Minimizing the surgical damage.
When Robotics met Minimally Invasive Surgery.
DARPA, NASA and a MIT student.
We never again went to the Moon.
How did Robotic Surgery come to happen
Primun non nocere
This principle is at the very foundation of Medicine.
Alas, causing some degree of harm is sometimes necessary.
It is true that though history doctors have caused pain; sometimes even more pain than relief. This was mainly due to lack of knowledge (or wrong believes, which counts the same). Modern medicine has largely overcome this situation, and today there are plenty of mechanisms to avoid unneeded harm. Patient safety is at the core of current medical practice.
But however you look at it surgery is always, by nature, to some degree, invasive. The surgical “damage” is the sum of two components. The first one is related to the disease that motivates surgery. For example, if you remove an organ or a part of the anatomy involved by a tumor, it is likely there will be sequelae. The other part is related to the approach. It is the damage the surgeon must do to “get to” the surgical target. A scar in the skin is an obvious stigma of this, but approach-related problems or sequelae are frequently much more complex than a simple scar.
Minimizing the surgical damage
Minimally invasive approach surgery is a very old concept. It is how surgeons design techniques to minimize the surgical damage related to the approach in surgical procedures.
There are two basic ways to do this. One is to use natural orifices: no scar and usually no approach-related harm at all. The other to use minimal incisions and introduce endoscopes and special instruments to perform the surgery. The scar is minimized as well as the “distortion” of the tissues inside.
It is important to understand that, although there is usually a cosmetic benefit, the most important contribution of the minimally invasive approach is beyond the visible. For example, when comparing an open abdominal surgery with a laparoscopic surgery, obviously, the scar in the abdomen will be substituted by the small scars of the of the trocars, but not “opening” the abdominal cavity will also avoid a temporary paralysis of the bowel, decrease pain and foster recovery after surgery (and, for several reasons decrease costs).
Minimally invasive surgery has been a standard, for many years, to carry out countless different procedures across surgical specialties.
When Robotics met Minimally Invasive Surgery
For obvious reasons, the development of Minimally Invasive Surgery has been strongly dependent on technological development. We need endoscopes that provide good quality images, and specific instruments to manipulate from the outside through a small passage.
This is already history also. Todays endoscope image quality is outstanding and improving day by day. We have an instrument for almost anything we need to do, most of them disposable.
Robotization brought a qualitative change (and this is contemporary history, if you might). Performing surgery at a console outside the proper surgical field brings two revolutionary advantages to endoscopic surgery.
The viewer at the console is natively a 3D viewer. There are separate images for the right and left eye of the surgeon, coming from a double-camera endoscope. The vision of the surgical field is stereoscopic. The only way to do this in conventional endoscopic surgery is by wearing polarized glasses in the scrub area while looking “up” at a 3D monitor. Surgeon´s disfavour performing surgery like this, as it is rather uncomfortable. With the arrival of robots, 3D endoscopic surgery upgraded, let alone a world of possibilities from digital image processing and computerized environment information.
And then, tele-manipulation of surgical instruments. Imagine making your hands small and long enough so that they could fit through a small passage to get inside the patient´s body. That is what robotization does. It is true that technology still must evolve. For example, upcoming innovations will hopefully achieve a better tactile feed-back. However, it is true that, robotic “hands” have many possibilities that human hands dont´t have.
DARPA, NASA, and a MIT student
The history of the technological and business development of surgical robotics would make for a movie script.
The history of what we call “soft tissue robotics” is the history of two Californian companies, Computer Motion and Intuitive Surgical. The former was the first in the race, but the last finally won.
The original interest in tele-manipulation with medical applications was shared by the Defense Advanced Research Projects Agency (DARPA) and the National Aeronautics and Space Administration (NASA). For different but analogous reasons, they were interested in performing medical tasks remotely (either at the battle-field or at the outer space). The first device was a system that could manipulate an endoscope, called AESOP (Automated Endoscopy System for Optimal Positioning). After different developments by Computer Motion, in year 1995 it became the Zeus robot.
