IEEE/ASME TRANSACTIONS ON MECHATRONICS, VOL. 19, NO.

6, DECEMBER 2014

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Array of Robots Augmenting the Kinematics

of Endocavitary Surgery
Giuseppe Tortora, Member, IEEE, Paolo Dario, Fellow, IEEE, and Arianna Menciassi, Member, IEEE

AbstractMinimally invasive surgery (MIS) has been introduced in the last decades with the goal of making scarless surgery
feasible. In general, an MIS approach allows concrete benefits in
terms of reduced trauma, quicker recovery times, and improved
cosmetics. On the other hand, in its current state, MIS introduces
more difficulties for surgeons, due to its intrinsic complexity. This
issue has inspired the major technological challenge of designing
miniaturized robots able to completely enter the body and to perform surgical procedures under intuitive teleoperation. The dream
of achieving a completely minimally invasive therapeutic procedure, while offering the typical advantages of traditional open
surgery, has brought to the complete elimination of external incisions by gaining access to the peritoneal cavity through a natural
orifice. These scarless procedures are known as Natural Orifice
Transluminal Endoscopic Surgery (NOTES) interventions. In this
paper, novel approaches to NOTES instruments and platforms are
presented, in which modular robots measuring 12 mm in diameter with basic functionalities (manipulation, cutting, vision, and
retraction) and multiple degrees of freedom are deployed inside a
human phantom and anchored on a supporting frame for the stable
execution of tasks. This paper illustrates the general concept, novel
design guidelines for the modular robots, and two robotic units
successfully assembled and tested with ten users, in order to assess
the capabilities of the system in pick and place experiments and
cutting tasks. Experiments for the assessing force and accuracy are
described as well.
Index TermsEndocavitary surgery, modular robot, Natural
Orifice Transluminal Endoscopic Surgery (NOTES).

I. INTRODUCTION
INCE their introduction in medical practice, robotic systems have been continuously improved, with the final aim
of allowing noninvasive surgical procedures and improving benefits for patients, in terms of lower number and size of incisions,
less complications, and shorter recovery time. The increasing
request to reduce the invasiveness of surgical procedures is followed by the technological challenge of giving the surgeon advanced capabilities in terms of dexterity, applied forces, and
view of the surgical scenario with respect to traditional laparoscopic surgery. The first generation of existing medical robots,

Manuscript received July 1, 2013; revised October 10, 2013 and December 20, 2013; accepted December 20, 2013. Date of publication January 13,
2014; date of current version June 13, 2014. Recommended by Technical Editor
F. Carpi. This work was supported by the ARAKNES FP7 European Project
224565 (http://www.araknes.org).
The authors are with the BioRobotics Institute, Scuola Superiore
SantAnna, 56127 Pisa, Italy (e-mail: g.tortora@sssup.it; p.dario@sssup.it;
arianna.menciassi@sssup.it).
Color versions of one or more of the figures in this paper are available online
at http://ieeexplore.ieee.org.
Digital Object Identifier 10.1109/TMECH.2013.2296531

where the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) is the most common example [1], aims to
provide a robotic substitute for holding traditional laparoscopic
tools inside the patient through standard trocars. The surgeon
can control the robotic arms from a dedicated console by looking
at a 3-D video streaming of the operative site. The da Vinci system is an advanced, commercially successful telerobotic system
for minimally invasive surgery (MIS) and is nowadays installed
worldwide. On the other hand, the da Vinci robot still requires
the same number of incisions as in traditional laparoscopy, thus
resulting in a similar level of invasiveness. Other surgical systems exploiting the same telerobotic concept have been developed worldwide, such as more compact and versatile systems
for robotic laparoscopy [2], [3].
A further step from a medical viewpoint has been taken
with the introduction of new surgical approaches: single-port
laparoscopy (SPL) and single-incision laparoscopic surgery
(SILS), based upon which multiple tools can be inserted through
a single incision generally made at the umbilicus. SPL and
SILS have inspired new solutions, such as an articulated robotic
arm for bimanual interventions based on internal motors [4], a
robotic system for SPL from Intuitive Surgical [5], or snake-like
robotic systems for single-port entry [6], [7].
Although these solutions are attracting increasing interest toward MIS and robotics potential [8], an important breakthrough
in medical perspective is represented by the introduction of Natural Orifice Transluminal Endoscopic Surgery (NOTES) which
aims to conduct surgery by entering narrow body natural accesses with long and slender tools. Several modified endoscopes
have been studied for NOTES [9][12]. Since the operation distal point might be quite far from the proximal insertion point,
stability at the end-effector level can be a problem [13]. On
the other hand, continuum robots take advantage of a highly
redundant kinematic structure for accomplishing surgical tasks
remotely from the insertion point [14][16].
Another approach to NOTES relies on delivering all the
robotic modules inside the abdomen for accomplishing specific
surgical tasks [17][20]. A modular approach has been proposed as well [21] in which small-scaled robotic modules are
ingested and assembled to form an articulated structure in the
stomach. Despite their functionalities, they still lack robustness
and stability in the working environment, and they are generally
affected by low dexterity and limited functionalities of the single robotic tool, which usually cannot be interchanged during
the surgical procedure.
In order to overcome these limitations, we propose a modular
magnetic platform for NOTES procedures composed of several
dedicated robotic tools with the possibility of being docked and

