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How Robots and AI are Creating the 21st-Century Surgeon
February 07, 2019      
Roger Smith

More than 5,000 surgical robots were used in more than 1 million procedures worldwide in the last year. These procedures spanned orthopedics, urology, general surgery, gynecology, neurology, thoracic, otolaryngology, bariatric, rectal and colon, multiple oncologies – even dental implants and hair transplants. Robotic surgery is no longer seen as a technology of the future – it’s an active and effective technology of today.

Intuitive Surgical’s da Vinci robot has dominated the medical, business, and technical communities, but few realize it’s just one of more than a dozen robotic devices that are FDA and CE approved for use in the U.S. and Europe. Lesser-known companies, such as Stereotaxis in cardiac catheterization, Medtronic/Mazor in spine and neurology, Accuray in cancerous tumor irradiation, Stryker’s Mako in orthopedic hip and knee replacement, Neocis in dental implants, and Restoration Robotics in hair implants are all improving the performance of human surgeons, and in turn, patient outcomes.

Origins of the surgical robot

As early as 1985, industrial robots were experimentally converted into surgical devices. The Kawasaki Puma 560 is an example of a manufacturing robot that was modified to insert a biopsy needle into patients at calculated angles and depths. The robot could move the needle more accurately than surgeons’ unaided hands, reliably arriving at the coordinates of a tumor deep in the brain.

Intuitive Surgical’s da Vinci Xi includes integrated table motion. Source: JPA Health Communications

In the 1990s, the U.S. Defense Advanced Research Projects Agency (DARPA) began combining robotics with computer networking to remotely treat injured soldiers on the battlefield. The data communication required to do experiments with remote instruments successfully proved to be well beyond the network capabilities of the time, but the design concept was very effective for delivering robotic precision to a locally performed procedure. The first da Vinci robot in the early 2000s was based on this technology and patents, creating a product line that has endured to this day.

Intuitive Surgical and the da Vinci’s success has spurred stakeholders to apply robotics to every surgical specialty. Some of the new devices compete with the da Vinci, while others reach entirely new specialties. The result has been more than a dozen robotic surgical devices in use today, with at least another three dozen entering the market in the next five years. Robotic assistance is becoming the norm for all surgical procedures, rather than the exception.

Categories of surgical robots

Existing surgical robots can be grouped into four categories, each of which represents a different method for augmenting human clinicians. Machines like the da Vinci, TransEnterix Senhance, CMR Versius and Titan SPORT convert surgeon movements into instrument movements through computer communications between a remote patient cart and a physician’s console. This category can be classified as “Surgeon Waldo,” inspired by the 1942 science-fiction short story “Waldo”, by Robert A. Heinlein, where a scientist named Waldo used similar devices for industrial manufacturing. Surgeon Waldos are designed to improve the precision of the human, augment strength, increase endurance and reduce hand tremors.

The Waldo category is the most known, but it’s not the only approach. Energy delivery robots like Accuray’s CyberKnife are “Programmable Automatas” that use a predefined treatment plan to calculate the positions and orientations to fire energy to focus on and destroy tumors at specific locations inside the body (see video, above).

Orthopedic and dental implant robots work from a digital map of the patient, similar to the previous category, but they function as an “Assistive Guide” to the human. They ensure that the human-initiated actions conform to the digital plan created in the preoperative stage. The robot can physically enforce adherence, avoiding deviations that could deliver non-optimal treatment.

“Motorized Laparoscopic” tools are a more modest family that bring more flexibility to straight laparoscopic sticks. An example would be adding motors and steering controls to laparoscopic handles, giving the surgical tip a flexible wrist joint similar to the Surgeon Waldo machines, but at a fraction of the cost and size. This category also includes the automation of laparoscopic cameras through voice, laser, eye-tracking, and other methods, enabling a surgeon to steer the camera without a camera-holding assistant.

These four categories – Surgeon Waldo, Programmable Automata, Assistive Guide and Motorized Laparoscopic – capture most of what’s being used or developed currently. However, new categories will certainly be required in the future as we continue to expand capabilities.

New partnerships on the horizon

Physically controlling electro-mechanical robots has been the focus of most devices from the 1980s to now. Heading into the 2020s, we are now seeing concepts like Google’s life science company, Verily, and its partnership with Johnson & Johnson’s Ethicon Endo Surgery. The joint venture, Verb Surgical, is still largely under wraps, but the partnership itself is an indication of what’s possible under new initiatives.

Ethicon can certainly construct a world-class surgical robot, but Google can deliver a networked software operating ecosystem beyond the capabilities of any existing robot. Google’s expertise in AI, operating systems, app stores and cloud computing could bring a new class of innovations to this market. Imagine a surgical robot that has the medical equivalent of all of the services in a modern smartphone.

One could imagine additional partnerships between surgical companies and technology companies. Imagine a world where Medtronic+Microsoft, Zimmer+Apple, Depuy+Amazon, Siemens+Facebook, Stryker+Uber, Philips+Alibaba, Abbott+Tencent, Steris+Baidu, etc., are collaborating on new projects.

AI-delivered advice instantly

We will also see more information exchange via cloud services among surgical robots. Any of the IT companies above could put a surgical robot on a protected internet with libraries of prior case information along with guidance from the best surgeons in the world. At the simplest level, surgeons could view data, animations, videos, simulations and real-time interactions applicable to a case. At a more advanced level, it creates the infrastructure needed for an AI to provide real-time warnings, guidance and advice during a procedure.

AI-delivered advice would be derived by machine-learning algorithms from thousands of previous cases and stored in the cloud for access when needed. For example, a visual overlay inside the surgical space could indicate where critical blood vessels lie behind the current operating plane, with the AI suggesting that the surgeon steer clear of those areas. It could also show how thousands of previous successful surgeons traversed the anatomy, and where they took action. The robot would also be aware of the specific tools loaded into the robotic arms, and might suggest previously successful alternatives.

This kind of AI and many other software capabilities from the partnerships listed above cannot stand alone without a foundation. Imagine a standardized and open operating system for surgical robots similar to your smartphone. This “Surgical Android” system could be licensed by multiple robotics manufacturers who no longer need to create costly software from scratch, but can leverage the skills, debugging and certifications of a commercialized software platform. This would significantly shorten the development and government approval of the software. Beyond AI capabilities, it could also deliver services similar to Google’s and Apple’s app stores, creating a market for third-party software to enhance the capabilities of the robot as an information processing device.

The surgical robotics future offers much more than mechanized extensions of a surgeon’s hands. Robotic software and hardware are the next generation of instruments and tools to improve surgeon skills and patient outcomes, just as technologies like MIS instruments, energy therapies and biologics have done in in the past. Exciting times lie ahead.

Roger Smith Nicholson Center surgeon articleAbout the author: Roger Smith, Ph.D., MBA, is the chief technology officer at the AdventHealth Nicholson Center. He was previously the CTO for U.S. Army Simulation, Training and Instrumentation (PEO-STRI) and a research scientist at Texas A&M University. Follow him on LinkedIn here.