Medical robotics: Would you trust a robot with a scalpel ?

Terminator

Driverless cars? Google has already wheeled one out. Robo-cops?

Prototypes are on the scene. Love-bots? One in six people say they would have sex with an android. But how many people would want to go under the knife of a robo-surgeon?

It might seem like a solution dreamed up by Aldous Huxley, but it’s already a reality. Since 2000, more than two million operations worldwide have been performed by about 3,000 da Vinci surgical robots. While each one fills a decent-sized room, their “hands” are super-small, high-precision instruments. Now researchers are racing to develop the next generation of surgical robots to help to seek and destroy cancers, set bones or even just a hold a camera during an operation.

It might conjure up an image of Star Wars’ C-3PO in scrubs, but many of these medical machines are actually closer to the robots used to build your car. “It’s not that the robots do any of the surgery themselves,” says Tony Belpaeme, professor of cognitive systems and robotics at Plymouth University. “They are instruments for the surgeons to use for keyhole surgery, as they offer greater precision than handheld tools, particularly in hard-to-access parts of the body such as close to the spinal cord, and recovery is then so much faster because the operation is so precise.”

Not that a lack of automation is anything to be sniffy about; these machines still use powerful computers to carry out difficult jobs. Their lack of automation is down to the technological challenges of giving a robot the skill and judgment of a surgeon, as well as the lurking fear of legal action and even just the desirable reassurance of having an expert on hand for those awful “what-ifs”.

Where the researchers are taking their cue from the seriously sexy technology of driverless cars is, for example, in the development of domestic robots for palliative care, be it helping you make a cup of tea or alerting the doctor if you skip your medication. “I don’t see any application for artificial intelligence during surgery at the moment,” says Belpaeme. “For a computer to do something intelligent, it has to be able to see what’s happening. Now that’s OK in a structured environment, but the operating theatre is just a mess to a computer and it will be very hard for it to make sensible decisions. However, I do see a role in the future for more autonomous robots giving surgeons a helping hand as an assistant during operation.”

Initially, the vision behind the da Vinci robot was that a surgeon in London could operate in safety on a sick child in Liberia or a wounded soldier in Afghanistan, but financial, technological and communication worries have, for the present, put paid to such dreams. Now the promise of medical robotics lies in facilitating operations that are quicker and more accurate, meaning shorter hospital stays, greater patient turnover, lower chances of patients catching hospital superbugs and an overall saving of money. Robots in the home offer further support, keeping patients eating, moving and medicating.

For surgeons, who are often backing the development of these robots, the benefits of a machine like the da Vinci system are manifold. “The natural instinct of a surgeon is to be hands on the patients, so sitting at a console staring at a screen controlling a robot does take some getting used to,” says Pardeep Kumar, consultant urological surgeon at the Royal Marsden, London, who regularly operates using the da Vinci robot. “But it is such an immersive experience that I’ve been able to carry out more operations, more quickly and successfully than I could have dreamed of. I just bumped into one of my patients being discharged three to four days after an operation using the robot, instead of the three to four weeks it would have taken in the past.”

But it isn’t just about high precision. “The physical demands of surgery aren’t talked about much,” says Kumar. “As a surgeon I have vowed to keep going until I am in my mid to late fifties, but the strain on the neck, shoulders and back make it difficult to keep going for much longer than that. However, operating sitting down using a robot means I could keep going for longer than I had thought.”

It isn’t just keyhole surgery that can benefit from cutting-edge tech. Sanja Dogramadzi, a reader in robotics in the department of engineering design and mathematics at the University of the West of England, is a pioneers of medical robotic technology for the operating theatre. In collaboration with Professor Roger Atkins, an orthopaedic surgeon at University Hospitals Bristol, she designed what is believed to be the first robot-assisted system to tackle the problem of complex joint fractures. For her, the attraction of medical robotics is about solving complex problems that can change lives: “Medical robotics has lots of potential to transform the quality of life of every single one of us. If you can put bones back together, then people can walk again. What’s more important than that?” For Dogramadzi, the main technological challenge is achieving accuracy while avoiding what some see as the cumbersome form of systems like the da Vinci. “We are building a modular system that consists of a number of small interlinked robots. And while each component can be accurate down to less than a millimetre or degree, the problem is, how accurate is the whole system when it is working together?”

