Humans versus robots: robot-assisted heart surgery

Science appears to be on the verge of the second generation of robotic surgery, with technological advances that may be able to dramatically increase the number of minimally invasive surgeries. Minimally invasive medical techniques aim to reduce the amount of extraneous tissue that is damaged during diagnostic or surgical procedures, thereby reducing a patient’s recovery time, discomfort and side effects. New scientific innovations will boost the medical industry by integrating new technologies (eg, artificial intelligence) with surgical robots. Robots are considered to be the future of surgery and this next phase will potentiate the technology’s capabilities and mitigate the challenges that it faces, such as:

• the need for back-up plans;
• security;
• ethics; and
• patient permission.

By 2020, the surgical robotics market will be worth approximately $5 billion.

Intuitive Surgical, a US corporation that develops, manufactures and markets robotic products designed to improve the clinical outcome of minimally invasive surgery (most notably using the da Vinci surgical system), has published the most inventions in this domain. An analysis of portfolios that have strong interactions with each other revealed that Intuitive Surgical is cited by most players, including:

• the Massachusetts Institute of Technology;
• Converge Medical;
• Cardeon Corp; and
• Gunter Niemeyer.

Therefore, it is likely to hold both pioneering and blocking portfolios.

The published inventions and scientific innovations suggest that the scientific community is mainly focusing on closed chest surgery. Key industry players (eg, Intuitive Surgical, PLA General Hospital, Converge Medical, Medivas and East Carolina University) have published inventions that focus on surgical devices which enablee closed chest surgery to be performed on a beating heart. Most of these inventions focus on a stabiliser (eg, a coronary tissue stabiliser used for beating heart surgery) or a retractor (ie, to retract tissue in order to expose the desired area of the cystic duct to the surgeon during cholecystectomy).

There are several reasons for researchers to have filed inventions for such stabilisers. First, it requires advanced surgical skill to create anastomosis properly during heart surgery, because even with the use of sutures to suspend the portion of the heart that is being operated on, the beating heart continues to move in the targeted area. The sutures may also cause a myocardial tear (an injury of the coronary artery branches) or complications (eg, as embolism or focal arteriosclerosis) due to the pressures of the ligatures on the artery. Second, the use of devices which compress the heart (eg, a local myocardial compression device) can cause local deterioration of cardiac functioning, particularly when a cardiopulmonary bypass is not used to supplement blood circulation. Such devices also do not address the problem of bleeding from a locally dissected coronary artery intended for anastomosis. Thus, there is the need for new and improved devices and methods to stabilise a surgical site (eg, a beating heart) or an internal treatment site during minimally invasive or robotic surgery.

Other patents have offered solutions to further issues surrounding robot-assisted surgery, including:

• devices, systems and methods that enable the components of a telesurgical robotic system to be selectively and independently repositioned;
• products that provide the protective function for a surgical head support frame;
• systems and methods which use servomechanisms under the control of a surgeon to augment the surgeon's ability to perform surgical procedures on a beating heart; and
• methods for heart imaging.

While this technology is emerging, key industry players are also collaborating with organisations and academic institutions to improve their portfolios. In March 2015 Ethicon (a Johnson & Johnson medical device company) collaborated with Google to work on surgical robots which are far more affordable than Intuitive Surgical’s da Vinci.

Comment

Robotic heart surgeons perform complex procedures, including:

• mitral valve repairs;
• coronary revascularisations;
• atrial fibrillation ablations;
• intracardiac tumor resections; and
• congenital heart surgery.

Minimally invasive telesurgical robotic systems are being developed to increase a surgeon's dexterity when conducting internal surgery, as well as to allow a surgeon to operate on a patient from a remote location. The adoption of robotic surgery has been comparatively slow, which is likely due to its complexity and the absence of formal training programmes. While the proposed robotic surgery systems offer significant potential for an increase in the number of minimally invasive procedures, further improvements are needed.

However, the proposed methods of performing robotic heart surgeries also pose many new challenges. The dexterity of the robotic surgeon must be improved compared to standard endoscopic techniques by providing more freedom to perform the surgery by means of an easily controlled mechanism, while at the same time allowing surgeons to use different tools (end effectors) which are quickly interchangeable during the course of an operation.