ThomasLangøPhD,ChiefScientist,MedicalTechnology,SINTEF,Trondheim

Coordinator@NorwegianNationalAdvisoryUnitforUltrasoundandImage-GuidedTherapy,St.Olavshospital,ResearchUnit

RobotikkinnenkirurgiHvaskjernåogifremtiden?

Disclaimer• Nocommercialbindings

• OneSINTEF-projectrunning:

• CollaborationMedTechandMathematics&CyberneticsatSINTEFandNTNU.Noindustrypartners.FundedbytheResearchCouncilofNorway.Focusoncombiningnonlinearstateestimationtechniqueswithmachinelearningmethodstoestimateandpredictthemotionofmovingobjectsbasedoninputfromdifferentsensors,suchas3Dcamerasandultrasoundprobes,andusingthistoenableroboticarmstointeractwiththeobjectsthroughdynamicinteractioncontrol.Themethodswillbetestedonusecasesfrombothindustryandmedicine,andinthelattercasethefocuswillbeonautomatedultrasoundexaminationswithoutanyintervention.

• PreviousstrategicSINTEFprojectsatMedTechgrouptoinetgraterobotarm(UR5)withtheCustusXplatform.

• Onemajorpublicationonroboticsinsurgery:

• SzoldA,LangøT,BergamaschiR,LutzS,BroedersIAMJ,DankelmanJ,ForgioneA,MelzerA,MintzY,MoralesS,RhodesM,TreglohanJ,SatavaR,Chung-ngaiT,VilallongaR.EAES(EuropeanAssociationofEndoscopicSurgeons)ConsensusStatementontheUseofRoboticsinGeneralSurgery.SurgEndosc,2015,Feb;29(2):253-288.

• (Morethanaverageinterestindevelopingusefultechnologyfordiagnosticsandinterventions)

Arobotisamachine—especiallyoneprogrammablebyacomputer—capableofcarryingoutacomplexseriesofactionsautomatically

Robot

Mechatronics

Roboticsforsurgery,not…foreverythingelse

Evolutionofsurgery-towardsrobotics

Briefhistory

• 1985:PUMA560,needleforabrainbiopsyusingCT

• 1988:Samerobotfortransurethralresection

• 1988:PROBOT(ImperialCollege)prostaticsurgery

• 1992:ROBODOCfromIntegratedSurgicalSystems:

• milloutfittingsinthefemurforhipreplacement

• 2000-1:

• ComputerMotionwiththeAESOP

• ZEUSRoboticSurgicalSystems

• IntuitiveSurgical,daVinciSurgicalSystem

Puma560,1985 PROBOT,1988

ROBODOC,1992

AESOP,1994

Robotsforsurgery

ArtemisEberhardKarlsUniversity

RoboticSurgicalSimulator(RoSS)SimulatedSurgicalSystemsLLC,2009

CardioArmsGrifantini,2008

Orthopilot(2001,FDA)

TheRIO™RoboticArmInteractiveOrthopedicSystem(MAKOSurgicalCorp)

ZeusRoboticSurgicalSystemComputerMotion,Inc.FDA2001

SRI’sM7TelesurgicalRobotDLRMIRO

NeuroMate SofieSurgicalRobot

TheNavioPFSRoboticSurgicalSystemBlueBeltTech

Surgical‘robot’vendors

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• Accuray• AesyntInc• AVRASurgicalRobotics• CambridgeMedicalRobotics• IMRIS• IRobot• Johnson&Johnson• KirbyLester• MAZORRobotics• Medrobotics• MedTech• Medtronic• NovaTractSurgical• Olympus• OmniGuideHoldings• Smith&Nephew• Stereotaxis• TransEnterix• VerbSurgical• VerilyLifeSciences

IntuitiveSurgical(daVinci)VerbSurgicalMedtronicTINAVIMedicalTechnologiesAKTORmedGmbHROBOTICSurgeryAurisSurgicalRoboticsStrykerTitanMedicalBrainLAB…

Technologyforabettersociety

2µm

• mindrereisingforpasientene• desentraliseringavhelsetjenester• egentligfjernstyringavenarmsomholderproben• tohjernerogfirehendersomstyrerettapparat…

•AutonomousUSimaging•TeleoperatedUSimaging•Human-robotcooperation

robot-assisted US imaging

Robot-assistedUSimaging

13

Robotsandpeopleworktogetherinthefutureworkplaces

Roboticsurgery,Robotically-assistedsurgery,Mechatronics,Mechanicaltele-manipulator,…

daVincisurgicalsystem

CompetitiontodaVinciisemerging

Senhance™SurgicalRoboticSystem

-laparoscopiccolorectalandlaparoscopicgynecologicsurgery

FDAin2017

CompetitiontodaVinciisemerging

Flex®RoboticSystemforScarfree™ColorectalProcedures

FDAin2017

CompetitiontodaVinciisemerging

SPORTSurgicalSystem

FDA:2019anticipated

-broadapplicationsofsingleandmulti-quadrantsurgeriespreviouslynotpossiblewithcurrentroboticsolutions

daVinciinuse

• 200.000surgeriesconductedin2012,mostcommonlyforhysterectomiesandprostateremovals