1083-4435 2014 IEEE. Personal use is permitted, but republication/redistribution requires IEEE permission.
See http://www.ieee.org/publications standards/publications/rights/index.html for more information.

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Fig. 1.
cavity.

IEEE/ASME TRANSACTIONS ON MECHATRONICS, VOL. 19, NO. 6, DECEMBER 2014

Schematic representation of the array of robots within the abdominal

docked from an anchoring frame when needed. This paper stems

from the idea to transfer the abilities of bimanual laparoscopic
surgery to the endocavitary surgical approach, in order to reduce
operative trauma and enhance the therapeutic outcome of certain
MIS procedures. An array of robotic multi-degrees-of-freedom
(DOF), able to perform basic tasks in endocavitary procedures,
is presented. The general approach of the array of robots designed to perform NOTES procedures is shown in Fig. 1, in
which the platform is introduced from the mouth, then along the
esophagus, and finally it crosses the stomach wall thus reaching
the abdominal cavity. The design concept of the novel robotic
units used for manipulation and cutting, performance analysis,
and final experiments are described to assess the capability of
the proposed NOTES platform.
II. MATERIAL AND METHODS
A. Medical Rationale
The role of modern medical practice is moving closer and
closer to the concept of prevention, with a view to fighting diseases at their early stage and enabling a truly minimally invasive
surgical approach, when needed. Early diagnoses allow diseases
to be treated therapeutically and surgically with lower risk and
higher chances of success. The concept we propose is based on
modular robotic units that aim to provide current NOTES with
smaller and less complicated devices capable of performing basic surgical tasks where low forces and small workspace are
required. Larger operative areas may thus be addressed since it
is possible to reposition the platform intraoperatively (see the
external handles in Fig. 1).
From a medical viewpoint, the following aspects were considered during the system design:
1) Size constraints are essential for NOTES robotic modules.
The robotic modules should be as small and compact as
possible. The maximum allowed diameter and rigid length
of the platform components are limited by the fact that
they are inserted through the esophagus and due to their
encumbrance in the abdominal cavity. The esophageal access port we considered in this paper is a 17-mm internal
diameter overtube (Guardus, US endoscopy, Mentor, OH,
USA).

