fr/∼duchemin/D2M2.htm
Remote-controlled surgery	DAVINCI	Intuitive Surgical Inc., Sunnyvale, CA	USA	Commercially available	www.intuitivesurgical.com [7], [8]
Remote-controlled surgery	ENDOPAR	Lehrstuhl Informatik VI, TU München	Germany	Experimental set-up	http://atknoll1.informatik.tu-muenchen.de:8080/tum6/research/sfb453C7 [40], [41]
Remote-controlled surgery	ENDOXIROB	LIRMM, CHU, LAAS, Sinters SA, Toulouse	France	Experimental set-up	www.endoxirob.com, www.lirmm.fr/∼michelin/ [42]
Remote-controlled surgery	GTSS	Stanford Research Institute	USA	Experimental use	www.sti.com [43]
Remote-controlled surgery	HYPERFINGER	Department of Micro System Engineering, Nagoya University	Japan	Experimental set-up	www.mech.nagoya-u.ac.jp [44]
Needle insertion under CT control	IRASIS	LSIIT, Université Louis Pasteur, Illkirch	France	Experimental set-up	http://hp2gra.u-strasbg.fr/fr/research/med_rob/insertion.html [39]
Surgery in MRI	KIMRO	Department of Mechanical Engineering, University of Oulu	Finland	Experimental set-up	http://konekilta.oulu.fi/kimro/ [45]
Remote-controlled surgery	LAPROTEK	endoVia medical, Norwood, MA	USA	Experimental use	http://endovia.millersystems.com [46], [47]
Different surgical interventions	LARS	CISST, Johns Hopkins University	USA	Experimental set-up	www.cisst.org [48–50]
Needle insertion under MR control	LPR	Laboratoire TIMC-IMAG, La Tronche	France	Experimental set-up	www.timc.imag.fr/ [51]
Robotic surgery	MARGE	LIRMM, LRP, CEA/SRSI, Montpellier and Pitié Salpêtrière hospital, Paris	France	Experimental set-up	www.lirmm.fr/∼michelin/ [52], [53]
Endoscopic surgery	MC^2E	Laboratoire Robotique de Paris (LRP), LIRMM (Montpellier), CEA	France	Experimental set-up	http://lrp6.robot.jussieu.fr/fra/personnel/morel/robotic_surgery.html [54], [55]
Tremor-compensation for ophthalmology	MICRON	Robotics Institute, Carnegie Mellon University, Pittsburgh, PA	USA	Experimental set-up	www.ri.cmu.edu/projects/project_32.html [56], [57]
Tremor-compensation for microsurgery	MICRO-SURGICAL ASSISTANT	Computer Integrated Surgical Systems and Technology, Baltimore, MD	USA	Experimental set-up	http://cisstweb.cs.jhu.edu/research/microsurgicalassistant/ [50], [58]
Puncture under MRI control	MIRA	Institut für angewandte Informatik, Forschungszentrum Karlsruhe	Germany	Experimental set-up	http://hbksun17.fzk.de:8080/imb/imb_www/
Endoscopic surgery	PADEMIS	Institute of Microsystems Technology, TU Ilmenau	Germany	Experimental set-up	www.maschinenbau.tu-ilmenau.de/pademis/[59]
Tremor-compensation for microsurgery	PADYC	Laboratoire TIMC, Grenoble	France	Experimental set-up	www.timc.imag.fr/olivier.schneider/perso/english/gb_rsp_main.html [60]
Remote-controlled surgery	RAMS/AMES	Jet Propulsion Laboratory, Pasadena, CA	USA	Experimental use	http://telerobotics.jpl.nasa.gov/tasks/rams/[61]
Biopsy under MRI control	ROBITOM	Institut für angewandte Informatik, Forschungszentrum Karlsruhe	Germany	Experimental set-up	http://hbksun17.fzk.de:8080/imb/imb_wwwwww.innomedic.de[62]
Remote-controlled surgery	ROBOTIC LASER COAGULATOR	Institute of Environmental Studies, University of Tokyo	Japan	Experimental set-up	http://bme.pe.u-tokyo.ac.jp/index_e.html [63]
Minimally invasive cardiac surgery	TEC HEARTLANDER	Robotics Institute, Carnegie Mellon University, Pittsburgh, PA	USA	Experimental set-up	www.ri.cmu.edu/projects/project_533.html [64], [65]
Remote-controlled surgery	Telesurgical Workstation	Medical Robotics Group, Berkeley, CA	USA	Experimental set-up	http://robotics.eecs.berkeley.edu/medical [66]
Remote-controlled surgery	TONATIUH	Dep. de Cirugía, Hosp. de Infectología	Mexico	Experimental use	[67], [68]
Tumour biopsy with ultrasonic control	UMI	ATRE-Lab, University of Tokyo	Japan	Experimental set-up	www.atre.t.u-tokyo.ac.jp/projects/hong/index.html [69]
Instrument positioning	VECTORBOT	Brainlab AG, Heimstetten	Germany	Experimental set-up	www.brainlab.com, www.robotic.dlr.de
Remote-controlled surgery	ZEUS	Intuitive Surgical Inc., Sunnyvale, CA	USA	Commercially available	www.computermotion.com [6–8]
Remote-controlled surgery	Project name unknown: CAN2	School of Computing and Department of Electrical and Computer Engineering, Queen's University, Kingston, Ontario	Canada	Experimental set-up	www.ece.ubc.ca/∼tims/heart.html [70]
Remote-controlled surgery	Project name unknown: DEU1	Deutsches Zentrum für Luft und Raumfahrt, Wessling	Germany	Experimental set-up	www.robotic.dlr.de [71]
Needle guidance	Project name unknown: DEU8	IMP, Nürnberg	Germany	Experimental set-up	[72]
Instrument positioning	Project name unknown: DEU9	Institut für Robotik und Kognitive Systeme, Lübeck	Germany	Experimental set-up	www.rob.uni-luebeck.de [73]
Needle guidance	Project name unknown: FRA3	LSIIT, Université Louis Pasteur, Illkirch	France	Experimental set-up	http://hp2gra.u-strasbg.fr/ [39]
Needle guidance	Project name unknown: ISR3	Technion, Haifa	Israel	Experimental set-up	http://robotics.technion.ac.il/projects/flexible%20needle%20steering.html [74]
Surgery in MRI	Project name unknown: JAP1	Surgical Assist Technology Group, Tsukuba	USA, Japan	Experimental set-up	http://unit.aist.go.jp/humanbiomed/surgi http://splweb.bwh.harvard.edu:8000/index.html [75], [76]
Liver biopsy under MRI control	Project name unknown: JAP3	ATRE-Lab, University of Tokyo	Japan	Experimental set-up	www.i.u-tokyo.ac.jp/m-i/m-i-e.htm [77]
Endoscopic forceps	Project name unknown: JAP16	Institute for High-Dimensional Medical Imaging, The Jikei University School of Medicine, Tokyo	Japan	Experimental use	www.jikei.ac.jp/eng/index.html [78], [79]
Endoscopic tools	Project name unknown: JAP17	Department of Mechanical Engineering, Iwate University	Japan	Experimental set-up	www.mech.iwate-u.ac.jp/ [80]
Thermotherapy of liver tumors	Project name unknown: JAP21	Department of Mechano-Informatics, University of Tokyo	Japan		www.atre.t.u-tokyo.ac.jp [81]
Tumor biopsy with ultrasonic control	Project name unknown: SING1	CIMIL-Lab, Singapore	Singapore	Experimental set-up	http://mrcas.mpe.ntu.edu.sg/research/neurobot/index.htm [82]
Biopsy under CT control	Project name unknown: USA3	Philips Medical Systems, Cleveland, OH	USA	Experimental use	www.medical.philips.com [83]
Remote-controlled surgery	Project name unknown: USA7	Microdexterity Systems, Inc., Albuquerque, NM	USA	Experimental set-up	www.microdexsys.com [84]
Coronary artery graft bypass surgery	Project name unknown: USA8	Columbia University, New York, NY	USA	Experimental setup	http://www1.cs.columbia.edu/∼laza/stewart/
OMS, ENT
Surgery of the sphenoid sinus	A73	HNO-Klinik, Erlangen	Germany	Experimental set-up	www.hno.med.uni-erlangen.de www.medint.de [85]
Maxillofacial surgery	NAVIGATED CONTROL	Surgical Robotics Lab, Berlin	Germany	Experimental use	www.srl-berlin.de [86]
Prosthesis placement	OTTO	Surgical Robotics Lab, Berlin	Germany	Experimental use	www.srl-berlin.de [87], [88]
Prosthesis placement	OTTO2	Surgical Robotics Lab, Berlin	Germany	Experimental set-up	www.srl-berlin.de
Skull surgery	ROBACKA	Universität Karlsruhe, Universität Heidelberg, DKFZ	Germany	Experimental set-up	http://sfb414.ira.uka.de/ [89–91]
Hearing aid implantation	ROBIN	Laboratorium für Medizinrobotik, Sektion sensorische Biophysik, Tübingen	Germany	Experimental set-up	www.medizin.uni-tuebingen.de/hno/mednavrobotik/projekt/projekt.htm [92]
Maxillofacial surgery	ROBOPOINT	Surgical Robotics Lab, Berlin	Germany	Experimental use	www.srl-berlin.de
Hearing aid implantation	RONAF	Lehrstuhl für angewandte Informatik III, Bayreuth	Germany	Experimental set-up	http://ai3.inf.uni-bayreuth.de [93]
Maxillofacial surgery	SURGICOBOT	CEA-List, CHU Amiens	France	Experimental set-up	[94]
Dental implantology	X1	Med3D GmbH, Heidelberg	Germany	Commercially available	www.med3d.de
Maxillofacial surgery in CT scanner	Project name unknown: DEU5	Surgical Robotics Lab, Berlin	Germany	Experimental use	www.srl-berlin.de
Laryngoscopy	Project name unknown: DEU11	ICCAS, Leipzig	Germany	Experimental set-up	www.iccas.de [95]
Remote-controlled surgery	Project name unknown: USA9	CISST, Johns Hopkins University, Baltimore, MD	USA	Experimental setup	www.cisst.org [96]
Neurosurgery
Remote-controlled neurosurgery	ALPHA	Microdexterity Systems, Inc., Albuquerque, NM	USA	Experimental use	www.microdexsys.com [97]
Skull reconstruction	CRANIO	Lehrstuhl für Biomedizinische Technik, RWTH-Aachen	Germany	Experimental set-up	www.hia.rwth-aachen.de/research/cht/cranio.html [98]
Guidance of tools and endoscopes	EVOLUTION 1	URS GmbH, Schwerin	Germany	No longer commercially available	www.medicalrobots.com
Tool guidance	IGOR	Laboratoire TIMC, Grenoble	France	Experimental set-up	www.timc.imag.fr/[99]
Guidance of tools under CT control	MINERVA	Group for Surgical Robotics and Instrumentation, Grenoble	Switzerland	Experimental use	http://dmtwww.epfl.ch/imt/robchir/Minerva.html [100]
Guidance of tools under MRI control	NEUROARM	Department of Clinical Neurosciences, Calgary	Canada	Experimental set-up	www.mdrobotics.ca/neuroarm.htm [101–103]
Microforceps	NEUROBOT	ATRE-Lab, University of Tokyo	Japan	Experimental use	www.atre.t.u-tokyo.ac.jp [104], [105]
Milling of lateral skull-base	NEUROBOT	CIMIL-Lab, Singapore	Singapore	Experimental set-up	http://mrcas.mpe.ntu.edu.sg/research/neurobot/index.htm
Stereotactic neurosurgery	NEUROMATE	Integrated Surgical Systems Ltd., Davis, CA	USA	Commercially available	www.robodoc.com [106]
Stereotactic neurosurgery	NEUROSISTA	Armstrong Healthcare Ltd., High Wycombe	UK	Experimental set-up	www.armstrong-healthcare.com
