Robots in the Hands of Your Surgeon

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The evolution and future use of robotic devices in human surgery

The evolution and future use of robotic devices in human surgery

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  • At the Florida Hospital Nicholson Center we train surgeons to perform new procedures and to use new equipment. Increasingly, this equipment is a robot that augments the surgeon’s natural abilities – stereo vision, 10X magnification, improved dexterity, multiple surgical arms, and personal camera control. Today most surgeons are clamoring to use one specific brand of robot, but we see several more on the verge of entering the field. In he future you can expect all complicated procedures to use a robot to give him super powers.
  • Automated robotic performance was actually first suggested by Leonardo da Vinci. In his notebooks he proposed to insert machinery into a suit of armor to allow it to stand upright and move on its own. The Mechanical Turk became a sensation in the 1770’s when it toured Europe playing chess against human opponents. The Turk seemed to have the ability to make intelligent decisions and move chess pieces without assistance from a human operator. But, it was actually a stage magician's magic trick. The human player was skillfully hidden inside the chest beneath the board. When the wooden case was opened, only the gears that moved the arms could be seen. Audiences were fooled for years before the secret was revealed.
  • [The Gross Clinic] and [The Agnew Clinic], by Thomas Eakins (1844-1916) Surgery has always been a messy business and something that is difficult to teach others to do. Classic painters brought the reality of the surgical experience to the elite class with their paintings. Prior to 1900 most people preferred to live or die with their conditions rather than taking their chances on the operating table.
  • Laparoscopy is a form of Minimally Invasive Surgery in which long thin instruments enter the body through “keyhole” incisions, rather than opening a hole large enough for the surgeon’s hands. Surprisingly, this practice was pioneered by Hans Christen Jacobaeus in Sweden in 1910. His equipment was quite primitive and he limited himself to practicing on dogs. But the seed was planned and practice of lap-surgery or MIS exploded in the 1980’s when the technology became advanced and safe enough to perform on humans. But, to this day, these instruments create serious limitations on the surgeon’s ability to maneuver and manipulate tissue inside the body. The surgeon needs a helper.
  • In a 1942 short story, Robert Heinlein described a reclusive genius named “Waldo” who had invented multiple sets of mechanical arms that would allow him to control robots that could destroy a building, construct an armored tank, build an electronic circuit board, or perform micro surgery. The technology augmented Waldo’s natural movements, giving him the super-human abilities. Many of today’s military robots and exoskeletons are implementations of this concept.
  • Which brings us to the field of medicine. Isaac Asimov’s 1988 novel “Fantastic Voyage” describes automatic, intelligent, remote, internal surgery of a human body. The surgery is not achieved through human augmentation, but through human miniaturization. Science has created the ability to shrink humans, instruments, and a submarine to the microscopic scale while still retaining all of its capabilities. The submarine is then injected into the patient and navigates its way to the virus that is killing the patient, where machine and virus battle to the death.
  • Like laparoscopic surgery between 1910 and 1980, robotic augmentation in medicine has been around for decades without receiving a lot of widespread attention. The PUMA 560 robot performed one crucial function during an operation on the brain. Using images of the patient’s brain, it could be programmed to insert a needle into the head and navigate the tip to a precisely identified part of the brain for extracting a biopsy. The robot performed the same movements that are normally done by a human surgeon; it just did the task with much less trembling of the hand and estimation of direction and depth. The robot is little more than a generic arm which can be guided to a specific position. It becomes medical when you place a biopsy needle in its hands. http://en.wikipedia.org/wiki/Robotic_surgery
  • The 1988 PROBOT, developed at Imperial College London, was used to perform prostatic surgery by Dr. Senthil Nathan at Guy's and St Thomas' Hospital, London. The end effector scoops/cuts cones of tissue from the prostate, rotating so it can take tissue away from any part of the prostate. The PROBOT avoids the large moving mechanical arm of the PUMA because that equipment can potentially rotate and strike the surgical team in its vicinity. This device is manually positioned and inserted into the prostate. The probe and tip rotate inside of a much smaller area where no people are in the way.
  • In 1999, with NASA funding, Computer Motion Inc. created a robotically controlled endoscopic camera. This device would steer the camera inside the patient’s body through voice controls. The surgeon could speak to the computer as he would a human assistant, while keeping both of his hands on the operative instruments. Computer control and mechanical mounting also provided a much more stable image than when the camera was balanced in human hands for long periods of time.
  • Zeus introduced the concept of a seated cockpit for the surgeon. Traditionally, a surgeon has stood over a patient, slightly bent to access a specific area. This position is uncomfortable and leads to stress injuries in the surgeon. Zeus provided a seated position in which the surgeon “flew” the instruments in a manner similar to that of a fighter pilot. Along with the cockpit, there are robotic arms mounted above the patient and the surgeon performs the surgery from a distance of a few feet or a few miles. Zeus also introduced “tremor filtration” in which very small tremors in the surgeon’s hands are not transmitted to the robot, allowing a surgeon to operate steadily for a longer period of time.
  • In September 2001, Dr. Jacques Marescaux put the Zeus robot on the world-wide stage by performing surgery from over 4,000 miles way. While he sat in New York in the surgeon's cockpit, the patient was in Strasbourg, France. He removed a woman’s gallbladder in the first transatlantic telesurgery in history. The data travelled a round-trip distance of 8,700 miles through a dedicated transatlantic cable with a latency of only 200ms. The operation was named after Charles Lindberg who was the first to fly solo from Paris to New York in 1927. http://news.bbc.co.uk/2/hi/science/nature/1552211.stm
