New technology
Surg Endosc (1999) 13: 528–531
Trocar and instrument positioning system TISKA
An assist device for endoscopic solo surgery
M. O. Schurr,1 A. Arezzo,1 B. Neisius,2 H. Rininsland,2 H.-U. Hilzinger,3 J. Dorn,3 K. Roth,1 G. F. Buess1
1
Section for Minimally Invasive Surgery, Department of General Surgery, Eberhard-Karls University, Waldhörnlestrasse 22, D-72072
Tübingen, Germany
2
Karlsruhe Research Center, Department of Technical Engineering, Karlsruhe, Germany
3
Karl Storz Endoscopy GmbH & Co., Tuttlingen, Germany
Received: 29 December 1997/Accepted: 24 July 1998
Abstract. The assistance received by the surgeon from sup-
port personnel during surgical laparoscopy is extremely im-
portant. This includes the retracting of instruments and the
positioning of the endoscope. However, human assistance is
costly and often does not provide satisfaction for the sur-
geon. The aim of the project was to develop a mechanical
arm capable of manipulating a laparoscopic instrument un-
der the control of the operating surgeon. The system design
is based on a particular kinematic construction that main-
tains an invariant point of constraint motion coincident with
the trocar puncture site through the abdominal wall. The
guidance system allows transparent and intuitive operation,
and its setup is easy and quick. It may be adapted either as
an instrument retractor or as an optic positioning device. A
new generation of instrument positioning systems, with im-
proved ergonomy, will be a first step toward the diffusion of
solo surgery techniques in minimally invasive therapy. We
believe this prototype represents a valid compromise be-
tween human and robotic control for conventional laparo-
scopic instruments.
Key words: Endoscopic surgery — Retractors — Solo sur-
gery — Surgical robotics
In recent years minimally invasive surgical techniques have
improved the quality and efficiency of several surgical pro-
cedures. Nevertheless, surgeons sometimes face difficulties
in reaching a stable and optimal position for laparoscopic
instruments and endoscope.
First mechanical retractors and then automated surgical
robots were developed to alleviate the problem of instru-
ment guidance. At the time of this writing, different tasks
Correspondence to: G. F. Buess
© Springer-Verlag New York Inc. 1999
are performed with the help of mechanical or robotic de-
vices not only in general surgery, but also in neurosurgery
[1, 3, 4], orthopedics [5, 10], and urology [2].
A new instrument positioning system is described, re-
cently developed in cooperation with the Karlsruhe Re-
search Center and Karl Storz Endoscopy, Tuttlingen, Ger-
many. It is provided with a characteristic geometry that
should improve the efficiency of laparoscopic surgical ma-
neuvers by providing assistance to the surgeon.
Materials and methods
Technology
The aim of the project was to develop a mechanical arm capable of ma-
nipulating and fixing a laparoscopic instrument in position under the con-
trol of the operating surgeon. The geometry of an instrument guidance
system for laparoscopic surgery should respect the principle of the invari-
ant point of motion [7, 9] where the trocar enters the adominal cavity.
For the Trocar and Instrument Positioning System Karlsruhe (TISKA)
project, a special kinematic principle was adopted that establishes a remote
center of instrument motion, ensuring that no lateral force is exerted around
the trocar puncture site. This was achieved by designing a system in which
the shaft of a laparoscopic instrument can be moved around the point of
trocar insertion as well as rotated and translated in its longitudinal axis. The
principle of maintaining the invariant point of motion through mechanical
constraints has been described by Mueglitz et al. [7]. They described a
robotic motion principle along virtual axes, intersecting at the point of
trocar insertion. This is of particular importance for the control scheme of
electrically driven robotic devices [7]. Moreover, it is a helpful kinematic
principle in purely mechanical instrument guidance devices.
Experimental evaluation
Evaluation of prototypes proceeded in parallel with the technical develop-
ment of the device. We usually assess new technologies under experimen-
tal conditions, using phantom models with integrated animal organs. The
Tübingen Lap-Trainer (Coburger Lehrmittelanstalt, Coburg, Germany)
was equipped with porcine liver segments including the gallbladder to
 529

Fig. 1. Basic design of the TISKA Endoarm.