Stereotactic neurosurgery	PATHFINDER	Armstrong Healthcare Ltd., High Wycombe	UK	Commercially available	www.armstrong-healthcare.com
Spinal interventions	WAM	Z-Kat Inc., Hollywood, FL	USA	Experimental use	www.z-kat.com [107]
Interventions in CT Scanner	Project name unknown: DEU4	Lehrstuhl für Informatikanwendungen in der Medizin TU München	Germany	Experimental use	http://wwwnavab.in.tum.de/ [108]
Stereotactic interventions	Project name unknown: DEU6	German Cancer Research Center, Heidelberg	Germany	Experimental set-up	www.dkfz.de/medphys/medeng/research3.html [109], [110]
Stereotactic laser ablation	Project name unknown: DEU7	MRC Systems GmbH, Heidelberg	Germany	Experimental use	www.mrc-systems.de [111]
Stereotactic neurosurgery in open MRI	Project name unknown: JAP7	Mechanical Engineering Research Laboratory, Hitachi; ATRE-Lab, Tokyo and Brigham and Women's Hospital, Boston, MA	Japan, USA	Experimental set-up	http://splweb.bwh.harvard.edu:8000/pages/ppl/noby/robot/mrtrobot.htm [112], [113]
Remote-controlled instrument guidance in open MRI	Project name unknown: JAP8	Mechanical Engineering Research Laboratory, Hitachi; Waseda University	Japan	Experimental set-up	[114]
Brain retract manipulator for use in MRI-scanner	Project name unknown: JAP10	Faculty of Advanced Techno-Surgery, Tokyo Women's Medical University	Japan	Experimental set-up	www.twmu.ac.jp/abmes/FATS/index-e.html www.mech.waseda.ac.jp/ [115]
Stereotactic neurosurgery in open MRI	Project name unknown: JAP12	Advanced Therapeutic Engineering Laboratory, Tokyo Denki University	Japan	Experimental set-up	www.atl.b.dendai.ac.jp/lab/atlab-e.htm [116]
Transnasal neurosurgery in MRI	Project name unknown: JAP13	Surgical Assist Technology Group, Tsukuba, Ibaraki	Japan	Experimental set-up	http://unit.aist.go.jp/humanbiomed/surgical/[117]
Microsurgical interventions in the brain	Project name unknown: JAP14	Department of Micro System Engineering, Nagoya University	Japan	Experimental set-up	www.mech.nagoya-u.ac.jp/index-e.html [118]
Remote-controlled surgery	Project name unknown: JAP19	School of Engineering, Tokyo University	Japan	Experimental set-up	[119]
fMRI experiments	Project name unknown: USA10	Laboratory for Computational Motor Control, Johns Hopkins University, Baltimore, MD	USA	Experimental use	www.bme.jhu.edu/∼reza/fmri_robot.htm
Orthopaedics
Knee replacement	ACROBOT	The Acrobot Company Ltd., London	UK	Commercially available	www.acrobot.co.uk [120], [121]
Percutaneous vetebroplastic	ACUBOT	Brady Urological Institute, Johns Hopkins University, Baltimore, MD	USA	Experimental use	www.visualization.georgetown.edu/research/image_guided/image_guided.htm [122]
Hip replacement	ARTHROBOT	Telerobotics and control Laboratory, Seoul	Korea	Experimental set-up	http://robot.kaist.ac.kr/project/hwrs/arthrobot/main.htm [123]
Knee replacement	BRIGIT	LIRMM, Medtech, Montpellier	France	Experimental set-up	www.medtech.fr/ [124]
Hip and knee replacement	CASPAR	URS GmbH, Schwerin	Germany	No longer commercially available	www.medicalrobots.com
Image-guided hip surgery	CRIGOS	Lehrstuhl für Biomedizinische Technik, RWTH-Aachen	Germany	Experimental set-up	www.hia.rwth-aachen.de/research/cht/crigos1.html
Knee replacement	GALILEO NAV	Precision Impants AG, Aarau	Switzerland	Commercially available	www.pisystems.ch [125]
Knee replacement	GP-System	MEDACTA AG	Switzerland	Commercially available	www.medacta.ch
Knee replacement	IMAGE REGISTRATION	Division BMGO, Leuven	Belgium	Experimental set-up	www.mech.kuleuven.ac.be/bmgo/research/project_robot_en.phtml
Pedicle screw placement	ITD	Labor für Biomechanik und experimentelle Orthopädie, Mannheim	Germany	Experimental set-up	www.intelligent-tool-drive.de [126–129]
Pedicle screw placement	LUKE	Brainlab AG, Heimstetten	Germany	Experimental set-up
Pedicle screw placement	MARS/SpineAssist	Technion—Israel Institute of Technology, Haifa	Israel	Experimental use	http://meeng.technion.ac.il [130–132]
Active arthroscope	MIAS	CRIM Lab, Scuola Superiore Sant'Anna, Pisa	Italy	Experimental set-up	http://www.crim-sssup.it/research/projects/mias/defaultarthro.htm [133–135]
Bone-cement removal (hexapod kinematics)	MINARO1	Lehrstuhl für Biomedizinische Technik, RWTH-Aachen	Germany	Experimental set-up	www.hia.rwth-aachen.de/research/cht/minaro.html [136]
Bone cement removal (hybrid kinematics)	MINARO2	Lehrstuhl für Biomedizinische Technik, RWTH-Aachen	Germany	Experimental set-up	www.hia.rwth-aachen.de/research/cht/minaro.html [136]
Hip replacement	MODICAS	Institut für Regelungs- und Steuertechnik; Zentrum für Sensorsysteme, Siegen	Germany	Experimental use	www.modicas.de [137]
Pedicle screw placement	NAVIPED	Deutsches Zentrum für Luft- und Raumfahrt, Wessling	Germany	Experimental set-up	www.robotic.dlr.de [138]
Implantation of screws	ORTHOSISTA	Armstrong Healthcare Ltd., High Wycombe	UK	Experimental set-up	www.armstrong-healthcare.com
Knee replacement	PFS	Center for Medical Robotics and Computer Assisted Surgery, Pittsburgh, PA	USA	Experimental set-up	www.mrcas.ri.cmu.edu [139]
Knee replacement	PRAXITELES	PRAXIM medivision (La Tronche), France, TIMC, NCL laboratory at the University of British Columbia in Vancouver, Canada	France, Canada	Experimental use	www.praxim.fr; www.surgetics.com [140]
Acetabular cup rotation	RAO ASSIST MANIPULATOR	Waseda University, Tokyo	Japan	Experimental set-up	[141]
Hip replacement	ROBODOC	Integrated Surgical Systems Inc., Davis, CA	USA	Commercially available	www.robodoc.com [142–145]
Hip replacement	ROBONAV	Integrated Surgical Systems Inc., Davis, CA	USA	Experimental use	www.robodoc.com [146], [147]
Pedicle screw placement	VISAROMED	Fraunhofer-IPA, Stuttgart	Germany	Experimental set-up	www.ipa.fhg.de/medizin [148], [149]
Knee arthroscopy	Project name unknown: ISR1	Technion, Haifa	Israel	Experimental set-up	http://robotics.technion.ac.il/people/nabil/project.html
Bone registration	Project name unknown: ISR2	Technion, Haifa	Israel	Experimental set-up	http://robotics.technion.ac.il/projects/registration.html [150]
Knee replacement	Project name unknown: ITA1	Biomechanics Lab, Istituti Ortopedici Rizzoli, Bologna	Italy	Experimental use	www.ior.it/biomec/homeenglish.htm [151]
Orthopaeadic surgery under MRI control	Project name unknown: JAP6	Advanced Therapeutic Engineering Laboratory, Tokyo Denki University	Japan	Experimental set-up	www.atl.b.dendai.ac.jp/lab/atlab-e.htm
Spine surgery	Project name unknown: JAP11	Advanced Therapeutic Engineering Laboratory, Tokyo Denki University	Japan	Experimental set-up	www.atl.b.dendai.ac.jp/lab/atlab-e.htm [152]
Knee replacement	Project name unknown: JAP20	University of Tokyo, Japan	Japan	Experimental set-up	[153]
Spine surgery	Project name unknown: KOR1	CISS, Hanyang University, Seoul	Korea	Experimental set-up	http://ciss.hanyang.ac.kr [154]
Radiosurgery
Tumor ablation	CYBERKNIFE	Accuray Inc., Sunnyvale, CA	USA	Commercially available	www.accuray.com [155]
Patient positioning	HEXAPOD	Medical Intelligence GmbH, Schwabmünchen	Germany	Commercially available	www.medical-intelligence.com
Tumor ablation	MOCOMP	Medical Applications Research Group, München	Germany	Experimental set-up	http://wwwradig.informatik.tu-muenchen.de/research/med/index_e.html [156]; http://wwwradig.in.tum.de/research/med/projects/mocomp/index.php
Tumor ablation with proton beam	Project name unknown: FRA1	IPN, CPO, Orsay	France	Experimental set-up	http://ipnweb.in2p3.fr/ [157]
Trauma surgery
Mobile medical robot, military use	BLOODHOUND	Irobot Corp., Burlington, MA	USA	Experimental set-up	www.irobot.com [158]
Automatic dermatome	DERMAROB	LIRMM UMR 5506 CNRS; Sinters SA, Toulouse	France	Experimental set-up	http://141.161.165.150/Robotics%20Workshop/presentation/ cars-250603-e_dombre_files/frame.htm [159], [160]
Bone repositioning	INTELLIGENT FIXATOR	BG Unfallklinik Hamburg	Germany	Experimental use	www.tu-harburg.de/mst/deutsch/forschung/weinrich.shtml [161], [162]
Bone repositioning	REPOROBO	Mechatonics Faculty, FH Regensburg	Germany	Experimental set-up	http://homepages.fh-regensburg.de/∼mog39099/mk.org/mru/projekt/reprobo/reprobo.htm [163], [164]
Automatic dermatome	SCALPP	LIRMM UMR 5506 CNRS; Sinters SA, Toulouse	France	Experimental set-up	http://141.161.165.150/robotics%20workshop/presentation/cars-250603-e_dombre_files/frame.htm [159]
Bone repositioning	Project name unknown: DEU3	Institute for Robotics and Process Control, Uni Braunschweig	Germany	Experimental set-up	www.cs.tu-bs.de/rob/welcome.html [165]
Urology
Kidney biopsy	PAKY (ACUBOT)	Brady Urological Institute, Johns Hopkins University, Baltimore, MD	USA	Experimental use	http://urology.jhu.edu/urobotics/projects/rcm/http://robotics.me.jhu.edu/∼llw/paky/paky.htm [166]
Resection of the prostate	PROBOT	Imperial College, London	UK	Experimental use	www.me.ic.ac.uk/case/mim/projects/probot/[167]
Resection of the prostate	UROBOT, SABOT	CIMIL-Lab, Singapore	Singapore	Experimental use	http://mrcas.mpe.ntu.edu.sg/research/urobot/index.htm
Prostate brachytherapy	Project name unknown: CAN3	Imaging Research Laboratories, Robarts Institute, London, ON	Canada	Experimental set-up	www.imaging.robarts.ca/∼afenster/html/researchIntereststwo.html [168], [169]
Kidney biopsy	Active holder for MR-guided surgery: JAP7	ATRE-Lab, University of Tokyo	Japan	Experimental set-up	www.atre.t.u-tokyo.ac.jp/index.html
Transrectal prostate biopsy	Project name unknown: USA4	ATRE-Lab, Tokyo, Japan; Johns Hopkins, Baltimore, USA	Japan/USA	Experimental use	http://cisstweb.cs.jhu.edu/people/gabor/[170], [171]

