The working group focusses on computer- and robot-assisted procedures in head and neck surgery. The focus is on establishing new procedures, expanding the range of indications in ENT surgery and optimising existing systems. The clinic co-operates with various manufacturing companies and technical chairs in order to accelerate the development of new procedures and instruments. The excellent infrastructure at Ulm University Hospital provides access to state-of-the-art technology and innovative surgical assistance systems.

System development

 

sMAC system. Based on a cMAC video laryngoscope (Storz) and flexible surgical instruments (Lumendi), an innovative system for laryngeal surgery is being developed. The advantages of the system are its intuitive handling and simple manufacture from clinically proven medical devices. The development is being carried out in close co-operation with the Continuum Robotics Laboratory (CRL) and the Department of Mathematical and Computational Sciences at the University of Toronto Mississauga, Canada. The project is funded by the German Research Foundation (DFG).

PET-MRI for head and neck cancer. As part of a clinical pilot study, patients with head and neck cancer are undergoing PET-MRI examinations with FDG tracers before and after primary radiochemotherapy. The data analysed using the combined diffusivity metabolic index may be used to make a prognostic statement for the patients.

Laser surgery. Together with the Institute for Laser Technologies in Medicine and Metrology at the University of Ulm, the properties of the novel pulsed Er:YAG laser are being investigated. To this end, ex vivo experiments are being carried out to compare the cutting properties with the routinely used CO2 laser.

The biomechanical properties of carcinoma tissue are being investigated in co-operation with the Institute for Biomechanics and Trauma Surgery Research at the University of Ulm. For this purpose, human tumour tissue is examined ex vivo using stress relaxation tests for the aggregate mode, hydraulic permeability and equilibrium modulus. Differences to healthy reference tissue are shown.

Virtual reality (VR) technology is being used in a clinical study. Patients undergoing surgery under local anaesthesia are offered the intraoperative use of VR goggles. The occurrence of anxiety and feelings of relaxation will be investigated.

The technique of fluorescence imaging and hyperspectral imaging is being evaluated in the surgical treatment of head and neck tumours. A state-of-the-art fluorescence microscope (Kinevo) is used here. The aim is to improve the visibility of tumours and support the surgeon in performing the operation safely.

The uRALP system was developed as part of an EU-funded initiative for transoral laser surgery (www.microRALP.eu). After the funding was finalised, the ENT University Hospital Ulm was able to contribute to the further development of the system at the Hannover Medical School through preclinical user studies.

Head of the robotics working group

Profilbild von Univ. Prof. Dr. med. Thomas Hoffmann

Univ. Prof. Dr. med. Thomas Hoffmann

Ärztlicher Direktor der Klinik für Hals-, Nasen-, Ohrenheilkunde, Kopf- und Halschirurgie

Kontakt Details

Further employees:

  • Prof Dr J. Greve
  • Prof Dr M. Scheithauer
  • Prof Dr F. Sommer
  • Dr F. Böhm
  • Dr R. Lehner
  • Dr C. Schwamborn
  • cand. med. L. Schild
  • cand. med. L. Kienle
  • cand. med. dent. L. Tippelt

Haptics and tactile feedback

 

The DaVinci system (Intuitive Surgical, Sunnyvale, USA) is the best-known system approved for robot-assisted surgery. It is regularly used by various specialities for surgical procedures. In addition to the increased cost, the lack of haptics and tactile feedback is a further obstacle to the wider use of the system. Our working group is investigating these circumstances in order to achieve possible improvements for use in the head and neck area. Due to its many highly sensitive anatomical structures, the neck area always places special demands on the surgeon and the instruments. Together with co-operation partners from the Institute of Biomechanics and Trauma Surgery Research at the University of Ulm, experimental models are being developed to objectify the tactile feedback of the available assistance systems. Another project is investigating the haptic properties of human tumour tissue. These experiments also aim to improve the recognition and localisation of tumour tissue during an operation using robotic aids. This work was honoured with the Mobility Scholarship of the German Society for Computer- and Robot-Assisted Surgery.

i2Soul Initiative. The robotics working group co-operates closely with the i2Soul initiative at the University of Ulm. The initiative promotes science in the field of surgical oncology and is an association of the surgical disciplines at Ulm University Hospital (otorhinolaryngology, head and neck surgery; gynaecology; trauma surgery; urology).