• 2016fiscalyear;IntuitiveSurgicalreportedrevenueof$670million

• Roboticsurgerygenerallycostsanywherefrom$3.000to$6.000morethantraditionallaparoscopicsurgery

• “Withinfiveyears,oneinthreeU.S.surgeries—morethandoublecurrentlevels—isexpectedtobeperformedwithroboticsystems,”(Fortunemagazine,2016)

• In2016:3.803unitsworldwide–2.501inUSA,644inEurope,476inAsia,and182intherestoftheworld(http://phx.corporate-ir.net/phoenix.zhtml?c=122359&p=irol-faq)

https://en.wikipedia.org/wiki/Da_Vinci_Surgical_System

• ECRIInstitute(nonprofitorganization)analyzedmorethan4.000studiesonroboticsurgery:

• evidenceisn’tstrongenoughtodetermineifarobotisbetterthantraditionalminimallyinvasivesurgery

• evidenceindicatesthatit’sbettercomparedtoopensurgery

daVinciinuse

“ThedaVincirobot-assistedsurgerydeviceisasolutioninsearchofaproblem—butonehellofamarketingmachine”

Roboticsinsurgery

• Thereisnohigh-qualityevidencetoinformthecomparativeeffectivenessofLRPorRARPcomparedtoORPforoncologicaloutcomes.Urinaryandsexualqualityoflife-relatedoutcomesappearsimilar.

• Overallandseriouspostoperativecomplicationratesappearsimilar.Thedifferenceinpostoperativepainmaybeminimal.MenundergoingLRPorRARPmayhaveashorterhospitalstayandreceivefewerbloodtransfusions.Allavailableoutcomedatawereshort-term,andthisstudywasunabletoaccountforsurgeonvolumeorexperience.

Robotic-AssistedvsLaparoscopicRadicalNephrectomy

• Theproportionofradicalnephrectomiesusingrobotic-assistedoperationsincreasedfrom1.5%in2003to27.0%in2015

• Althoughtherewasnosignificantdifferencebetweenrobotic-assistedvslaparoscopicradicalnephrectomyinmajorpostoperativecomplications,robotic-assistedprocedureswereassociatedwithlongeroperatingtimeandhigherdirecthospitalcosts.

JAMA.2017;318(16):1561-1568.doi:10.1001/jama.2017.14586

Robotic-AssistedvsConventionalLaparoscopicSurgeryonRiskofConversiontoOpenLaparotomyAmongPatientsUndergoingResectionforRectalCancer

• Amongpatientswithrectaladenocarcinomasuitableforcurativeresection,robotic-assistedlaparoscopicsurgery,ascomparedwithconventionallaparoscopicsurgery,didnotsignificantlyreducetheriskofconversiontoopenlaparotomy.

• Thesefindingssuggestthatrobotic-assistedlaparoscopicsurgery,whenperformedbysurgeonswithvaryingexperiencewithroboticsurgery,doesnotconferanadvantageinrectalcancerresection.

JAMA.2017;318(16):1569-1580.doi:10.1001/jama.2017.7219

PossibleadvantagesofRoboticsurgery• Shorterhospitalization

• Reducedpainanddiscomfort

• Fasterrecoverytimeandreturntonormalactivities

• Smallerincisions,resultinginreducedriskofinfection

• Reducedbloodlossandtransfusions

• Minimalscarring

• Advantagesforsurgeonsusingroboticsurgeryinclude:

• Greatervisualization

• Enhanceddexterity,nofulcrumeffect

• Greaterprecision

• Surgeoncansit,lessrestraining

• Handtremorsfiltered,scaledmotion

PossibledisadvantagesofRoboticsurgery• Longeroperatingtime

• Learningcurve

• Lackofstudiesonlongtermresults

• Costs-1.8millUSDanddisposables2.000USDperprocedure

• Noconsistentprotocolstoproperlydeterminewhichpatientsarethebestcandidatesforthevariousroboticprocedures

• Arcing;electricalcurrentsleakoutofthedeviceduringsurgerycausingsparks

• Disdvantagesforsurgeons/researchersusingroboticsurgeryinclude:

• Immobileandweighsmorethanhalfatonne

• Proprietarysoftware

• Madeforremotetelesurgery(awayfrompatient)

• (Almost)nohapticfeedback(forceofinstruments)

• Non-ergonomicneckandtrunkangle(armrestheighthasalimitedadjustmentrange)

• =>Increasedcognitiveload

Intuitiveisadefendantinapproximately50lawsuitsallegingproductliability

Roboticsinsurgery-othercriticalviews…• Robotintroducedin2000.Unlikethecellphone,ithasnotevolvedintoabetter,sleekertechnologyand

itisn’tcheaper.