2) A natural access, such as the mouth, should be accessed

by all the platform components. Since there are many
limitations as to the application of wireless devices in
surgery, and due to safety reasons also, only thin wires
for powering, imaging, and functional needs should be
left back in the access port. After insertion, each module
should be able to be fixed in a convenient position and
changed as needed during the surgical procedure. This will
allow additional assistive tools (i.e., a flexible endoscope
as shown in Fig. 1) to be inserted when needed;
3) The delivery of many tools inside the human body, rather
than a single one, allows surgeons to have the right tool
they need during the surgical procedure. Tool interchangeability during the procedure is essential.
4) The platform components should be able to perform at
least basic tasks, such as vision, manipulation, and cutting.
In laparoscopic procedures, typical applied forces are in the
range of 510 N and typical speeds reach 360 /s [22]. Forces
and speeds in these ranges are difficult to be matched by miniature devices, but design flexibility in terms of intraoperative
repositioning of the platform thanks to magnetic anchoring can
dramatically assist in surgical tasks. In addition, high forces
(e.g., for pure retraction tasks) can be generated as well by the
magnetic coupling itself or by the assistive endoscope rather
than by the single miniature robots. On the other hand, the
robotic units can still perform other useful and basic tasks, such
as inserting a probe in a soft tissue which requires about only
0.45 N [23].
B. System Overview
Following the aforementioned medical guidelines, the platform we propose is based on modular robotic units that can be
inserted through an esophageal access port and assembled on
a dedicated anchoring frame by using an assistive endoscope.
The robotic units which are considered essential during a typical
surgical procedure are the following: a manipulator, an electrocutter, a tissue retraction device, and a camera.
The full insertion procedure and positioning of the endocavitary platform consist of the following four steps.
1) Insertion of the Access Port: The insertion of the access
port prepares the insertion of the platform components into the
abdominal cavity. This is a standard procedure for NOTES, and
it is essential to prevent damage to the esophageal walls due to
the introduction of the robotic modules.
2) Insertion and Positioning of an Anchoring Frame: The
anchoring frame is a three-segments supporting frame that is
used during the procedure to provide stability to the robotic
units. The frame is inserted in a straight configuration and then
it recovers its original triangular shape thanks to shape memory
alloys springs placed between the frame segments, as described
in [24]. The anchoring frame can be moved intraoperatively,
thus allowing the platform to rely on an enhanced workspace.
3) Insertion and Deployment of the Robotic Units: The
robotic units are inserted through the port. This makes it possible
to insert as many robotic units as needed by the specific surgical
procedure (i.e., different graspers, loops, electro-cutters, etc.).

TORTORA et al.: ARRAY OF ROBOTS AUGMENTING THE KINEMATICS OF ENDOCAVITARY SURGERY

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Fig. 2. Schematics of consecutive phases of the platform insertion through the

esophageal access port; the encumbrances of the modules is represented.

An assistive endoscope is used to dock the modules to the specific docking site on the anchoring frame.
4) Activation of the System: Once the system is positioned,
the surgeon can remotely perform basic procedures by acting
on the robot controllers.
III. ARRAY OF ROBOTS
The concept of an array of robots was carried on by keeping
in mind a single common design (with slight modifications)
aimed at developing different robotic units for the performance
of dedicated tasks in NOTES. The first proposed design was
used for a camera robot, as described in [25]. In this paper,
additional robotic units, such as retraction, manipulator, and
electro-cutting robots, were developed starting from a similar
concept of basic module.
In Section III-A, details on the design of the basic module
as a unit for assembling the electro-cutter robot (see Section
III-B) are given, slight variations needed for the realization of
the manipulator robot are described in Section III-C. For the
sake of clarity and in order to give an overview of the whole
array of robots integrated together, a description of previously
developed robotic units (i.e., the camera and retraction robots)
is given in Sections III-D and III-E.
A. Basic Module
The final aim is to provide small and simple robotic tools
to be used in NOTES, depending on the specific tasks to be
performed, as in traditional surgery. One of the limits of current
robotics for NOTES is that it is impossible to easily change the
desired tool. For this purpose, the array of robots was designed
by keeping in mind the modularity approach and the possibility
of easily assembling new tools depending on the specific surgical
needs. The surgeon can select the desired robotic tools during
the preoperative phase; basic and advanced robotic units will
be assembled and prepared by medical assistants to be used
intraoperatively.
Based on these requirements, a cylindrical basic module was
designed with 2-DOFs and with the possibility of assembling
more modules/tools together. Based on medical guidelines, the
basic module diameter is 12 mm, which is compatible with insertion in the access port partially taken from the anchoring frame
powering, and allows use of a flexible endoscope through the
access port [26]. Fig. 2 shows the consecutive phases of platform

Fig. 3. Top: detail of the pitch and roll mechanisms of the basic module with
2 DOFs; bottom: manufactured module.

