MedûalKobolirs

ROGER ALLAN | Contributing Editorrsallan®opton(ine.net

ROBOTICS GIVE DOCTORSA HELPING HANDTHANKS TO ENHANCED TECHNOLOGY, ROBOTIC SYSTEMS PROVIDE SAFER, FASTER,AND MORE ACCURATE SURGERY.

Advances in robotics tech-nology are completelytransforming today'shospital operating rooms.With robot control andassistance, surgery for anykind of injury or ailment isfaster, more accurate, and

less invasive than ever before.

Because robots help accelerate proce-dures, operations become safer. With con-ventional surgery, a surgeon performing anoperation lasting several hours can becomeexhausted. As a result, the surgeon's handcan be subject to harmful errors, particularlyfor complicated and delicate tasks like neu-rosurgeries. But a robot hand never tires,and it won't waver out of position.

Improvements in sensing (particularlyhaptic sensing), imaging, better robotic con-trol and articulation, and the developmentof robots that are more dexterous havespurred the dramatic rise in robotic surgery.The medical community is now developing agreater understanding of its benefits as wellas the processes involved in ensuring seam-less interfacing between a surgeon and arobotic system.

Medical robots aren't completely autono-mous, and they don't perform the surgeryby themselves. Instead, they assist the sur-geon, who commands and controls them. Asa result, surgery is fast becoming a partner-ship between man and machine. Accordingto BCC Research, the market for surgicalrobots in the U.S. alone will total $2.5 billionby 2011. This market is projected to growbetween 2006 and 2011 by an expectedannual growth rate of 43%.

Medical robots are assisting in urological,neurological, gynecological, cardiac, orthope-dic, gastrointestinal, pédiatrie, and radio-sur-gical procedures. Depending on the degreeof the surgeon's interaction during an opera-tion, these systems can be broadly dividedinto three categories: supervisory-controlled,telesurgical, and shared-control systems.

During supervisor-controlled surgeries, therobot executes the procedure in responseto programmed computer inputs from thesurgeon. In telesurgery (or remote surgery),the surgeon manipulates the robot's handfrom a distance using real-time imaging andhaptic feedback. Surgeons are most involvedin shared-control procedures, where they usethe robot to obtain "steady hand" manipula-tion of the surgical instruments in use.

The U.S. government aiso is pursuingrobotic surgery. The Trauma Pod programfrom the Defense Advanced ResearchProjects Agency (DARPA) envisions the oper-ating room of the future. Led by SRI, thismultiphased program seeks to use roboticsto project the skills of surgeons to preciselywhere they're needed on the battlefield (Fig.1). It includes contributions from the univer-sities of Washington, Texas, and Maryland;Oak Ridge National Laboratory; GeneralDynamics; Intuitive Surgical; General Electric;Integrated Medical Systems; and RoboticSurgical Tech.

The most notable product on the market,the da Vinci Surgical System from IntuitiveSurgical Co., consists of a viewing and con-trol console and a surgical arm unit (Fig. 2).Used worldwide, it's the only robotic-assisteddevice being used for laproscopic as wellas a variety of minimally invasive keyhole

surgeries. It's also been used successfullyin a number of gynecological, urological, andcardiac procedures.

WITH

For all its advantages, robotic surgery stillneeds better computer modeling, imageprocessing, and haptic sensing for a moreseamless integration of man and machinein surgical operations. Such improvementswill enable better pre-surgical planning, too.

allowing doctors to perform virtual surgeriesbefore the actual operation.

The university of Washington Is developing a"holomer" system that serves as a total bodyscan to guide intra-operative navigation duringsurgery. A surgeon can then use this infomia-tion to perform a virtual operation on a patientprior to performing the real operation.

Thafs also the goal at the Johns HopkinsUniversity Engineering Research Center forComputer Integrated Systems and Technology.Its surgical CAD-CAM system offers "one-stop

I, fis foreseen by

the Trauma Pod uses a

totally integrated system

for robotic surgeries. Once

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MedîcalRoliotics THE MARKET FOR SURGICAL ROBOTS IN THE U.S. ALONE WILL GROW AT AN ANNUAL

RATE OF 4 3 % AND TOTAL $ 2 . 5 BILLION BY 2 0 1 1 .

2. The da Vinci sufgicai robot system from Intuitive Surgical is used in medical

facilities around the world. It consists of a viewing and control console (a) and a

surgical LndoWrist arm unit (b). While other personnel perform routine duties, the

surgeon uses the system tor the actual procedure (c).

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shopping" to integrate re-planning throughpost-operation evaluation and to createmodular systems for "plug-and-play" sur-gery (Fig. 3).

The researchers also are investigatingthe sense of touch, which is very impor-tant in delicate surgeries. "Surgeons haveasked for this kind of feedback. So vi/e'reusing our understanding of haptic technol-ogy to try to give surgeons back the senseof touch they lose when they use roboticmedical tools." says Allison Okamura, aleading researcher In man-machine inter-action at Johns Hopkins.

