MedicalExpo e-Magazine - #18 – The Rise of Robot SurgeonMedicalExpo e-Magazine

The Smart Magazine About Medical Technology Innovations

The Rise of the Robot Surgeon




Welcome to the amazing world of surgical robots able to perform minimally invasive surgery. In this edition, you will read how a U.S. research team got the brilliant idea of using origami folding techniques to create minimally invasive tools for the da Vinci robot—the best known robotic surgical system available today. You also will discover miniature robotically assisted devices that perform surgery from within the body, and new autonomous systems that suture soft tissue with more precision than the best surgeons. However, even though these robots provide ever more valuable assistance, there is still a long way to go before they can replace surgeons.

 

Smart People
There is a goal that in the future the size of the instruments will be so small that the body would heal with no scar at all
Tools at the tip of the da Vinci robot (Courtesy of Intuitive Surgical)

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The extremely small surgical tools placed at the working end of the da Vinci robot—the best known robotic surgical system available today, which was approved by the FDA in 2000—are used for minimally invasive procedures. These tiny instruments were designed using origami folding techniques by a group of researchers at...


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Hot Topic
The miniaturisation of the robotic arms allows them to be inserted through a single incision or preferably a natural orifice
Virtual Incision's miniature surgical robot (Courtesy of Virtual Incision)

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Since its mainstream introduction in the 1980s, minimally invasive surgery (MIS) has been used for an ever increasing number of procedures.  Regardless of the aim of the operation, surgeons are continually seeking to decrease incision size for better clinical and aesthetic outcomes. New miniature robotically assisted devices are now able to perform surgery directly from within the body.

 

Robotic minimally invasive surgery has limitations. The small entry site or use of a natural body orifice means not all surgical sites are accessibleMoreover, those that require the use of instruments mounted on long, flexible scopes offer poor ergonomics, are difficult to manipulate, may transmit tremor and, most importantly, do not give the surgeon haptic feedback. This means it is often difficult to feel the resistance in the tissues being manipulated and to know how much force to apply.

Three-D robotic views of the surgical site have improved to the point of “seeing better than the human eye,” according to Professor Law Wai-lun, Director of Surgical Skills Centre at Hong Kong University. But the lack of ergonomics and haptic feedback have been serious barriers to adoption. This led his department to follow the Western model of collaborating with robotics experts, giving engineers from the Hong Kong Polytechnic University their surgical wish list.

The NSRS system (Courtesy of the Hong Kong Polytechnic University)

The NSRS system (Courtesy of the Hong Kong Polytechnic University)

The Robotic Arms Inserted Inside the Body

The PolyTech University robotics team has a long history of working in the Chinese government space program. Their robots now can be controlled from earth while exploring the moon. Thus, working within the human body required “some downscaling in dimensions,” explained Law. However, the basics of haptic feedback were well understood and have been built into a prototype, the Novel Surgical Robotic System (NSRS), currently being tested in animals. The miniaturization of the robotic arms allows them to be inserted through a single incision or a natural orifice. They then unfold inside the body. The system has been designed to perform a variety of abdominal and pelvic procedures.

The miniaturization of the robotic arms allows them to be inserted through a single incision or a natural orifice.

The NSRS arms are controlled by specially designed micro-motors that are able to work without large external machinery to drive the tools. Additionally, they are placed next to the end-effectors for great precision. This also enables them to provide information about the resistance encountered.  

“The arms have 10 degrees of freedom in movement which we are testing in different procedures. Several different prototypes have been created and redesigned over the past one to two years as the surgical teams test the robotics,” explained Law. “We have successfully performed a cholecystectomy on an anesthetized pig, but we still need to perform further operations on cadavers, as the organs are not in the same positions in humans and animals, before we can seek FDA approval and start the first in-human trials.” “Our aim,” he went on to explain, “is to have a low-cost system that is small and efficient, provides excellent haptic feedback and is ideal for a wide range of different abdominal surgeries.”

