Robotic technologies appear in many areas that directly affect patient care. They can be used to disinfect patient rooms and operating suites, reducing risks for patients and medical personnel. They work in laboratories to take samples and the to transport, analyze, and store them. This is especially good news is you have ever had blood drawn by someone who had to try several times to find a “good vein.” The robotic lab assistant can locate that vessel and draw the blood with less pain and anxiety for the patient.
Robots also prepare and dispense medications in pharmacological labs. In larger facilities robotic carts carry bed linens and even meals from floor to floor, riding elevators and maneuvering through automatic doors. There are also “gears and wires” robotic assistants that help paraplegics move and can administer physical therapy.
Robotic personal assistants can be built to look friendly and the Japanese have taken the lead on this front. One of their machines, called Paro, responds to human speech and looks like a decidedly non-threatening baby seal. Other robotic technology is humanoid and used for help with personal care, socialization and for training. One used in training emergency personnel to respond to trauma, for instance, looks like a victim who screams, bleeds and even responds to treatment. The ultimate question for robotics in healthcare is whether they will take jobs away from humans.
There are several reasons why the machines will not replace their human counterparts. For one thing, most hospitals have less than 300 beds. They simply cannot afford the technology. The automated guided vehicles require a dedicated hall or floor tracks and the installation of navigation devices throughout the facilities. Other carts work with the help of a laser-drawn map of the hospital programmed into them that includes elevators, turns and automated doors. That process is also extremely expensive. But ultimately, robotic assistants cannot replace basic human contact.
Even though the technology is expensive and some of it is years from being implemented, the use of robots is changing healthcare and-in ways we can only imagine- will continue to do so.
Robots are in use across the whole pharmaceutical supply chain, from basic research to the production of medicines, quality inspection and packaging. Robots support the discovery of vital new treatments; enable faster medical tests for patients; help pharmaceutical manufacturers to meet increasingly strict regulations for the production of medicines and maximise the efficiency of drug production. Since industrial robots have their origin in manufacturing sectors, it’s no surprise that they are most established in the manufacturing phase of the drug development lifecycle.
The technologies needed for performing repetitive tasks with high degrees of precision and accuracy are already mature. The main focus of robots in the manufacturing process is at the filling, assembly and packaging stage, where tasks include filling and labelling containers, assembling finished products such as syringes and packaging assembled products.
Brain surgery involves accessing a buried target surrounded by delicate tissue, a task that benefits from the ability for robots to make precise and accurate motions based on medical images. Thus, the first published account investigating the use of a robot in human surgery was in 1985 for brain biopsy using a computed tomography (CT) image and a stereotactic frame. In that work, an industrial robot defined the trajectory for a biopsy by keeping the probe oriented toward the biopsy target even as the surgeon manipulated the approach.
This orientation was determined by registering a preoperative CT with the robot via fiducials on a stereotactic frame attached to the patient’s skull. That project was discontinued after the robot company was bought out, due to safety concerns of the new owning company, which specified that the robot arm (54?kg and capable of making 0.5?m/s movements) was only designed to operate when separated by a barrier from people. Then in 1991, the Minerva robot (University of Lausanne, Switzerland) was designed to direct tools into the brain under real-time CT guidance. Real-time image guidance allows tracking of targets even as the brain tissue swells, sags, or shifts due to the operation. Minerva was discontinued in 1993 due to the limitation of single-dimensional incursions and its need for real-time CT.
The currently available neurosurgery robots exhibit a purpose similar to historical systems, namely, image-guided positioning/orientation of cannulae or other tools. The NeuroMate (by Renishaw, previously by Integrated Surgical Systems, previously by Innovative Medical Machines International) has a ConformitéEuropéenne (CE) mark and is currently used in the process for FDA clearance (the previous generation was granted FDA clearance in 1997). In addition to biopsy, the system is marketed for deep brain stimulation, stereotactic electroencephalography, transcranial magnetic stimulation, radiosurgery, and neuroendoscopy. Li et al. report in-use accuracy as submillimeter for a frame-based configuration, the same level of application accuracy as bone-screw markers with infrared tracking, and an accuracy of 1.95?mm for the frameless configuration.
The expected benefit of robot assistance in orthopedics is accurate and precise bone resection. Through good bone resection, robotic systems (can improve alignment of implant with bone and increase the contact area between implant and bone, both of which may improve functional outcomes and implant longevity. Orthopedic robots have so far targeted the hip and knee for replacements or resurfacing (the exception being the Renaissance system and its use on the spine). Initial systems required the bones to be fixed in place, and all systems use bone screws or pins to localize the surgical site.
Prior to the 1980s, surgical procedures were performed through sizable incisions through which the surgeon could directly access the surgical site. In the late 1980s, camera technology had improved sufficiently for laparoscopy (a.k.a. minimally invasive surgery), in which one or more small incisions are used to access the surgical site with tools and camera. Laparoscopy significantly reduces patient trauma in comparison with traditional “open” procedures, thereby reducing morbidity and length of hospital stay, but at the cost of increased complexity of the surgical task. Compared with open surgery, in laparoscopy the surgeon’s feedback from the surgical site is impaired (reduced visibility and cannot manually palpate the tissue) and tool control is reduced (“mirror-image” motions due to fulcrum effect and loss of degrees of freedom in tool orientation).
