How robotics will define the surgical future

Promaxo is bringing imaging machines in-office, to eventually do surgical procedures in that space

On the battlefield, the breakthroughs in video imaging, robotics and artificial intelligence have enabled pilots to apply a surgical strike at a target thousands of miles away, sometimes in densely populated areas. Now imagine surgeons using joysticks to operate small, lithe, steady robotic hands as they’re guided by state-of-the-art cameras and artificial intelligence to conduct remote precision surgeries on people in other towns, states, faraway countries or outside of a standard operating room and inside clinicians’ offices.  

As sci-fi as that sounds, we might see such advancements in our lifetime.

This year, it's projected that there will be over 1,500 surgical robots in use, a staggering 22-fold increase in the last decade since 69 were installed in 2010. Driving that leap in usage is the capital flowing to make these innovations a reality. The global healthcare robotics market is projected to more than double to $11.44 billion from $5.4 billion in 2017. 

At Promaxo, we’re doing our part by miniaturizing the hardware, in this case the bulky MRI machines, to bring these robust imaging machines into the office setting, allowing physicians to initially conduct diagnostics and eventually surgical procedures inside that space, thereby dramatically reducing the time between a doctor’s visit and the operating room. It’s a vision that is very much aligned with the overall market trends and validated amongst fellow innovators who are also shaping the surgical landscape of the future.     

A confluence of different modalities 

The benefits of having a robot assist in surgery are manifest: thanks to their small size, they can go deeper into impenetrable places too imposing for a human to get to and handle high-definition cameras to give surgeons a more accurate view of the operating area. They can also provide decision-making guidance during the procedure by leveraging knowledge accrued from thousands of surgeries analyzed and reviewed in the database. The benefits for patients are smaller incisions, therefore less bleeding, which leads to faster recovery times, and overall a time-and-cost-savings experience.  

In order to achieve these benefits, a number of methods have to and are starting to work together.  

“Very soon, we’ll be combining imaging modalities, such as MRI, CT scan and x-ray, with artificial intelligence so that physicians will be able to get on their computer in their office and telerobotically manipulate catheters. If we build in this AI with imaging, we can use communal expertise and experience along with individual abilities to enhance catheter technique, manipulation as well as decision making,” said Louis Cannon, MD, FACC, FSCAI, whose venture firm BioStar Capital invests heavily in medical device innovation.

Both Cannon and I also expect that these combined modalities will be used in more complicated procedures, such as heart and brain surgery. “We’ll take that robotic precision that they’ve developed in urology and gynecology and other procedures, combine that with AI as well as imaging modalities, into valve surgery, carotid artery surgery, brain surgery, orthopedic surgery. The field is just developing and we’re seeing a lot of innovation coming out in those areas.” 

Indeed, urological and gynecological surgeries are the leading areas we’re seeing robotic surgery applied. In fact, the use of robotic assistants account for more than half of the gynecologic and urologic procedures. 

The next step, however, is advancing the modalities enough to allow surgeons to execute without even being in the same room as the patient.   

Moving surgical procedures in-office

As stated above, our vision is to do just that: take surgeries out of the operating room and into a clinician’s office, whereby a remote surgeon can be networked in and take over.  

It is a vision shared by Abel Ang, CEO of medical device company Advanced MedTech, a medical device company and a leader in the field of urology. The “Holy Grail” for remote surgery is when we get robotic surgery procedures out of the operating room and into the doctor’s office, Ang believes.

“When you shift the site of care out of the acute care setting, into a doctor’s office, you also shed a whole bunch of costs as well, which is why you see in the US this push toward ambulatory surgery centers,” Ang said. “There’s going to be a lot of reward for a company that can enable this. But it’s a function of finding a procedure for which you are going to be reimbursed well. It’s just a matter of time, however, because that’s where the opportunity is.” 

