Operating room technology
patient’s feet is a remote-controlled unit that advances or retracts the guidewire. When the wire reaches its target, the system deploys a catheter which is followed by either drugs or a stent retriever – a kind of net that captures the clot and removes it. All of this can be done in a matter of minutes, or even seconds, says Zhao. “It’s very fast, because all the navigation can be controlled by the magnet.” Currently, the system has been tested successfully on pigs from the next room.
While the system relies on network speed and connectivity, the guidewire itself moves slowly, so if you’re cut off briefly you can just stop and wait until you reconnect, Zhao explains. The system would be able to work on 5G, he adds. “Stroke is the number one cause globally of long-term disability and the number two cause of death – the impact is even higher than cancer,” says Zhao. “The ultimate goal is that we’ll deploy this robotic system at hospitals… and neurosurgeons can control the robot from bigger centres and treat stroke remotely.”
Heart disease “If you are a patient living in a rural location, and you have a heart attack, your local hospital may not have the expertise to open that up quickly and save your life,” says Dr Ryan Madder, section chief of interventional cardiology and director of the Cardiac Cath Lab at Spectrum Health. “We think we can reach those rural hospitals using telerobotics.” Madder and his team have been exploring the possibility of using a robotic system to fix blocked arteries in the heart remotely – a procedure they’ve termed “telestenting”. “We know that it’s technically feasible right now, based on the research we’ve done,” he says. To place a stent, a catheter is inserted into an artery and guided to the blockage. A thin, flexible wire is threaded through the catheter, and a balloon with a stent inside is passed over it. The balloon is inflated and the stent locks into place; the balloon deflates and is removed. Aside from leading the catheter to its target, the robotic system can perform the entire procedure. A robotic arm at the patient’s bedside applies force to drive the guidewires, balloon, and catheters, which is controlled via buttons and two joysticks in a separate room. The surgeon’s attention is fixed on a screen, which shows a real-time x-ray feed of the heart. In the REMOTE-PCI trial, published in 2017, this system was tested successfully while 55 feet away from the patient, using a Wi-Fi connection. In 2018, Madder used it to place stents in pig arteries from more than 100 miles away. A year later, the team wanted to see how far the robot could be from the cockpit while still operational. From Boston, Madder placed stents in endovascular simulators in San Francisco – more
Practical Patient Care /
www.practical-patient-care.com
than 3,000 miles away – using both wired and 5G wireless networks. “We think we can probably reach anywhere that has an adequate quality of service in the continental United States,” he says. But there’s still a way to go before patients can access it, Madder adds. “We still need to understand a little bit more about how those robots function when the commands from the robotic controls are being passed over the network.”
Making remote surgery a reality While robotic surgery is technically viable right now, we’re probably still a good few years away from remote operations becoming routine. For example, Zhao’s team is planning to launch a company to bring their technology to clinics, with hopes of getting FDA approval within 3-5 years. However, he predicts it could take maybe a decade for it to be used remotely: first, big hospitals need to get to grips with it, before it trickles down to smaller centres.
“Twenty-two years after what we have done, now everybody understands that this is the future.” Dr Jacques Marescaux
It’s hard to say whether the proof of concept for widespread remote surgery will come from a routine procedure like stenting or an emergency operation like a thrombectomy. But either way, it seems clear that maintaining a consistent connection with the robotic system involved, or at least having a safety control in place for variations in latency, will be key to gaining approval from regulators and acceptance from the medical community.
In any case, remote and robotic procedures are requisite learning for the next generation of surgeons, says Marescaux. “Twenty-two years after what we have done, now everybody understands that this is the future.”
A diagram showing the balloon stenting procedure Dr Ryan Madder is working to achieve remotely using robotics.
3,000+
Dr Ryan Madder’s team placed stents in endovascular simulators while over 3,000 miles away.
Spectrum Health 53
Sezer33/
Shutterstock.com
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