insertion with a clear representation of the encumbrances of all

the platform components, that set the mechanical constraints
for the overall design. At the beginning of the procedure, the
esophageal access port is inserted (I). After the insertion of the
anchoring frame (II), that takes almost completely the section
of the access port, only communication and powering wires remain to take a small area of the access port (III). The insertion
of the robotic units is always possible (IV). Afterward, the flexible endoscope can be used as assistive tool in order to position
and dock the robotic modules for a complete deployment of the
platform (V).
The overall length of the module in Fig. 2 is 42.5 mm for a
total weight of 8 g including motors (4-mm diameter brushless
motors by Namiki Jewels, Tokyo, Japan) and electronics. The
manufacturing processes involved a microcomputer-numericalcontrol machine Kern Hspc, a Sarix Micro Sink EDM, and
a Sodick AP 200 L wire electrical discharge machine. An
aluminum alloy was used as the manufacturing material. The
basic module was designed including an internal channel to enable powering when active tools (e.g., electro-cutters and active
graspers) are used as end-effectors. The two sides of the basic
module were kept free for embedding the electronics, while the
link embeds two rotational motors and respective mechanisms.
Each module includes a pitch and roll DOF. The basic module
and the embedded mechanisms for pitch and roll, together with
the manufactured prototype before the final assembly, are shown
in Fig. 3.
The position of the motors strongly influences the mechanical design. Moreover, a 2-mm central channel is left free for
the inclusion of additional functional elements, such as wires
or cables for different tools. The design of the mechanisms for
the pitch DOF consists of a worm meshed with a helical gear,
resulting in a 0.028 transmission ratio (i.e., the output speed
divided by the input speed). This mechanism is used to transmit motion between the axis of the motor and the orthogonal
pitch joint axis. Due to the high reduction ratio, the system
is nonbackdrivable. This can be considered an advantage, because the force can be maintained without providing energy
during static procedures (e.g., for keeping a tissue steady in a desired position). Safety is guaranteed by the module dimensions:
in any possible pitch rotation, the maximum diameter of the

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Fig. 4. Assembling of two basic modules (left) and prototype of powering

connection between modules (right).

projection of the single module on the transversal plane of the

robot (plane XY as in Fig. 5) is less than 16 mm, thus allowing a
safe extraction in case of failure after disassembling the robotic
unit in single modules with the aid of the flexible endoscope.
The rotational joint is located on the opposite end of the module. This involves two spur gears as a reduction stage, and a
rotating output shaft supported by a ball bearing. In particular,
the spur gear is manufactured preserving the aforementioned
central channel. The transmission ratio of this mechanism is
0.43. Regarding the range of motion, the maximum bending for
the pitch is 180 , essential to preserve the widest workspace
possible; the roll can rotate indefinitely in both directions, since
there are no physical constraints between the modules.
Thanks to the cylindrical shape of the basic module and the
coupling between mating ends, connection between modules or
tools is easy, thus allowing the assembly of different miniature
robots by simply attaching two modules, as shown in Fig. 4
(Left), as detailed in Section IV. It is worth noting that each
module is functionally self-consistent and integrated with actuators, mechanisms, and electronics.
A commercial six-axis load cell (Nano17, ATI, Industrial
Automation, Apex, NC, USA) having a resolution of 3.18 mN
has been used for characterizing the basic module mechanisms,
including the motor, in terms of an output torque. The maximum
measured output torques considering mechanism efficiencies
were 51.2 Nmm for the worm/helical gear and 10.15 Nmm for
the spur gears, from which the tip forces of the robots, relying
on the same mechanisms, are derived.

B. Electro-Cutter Robot
The electro-cutter robot is obtained by assembling two basic
modules and integrating a commercial tip as a tool.
The design of the basic module results in a roll as last DOF of
the kinematic chain for the electro-cutter robot, as represented
in Fig. 5.
Although this DOF is not used in this specific case, because
of the needle-shaped tip of the electro-cutter (i.e., there is no
need to change the orientation of the axis), it will be very useful
when a grasper will be integrated on the robot tip for performing
suturing tasks. The overall dimensions of the electro-cutter robot
are 12 mm in diameter and 85 mm in length. Thanks to the
performance of the basic module, these robotic units can achieve
a wide range of motion. J1 and J3 sweep 180 while J2 and J4

Fig. 5.

Arrangement of the DOFs and joints in the electro-cutter robot.