Imaging

The CLEM system1 (Compact Laparoscopic Endoscope Manipulator) is used to guide an endoscopic camera in three DOF. Pneumatic muscles are used as actuators. The system is controlled by a keypad or via voice control and a foot switch [10]. Pre-clinical results have been reported [9].

The project COPRIN2 deals with the control of a miniature endoscopic camera. Parallel kinematics with three DOF are used. The construction measures ∼8 mm in diameter, is 25 mm long and can carry 500 g of axial weight. Information on clinical use is not available.

The robot CROBOT3 (ENDOCRAWLER) uses special serpentine kinematics to move an endoscope through the patient's intestines. To do this, specific elements of the construction change their diameter and distance. No clinical experience has been obtained so far.

The EDR system4 is used for telesonography purposes and uses three-DOF hybrid kinematics (‘Pantograph’) [11]. The sonode is moved by remote control over the abdomen of the patient. Additionally, the system provides a real-time video-conference system. Experimental results are available [12].

The robot EMIL5 (Endoscopic Microcapsule Locomotion) is used for examination of the gastrointestinal tract. Its purpose is to transport an endoscopic microcapsule.6 The device moves in a snake-like manner by alternately changing the diameter of its segments and the distance between these segments. In vivo tests on pigs have been reported [13].

ENDOASSIST®7 is a commercially available system for automatically controlling the camera during endoscopic operations. The system is based on a five-axis SCARA arm and can be used clinically. The company also introduced the system ENDOSISTA, which cannot yet be purchased.

The FIPS8 system provides remote-controlled imaging for endoscopic operations. A three-axis kinematics device is attached to the OR table and moves an endoscope around the entry point. It is controlled with a joystick by the surgeon. The system is licensed by the Storz Company, Tuttlingen, Germany. Information on clinical use is not available.

The system GABIE9 (Guidage Actif Basé sur l'Imagerie Echographique) is used for endoscopic telesonography. A sonode is attached to a surgical tool. No information on kinematics or use is available, and clinical experience is not yet reported.

The system HIPPOCRATE10 provides automated user-independent ultrasonic imaging and can also be used for telesurgery [16]. The sonode is moved over pre-defined parts of the patient with constant velocity. The kinematics of HIPPOCRATE are based on special serial kinematics with six DOF. The development, which is not commercially available, is being driven by several European institutions and companies11.

HYPER-ENDOSCOPE12 is a prototype of an active-serpentine endoscope. It can be used as a remote-controlled surgical system and moves through the intestines by changing the diameter and distance of the single segments. Other projects concern microsurgical instruments and force feedback for virtual endoscopy.

The LAPARO-NAVIGATOR13 (or NAVIOT) system uses two-DOF parallel kinematics to automatically control an endoscope. The drive is positioned beside the patient and a lever gear moves the endoscope. Clinical experiences have been reported [17].

The LER14 provides automatic imaging for endoscopic surgery. To do this, a ring is positioned on the abdominal wall using straps, an articulated arm or suturing. A camera unit can be rotated and tilted via a cross arm. Additionally, the objective can be moved back and forth in the trocar so that three DOF can be gained. The velocity of the moving parts is limited to 20°/s and 20 mm/s. It takes ∼30 s to remove the system from the patient [18]. Control is performed via a keypad or voice control. Experiments on pigs have been performed.

The system MINOP215 has been developed by a consortium of several institutes and enterprises. Within the scope of this project, an exoscope for neurological applications has been set up. This system comprises a five-DOF articulated arm, which carries a stereo camera and a set of lenses, and 3D-vision goggles to be worn by the surgeon. Thus, the usual disadvantages of a surgical microscope should be avoided [19]. No information on clinical experience is available.

The MUSYC16 project deals with the development of a robot for coloscopy [20]. The device travels in a snake-like manner through the intestines by segmentally ingesting the abdominal wall. It is propelled by pneumatic actuators in an inchworm-like way. The robot can be used for imaging and biopsy. Results are available from in vitro trials [21].

The system OTELO17 provides automated user- independent ultrasonic imaging and can also be used for telesurgery [16]. The sonode is moved over pre-defined parts of the patient with constant velocity. The kinematics of OTELO comprise a set-up that is directly placed on the patient. The system is not commercially available. Development has been undertaken by several European institutions and companies.18

The system PAROMIS19 is used for robotic endoscopic camera guidance. It is based on hexapod kinematics and can be attached to the OR table. The system weighs ∼4 kg. It is controlled by speech or a touch screen. Force–torque sensing is implemented [22]. Information on clinical experiences is not available.

The TER20 system is used for telesonography [23]. A frame is attached to the patient using straps. On this frame, a sonode can be remotely rotated and tilted. Information on clinical experiences is not available.

ULTRASOUND ROBOT, a robot for telesonography, is under development in Stockholm.21 This six-DOF articulated arm robot is mounted on a trolley and remotely controlled by the surgeon using a joystick. It carries a US-sonode and can also be controlled over long distances. Information on clinical experiences and disposability is not available.

A robot for remote-controlled ultrasonic imaging was introduced by Abolmaesumi and Salcudean22 (project ‘CAN1’). This robot is based on parallelogram kinematics and guides an ultrasonic probe over the patient's skin in six DOF around an invariant point. The patient can move the robot aside by hand when necessary. The robot is controlled via a force-feedback joystick or a space mouse. There is information on clinical experiences available [24], [25].

A C-arm with robotic functions is under development in Lübeck23 (project ‘DEU10’). This system features a C-arm with five DOF to provide isocentric movement in virtually any axis around a point. In addition, acquiring larger pictures by building a mosaic becomes possible. The system uses a smaller C-arm when compared with known isocentric C-arms [26]. Information on clinical use is not available.

At the University of Malaga,24 a robot for endoscopic surgery is under development (project ‘SPA1’). This system comprises a self-made SCARA-type robotic arm mounted on a vertical rail to move an endoscopic camera within four DOF. Experiments on a patient simulator and animals have been reported [27].

An active endoscopic system has been introduced by the group of Brudick25 (project ‘USA2’). This robot winds through the intestines [28] and consists of a number of flexible combined segments which alternately enlarge their diameter and push on each other. There is room inside for an optical fibre to inspect the intestinal walls. Information on clinical experiences is not available.

Three robotic camera holders have been introduced by Rentschler26 et al. (project ‘USA5’). These robots are used to provide imaging during laparoscopic surgery. The first system is a small (15 mm diameter and ∼75 mm long) battery-powered camera fixed to the inner abdominal wall by a clamp. It uses LED lights to illuminate the region of interest. Camera data are submitted via a wireless connection. The second system uses the same camera, but provides pan and tilt movements (360°, ± 45°). Here, a cable is used to provide power to the motors and the camera. The third system uses two wheels to propel itself to the region of interest. Here also a cable is used. In vivo experiments have been performed on pigs [29].

Abdominal and thoracic surgery

At the Department of Mechano-Informatics at the University of Tokyo,27 the ‘Active Trocar’ project is pushed ahead. This manipulator for endoscopic interventions is able to move the forceps in six DOF and is mounted on the OR table with a small passive arm. This master–slave system has been tested on a pig [30].

The system AKTORMED28 is a robot for master–slave applications in minimally invasive surgery [31]. It uses a three-DOF articulated arm with an hydraulic actuator.29 The system is set up next to the OR table. Information on clinical experience is not available.

The telesurgical experimental set-up ARTEMIS30 consists of a cockpit unit and several manipulator arms for endoscopic surgical steps and for imaging. Serial kinematics and specially developed joysticks for control by the surgeon are used [32]. Clinical information is not available.

Surry et al. introduce BBA31 (Breast Biopsy Apparatus), a system for breast biopsy under ultrasonic control. A fusion of stereotactic mammography, freehand ultrasound and 3D-ultrasound is performed to define the region of interest. The system provides three DOF on a Cartesian stage. Experiences from animal trials have been reported [33].

BLACK FALCON is a surgical robot for remote-controlled procedures.32 This self-made articulated arm provides four DOF to move a surgical tool [34]. Information on clinical experiences is not available.

Within the BLUE DRAGON33 project, a system for the guidance of endoscopic instruments has been developed. It is based on parallelogram kinematics and provides four DOF. Owing to this set-up, movements around a pivot point are possible. One of the project aims is to measure forces and torques, which appear during surgery [35]. Pre-clinical results are available [36].

The B-ROB 134 robot is used for radiologically controlled biopsy extraction [37]. It is built around special seven-axis kinematics with a serial configuration. The slender set-up enables operations to be performed inside a CT scanner. Information on clinical experiences is not available.

Its predecessor, B-ROB2, is based on a modular approach using several two-DOF stages [38]. In a first prototype, two of these stages were mounted in a parallel fashion, allowing control of entry point and direction of a biopsy needle. The stages were mounted on a passive arm and could be used in a CT scanner environment. An MRI-compatible set-up is under development. Information on clinical experience is not available.

CT-BOT is a robot for percutaneous interventions inside a CT scanner and was introduced by a group from Strasbourg.35 The system uses parallelogram kinematics and provides five DOF. It is built from radiolucent material, uses ultrasonic actuators, and carries a needle driver unit which provides two additional DOF [39]. The system is mounted on the patient's abdomen with straps. It is remotely controlled via a six-DOF joystick which provides force feedback. There is no information on clinical experiences available.

The system D2M2 (Direct Drive Modular Manipulator) is under development for endoscopic surgery in Montpellier.36 It comprises a self-made SCARA-arm attached to a vertical guide. The arm itself carries an endoscopic tool which moves in six DOF for minimally invasive interventions. The robot is controlled by a master input device. Clinical experience has not been reported.

The systems DAVINCI^®37 and ZEUS® or AESOP^®38 from the recently merged companies Computer Motion and Intuitive Surgical, both from USA, may be purchased. These telesurgical workstations consist of a cockpit unit with joysticks, imaging elements and a manipulator unit whose three arms control the instruments and endoscopic camera [6]. SCARA kinematics with six DOF (DAVINCI) and four DOF (ZEUS, AESOP) are used. These systems are used for laparoscopic surgery (visceral surgery, gynaecology and urology [7]) and in the field of minimally invasive cardiac surgery [8].

The system ENDOPAR39 is a telemanipulator for laparoscopic interventions. This system uses three industrial PUMA robots to move the instruments (known from DaVinci) and to guide the endoscopic camera [40]. The intention of the project is to automate several tasks such as suturing [41]. The system has not yet been tested in a surgical environment.

The ENDOXIROB40 system has been developed for endoscopic operations. It features two arms to control the instruments and to align the endoscopic camera. This development has been driven by several French institutes and companies.41 For the first experiment, a six-axis industrial-articulated robot is used. Another prototype with parallelogram kinematics has been introduced [42]. This set-up allows movements in three DOF around an invariant point. There is no information on clinical experiences available.

The Green Telepresence Surgery System (GTSS) was developed at the Stanford Research Institute.42 This telemanipulation system consists of a workstation with two joysticks and a stereo visualizing device and a robot with two articulated arms at the surgery site [43]. In addition, acoustic information and force feedback are provided. This system was the predecessor of the DaVinci surgical system.43

The HYPERFINGER44 is a manipulator for microsurgical interventions. This master–slave system maneuvers the forceps in seven DOF using a small linkage system. The slave subsystem is set up on a tripod next to the OR table and is 10 mm in diameter. The system has been tested on a pig [44].

The system IRASIS (Insertion Robotisée d'Aiguille sous Imagerie) is developed by the LSIIT within the ROBEA program.45 This robot is intended to insert a needle into a tumor in the liver under CT control. A self-made six-DOF articulated arm robot is used [39]. The system is a successor to the project CT-BOT. Information on clinical experience is not available.

KIMRO is a robotic system for interventions in the MR scanner and has been introduced by Virtanen et al.46 This system uses a long arm made from plastics and titanium to move a needle or other surgical tools within the field of an MR scanner [45] in five DOF. No information on surgical experiences is known.

The system LAPROTEK47 is used for remote-controlled laparoscopic surgery. It is commercially available (but not FDA approved). The system comprises a workstation with joysticks and visualization and a robotic device attached to the OR table [46]. The instruments have a diameter of 7.5 mm and are disposable. Information on clinical experience has been reported [47].

The LARS48 system was used experimentally for percutaneous renal access [48] and for minimally invasive neurosurgical [49] and laparoscopic [50] interventions. In these procedures, the system was used to guide an endoscopic camera. Mechanically, the system is based on a serial articulated arm. No information on DOF is available. On the basis of LARS, several other robotic systems have been developed (see PAKY, ACUBOT and Steady-Hand Robot).

The LPR49 (Light Puncture Robot) is a system for use inside the MR scanner. The device provides five DOF and is set directly onto the patient's abdomen. The systems LER and TER use straps for fixation; here, these straps are actuated by pneumatic motors to move the device. The robot weighs 1 kg and is made from plastic material [51]. Information on clinical experience is not available.

