Operating room technology Orthopaedic surgical robots
A lot of the focus in surgical robotics is on devices like Versius and Senhance, which are geared towards making general surgery easier – but orthopaedic surgeons have their own mechanical assistants. Mako – Stryker’s Mako device combines 3D CT-based planning, haptic feedback and data analytics to make minimally invasive joint replacement procedures, such as total knee and hip arthroplasty, simpler to carry out. The medical device giant bought Mako Surgical Corp to take ownership of the robot back in 2013. Mako‘s co-founder Rony Abovitz was part of the company‘s predecessor Z-KAT, which developed its initial haptic robotic arm technology, known as the Whole Arm Manipulator (or WAM Arm) in coordination with Massachusetts Institute of Technology and robotics specialist Barrett Technology. Mako improved the haptic system and demonstrated its ability to perform accurate bone shaping through minimally invasive incisions and performed 23,000 total or partial joint replacement procedures by 2012, which was enough to capture Stryker’s interest.
Rosa – Mako isn’t the only option for orthopaedic surgeons carrying out
arthroplasty procedures, there’s competitor Zimmer Biomet with its own device named Rosa (robotic surgical assistant). Interestingly, Zimmer opted not to include a haptic feedback system akin to Mako’s, as it felt the feature could limit surgeons’ ability to perform full bone cuts comfortably.
Rosa comes in several varieties: The Rosa One Knee System, the product designed to rival Mako, as well as the Rosa One Spine System and Rosa One Brain System – a product made for stereotactic brain surgery.
Space is often at a premium in hospitals – in many cases, there simply isn’t enough room to convert every OR into a hybrid. The size also increases the risk of infection. A larger OR will usually have more people in it, says Slack, adding: “There is a relationship between volume of the theatre, the number of people and infections. And if you have too many people you do get a rise in infections.” He notes, however, that this risk “is largely overcome by increasing the rate of filtration, and you change your air more commonly”. Most hybrid ORs use laminar air flow diffusers to ensure that air flow is of a uniform direction and speed.
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The other barrier to universal adoption of hybrid ORs is the cost. Both the initial investment and the ongoing maintenance and upgrade costs are roughly double that of conventional ORs. Kock points out that the more sophisticated the technology, the greater likelihood there is of technical difficulties. “The technology is so complex that you as a user, a vascular surgeon, don’t have the knowledge or expertise to solve these technical problems,” he says. There is also a maintenance burden: every few months surgeons will lose the OR for a day or two because of the need for regular inspections and checks of the equipment. So, what might change? Can the barriers to adopting minimally invasive surgery be overcome so that it makes sense to convert all, or most, ORs to hybrid status?
The amount of time in minutes it takes for surgeons to learn complex procedures using Versius.
From keyhole to robotic
The most promising developments come in robot technology, which could enable far more surgeons to perform minimally invasive techniques. Until recently, says Slack, deficiencies in robot design – including the huge footprint – have made uptake relatively low;
the vast majority of keyhole surgeries are still carried out manually. Innovators are, however, making robots smaller, more ergonomic and easier to use. Versius, the robot designed by Slack and his colleague Luke Hares, is guided by the surgeon from a 3D magnified monitor. The four robotic arms controlling the instruments move independently of each other, and, like human arms, have wrists on the end. “Because it’s modular, and all the bases are a separate unit, we can mimic the port placement and the procedural steps of keyhole surgery,” says Slack. Complex procedures that would normally take up to 60 hours to learn, such as tying a surgical knot, can be learnt in 30 minutes. The robot is also easily portable from one OR to another. Versius does not achieve better outcomes than a very skilled laparoscopic surgeon, says Slack. Its advantage is that it creates a far bigger pool of surgeons able to use laparoscopic techniques, thereby allowing more patients to benefit from it. Ultimately, the cost to hospitals, from shorter patient stay and fewer infections, is also significantly reduced. Similarly, Asensus Surgical’s Senhance Surgical System is designed to reduce surgical errors by combining augmented intelligence, machine vision and deep learning. The 3D HD visualisation “provides the surgeon with additional intelligence regarding depth and spatial relation of organs,” says Fernando. The more ergonomic design enables the surgeon to sit comfortably and move their hands rather than keeping them static. It also addresses some of the cost issues that have proved a deterrent to robot adoption. Because the technology uses “standard reusable instruments and an open-platform architecture strategy” the cost-per-procedure, says Fernando, is “comparable to manual laparoscopy.” Minimally invasive techniques have already proved their worth, particularly in cardiac surgery, and Slack believes there is increasing desire among surgeons to take advantage of these techniques. Chest surgeons, for example, “are trying to get away from splitting the chest, so increasingly the valves are put up through the arteries and so that needs hybrid theatres”. Similarly, a hybrid OR makes it possible to perform image-guided biopsies – in a lung resection, without a clear image of the tumour, surgeons may resect too much material, Slack explains. If robot technology is able to remove some of the current barriers to adoption, then it seems highly likely that minimally invasive surgery – and hybrid ORs – will become more and more widespread, perhaps eventually replacing the traditional OR altogether. Surgery is undergoing a “sea change moment”, Slack argues, with even small hospitals starting to invest in robot technology: “In the 1990s we went from open to keyhole surgery. Now we are going from keyhole to robotic.”
Practical Patient Care /
www.practical-patient-care.com
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