Virtual Incision’s Miniaturized Surgical Robot

The Virtual Incision's robot (Courtesy of Virtual Incision)

The Virtual Incision’s robot (Courtesy of Virtual Incision)

This niche in the marketplace has been spotted by other manufacturers. Virtual Incision, based in Pleasanton, California, recently announced the successful first-in-human use of its miniaturized robotically assisted surgical device (RASD) for colon resection, a procedure performed to treat patients with lower gastrointestinal diseases. 

The robotically assisted colon resection procedures were completed in Asunción, Paraguay, as part of the safety and feasibility trial for the technology. The surgeries were successful and the patients are recovering well. More than two million patients undergo colon resection procedures globally each year. Approximately two-thirds of these procedures are performed via a completely open surgical procedure involving a 20- to 30-centimeter incision and up to six weeks of recovery time.

Like the NSRS system, the Virtual Incision robot is small enough to position in the abdominal cavity via an umbilical incision. Only the handle and cables stay on top. It is quite compact and does not need a specialize operating room. Because of its much smaller size, it is expected to be significantly less expensive than existing robotic alternatives for laparoscopic surgery, according to Virtual Incision which is working toward FDA 510(k) clearance for the system in the United States.

 


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The STAR robot is the first in the world to autonomously sew together soft tissue with more precision than the most skilled surgeons
The STAR autonomous robot (Courtesy of Children’s National Hospital Center)

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Look ma, no hands! Imagine a robot suturing up soft tissue in the operating room without human guidance. That’s precisely what a U.S. research team reported in the May 4 issue of the journal Science Translational Medicine.   Called “Smart Tissue Autonomous Robot” or STAR for short, the robot is the first in the world to...


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A team of researchers from Seoul National University in South Korea is developing a smart patch to replace finger-prick glucose tests and drug injections. Made...



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  • Projection Vein Finder VIVO100 (Courtesy of Vivolight)

    The start-up Vivolight is currently one of China’s most promising biomedical device SMEs. It showcased two new products at the 75th China International Medical Equipment Fair (CMEF), held in April in Shanghai. MedicalExpo e-magazine talked with its founder and general manager, Zhu Rui.

    It was when Zhu Rui’s mother became ill in 2009 that the seeds of Vivolight were sown. “The doctors in the hospital couldn’t make a proper diagnosis because the medical imagery was unclear,” he explained. “It was all very frustrating.” Zhu, an optical sciences student at Beijing’s Tsinghua University at the time, began dreaming of simple yet innovative devices that could help doctors and patients by boosting diagnostic accuracy. Seven years on and Zhu’s Shenzhen-based start-up Vivolight – founded in 2012 and now employing over 60 people – is going from strength to strength. The company’s award-winning projection vein finders are now used in hospitals across China, and have been exported to over 30 countries around the world.

    Two New Products at CMEF

    Vivolight chose the CMEF 2016 to showcase two new products – the VIVO100 (fixed) and VIVO500S (handheld) projection vein finders. These devices operate on the basis that human hemoglobin absorbs more infrared light than other tissue.  Anna Wei, Vivolight’s overseas sales manager, explained:

    Human hemoglobin absorbs more infrared light than other tissue (Courtesy of Vivolight)

    Hemoglobin absorbs infrared light (Courtesy of Vivolight)

    The enhanced image processing on these products means that up to 80% of veins can be detected to a depth under the skin of around six millimetres. The processed vein image is then projected back onto the skin surface.

    The VIVO100’s unique “green light” projection simulates the colour of veins, making them stand out more on the skin, while the 500S boasts improved image quality (compared to earlier models) and adjustable brightness. Both should prove invaluable tools for nurses during injection procedures. Zhu Rui said:

    Clinical tests with our vein finders show that they reduce injection failure rates from 20% to 5%. They also shorten the time of the injection by between a third and a half.