The project MARGE50 deals with robotics for microsurgical applications [52], [53]. The robot is programmed to automatically restrict its movements according to the area of the body in which it moves. In addition, common tasks like suturing are pre-programmed. A Mitsubishi PA10 articulated arm robot is used. Information on clinical experience is not available.

The system MC2E (Manipulateur Compact de Chirurgie Endoscopique) is a joint project51 for endoscopic surgery [54], [55]. The project is connected to the MARGE project and the ROBEA program. The system's base is mounted on the patient's stomach by belts or straps. The endoscopic tool is moved by a small robotic arm attached to the base. In vivo trials on pigs have been reported.

Within the MICRON52 project, a hand-held three-DOF manipulator to compensate for tremor during intra-ocular microsurgery has been developed [56], [57]. It consists of three-legged parallel kinematics with piezo drives and inertial or optic measuring systems [172]. The range of movement is 0.5 mm and the maximum force is 0.05 N. There is no information on clinical experiences available.

The MICROSURGICAL ASSISTANT53 project (‘Steady-Hand Robot’) deals with robot technologies in microsurgical applications. The instrument is attached to a manipulator arm (serial, six DOF), which damps or stops certain undesirable movements such as hand tremor or departure from pre-defined trajectories [58]. The system is based on the PAKY [166], the LARS project. No information on clinical experiences is available. Dewan54 et al. [173] present an ophthalmologic application.

The MIRA manipulator system55 can be used inside the MR scanner for minimally invasive interventions, e.g., on the spine. Thus, it is possible to remotely puncture vertebral bodies under near real-time imaging. The mechatronic components for the special four-axis serial kinematics are made from MR-compatible material. No clinical experiences are known to have been reported.

The system PADEMIS56 (Peristaltically Actuated Device for Minimal Invasive Surgery) is under development for minimally invasive surgery. This worm-like structure has a diameter of 4 mm and comprises three groups of six segments which change diameter and length periodically to create peristaltic movement. Each segment consists of six chambers in a radial assembly. The direction of movement can be controlled by actuating each chamber differently. A flexible tube provides pressure to the silicone rubber segments and access to the tip of the device for endoscopic procedures [59]. Clinical experience has not been reported.

The robot PADYC57 has been developed for applications in the field of pericardiac punctures. Via the robot arm, the movements of the surgeon are checked and, if needed, restricted if pre-defined trajectories or perimeters are exceeded [60]. The system uses a three-axis SCARA robot with additional rotational and linear axis and contains six DOF altogether. Spatial orientation is provided by an optical tracking system. There is no information on clinical experiences available.

The RAMS (or AMES) surgical robot project is a miniaturized six-DOF telemanipulator with master and slave subsystems, programmable tools, force feedback and tactile feedback. This project is driven by NASA58 and an industrial partner [61].59 Master and slave arms are ∼2.5 cm thick and 25 cm long and have six DOF each. The system has been deployed for testing purposes.

The ROBITOM60 manipulator system can be used in MR as well as in CT scanners for biopsy of breast tumors. The mechatronic components for the special three-axis kinematics are built from MR-compatible materials [54]. There are no clinical experiences known so far.

A ROBOTIC LASER COAGULATOR was presented by Suzuki61 et al. [63]. This device combines a video endoscope, a light source, a visible laser pointer and a coagulating laser diode in the forceps. This two-DOF system is 11 mm in diameter and 26.5 mm long and can be integrated into a telerobotics system. Clinical experiences have been carried out on a porcine liver.

The system TEC (Tethered Epicardial Crawler, project HEARTLANDER) is currently being developed62 for minimally invasive heart surgery [64]. The device is inserted through a small incision and moves on the heart's surface. To do so, the device consists of two suction pads (13 mm in diameter, 13 mm high) connected to each other by 3 nitinol alloy wires [65]. The length of these wires can be controlled by the surgeon via a joystick and a digitized fiberscope. In vivo trials on pigs have been reported.

The group of Sastry63 is dealing with the development of telesurgical manipulators and interfaces. The objective is to realize force feedback as well as exact haptic feedback on endoscopic interventions [66]. There are no clinical experiences known so far.

Within the TONATIUH project,64 a robot for telesurgical procedures is being developed. The group first collected experiences in robot-aided laparoscopic surgery using a PUMA 6000 robot. The TONATIUH-robot has four DOF and a maximum reach of 40 mm, a payload of 300 g and a weight of 18 kg. The system is remotely controlled by a joystick [67]. Surgical experience has been reported on pigs and dogs [68].

To place a needle in a tumor under ultrasonic control, the ATRE-Lab65 has developed a manipulator called UMI [174]. This special set-up, which consists of a sonode and a needle driver, is adducted to the skin by a PUMA robot [69]. There are no clinical experiences known so far.

The system VECTORBOT is under development for positioning66 instrument such as needles, electrodes or drill guides. The system seems to be based on an articulated arm (DLR ‘Hand III’⁶⁷). Further information is not available.

A robotic system for minimally invasive coronary artery bypass (CABG) surgery has been introduced by the group around Salcudean [70] (project ‘CAN2’).68 The system is based on parallel kinematics and provides six DOF. It is supposed to move the instrument in synchrony with the heart's movements when performing surgery in such a way that the instrument virtually stands still. It is controlled by the surgeon via force-feedback joysticks. There is no information on clinical experiences available.

Research in the field of telesurgery and automated robotic camera-guidance systems for endoscopic surgery is being done at the German Aerospace Center.69 For example, one of the developed systems is intended to automatically keep the view of the camera on the instrument or virtually ‘freeze’ the heart's movements by synchronizing the movement of the instrument with the heartbeat [71]. Special articulated kinematics (project ‘DEU1’) are used.

The project NAVIPED deals with robotic aid for pedicle screwing [138]. There are no clinical experiences known so far.

A robot system for needle placement under CT control is under development in Erlangen70 (project ‘DEU8’). This six-DOF industrial PUMA robot is implemented in a CT environment. Information on clinical experiences is not available.

A robot for the puncture of retinal vessels is under development in Lübeck71 (project ‘DEU9’). This system comprises a six-DOF hexapod known from the EVOLUTION1 system. It is planned to use the system to insert a 22-gauge needle into the vessels of the retina. Heartbeat and other motions of the patient are to be compensated for [73]. Information on clinical experience is not available.

A robot system for CT-guided interventions has been presented in Strasbourg72 (project ‘FRA3’). The system is composed of self-made five-DOF parallel kinematics for the positioning of a three-DOF needle driver [39]. The parallel structure is made of two six-bar lever mechanisms. Force sensors for force feedback are implemented and a commercial force-feedback input device is used. All actuators are installed in such a way that they do not disturb the CT scanner. Information on clinical experience is not available.

At the Technion in Israel,73 a robot for the registration of bone surfaces is under development (project ‘ISR3’) (see RSPR3).

The Surgical Assist Technology Group74 has developed a system to control instruments for surgery. It uses hexapod kinematics (six DOF) which can be deployed in an open MRI (project ‘JAP1’). Together with the Surgical Planning Laboratory,75 a system has been developed which serves to place radioactive seeds under MRI control and uses special serial kinematics with five DOF [75], [76] (see project ‘JAP7’). Clinical experiences are not known.

A robot for use in an open MRI has been developed in Tokyo.76 It enables minimally invasive liver biopsy, works via electro-hydraulic-driven kinematics and can be sterilized [77] (project ‘JAP3’). There are no clinical experiences known so far.

A forceps manipulator for a couple of endoscopic procedures has been introduced by Suzuki [175] (project ‘JAP16’).77 The system provides two microforceps (with four DOF each), a light source and an endoscopic camera in a single tube. For image overlay, a magnetic tracking sensor is also attached to the tube [78]. The system is controlled by force-feedback joysticks to provide haptic control. The endoscopic tube is attached to a five-DOF robotic arm [79]. In vivo tests on pigs have been reported [78].

A robot for telemanipulation and laparoscopic surgery has been presented by Shimachi78 et al. (project ‘JAP17’). The system is in an experimental state and provides movements for a forceps in four DOF. To achieve accurate force feedback for the operator, a special force-sensing trocar is used [80]. Information on clinical experiences is not available.

Dohi79 et al. presented a robot for MR-guided thermotherapy for liver tumors (project ‘JAP21’). The system uses a five-bar linkage mechanism to orient the needle in two DOF. A third DOF is provided by moving the set-up vertically. The device is made from aluminum and stainless steel and actuated by ultrasonic motors. It has a maximum height of 240 mm in the MR gantry [81]. Information on clinical experiences is not available.

A robot system for breast biopsy under ultrasonic control is being developed at the CIMIL Laboratory80 (project ‘SING1’). A SCARA-robot with a second forearm is used. The first forearm carries a needle driver and provides seven DOF. The second arm carries the ultrasonic probe and allows movements in four DOF. Using this set-up, the needle can always be held within the range of the ultrasonic probe. For navigation, internal encoders and an external optical tracking system are used [82]. There is no information on clinical experiences available.

A study group at Philips Medical Systems81 has developed a robot to be deployed in a CT scanner (project ‘USA3’). The system directs a needle and is controlled by CT data, whereas the needle is aligned automatically. Details of pre-clinical experiences are available [83].

A system for telesurgery is under industrial development82 (project ‘USA7’). The device moves a surgical tool in six DOF and uses special hybrid kinematics: two compound rests are mounted in parallel fashion and guide a tool. This assembly rotates on a ring which is mounted on the OR table. The tool itself can rotate around its axis [84]. Information on clinical experience is not available. The company is also involved in the RAMS surgical robot project.

A robot for CABG is under development at the Columbia University83 (project ‘USA8’). This system is set up using parallel kinematics and moves the surgical tool in six DOF. The heart's surface is tracked optically and the robot is controlled in such a way that the beating heart virtually stands still when watched through the visualization device also attached to the robot. Information on clinical experiences has not been reported.

Oral- and maxillofacial surgery, ear, nose and throat surgery

The A73 system84 has been developed for automated telesurgical interventions in the sphenoid sinus. It uses a common articulated robot with six DOF and can either work automatically or be remotely controlled using a six-axis joystick [85]. It has been developed in collaboration with industrial partners.85 Details of pre-clinical experiences are available.

The Surgical Robotics Lab86 has introduced several projects. ROBOPOINT is a small, sterilizable robot with special hybrid kinematics (four DOF) [87]. Possible applications are the control of instruments, punctures or the milling of bones. The OTTO system (which is based on the SurgiScope^®87 system) is attached to the ceiling over the OR table and is deployed in head surgery to implant aesthetic prostheses [88]. It uses parallel kinematics with seven DOF. OTTO2 provides a seven-DOF articulated robot (adapted industrial robot) for instrument guidance. ROBODENT® has been developed for dentistry but is actually not a robotic device. Another system (project ‘DEU5’) is used for maxillofacial interventions in a CT scanner. This comprises a three-axis robotic milling device that is attached to the scanner. Some of the systems have been tested clinically. Another system for maxillofacial surgery is under development: NAVIGATED CONTROL is used for bone milling [86]. A shaver is hand-held and guided by a navigation system. The software switches the shaver off when a pre-defined spatial area is left. By doing so, a cavity can be resected. Details of clinical experiences are not available.

Within the Collaborative Research Center 414, ‘Computer and Sensor Based Surgery’,⁸⁸ of the German Research Foundation (DFG), the Universities of Heidelberg and Karlsruhe, Germany, are working on several concepts for robot-aided cranio-maxillofacial surgery [89]. The ROBACKA project [90], [91] is used for milling the skullcap. It uses a six-axis articulated robot which is able to autonomously follow certain trajectories and which can also be used for passive navigation.

The robot ROBIN for milling of the lateral skull base and implantation of hearing aids is being developed in Tübingen89 and Stuttgart.90 It is based on hexapod kinematics and is also described as a combination of surgical robotics and navigation [92]. To expand the workspace, the robot is attached to a bracket. Information on clinical experiences is not available.

The RONAF91 project deals with the milling of the lateral skull base. To do this, an industrial robot with six DOF has been programmed to mill a cavity for an implanted hearing aid without perforating the skullcap, either under ultrasonic control or via force-based local navigation [93]. Information on clinical experiences is not available.

