The grand challenges of medical robotics
A great article appeared in Science Robotics on the big challenges of robotics from a group of senior experts: The grand challenges of Science Robotics. They collected the major technological open issues in the various domains of robotics. Regarding medicine, the followings were stated:
"Medical roboticsFrom minimally invasive surgery, targeted therapy, hospital optimization, to emergency response, prosthetics, and home assistance, medical robotics represents one of the fastest growing sectors in the medical devices industry.
The impact of robotics on medicine is undeniable. The therapeutic and commercial success of Intuitive Surgical’s da Vinci system has spurred a number of commercial ventures targeting surgical applications, which echo the emerging trend in precision surgery, focusing on early malignancies with minimally invasive intervention and greater consideration of patient recovery and quality of life (86, 87). These efforts will continue to improve healthcare in terms of both outcomes and cost. Other research and commercial efforts are focusing on what many see as an inevitable future in which intelligent robotic devices assist healthcare workers in a variety of ways. As we move toward this future, however, many grand challenges remain. One of the primary challenges in surgical and interventional robotics is a move toward systems that exhibit increasingly higher degrees of autonomy (85). A second grand challenge is the creation of fully implantable robots that replace, restore, or enhance physiological processes. A third grand challenge is in the realization of microand nanorobotic devices of clinical relevance (Fig. 9). In those industries in which robots are most successful (e.g., manufacturing and warehouse automation), teleoperation has been replaced by semiautonomous or autonomous operation. Autonomy in medical robotics is incredibly challenging (88); whereas products and assembly lines can be designed to fit the capabilities of robots, this is not possible with the human body. Consequently, autonomy in existing medical robots remains limited. In most cases, the contribution of the robot has been to enhance the skill level of the surgeon. For example, Intuitive Surgical’s da Vinci robot makes laparoscopy easy (89); routine procedures can be performed at a higher level of proficiency, and difficult cases that would otherwise be treated with open surgery can be performed laparoscopically. Similarly, Stryker’s Mako robotic arm enhances hip and knee replacement by enabling more precise bone drilling than the surgeon can perform on his or her own. In both these examples, the robot acts as an extension of the surgeon’s hand, and its motion is continuously under the surgeon’s control. Other systems, such as Think Surgical’s Robodoc system, execute precomputed and surgeon-approved cutting paths based on medical images. All these systems exercise some degree of “autonomy” in translating a surgeon’s intentions (expressed in joystick motions or in preoperative planning) into the actual motions of the robot’s actuators. The challenge arises when the controller needs to make more complex decisions in interpreting the clinician’s intentions. Thus, we anticipate that the development of autonomy in medicine satisfying regulatory and ethical concerns will progress in stages. Two examples are described below. Although medical robot autonomy is often discussed within the context of surgery, emergency medicine provides another set of challenges and opportunities. In this case, an emergency medical technician (EMT) needs to assess the condition of a patient quickly, prioritize problems, and often take timeurgent steps to stabilize the patient. Intelligent robotic systems that could assist with such tasks as placing and monitoring sensors, inserting intravenous lines or breathing tubes, and preparing a patient for transport could significantly improve the ability of an EMT to provide urgent care. In addition to obvious challenges in dexterity and device development, there are also difficult computational challenges. The robot assistant will need to recognize relevant patient anatomy in what is often a highly unstructured environment. It will need to use its situational understanding to perform tasks appropriately under direction of the EMT, who is likely to rely primarily on spoken commands, supplemented with gestures, to explain what needs to be done. A long-term challenge is to enable one surgeon to supervise a set of robots that can perform routine procedure steps autonomously and only call on the surgeon to take control during critical, patient-specific steps. For example, intracardiac interventions involve navigating from percutaneous entry in the peripheral vasculature to specific locations inside the heart using a combination of preand intraoperative imaging. The theory of image-based robot navigation is well developed, so developing safe navigation algorithms seems quite feasible. As clinical experience with intracardiac devices (e.g., transcatheter valves) grows, the deployment of these devices may become sufficiently standardized to enable automated deployment. Furthermore, miniaturized and multifunctional fully implantable robots represent an emerging area of development (90, 91). Issues related to biocompatibility, packaging, power efficiency, and harvesting are important to be addressed (92). Perhaps the most significant challenge of automating any clinical task is to be able to anticipate, detect, and respond to all possible failure modes. Medical device regulation of autonomous robots will likely need to develop in a manner that balances the requirements for provably safe algorithms with compliance costs. An emerging area of medical robotics is implantable robotic devices. These bionic systems are being proposed as replacement organs, e.g., for the pancreas (91); as assist devices for damaged organs, e.g., for the heart (90); and to induce organ growth, e.g., of the esophagus and bowel (93). There are a number of challenges that must be addressed to advance this field. These include biocompatibility, reliability, adaptability, security, and providing power. Full biocompatibility is important in order to maintain long-term functionality. Furthermore, for those implants that provide temporary physiological support, designing the implant to be resorbable could eliminate the need for surgery to remove the device. Implants must also be designed to react to changing conditions, such as exercise, and extreme reliability is a necessity because malfunction could quickly lead to death. Although remote programming to provide software updates is advantageous, security is critically important to prevent one’s organ from being hacked. Last, because the power requirements of a robotic device are high in comparison to, e.g., a pacemaker, the capability for wireless power transfer will be crucial. An other emerging area of medical robotics is micro- and nanorobotics, with increasing numbers of groups maintaining high-profile research efforts. The field has made impressive strides over the past decade as researchers have created a variety of small devices capable of locomotion within liquid environments (94). Robust fabrication techniques have been developed, some devices have been functionalized for potential applications (95), and therapies are being actively considered (96). Although excitement remains high for this field, it faces a number of significant challenges that must be addressed head-on to make continued progress toward clinical relevance. The primary roadblocks to overcome include the development of biodegradable and noncytotoxic microrobots, development of autonomous devices capable of self-directed targeting, catheter-based delivery of microrobots near the target, tracking and control of swarms of devices in vivo, and the pursuit of clinically relevant therapies."
