Smart surgery - from technical fascination to clinical reality

Even today, there are many AI applications in the OR: intelligent systems monitor the interventions; they record any problems that occur, the instruments that are used and how much blood the patient lost during surgery.

As of next year, intelligent post-surgery drainage systems will be available that recognize pathologies and inform the surgeon automatically when any anomalies occur. “We will be able to cut the response time from the moment the pathology is detected from six or eight hours to about 30 minutes. Thus we will reduce the impact of complications and increase the speed of recovery. We have already tested the prototype in our lab,” Professor Karcz reports.

Robot or not?

The use of AI in robot-assisted surgery is well known beyond the medical world. In 1985, the first robot-assisted intervention was performed when the robotic arm PUMA 560 placed the needle during a CT-guided brain biopsy. Since then, increasing automation and focus on minimally invasive surgery have driven progress. Intuitive Surgical for example has deployed 5000 DaVinci robots worldwide.

Professor Karcz however does not consider these support systems autonomous robots. “When we hear the word ‘robot’, we think of Star Wars where the robots think and act autonomously. Today’s robots in the OR do not perform any autonomous tasks, they are nothing but the surgeon’s extended arm,” he explains. Equipped with seven degrees of freedom they act as telemanipulators which execute the surgeon’s movements. The control of the robotic support systems remains entirely with the surgeon.

Small and intelligent

The telemanipulators that are currently in use are heavy, large and take up considerable space in the OR; thus Professor Karcz is sure that “the next wave in robot-assisted surgery or intervention will be miniaturization.”

The Israel-based company Human Xtensions has already miniaturized the arm of such a telemanipulator and developed a bionic OR instrument with seven degrees of freedom that enables precise movement directly on the patient undergoing surgery.

Researchers meanwhile are working on alternatives to the conventional intraluminal interventions. “The patient ingests a mini-robot in a capsule that moves through the body to sample tissue or to destroy diseased tissue. What might sound like science fiction is already clinical reality in the test phase,” Professor Karcz explains with reference to the tiny encapsulated robot a team of researchers previously presented¹.

A similar invention is the Origami robot which was presented in 2016 by researchers at the Massachusetts Institute of Technology, the University of Sheffield and the Tokyo Institute of Technology. It unfolds from a capsule the patient swallowed.² This mini-robot consists of two layers of material enveloping a third material which shrinks when heated. A pattern in the outer layer defines how the robot “develops” when the middle layer shrinks. A permanent magnet is placed in one of the folds. It reacts to changes in the magnetic field outside the patient body that control the robot movements. Primarily rotational forces are applied to the robot: the robot rotates quickly around its central axis or more slowly around one of its fixed legs. In addition, the robot can move forward in a caterpillar-like stick-slip movement.

In one experiment the robot removed a button battery a child had swallowed from the stomach. The researchers aim to use the robot to close internal wounds without surgery. Researchers at Max Planck Institute for Intelligent Systems also developed a magnetically controlled tiny robot. It enables drugs to be delivered right to the location in the body where they are needed. Professor Karcz is even going a step further and envisages “mini-robots joining forces to autonomously take samples and deliver different therapies”.

Visualisation

Surgical visualisation is also making progress. Professor Karcz explains the differences between analog, digital and hybrid augmentation. Analog augmentation is based on a merely chemical reaction: indocyanine green (ICG) for example consists of particles showing diffuse fluorescence when stimulated by near-infrared light (NIR) (λ = 600-900 nm) with certain optical systems. In fluorescence imaging the patient receives an ICG injection. This method is routinely used in laparoscopic visceral surgery where it provides important information, for example on blood flow.

Digital augmentation, Professor Karcz points out, is the use of augmented reality. Radiology images are post-processed digitally to extract the organs of interest. Thus an image is created which does not mirror reality, but the surgeon can use it during surgery to highlight certain target areas in the body. “AR is very useful when we need to know where exactly the relevant veins, vessels or tumours are located,” says Professor Karcz. 

In hybrid augmentation fluorescence images are superimposed on digitally processed images to colour-code certain tissue types thus allowing the surgeon to recognize tumours in real-time. “Imagine using laparoscopic lasers that make malignant tumours visible!” This technology was developed as a microscope by researchers at the Leibniz Institute for Photonic Technologies (Leibniz-IPHT) at Friedrich Schiller University, the University Hospital and the Fraunhofer Institute for Applied Optics and Precision Engineering in Jena. On top of Professor Karcz’s wish list: “We would like to receive all this information on a multi-layered video image of the laparoscope monitor.”

Change in curriculum

While these developments will take years, Professor Karcz is convinced that technological progress will change the role of the human surgeons, maybe even making them obsolete very far down the road.

In view of the current trends in technology medical training will also have to adapt. Professor Karcz predicts the conventional classroom lectures to be replaced by virtual training. Even more: “The multi-faceted application of AI and other new technologies will change the conventional medical training. Thinking robots will perform tasks autonomously in the future and the surgeon will control these activities. Thus, the focus of medical training will be to teach the students how to work with these technologies.”

<sup>1. Designer: Mats A. Heide, SINTEF, Norway. https://www.tandfonline.com/doi/full/10.1080/17434440.2019.1608182, http://vector-project.com/press/index.html.
2. Shuhei, Miyashita, Steven Guitron, Kazuhiro Yoshida, Shuguang Li, Dana D. Damian, and Daniela Rus. "Ingestible, Controllable, and Degradable Origami Robot for Patching Stomach Wounds." 2016 IEEE International Conference on Robotics and Automation (May 2016). https://dspace.mit.edu/handle/1721.1/103071.</sup>

Profile:
Professor W. Konrad Karcz MD, PhD, PHM, leads the Minimally Invasive Surgery Section at the General, Visceral and Transplant Surgery Clinic of Ludwig Maximilian University Hospital in Munich, Germany. He gained many years of experience in conventional, minimally invasive and robot-assisted surgery as well as management training in renowned institutions such as the Silesian Medical University in Katowice, Cornell University in New York, Albert Ludwig University in Freiburg, University of Lübeck, Harvard Medical School and the Massachusetts Institute of Technology, Boston. For his scientific and didactic achievements in 2019 he received the Karl Storz Prize by the German Surgical Association and a professor nomination in medicine from the President of the Republic of Poland.

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