Medical Robotics Precision Robots Are a Game Changer in Surgery

The technological preconditions—advancements in computing, sensing, motor control, and data systems—are now in place, enabling a new generation of surgical robots to emerge. These robots will perform with greater precision than human surgeons, reducing risk and enabling customised procedures.

About 500 million years ago, all major types of animals on earth appeared over a period of only 25 million years or so. This event, known as the Cambrian explosion, occurred because all the preconditions were right for animals to diversify. Simple organisms had many years to mature before the event. The explosion happened because multicellular structures, circulation systems, sensing, motor control and more were available for the first time.

A similar thing is going on in medical robotics today. The pioneering teleoperated robotic surgery system, Intuitive Surgical’s DaVinci, has been operating for over 20 years. It works with end effectors that look like sticks, and is used in only a few types of procedures, mostly in the urology and gynecology areas. But now, computing, sensing, motor control, data flow architecture, and more are finally capable of powering a new generation of medical robots. Operating rooms are transforming into digital surgery platforms. These systems will take on most every type of surgical procedure. This robotic explosion will change surgery more than anything in the last hundred years.

For instance, imagine you are an orthopedic surgeon specializing in knee replacements. The preconditions are there for robotic assistance. Compared to only a few years ago, prosthetic knees are commonplace these days. In fact, it’s become so common that efficiency is critical; surgeons handle almost 1 million operations in the U.S. each year. Robotic technology, including sensing, control, data flow, and intelligence, is ready for application. Specialized robotic systems will soon change both the process and economics of these procedures.

The Manual Process Looks Like This

Preparation:

• Obtain X-ray or CT images of the knee.

• Design how the new joint will function. This is complex and involves balancing positioning, alignment, laxity (joint play), and other factors. The biomechanics must be precise. You can use computer-aided design (CAD) tools to plan exactly how it will work.

• Choose a prosthesis: metal and plastic components designed to function as a "new knee." Most modern prosthetics are standardized parts available in various sizes, with one component for each bone in the joint.

• Plan where you will make the cuts and how you will install the new joint.

Surgery:

• While the patient is under anesthesia, remove the damaged bone, shape the remaining bone to fit the prosthetic, and install the new joint.

• This is not straightforward. It’s difficult to know exactly where to cut and how to shape the bone for the prosthetic. Sometimes, real-time imaging systems are used to guide the cuts, but often it’s a trial-and-error process—cutting, temporarily installing the prosthesis, testing motion, and making adjustments. Guides, alignment jigs, and test instruments may be used, but experience is key.

• Since perfect cuts are hard to achieve, the prosthetic is cemented in place to close any gaps.

• Then, restore the soft tissues (ligaments, tendons, etc.).

Finally, recovery: Additional images are taken to confirm proper function. The patient is then referred for physiotherapy.

Robots Are More Precise Than Surgeons

Of all these steps, making accurate cuts is by far the most difficult and important. Setting up the table and patient to ensure alignment of the cuts is the most expensive part. It can take 2-3 hours to get everything in the right position for the operation. Much of this must be done with the patient on the table. Together, setup and cut planning and evaluation drive much of the cost and risk. In the end, however, humans aren't very good at making precise angular cuts. Even trained surgeons can't make perfect cuts. And adapting the diversity of human bone to standard parts means that most patients don't get an optimal result.

Robots can follow extremely precise cut paths generated by the imaging and CAD plans. The resulting precision angles and ultra-smooth surfaces are so clean that many operations don’t require cement; the part is press fit and the bone grows into the part like your natural joint. With robotic accuracy and flexibility, custom joints become realistic to install. Instead of adapting the patient to a standard part, a custom part can be 3D printed from the imaging information. Manually adapting procedures to install these unique parts is impractical for humans. It’s entirely possible for a robot.

Of course, it’s not quite that simple. Importantly, the robot has to know exactly where the bone is, a process called “registration.” That’s done with an imaging system that can track something that looks like an antenna with reflective targets on it. This is attached (screwed into) the bone, and then another probe with targets on it is used to locate bone points exactly. After that, the vision system knows exactly where the bone is while it’s cutting.

