Dr. Rajni Patel and one of the minimally invasive surgical robots in the Canadian Surgical Technologies & Advanced Robotics (CSTAR) research lab. (Courtesy of CSTAR)

Robotic technology has been used in the health-care sector for several years, both to help surgeons operate more efficiently and to allow doctors to check in on their patients even when they are kilometres apart.

On May 4, 2007, a team of surgeons in London, Ont., performed coronary bypass surgery by making four tiny incisions in the patient's chest. The minimally invasive surgery (MIS) was made possible through robotics — the surgeon sat at the controls of a robotic system that makes it possible for the surgeon to be far more precise than by opening up the patient's chest. The end result is the patient spends much less time in hospital and faces a much shorter recovery phase at home.

Dr. Rajni Patel is professor and chair in the Department of Electrical and Computer Engineering at the University of Western Ontario. He's currently working on ways to take robotic surgery a step further — giving surgeons the ability to sense the force of interaction between the robotic surgical tools and the tissue of the organs inside the patient's body.

Patel also holds the Canada Research Chair in Advanced Robotics and Control. He recently spoke with CBCNews.ca about his work.

You've been involved in robotics for quite some time. How has the field changed health care over the past decade or so?

The advent of robotics for surgery and therapy has enabled greater use of minimally invasive techniques. These procedures are performed using laparoscopic (endoscopic) surgical instruments and a camera (endoscope) that are inserted into the patient's body through small incisions about a centimetre across. In the U.S.A., which has the largest number of MIS robotic systems currently in clinical use, a substantial number of procedures, such as prostatectomy (surgical removal of the prostate) and cholesystectomy (surgical removal of the gall bladder) are now being performed quite often using robot assistance. Robotics-assisted MIS has advantages over conventional (non-robotic) MIS by providing the surgeon with greater dexterity, fine motion capability, tremor filtering and better ergonomics.

How do you see robotics changing the face of health care in the next 10-20 years?

At present, there is only one MIS robotic system — the da Vinci — approved for clinical use by the FDA in the U.S.A. Therefore the cost of the technology is rather high. There are other systems under development or undergoing testing. I think that there will be several competing technologies that will be available in the next 10-20 years which will reduce the cost of surgical robotic systems considerably and lead to more widespread use. As robotics begins to have greater impact on health care, it is likely that we will see more cost-effective, small-scale specialized robotic systems, as opposed to the current fairly general purpose systems such as the da Vinci. Also, there is considerable effort and significant progress being made today on “image-guided” surgery. This technology will have a profound effect on surgical robotics in that a surgeon will be able not only to use pre-operative patient-specific imaging to plan a surgical procedure, but also use intra-operative imaging with robot assistance to perform the surgery much more efficiently, safely and reliably. Current research in haptics (sense of touch) for MIS is aimed at providing the surgeon performing robotics-assisted MIS the capability to feel tool/tissue interactions.

Under what circumstances is a robot "surgeon" more effective than a real live surgeon?

In the current practice of (non-robotic) minimally invasive surgery, a surgeon is faced with problems such as a lack of dexterity because of restricted port access to the surgical site, a lack of fine manipulation capability and magnification of hand tremors because of the long surgical instruments, visual problems resulting from the movements and orientation of the endoscopic camera, and significant degradation of the touch sensation for the surgeon with regard to the interaction of the surgical tool with tissue.

The use of robots in MIS has solved several of the problems associated with non-robotic surgery. For instance, the end tool of the da Vinci surgical robotic system includes a wrist that adds three rotations to the motions conventionally available in a minimally invasive environment in order to improve the surgeon’s dexterity. Also, the endoscopic camera is controlled by one of the arms of the robot and can be held steady by the robot, as well as manoeuvred to give a properly oriented view at all times. The use of a robot between the surgeon and the patient provides the capability of fine manipulation and filters out hand tremors.

When we hear stories of robotics in surgery, it still has that "gee whiz" air about it — the public seems to perceive it as unusual. What will it take for robotics to become widespread in the health-care industry?