Sensors could be attached to the robot-ic tools to convey how much force is beingapplied to, say, a surgical suture. Also,mathematical models would represent themoves made by the robotic tools, and thisdata wouid be converted to haptic feed-back sent to the surgeon.

Okamura's team developed a visualhaptics system that sends haptic informa-tion observed by a surgeon on a displayduring suturing. A colored circle followsthe image of the suturing tool, with redshowing too much force (where a suturemight snap) and green and yellow indicat-ing just the right amount of suture force.

Researchers at Tufts University are alsoinvestigating methods of simulating minimallyinvasive surgery that uses visualization coupledwith haptics to incorporate feedback into roboticsurgical training. They're concentrating on devel-oping tools for laproscopic surgery using a videocamera and force-feedback sensors.

"In teleoperation, force feedback or hapticfeedback is very important," says CarolineCao, assistant professor of mechanical engi-neering at Tufts. "Otherwise, you don't feelwhat it is that you're dealing with. You endup either colliding into your targets or youdon't know how to control the forces in orderto manipulate your target."

Till: lMi»<»Kr\f\a; Oi V'isi<»\ Si;\si!%With vision-sensing platforms, surgical

robots see where a procedure is being used aswell as how precisely that procedure is beingperformed. These platforms are essential tobringing accurate and affordable robotic surgeryto the market. One company, Prosurgics, iscollaborating with Adept Technology to producenext-generation surgical robotic systems.

"This collaboration will combine our exper-tise in robotics for image-guided and navigatedneurological and soft-tissue surgery with thoseof Adept Technology in robotic control andvision-guided applications to provide affordablesurgical robotic products for improved patientcare and optimized economies for healthcareproviders," says Colin Robertson, Prosurgics'business development marketing director.

"Our experience in image-guided roboticsis very broad and strong. This includes theassembly and manufacturing of mobile phones,computer disk drives, solar cells, and food han-dling. It will provide valuable assistance to themedical robotics field," adds Dave Pap Rocki,Adept Technology's chief technology officer.

Prosurgics offers advanced surgical toolslike the PathFinder, an image-guided manipu-lator for precise localization in neurosurgicalprooedures (Fig. 4). With this technology,surgeons can position stereotactic instru-ments to within an accuracy of 1 mm. Thefirm additionally makes the EndoAssist, animage-guided manipulator for endoscopesthat's used in minimally invasive thoracicand abdominal surgeries.

54 06.19.08 ELECTRONIC DESIGN

I I

O N T i i i ^ ^ l m i jImage-guided orthopedic robotic

surgeries represent one of thefastest growing medical areas.Approximately 400.000 people eachyear have knee-replacement surgery,which generally requires lengthy sur-gical incisions and can cause a con-siderable amount of pain. Moreover,patients face lengthy recovery timesbefore they're on their feet. This ischanging, though, with robotic ortho-pedic procedures that require shorterincisions, are less painful, and allowfor much faster recovery times.

A study involving engineers andsurgeons from the Imperial College ofLondon shows that robotic assistanceimproves accuracy in knee surgery,leading to knee replacements thatfunction better and last longer thanconventional surgical techniques. Thestudy was funded by the Acrobot Co.Ltd.. a spin-out of the Imperial Collegeof London.

One prominent procedure isMAKOplasty knee resurfacing fromMako Surgical Corp. Its tactile guid-ance system (TGS) allows surgeons toaccurately plan the size of the kneeimplant and optimize the implant'sposition and orientation, relative to aCT scan taken before surgery.

The Robodoc surgical assistant sys-tem from Integrated Surgical Systemsalso supports image-guided orthopedicsurgery. It integrates the company'sOrthodoo Presurgical Planner with acomputer-controlled robot for joint-replacement surgeries. It can also beused for neurosurgical procedures.

The German Federal Ministry ofEducation and Research is fund-ing OrthoMIT, a "Gentle Surgery byInnovative Technology" project knownas SOMIT. It aims to develop an intel-ligent platform for gentle operativetherapy in robotic orthopedic and trau-matology procedures, particularly hip,knee, and spinal-column surgery.

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IMAGE-GUIDED ORTHOPEDIC ROBOTIC SURGERIES REPRESENT ONE OF THE FASTEST

GROWING AREAS, WITH ABOUT 4 0 0 , 0 0 0 PEOPLE GETTING

KNEE-REPLACEMENT SURGERIES EACH YEAR.

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Robotic radiosurgery has also been shown as an excellent alternativetreatment for tumors. The Cyber Knife from Accuray and the GammaKnife from Elekta use highly precise beams of radiation to destroytumors quickly, painlessly, and without downtime or lengthy hospitalstays. Tumors anywhere in the body can be treated, even those previ-ously considered untreatable. Using CT images, these tools enablesurgeons to construct a very precise pre-surgical plan to deliver a totaldose of radiation to the tumor while minimally exposing the surroundingnormal tissues.