That same year a new company, Intuitive Surgical, acquired the patent rights of the SRI system (Stanford Research Institute), developed at Stanford University with NIH (National Institutes of Health) support, and hired the services of a young engineer from the MIT (Massachusetts Institute of Technology). Akhil Madhini, together with his fellow MIT students Günter Niemeyer and Kenneth Salisbury, developed a “Teleoperated Surgical Instrument for Minimally Invasive Surgery”. Based on Akhil`s doctoral thesis, their work was targeted to improve the dexterity of the instruments for endoscopic surgery. The original Silver Falcon was a tele-manipulated arm for endoscopic surgery with 7 degrees of freedom and a revolutionary “wrist” articulation. The next device, the Black Falcon, was presented at the IEEE-RSJ meeting (International Conference on Intelligent Robots and Systems) in Victoria, BC, Canada, in 1998. The design is basically the same that today´s da Vinci´s robotic arms and master manipulators. The Black Falcon stays at the MIT museum.
After establishing a technology transfer agreement, Akhil and Kenneth joined Intuitive Surgical. The “wrist mechanism for surgical instruments for performing minimally invasive surgery with enhanced dexterity and sensibility” was patented in August 25, 1998, by Intuitive Surgical with Akhil and Kenneth as inventors.
We never again went to the Moon
The race was at its peak.
And in year 2001 Computer Motion marked a milestone.
Since 1995 Intuitive Surgical had been developing prototypes with names inspired on Leonardo da Vinci (Lenny, Mona…). In 1997 they were able to perform a laparoscopic cholecystectomy using a device with a “master-slave” configuration, where the surgeon sat at a console manipulating robotic arms that exactly reproduced the movement of his hands. A laparoscopic bariatric surgery followed in 1998. In 1999 they launched the da Vinci; in July 17th, 2000, it was cleared by the FDA (Federal Drug Administration) for laparoscopic abdominal surgical procedures.
The Zeus had already got the CE (Conformité Européenne) mark, but it will not get FDA clearance until 2001. Then came the Lindbergh Operation.
It was named after Charles A. Lindbergh, the first man to cross the Atlantic Ocean in a non-stop fight from New York to Paris in 1927. The patient was at the IRCAD (Institut de Recherche contre les Cancers de l’Appareil Digestif) and advanced research and training center for minimally invasive surgery in Strasbourg (France). The surgeon was in New York. In September 7, 2001, Jacques Marescaux performed the first remote surgical procedure ever, more than six thousand kilometers away from the patient. It was a technological achievement, but also from the telecommunications point of view (think about it: twenty years ago, ages for communication technology).
Yes, it was possible. Like getting to the moon in 1969. But not really useful. Not yet. Sometime perhaps. Even though a lot was learnt in the process, the priorities were different.
In 2001 Computer Motion sued Intuitive Surgical for patent violation. The legal conflict lasted until 2003 when Intuitive Surgical acquired its main rival. The project Zeus was discontinued and efforts focused on the da Vinci. Now in its fourth generation, the da Vinci robotic surgery system is used worldwide, and is, de facto, in a situation of world monopoly.
Epilogue. Back to Asimov.
Robotic surgery is the most advanced technique used to perform endoscopic minimally invasive surgery. Its real contributions for many indications are still to be stablished but the road ahead appears quite clear.
The tools used will not make a better surgeon, but they will contribute to improve patient safety and expanding possibilities. In the end, it might end up making a better surgery. The idea behind Computer Assisted Surgical Systems (CASS) is to take advantage of a computerized environment in the Operating Room where the surgeon can immediately get the required information and make use of different effector tools.
If you did not already know, what we are using now are not real robots. We have basic hardware and a lot of software. But surgery still eludes real robotization and possibly it will be so for some time. “Art” still occuppies a great part in surgery, and our devices are not smart enough yet.
Remember the first and second laws of robotics by Isaac Asimov? “A robot shall not harm a human, or by inaction allow a human to come to harm” and “a robot shall obey any instruction given to it by a human except where such orders would conflict with the First Law“.
Of course this is science-fiction but visionary science-fiction. Surgery causes harm. How will we solve this dichotomy?
J Granell, October 2020