Your Robot Surgeon Will See You Now

11 July 2022

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Potentially one of the most disruptive innovations in medicine is a faceless white robotic cylinder about the size of a breath mint, attached to the end of a catheter. At Boston’s Children’s Hospital is Massachusetts on an operating table, researchers are showing how it can navigate to a patient’s leaking heart valve better than some surgeons can with years of training. The assembly is inserted into the base of the heart. Then it propels itself using motorised drive system along the pulsating ventricular wall to a damaged valve near the top of the ventricle, guided by vision and touch censors. The robot will wedge itself into position near the leaking valve. From there the surgeon will take over to launch an occluder – a miniscule stopper – from the robot that plugs the leak.


The “patient” on the table is not human, but a pig. Researchers behind the device predict it’ll be years before the robot creation is performing valve repair on people. It’s abilities hint at the dawning of a new era of surgery. Intelligent surgical robots with varying degrees of autonomy are proving in early tests to be the equals of surgeons at some technical tasks, such as locating wounds, suturing, and removing tumours. These precise, tiny operators promise clean results and broader access to specialised procedures – and the robots are prompting some surgeons to think what their role will be in an increasing automated landscape.


Cruise control


Instruments such as Da Vinci by Intuitive Surgical in Sunnyvale, and the Senhance by TransEnterix in Morrisville, North Carolina are already in use. Which allows surgeons to take control of multiple robotic arms through a hand-operated console and give them greater dexterity and vision when operating in hard-to-reach areas. Devices like the capsule robot at Boston’s Children’s Hospital go one step further: they can operate independently, at least for part of the procedure.


The next level of assistance allows intricate surgical feats to be performed without the surgeon worrying that their hand might slip, or their grip falter – a positive development, given that mistakes by clinicians lead to more than 200,000 deaths each year. “A surgeon can go click, click, click, these are the places I want a suture to happen,” says Animesh Garg, a computer scientist at the University of Toronto in Canada who has worked on surgical automation for the best part of a decade. “We wanted this to be like cruise control of surgery.”


Not all surgical manoeuvres are good candidates for robotic automation, according to engineer and urogynaecological surgeon at the Pelvic Floor Institute in Tampa, Florida, Lennox Hoyte. Suturing and valve repair are good candidates as they tend to be tasks that surgeon’s find boring and repetitive. The simpler a procedure is to break down into simple commands, the easier it is for smart robots to learn and execute. “The mindset is often more complex tools, but simpler motions,” says Pierre Dupont, an engineer in Boston Children’s Hospital’s robotic research team.



One step at a time


Suturing can be broken down into easily defined movements, and therefore is an ideal task for independent surgical robots. A team including engineer Axel Krieger, then at Children’s National Health System in Washington DC, developed a system that uses a lightweight robotic arm to place a line of specialized sutures all by itself. Krieger and his colleagues wanted to automate intestinal anastomosis, a surgical task where two segments of the intestine are stitched together after a portion of the organ is removed. This procedure typically requires intricate and awkward hand movements that even the best surgeons struggle to do perfectly. “You have to apply 20 sutures very precisely, and if you miss one, you have a leak,” says Krieger, now at the University of Maryland in College Park.


Krieger knew that for a robot to pull this off it would need to be adept at pushing a needle through soft tissue. This is a challenging task as tissue can shift unpredictably as the needle pokes through it. So, the team fitted their surgical robot, named Smart Tissue Autonomous Robot or STAR, with a force sensor to ensure the needle does not push too hard and deform the tissue.


The robot is guided to where to suture by dots in infrared bioglue that the researchers put on the colon tissue. These markers allow the robot to track the tissue when it moves and adjust every stitch. The robot would be able to do this in an environment as dark and confined as the abdominal cavity. In a trial in living pigs, STAR placed sutures that were more evenly spaced and leak-proof than those made by specialists. The researchers supervised the automated procedure to make sure each stitch was performed correctly, sometimes making small adjustments to the thread’s position.


Krieger is also teaching the robot the skill of tumour removal. Krieger and his colleagues use infrared markers, but this time to flag areas of cancerous tissue. The robot will then selectively excise these parts with a heated electrode tip. Early testing on pig tissue has shown that STAR can remove tumours and cut tissue precisely as surgeons can – a crucial skill because leaving even a few tumour cells behind could allow the cancer to return. “You have to be incredibly precise, so you don’t leave any tumour behind [or] cut out any of the healthy tissue,” Krieger says.


Heart-valve repair tests the mettle of surgeons, owing in part to the challenge of positioning surgical instruments correctly in a confined space. It was that difficulty that prompted Dupont and his team to develop an autonomous robot for the task. To minimise surgical risk, the team’s small robot would need to complete its precise journey from the base of the heart t the defective valve while the person’s heart was beating, meaning it needs to navigate an environment that is in constant, vigorous motion.


The robot was given a detailed map of a typical heart, including the locations of specific vessels and valves. This information is used as a rough guide in each procedure. But the device is also highly adaptable, using input from built-in touch and vison sensors to locate valve leaks in each heart. To pinpoint its precise location, the robot makes repeated gentle tapping contact with the heart wall, “like cockroaches tapping with their antennae”, Dupont says. In animal trials this year, the robot successfully navigated from its entry point to the damaged valve area 95% of the time.


A slow, steady revolution


The hope is that autonomous surgery will make specialised procedures available to many more people. In the United States, “the distribution of surgeons across the country is not uniform,” says urologist Kirsten Greene at the University of California, San Francisco. “There are a lot of areas where people don’t have access.” The same is true of countries around the world. Autonomous robot assistance could help to fill gaps in surgical expertise. The technology could reduce the time it takes for aspiring surgeons to learn their trade. Performing more complex procedures with fewer training years.


It is not yet possible for robot surgeons to execute a whole procedure from start to finish. “A decade down the line, certain regular procedures might be automated,” Garg says. For example, “surgeries which are very high volume — gall-bladder removal, appendectomy.” However, this is still some way away, because surgeons are still much better than robots at weighing their experience to make complex surgical decisions, such as what to do if a blood vessel is in a different place than expected. It is most likely that autonomous surgical devices will enter clinical practise gradually, just as features such as cruise control and, later, lane-keeping systems have made their way into cars ahead of self-driving capabilities. In addition to well established robotic assistance such as Da Vinci, robots are also being used for procedures such as bone cutting and radiation delivery for cancer treatments.


Self-guided robots could be built onto surgical tools that some hospital systems already have, which might help to accelerate automation. Some of Garg’s designs, can be attached the Da Vinci robotic system, which has been used for more than 6 million human guided surgeries around the world. If you have an established robotic platform,” Dupont says, “you can slowly add these layers of autonomy.” At each step, researchers will need to prove their devices are ready for clinical use.


Questions are being raised about greater automation and how the surgeon’s role will evolve if intelligent robots take over the trickiest manoeuvres. Most in the field still see a place for surgeons – although they will need to become consummate managers, proving their skill not just at specific procedures, but at using an array of automated tools to best effect.


At least for now that is the plan. If autonomous robot’s surgeons are deployed on a large scale, they could start to evolve in unexpected ways. Garg for example, is developing self-guided robots that learn from their failures and their successes in the same way as people, narrowing the human advantage. Robots could share insights gathered over hundreds of operations with all the other robots in a vast network, supercharging their performance. IT is also being stressed that autonomous robots are designed to assist human surgeons, not outshine them. “If you have a system that can bring clinicians up that learning curve faster and help them do parts of the procedure, that’s going to be the real benefit.”​

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