Tool-tissue forces in surgery: A systematic review

Abstract

Background Excessive tool-tissue interaction forces often result in tissue damage and intraoperative complications, while insufficient forces prevent the completion of the task. This review sought to explore the tool-tissue interaction forces exerted by instruments during surgery across different specialities, tissues, manoeuvres and experience levels. Materials & methods A PRISMA-guided systematic review was carried out using Embase, Medline and Web of Science databases. Results Of 462 articles screened, 45 studies discussing surgical tool-tissue forces were included. The studies were categorized into 9 different specialities with the mean of average forces lowest for ophthalmology (0.04N) and highest for orthopaedic surgery (210N). Nervous tissue required the least amount of force to manipulate (mean of average: 0.4N), whilst connective tissue (including bone) required the most (mean of average: 45.8). For manoeuvres, drilling recorded the highest forces (mean of average: 14N), whilst sharp dissection recorded the lowest (mean of average: 0.03N). When comparing differences in the mean of average forces between groups, novices exerted 22.7% more force than experts, and presence of a feedback mechanism (e.g. audio) reduced exerted forces by 47.9%. Conclusions The measurement of tool-tissue forces is a novel but rapidly expanding field. The range of forces applied varies according to surgical speciality, tissue, manoeuvre, operator experience and feedback provided. Knowledge of the safe range of surgical forces will improve surgical safety whilst maintaining effectiveness. Measuring forces during surgery may provide an objective metric for training and assessment. Development of smart instruments, robotics and integrated feedback systems will facilitate this.

Stiffness Assessment and Lump Detection in Minimally Invasive Surgery Using In-House Developed Smart Laparoscopic Forceps

“…The measured grasping force was 3.7 ± 1.7 N (average ± standard deviation) out of 15 grasps-releases events, with a minimum and maximum of 2 N and 7.5 N, respectively. These tissue grasping forces are in line with other studies reporting on the surgical grasping parameters [39] .…”

Soft Robotic Deployable Origami Actuators for Neurosurgical Brain Retraction

“…Other studies of tool and brain tissue interactions showed a range of forces between 0.5-6 N (Aggravi et al, 2016). A review of 13 studies found mean maximum force output from hand tools in neurosurgery to be 1.48 N. Similarly, the review found that three studies reported a mean maximum force output from retraction tasks to be 2.5 N (Golahmadi et al, 2021). The soft retractor should target force output values in a similar range with a maximum of 3 N to generate forces comparable to current retraction procedures and ensure safety.…”

Robot-Assisted Minimally Invasive Surgery—Surgical Robotics in the Data Age

“…Another feature currently not implemented profoundly in clinical RAMIS systems is the ability to sense interaction forces between instruments and tissue and enable a sense of touch through haptic feedback [77]- [79]. This could be an important development allowing fine-tuned surgical actions for instrument manipulation to adapt to various important vibrations, pressure, or texture that have clinical meaning while operating [80].…”