The SURGICOBOT92 is a system designed to supervise and restrict movements of the surgical tool. The tool is mounted freely on a small six-DOF robotic arm and is restricted to certain pre-programmed areas. If such a boundary is reached, the movement of the tool is stopped. Experiments on resin jaws have been performed [94].

The system X1 is available for dental implant navigation.93 This passive hexapod is used to precisely manufacture drill guides. Strut lengths are provided by the control software and realized manually. An integrated mill is then used to cut the drill guide. The system is commercially available.

A system for robot-aided laryngoscopy is under development in Leipzig94 (project ‘DEU 11’). The purpose of this system is to register forces during surgery and to move to different view positions [95]. Information on clinical experiences is not available.

A robot for surgery of the upper airway and the throat has been presented by Taylor et al.95 (project ‘USA9’). This system consists of three manipulator arms (4.2 mm diameter). These devices implement Distal Dexterity Units (DDU) which are composed of snake-like units and detachable parallel manipulation units. The units provide bending of up to 70° with a radius between 18 and 29 mm in every direction and forces up to 1 N [96]. Therefore, movements of the forceps attached to the distal end of the set-up is possible in six DOF.

Neurosurgery

The system ALPHA has been introduced by a commercial entity.96 It is based on a parallel lever mechanism and provides five-DOF movements around a remote center of rotation for microsurgical procedures [97]. It is remotely controlled by the surgeon using a joystick. The company has published pictures of surgical procedures performed with this system.

The system CRANIO97 has been developed for milling of the skull cup [98]. Pre-operatively planned bone resections are performed. Within this project, individual implants are manufactured to fit exactly to the resection. The system uses a small hexapod set-up to move the milling device in six DOF (CRIGOS). Information on clinical experience is not available.

The EVOLUTION1®⁹⁸ system guides tools or endoscopes on hexapod kinematics and an additional linear axis, which provides further workspace. It is used for neurosurgical applications. The hexapod is attached to a boom. The system has been clinically deployed but is no longer in production.

The system IGOR99 (Image Guided Operating Robot) [99] serves for image date fusion, for surgical planning and for performing neurosurgical interventions. A six-DOF articulated arm is used. Information on clinical experiences is not available.

The MINERVA100 robot for neurosurgical applications works inside a CT scanner. The surgeon is oriented by the images provided by the scanner and controls the robot step by step. Simultaneously, the system checks the surgeon's actions to determine whether the momentarily desired trajectory might destroy vital structures [100]. The robot consists of special serial kinematics with five DOF. The system has been clinically deployed for testing purposes.

The NEUROARM101 project deals with the development of an MR-compatible manipulator for remote surgery. The system uses three specially developed articulated arms with seven DOF and piezo-electric motors for manipulation and imaging [101–103] and works in an MRI scanner. Information on clinical experiences is not available.

The NEUROBOT102 project of the ATRE Laboratory in Tokyo is a manipulator for microsurgery. Within a pipe of 10 mm diameter, two surgical forceps and a 3D endoscope, as well as tubes for irrigation and suction are contained. The forceps are remote-controlled by a joystick. Clinical experiences have been reported [104], [105].

The NEUROBOT103 of the CIMIL Laboratory in Singapore is used for the milling of bones in the skull base area. Mechanically, it consists of two units: a base (three DOF) which is positioned before the actual robot (hexapod, six DOF). The hexapod executes the milling process. Information on clinical experiences is not available.

The NEUROMATE^®104 system of the US company ISS was originally developed by the French University of Grenoble and was sold by the IMMI company before this company was taken over by ISS. An articulated robot of six DOF is used to place and guide a tool in the skull area [106]. The actual surgical task is performed by the surgeon. The robot is commercially available.

The PATHFINDER®¹⁰⁵ system moves tools according to a pre-operatively defined trajectory. On the basis of serial articulated kinematics, it works without a stereotactic frame and registers the patient autonomously. The system is commercially available. This company also introduced the NEUROSISTA system which is not available and no clinical experiences have been reported. It consists of two SCARA robots with five DOF each.

The robotic system WAM106 was developed for spinal interventions. It is based on a seven-DOF articulated arm developed for industrial applications.107 The system for surgical applications is restricted to four DOF. The instrument is attached to the robot which allows movements only under pre-defined constraints [107]. Experiences from phantom trials have been reported.

Navab and Loser108 introduced a robotic system for percutaneous interventions (project ‘DEU4’). This systems provides a two-DOF needle driver on a passive articulated arm and can be used in CT scanners [108]. Results of animal trials have been reported.

At the German Cancer Research Center,109 a robot for stereotactic interventions has been developed (project ‘DEU6’). The system consists of an adapted measuring arm intended for industrial application which has been motorized and is controlled by the surgeon via a joystick and a conventional stereotactic frame [109]. Special software to compute the ideal position of the robot base and for visualization of the robot's movements for collision avoidance is also included [110]. There is no information on clinical experiences available.

A system for robot-aided laser ablation in neurosurgery has been introduced by a commercial entity110 (project ‘DEU7’). The device is mounted on a standard stereotactic frame and guides a laser-beam in two DOF (in/out and rotation). Brain-tissue fragments are removed from the cavity by continuous irrigation and suction through the laser probe. Blood vessels are detected by a confocal laser-scanning microscope, which is integrated into the probe. An additional coagulating laser is included in the probe to close vessels. The tube used has a diameter of ∼5.5 mm [111]. Clinical trials have been reported.

From the ATRE lab111 of the University of Tokyo comes an MRI compatible robot (project ‘JAP7’). It uses special serial kinematics made from synthetic material with five DOF for needle insertion in stereotactic neurosurgery. It works in an open MRI [112]. The group is collaborating with the CISST-group at Johns Hopkins University, Baltimore, MD, USA. The system is also used for urological applications [113]. Information on clinical experiences is not available.

A telesurgical workstation with MR-compatible arms to move tools and for imaging purposes has been introduced by Tajima112 (project ‘JAP8’). The experimental set-up is radially placed around a vertical-field MRI and is remotely controlled by a six-DOF joystick. Two arms with serial kinematics of MR-compatible material are used [114]. Information on clinical experiences is not available.

An MR-compatible brain retracter manipulator (project ‘JAP10’) has been introduced by Okamoto et al.113 Two-segmented tongues, each with 10 individually controllable pieces, push aside the brain tissue in order to create space for further manipulators. Each segment of the hydraulically controlled tongues monitors and regulates the pressure put on the brain tissue [115]. Experiences on animal experiments have been reported.

A manipulator for use in open MRI has been introduced by Masamune et al.114 (project ‘JAP12’). The system is for use in stereotactic neurosurgery. The robot has five DOF and is able to move a needle towards the injection point. To do this, a pivotable bow is seated on a Cartesian x–y–z guide along which the needle-driver can be moved [116]. Information on clinical experiences is not available.

At the AIST Institute,115 a manipulator for transnasal neurosurgery is being developed (project ‘JAP13’). This three-axis robot is based on serial parallelogram kinematics and is able to move a surgical tool in an open vertical field MRI scanner [117]. There is no information available on clinical experiences.

A micromanipulator for neurosurgical applications was presented at the Nagoya University116 (project ‘JAP14’). This device is composed of a master–slave system with seven DOF which can be used in small cavities. To obtain a good maneuverability, a guided tube is used. The set-up has a diameter of 3 mm. There is information available on experiences from an experiment on chicken [118].

A master–slave system for microneurosurgery was presented by Asai et al.117 (project ‘JAP19’). This system consists of a master-console, providing three-DOF joysticks, visualization (microscope and endoscopic stereo camera) and some foot switches and a manipulator set-up with two arms (four DOF: three rotational, one translational). Forceps are attached to the arms. In vivo experiments on rats have been carried out [119].

Shadmer118 et al. have presented a robot for functional MRI experiments (project ‘USA10’). This two-DOF system is able to apply forces on the hand of a test person. The device is pneumatically driven and made from plastic components.

Orthopaedics

The ACROBOT®¹¹⁹ robot mills the implant bed for a unicondylary knee prosthesis [120], [121]. It is mechanically based on an articulated robot arm designed for industrial purposes (six DOF). The end effector is controlled by the surgeon and allows only certain, pre-defined trajectories. The system is commercially available.

The ACUBOT120 system (see also PAKY121) is used for the robot-aided insertion of a needle for percutaneous vertebroplasty [122].122 It is based on special active serial kinematics (‘RCM’, three DOF) on passive carrier arm (three DOF). This arm is attached to a Cartesian stage with three DOF and places a needle under CT or fluoroscopic control according to a pre-defined plan. This robot is also used for urological procedures (discussed later). Information on clinical experiences is not available.

The ARTHROBOT123 robot is used for the implantation of hip endoprostheses [123]. It is based on parallel kinematics with four DOF and is attached directly to the bone. A mechanical registration procedure is used. There are no reports of clinical experiences. The same group124 is working on several other medical robotics projects. These are remote-controlled manipulators and the appropriate interfaces.125 Information on clinical experiences is not available.

A system for orthopaedic use (knee arthroplasty) has been presented by Dombre et al.126 The system BRIGIT (Bone Resection Instrument Guidance by Interactive Telemanipulator) is under development in collaboration with an industrial partner.127 An industrial six-DOF articulated arm robot was adapted [124] and mounted on a trolley together with the control cabinet. For surgery, the trolley is attached to the OR table. Information on clinical experience is not available.

The CASPAR128 system uses an articulated industrial robot with six DOF for hip and knee endoprostheses, as well as for cruciate ligament replacement. The system was commercially available and has been used clinically, but the production has now stopped.

The Helmholtz Institute for Biomedical Technologies in Aix-la-Chapelle129 is working on the robotic system for bone treatment called CRIGOS.130 The system is technically based on parallel kinematics with six DOF. For applications, see CRANIO, MINARO and MINOP2.

The PI GALILEO NAV131 system uses two perpendicular linear axis to navigate and to automatically move the saw block to prepare the implant bed for knee replacement [125]. For navigation purposes, the system uses an optical tracking system. The device is commercially available.

The GP-System is a motorized saw-blade guide for knee arthroplasty.132 The system automatically moves the saw block in two DOF and can be used with any prosthesis system. No pre-operative CT scan is necessary for planning. There is no information available on clinical use.

The BMGO133 work group is dealing with the milling of implant beds for knee replacement. The project IMAGE REGISTRATION uses a six-DOF industrial robot which carries a mill and a camera to track the bone surface. The bone is not clamped, but its movements are tracked by a special imaging system.134 Details of clinical experiences are not available.

The ITD system (Intelligent Tool Drive)135 is a hand-held six-DOF manipulator for the machining of bones [126], [127]. This device compensates for unintentional movements of the surgeon (e.g., tremor) and a tool is stabilized with respect ro the bone. The spatial alignment of the device and the bone is tracked by a special optical tracking system [128].136 The first prototype is based on parallel kinematics (hexapod) with electrical linear motors; another set-up, which may become possible in the future, is based on epicyclic hybrid kinematics [129]. The system has not been deployed clinically so far.

The robot LUKE is under industrial137 development for pedicle screw placement. This articulated arm robot provides six DOF to move the surgical tools. Information on clinical experiences is not available.

The MARS138 system is a carrier system for the positioning of a drill for spinal surgery. The miniaturized hexapod kinematics with six DOF carry a drill sleeve and are attached to the vertebral body via a clamp. After an automated powered alignment of the tool platform via fluoroscopic images, the drilling process can be carried out by the surgeon [130], [131]. Information on experiences from animal experiments is available. This procedure can also be used for long bone intra-medullary distal locking [132] and has been developed in collaboration with an industrial partner139 for commercialization under the name SpineAssist.

The system MIAS140 is under development for minimally invasive arthroscopy [133–135]. This hand-held system features a remote-controlled tip with one DOF (bending) for moving a small endoscopic tool. The arthroscope is a cylinder with an outer diameter of 4 mm and 350 mm total length. The 25 mm distal section of the arthroscope is dirigible (bending range 0–110°). The system also comprises a special navigation system. Information on clinical experiences is not available.

Within the MINARO141 project, robotic devices for bone-cement removal during revision hip surgery [136] are under development. One system (MINARO1) is based on a hexapod known from the CRIGOS project. The robot is mounted next to the OR table. Another set-up (MINARO2) is based on small bone-mounted four-DOF kinematics [176]. Details of clinical experiences are not available.

