Image Guidance and Navigation Technologies for Robotic Surgery

As the field of robotic surgery evolves, medical imaging is becoming its backbone. Frost & Sullivan has identified several advancements that support growth.

When we think of medical imaging, we think of the typical X-ray imaging, large magnetic resonance imaging and computed tomography (CT) machines, and ultrasound. But what we often forget is how extensively these machines are used: their role has expanded beyond just diagnosing patients’ medical issues, such as fractures or the presence of cancer in the lungs; they are now being integrated into therapy systems and used as guidance tools during surgical procedures.

Image-guided therapy applications include focused ultrasound and proton beam therapy, but the most relatable one is that of radiation therapy for cancer patients, i.e., the use of image guidance to pinpoint a tumor location and then provide radiation to kill the cancerous cells.

Image-guided surgery (IGS), sometimes considered similar to a global positioning system, is gaining prominence because it allows surgeons to perform minimally (or at least less-) invasive surgeries that are also safer. They are also enabling surgeries that were once considered impossible because of the location in the body. This is most common in brain tumor removal, where IGS allows for measurement of the position, location and size of a patient’s tumor to help plan access and track the surgical instruments during the procedure.

Frost & Sullivan considers the development of IGS to be revolutionary as a means to improve outcomes. Analysts have identified several advancements that have supported this field:

  • IGS became a prominent force in health care by increasing surgeons’ precision and confidence. However, with the advent of surgical robots, IGS is now a prerequisite because navigation of surgical tools during minimally invasive surgeries requires real-time visualization—a direct view of internal structures during these procedures is not possible.
  • Higher processor speeds have enabled high-quality, real-time imaging.
  • Augmented and mixed-reality displays now make it possible for surgeons to have interactive and dynamic visualization.

Public Funding Support

In the United States, the National Institutes of Health (NIH) has been a primary source of funding for academic laboratories’ development of IGS techniques. From 2014 to 2017, a total of $216 million was awarded to IGS research projects, spread over 466 deals. The NIH’s National Cancer Institute is the lead funding agency, having supported 244 of these projects. This underscores the importance of IGS in the field of cancer surgery. A project by On-Target Laboratories, for example, received $1.25 million in 2017 to develop a novel bimolecular cocktail tagged with fluorescence markers for intraoperative use in lung cancer resection surgery. Essentially, before surgery, the cocktail (injected in to the patient’s blood) finds its way to the tumor. During surgery, the doctor can then cut along the exact edges of the tumor which will fluoresce, keeping normal tissue intact—a major challenge during most cancer surgeries. The research project is ongoing and expected to end in 2019.

Venture Funding Support

Over the past few years, venture capital firms have provided more than $400 million to start-ups in the IGS space. Redwood City, Calif.-based Auris Health (formerly Auris Surgical Robotics), which develops products targeting lung cancer, raised $280 million in Series D funding, one of the largest deals in this space. After recently gaining U.S. Food and Drug Administration (FDA) approval for its Monarch platform, details have now emerged about the company. The Monarch platform leverages bronchoscopy, a common endoscopy procedure,  to insert a flexible robot that can access hard-to-reach areas in the complex lung structures and—in the least invasive way possible—take samples for further testing of whether a mass is cancerous A trained doctor can use a video-game style controller to guide the robot while viewing its video feed in context of previously taken CT scans to position it correctly. With the funding and FDA approval in place, Auris plans to make the product available to U.S. hospitals by the end of this year.

Another well-known name is Mazor Robotics from Israel, primarily because of its association with the large medical technology firm Medtronic. Mazor’s robotic surgery platforms, Mazor X and Renaissance, target the orthopedic, spinal and neurosurgery areas. Medtronic has invested more than $70 million in Mazor for equity, and has warrants to buy shares worth an additional $53 million. Why this interest? Medtronic’s spine portfolio revenue grew about 3% in 2017, but its core spine revenue actually dipped that year. To instill growth in its spine business, Medtronic invested in Mazor to become the exclusive distributor for Mazor’s products. Spinal surgery is a delicate procedure with little room for error, especially because of the proximity to the spinal cord.  Mazor’s platforms allow surgeons to plan the procedure using 3-D technology, and also guide them during the surgery. The use of robotic systems improves precision and efficiency. Medtronic’s association and the excellent product itself have helped Mazor achieve triple- digit sales growth in two of the last four quarters.

Google’s Entry into the Operating Room

The company that is most likely to shake up the entire space is Verb Surgical. One of the companies under Google’s parent, Alphabet, Verb is a joint venture with Johnson & Johnson. Google/Alphabet has a rich and deep understanding of the data space and is adept at making sense of seemingly unintelligible data through advanced algorithms such as deep learning, machine learning and other artificial intelligence tools. Johnson & Johnson, through subsidiary Ethicon, is a veteran in minimally invasive surgeries, especially endoscopic procedures. Verb’s vision is to create an advanced surgery platform called Surgery 4.0, which is built on five technology pillars:

  • A robust robotics platform
  • Advanced visualization (IGS would benefit from this)
  • Smart instrumentation
  • Data analytics
  • Connectivity

While Verb’s prototype is ready, it has not been made public yet. However, simply because of the convergence of multiple technologies, a combination of which has not been seen before in the surgical space, this product is likely to be revolutionary. But as is always the case in health care—and most industries, for that matter—the price tag will dictate the level of adoption. Google has not always been successful with bringing revolutionary products to the market: Google Glass is an example in the consumer space and not directly related to IGS, though it is being used by physicians now thanks to the company Augmedix. Google was unable to find a use case that would make the product a success, but Augmedix found a way for remote scribes to take notes when Glass-wearing physicians interacted with and examined their patients. But with Verb, Ethicon’s expertize in understanding the market will greatly benefit the venture.

The Road Ahead

As the field of robotic surgery evolves, medical imaging is becoming its backbone. Advanced visualization is critical in providing comprehensive displays that include anatomical, physiological, functional and other supporting information useful for the procedure. Naturally, artificial intelligence (AI) and Big Data can enhance a surgeon’s skills in this regard, such as by highlighting blood vessels, nerve cells or tumor margins in tissue that can be hard to discern by eye or on a screen. Medical imaging AI is already the bellwether application of the technology in health care, with significant advances that leverage deep learning technologies. With robotic surgery also comes the possibility of surgeons operating remotely using robots and IGS technology.

Indeed, the field of surgery probably has never seen as many revolutionary changes as are occurring today. The very nature of the surgeon’s job is changing quickly, possibly ushering in an age in which procedures are much more efficient, less invasive, and therefore less painful.

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