Hands of Steel

Used for hospital ancillary support, laboratory medicine, rehabilitative medicine, and surgery, Robotics is revolutionising healthcare, Sonal Shukla discovers

Keeping a 'virtual eye' on patients 24x7 might have appeared an impossible task at first thought, a decade back. But with the advent of robotics anything looks achievable. Robots have always caught the imagination of medicos to replace human tasks by a machine that can more accurately, efficiently, and rapidly perform a job. They can even improve surgical outcomes.

Recently, doctors from Baltimore's Sinai Hospital found a way to use a videoconferencing robot, introduced by a surgeon at their hospital, Dr Alex Gandsas, to check on patients in their absence. Equipped with cameras, a screen and microphone, the joystick-controlled robot tries to substitute for a real doctor. Of 376 of Dr Gandsas's patients, the 92 patients who had additional robotic visits had shorter hospital stay, reveals a chart review study published in the July 2007 issue of the Journal of the American College of Surgeons.

Robots used for the implantation of prostheses of the hip and knee help in more stable insertion, shorter recovery time, and a proposed longer life for the implanted prosthesis. Given robot ability to improve efficiency without the cost of extended treatment time, medical researchers have begun to develop application of robots in the sphere of healthcare. "In the last three-four years, there has been an explosion in usage of robots around the world. As robots become more compact, versatile and cost-effective, we expect to see increased use in developed and developing nations," opines Dr (Prof) AK Hemal, Professor of Urology AIIMS, New Delhi. AIIMS, which has been offering robotic surgery since July 2007, has performed more than 200 such surgeries including radical prostatectomies and many other procedures such as pyeloplasty, radical cystectomy, adrenalectomy and repair of vesicovaginal fistulae to name a few.

"Today, laparoscopic and robotic radical prostatectomy for prostate cancer has made 'open' surgery obsolete" - Dr Anup P Ramani Urological Laparoscopic Surgeon Jaslok Hospital, Mumbai

"We need to develop centralised robotic service, making it available in different parts of India, lest robotics die" - Dr Shabeer Ahmed Gastrointestinal and Minimal Access Surgeon Wockhardt Hospitals, Bangalore

Versatile Applicability

Around the world, four areas in the sphere of healthcare have been investigated in terms of robotics: hospital ancillary support, laboratory medicine, rehabilitative medicine, and surgery.

Hospital ancillary support: Robots as hospital ancillary support have helped deliver patient meals, medications, and X-rays to specified areas of the hospital. The navigation system of these robots uses motion sensors to prevent collisions while tracking within a hospital blueprint. Help-Mate, Transitions Research Corporation, Milford, Conn are some manufacturers of such robots.

Rehabilitative medicine: Assisting people with physical disabilities is another area for which robots have been developed. Typical devices include robotic arms that aid the patient with eating or tool manipulation as well as devices that help with automated locomotion.

Surgical purposes: Major advances aided by surgical robots have been remote surgery, minimally-invasive surgery, and unmanned surgery. Major potential advantages of robotic surgery are precision, miniaturisation, articulation beyond normal manipulation and three-dimensional magnification. Surgical robots can be classified into active or passive. A passive robot would be used to position a fixture appropriately and then be switched off, to be followed by the surgeon inserting his instruments. "An example of this would be a robot to help position a device for guiding neurosurgical biopsy needles. By contrast, an active robot would actually move the tools," says Dr Shabeer Ahmed, Consultant Gastrointestinal and Minimal Access Surgeon, Wockhardt Hospitals, Bangalore. These include laparoscopic camera holders, telemanipulators, and robots used for burring out tissue, such as the Probot for prostatectomies and RoboDoc system by Integrated Surgical Systems, Inc, Sacramento, Calif, for hip prostheses. Currently, the one robotic system which is said to have taken over all the other systems is the da Vinci System which FDA cleared for a variety of surgical procedures including surgery for prostate cancer, hysterectomy and mitral valve repair and used in over 800 hospitals in America and Europe. The da Vinci System was used in over 48,000 procedures in 2006 and sells for about $1.2 million.

The Popular One

The da Vinci Surgical System comprises three components: a surgeon's console, a patient-side robotic cart with four arms that are manipulated by the surgeon at the console and a high definition 3D vision system. Articulating surgical instruments are mounted on the robotic arms which are introduced into the body through cannulas. The surgeon's hand movements are scaled and filtered to eliminate hand tremor then translated into micro-movements of the proprietary instruments. In gastrointestinal surgery, multiple procedures have been performed with either the Zeus or da Vinci robot systems, including bariatric, pancreatic, hepatic and bowel surgery. The da Vinci surgical system is a computer-enhanced system that interposes a computer between the surgeon's hands and the tips of micro-instruments. "The system replicates the surgeon's movements in real time. It cannot be programmed, nor can it make decisions on its own to move in any way or perform any type of surgical manoeuvre," Dr M Ramesh, Bariatric Surgeon, Narayana Hrudayalaya, Bangalore.