The system MODICAS142 orients an implantation tool for hip prostheses towards the patient with a small six-DOF articulated robot. An optical tracking system is used [137]. A pre-operative planning based on CT data is performed. The steps of the work on the bone are carried out by the surgeon. The system has been tested clinically.

The project NAVIPED143 deals with robotic aid for pedicle screwing [138]. An articulated arm robot is used. Information on kinematics and clinical experiences is not available.

The ORTHOSISTA^®144 system serves as a carrier for a drill sleeve for orthopaedic applications. On the basis of two orthogonal intra-operatively acquired radiographs, the trajectory of, e.g., a screw, can be determined. The robot aligns the sleeve accordingly. The system is based on special hybrid kinematics with four DOF. The producer has reported clinical experiences.

The MRCAS145 group is working on a system for precision freehand sculpting of bone, PFS. A hand-held nibbling-device is held against the bone and is switched on automatically when located in a pre-defined area so that only the planned bone surface remains [139]. Clinical experiences with the system have not been reported so far.

The system PRAXITELES146 is under development for knee surgery. This bone-mounted robot is able to orient a cutting block for image-free knee arthroplasty [140]. The system consists of a subsystem to manually adjust the position of the implant according to the planning performed with a navigation system, and a two-DOF robotic device which automatically adjusts the alignment of the implant to the anatomical axis. Experiences with cadaver trials have been reported.

The system RAO ASSISTANT MANIPULATOR has been designed by Yanagihara et al.147 to assist the surgeon during rotational acetabular osteotomy on the hip. This system uses a three-segmented tongue to retract the muscle tissue from the bone to allow minimally invasive procedures [141]. The tongue is force-controlled and moved to the operation site by a six-DOF articulated manipulator. Details of clinical experience are not known but tests on pigs have been performed.

The ROBODOC®148 system is the best-known system for robot-aided surgery and is used for the milling of cavities in the femur for hip prosthesis purposes [142], [143]. It uses an industrial SCARA-robot with five DOF. The system is commercially available and has been applied over 10,000 times. Several work groups [144], [145] are dealing with related problems and use ROBODOC. In the meantime, the pins formerly required to perform the procedure have been replaced by a surface-matching procedure. The planning of the surgery is done before the operation on a proprietary planning station named ORTHODOC®.

For determination of the patient's alignment during robot-aided hip surgery, the ROBONAV149 project uses an optical tracking system along with the surgical robot ROBODOC® in such a way that the bone structure is recognized optically and undesirable movement of the patient is detected [146]. Details of clinical experiences has been reported [147].

The robot of the VISAROMED150 project is used for pedicle screwing. An industrial hexapod with a horizontally and vertically adjustable carrier arm is used. The robot moves the drill with six DOF along the spinal column of the patient. There is no information available on clinical experiences with this robot. This work group also works in other fields of computer aided surgery [148], [149].

The robot RSPR3 has been developed in Israel.151 This parallel-kinematics-based platform is used for several medical applications. One project deals with knee arthroscopy152 (project ‘ISR1’), another [150] with the insertion of needles in soft tissue153 (project ‘ISR2’), and a third154 with the registration of bone surfaces [74] (project ‘ISR3’). This robot consists of three identical kinematic chains. Each chain contains a lever rotating around a pivot perpendicular to the base platform and offset from the center of the base. At the other end of the lever, a linear actuator is attached by a ball-and-socket joint. The upper end of the linear actuator is connected to the moving platform by a fork joint [177]. This set-up leads to only a small number of singularities. Information on clinical experiences is not available.

A robot for total knee replacement has been introduced by Marcacci et al.155 (project ‘ITA1’). This system uses a custom-built five-DOF articulated robot which positions a plane guide. This guide is used by the surgeon to move the mill by hand [151]. Results from trials on phantoms and biological specimens have been reported.

At the Advanced Therapeutic Engineering Laboratory,156 systems for orthopaedic surgery have been developed. One system uses z-like kinematics, manufactured from MR-compatible material (project ‘JAP6’) [152]. Another system uses a simple set-up with two DOF for spinal surgery (project ‘JAP11’). Information on clinical experience is not available.

A robot for total knee arthroplasty was presented by Sugita157 et al. (project ‘JAP20’). This self-made articulated arm robot provides six-DOF motion for the milling tool. The special configuration of the axis leads to improved safety of the surgical process [153]. The robot itself is 810 × 1500 × 2050 mm3 in size and weighs 900 kg. Information on clinical experience is not available.

A robot for percutaneous spine surgery has been developed at CISS158 in Korea (project ‘KOR1’). The system is ceiling-mounted and uses a self-made articulated arm to guide the tool [154]. The system is remotely controlled using a workstation and joysticks. Information on clinical experience is not available.

Radiotherapy

The CYBERKNIFE® 159 is an articulated arm robot maneuvering a linear accelerator. The patient is attached to the operating table via a flexible mask, and the linear accelerator is aimed at the tissue to be treated. An X-ray tracking system monitors the patient periodically for the position of the tumor throughout the treatment [155]. The system is commercially available.

The system HEXAPOD is a six-DOF robotic radiation treatment couch.160 Providing six DOF, the patient can be placed in any alignment relative to the radiation source. Movements of ± 30 mm in the x- and y-axis and ± 40 mm in the z-axis, as well as rotations of ± 3° are possible. Information on clinical experience is not available.

Robotic applications for radiotherapy (the MOCOMP project) have been developed in Munich161 and Lübeck.162 Here, the spatial alignment and movement of the patient are tracked by an optical tracking system. On the basis of this data, the location of the tumor is calculated and a linear accelerator is aimed at it by a six-DOF articulated robot [156]. Information on clinical experiences is not available.

At the Institute of Nuclear Physics163 in co-operation with the Centre Protonthérapie d'Orsay,164 a robot for tumor irradiation is developed (project ‘FRA1’). A special software called CARABEAMER is used. This robot maneuvers the patient in a proton beam around an isocenter. An articulated robot designed for industrial applications is used [157]. There is no information available on clinical experiences.

Trauma surgery

The system BLOODHOUND165 is a mobile medical robot for battlefield deployment [158]. It moves on four crawlers and has an articulated arm to provide examination, drug delivery and bandages to casualties. It is supposed to move autonomously (guided by GPS) to the site and medical action is then remotely controlled by a surgeon. Information on its use by armed forces is not available.

The system DERMAROB166 (predecessor SCALPP167) actively moves a dermatome to achieve skin transplants for the treatment of burned skin [159], [160]. The dermatome is attached to an articulated arm robot (SCALPP) and a SCARA robot (DERMAROB) and is automatically moved with constant velocity and pressure over the skin of the patient. Information on animal experiments reported.

The system INTELLIGENT FIXATOR168 comprises an external fixator which is set up with parallel kinematic structure. Each strut is actuated by a linear spindle, and strut forces are measured. The system can be used for bone repositioning as well as for deformity treatment [161], [162]. Clinical experience has been reported.

The REPOROBO169 project deals with the robot-aided repositioning of long bones. A six-axis industrial articulated robot is used. One bone fragment is attached to the robot and maneuvered under fluoroscopic control to fit the other fragment. Information on clinical experiences is not available.

At The Institute for Robotics and Process Control,170 a robot system for the reposition of bone fragments has been developed. A six-axis industrial articulated robot (Stäubli) is attached to the OP table and joins the bone fragments (project ‘DEU3’) [164], [165]. Clinical experiences have not been reported so far.

Urology

The ACUBOT171 system (PAKY, RCM robot) is used for the robot-aided insertion of a biopsy needle into the kidney. It uses special kinematics (‘RCM’, three DOF) on a passive carrier arm (three DOF) and places the needle as planned before surgery [166]. The needle itself is then driven by the PAKY unit under fluoroscopic control.

The PROBOT172 is used for automated prostate resection. A boom is used to carry special circular kinematics. These in turn carry a semicircular handle on which a carriage is moved along. The tool is attached to this carriage and can move back and forth so three DOF are achieved [167]. Clinical experiences have been reported.

The UROBOT173 project deals with several set-ups for urological treatments: prostate resection, implantation of radioactive seeds, and urethral surgery, among others. Special kinematics are attached to a conventional six-axis articulated arm robot. The project is based on the SARP174 project. The commercial prototype is called SABOT. Clinical experiences have been reported from the prostate resection field.

A TRUS (transrectal ultrasound) guided robotic system (project ‘CAN3’) has been developed by Fenster et al.175 It is designed to be used for brachytherapy of the prostate. The system consists of a six-DOF robot, a 3D TRUS imaging system [168] and a needle rotation assembly mounted at the end of the robot arm [169]. There is no information available on clinical experiments.

At the Engineering Research Center,¹⁷⁶ a manipulator for transrectal prostate biopsy is being developed (project ‘USA4’). This system can be used in an MRI scanner. The biopsy needle is driven by special three-DOF kinematics in serial configuration which steer the needle through the rectum to a user-defined point [170]. The system has been tested on a dog [171]. The group is collaborating with the ATRE Laboratory in Tokyo.

Synopsis

We were able to identify 159 systems or projects (Table II, Figure 1).

Figure 1. Summary of robots for different disciplines. ENT: ear nose throat surgery; OMS: oral- and maxillofacial surgery.

Table II.  One hundred and fifty-nine robotic systems for medical applications in different disciplines.

Number of developed systems	Discipline
25	Imaging
52	Abdominal and thoracic surgery
12	Oral- and maxillofacial surgery (OMS) and ear, nose and throat surgery (ENT)
23	Neurosurgery
31	Orthopaedics
4	Radiosurgery
6	Trauma surgery
6	Urology

Fifty-five percent of the systems originate from Europe, 23% from North America and ∼22% from Asia. The detailed distribution is displayed in Figure 2.

Figure 2. Distribution of development sites of robot-aided systems.

Most of the systems (68%) are based on serial kinematics with approximately one third using articulated robots (also known as PUMA or SCARA robots¹⁷⁷) originally designed for industrial deployment. About 20% of the kinematics used are parallel kinematics from industrial production or have been specially developed for this purpose. A total of 70% of the robot systems were especially designed for medical use (Figure 3).

Figure 3. Robot kinematics used.

The number of DOF gives an impression of the complexity of the systems. The higher the number of DOF of a robot, the more flexible and also the more complicated it is. For complete mobility six or more DOF are required. Systems with fewer DOF are normally smaller in size and are specially adapted to their purpose. About 46% of the described systems have six or more DOF. About 42% of the systems have five or less DOF. For ∼6% of the systems giving the configuration of the DOF is not meaningful, e.g., in the serpentine set-up of an endoscope for coloscopies (Figure 4).

Figure 4. DOF of the reviewed robot systems.

About 67% of the examined projects are at an experimental stage and have not yet been tested on patients. Twenty-four percent are used experimentally and 9% are commercially available in some countries.

Discussion

The present listing provides an outline of the worldwide state of the art in surgical robotics systems. The descriptions are limited to the basic facts and provide references for further study. Accurate assignment of systems, workgroups and medical fields is difficult due, in part, to the varying public relations of the institutes involved, especially in the Asian hemisphere. There are some systems which are used by two or more groups for different applications (e.g., ACUBOT/PAKY, CRIGOS/CRANIO/MINARO or project ‘JAP7’). However, the data collected in the presented study seems to allow the conclusion that most of the currently existing systems are presented.

Well-known reviews, such as those by Cleary and Nguyen [1] or Taylor and Stoianovici [2], provide a restricted survey of the state of the art concerning the number of systems described. Others are limited to certain fields [4], [5], [178], [179] or to particular technologies [180], [181].

Reflecting the presented data, the work on research and development in the field of medical robotics shows a wide extension of the technology. The systems have to fulfil several tasks, such as milling cavities in bone, harvesting skin, screwing pedicles or irradiating tumors, among others.

From the technical point of view, most systems are designed for only one dedicated application. A couple of systems are used for two or more applications, and other set-ups are used by some groups for different types of procedures. Systems which are designed for one application exclusively provide a smaller number of DOF and seem to be more compact. Alternatively, industrial robots are modified for the surgical working field (e.g., ROBODOC, CASPAR^©). These robots are typically more effective and bigger than necessary for the surgical task, but their acquisition and handling are easier than using a self-made robot.

