Faster, Better, Cheaper: The Future of Medical Robotic ...

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  • The benefits of minimally invasive procedure are profound when one makes a conventionally open procedure closed. These benefits include reduced pain, decreased costs, and improved access to medical care, especially in remote locations. We have only seen the tip of the iceberg with conventional technology. Robotics technology is a game changer ---------------------------------------------------------------- Reduced Post Operative Discomfort The clinical benefits to patients are profound when an “open” procedure can be made minimally invasive. By definition, performing any procedure less invasively results in less soft tissue disruption, with the positive effects of reduced pain, faster healing and recovery, and fewer complications. Documented advantages of less invasive procedures include smaller incisions and fewer injuries to major blood vessels and nerves. Other benefits reported include reduced blood loss and decreased post-operative pain, shorter hospital stays, and faster return to normal activity for the patient. Furthermore, despite the higher capital expense of equipment needed to operate in a minimally invasive fashion, overall costs of minimally invasive procedures can actually be significantly lower Reduced Costs Shorter hospital stays (reduce room and board, pharmacology, etc.) Shorter recovery times and return to work Enable more procedures to be done
  • To see how robotics can help, let consider the cardiac domain. For every year in the previous century, cardiovascular disease has been the number one killer of Americans, except in 1918. 1 death every 34 seconds in the US. Clearly, the sternuomoty is a major invasion and source of pain, complications, costs, etc. MIS tools cannot access the heart either because they are linear and rigid, or flexible but buckle easily. A small surgical snake robot is both rigid and linear. Therefore, we can access locations on the heart without breaking the ribs but rather entering through the solaplexus, make a 1/4in turn one way and the other and we are behind the heart. This reduces post-operative discomfort, reduces cost, and disseminates care because more can be done. Our story begins with a need in minimally invasive surgery that came to us from Marco Zenati, a cardiac surgeon at UPMC. Currently, we have laporascopes that are rigid and linear, and endoscopes, which are flexible and buckle easily. My research group develops snake robots. CLICK A By reducing its size, small surgical snake robot is both rigid and flexible. Therefore, instead of cracking the chest, now we can enter through the subsyphoid process, make a ¼ inch turn one way, a ¼ inch turn another and we are behind the heart ready to deliver therapeutics. CLICK Now, of course, this is in not minimally invasive surgery and this is actually what happens. At about the time when we reached this technology readiness, Marco and I started Cardiorobotics and through the help of the local economical development agencies, we were able to attract high quality management talent which was able to develop a plan for true innovation and acceptance, which ultimately attracted investment dollars. Now, Cardiorobotics is poised to do its first in man operation in November.
  • Certainly we are not the only ones development new technology……list others including virutal incision, JHU However, many of these efforts, including our own, have come about in a haphazzard random manner (MAYBE MAKE THAT COMMENT AFTER THE NEXT SLIDE) Most people have this notion that a robot takes a hiumanoid form but really there are others such as snakes and caterpillers. We have developed all sorts of snake robot that exploit their many internal degrees of freedom to reach anatomical targets in a minimally invasive manner. Current technology, say colonoscopes, is flexible but buckles easily, or a laporascope is rigid but linear. The snake is both so we can perform some heart surgeries without cracking the chest. Heart lander is a caterpiller like devices that can literally walk along the heart delivering medicines again with minimal invasion.