Surgical Application

Neurosurgery: Several systems for stereotactic intervention are currently in the market. Three types of devices—neuronavigators, stereotactic localisers, and robotic assistants—have been developed in neurosurgery to improve spatial accuracy and surgical precision within the skull.

Orthopaedic Surgery: It was one of the first areas of surgery in which robot applications were developed. Compared with soft tissues, bones are relatively easy to manipulate and deform little during cutting, so image-guided techniques are relatively straightforward to implement. "The result is that robotic procedures can result in far better agreement with a preoperative plan than with the analogous manual procedure," explains Dr Ahmed. Orthopaedic applications that have received the greatest attention are hip and knee replacement and spinal fusion; additional work is under way in a variety of other areas, including craniofacial reconstruction and fracture treatment. In orthopaedic surgery, robots have been developed capable of carving and preparing a human femur for artificial hip replacement. The RoboDoc system, released in 1992, cuts a cavity 10 times more accurately than manual reaming, with an accuracy of 0.5 to 1.0 mm.

Urology: Coupled with the 14x magnification and ergonomic ease for the surgeon, robotic technology is ideally suited for complex urological procedures. Robotic devices to assist urologists with laparoscopy, percutaneous access to the kidney, transurethral resection of the prostate and prostate biopsy are currently in development or already in clinical use. Cutting-edge telemedicine and virtual reality applications have also integrated robotic technology. In order to apply robotics in urology, surgeons are now comparing this new technology to the currently accepted gold standard of 'open' surgery. "The results with robotic radical prostatectomy at this early juncture appear comparable to open surgery with respect to oncological outcomes, continence and return of erectile function," says Dr Hemal. The ability to suture with ease in a laparoscopic environment makes it a favourite tool of all urologists. "Today, laparoscopic and robotic radical prostatectomy for prostate cancer has all but made 'open' surgery obsolete," explains Dr Anup P Ramani, Consultant Urological Laparoscopic Surgeon, Jaslok Hospital, Mumbai and Ex-Director of Laparoscopy of The University of Minnesota, Minneapolis, USA.

He adds that laparoscopic surgery for prostate cancer leads to minimal blood loss and minimal pain as compared to open surgery, and patients are discharged within a day or two. "Cancer outcomes are excellent which is why most patients with prostate cancer are now choosing the laparoscopic option. The laparoscopic magnification also allows for excellent nerve sparing during surgery which translates into good erections after surgery. Dr Ramani added that robots are also used for other urological surgeries like pyeloplasties and nephrectomies.

Cardiology: The advancement of computerised robotic technology is one of the most exciting breakthroughs in cardiac surgery to date, enabling surgeons to perform complete, bypass surgery less invasively in addition to bypass procedures. The robotic system is being used for heart valve operations and will soon be able to assist with aortic procedures and the treatment of heart failure and rhythm management. Totally closed chest, endoscopic mitral valve surgeries are also being performed now with the robot. When a doctor performs a heart surgery manually, in spite of all the skill and expertise, in order to see and repair properly, the opening that is made in the body is generally quite large, leaving a mark after the operation. Also, the patient has to be kept on a heart-lung machine, to stop the beating of the heart during suturing. All this together, requires three to four hours of extra work. But with the help of robotics heart surgery, the incision made is quite small and the doctor can perform the entire surgery with just two or three holes in the heart. In an earlier article in Express Healthcare written by Dr Naresh Trehan, Former Executive Director of Escorts Heart Institute, New Delhi, he had explained, "The arms of the robot are made to rotate at an angle of 360 degrees. It is possible to reach every nook and corner required. The heart-lung machine is also not needed because with this technology we can actually perform beating heart surgery."

Other Specialities: In gynaecology, reproductive surgery and ablative surgery including hysterectomy have been performed with the help of robots. In paediatrics, surgical robotics has been used in tracheoesophageal fistula repair, cholecystectomy, nissen fundoplication, morgagni hernia repair, kasai portoenterostomy and congenital diaphragmatic hernia repair.

"Many centres are also using robots in general surgery for procedures on the oesophagus or for removal of the gall bladder. Gynaecologists are also using the robot for pelvic operations," opines Dr Hemal. The robot is ideally suited for pelvic surgery because access via open surgery can often be suboptimal, whereas with the robot excellent vision can be obtained and delicate procedures performed.

Better than Real

Automated Endoscopic System for Optimal Positioning (AESOP) is a 3D camera used in robotic surgery. It can be zoomed in by either voice activation or by pedals located at the surgeons foot.

Doctors who have used this argue that AESOP actually gives a better image than human vision. This is particularly true for surgeons with poor vision or in microscopic surgeries that deal with nerves. However, the clear advantage of using robots is in long operations, particularly ones that deal with nerve or tissue reconstruction. Surgeons often tire easily after performing microscopic surgeries that last for hours.

