Technology Convergence for Robotic and Image-Guided Surgery

The convergence of image-guided technologies and robotics can compensate for a basic and unavoidable problem: patient movements on the table or micromovements within the body due to respiration and physiological changes. Frost & Sullivan continues to explore innovations in this space and has found a number of developments.

Medical imaging technologies have been a foundation of medical diagnosis. More recently, they have come to serve another important use: providing navigational support and guidance during surgeries and radiation therapy. As surgical robots become more autonomous and as instrumentation complexity increases, emphasis is being put on more careful navigation. Similar to a self-driving car, a surgical robot should “know” how to navigate and which areas to avoid in order to precisely and safely perform a procedure. Obtaining visual, tactile and other sensory feedback is considered to be vital for clinical safety.

The convergence of image-guided technologies and robotics can compensate for a basic and unavoidable problem: patient movements on the table or micromovements within the body due to respiration and physiological changes. This could, for example, cause a tumor to move or change shape and a radiation beam to be misdirected. Conventional methods to immobilize a patient, such as using physical restraints, head-mounted metallic frames to map brain tumors, or the insertion of a rectal balloon for prostate cancer treatment, can be rendered ineffective due to micromovements.

Frost & Sullivan continues to explore innovations in this space and has found a number of developments, including those from these pioneering companies.

Accuray (Sunnyvale, Calif.)

Accuray has long been a leader developing tumor treatment platforms. Its CyberKnife, originally developed at a Stanford University research lab, is a fully robotic radiation delivery system that has been in use for nearly two decades.  The system’s image-tracking software records minute changes and controls a robotic arm that is fitted with a linear accelerator and moves as the target area moves, eliminating the need for rigid immobilization. The arm is capable of swift movement along three axes, and is supported by sensors that can detect minor changes in the target location. Beams directed from as many as 200 distinct angles “coat” a tumor with high-energy radiation.  The company’s TomoTherapy system uses computed tomography information to detect changes in tumor location between treatments and reconstruct 3-D anatomical images to deliver a highly focused radiation beam to the tumor region. 

Accuray’s latest triumph came in July 2017, when its iDMS (integrated data management system) received U.S. Food and Drug Administration (FDA) clearance. The centralized database integrates patient records for access by multiple Accuray platforms as well as third-party systems. This newly enabled connectivity gives treatment centers the flexibility to better plan therapies and move patients between systems using a single treatment record. Accuray said in December that Heidelberg University Hospital in Germany and the Oscar Lambret Cancer Center in Lille, France, were the first to connect the iDMS with their CyberKnife and Tomotherpy platforms.

Surgical Theater (Mayfield Village, Ohio)

The company’s Surgical Navigation Advanced Platform (SNAP) and Surgical Rehearsal Platform (SRP) are both FDA-cleared for clinical use. The SRP reconstructs DICOM images into 3-D images that can be manipulated—for example through panning, zoom or rotation—on a console or a touch-sensitive screen so surgeons can plan for and practice complicated surgeries. SNAP is an advanced navigation and imaging module that is integrated with the surgical workflow. It gives surgeons an immersive experience with multiple 3-D points of view that they can see through their surgical microscopes. A segmentation feature makes internal structures semi-transparent for monitoring of tumor size, morphology, and progress. The technology was developed keeping MRI and CT imaging modalities in mind, but it can be expanded to incorporate optical imaging capabilities too.

Royal Philips (Amsterdam, Netherlands)

In January 2017, Philips announced that it is developing an augmented reality-based visualization platform for spinal surgeries. The technology uses high-resolution optical imagers to capture a patient’s body surface and a low-dose X-ray imager to capture internal organs. An image processor integrates these distinct images to create a 3-D composite image that provides both anatomical and physiological information. The composite image is overlaid on the patient’s body to map incision sites on the skin and surgical sites on the spine, eliminating the need for uncomfortable or painful pedicle screw placement. A preclinical study comparing the accuracy of pedicle screws and the Philips platform indicated that the latter showed an accuracy of 85 percent in guiding surgeries, while the screws were only 64 percent accurate. The system is expected to be ideal for minimally invasive spinal, cranial and other traumatic surgeries.

The Road Ahead

One of the trends that Frost & Sullivan observed in robotic surgery is the changing nature of the system: from a master-slave configuration to a more collaborative approach. It becomes essential that the system provides insights that help surgeons make informed decisions. Multi-sensory inputs will act as a system’s eyes, ears and hands. The concept of smart surgical systems means that the robotic system would have tools that are human hand-like in their dexterity, tenderness and multisensory responsiveness. Advanced visualization would complete the picture. Imaging and display systems that are not limited to the human visual spectrum but instead provide a comprehensive display that includes anatomical, physiological, functional and other supporting information useful for the procedure.

All of this would support telerobotics, which can eliminate the need for a surgeon’s physical presence. This would benefit smaller and more rural hospitals in the United States and have a huge bearing on medical care in developing countries that lack access to specialized surgeons. Similar to the way Accuray’s  iDMS integrates patient data, telesurgery platforms would pool knowledge of thousands of similar procedures that both the surgeon and the robot can access for reference and learning to improve outcomes.

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