The big industrial robots of former systems were not always able to satisfy the user's expectations [182]. It is assumed that, in the field of robot-aided surgery, future mechatronic devices will become smaller [56], [58] and easier to handle [126], [139]. Miniaturization can be achieved by differentiation according to applications, optimization of components and re-designing the kinematical set-ups.

In everyday life, surgeons only use a very small number of systems [183]. This can be explained by the high complexity of use, the strict safety precautions, missing FDA clearances and the fact that many of the systems are developed in a university environment. In addition, all systems that were not clearly described as being in experimental use were considered to be experimental set-ups.

Basically, the objective of further research and development of medical robotics is the unification and simplification of procedures and the improvement of achieved outcomes. Whether this can be with the presented robotic systems must be evaluated by clinical trials.

Recent studies and the data presented here brought us to the conclusion that the acceptance of robotic devices has to be enhanced by the improvement of handling, e.g., by the miniaturization of the devices.

Acknowledgment

The work on project ITD is funded by the German Research Society under grants SCHA 952/1-1 and MA 1150/39-1.

Notes

1. Laboratoire TIMC, Grenoble, France; http://www-timc.imag.fr/.

2. Institut national de recherche en Informatique et en Automation, Le Chesnay, France; http://www-sop.inria.fr/coprin/index.html.

3. CIMIL Laboratory, Nanyang Technological University, Singapore; http://mrcas.mpe.ntu.edu.sg/research/crobot/index.htm.

4. Department of Medical Informatics, Ehime University Hospital, Japan; www.medinfo.m.ehime-u.ac.jp.

5. CRIM, Scuola St'Anna, Pisa, Italia; http://www-crim.sssup.it/research/projects/emil/default.htm.

6. Given Imaging, Israel; www.givenimaging.com.

7. Armstrong Healthcare Ltd., High Wycombe, UK; www.armstrong-healthcare.com.

8. Institut für Medizintechnik und Biophysik, Forschungszentrum Karlsruhe, Germany; http://hbksun17.fzk.de:8080/imb/de/home.html?med/systeme/fips.html∼top.main.

9. LIRMM (Montpellier), LRP (Paris), TIMC (Grenoble), CEA (Fontenay aux Roses), Groupe Hospitalier Pitié-Salpêtrière, CHU de Grenoble; www.lirmm.fr/∼w3rob/SiteWeb/detail_resultat.php?num_resultat = 33&num_topic = 1&num_projet = 1&num_activite = 1.

10. LIRMM, France; www.lirmm.fr/∼duchemin/Hippo.htm; Sinters SA, Toulouse, France; www.sinters.com.

11. OTELO Consortium: (1) Université d'Orleans, Laboratory of Vision & Robotics, France; www.bourges.univ-orleans.fr. (2) Sinters Group, Toulouse, France; www.sinters.fr. (3) Kell Company, Roma, Italy; www.kell.it. (4) Center for Research and Technology—Hellas (CERTH), Thessaloniki, Greece; www.eng.auth.gr. (5) Université de Tours, UMPS, Tours, France; www.med.univ-tours.fr. (6) Brunel University, Uxbridge, Great Britain; www.brunel.ac.uk. (7) Elsacom Company, Rome, Italy; www.elsacom.com. (8) Corporacio Sanitaria Clinic (CSC), Barcelona, Spain; www.clinic.eb.es. (9) Ebit Company, Geneva, Italy; www.ebit.it.

12. Biochemical Micro System Engineering Laboratory, Department of Micro System Engineering, School of Engineering, Nagoya University, Japan; www.bmse.mech.nagoya-u.ac.jp/index-e.html.

13. Bio-Medical Precision Engineering Laboratory, Institute of Environmental Studies, Graduate School of Frontier Sciences, University of Tokyo, Japan; http://bme.pe.u-tokyo.ac.jp/index_e.html.

14. Laboratoire TIMC, Grenoble, France; http://www-timc.imag.fr.

15. Aesculap AG, Tuttlingen, Germany; www.minop.de/.

16. ARTS Lab, Scuola Superiore Sant'Anna, Pisa, Italy; http://www-arts.sssup.it/research/projects.htm.

17. Laboratoire Vision and Robotique (LVR), Université d'Orléans, Bourges, France; www.bourges.univ-orleans.fr/otelo/site.html.

18. OTELO Consortium: (1) Université d'Orleans, Laboratory of Vision and Robotics, France; www.bourges.univ-orleans.fr. (2) Sinters Group, Toulouse, France; www.sinters.fr. (3) Kell Company, Roma, Italy; www.kell.it. (4) Center for Research and Technology—Hellas (CERTH), Thessaloniki, Greece; www.eng.auth.gr. (5) Université de Tours, UMPS, Tours, France; www.med.univ-tours.fr. (6) Brunel University, Uxbridge, Great Britain; www.brunel.ac.uk. (7) Elsacom Company, Rome, Italy; www.elsacom.com. (8) Corporacio Sanitaria Clinic (CSC), Barcelona, Spain; www.clinic.eb.es. (9) Ebit Company, Geneva, Italy; www.ebit.it.

19. Helmholtz-Institut für biomedizinische Technik der RWTH Aachen, Germany; www.hia.rwth-aachen.de/research/cht/paromis.html.

20. Laboratoire TIMC, Grenoble, France; http://www-timc.imag.fr.

21. Mobile Robotics SA, Stockhom, Sweden; www.mobile-robotics.com.

22. School of Computing and Department of Electrical and Computer Engineering, Queen's University, Kingston, Ontario, Canada; www.cs.queensu.ca/∼purang/projects. htmlty.

23. Institut für Robotik und Kognitive Systeme, Universita¨t Lübeck, Germany; www.rob.uni-luebeck.de.

24. Instituto de Automática y Robótica Avanzada de Andalucía, Universidad de Málaga, Severo Ochoa, 4. Parque Tecnológico de Andalucía, Málaga, Spain.

25. Department of Mechanical Engineering, California Institute of Technology, Pasadena, CA, USA; http://robotics.caltech.edu/∼jwb/medical.html.

26. Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA.

27. Department of Mechano-Informatics, The University of Tokyo, Japan; www.ynl.t.u-tokyo.ac.jp/index.html.

28. Arbeitsgruppe MITI, München, Germany; www.aktormed.com.

29. DELTA Engineering GmbH, Barbing, Germany; www.delta-engineering.info.

30. Institut für angewandte Informatik, Forschungszentrum Karlsruhe und Sektion Minimal Invasive Chirurgie, Universitätsklinik Tübingen, Germany; www.iai.fzk.de/medtech/medrob/artemis/welcome.html.

31. Robarts Research Institute, London, ON, Canada; www.imaging.robarts.ca/∼kath/.

32. Artificial Intelligence Lab, IT, Cambridge, MA, USA; www.ai.mit.edu/people/madhani.

33. Biorobotics Laboratory, University of Washington, Seattle, USA; http://brl.ee.washington.edu/Research_Active/Surgery/Device_BlueDRAGON/BlueDRAGON.html.

34. Austrian Research Centers, Seibersdorf, Austria; www.arcs.ac.at.

35. l'Equipe AVR; LSIIT, Université Louis Pasteur, Illkirch, France; http://hp2gra.u-strasbg.fr/.

36. LIRMM, Département Robotique, Montpellier, France; www.lirmm.fr/∼duchemin/D2M2.htm.

37. Intuitive Surgical, Sunnyvale, CA, USA; www.intuitivesurgical.com.

38. www.computermotion.com.

39. Lehrstuhl Informatik VI, TU München, Germany; http://atknoll1.informatik.tu-muenchen.de:8080/tum6/research/sfb453C7.

40. www.endoxirob.com.

41. Sinters SA, www.sinters.fr; CHU Toulouse, France, www.chu-toulouse.fr; LAAS, www.laas.fr; CEA-CEREM, www-dta.cea.fr/home_cerem.htm; INRIA, www.inria.fr/chir; IET, www.chu-toulouse.fr; ONERA, www.cert.ft; LIRMM, www.lirmm.fr/∼michelin/.

42. Stanford Research Institute, www.sri.com.

43. http://biomed.brown.edu/courses/BI108/BI108_2004_groups/group02/group%2002%20website/history_robotic.htm.

44. Department of Micro System Engineering, Nagoya University, Japan; www.mech.nagoya-u.ac.jp.

45. LSIIT, Illkirch, France; http://hp2gra.u-strasbg.fr/fr/research/med_rob/sauver.html.

46. Department of Mechanical Engineering, Oulu University, Oulu, Finnland; http://konekilta.oulu.fi/kimro/.

47. endoVia Medical (former Brock-Rogers Surgical), 150 Kerry Place, Norwood (MA), USA; http://endovia.millersystems.com.

48. CISST, Johns Hopkins University, Baltimore, MD, USA; www.cisst.org.

49. Laboratoire TIMC-IMAG, La Tronche, France; http://www-timc.imag.fr/.

50. LIRMM (Montpellier), LRP (Paris), CEA/SRSI (Fontenay-aux-Roses) and Pitié Salpêtrière hospital (Paris), in the framework of ROBEA (supported by the CNRS); www.lirmm.fr/∼michelin/.

51. Laboratoire Robotique de Paris (LRP), LIRMM, CEA; http://lrp6.robot.jussieu.fr/fra/personnel/morel/robotic_surgery.html.

52. The Robotics Institute, Carnegie Mellon University, Pittsburgh, PA, USA; www.ri.cmu.edu/projects/project_32.html.

53. CISST ERC, Johns Hopkins University, Baltimore, MD, USA; http://cisstweb.cs.jhu.edu/research/ microsurgicalassistant/.

54. Department of Computer Science, Johns Hopkins University, Baltimore, MD, USA.

55. Institut für Angewandte Informatik, Forschungszentrum Karlsruhe, Germany; www.iai.fzk.de.

56. Institute of Microsystems Technology, TU Ilmenau, Germany; www.maschinenbau.tu-ilmenau.de/pademis.

57. Laboratoire TIMC, Université de Grenoble, France; http://www-timc.imag.fr/olivier.schneider/perso/english/gb_rsp_main.html.

58. Jet Propulsion Laboratories, Pasadena, CA, USA; http://telerobotics.jpl.nasa.gov/tasks/rams/.

59. MicroDexterity Systems, Inc., Albuquerque, NM, USA; www.microdexsys.com.

60. Innomedic GmbH, Karlsruhe, Germany; www.innomedic.de.

61. Institute of Environmental Studies, University of Tokyo, Japan; http://bme.pe.u-tokyo.ac.jp/index_e.html.

62. The Robotics Institute, Carnegie Mellon University, Pittsburgh, PA, USA; www.ri.cmu.edu/projects/project_533.html.

63. University of California, Berkeley, CA, USA; http://robotics.eecs.berkeley.edu/medical/.

64. Dep. de Cirugía, Hosp. de Infectología, Centro Médico Nacional la Raza, IMSS.

65. Advanced Therapeutic and Rehabilitation Engineering Laboratory, University of Tokyo, Japan; www.atre.t.u-tokyo.ac.jp/projects/hong/index.html.

66. Brainlab AG, Heimstetten, Germany; www.brainlab.com.

67. German Aerospace Center, Oberpfaffenhofen; www.robotic.dlr.de.

68. School of Computing and Department of Electrical and Computer Engineering, Queen's University, Kingston, Ontario, Canada; www.ece.ubc.ca/∼tims/heart.html.

69. Deutsches Zentrum für Luft- und Raumfahrt, DLR, Wesseling; Germany; www.robotic.dlr.de.

70. Institute of Medical Physics, Erlangen, Germany; www.imp.uni-erlangen.de.

71. Institut für Robotik und Kognitive Systeme, Universita¨t Lübeck, Germany; www.rob.uni-luebeck.de.

72. LSIIT (UMR CNRS-ULP 7005), Université Louis Pasteur, Strasbourg, France; http://hp2gra.u-strasbg.fr/.

73. Technion, Haifa, Israel; http://robotics.technion.ac.il.

74. Surgical Assist Technology Group, Tsukuba, Ibaraki, Japan; http://unit.aist.go.jp/humanbiomed/surgical/.

75. Brigham and Women's Hospital, Boston, MA, USA; http://splweb.bwh.harvard.edu:8000/index.html.

76. Department of Mechano-Informatics; Institute of Environment Studies, Tokyo University; www.i.u-tokyo.ac.jp/m-i/m-i-e.htm.

