The field of surgical robotics continues to evolve at a rapid pace. Intuitive Surgical was the first company to market and currently dominates the field, but other large players such as Johnson & Johnson, Medtronic and Stryker are entering the space, along with a host of smaller medical device companies. In Part 2 of our series, we explore how advancements in sensor technologies, haptics, and usability / ergonomics are opening up new possibilities and applications for robotic surgery.
4. Sensor Technologies
Small, high precision sensors used for imaging, force, pressure, torque, and other measurement parameters can be critical to a surgical robot’s performance and potential applications. Manta client Medrobotics’ Flex Robotic System incorporates a high-resolution camera to provide surgeons 3D high-definition visualization of both the navigation path and surgical site. Vicarious Surgical is exploring the use of virtual reality headsets coupled with a high-resolution camera to provide surgeons the perspective of being inside the patient.
Vision sensors combined with touch sensors are being used to increase the adaptability and intelligence of the surgical robot. The STAR robot developed by Children’s National Health System in D.C. uses touch and vision sensors to locate valve leaks in the heart. To pinpoint its precise location, the robot makes repeated gentle tapping contact with the heart wall. In animal trials this year, the robot successfully navigated from its entry point to the damaged valve area 95% of the time.
And in the lab, researchers like those at MIT’s MCube Lab, which spun out Manta client Gelsight, are also developing vision-based tactile sensors. These sensors could be used to provide surgeons with high-resolution images of the texture and topography of tissue.
Surgeons will rely less on traditional direct visualization and tactile interaction as new sensor technologies provide enhanced 3D visualization.
Haptics, also known as kinaesthetic communication or 3D touch, refers to the use of touch to communicate information to users. Haptics typically involves applying forces, vibrations, or motions to the user, such as the vibration of a cell phone or game controller. In surgical robotic applications, haptic feedback to the surgeon is typically linked to the outputs of sensors that are incorporated into the robot components that enter the patient.
Many current robotic-assisted surgical systems lack sufficient and accurate haptic feedback, which surgeons otherwise use to navigate, detect tissue, and gauge forces. A lack of such haptic feedback makes it difficult for a surgeon to maintain precise control without damaging surrounding tissues. Accordingly, various groups are beginning to embed force and other sensors into robotic arms. Haptic enabling sensors require both miniaturization and biocompatibility. In single use applications, these sensors also need to be highly cost-effective. In reusable applications, the sensors need to be autoclavable / re-sterilizable.
One of the most significant advances in haptics was made by Mako Surgical (acquired by Stryker for $1.65B). In 2006, the company began offering a robot that provides precise feedback to surgeons repairing arthritic knee joints. More recently, Cambridge Research & Development pioneered a new haptic device that a surgeon can wear anywhere on the body which uses linear actuation to mimic the sense of touch.
By coupling haptic feedback to force, pressure, torque and other sensors resident in the surgical robotic instruments, surgeons can obtain greater feedback that improves accuracy and dexterity while minimizing trauma to the patient.
Haptic enabled robotic-assisted surgical systems greatly enhance the surgeon's ability to sense and "feel" anatomical features.
6. Usability and Ergonomics
Ergonomics and comfort are key drivers for surgeons’ adoption of robotic systems. The design of robotic surgery systems offers the potential for improvements over the ergonomics of traditional surgery by putting surgeons in a more upright position, such as with Intuitive’s console. Manta client Corindus’ Corepath GPX System offers the dual benefit of reduced radiation and elimating the requirement to wear heavy lead aprons during the procedure, as the control module is remotely located from the radiation path. These lead aprons are well documented to cause orthopedic problems in surgeons and other operating room personnel over time.
Even more critical is the design of the robotic controls, both in the type and layout of the controls. Controlling surgical robots typically involves two types of grips: the "pinch grip" and "power grip." The pinch grip, which brings together the thumb, middle, and index fingers, has been used in surgery for centuries to achieve high-precision movements. On the other hand, the power grip involves grabbing a handle with the entire hand and is more suitable for forceful work and large movements.
Because the pinch grip puts tension on certain muscles of the hand and fingers, it is more likely to cause finger fatigue and discomfort in the hand. This can negatively impact the overall performance of surgical procedures. Although the power grip does not seem to cause such discomfort, it offers less precise control. As Manta VP of Design Betsy Goodrich has observed as part of the development a wide variety of surgical instruments, an individual surgeon’s hand size and natural grip strength can also impact control and feelings of discomfort.
Now, new robotic surgery systems, like one designed at the Tokyo Institute of Technology, are finding ways to offer both types of grips, along with a combined grip that results in more efficient positioning and performance, ease of use, and greater comfort. Ergonomic assessments, like those done by MANTA UI / UX researchers and designers, can lead to improved designs that decrease muscular fatigue while preserving instrument performance.
Robot-assisted surgical systems improve a surgeon's abilities and extend careers by eliminating awkward or stressful maneuvers and resulting in improved accuracy, sustained mental focus and reduced fatigue.
Conclusion: Impact of Robots on the Future of Surgical Procedures
Robotic surgery is evolving at a rapid pace both in terms of new technologies and applications. With the promise of enabling greater precision and more minimally invasive approaches, robotic surgery can lead to improvements in patient recovery and outcomes across the board.
Surgeon training remains an important item related to widespread implementation of robotic surgery. As robotic surgical systems become more autonomous, the hope is that they will reduce the training time for complex procedures. This would ideally increase the number of competent practicing surgeons.
Patient access is another factor that needs to be addressed. Access to surgery is unevenly distributed globally, but robotic arms and micro instruments that a surgeon can remotely control raises the prospects of telesurgery as a way to improve access to immediate, high-quality surgical care. As a test case, our client Corindus’ research in India demonstrated the world’s first percutaneous coronary intervention (PCI) conducted remotely outside the Cath lab.
Robotic surgery offers great promise, but is still very much an evolving field. The greatest challenge in the future of robotic surgery will be demonstrating the improvement these systems deliver on surgical performance and patient outcomes over traditional methods. To this end, sensor technologies, haptics and system ergonomics will all play critical roles.
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