Such a move will also mean a shift in what modalities are used for diagnosis, and even treatment. There’s already a move away from x-rays to MRIs and ultrasounds, mostly due to the fact that there’s no cancer risk with an MRI or ultrasound thanks to the lack of radiation exposure. That’s why they’re already being used for things like kidney stones, as well as for treating prostate enlargement, also known as benign prostatic hyperplasia (BPH).

“There seems to be a significant push in the US right now to move away from x-ray as an imaging modality. We see that a lot in urology. The amount of interest that I have seen in ultrasound imaging for something as simple as kidney stones has been incredible,” said Ang. “I see ultrasound as potentially a leading indicator of this move away from traditional imaging modalities into the newer imaging modalities, and MR is a good example of that.”

The goal of the surgical future: remote surgeries 

If we can shift the surgery into a doctor’s office, then it shouldn’t be long before we conduct cross-state, cross-country and cross-continent surgeries. Such a scenario would be beneficial for patients in remote and rural areas, where they don't currently have access to the best surgeons. 

BioStar’s Cannon agrees. His observation: “If you look at a state like Michigan, we have a lot of major centers in places like Detroit and Ann Arbor, but if you look at the upper peninsula, there’s a huge population that really has no access to interventional radiology or cardiology. So, it’s important to have imaging modalities in those smaller community hospitals, and the ability to have some type of lab, where an emergency physician or a phlebotomist can put in an arterial line, get the first catheter ready in the robot, and then the catheters can be manipulated from afar by a surgeon,” he said.

The potential use cases for remote surgery are practically endless: think of someone on a cruise ship, for example, who needs emergency surgery but can’t get back to the mainland in time, or a soldier in the field of battle, where instead of having to be airlifted out and taken somewhere else to get surgery, that procedure could be done right then and there, saving time and potentially their life. 

While these are life-changing advances, there’s multiple events that need to happen first, not the least of which is removing latency -- the potential lag between what the surgeon is seeing and what’s actually happening inside the patient.  

This is where 5G networks can make big inroads. Stefano Bini, Chief Technology Officer for orthopedic surgeries at UCSF, also believes that without that upgrade in network capacity, we won’t realize the potential of robotic surgery.   

“5G will have a significant potential impact in remote robotics surgery, as well as on the use of data collected from the robots,” said Bini. “It will allow us to connect that data across multiple sites, and large enough datasets, from which we can optimize machine learning algorithms for a specific outcome, and then optimize that outcome by supporting the surgeons on the decision-making side.”

Most importantly, we both believe 5G can be used to improve how imaging is collected from the tissue being managed so that we can improve the accuracy of the robot as it performs its functions. Notably, that is where he thinks that the largest and the fastest changes are coming right now. 

“With soft tissue imaging, it has some value, but imaging at the time of surgery has even more value and that is happening now with fluorescents that identify the structure of interest to camera-vision-enabled robots.” 

Another current issue in robotic surgery is around licensure. Even if the industry can prove that a machine learning algorithm can provide better diagnostics than a clinician,  the machine can’t actually make a decision on treatment without a human being present because only a human has the license to make that call.  

What Bini has observed is that machine learning algorithms can pick up a fracture with 99.99 percent accuracy, which is more accurate than a regular radiologist. “We already know we can do that,” he said. “But it’s one thing to make a diagnosis, it’s another thing to act on it because it requires the robot to have a medical license.” 

Conclusion

We’ve come a long way since the first robotic system was deployed back in 1985. Particularly in urology, robotic surgery is already pervasively used in simple surgeries, and in time will be applied to more complex ones. The “Holy Grail” of allowing for surgeries in-office is around the corner as telerobotics becomes a reality.    

“I think we’re actually going to see the realization of this within five to 10 years,” Cannon tells me. “I believe the armed forces are already significantly looking into how to bring acute trauma and injury care to the patient so as to not take the patient to where they can be treated but take treatment to them.”

There’s still a number of things that have to happen in that time, including a better connection, which 5G will help with, but once it does, not only will procedures finally be able to be done remotely, but also in-office, making them not only more accessible but also cheaper. 

Say hello to your robot surgeon.

(Image source: hub.umd.edu)