How Cambridge companies are creating next-generation surgical robotics
One thing is clear about the field of robotics: it’s growing fast. With wide applications across medicine, manufacturing, agriculture and, increasingly, our everyday lives, it’s an exciting time to be working with robots - and Cambridge companies are at the heart of this latest technological revolution. In the first of a two-part report on robotics, PAUL BRACKLEY investigates how surgical procedures will be transformed.
Robotics is transforming how surgery is carried out - and the future is smaller.
Miniature robotics systems are being developed that will enable procedures to be carried out with less invasiveness and greater precision.
One of the smallest known robots for surgical use was showcased by Cambridge Consultants in November.
The firm says the Axsis technology heralds the next wave of surgical robotics innovation - and a glimpse into the future.
Axsis has an external body the size of a drinks can and instruments just 1.8 millimetres in diameter.
The prototype is designed for use in cataract surgery, which helps restore sight to 20 million every year but is still carried out by hand.
During the procedure, surgeons scrape away a cloudy lens that is about 10mm in diameter and replace it with a plastic lens.
Chris Wagner, head of advanced surgical systems at Cambridge Consultants, said:"It is currently done by hand under a surgical microscope.
"It's the world's most common surgery, yet there are still critical complications that can result due to the small size and delicate nature of the eye, and the experience and skill of the surgeon.
"Now this is an area that seems ripe for the sorts of benefits that robotics can provide - motion scaling, tremor reduction, image guidance to avoid sensitive tissues - but building a robot on that size scale is very difficult. But what we're showing here is technology that overcomes many of those technical limitations that prevent you from building a robot that, for example, could access the eye.
"Traditional surgical robots operate on a long, straight instrument where to get motion on the inside of the body you also need to have large motion on the outside of the body, so not only does the robot take up a lot of room but the instruments moving around take up a lot of room. So what we've done is devised a system with a parallel mechanism that does not move on the outside of the body yet still gives full performance moving the actuation and the articulation to the inside of the body.
"So we're showing a robot that is both small on the inside, small on the outside, able to easily integrate with the current operating room workflow."
Traditional surgical robots are also large because of the forces they need to exert on the body during surgery, the need to adapt to multiple configurations and the freedom required to operate them effectively.
But by using flexible instead of straight instruments, the Cambridge Consultants prototype enables novel motor and control configurations. This reduces the overall size of the robot significantly and eliminates the need for a large range of motion outside the body. The firm says with the right instrument design, the outer diameter of the minimally invasive access point can also be reduced.
The robot is operated by two joysticks and features cables that are 110 microns in diameter - the size of a human hair - going through a 150-micron hole.
Made from gel-spun polyethylene, it is stronger than kevlar and is what NASA uses in some of its solar sails.
Chris said:"This level of innovation in surgical robotics has the potential to significantly enhance medical treatments and procedures for surgeons and patients alike.
"We've also designed low friction mechanisms to be able to provide the capability of force feedback and so forces interacting at the tip of the instrument can be relayed back to the surgeon's hands, providing a sense of touch.
"This is a capability that is not in current surgical robots.
"This demonstrates the fact that robotics technology can apply to a size scale that has never been addressed before."
Such miniature systems could revolutionise procedures requiring very small and precise movements to access complex or obstructed structures within the body.
A smaller robot allows for surgeons and doctors to work with multiple types of tools and get closer to a patient without the barrier of large equipment.
Cambridge Consultants says the technology could have applications from early intervention procedures for cancer to expanding the reach of natural orifice surgery for oesophageal and gastrointestinal tract procedures. Ultimately, robotics could be used in procedures currently performed by hand, such as the placement of neurostimulation implants.
Axsis's small size could also significantly reduce costs and open the door for less experienced robotic surgeons and smaller hospitals to utilise the systems, with robotic tools swapped in and out as required.
Chris said:"Axsis proves that it is not only possible to create surgical robots that are smaller than ever before - but also to target surgical procedures with robotics that were previously out of reach."
Cambridge Consultants robotics' work also covers industrial, agricultural and consumer technologies.
The current market for surgical robotics is currently dominated by hysterectomy and prostatectomy procedures performed in the United States.
But in September, the UK's first kidney transplant carried out by robot was performed on 42-year-old Siobhan Morris at London's Guy's Hospital.
The huge da Vinci robot, with four arms and 3D vision, reduces bleeding by improving accuracy and surgical tremors.
More than three million patients worldwide have been operated on by some 3,600 da Vinci machines, created by US firm Intuitive Surgical, which says the number of procedures rose 16 per cent in the second quarter of 2016, compared with the same period last year.
Meanwhile, one market report last month reported that the global gynaecology robotic surgery market will grow by more than 10 per cent from 2016-20.
The cost and size of existing robots are significant issues for hospitals though. There are 60 at work in UK hospitals - including two at Guy's, which cost £1.8million each and were paid for by grants and donations.
Another firm working to expand the market significantly with new, more flexible and lower cost technology is Cambridge Medical Robotics.
Its aim is to reduce costs of owning the equipment by more than 50 per cent - making it comparable with equivalent manual keyhole procedures.
The firm, which has 80 patents filed in the UK, secured $20.3million in a Series A funding from new investors, including ABB Technology Ventures, LGT Global Invest and Cambridge Innovation Capital in July, following successful clinical trials the previous month on cadavers at The Evelyn Cambridge Surgical Training Centre.
CMR medical director Mark Slack, a consultant surgeon and the head of urogynaecology at Addenbrooke's, who led the team carrying out the tests, said:"The trials allowed us to demonstrate the advanced capabilities of the CMR system including haptic force feedback, fully wristed 5mm instruments and the ability to perform a wide range of multi-quadrant minimal access procedures including urological, gynaecological, upper gastrointestinal and colorectal procedures, all with standard port placements, making the future transition to robotics as easy as possible for surgeons.
"Within the next decade I now believe surgical robotic systems will become a standard feature in operating theatres and a critical extension of the modern day surgeon. With its small and light weight form factor, ease of set up and versatile design the CMR system is strongly positioned to extend the benefits of minimal access surgery to a greater number of patients."