Surgical Robots: Look Who's Coming To The OR
Intuitive Surgical's da Vinci system dominates the field, but it doesn't have a lock on innovation. Take a look at present and future surgical robots.
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The surgical artist
Robotic surgery today is virtually synonymous with the da Vinci system from Intuitive Surgical, which allows a surgeon to control a four-armed machine that can be used to perform minimally invasive surgery. Three of the arms are designed to wield surgical tools while the fourth probes the surgical site with a high-definition camera that sends a 3D image to the surgeon's console.
Although robots play other roles at hospitals, such as sorting and delivering medication, none of those applications has captured the public's imagination as much as the idea of robots performing surgery with inhuman precision. The da Vinci system is the most flexible example in production, capable of performing multiple operations. The next-most-significant surgical robots in use today are probably those from Mako Surgical, which are specialized machines for performing knee and hip replacement surgery.
Intuitive says it chose to name its product after Leonardo da Vinci because he designed the first "robot", a sort of animated suit of armor, plans for which were found in one of his sketchbooks. Intuitive's armor has been its patent portfolio. Competitors also face the steep challenge of designing a complex medical device and getting it approved for use.
Hospitals are looking for alternatives because of the cost of the da Vinci robot and its questionable impact on clinical outcomes. However, according to The Advisory Board Company, a healthcare technology advisory firm, the alternatives are years away from commercial availability. While those products are in development, Intuitive also has the opportunity to continue improving its own products.
"Competitors are going to have to come to market with something that is significantly cheaper or that demonstrates an outsize clinical benefit," said Rachel Klein, a research and insights consultant at The Advisory Board Company.
Competitors might be able to find a market opening, because the da Vinci system costs almost $2 million and comprises several large pieces of equipment that use up a lot of space in a hospital, Klein said. A couple of years ago, hospitals looking to showcase their cutting-edge technology were talking about adding a second robot. Today, they're more likely to be thinking about how to maximize the effectiveness of the equipment they already have.
With some studies questioning the assumption that robotic surgery really delivers superior clinical results, hospital leaders are also taking a second look at whether the da Vinci robot is being used effectively at their facilities and when its use is necessary, according to Klein. There seem to be a few procedures for which the da Vinci legitimately delivers superior results, she says. In other cases where other techniques for laparoscopic surgery are available, bringing a robot into the operating room could add to the cost and complexity of a procedure unnecessarily.
All that's needed to change the cost-benefit equation is the demonstration of greater benefits, ideally combined with lower cost and smaller units. But the upstarts will find Intuitive to be a formidable competitor.
Photo: Intuitive Surgical
Healthcare robotics is in a period of intense research and development, with many patent applications revealing concepts for new surgical robots under development.
Yet the most significant patent portfolio so far is the one held by Intuitive Surgical, maker of the Da Vinci system. Shown here is a drawing from Intuitive's patent on a "Cooperative minimally invasive telesurgical system." In 2003, Intuitive merged with Computer Motion Inc. -- which had previously sued Intuitive for patent infringement -- and since then their combined patent portfolio has been one factor in fending off potential rivals. Computer Motion's Zeus surgical robotics system was subsequently phased out.
"Since that time, it's been a one-horse race," said John Hargrove, CEO of Titan Medical, which is in the process of preparing to bring its own surgical robot to market, with a design that Titan believes is sufficiently distinct from that of the da Vinci to avoid infringement claims.
Titan invented the "single-port" design, as opposed to the da Vinci's original "dual-port" design, meaning it's meant to perform surgery with one small incision rather than two. But while Titan works to bring its product to market, Intuitive has already introduced a single-port upgrade to the da Vinci.
The da Vinci uses a "docking" mechanism to hold its instruments in place and make their movement within the body more precise.
Source: Intuitive Surgical
In an upgrade from the basic configuration, the da Vinci can be equipped with dual consoles, making it possible for two surgeons to collaborate on the same procedure. This setup is commonly used for training doctors who are new to robotic surgery or teaching new techniques.