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Minimally invasive "keyhole-like" robotic surgeries will continue tomake strides with even greater agility. The payoff will be shorter patienthospital stays, more accurate and effective procedures, and lower risks(e.g.. infections) thanks to smaller surgical openings and faster proce-dures. For example. Japan's Tokyo Institute of Technology is investigat-ing an approach that allows the assembly of robotic components withinthe body, prior to surgery, to assist in robotic surgeries on large andslippery internal organs like the liver.

These researchers are developing a three-fingered steel hand, witheach finger 5 cm long, for grasping internal organs. They're using ahollow arm, 30 cm long and 16mm in diameter, that's insert-ed into the body via a smallincision. The three fingers arethen passed part of the waythrough a nearby keyhole andthen snapped into place onthe arm. Stiff wires along the » Ï A ^ ^ ^ ^ ^ ^ H F Jarm allow the fingers to grasporgans. Experiments inside adummy body cavity have shownthis approach to be effective.

At Johns Hopkins University,researchers hope to soon unveiladvanced robotic grippers andretractors with force sensors forhuman trial runs. These tools willallow surgeons to avoid gripping bloodvessels too tightly. Additionally, theywill allow oxygen sensors to differentiatediseased tissue from healthy tissue. Onetoo! flexes much like an elephant trunk toglide down a patient's throat for scar-lessrepairs of the upper airways. Another toolthat's now under development will letsurgeons bust eye clots Inside minusculeblood vessels.

4. The Prosurgics PathFinder neurosurgical robot can position

stereotactic instruments with I-mm accuracy.

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Robotic snake-like tools are underdevelopment at the Imperial Collegeof London and Carnegie MellonUniversity. The Imperial College'si-Snake project, a $4.2 million pro-gram funded by the Wellcome Trust,a large U.K. charity that funds inno-vative biomédical research, centerson a flexible robotic arm that actsas a surgeon's hands and eyes.The technology will permit surgeonsto navigate difficult and restrictiveregions of the body, such as thealimentary tract and cardiovascularpathways, faster and more preciselythan they could while using conven-tional techniques.

Carnegie Mellon's miniatureHeartLander facilitates minimallyinvasive therapy on the surface ofthe beating heart (Fig. 5). Underphysician control, the robot entersthe chest through an incision belov/the sternum and adheres to theepicardial surface of the heart. Itthen autonomously navigates to

the specified location and admin-isters the treatment. Comparedwith existing approaches, itimproves the precision and stabil-ity of interaction with the heart's

surface while decreasing themorbidity associated v ithaccess.

One of the greatest chal-lenges lies in developing arobotic system that worksin a magnetic-resonanceimaging (MRI) environmentvjhere surgery is being per-formed. MRIs have strongand sensitive magnetic fieldsthat must be bypassed.Otherwise, the MRI image

7 will be distorted. The JohnsHopkins PneuStep, a robotic

tool that's designed for pros-tate surgery, alleviates these MRIproblems.

PneuStep consists of six motorsthat power an MRI-compatible robot.

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MINIMALLY INVASIVE "KEYHOLE-LIKE" ROBOTIC SURGERIES WILL CONTINUE TO MAKE

STRIDES FOR MORE ACCURATE PROCEDURES, LOWER RISKS OK INFECTION, AND

SHORTER HOSPITAL STAYS.

Sttdion lineHeortLooder moves usingsuction and push/pullwires at up to 18 cmper minute

How It movesReor section applies suction

Three pistons are connected to a seriesof gears. The gears are turned by airflovi/, which is in turn controlled by acomputer located in a room adjacentto the MRI machine. The system canachieve precise and smooth motion upto 50 pm, finer than a human hair andwell above that of a human surgeon.PneuStep is currently undergoing pre-clinical trials.

5. The HeartLander. under development at

Carnegie Mellon university, is a snake-like

miniature and flexible robotic tool. With it,

surgeons can enter the chest via a small

incision below the sternum to examine

and treat heart ailments.

The neuroArm is another MRI compatiblerobotic tool being developed at Canada'sUniversity of Calgary. This machine can pro-vide precision motions up to 25 pm. It useslead-zirconium-tltanate (PZT) motors to movea small ceramic finger back and forth. Thefinger rotates a ceramic ring, creating motionthrough friction.

In the near term, cost will limit the wide-spread adoption of full-fledged large robotic sur-gical systems, which can go for $1 million ormore and are expensive to maintain. Yet stud-ies reveal that most surgeons who used suchsystems have become converts to this technol-ogy. Clearly, lower-cost systems are needed,and many researchers worldwide are busy work-ing to reach that goal. © ED ONLINE 19050

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