Fig. 6. Assembled electro-cutter robot with an integrated control board; in the

inset, a detail of the distal module.

do not have limits in rotation. The assembled robot is shown in

Fig. 6.
The force available on the tip, due solely to the activation
of J1 and considering the total robot length, is 0.65 N, that is
a value compatible with the execution of dedicated tasks (i.e.,
cutting of tissue samples) in endocavitary surgery [23]. The total
weight that can be manipulated is thus 65 g, which is up to four
times the robot weight (i.e., 16 g). A maximum speed of 90 /s
for the pitch and of 190 /s for the roll can be obtained for each
joint.
Considering the structure of the electro-cutter robot and
the DenavitHartenberg (DH) representation, the reachable
workspace is represented as in Fig 7.
Accuracy measurements within the robot workspace have
been performed in order to estimate the overall system accuracy.
The robot has been controlled to follow three 20-mm straight
trajectories on xy, xz, and yz planes within the robot workspace,
automatically generated by the PC in a teleoperated fashion. The
position of the end-effector has been tracked by an electromagnetic localizer (Aurora Electromagnetic Measurement System,
NDI, Waterloo, ON, Canada). Results of accuracy measurements in terms of root mean squares (RMS) with respect to
the planned trajectory are reported in Table I. For every data
acquisition, the trajectories have been repeated five times for
improving statistics. The maximum absolute errors are 1.64,

TORTORA et al.: ARRAY OF ROBOTS AUGMENTING THE KINEMATICS OF ENDOCAVITARY SURGERY

Fig. 7. Graphical representation of the workspace of the electro-cutter robot,

units in millimeters (top left: XY; top right: ZX; bottom right: ZY; bottom right:
3-D).
TABLE I
ACCURACY EXPRESSED IN TERMS OF RMS ALONG 20-mm STRAIGHT
TRAJECTORIES ON XY, XZ, AND YZ PLANES

1.87, and 2.57 mm on x, y, and z paths, respectively. This result is essentially due to the lack of motor encoders and to the
modality used by the software to predict the robot position that
could be improved by new software algorithms. These results
also include backlash effect. Additional efforts will be devoted
to backlash reduction during robots assembly.
C. Manipulator Robot
The manipulator robot is slightly different from the electrocutter robot.
Specifically, the manipulator robot was used to provide the
platform with an actuated tool for grasping. The kinematic chain
of this robot, shown in Fig. 8, includes an active end-effector.
The roll of the end-effector is not possible for this robot, because the motor activating the roll in the previous robot is now
devoted to activating the grasper. The overall dimensions of the
manipulator robot are 12 mm in diameter and 95 mm in length,
with a total weight of 22.5 g. The force available at the tip thanks
to the action of J1 is 0.65 N.
D. The Retraction Robot
Another essential module to be used in surgical procedures
is the retraction robot. The design of this unit was inspired by a
previous work [25] and was optimized by including the support
for a magnet used to anchor the robot to the abdominal wall.

Fig. 8.

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Arrangement of the DOFs and joints in the manipulator robot.

In this way, the retraction robot can be used as an independent

robotic tool when needed. The retraction robot has a diameter
of 12 mm and a total length of 52 mm, including the support for
the magnet, and a weight of 12 g.
Since the main goal of retraction tasks is to retract tissue
and allow the manipulation of the underlying tissues by another
robotic unit, we made the technical choice to integrate two motors into the robot for a pitch DOF and for the opening/closing
mechanisms of the gripper, in order to keep the module shorter
and maximize the retraction force. The workspace is 1-D, since
the only task consists of pulling the retracted tissue toward the
abdominal wall in order to expose the target site. The motion
range of the pitch DOF is 180 , while the maximum pulling
and grasping forces are 1.53 and 5.3 N, respectively. The retraction robot reachable workspace can be enhanced thanks to
the motion of the external magnetic handle. In fact, thanks to
the magnetic link, the retraction robot relies on three additional
external DOFs for the correct positioning of the robot in the
abdomen. In addition, the handle can be pushed against the
insufflated abdomen for the approximation of the target tissue
with the robot. The retraction robot and anchoring frame external handles can be used without problems on the abdomen
since they are embedded in soft cases that limit magnetic interferences. In a real scenario, it is supposed that both handles
are maintained in position by medical assistants, who move the
handles according to surgeons indications.