Robot assistance for soft-tissue surgery was first done in 1988 using an industrial robot to actively remove soft tissue during transurethral resection of the prostate as with neurosurgery, the researchers deemed use of an industrial robot in the operating room to be unsafe. The experience provided the impetus for a research system, Probot, with the same purpose
Many more medical robots are currently being researched. Such research will lead to the new capabilities of future commercial systems.
Two prominent academic robot-assisted surgical systems are currently used for research into endoscopic telesurgery: RAVEN II and MiroSurge. The RAVEN II (University of Washington and UC Santa Cruz) is a teleoperated laparoscopic system that was designed to maximize surgical performance based on objective clinical measurements. The system has two patient-side arms that are cable-driven with 7 degrees of freedom each. The arm kinematics are based on a spherical mechanism such that the tool always passes through a remote center (e.g., the insertion points for minimally invasive surgery).
The length and angles of the links were optimized to maximize performance throughout the workspace. The arms are lighter, smaller, and less expensive than current robotic systems for laparoscopy. The instrument controllers are haptic devices, allowing force feedback on the operator’s hands based on tool forces or virtual fixtures (e.g., forbidden regions) defined with respect to patient anatomy (for the impact of haptics on surgery). Teleoperation experiments have been conducted with the RAVEN, including routing the data transmission through an unmanned aircraft. In February 2012, five systems were provided to various other surgical robotics research labs to spur collaboration and further development efforts.
In another endoscopic research effort, the German Aerospace Center (DLR) is developing MiroSurge to be highly versatile with respect to the number of surgical domains, arm-mounting locations, number of robots, different control modes (e.g., control of position versus control of force), and the ability to integrate with other technologies. The expectation is for a base robot system to hold specialized instruments, such as DLR’s MICA instrument (which is itself a robotic tool with 3 degrees of freedom and force sensing).
By using a general robotic base to hold a specialized robotic instrument that has its own motors, sensors, and control electronics, the same base system can be specialized for various procedures just by switching the instrument. The base robot, the DLR Miro, masses 10?kg with a 3?kg payload and has serial kinematics that resemble the kinematics of the human arm, with joint ranges and link lengths optimized based on certain medical procedures. Unlike the RAVEN II, the MIRO arm does not have a remote center of motion, and thus must be controlled to direct the instrument through any insertion point, but is more easily able to handle moving insertion points (e.g., through the chest wall during respiration).
Amadeus: Titan Medical Inc. is currently developing Amadeus, a four-armed laparoscopic surgical robot system, to compete with Intuitive Surgical’s da Vinci system. The Amadeus uses snakelike multiarticulatingarms for improved maneuverability, and the system is being designed to facilitate teleoperation for long-distance surgery. Human trials are planned for late 2013.
NeuroArm and MrBot: At least two renowned research systems are investigating improved MR-compatible robots. The neuroArm (University of Calgary, MacDonald Dettwiler and Associates, IMRIS) is a two-armed, MRI-guided neurosurgical robot actuated via piezoelectric motors. The neuroArm end effectors are equipped with 3 degrees of freedom optical force sensors and are accurate to tens of micrometers. The MrBot (Johns Hopkins University) is a parallel linkage arm designed for MRI-guided access of the prostate gland, actuated by novel pneumatic stepper motors for reduced MR interference.
TraumaPod: TraumaPod (highly collaborative, led by SRI International) is a semi-autonomous telerobotic surgical system designed to be rapidly deployable. The surgical cell consists of a surgical robot (da Vinci for Phase I testing), Scrub Nurse Subsystem, Tool Rack System, Supply Dispensing System, Patient Imaging System (a movable X-ray tube), predecessor of the aforementioned LS-1 (“suitcase intensive care unit”), and Supervisory Controller System. The TraumaPod has demonstrated successful teleoperation of a bowel closure and shunt placement on a phantom without a human in the surgical cell. That success implies the potential for increased automation in the operating room, though challenges were reported in sterilization, anesthesia, and robustness.
HeartLander: The heart has long been a target for surgical robots and various systems continue to investigate how best to treat cardiac diseases, particularly while the heart is beating. The HeartLander (HeartLander Surgical) is a minimally invasive robot that uses suction to crawl around the surface of the heart. The system is designed for intrapericardial drug delivery, cell transplantation, epicardial atrial ablation, and other such procedures.
Medical robotics is a young and relatively unexplored field made possible by technical improvements over the past couple of decades. Currently available systems have been available for too short time to allow long-term studies. Nor are the benefits potentially provided by medical robots fully understood. Medical robots have only passed through a few technological generations and the technology continues to change and leap into new areas. Yet by looking at the current market and representative research systems, educated guesses can be made about the impacts of robots on near-future medicine.
In surgical robotics, there has been a trend away from autonomous or even semiautonomous motions, and toward synergistic manipulation and virtual fixtures. Thus, the robot acts as a guidance tool, providing information (and possibly a physical nudge) to keep the surgeon on target. Such use requires accurate localization of the tissues in the surgical site, even as the tissues are manipulated during surgery.
Improved imaging systems (e.g., Explorer, an intraoperative soft tissue tracker by Pathfinder Therapeutics or robot compatibility with MRI or CT will provide that localization. In particular, MRI-guided robots will benefit from intraoperative 3D images with excellent soft tissue contrast and accurate registration between the tool and the tissue, thus allowing precise virtual fixtures, “snap-to” and “stand-off” behaviors. Further, such imaging will allow modeling and rapid prototyping of patient-specific templates/jigs/implants.