BHS Technologies. The RoboticScope digital microscope received CE approval in 2020. Our working group has so far participated in the validation studies and conducted preclinical experiments on the lateral skull base and on microvascular surgery. Furthermore, clinical interventions such as cochlear implants and microvascular anastomoses have been performed.

Medineering. The computer-assisted endoscope holder 'Cirq' from Brainlab-Medineering received CE approval for operations in the head and neck area in 2017. Our working group contributed to the development of the system with both preclinical experiments on the anterior skull base and clinical studies on the lacrimal ducts.

Medrobotics. From 2010 - 2016, we worked closely with the company Medrobotics (Raynham, USA). Our working group accompanied the development, optimisation and clinical introduction of the Flex system from the very beginning and, together with three other sites, was the first clinic in the world to use the system on patients. Prior to this, the Flex System was trialled and further developed in multiple cadaver studies. In the clinical phase I study on the applicability and safety of the system (NCT02262247), 14 oncological patients were successfully treated at the Ulm centre. The results of the study formed the basis for the approval of the system in the USA. In 2015, the project was awarded the 'Cooperation Prize for Science and Industry' by the University of Ulm.

Conclusion

 

The development of computer- and robot-assisted surgical procedures also promises great potential for improving patient care in the head and neck area. However, the various systems have not yet been able to establish themselves in routine practice, particularly due to the financial burden and the limited actual added value. The aim of our working group is therefore to develop robot-assisted assistance systems that bring clear benefits to the patient and are economically viable.

Haptic measurement

The haptic properties of computer- and robot-assisted surgical systems are evaluated using specially developed measurement setups.

Surgical assistance system sMAC based on a video laryngoscope and flexible surgical instruments.

Use of the fluorescence technique (5-ALA) in the surgical resection of a laryngeal tumour

Co-operation partner:

  • Institute for Biomechanics and Trauma Surgery Research at Ulm University Hospital (Dr A. Seitz)
  • Institute for Laser Technologies in Medicine and Metrology at the University of Ulm (Dr K. Stock, Dr H. Wurm)
  • Urological Clinic of the University Hospital Ulm (Prof Dr C. Bolenz)
  • Institute for Microelectronics at the University of Ulm (Prof. Dr.-Ing. M. Ortmanns)
  • Continuum Robotics Laboratory (CRL) at Mathematical and Computational Sciences, University of Toronto Mississauga, Canada (Prof. Dr.-Ing. J. Burgner-Kahrs)
  • Department of Mathematical and Computational Sciences, University of Toronto Mississauga (Prof. Dr.-Ing. L. Kahrs)
  • Institute for Intelligent Catheters (INKA) and ENT University Clinic of the Otto-von-Guericke University Magdeburg (Dr.-Ing. A. Böse)
  • SURAG Medical GmbH - Surgical Audio Guidance (Dr A. Illanes)
  • Harvard John A. Paulson School of Engineering and Applied Sciences Harvard University (Prof. R. Wood)
  • Storz (Tuttlingen); Siemens (Munich); Brainlab-Medineering (Munich); Lumendi (Buckinghamshire, GB); BHS-Technologies (Innsbruck, A); SyncVR Medical BV (Utrecht, NL); Siemens (Munich); Zeiss AG (Oberkochen)

Publications of the working group:

