Healthy Week 2010

Surgical Robots Draw Fans and Controversy

Shelly K. Schwartz, |Special to

When David Samadi started his career in 1994, prostate surgery was an open procedure taking 3 to 4 hours, resulting in significant blood loss, a 20-percent transfusion rate and a hospital stay of two to four days.

Source: Intuitive Surgical

Today, the chief of the division of robotics and minimally invasive surgery at Mt. Sinai School of Medicine in New York, completes the procedure in less than half the time, with almost zero blood loss and virtually no need for transfusions. Most of his patients are discharged within 24 hours.

His weapon in the war against prostate cancer? Surgical robots.

Samadi is among the pioneers of robotic surgery, performing over 2,500 procedures using the breakthrough da Vinci Surgical System.

Developed by Intuitive Surgical in Sunnyvale, Calif., it consists of a surgeon’s console, a patient-side cart with four interactive robotic arms and a three dimensional high definition vision system.

To perform a procedure, surgeons use the master controls to maneuver the robotic arms, which hold the surgical instruments and endoscopic camera, allowing greater precision and a minimally invasive approach for complex procedures.

To date, tens of thousands of procedures, including general, urologic, gynecologic and thorasoscopic procedures have been performed using the da Vinci tool, helping patients experience less pain, fewer scars, a lower risk of infection and faster recovery.

“I went through the whole surgical evolution,” says Samadi. “I started in open surgery with 8-inch incisions using my hands to perform procedures. I always had two gloves on and worried about the risk of HIV and hepatitis. Then, we moved to laparoscopic surgery and now robotics. It already has revolutionized the field.”

Samadi stresses, however, that medical robots are only as good as the surgeons behind them.

The da Vinci System, for example, is designed to replicate the movement of the surgeon’s hands with the tips of micro-instruments. It does not make decisions or perform a movement without the surgeon’s input.

Next Generation

That’s what the next generation of surgical robots seeks to change.

In the quest to deliver ever smaller, ever smarter technology, medical device companies are rolling out new robotics that take human error out of the equation.

While the da Vinci System and others like it are categorized as “haptic,” which act as an extension of the surgeon’s touch (and provide the instrument control necessary for many procedures), companies like Curexo Technology in Fremont, Calif. are developing “active” robotic systems for other applications that guarantee precision.

Its ROBODOC Surgical System, for example, allows surgeons to perform virtual joint replacement surgery on a computer workstation days before the procedure using 3D data from a CT scan of the patient.

The virtual surgery, in which the bone is milled or shaped to ensure an exact fit of the implant, is loaded on ROBODOC in the operating room the day of the surgery and provides precise execution of the surgeon’s plan every time. The surgeon, however, is still an active participant in the operation, installing the actual implant.

During conventional hip replacement surgery, the surgeons prepare the surface of the bone for implant using hand tools, including broaches, mallets and power reamers, which do not always provide the desired fit or position of the implant.

X-ray of pelvis showing hip replacement
RNHRD NHS Trust | Stone | Getty Images

“It’s like the best golfer’s being able to hit the center of the fairway 350 yards out every time regardless of the weather," boasts the company.

Tiny Is Better

While surgical robots are already delivering better patient outcomes, though, it’s the microscopic machines, or nanorobots, still in the research and development labs that offer greater promise still.

At present, billions of dollars are being invested in this nascent field as scientists develop biomechanical devices that will someday be injected into the blood stream to work at the atomic, molecular and cellular levels—performing specific biological tasks, like repairing tissue damage, cleaning arteries, diagnostics and medical defense against pandemic viral outbreaks and chronic disease, like cancer.

Such devices, which are largely being constructed using carbon atoms, will eventually be controlled, and even re-programmed, within the body via acoustic signaling, or sound waves.

Strategically placed nanorobots that transmit data from inside the body will enable doctors to monitor the position and progress of the devices during procedures. All would be flushed from the patient’s body once their function is complete.

Early stage nanorobots, which are built on the nanoscale (1 nanometer is one billionth of a meter), will likely be used as drug delivery systems, transporting drugs more directly to the site of injury or disease.

But Erkki Ruoslahti, a distinguished professor at Sanford-Burnham Medical Research and founding member of the University of California, Santa Barbara-Sanford Burnham Center for Nanomedicine, says the potential application of nanorobots in health care is limitless.

At present, Ruoslahti’s team is developing nanorobots that are capable of targeting diseased cells, making anticancer drugs already on the market more effective.

“At this point, we can increase the activity of any anticancer drug by three fold or better,” he says. “We get more drug to the tumor and that makes a huge difference. If you can increase its concentration, the side effects remain the same, but the effectiveness is higher.”

Alternatively, he notes, by delivering a greater concentration of drugs to the diseased cells, you could use a lower dose of the same drug and realize the same efficacy with fewer side effects.

“It’ll be significant, but whether it’s going to be transformative, it’s too early to tell,” says Ruoslahti.

Sending Signals

Eventually, though, nanorobots will be capable of emitting a diagnostic (or theranostic) signal, in which particles send information for imaging as well as the release of a drug, he says.

They may also become self-amplified, in which nanoparticles that find their target site recruit more particles to fight disease.

“You can also potentially have one particle synergize with another at the target site so you could arrange the drug release in such a way that it happens upon command or more slowly or at certain times,” says Ruoslahti. “There are many advantages to controlling drug release and drug delivery.”

Though many estimate widespread application of such products is still 20 to 30 years out, a small number of products are already in the clinical testing pipeline.

“These systems are ready to go to clinical trial and some are already in trials,” says Ruoslahti. “It may take another five to 10 years to get to the clinic from where some of the new nanomedicine applications are now, but this isn’t a pie in the sky kind of thing. This is reality.”

Nanomedicine, of course, is not without critics.

While much of the dialogue surrounding medical robots has centered around their potential to improve quality of life, there are those who suggest research in this field is progressing too fast to adequately assess the risks.

Some, for example, maintain that nanoparticles have the potential to increase in toxicity once introduced into the body, or that they could disrupt the body’s natural immune system. Others fear unforeseen side effects and the impact of nanorobots on animals and the environment once dispelled by the human body.

Whatever your position, one thing is clear: robotic medicine is here to stay.

“The impact of this new field of science, termed nanomedicine, on medicine and life-sciences, will be hugely transformative, comparable in magnitude to the transition from transistors to silicon chips in computer sciences,” the Sanford-Burnham Center for Nanomedicine writes.