Being able to be seated and have less strain on the eyes, surgeons can control their natural flinching or nerves more efficiently. Percutaneous coronary intervention (PCI) has become the major method of revascularisation for coronary artery disease, with over two million coronary interventions performed annually. "The robotic remote control PCI system not only helps patients avail services of their preferred doctors over a distance, but also helps physicians operate in an X-ray free and relaxed environment with less chances of spinal risk, thereby increasing their ability to deal with long procedural hours," says Dr AP Ganesh Kumar, Chief Interventional Cardiologist, Dr LH Hiranandani Hospital, Mumbai.

In May 2007, the world's first robotic arm for angioplasty arrived in India at Dr LH Hiranandani Hospital and till date 11 angioplasties have been done using this robotic arm with 100 per cent success rate by Dr Kumar. According to him, "In contrast with the present angioplasty procedure that requires two cardiologists, the robotic remote control procedure requires no assistance, thus making the process efficient and error free." The patient has decrease in pain and scarring due to tiny incisions. Earlier in December 2003, Dr Kumar teamed up with Rafael Beyar (considered the father of stents) and other eminent members including Tal Wenderow, Doron Lindner, and Rona Shofti, in Israel, to develop and test the robotic arm. The result of this path-breaking study was published in Europe's EuroIntervention journal in November 2005. The study concluded that remote navigation system for coronary interventions including balloon angioplasty and stenting is feasible.

Hurdles to Surmount

Brain surgery is also possible with the help of robots

Although the available minimally-invasive surgical techniques have clear advantages, these procedures continue to cause problems for patients. From the surgeon's point of view, present tools are limited by set axes of movement, restricting the degree of freedom available to the surgeon. In addition, depth perception is a key for task performance and is lost with the use of two-dimensional viewing systems used traditionally in laparoscopic surgery. As surgeons view a 'virtual' target on a television screen, they are hampered by decreased sensory input and a concurrent loss of dexterity. According to experts, the development of robotic assistance systems could be the key to overcoming these difficulties.

The human error of camera assistants also needs to be eliminated for optimal vision and clarity. Achieving real time synchronisation between the surgeon's decisions and the camera assistant's end-actions is essential. A computer interface mechanical camera holding arm is the answer, believe experts. Also, much time is spent on altering table position, instrument exchange, robotic positioning, and moving machines. One requires an operating theatre that is large enough for the robot, as the robot itself includes the console, patient-side cart and numerous instruments.

A Working Wonder

An overview of robotic surgery A robot is a combined mechanical, electronic, and computer system that follows a simple cycle of commands and task execution for operation. First, the computer learns environmental information from its sensors. Based on this information and the task to be accomplished, computer algorithms calculate appropriate commands for the motors. These commands are sent to the mechanical system, which executes the task, and the cycle repeats. "Apart from giving the surgical robot commands to be carried out via a sequence, all actions of the robot have to be continually monitored to correct deviations from the planned trajectory. There are several basic terms essential to the understanding of robotic function," explains Dr Shabeer Ahmed, Consultant Gastrointestinal and Minimal Access Surgeon, Wockhardt Hospitals, Bangalore. The basic configuration encountered in medical applications is an arm-like device called a manipulator. The range of motion of each manipulator is called its working envelope. The manipulator is normally connected to a base (floor, ceiling, operating table, etc) and composed of a succession of joints and links (appendages). The instrument with which the robot performs the desired task is attached to the last link of the arm and is referred to as the end-effector. In surgical robots, an end-effector can be a needle, grasper, scalpel, or even a resectoscope.

Accessing India

Although use of robotics is pretty common abroad, in India, its usage is restricted and limited to a handful of hospitals like New Delhi's AIIMS and Escorts Heart Institute and Hyderabad-based Care Hospital. The primary reason is cost, with an initial investment of over a million dollars and then an annual maintenance of over $2,50,000 (Rs 1.5 crore). When the hospital buys a robot, it needs to use the robot for at least 10-12 cases a week just to break even.

"The presence of highly-trained laparoscopic surgeons makes up for lack of robots, as patients gets the same precision as with a robot. This is especially true for surgeries like laparoscopic prostate surgery for prostate cancer," opines Dr Ramani. However, Dr Hemal believes that the demand for robotic surgery in India is such that in a very short while, India will have huge number of robots being used, which will be equal to the best institutions abroad.

Dr Ahmed feels, "We need to develop centralised robotic service, making it available in different parts of India, lest robotics die. We need to generate a new breed of robotic surgeons who will master, deliver and contribute in various specialities."

The Future

In the next 10 to 20 years, robotics and computer-assisted technology will play a major role in healthcare.

According to experts, as the field matures and engineering expertise with these systems increases, costs are likely to decrease. In addition, many robotic systems are now dedicated to specific procedures. Hence, systems for knee replacement will not be able to perform hip replacements, even though the procedures are similar in many respects. With growing maturity of the field, systems may gain flexibility, so that the same robot can be used for a variety of procedures in a single surgical speciality, serving to reduce costs.

sonal.shukla@expressindia.com