The surgical robots that have been designed and/or used so far are essentially sophisticated assistive tools or systems for the surgeon. I think that the main factors currently limiting their widespread use in the health-care sector in Canada are cost and the limited number of procedures that have so far been demonstrated using the systems.

However, in the U.S., where health-care funding and costs are quite different, most major hospitals have either acquired or are about to acquire one or more da Vinci surgical systems, and there are therefore more robot-assisted minimally invasive surgeries being performed there than people realize. It is likely that with greater use of robotic surgical systems, a wide range of robotics-assisted surgical procedures will be performed, making it easier to find acceptance for the technology in the health-care sector.

How will technology make the delivery of health care more efficient?

The use of robots in performing MIS significantly increases the efficiency, reliability and safety of these procedures. In the long term, this should increase the number of MIS procedures performed. Since in MIS, a camera and surgical instruments are inserted into the body cavity through small incisions, MIS has the important advantages of reducing trauma to the body, post-operative pain and length of hospital stay, compared to open surgery.

The robotic systems currently used for surgery are “teleoperated” or “master-slave” systems, where the surgeon sits at a console (the master) and manipulates the surgical robot (the slave) located near the patient via appropriate computer control. The slave and the master can be in different places many kilometres apart. Therefore, if there are dedicated network and/or satellite connections available with appropriate redundancies to improve fault tolerance and ensure reliable performance, it is possible to use these robotic systems to perform surgery at a distance — telesurgery. This has obvious advantages for a large country like Canada.

What do you see as the most exciting recent development in robotics in Canada?

Of course, the major robotics development in Canada is in the area of space robotics — Canadarm 2 and its associated systems, such as the Special Purpose Dexterous Manipulator, and the Mobile Base System. With regard to medical applications, a new surgical robotic system with haptics capability has recently been developed in Calgary for neurosurgery that is designed to operate in a magnetic resonance imaging (MRI) environment. I think this is a major step forward in surgical robotics. Other major developments have been in the new surgical procedures that are being performed using robotic systems for MIS — there have been several world, North American and Canadian “firsts” performed by surgeons at CSTAR (Canadian Surgical Technologies & Advanced Robotics), a research initiative of the London Health Sciences Centre, the Lawson Health Research Institute and the University of Western Ontario. These include minimally invasive robotics-assisted cardiac bypass surgery on a beating heart, robotics-assisted left atrial appendage ligation, and the removal of a renal artery aneurysm using an MIS robotic system. Another major development in surgical robotics in Canada is the work that has been done at CSTAR and at McMaster (University) to demonstrate the feasibility of robot-assisted telesurgery, i.e., surgery at a distance.

What are some of the projects that you are involved in right now?

I am currently serving as director of engineering for CSTAR, where I am involved in several ongoing multidisciplinary research projects in the area of robotics-assisted surgery and therapy.

I am leading a project on developing technology to provide haptic feedback to surgeons using robotic systems for MIS. One of the major drawbacks of using robotics in MIS is that the surgeon does not have any feedback of the force of contact with tissue. Our research is exploring ways of providing this feedback.

I am also involved in a project led by Dr. Richard Malthaner, a surgeon with expertise in thoracic surgery and surgical oncology, on the development of a procedure for lung brachytherapy using a minimally invasive surgical robotic system. Brachytherapy is a form of radiation therapy where radioactive isotopes in the form of small pellets (called seeds) are inserted into cancerous tumours to destroy cancer cells in their neighbourhood, but with reduced exposure of healthy tissue to radiation.

In another project led by Dr. Kiaii, a cardiac surgeon, we are working on developing an optimal planning strategy for robot-assisted minimally invasive cardiac surgery. As an illustration of this approach, we are exploring ways to determine pre-operatively which patients will be well-suited for robotic-assisted minimally invasive bypass surgery.

A new project in which I am involved at CSTAR is concerned with the development of robotic technology for Natural Orifice Transluminal Endoscopy Surgery (NOTES). This project is led by Dr. C. Schlachta, the medical director of CSTAR, and is concerned with the development of robotics-assisted surgical tools that can be used to access the surgical area via a natural orifice in the body. This form of surgery can be regarded as the next step in the evolution of MIS.

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