However, she too believes it could be a while before autonomous systems are admitted to theatre. “Hardware would, for example, need positional sensors and safety stops to prevent accidents,” Dogramadzi says. “The software would have to be able to work on many different levels at the same time – what the scalpel was doing, what was going on with the auxiliary staff in the operating theatre – then bring it all together to make a decision. This is a big challenge. By keeping the surgeon in the operating theatre it makes our research easier, cheaper and quicker.”

But if physically constructing medical robots is difficult, the real sticking ground is the quagmire of ethics. “Who is responsible if something goes wrong? It is not always going to be one organisation. It’s going to be complicated,” says Dogramadzi.

Yet while scalpel-wielding robots might alarm patients, there is evidence that, for some procedures at least, they may be cautiously welcomed. “The initial pilot study in 2013 into patients’ perceptions of using robots in foot fracture surgery was generally positive,” Dogramadzi says. But, as she points out, surgeons were clearly in the picture. “I doubt that the response would have been so positive if the robot was fully autonomous.”

These are issues of huge import, yet to those at the bench it makes progress frustratingly slow. “Obviously you should not be able to go and do whatever you want,” Dogramadzi says, “but there are so many obstacles in the way of actually doing a project like this.”

One that has risen to the fore in the wake of the NSA revelations is that of privacy and security. Indeed, while home-help robots, such as Mobiserv, have a beguilingly innocent face, the data they hold could make them prime targets for hackers. Autonomous surgeons, robotic pills and contraceptive chips take concerns to a whole new level.

And well they might. This year a security audit published by Essentia Health, which runs about 100 hospitals, doctor’s surgeries and pharmacies in Minnesota and neighbouring states, helped to reveal to the public how badly protected much of our current healthcare technology is. Critical equipment, such as pumps that distribute antibiotics around the body and defibrillators, were, according to the report, vulnerable to hackingwith one of the issues being the poor use of passwords and rare employment of data encryption. It was even possible to change medical records or reboot machines or reboot machines. The firewalls of surgical robots in particular were easy to take down.

Despite such concerns, Dogramadzi, believes there will be a rise in robotics in many areas of medicine. “I am working now with a radiographer to see how we can use novel robotic technology to help position people during radiography,” she says. But it seems that even if questions of security and privacy can be ironed out, some procedures that will always be tackled the analogue way: “Culturally we still like to have a human there to look after you if something goes wrong, like in childbirth. We could go in that direction – but probably shouldn’t.”

Say hello to your life saver

It may seem hard to imagine that this robot, with its ridiculous balloon-shaped head and a tablet computer strapped to the front, might possibly mean the difference between life and death.

Yet if you were elderly and unwell, or recovering from a serious operation, it just might. The robot is designed to work with you to share certain information – such as your heart rate, eating habits and even whether you have taken your medication – with your family, doctor and other carers. It can summon help if it notes unusual behaviour. And in extreme situations – say if you had a heart attack or stroke – it is planned that future models could even take control of the situation.

As part of their research for the European FP7 programme, researchers at the Bristol Robotics Laboratory were, according to project leader Dr Praminda Caleb-Solly, “exploring embodiments” – an important part of how to make the domestic care robot’s interface more friendly for older adults who might not feel comfortable with technology.

“Mobiserv” was a European research project on smart technology that ran from 2009 to 2013. The aim was to develop robots, smart clothing, activity recognition systems and even smart medicine bottles to assist older people to maintain active, independent lives.

“What we found is that people want to be able to customise and personalise the robot by such means as changing the way it speaks, for instance giving it a cheeky character, making it hum while working and even giving it a smell,” says Caleb-Solly. But she says the negative portrayal of robots in popular culture is a problem –people may simply be alarmed by robo-helpers. “For example if you suddenly found the robot by the side of your bed in the night because you’d had a heart attack, demonstrating some degree of intelligence and taking control when you are not able to.” With more field-testing Caleb-Solly and her team hope to fine tune the robot to optimise their usefulness around the house in a range of situations.