2022
  • Wurm H, Schuler PJ, Hausladen F, Grossi A-S, Hoffmann TK, Stock K, Reins EF. Comparative in-vitro investigations on the cutting quality of the CO2 laser and the diode pumped Er:YAG laser. Frontiers in Surgery. Dec 14;8:764450.
  • Boehm F, Schuler PJ, Riepl R, Schild L, Hoffmann TK, Greve J. Performance of Microvascular Anastomosis with a New Robotic Visualisation System - Proof of Concept. Journal of Robotic Surgery. Jun;16(3):705-713.
2021
  • Schild LR, Boehm F, Boos M, Kahrs LA, Coburger J, Greve J, Dürselen L, Hoffmann TK, Schuler PJ. Adding flexible instrumentation to a curved video laryngoscope - a novel tool for laryngeal surgery in an ex vivo animal trial. Laryngoscope. 2021 Feb;131(2):E561-E568.
  • Schuler PJ*, Böhm F*, Greve J, Schild L, Hoffmann TK. Robotics in head and neck surgery. Review. ENT. 2021 Feb;69(2):131-139.
  • Böhm F, Grässlin R, Theodoraki MN, Schild L, Greve J, Hoffmann TK, Schuler PJ. Current Advances in Robotics for Head and Neck Surgery - a systematic review. Cancers. 2021 Mar 19;13(6):1398.
  • Böhm F, Greve J, Riepl R, Hoffmann TK, Schuler PJ. Robot-assisted surgery in otorhinolaryngology. CME article. ENT. 2021 Sep;69(9):765-776.
  • Kundrat D*, Graesslin R*, Schoob A, Friedrich DT, Scheithauer MO, Hoffmann TK, Ortmaier T, Kahrs LA, Schuler PJ. Preclinical Performance Evaluation of a Robotic Endoscope for Non-Contact Laser Surgery. Ann Biomed Eng. 2021 Feb;49(2):585-600.
  • Schild LR, Boehm F, Seitz A, Kahrs LA, Boeckers TM, Greve J, Hoffmann TK, Schuler PJ. Evaluation of a curved surgical prototype in a human larynx. 2021. Eur. Arch. ORL 2021 Aug;278(8):2927-2935.
  • Riepl R, Greve J, Schild L, Böhm F, Goldberg-Bockhorn E, Hoffmann TK, Schuler PJ. Application of a new computer-assisted robotic system in cochlear implantation - proof of concept. Int J Med Robot. 2021 Oct;17(5):e2301.
  • Böhm F, Greve J, Riepl R, Hoffmann TK, Schuler PJ. Robot-assisted surgery in otorhinolaryngology. CME article. ENT. 2021 Sep;69(9):765-776.
2020
  • Boehm F, Friedrich DT, Sommer F, Scheithauer MO, Greve J, Hoffmann TK, Schuler PJ. Nasolacrimal duct stenosis - surgery with a novel robotic endoscope positioning system. Int J Med Robot. 2020 Dec;16(6):1-5.
  • Schild LR, Lemke D, Boehm F, Greve J, Dürselen L, Scheithauer MO, Hoffmann TK, Schuler PJ. Force effects on anatomical structures in transoral surgery - videolaryngoscopic prototype vs. conventional direct microlaryngoscopy. Current Directions in Biomedical Engineering. 2020. 6(1): 20200021.
2019
  • Kundrat D, Schoob A, Piskon T, Grässlin R, Schuler PJ, Hoffmann TK, Kahrs LA, Ortmaier T. Toward Assistive Technologies for Focus Adjustment in Teleoperated Robotic Non-Contact Laser Surgery. IEEE Transactions on Medical Robotics and Bionics. 2019 Aug 1; 1 (3): doi: 10.1109/TMRB.2019.2931438.
2018
  • Schuler PJ. Robotic surgery - Who is the Boss? Review. LRO. 2018 Mar;97(S 01):S231-S278.
  • Schuler PJ. New partners in the operating theatre. Review. Clinic Management News. 2018.
  • Friedrich DT, Dürselen L, Mayer B, Hoffmann TK, Schuler PJ, Greve J. Evaluation of haptic and tactile feedback in transoral robot-assisted surgery - first comparison of competitive techniques. J Robot Surg. 2018 Mar;12(1):103-108.