Fig. 2. TISKA Endoarm: current prototype.
Fig. 3. The adaptation to the operating table that allows a clear definition of the sterile limit.
530
Fig. 4. The invariant point of constraint motion is maintained when the
instrument is moved.
Fig. 5. The low space requirements allow the system to be combined with
further positioning systems: the operating field when two TISKA Endoarm
systems are used.
simulate laparoscopic cholecystectomy. Conventional laparoscopic operat-
ing room equipment (video unit, HF, etc.) and a regular set of instruments
were used. The prototypes were applied to guide assisting instruments for
retracting the gallbladder or to guide the optic during laparoscopic chole-
cystectomy.
The experiments were not a standardized series, but tests to clarify the
functionality and handling properties of the new device. Intuitiveness of
handling, practicality of use under operating room conditions, and me-
chanical stability of the TISKA system were judged subjectively. The test
results were used to further refine the design of the device until optimal
functionality was achieved in the final version. This device was used in
three animal experiments (domestic pig) for laparoscopic cholecystectomy
to confirm that the phantom test results could be transferred to surgery.
Results
Technological results
The kinematic design of the system (Fig. 1) comprises a first
axis pointing directly through the point of incision. A sec-
ond axis intersects the first perpendicularly at the point of
incision. A planar double parallelogram mechanism con-
nects the two axes. This geometry allows movements only
around an arc whose center corresponds to the point of
incision. Thus, a remote center of motion is established at
the point where the two axes intersect. When the trocar tube
and the inserted instrument are moved, they are guided pre-
cisely through the invariant point of trocar insertion, with-
out any force being exerted on the abdominal wall. Trans-
lation and rotation around the longitudinal axis of the in-
strument are possible, completing the four degrees of
freedom necessary to guide the instrument in the abdominal
cavity. Furthermore, a spherical wrist joint was included in
the design of the system incorporating the parallelogram
mechanism described earlier. This additional joint is used to
align the position of the device with the anatomy of the
patient.
A prototype of the instrument-positioning system was
created and called the TISKA Endoarm (Fig. 2). The system
is composed of a power supply unit, an operating table
attachment, a positioning device, and a trocar tube adapta-
tion clip. The position of the double parallelogram is locked
and unlocked by electromagnetic brakes controlled by a
footpedal, whereas translation and rotation of the laparo-
scopic instrument are locked by a mechanical clamp.
After the device is attached to the operating table, it can
be covered with a sterile plastic sac. A special technique
allows the precise definition of the sterile area: The carrier
system of the TISKA device is attached to the standard rail
by means of a larger rail screwed under the sterile drape
covering the operating table. This larger rail has rounded
edges to prevent it tearing the drape and to allow easy
translation of the base along the operating table. The whole
arm is covered by a transparent plastic tube fixed to the base
of the carrier system (Fig. 3). Thus a clear limit of the sterile
field is defined. The entire arm is made of stainless steel and
may be gas sterilized if required.
Experimental results
The evaluation of the prototype was conducted in phantom
models and confirmed in animal experiments. The overall
handling of the system was found to be simple and did not
require specific training. The trocar tube can easily be
mounted on the instrument guiding device. When the de-
sired position of the instrument is reached, the surgeon may
lock axes 1 and 2 by simply releasing the pressure on the
footpedal. This was subjectively judged to be very intuitive
and easy to perform. It was found to be a particular advan-
tage of the system that repositioning does not require the
involvement of both hands but can be done with only one
hand.
During phantom and animal experiments, the principle
of the invariant point of motion (Fig. 4) was confirmed, and
the device was found to be atraumatic around the trocar
puncture site. Space requirements of the TISKA device at
the operating table are low and allow the combination of
two systems (Fig. 5) for guiding both the assisting instru-
ment and the laparoscope. For this purpose, both devices
must be attached to the operating table opposite the surgeon
to avoid conflict.
Discussion
In recent years, laparoscopic surgery has become increas-
ingly widespread, supported by new developments in in-

strumentation. Less attention has been paid to the comfort of
the first surgeon and his or her assistant, who often are
forced into tiring standing positions and monotonous tasks.
This can result in an unsatisfactory interaction between the
two, making it difficult to find an optimal working position.
Moreover, the high costs of the operating theater, even for
standard laparoscopic procedures, require the involvement
of less experienced fellows, such as residents, which leads
to a further increase in the operating time [11]. Especially in
community hospitals and private institutions, where the role
of the surgical assistant is assumed by either assistant phy-
sicians or trained nurses, the introduction of positioning
systems for laparoscopic procedures may alleviate some of
the pressure due to limited resources [11].
Mechanically assisted systems, such as Iron Intern (Au-
tomated Medical Products, New York, NY) and Omnitract
(Minnesota Scientific, St. Paul, MN), incur low costs. On
the other hand, they turn out to be unergonomic as they
do not offer a true instant release capability to the laparo-
scopic surgeon, and are therefore rarely used [6]. This is
mainly a consequence of their direct derivation from open
surgery. Pneumatically assisted systems, such as
Robotrac (Aesculap, Tuttlingen, Germany) or First Assis-
tant (Leonard Medical, Huntington Valley, PA), also pro-
vide a significantly increased degree of stability compared
with human assistance, while they do not fatigue or antici-
pate surgical movements during complex operations. Nev-
ertheless, they require some experience before smooth
working interaction can be achieved [6]. We were able to
confirm these impressions from personal experience on
phantom models using retractors originally designed for
open surgery. Therefore we decided to develop a passive
positioning system designed to meet the requirements of
laparoscopy.
The geometric design of the new TISKA Endoarm,
based on the principle of mechanical maintenance of the
invariant point of motion, allows simple, single-handed op-
eration. According to our personal experience, the release of
the brakes through the footpedal does not add significant
complexity to system operation. Motion of the abdominal
wall (i.e., as a result of the patient’s breathing), has practi-
cally no influence on the position of the instrument. The
position of the trocar sheath is maintained while the instru-
ment is changed.
Studied mainly as a simple instrument retractor, the
Endoarm may easily be used as a passive optical positioning
device, although simpler than advanced robotic guiding sys-
531
tems. The low space requirements of the system allow it to
be combined with further positioning arms, even on the
same side of the patient, which is not always possible with
systems moving in a horizontal plane. A combination of two
TISKA Endoarm systems can be used for both optic and
instrument positioning, thus avoiding the need for an assis-
tant surgeon in standard laparoscopic procedures. In phan-
tom and animal experiments personally conducted, this
solosurgery solution appeared to be comfortable for the sur-
geon. We believe the Endoarm represents a valid compro-
mise between human and robotic control [9] of laparoscopic
instruments. Further data concerning the influence of guid-
ance systems on the course of solo surgery, setup, and in-
tervention times will be derived from standardized experi-
mental trials currently underway.
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