E. Camera Robot
The camera robot consists of a 2-DOFs robotic unit, conceived to enable workspace vision during NOTES. The camera
robot is based on a roll/pitch module linked to a passive support for holding the vision system. An additional viewpoint is
constantly provided by the flexible endoscope if needed.
The vision system was integrated in the distal part of the
camera robot. It includes a camera and a source of illumination in

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order to optimize the lighting conditions in a dark environment,

such as the abdominal cavity.
In this paper, a standard 2-D camera was integrated to provide
on board platform vision. The camera (Misumi Electronics Corporation, New Taipei City, Taiwan) is characterized by a frame
rate of 30 frames/s and a resolution of 320 240 pixels. It is
10 mm in length and 8.6 mm in diameter, and power consumption is 110 mA @ 3.3 V. These features are compatible with the
application in terms of frame rate and resolution (they are sufficient for the proposed tasks), dimensions (the camera can be
easily integrated in the robotic module), and power supply and
consumption (there are no critical energy constraints because
the camera is wire-supplied from an external power source at
3.3 V). The camera was chosen because it is easily available
off-the-shelf. Appropriate lighting conditions were guaranteed
by a printed circuit board integrating four white LEDs by Nichia
Corporation.
F. Anchoring Frame and Docking System
A triangle-shaped anchoring frame was used to support the
array of robotic modules in a stable position inside the abdomen.
This device is described in detail in [24]. It is magnetically anchored to the abdominal wall by means of an external magnetic
handle. In particular, the anchoring frame has a three-segment
snake-like structure that allows insertion through the esophageal
access port. Once inside the abdomen, the anchoring frame recovers its triangular shape thanks to the action of shape memory
alloy springs positioned on the vertexes of the structure. The
anchoring frame is equipped with three docking systems for positioning the robotic units. The robotic modules can be docked
and undocked during surgical procedures depending on medical
needs, thus enabling the platform to change tools. This is crucial
during medical procedures and is usually a main limitation for
research-level surgical robots. A dedicated reversible mechanism has been implemented for the docking and undocking of
the robotic modules [27]. In this paper, a modified mock-up of
the anchoring frame was used, in order to integrate additional
elements (in particular the control board for communication between modules). The role of the anchoring frame is twofold:
providing stability to the entire platform, and being the central node of communication between the robots, as explained in
Section IV.
IV. CONTROL AND DRIVING ELECTRONICS
The robotic units are designed to integrate mechanisms, electronics, and miniature motors.
A wireless microcontroller (CC2430, Texas Instruments, Dallas, TX, USA) together with the motor drivers was embedded
on a dedicated electronic board having dimensions of 10.8 mm
in diameter and 2.3 mm in thickness. Each board can control
up to two brushless motors and provide wireless communication. The main advantage of using custom boards is that there
are no power limitations with respect to commercial controllers,
thus allowing us to get better performance from the motors in
terms of an output torque. All the embedded boards can be

Fig. 9. Top: assembled platform with integration of the control board on the
anchoring frame; in the inset, detail of the control board; Bottom: schematics
of the overall platform architecture showing the communication links between
components.

powered through dedicated electrodes positioned on the modules, as shown in Fig. 4 (Left).
An intraabdominal wireless network is set up for communication between the platform components (i.e., the anchoring frame
and the robotic units), by exploiting a ZigBee star architecture.
The central node (i.e., the master) of the network is the board
integrated in the anchoring frame, while the other nodes are
constituted by the boards integrated in the robotic units. Thus,
the electronic boards provide both low-level motor control and
manage network wireless communication between the active
elements of the system. On the other hand, the central node provides robust and stable internalexternal cabled communication.
This is a clear advantage of the proposed system, which relies
on wireless communication between modules (enabling the tool
to change intraoperatively) and at the same time prevents disturbances in wireless transmission through human tissues. An
overview of the platform with the integrated master board and
schematics of the system architecture are reported in Fig. 9.
Embedded electronics successfully solves the problem of
wireless/wired communication. However, a major drawback
of the 4-mm Namiki motor is the lack of embedded encoders
that makes the implementation of position control difficult. Although this is advisable for controlling the robotic units before
application in real surgery, in a way it can be considered a consolidated methodology that we will implement as soon as miniaturized encoders will be available. We explored a control strategy
based on the prediction of the robot position directly through the

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TABLE II
DENAVITHARTEMBERG PARAMETERS OF THE 4-DOFS ROBOTS

Fig. 10.