• Therobotrepresentsanattempttoaddresstheergonomiccrisisinsurgery(forsurgeons)?

• Iftherewereanadvantageinprecisionorgettingintosmallspaces,itwouldshowupinthedata?

• Intherapidlyevolvingenvironmentofvalue-basedmedicine(outcomepercost)therobotloses…

• Hospitalspayannualsix-figuremaintenancefee.Aftertenyears,theinitialcostofthepurchasehasdoubled!

• Reprocessingarobot:approx.of4.5hoursoflabor.Usuallymore.• mostgoodreprocessingtechscanturnoverinstrumentsfor13ORsinthesametimeittakestoreprocessoneroboticcaseinoneOR

• Instrumentamortization.Breakanarmoranattachment,add$40Ktoyoursix-figurebillfortheyear.Incontrast,ahigh-qualitylaparoscopicinstrumentwillcostaround$1Ktoreplace.

PeterF.Nicholischiefmedicalofficer,MedawareSystems

VisualizationinMIS

Robotics in medicine Integrating Surgical Systems for Autonomy in the future OR

“Penelope” – robotic scrub nurseMichael Treat MD, Columbia Univ, NYC. 2003

da VinciSurgical master-slave “robot” system

FromtraditionalsurgerytosmallerproceduresoutsidetheOR

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Futureofroboticsurgery-tailoredinstruments

http://microsure.nl

32

Futureofroboticsurgery-tailoredinstruments

CambridgeMedicalRoboticsVersiussystemcapabilitytooperateacrossallfoursurgicalquadrants,allowingittobeusedingynaecology,urology,upperGIandcolorectalsurgery

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Electromechanicaltool HumanExtensions,Israel

Futureofroboticsurgery-automaticcameracontrol AutoLap,Israel

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Futureof‘robotic’surgery-tailoredinstruments

http://www.laparasurgical.com

Therapyfromwithintubes-Flexibleendoscopy

•Cardiacsurgery•GIsurgery(endoluminalsurgery)•Gynaecology•Urology•ENT•Neurosurgery•Vascularsurgery(endovascular)

Flexibleplatforms-Mainchallenge…

Madefordiagnosis,notsurgery

April2nd,2007,Marescauxetal,IRCAD

Flexibleplatforms-Instrumentplatform

EndoSAMURAI,Olympus

Roboticflexibleendoscopyplatformsindevelopment

NeoGuidesystem

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Singleincisionroboticplatforms

SurgiBot

SpiderSurgery

VirtualIncision

Flexibleplatforms-Instrumentplatform

Medrobotics,FlexRoboticsSystem,FDAclearedJuly2015

Robot-AssistedEndovascularCatheterization

RAFII-TARIetal.CurrentandEmergingRobot-AssistedEndovascularCatheterizationTechnologies:AReview.AnnalsofBiomedicalEngineering,Vol.42,No.4,April2014(Ó2013)pp.697–715

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Futureofroboticsurgery Magellanroboticsystem,HansenMedical

Futureofroboticsurgery-Opensource

Opensourceplatform

TheRavensystem

TheRavenisanopen-architecturesurgicalrobotforlaparoscopicsurgeryresearchfromAppliedDexterity.Ithastwocable-driven7DOFarms(6DOF+grasp).Itisintendedtofacilitatecollaborativeresearchonadvancesinsurgicalrobot

Futureofroboticsurgery http://bionics.seas.ucla.edu

RobotassistedproceduresinMIT

Courtesy:AØstvik,SINTEF/NTNU,EHofstad,SINTEF

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Cognitiverobotics

http://www.zividlabs.com

Accuratereal-time3Dcolorcamera

KunstigintelligensDyplæring

Maskinlæring

USguidedFUS

CourtesyAMenciassi,Pisa,www.futuraproject.eu

Futureofroboticsurgery TwenteUniv.,TheNetherlands

Futureofroboticsurgery TwenteUniv.,TheNetherlands

FromtraditionalsurgerytosmallerproceduresoutsidetheOR

Nanoroboticist Metin Sitti shows the tiny robot that cantake pictures, biopsy, and deliver medicine inside of you

http://nanolab.me.cmu.edu/projects/capsules/SoftMagneticCapsule.shtml

www.vector-project.com

GII2015 GlobalInnovation

Index(GII)isanannualrankingofcountriesbytheircapacityfor,andsuccessin,innovation

GII2017 GlobalInnovation

Index(GII)isanannualrankingofcountriesbytheircapacityfor,andsuccessin,innovation

Røros

Technology for a better society

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