  • In 2007 the NEEMO project provided a unique demonstration of surgery within a submersible beneath the ocean in the Florida Keys. Scientists continue to explore telesurgery under various challenging conditions. Most of the mechanical challenges have been solved. But the speed and reliability of long-distance communication networks remain a serious limitation on telesurgery. Networks which are good at delivering email, streaming video in one direction, and even sending computer game commands in two directions, are not sufficient for supporting the full-motion, 3D video that is used in modern robotic surgery.
  • The most advanced surgical robots transfer four important streams of data between the surgeon and the patient. The first is the command stream which contains movement and action orders originating from the instruments in the surgeon’s hands. These commands are a relatively small amount of data, similar to a constant stream of small text messages. The second and third are audio streams from the surgeon to the patient-side assistants and from the assistants back to the surgeon. Much like a digital cell phone or Skype call, these streams are quite manageable. The last is the most challenging. The da Vinci robot provides the surgeons with 3D high definition video of the surgical site. These two streams of data are similar in size to a household watching two simultaneous HD movies from a streaming service like Netflix, Amazon, or Hulu. But there is an important difference; the streaming has to be delivered in almost real time. The images of surgery cannot be buffered up at the destination and start playing when the service is reasonably certain the movie will not be interrupted by intermittent data service. In surgery, the image is being created right now and needs to be delivered at “right now plus milliseconds”, this has to be performed reliably by the computers and networks constantly through a 30 minute, 1 hour or 4 hour surgery. Quite a challenge.
  • Potentially, there are two thresholds in the amount of latency that can be tolerated in such a system. The shortest is the point just below here a human surgeon can perceive that there is a delay in the video stream. Below this level, data arrives fast enough that the human eye/senses cannot perceive it and a telesurgery would appear to be extremely safe under these conditions. But once the latency is perceptible by the surgeon there is some level of interference that it will cause in the operation. Human surgeons have shown an ability to compensate for this lag up to a point. They slow their movements, become more methodical, break movements into shorter segments, and at the highest levels create and follow mental models of what they imagine is happening to the instruments before they actually see it on the screen. The legal system MIGHT be convinced to allow telesurgery within the imperceptible range, but very unlikely in the adaptable range beyond that. But at some point, the latency becomes a barrier too large to overcome and no surgeon is able to perform effective or safe operations.
  • The da Vinci robot is the most widely used and widely known surgical robot in the world. There have been over 300,000 procedures performed using this machine and the number continues to explode every year. For men, 98% of all prostate removals are now done with this robot. It has such important advantages in reduced nerve damage that most men would not do the surgery any other way. For women, about 30-40% of hysterectomies are now done with this robot.
  • Robotic augmentation has become such a powerful tool that specialized devices are being created for many other surgeries as well. The Mako Rio robot assists orthopedic surgeons in accurately drilling out leg bones for the placement of artificial knees and hips. The surgeon plans a surgery using scanned data from the patient and the robot insures that the surgeon places the equipment exactly where it was in the plan.
  • The Mazor Renaissance robot is used to assist in spinal surgery to correct sclerosis of the spine. Again, the surgeon plans the placement of screws and tension rods in the spine based on scans of the patient’s body. The robot then insures that the screws go into the vertebrae in exactly the position and orientation that was in the plan. This company is just getting started in the US and there have been 15,000 spinal surgeries with the robot’s assistance.
  • The ultimate goal is to transition from robot-assisted surgery to automatic robotic surgery in which the human is not involved in the actual surgery at all. The human surgeon would become a planner for the exact details that are performed by the machine. This would be programmed and the robot would carry out the instructions exactly as planned. The human surgeon would stand-by in case there are complications which were not programmed, but 90% of procedures would be handled by the more precise robot. But, like Bill Paxton’s character in the Aliens movie, most people are not ready to trust a robot this much. But it will come.
  • In the near future, you should get used to the idea of surgeon’s being assisted by robots to perform procedures more precisely. Your next surgery will probably involve some form of robotic augmentation of your surgeon’s capabilities. This is a good thing. This is precision, predictability, and compensation for the limitations of all human surgeons. Robots cannot make a carpenter into a surgeon, but they can make a good surgeon into a great surgeon.
  • You may be thinking that a surgical device could be located at the local mall in the food court or game arcade. That is just one step away from the lasik surgeons and tattoo artists that are already there. One day you may even have a surgical console that will come to your home and plug into your X-box. Pop in the game of “Radical Prostetectomy” and you do not even have to leave home.
  • At the Florida Hospital Nicholson Center we train surgeons to perform new procedures and to use new equipment. Increasingly, this equipment is a robot that augments the surgeon’s natural abilities – stereo vision, 10X magnification, improved dexterity, multiple surgical arms, and personal camera control. Today most surgeons are clamoring to use one specific brand of robot, but we see several more on the verge of entering the field. In he future you can expect all complicated procedures to use a robot to give him super powers.