77. Institute for High-Dimensional Medical Imaging, the Jikei University School of Medicine, Tokyo, Japan.

78. Department of Mechanical Engineering, Iwate University, Iwate, Japan; www.mech.iwate-u.ac.jp/.

79. Department of Mechano-Informatics, University of Tokyo, Japan; www.atre.t.u-tokyo.ac.jp.

80. CIMIL Laboratory, Nanyang Technological University, Singapore; http://mrcas.mpe.ntu.edu.sg/research/neurobot/index.htm.

81. Philips Medical Systems, Cleveland, OH, USA.

82. MicroDexterity Systems, Inc., Albuquerque, NM, USA; www.microdexsys.com.

83. Columbia University, Department of Computer Science, New York, NY, USA; http://www1.cs.columbia.edu/∼laza/stewart/.

84. Department of Otorhinolaryngology, Head and Neck Surgery, University of Erlangen-Nürnberg, Germany; www.hno.med.uni-erlangen.de.

85. CAS Innovations GmbH, Erlangen, Germany; www.cas-innovations.de; Medical Intelligence GmbH, Schwabmünchen, Germany; www.medint.de.

86. Surgical Robotics Lab, Berlin, Germany; www.srl-berlin.de.

87. ISIS S.A.S., St Martin d'Heres, France; www.isis-robotics.com.

88. http://sfb414.ira.uka.de/.

89. Laboratorium für Medizinrobotik, Sektion sensorische Biophysik, Universitätsklinikum Tübingen, Germany; www.medizin.uni-tuebingen.de/hno/mednavrobotik/projekt/projekt.htm.

90. Fraunhofer Institut für Produktionstechnik und Automatisierung, Stuttgart, Germany; www.ipa.fhg.de/medizin.

91. Lehrstuhl für Angewandte Informatik III, Universität Bayreuth, Germany; http://ai3.inf.uni-bayreuth.de.

92. CEA-List, Service Robotique et Systèmes Interactifs, Centre de Fontenay-aux-Roses, France; CHU Amiens, Service de Chirurgie Maxillo-Faciale, Amiens, France.

93. Med3D GmbH, Heidelberg, Germany; www.med3d.de.

94. Innovation Center Computer Assisted Surgery, Leipzig, Germany; www.uni-leipzig.de/∼herz/_iccas/de/.

95. CISST, Johns Hopkins University, Baltimore, MD, USA; www.cisst.org.

96. MicroDexterity Systems, Inc., Albuquerque, NM, USA; www.microdexsys.com.

97. Helmholtz-Institut für biomedizinische Technik der RWTH Aachen, Germany; www.hia.rwth-aachen.de/research/cht/cranio.html.

98. Universal Robotic Systems GmbH, Schwerin, Germany; www.medicalrobots.com.

99. Laboratoire TIMC, Grenoble, France; http://www-timc.imag.fr/.

100. Group for Surgical Robotics and Instrumentation, Université de Lausanne, Switzerland; http://dmtwww.epfl.ch/imt/robchir/Minerva.html.

101. Department of Clinical Neurosciences, University of Calgary, Canada; www.mdrobotics.ca/neuroarm.htm.

102. Advanced Therapeutic and Rehabilitation Engineering Laboratory, University of Tokyo, Japan; www.atre.t.u-tokyo.ac.jp/index.html.

103. CIMIL Laboratory, Nanyang Technological University, Singapore; http://mrcas.mpe.ntu.edu.sg/research/neurobot/index.htm.

104. Integrated Surgical Systems, Inc., Davis, CA, USA; www.robodoc.com.

105. Armstrong Healthcare Ltd, High Wycombe, UK; www.armstrong-healthcare.com.

106. Z-Kat Inc, Hollywood, FL, USA; www.z-kat.com.

107. Barett Technology Inc., Cambridge, MA, USA; www.baretttechnology.com.

108. Chair for Computer Aided Medical Procedures (I-16), Technical University Munich, Germany; http://wwwnavab.in.tum.de/.

109. German Cancer Research Center, Heidelberg, Germany; www.dkfz.de/medphys/medeng/.

110. MRC Systems GmbH, Heidelberg, Germany; www.mrc-systems.de.

111. Advanced Therapeutic and Rehabilitation Engineering Laboratory, University of Tokyo, Japan; www.atre.t.u-tokyo.ac.jp/index.html.

112. Mechanical Engineering Research Laboratory, Hitachi Ltd., Kandatsu, Tsuchiura, Ibaraki, Japan; www.hitachi.co.jp/div/merl/index-e.html.

113. Department of Mechanical Engineering, Waseda University Tokyo, Japan; www.mech.waseda.ac.jp/.

114. Advanced Therapeutic Engineering Laboratory, Tokyo Denki University, Japan; www.atl.b.dendai.ac.jp/lab/atlab-e.htm.

115. National Insitute of Advanced Industrial Science and Technology, Tsukuba, Japan; http://unit.aist.go.jp/humanbiomed/surgical/.

116. Department of Micro System Engineering, Nagoya University, Japan; www.mech.nagoya-u.ac.jp.

117. School of Engineering, Tokyo University, Japan.

118. Laboratory for Computational Motor Control, Johns Hopkins University, Baltimore, MD, USA; www.bme.jhu.edu/∼reza/fmri_robot.htm.

119. The Acrobot Company Ltd., London, UK; www.acrobot.co.uk.

120. ISIS, Georgetown University, Washington, DC, USA, Urobotics Lab, Johns Hopkins Medical Institutions, Baltimore, MD, USA.

121. Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, MD, USA; http://urology.jhu.edu/urobotics/projects/rcm/.

122. Imaging Service and Information System, Georgetown University, Washington, DC, USA; www.visualization.georgetown.edu/research/image_guided/image_guided.htm.

123. http://robot.kaist.ac.kr/project/hwrs/arthrobot/main.htm.

124. Telerobotics and Control Laboratory, Korea Advanced Institute of Science and Technology (KAIST); http://robot.kaist.ac.kr/.

125. http://robot.kaist.ac.kr/research/main/telesurgery.html.

126. LIRMM, Département Robotique, Montpellier, France; www.lirmm.fr/xml/fr/0023-28.html.

127. Medtech S.A., Cap Omega, Montpellier, France; www.medtech.fr/.

128. At first Ortomaquet GmbH, Rastatt, Germany, later from May '01 URS GmbH, Schwerin, Germany.

129. Helmholtz-Institut für Biomedizinische Technik der RWTH Aachen, Germany; www.hia.rwth-aachen.de.

130. www.hia.rwth-aachen.de/research/cht/crigos1.html.

131. PI precision implants AG, Aarau, Switzerland; www.pisystems.ch.

132. MEDACTA AG, Castel San Pietro, Switzerland; www.medacta.ch.

133. Department of Mechanical Engineering, Katholieke Universiteit Leuven, Belgium; www.mech.kuleuven.ac.be/bmgo/research/project_robot_en.phtml.

134. www.lirmm.fr/manifs/uee/docs/students/andrearanftl.pdf.

135. Labor für Biomechanik und experimentelle Orthopädie, Orthopädische Universitätsklinik, Mannheim, Germany; www.intelligent-tool-drive.de.

136. Lehrstuhl für Informatik V, Universität Mannheim, Germany; http://www-li5.ti.uni-mannheim.de/.

137. Brainlab AG, Heimstetten, Germany; www.brainlab.com.

138. Faculty of Mechanical Engineering, Technion, and Masor Robotics Ltd., Haifa, Israel; http://meeng.technion.ac.il.

139. Mazor Surgical Technologies, Caesarea 38900, Israel; www.mazorst.com.

140. CRIM, Scuola St'Anna, Pisa, Italia; http://www-crim.sssup.it/research/projects/mias/defaultarthro.htm.

141. Helmholtz-Institut für Biomedizinische Technik der RWTH Aachen, Germany; www.hia.rwth-aachen.de/research/cht/minaro.html.

142. Universität Siegen, Germany; www.modicas.de.

143. German Aerospace Center, Oberpfaffenhofen, Germany; www.robotic.dlr.de/tobias.ortmaier/.

144. Armstrong Healthcare Ltd, High Wycombe, UK; www.armstrong-healthcare.com.

145. Carnegie Mellon University, Pittsburgh, PA, USA; www.mrcas.ri.cmu.edu.

146. Praxim-Medivision, La Tronche, France; www.praxim.fr.

147. Waseda University, Tokyo, Japan.

148. Integrated Surgical Systems, Inc., Davis, CA, USA; www.robodoc.com.

149. Witherspoon, ISS, Davis, CA, USA; www.robodoc.com.

150. Fraunhofer Institut für Produktionstechnik und Automatisierung, Stuttgart, Germany; www.ipa.fhg.de/medizin.

151. Technion, Haifa, Israel; http://robotics.technion.ac.il.

152. http://robotics.technion.ac.il/people/nabil/project.html.

153. http://robotics.technion.ac.il/projects/flexible%20needle%20steering.html.

154. http://robotics.technion.ac.il/projects/registration.html.

155. Biomechanics Lab, Istituti Ortopedici Rizzoli, Bologna, Italy; www.ior.it/biomec/homeenglish.htm.

156. Advanced Therapeutic Engineering Laboratory, Tokyo Denki University, Japan; www.atl.b.dendai.ac.jp/lab/atlab-e.htm.

157. University of Tokyo, Japan.

158. CISS, Hanyang University, Seoul, Korea; http://ciss.hanyang.ac.kr.

159. Accuray, Inc., Sunnyvale, CA, USA; www.accuray.com.

160. Medical Intelligence GmbH, Schwabmünchen, Germany; www.medical-intelligence.com.

161. Lehrstuhl Informatik IX, TU München, Germany; http://wwwradig.informatik.tu-muenchen.de/research/med/index_e.html.

162. Institut für Robotik und kognitive Systeme, Universität Lübeck, Germany; www.rob.uni-luebeck.de/.

163. Institute for Nuclear Physics, Orsay, France; http://ipnweb.in2p3.fr/.

164. Centre Protonthérapie d'orsay, France; www.protontherapie-orsay.fr/.

165. iRobot, Burlington, MA, USA; www.irobot.com.

166. www.lirmm.fr/∼duchemin/Scalpp.htm.

167. Laboratoire d'Informatique de Robotique et de Microélectronique de Montpellier (LIRMM), SINTERS SA, Toulouse, L'Hôpital Lapeyronie, Montpellier, France; www.lirmm.fr/∼duchemin/indexrm.htm.

168. BG Unfallklinik Hamburg, Germany; www.tu-harburg.de/mst/deutsch/forschung/weinrich.shtml.

169. Mechatronics Faculty, FH Regensburg, Germany; http://homepages.fh-regensburg.de/∼mog39099/mk.org/mru/projekt/reprobo/reprobo.htm.

170. IRP, Universität Braunschweig, Germany; www.cs.tu-bs.de/rob/femur.html.

171. Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, MD, USA; http://urology.jhu.edu/urobotics/projects/rcm/.

172. Imperial College London, UK; www.me.ic.ac.uk/case/mim/projects/probot/.

173. CIMIL Laboratory, Nanyang Technological University, Singapore; http://mrcas.mpe.ntu.edu.sg/research/urobot/index.htm.

174. Imperial College London, UK.

175. Imaging Research Laboratories, Robarts Institute, London, ON, Canada; www.imaging.robarts.ca/∼afenster/html/researchintereststwo.html.

176. Engineering Research Center, Johns Hopkins University, Baltimore, MD, USA; http://cisstweb.cs.jhu.edu/.

177. PUMA is a common abbreviaton for articulated robots and stands for Programmable Universal Machine for Assembly (www.eng.monash.edu.au/control/labecse.html#PUMA%20560). SCARA stands for Selectively Compliant Articulated Robot Arm (www.systemdevices.co.uk/robots/scara.html).