embedded microcontroller, as proposed in [28]. Sensorless position control, based on this approach, was implemented on an
external control unit (i.e., a PC), communicating via serial port
with the master network node. A two-channel joystick (Cyborg
Rumble Pad, Saitek, Torrance, CA, USA) was used for controlling both robots, while a dedicated controller was used for
moving the camera robot. The new position retrieved from the
joystick interface results in a new position for the joints, which
are calculated by implementing inverse kinematic algorithms
on the basis of the robot DH parameters reported in Table II.
However, after a short operating time, the position errors of the
predictive algorithm were too high to guarantee robust control
of the robot. For this reason, an open-loop control was preferred
in order to demonstrate the performance of the robotic platform
as is. This was suitable to show the feasibility of the robotic
platform and to perform the experimental session described in
the following section.
V. EXPERIMENTS
The aim of the experimental session was twofold:
1) to assess the feasibility of the insertion procedure of the
array of robots based on the sequence described in Section
II-B;
2) to determine the robot capabilities to perform simple tasks
(i.e., pick and place, surgical cutting).
These experiments were performed to assess the system technical capabilities. Medical assessment will be performed as a
future work.
The procedure regarding the insertion and positioning of the
array of robots is described in Section V-A. Pick and place
tests on different users and cutting experiments are subsequently
given in Section V-B and V-C, respectively.
A. Insertion and positioning of the Array of Robots
The complete platform was tested in a phantom abdominal
cavity to assess overall compatibility of the platform with the
esophageal access port. In particular, in this paper, the steps described in Section II-B were performed for all robotic modules
to show the feasibility of the procedure. Once the access port has
been inserted, a user with nonmedical experience performed the
insertion of the robots in about 15 s for each unit. Afterward, the
docking of the camera robot using the assistive endoscope was
performed in less than 4 min and 30 s. The medical procedure

Assembled NOTES platform in a human abdomen simulator.

will be assessed during future in vivo evaluation with medical

staff. In addition, the retraction module was inserted and anchored to the abdominal wall through magnetic coupling. The
overview of the deployed array of robots in a human abdomen
simulator is shown in Fig. 10.
B. Pick and Place Experiments
The bimanual miniature robotic platform was tested for pick
and place experiments. These experiments were performed on
a group of people with technical skills in robotics. In particular, ten engineers (five males, five females) performed pick and
place exercises. The experiments were designed to assess the
functionalities of the overall system in its current implementation. The users performed the exercises by using the joystick
and controlling the manipulator and electro-cutter robot, under
direct visual feedback from the operative environment. During
these experiments, the tip of the electro-cutter was replaced with
a metallic hook, since there was no need for electro-cutting.
The first exercise consisted in a peg-transfer setup, according
to SAGES manual skills tests [29]. However, since only one
manipulator robot was available, the users were asked to perform
the following tasks using a single peg:
1) Task 1: pick the peg from one position of the pegboard
using the manipulator robot;
2) Task 2: place the grasped peg in a different position of the
pegboard using the manipulator robot;
3) Task 3: hit the peg just released using the electro-cutter
robot.
The time spent for each task was recorded to report the preliminary results for the pick and place experiments with the
current control implementation. The experiment was repeated
until all the tasks were completed without losing the peg. Each
time the peg was lost during the experimental tasks (i.e., when
it was placed outside the robot workspace or when it fell), a
failure event was recorded. A summary of the experimental session, including the time for performing the single tasks per user
and the number of failures, is reported in Table III. A snapshot
during the pick and place experiment is reported in Fig. 11.
C. Tissue Cutting
Tissue cutting experiment has been performed with the
twofold aim of proving the interaction capability of the two

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IEEE/ASME TRANSACTIONS ON MECHATRONICS, VOL. 19, NO. 6, DECEMBER 2014

TABLE III
PICK AND PLACE EXPERIMENTS

Fig. 11.

Miniature robots during pick and place experiments.

Fig. 12.

Miniature robots performing tissue cutting in consecutive snapshots.

arms in a real exercise and for demonstrating the compatibility

between the commercial cutting tip and the wireless communication during cutting. A tissue sample was positioned within the
robot workspace to be manipulated and cut. The tissue sample
had the following dimensions: 80 mm (length), 60 mm (width)
and 4 mm (thickness). The tip of the electro-cutter robot was
connected through an electric cable to the external commercial
unit (Erbe, Tubingen, Germany). The user was able to control
activation of the electro-cutter by using a foot-pedal and control
the miniature robots by using the joystick. A snapshot of the
tissue cutting experiment is shown in Fig. 12. Tissue cutting
was performed in 2.5 min without any technical problem. This
task was performed to qualitatively demonstrate the feasibility
of tissue cutting rather than providing a statistical analysis.