Transcript

  • 1. Robots in the Hands of Your Surgeon by: Roger.Smith @flhosp.org
  • 2. 1770 Mechanical Turk - robot assisted chess
  • 3. 1889 Surgery – a messy business
  • 4. 1980 Laparoscopy – gaining some distance
  • 5. 1942 Science Fiction – robot assisted operations
  • 6. 1988 Science Fiction – remote surgery
  • 7. 1985PUMA 560 - needle placement for brain biopsy
  • 8. 1988 PROBOT – robot assisted prostate surgery
  • 9. 1994AESOP - voice controlled laparoscopic camera
  • 10. 1998 ZEUS - two handed remote surgery
  • 11. New York2001 FranceOperation Lindberg - Transatlantic telesurgery
  • 12. Alberta, CA2007 Key Largo, FL Project NEEMO - aquatic telesurgery
  • 13. 1 Robot Commands 1 2 Surgeon Audio 2 3 Team Audio 3 4 Stereo HD Video 4Telesurgery - data streams
  • 14. Unacceptable Adaptable ImperceptibleTelesurgery - latency thresholds
  • 15. 2000 da Vinci - 300,000 abdominal surgeries
  • 16. 2009 Mako Rio – 17,688 knee/hip surgeries
  • 17. 2011Mazor Renaissance – 15,000 spine surgeries
  • 18. 2020+ Automatic Surgery – the ultimate precision
  • 19. Today Welcome to Your Future
  • 20. But there is no need to go to the hospital …
  • 21. Thank YouRoger.Smith@flhosp.org