  • Friedrich DT, Modes V, Hoffmann TK, Greve J, Schuler PJ, Burgner-Kahrs J. Teleoperated Tubular Continuum Robots for Transoral Surgery? - Feasibility in a Porcine Larynx Model. Int J Med Robot. 2018 Oct;14(5):e1928.
2017
  • Schuler PJ, Hoffmann TK, Veit JA, Rotter N, Friedrich DT, Greve J, Scheithauer MO. Hybrid procedure for total laryngectomy with a flexible robot-assisted surgical system. Int J Med Robot. 2017 Jun;13(2).
  • Friedrich DT, Scheithauer MO, Greve J, Doescher J, Hoffmann TK, Schuler PJ. Application of a computer-assisted flexible endoscope system for transoral surgery of the hypopharynx and upper esophagus 2017. Eur Arch ORL. 2017 May;274(5):2287-2293.
  • Friedrich DT, Sommer F, Scheithauer MO, Greve J, Hoffmann TK, Schuler PJ. An innovative robotic endoscope guidance system for transnasal sinus and skull base surgery: Proof of Concept. J Neurol Surg B Skull Base. 2017 Dec;78(6):466-472.
  • Friedrich DT, Scheithauer MO, Greve J, Hoffmann TK, Schuler PJ. Recent advantages in robot-assisted head and neck surgery. Review. Int J Med Robot. 2017 Jun;13(2).
  • Rotter N, Schmitz B, Sommer F, Roehrer S, Schuler PJ, Bischof F, Hoffmann TK. First use of flat-panel computed tomography (Dyna-CT) during cochlear implant surgery: perspectives for use of advanced therapies in cochlear implantation. ENT. 2017 Jan;65(1):61-65.
  • Lang S, Mattheis S, Hasskamp P, Lawson G, Gueldner C, Mandapathil M, Schuler P, Hoffmann TK, Scheithauer MO, Remacle M. A European Multicentre Study Evaluating the Flex Robotic System in Transoral Robotic Surgery. Laryngoscope. 2017 Feb;127(2):391-395.
  • Veit JA, Thierauf J, Egner K, Wiggenhauser S, Friedrich D, Scheithauer M, Greve J, Schuler PJ, Hoffmann TK, Schramm A. Virtual planning in epithelial orbital surgery. LRO. 2017 Jun;96(6):374-379.
2016
  • Hoffmann TK, Friedrich DT, Schuler PJ. Robotics in Head and Neck Surgery. Review. ENT. 2016 Sep;64(9):658-66.
2015
  • Schuler PJ, Hoffmann TK, Greve J, Duvvuri U, Rotter N, Scheithauer MO. Demonstration of nasopharyngeal surgery with a single port operator controlled flexible endoscope system. Head & Neck. 2015 Mar;63(3):189-94.
  • Schuler PJ, Scheithauer MO, Rotter N, Veit J, Duvvuri U, Hoffmann TK. A single port operator controlled flexible endoscope system for endoscopic skull base surgery. ENT. 2015 Mar;63(3):189-94.
  • Friedrich DT, Scheithauer MO, Sommer F, Greve J, Hoffmann TK, Schuler PJ. Potential advantages of a single port operator controlled flexible endoscope system for transoral surgery of the larynx. Ann of ORL. 2015 Aug;124(8):655-62.
  • Schuler PJ, Scheithauer MO, Duvvuri U, Friedrich D, Hoffmann TK. First use of an operator controlled flexible endoscope for transoral surgery. Case report. Laryngoscope. 2015 Mar;125(3):645-8.
2014
  • Hoffmann TK* and Schuler PJ*, Bankfalvi A, Greve J, Heusgen L, Lang S, Mattheis S. Comparative analysis of resection tools suited for transoral robot-assisted surgery. *equal contribution. Eur Arch of ORL. 2014; 271(5):1207-13.
  • Mattheis S, Schuler PJ, Dominas N, Lang S, Hoffmann TK. The use of a flexible CO2-laser fibre in transoral robotic surgery (TORS). Laryngorhinootology. 2014; 93(2):95-9.