VI. DISCUSSION AND CONCLUSION

In this paper, an array of different robots integrated in a multifunctional platform for application in NOTES has been presented. The system offers the possibility of performing procedures intraabdominally, by setting up a surgical room in the patients abdomen. In particular, the whole platform is composed
of an anchoring frame able to support two miniature robots for
manipulation and cutting, and a robotic camera enabling vision
of the operative scene. In addition, a retraction robot can be
positioned in the abdomen for tissue retraction tasks. The concept of modularity adopted in the design allows the modules to
be interchanged during the surgical procedure, thanks to implementation of an intraabdominal wireless network. Each robotic
unit communicates via wireless with the anchoring frame, which
manages overall communication and is interfaced via wires with
the external control unit, overcoming the current limitations of
a full wireless approach.
The complete platform was successfully inserted in a phantom
abdominal cavity to assess the platforms overall compatibility
with the esophageal access port. As additional outcome, the
measured time from the insertion of the camera robot to the
final docking was 4 min and 34 s. A maximum tip force of
0.65 N has been measured for the robots, with an accuracy
expressed in terms of RMS of 0.39, 0.67, 0.67 mm on x-,
y-, and z-axes, respectively, measured on straight trajectories.
Pick and place experiments were performed by ten users to
assess the overall performance on a bench test. Manipulation
and tissue cutting tasks have also been demonstrated.
Results showed that pick and place can be performed in a
mean time of 160.5 s with a minimum execution time 55 s without any training session. In addition, tissue cutting (2-cm long)
was performed in 2.5 min to prove the interaction capability
between the two arms in a real exercise. These figures can be
considered successful results, if considering that the joystick intuitiveness is intrinsically limited for controlling multiple DOFs.
Intuitive multiple-DOFs haptic interfaces will be implemented
on the master side as a future step.
In conclusion, this paper has demonstrated the possibility of
using an array of robots for performing basic tasks in NOTES
procedures. Once the platform will be finalized (in particular in
terms of sealing with respect to biological fluids), ex vivo and
in vivo experimental sessions involving medical experts will be
performed.
ACKNOWLEDGMENT
The authors wish to thank the colleagues of the BioRobotics
Institute for the precious support and A. Dimitracopoulos for
having inspired this paper.
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Giuseppe Tortora (S09M13) was born in Isernia, Italy, in 1983. He received the M.S. degree in
biomedical engineering from the University of Pisa,
Pisa, Italy, 2008, and the Ph.D. degree in biorobotics
from the BioRobotics Institute, Scuola Superiore
SantAnna, Pisa, Italy, in 2012.
In April 2007, he joined the Scuola Superiore
SantAnna, focusing his activity on medical robotics
and biomechatronic systems. He spent a period as a
Visiting Researcher at the Imperial College London
and Carnegie Mellon University in 2011. His main
research interests are in the field of biorobotics and minimally invasive robotic
surgery.

Paolo Dario (F02) received the Masters degree in

mechanical engineering from the University of Pisa,
Pisa, Italy, in 1977.
He is currently a Professor of biomedical robotics
at the Scuola Superiore SantAnna, Pisa, Italy, where
he supervises a team of about 150 young researchers.
His main research interest is biorobotics, including
mechatronic and robotic systems for rehabilitation,
prosthetics, surgery, and microendoscopy. He is the
author of more than 160 ISI journal papers, many
international patents, and several book chapters on
medical robotics.
Mr. Dario received the Joseph Engelberger Award as a Pioneer of Biomedical
Robotics.

Arianna Menciassi (M00) received the Masters degree in physics (Hons.) from the University of Pisa,
Pisa, Italy, in 1995, and the Ph.D. degree from the
Scuola Superiore SantAnna (SSSA), Pisa, Italy, in
1999.
She is currently an Associate Professor of biomedical robotics at SSSA. Her main research interests are
in the fields of biomedical micro- and nano-robotics
for the development of innovative devices for surgery,
therapy, and diagnostics. She is the coauthor of more
than 150 international papers, about 100 in ISI journals, and five book chapters on medical devices and microtechnologies.