Then, to make it all work, the right data has to get to the right place at the right time. The vision system communicates where the bone is, even if it’s moving. The surgeon controls when and how fast to cut. The robot uses those to execute a perfect cut along the pre-planned angle. This is all automated so it can even be done remotely, even with the surgeon thousands of miles away. It’s a bold new intelligent world. The knee-replacement robot essentially copies how surgeons work, but with better accuracy and precision. Increasing evidence shows that the results of robotic joint replacement are better. The robotic surgery in these studies improved implant positioning, alignment, and ligament balance. General-purpose robots can extend human capabilities in other ways. Robotic technology can enhance a surgeon’s environment with high-resolution 3D monitors, four robotic arms, and automatically-changeable tools. Connecting those through intelligent computing lets the surgeon measure anatomical structures to millimeter precision, generate “tags” for landmarks and training, and even monitor potential accidental injuries. The robot + surgeon system improves operating-room capability, communication, and outcomes.

A Wide Range of Medical Robots

Some robots can perform operations that a human cannot do. For instance, consider the problem of a lung biopsy. The current way to do a biopsy is to take a long needle, poke it through the chest into the lung and suck out a sample for analysis. But this has all sorts of problems. The needle goes through the skin into the lung, so bacteria can get in, risking infection. You have to puncture the lung, risking a pneumothorax (collapsed lung). It’s very hard to know where the needle actually is, so you need to run continuous X-rays (fluoroscope) and “poke around” a bit to find the right spot. It can work, but it’s messy, slow, risky, and expensive.

Now imagine instead that you have a robot that looks like a long thin tube about the thickness of a USB cable. It’s steerable with a simple controller. You can see through fiber optic video cable. When you get to the suspected tumor, a quick suction tube takes a sample. This tube robot makes no punctures, risks no infection or lung damage, and makes the procedure safer, faster, and more accurate. No human can match that. These are only a few of the hundreds of new-generation medical robots. The variety is incredible.

A laparoscope robot folds up to go through a hole the size of a dime, then unfolds into a praying-mantis-like device with eyes and hands. Another looks like two very dextrous snakes with gripper heads. Jointed arms, tiny grippers on sticks, human-like dual-armed systems, under-the-skin grippers, and more will soon populate operating rooms. Fletcher Spaght Inc. (FSI), an analyst in the industry, tracks over 200 robotic-assisted surgery products in various stages of development. Each is designed to perform precision motions in ways that humans cannot match. Medical robots will soon change nearly every procedure in the operating room.

Equally important, many of these systems will soon leverage AI. Applications include before (pre-op), during (intra-op), and after (post-op) the surgery. Pre-op, AI can help surgeons train for the specific challenge, model the patient, and develop custom process and implants. Closer to the surgery, AI can speed setup, making sure the patient and equipment are properly placed and calibrated. It can also help align images such as CT scans to the actual patient, ensuring accurate operation.

Robots During and After an Operation

During the procedure, AI can increase accuracy, enforce safety, and improve efficiency. For instance, smart robots can verify measurements, guide the robotic motion, and flag potential unsafe steps. Smart tools can automate some of the routine-but-slow steps like staple placement and suturing. Increasingly, the robot can also use AI to coordinate the operation with other devices in the operating theater like patient monitoring and anesthesiology. After the operation, AIs will improve both operations and patient outcomes. Automated systems can more closely monitor patients, analyze operational effectiveness, and even predict outcomes for early intervention.

In summary, surgical systems of tomorrow will teem with hundreds of types of robots. They won’t be just mechanical motion replicators, they will use AI to assist care teams in performing more accurate, faster, less invasive operations. They will fill every niche of surgery, adapting exactly to each procedure’s challenges and needs. Every operation can be customized to fit each patient’s unique condition and needs. The environment is incredibly fertile: Imaging, compute power, sensing, intelligence, software architecture, and mechanical design are all at inflection points, forming a truly unique junction.

The advent of these new applications is contingent upon the availability of data, or more accurately, upon the capacity for data flow. An approach to real-world software architecture, designated as "data centricity," ensures the delivery of pertinent data to the appropriate location at the optimal time. The data-centric approach facilitates the integration of sensor data into intelligent algorithms, which in turn are linked to the motors that perform the actions. In the context of artificial intelligence, data is the fundamental building block of intelligence. However, in the real-world context of sensors, motors, robots, instruments, and human interactions, data flow is the crucial element that enables the development of intelligent systems. Consequently, data flow is a pivotal aspect in the advancement of patient care. (heh)

* Stan Schneider is CEO at Real-Time Innovations (RTI).

(ID:50209399)