Source: Intuitive Surgical
Intuitive has been innovating in other ways as well to make robotic surgery more effective. The company recently received FDA clearance for expanded use of its da Vinci Fluorescence Imaging Vision System (Firefly), which makes it easier for a surgeon to see what he or she is doing.
With a glowing dye and a special camera, blood appears green, and tissue without blood flow appears gray. In gallbladder removal surgery, for example, Intuitive says this capability makes it easier to distinguish between the different types of ducts within the body -- where cutting the wrong one often results in a serious surgical complication.
The next most significant player in robotic surgery to date has been Mako Surgical, creator of the RIO robots for knee and hip replacement. The version for MAKOplasty partial knee resurfacing is shown here.
Source: Mako Surgical Corp.
Mako's approach to both knee and hip replacement is to use a CT scan and 3D imagery to guide the work of the surgeon, who uses a robotic arm inserted through a small incision to remove bone and replace it with an implant.
Source: MAKO Surgical Corp. (Creative Commons CC-SA 2.0)
Titan Medical hopes to be the next company to bring a robotic surgeon to market, targeting a 2015 release for its Single Port Orifice Robotic Technology (SPORT) Surgical System, which it plans to price at under $1 million, or less than half the cost of the da Vinci. In addition to being less expensive, the SPORT will be small enough to be wheeled from room to room.
"Over 3,000 hospitals do not have a robot as we speak," Titan CEO John Hargrove said in an interview. "A device with a smaller footprint, smaller capital cost is very intriguing to them."
Despite the inevitable comparisons, the SPORT will not compete head-to-head with the da Vinci, he said, instead being positioned to "expand the procedural scope" for the use of robots in surgery. "It's a smaller, less-complicated system that can be used for smaller procedures -- procedures that are more common, as well," Hargrove said. Eventually, there might be a few procedures such as benign hysterectomy that could be performed by either device, bringing them into closer competition, "but that's not our first area of focus."
In addition to having a single-port design for entering the body through a single incision or natural orifice, the SPORT features two small, flexible arms designed to snake into position for delicate work.
Pictured here is a simulated gall bladder removal.
Source: Titan Medical
The Raven II robot developed by the University of Washington in collaboration with the University of California Santa Cruz has gained attention for the developers' approach to open-source design of surgical robotics and its potential to change the economics of the industry in contrast with Intuitive's proprietary approach.
However, although the research project has spawned an active developers blog, it so far shows few signs of developing into a commercial product. The research also extends to labs at Harvard, Johns Hopkins, the University of Nebraska, and several University of California campuses, all working to prototype potential new applications for robotic surgery.
The ARAKNES project in Europe is pursuing several designs for surgical robots. The one closest to the da Vinci is the Sprint system for single-port surgery, which features two robotic arms and is designed for a smaller footprint in the operating room.
According to The Advisory Board Company, ARAKNES -- which stands for Array of Robots Augmenting the KiNematics of Endoluminal Surgery -- has several prototypes in development and has done animal studies, bringing it relatively close to winning regulatory approval in Europe first. However, some of ARAKNES's long-range inventions might still be several years away, according to this analysis.
Some of its most adventurous research is on magnetically levitating miniature robots within the surgical cavity or using other techniques to have miniature robots explore the inside of the body.
The ARAKNES project in Europe is pursuing several designs for surgical robots. The one closest to the da Vinci is the Sprint system for single-port surgery, which features two robotic arms and is designed for a smaller footprint in the operating room.
According to The Advisory Board Company, ARAKNES -- which stands for Array of Robots Augmenting the KiNematics of Endoluminal Surgery -- has several prototypes in development and has done animal studies, bringing it relatively close to winning regulatory approval in Europe first. However, some of ARAKNES's long-range inventions might still be several years away, according to this analysis.
Some of its most adventurous research is on magnetically levitating miniature robots within the surgical cavity or using other techniques to have miniature robots explore the inside of the body.
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