The steadiest hand in the theatre

It is said that a hi-fi system is only as good as its speakers. Similarly for keyhole surgery, according to Jeremy Russell, CEO of OR Productivity which includes FreeHand 2010: “An operating theatre is only as good as the person who holds the camera for the surgeon.” The FreeHand system replaces what can be a wobbly picture with a rock-steady image controlled by a camera on a scope held in the iron grip of a robotic arm. It has been estimated this robot can help to speed up operations by 10% by improving the quality of the image a surgeon sees on their monitor. The FreeHand works by giving the surgeon direct control over where the camera goes via a hands-free controller on a headband. The direction of the camera is controlled by a movement of the head, the three-speed unit is started and stopped by touching a foot pedal, and a tap on the table enables the zoom.

Master stroke: a needle that can travel through the brain

According to Robert J Webster III, director of the Medical and Electromedical Design Lab at Vanderbilt University in Nashville, Tennessee, the vision that unites the innovations coming out of his laboratory is simple: “To help doctors heal people more effectively by engineering better tools for them to use in doing so.” 

It is not surprising that Webster was attracted to solving the problem of blood clots in the brain - his father had one, though he was lucky and survived. Forty per cent of the people who develop one will go on to die from it. Webster’s team came up with a miniature robot made of a series of curved flexible tubes which allow it to navigate through delicate brain matter along a route mapped out by a doctor from a brain scan.

The doctor determines how much material is to be removed and the robot’s computer-controlled needle tip does the rest. Studies have suggested that it should be able to remove up to 92% of the clot. For Webster, integrating the robot with medical imaging equipment was the greatest challenge. He says it could take between four and 10 years before we see the robot used in hospitals, depending on how quickly the technology is transferred to a commercial partner.
Webster has moved on to other projects, including robots that use arms inspired by octopus tentacles and elephant trunks, enabling them to pick up and manipulate small objects more effectively. 

Exoskeleton gives stroke patients a hand

It might be chalky white and fairly bulky, but could transform someone’s life after a stroke has left them with no feeling in an arm or unable to grip things tightly.

That is at least the hope of Dr Thomas Burton, who designed the exoskeleton during his PhD at the Bristol robotics laboratory and built it using 3D-printing technology. This makes it easier to manufacture made-to-measure exoskeletons, which have the added advantage of enabling the mechanical joints to align with each person’s natural hand joints to improve what’s called biocompatibility. The exoskeleton is controlled by a computer which receives messages from sensors when the person tries to manipulate or grasp an object – picking up a cup of tea, for example – then activates motors to create a natural grasping motion, including an opposable thumb.

The aim is to give patients extra confidence to perform even basic tasks at home, as well as improving muscle tone. Now that the technology has been shown to make a real difference, the race is on to make it sleeker and suitable for anyone who needs support in everyday life.

The heavily-armed surgeon designed for the front line

With its four arms hanging over the patient, the da Vinci Surgical System looks more like a machine out of Alien than something that belongs in an operating theatre. Yet as of the end of June Intuitive Surgical had installed 3,102 da Vinci Surgical Systems in hospitals worldwide, and more than two million surgical procedures had been performed since the system’s approval by the US Food And Drug Administration in 2000.

According to Catherine Mohr, vice-president for medical research at Intuitive, the robot was “the brainchild of Darpa [Defence Advanced Research Projects Agency], who wanted a robot to work on soldiers injured in battle but didn’t want a surgeon exposed to the frontline”.

With this dream on hold, the focus has shifted to minimally invasive surgery for operations on patients with, for example, heart, urinary or prostate problems. This requires rearranging the conventional operating theatre to accommodate the console at which the surgeon sits to control the robot, as well as the cart with its four arms. “A surgeon with a handheld tool can be accurate to 100 micrometres, or one tenth of a millimetre,” says Mohr. “But using da Vinci even someone untrained can be accurate to 50 micrometres.” Although the da Vinci robot has been subject to a number of lawsuits, Mohr argues that surgery is never without risk and that Intuitive Surgical was found not liable the one time a case went to trial.

In the future, the da Vinci System could help the surgeon make better decisions, for example with “surgery by numbers” – where the monitor highlights target areas then helps guide the surgeon to the exact spot. But it’s unlikely to go the whole hog and end up driverless.