  • However, this is just the beginning. Robotic technology can blur the boundary between surgeon and specialist allowing the specialist to give surgical care and the surgeon the specialist’s “touch.,” that is surgical like interventions with minimal invasion. This in a sense empowers the specialist, which is good for the patient and cost structures, but is certainly not unemploying surgeons. If anything, we are offloading the burden for surgeons who are already incredibly overworked in the first place. If anything, this goes with the trend that we are already seeing – e.g., colonosopy, not abdominal surgery I believe the operating room of the future will be filled with ubiquitous technologies and not a monolithic anthropormic robot. It will look like conventional tools became intelligent or dare I say robotic, and not the surgeon becoming robotic. This runs against a notion telesurgery where we use robotic technology to multiplex a single surgeon; instead, we are developing intelligent and smart tools that allow specialists and perhaps field medics perform procedures that in the past were relegated to surgeons. Ultimiately, this both improves patient care and creates medical jobs. Finally, there is trend in single port and natural orifice access that our technology will enable – tell the story
  • We have the best medical technology, although not the best medical care, in the world. Clearly, we are the inventors of this and robotics technology. No other place in the world has both of these, but to really make new industry, jobs, and bring the improved patient care, you need enterprise. This country is founded on the entrepreneurial spirit and hence we have the critical three components to make this happen. I feel that being in Pittsburgh is like a microcasm for the entire United States with these three key components present Few places in the world have centers of excellence in medican and robotics, let alone so close to each other. Both Pitt and Carnegie Mellon have world class engineering programs. CMU has the robotics institute and Pitt has a bioengineering dept where I want to take their senior design course. But, Pittsburgh also has local economic devleopment organizations that provide money, and perhaps more importantly, advice and contacts. I cannot think of any place that has this combination and can lead these efforts. Already we are working with other regions like Rhode Island and Central Pennsylvania
  • Say: if the US is the best place for this technology to germinate, why do we need government leadership and support And in this middle ground, engineers and medical doctors need to be properly introduced


  • 1. Faster, Better, Cheaper: The Future of Medical Robotic Technology Howie Choset Carnegie Mellon
  • 2. Minimally Invasive Surgery Benefits
    • Reduced post-operative discomfort
    • Reduced Costs
    • Improved access to quality medical care
  • 3. Robotic Cardiac MIS vs. + = Reduce discomfort : no crack chest Reduce cost: shorter hospital stay Disseminate care: more can be done
  • 4. What has been done: Minimally Invasive Medical Robotics Heartlander Cam Riviere, and Marco Zenati DaVinci, Intuitive Surgical Steerable Needles, Dupont, et al; Rviere; Alterovitz, et al; Salcudean, et al., Okamura Sonic flashlight, Stetton Virtual Incision (U of Neb, Farritor) Given Imaging Dario, Webster, et al Tissue Engineering Weiss, et. al. Cyberknife proximal body suction pads distal body
  • 5. Vision for Medical Robotics
    • Blur the boundary between specialist and surgeon
    • Shorter length procedures
    • Enable New Procedures
      • Natural orifice
      • single port access
    • Robotic tools, not robotic surgeon
    proximal body suction pads distal body
  • 6. The United States is Unique Robotics & Engineering Medicine Enterprises
  • 7. Why Government Leadership?
        • Small companies and academia
          • playing in the middle
          • developing technology and innovative clinical approaches
          • can create a new industry
        • Haphazard way of engineers and doctors meeting
        • NIH is currently not the right match
    Capital equipment GE/Intuitive Surgical Vs. Operating room tools BSci, Guidant, Stryker
  • 8. Appendix
  • 9. Carnegie Mellon Spin0ff
    • Founded in 2005 …
    • Licensed IP from Carnegie Mellon and the Univ. Pittsburgh …
    • Inventors were 2006 recipient of $2.2 Million NIH grant for epicardial robotics…
    • Raised to date $11.6 Million (includes $2.6M convertible) in Series A financing…
    • Since 2004, there have been 6 generations of prototypes tested in animals and cadavers…
    • Clinical prototype complete and undergoing testing and verification…
      • Thirty five (35) patents and pending applications on snake robotics:
        • 2 issued US patent s
        • 33 other patents pending – 21 independent
      • Received ‘Freedom to Operate’ opinion from Pepper Hamilton Law PC…
      • Company received a formal opinion on their regulatory status as 510(k)…
    • Completed more than a dozen animal trials -- closed-chest access, pericardial navigation, direct visualization, transmural lesion ablation -- results published, no adverse hemodynamic or electrocardiographic impact from CardioARM…
    • Completed two human cadaver trials: closed-chest access, pericardial navigation, direct visualization, box lesion ablation pattern…
  • 10. Costs difficult to assess
    • Hospital characteristics (size, community or specialist setting, administration, etc.)
    • Surgeon’s ability and experience
    • Types of supplies used
    • Different procedures costs vary
    • Hospitalization/OR time costs vary
    • Role and use of residents/fellows
    • Learning curve issues (make it more expensive at first)
    • Players
      • Patient and employer
      • Insurance company
      • Tool makers
  • 11. DaVinci Systems 2008: 335 units sold Total: 1,111 units installed 875 million, 46% Income in 2008 increased by 59% to $387MM Source: Intuitive Surgical 10-K SEC report (ANNUAL REPORT 2008)