    Burgeoning Market in China

    China is currently one of the world’s most rapidly developing markets for medical devices. According to the United States Commercial Service, sales of such devices in the country reached RMB200 billion (US$30 billion) in 2013, making it the second largest market in the world after the United States. The China Pharmaceutical Materials Association Medical Device Branch expected this figure to reach RMB300 (US$46 billion) by the end of 2015.

    Underpinning this growth are factors such as China’s general economic development, demographic trends such as an ageing population, and significant government investment in better healthcare services.

    Projection Vein Finder VIVO500S (Courtesy of Vivolight)

    Projection Vein Finder VIVO500S (Courtesy of Vivolight)

    Beijing is now pushing innovation in its domestic medical device industry. Chinese medical device manufacturers are making substantial investments in research and development (R&D) to improve their technological competitiveness, and today they are becoming increasingly active in the export market. Anna Wei said:

    Backed by the government and market forces, innovation amongst Chinese medical device companies is definitely rising. But to be honest, we don’t have much choice. If you’re not inovative when doing business globally, you don’t sell.

    Vivolight is not resting on its laurels. The company will release an electronic injection pump for anaesthetics later this year, and an endoscopic OCT (optical coherence tomography) scanner in 2018. The latter uses light to capture images from biological tissue and is designed to assist doctors in arterial diagnosis and surgery.


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    The Swedish company ContextVision exhibited its range of 2D/3D/4D ultrasound imaging enhancement software at the CMEF Fair, April 17-20 in Shanghai. One of...



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    Mr. Wear ECG recorder/heart rate monitor (Courtesy of Mindray)

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    Some may think the wearable ECG market is overcrowded, but seeing big players joining the throng shows there is still room. At Shanghai’s CMEF, a significant player jumped in—Mindray, one of China’s biggest and most diversified health care equipment companies.

    Its Mr. Wear was officially released on the Chinese market during the trade show. What makes this ECG recorder/heart rate monitor special is its small form factor, which Mindray detailed (in Chinese) to OFweek. Looking like a band-aid, Mr. Wear weighs less than 9 grams and is only 6 mm thick. It is also fully wireless, able both to transmit data and be recharged wirelessly. The device also can be worn around the clock and is shower-resistant (IPX7-compliant).

    Mindray announced it would launch two types of Mr. Wear, a sports version and a medical version. Real-time monitoring of patients 24 hours a day, offline storage in Holter mode and event-triggered alerts are all available in the medical version. “Stress mode” is also available for high-intensity athletic activities.

    Multiple Medical Uses

    Mindray also wants to turn Mr. Wear into a platform, rather than remaining a mere stand-alone wearable.

    According to Mindray, the product could find multiple medical uses, from the identification of abnormal ECG readings for the detection of cardiovascular disease risk to postoperative patient rehabilitation assessment.

    Like numerous medical device manufacturers, Mindray also wants to turn Mr. Wear into a platform, rather than remaining a mere stand-alone wearable. The Chinese company is therefore also offering a “Mr. software” developer kit (SDK), for those interested in creating apps connecting both to Mr. Wear and to cloud services such as AliCloud. At CMEF, Mindray announced that “more than a dozen partners” are currently developing solutions related to Mr. Wear.


    CONTRIBUTORS



    Daniel Allen

    Daniel Allen is a writer and a photographer. His work has been featured in numerous publications, including CNN, BBC, The Sunday Times, The Guardian, National Geographic Traveller, Discovery Channel.


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    Celia Sampol

    Celia Sampol has been a journalist for 15 years. She worked in Brussels and Washington for national medias (Agence France Presse, Liberation). She’s now the editor-in-chief of MedicalExpo e-magazine.


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    Ludovic Nachury

    Ludovic Nachury has been innovation enthusiast for more than 10 years.


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    Laura Newman

    Laura Newman is a New York-based medical writer who writes frequently about medical technological advances and health policy.


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    Jane MacDougall

    Jane MacDougall is a freelance medical writer and journalist based near Paris.


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