“I would never say never about AI,” says Mohr, “but to be able to deal with the demands of an operating theatre the AI would have to learn like us, and we are simply not there yet.”

Puzzling out bone fractures

Dr Sanja Dogramadzi loves a puzzle and Professor Roger Atkins, an orthopaedic surgeon at University Hospitals Bristol, gave her a difficult one to solve – the solution to which they will soon be testing on human cadavers.

According to Dogramadzi, on a daily basis surgeons face the “difficult problem of having to solve the three-dimensional challenge of putting very small pieces of broken bones back together with two-dimensional images on their monitors: get it wrong and someone may never walk again”.

First she saw it as a mathematical puzzle, then had a revelation about how her robots could come to the rescue: “All we needed to do was put robots there, then we could sort out the fracture accurately, without the need for a major incision.” The solution was two imaging systems allowing the robots to grasp pieces of bone and put them back together in the right combination. One of the imaging systems is a standard CT scan on a computer, while the other is an external positioning system much like the Kinect motion-sensing input device used on Xbox gaming computers.

This tells the surgeon where the robots and their tools are in real time. For Dogramadzi it came down to “a systems integration problem of making the hardware and software work together and achieve a degree of accuracy that is better than the surgeon – or at least the same as a surgeon”. Some very small movements can even be completed by the robots independently.

With this technique, Dogramadzi believes that she and Atkins have developed a unique way to repair fractures in an operating theatre, using minimally invasive robot surgery. She believes that the technology could help repair a wider range of fractures and even have non-medical uses, such as helping archaeologists to put broken vases back together.

Radio-controlled contraceptive

In the future women will no longer have to worry about taking the pill if MIT spin-out MicroCHIPs has its way. It is developing a competitively priced radio-controlled microchip-based implant, the size of a postage stamp, that will deliver a daily dose of contraception for up to 16 years.

The chip is implanted under the skin in a simple outpatient procedure using local anaesthesia, and can be stopped remotely if the needs of the patient change without having to go into a clinic or hospital.

Each day a small electrical charge melts an ultra-thin seal of platinum and titanium around a pinhead-sized reservoir of a hormonal contraceptive releasing a carefully controlled dose into the body.

The next challenge is to make sure the implant cannot be hacked, activated or deactivated without the woman’s knowledge. One way of doing this is to make it only possible to communicate with the implant at skin level and by making sure that all communication to and from the implant is encrypted.

MicroCHIPS has also developed a sensor to go with the chip which can adapt the dosage to the needs of the user on a day-by-day basis

While research on the implant began in the 1990s, it has really gathered pace in the last few years with backing from Bill Gates, and a simple version of the implant has been successfully tested in Denmark.

MicroCHIPS will be submitting a more advanced implant for pre-clinical testing in the US next year – and the device could possibly go on sale by 2018.

Live-stream from smart pill

The small intestine is approximately 6.25m long and about 20mm in diameter and is incredibly hard for medicine to reach. However, researchers at Imperial College, London, think they have found the answer by developing a robotic pill which will do precisely this.

The pill itself is 11mm in diameter and 30mm long, and crammed inside is a camera that can rotate through 360 degrees, a repositionable syringe with the capacity for approximately 1ml of drugs, and a retractable anchor which holds the pill in place.

Like similar robot pills that are mostly used for diagnosis, after it has been swallowed the robot pill relies on the contraction and relaxation of the muscles known as peristalsis to move through the intestines.

The intention is that video will be ­live-streamed from the camera on the pill so that, unlike most other camera pills, which are a bit hit-and-miss, when the operator sees that they have reached the target area, he or she can operate the anchor to hold the pill in place.

“At the moment commercial camera pills are passive, but with this robotic pill you will be able to target specific regions of the small intestine,” says Stephen Woods, PhD student and head of design at surgical instrumentation manufacturers Duckworth & Kent.

However, there are “significant challenges” to miniaturise the new technology, Woods says, and inevitably these have caused delays although they are now mainly overcome.

A further £1m–£2m will be needed to finish the project.

Powered by Guardian.co.ukThis article was written by Mark Piesing, for The Observer on Friday 10th October 2014 09.00 Europe/London

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