The impact of robotics on medicine is undeniable. The therapeutic and commercial success of Intuitive Surgical’s da Vinci system has spurred a number of commercial ventures targeting surgical applications, which echo the emerging trend in precision surgery, focusing on early malignancies with minimally invasive intervention and greater consideration of patient recovery and quality of life (86, 87). These efforts will continue to improve healthcare in terms of both outcomes and cost. Other research and commercial efforts are focusing on what many see as an inevitable future in which intelligent robotic devices assist healthcare workers in a variety of ways. As we move toward this future, however, many grand challenges remain. One of the primary challenges in surgical and interventional robotics is a move toward systems that exhibit increasingly higher degrees of autonomy (85). A second grand challenge is the creation of fully implantable robots that replace, restore, or enhance physiological processes. A third grand challenge is in the realization of microand nanorobotic devices of clinical relevance (Fig. 9). In those industries in which robots are most successful (e.g., manufacturing and warehouse automation), teleoperation has been replaced by semiautonomous or autonomous operation. Autonomy in medical robotics is incredibly challenging (88); whereas products and assembly lines can be designed to fit the capabilities of robots, this is not possible with the human body. Consequently, autonomy in existing medical robots remains limited. In most cases, the contribution of the robot has been to enhance the skill level of the surgeon. For example, Intuitive Surgical’s da Vinci robot makes laparoscopy easy (89); routine procedures can be performed at a higher level of proficiency, and difficult cases that would otherwise be treated with open surgery can be performed laparoscopically. Similarly, Stryker’s Mako robotic arm enhances hip and knee replacement by enabling more precise bone drilling than the surgeon can perform on his or her own. In both these examples, the robot acts as an extension of the surgeon’s hand, and its motion is continuously under the surgeon’s control. Other systems, such as Think Surgical’s Robodoc system, execute precomputed and surgeon-approved cutting paths based on medical images. All these systems exercise some degree of “autonomy” in translating a surgeon’s intentions (expressed in joystick motions or in preoperative planning) into the actual motions of the robot’s actuators. The challenge arises when the controller needs to make more complex decisions in interpreting the clinician’s intentions. Thus, we anticipate that the development of autonomy in medicine satisfying regulatory and ethical concerns will progress in stages. Two examples are described below. Although medical robot autonomy is often discussed within the context of surgery, emergency medicine provides another set of challenges and opportunities. In this case, an emergency medical technician (EMT) needs to assess the condition of a patient quickly, prioritize problems, and often take timeurgent steps to stabilize the patient. Intelligent robotic systems that could assist with such tasks as placing and monitoring sensors, inserting intravenous lines or breathing tubes, and preparing a patient for transport could significantly improve the ability of an EMT to provide urgent care. In addition to obvious challenges in dexterity and device development, there are also difficult computational challenges. The robot assistant will need to recognize relevant patient anatomy in what is often a highly unstructured environment. It will need to use its situational understanding to perform tasks appropriately under direction of the EMT, who is likely to rely primarily on spoken commands, supplemented with gestures, to explain what needs to be done. A long-term challenge is to enable one surgeon to supervise a set of robots that can perform routine procedure steps autonomously and only call on the surgeon to take control during critical, patient-specific steps. For example, intracardiac interventions involve navigating from percutaneous entry in the peripheral vasculature to specific locations inside the heart using a combination of preand intraoperative imaging. The theory of image-based robot navigation is well developed, so developing safe navigation algorithms seems quite feasible. As clinical experience with intracardiac devices (e.g., transcatheter valves) grows, the deployment of these devices may become sufficiently standardized to enable automated deployment. Furthermore, miniaturized and multifunctional fully implantable robots represent an emerging area of development (90, 91). Issues related to biocompatibility, packaging, power efficiency, and harvesting are important to be addressed (92). Perhaps the most significant challenge of automating any clinical task is to be able to anticipate, detect, and respond to all possible failure modes. Medical device regulation of autonomous robots will likely need to develop in a manner that balances the requirements for provably safe algorithms with compliance costs. An emerging area of medical robotics is implantable robotic devices. These bionic systems are being proposed as replacement organs, e.g., for the pancreas (91); as assist devices for damaged organs, e.g., for the heart (90); and to induce organ growth, e.g., of the esophagus and bowel (93). There are a number of challenges that must be addressed to advance this field. These include biocompatibility, reliability, adaptability, security, and providing power. Full biocompatibility is important in order to maintain long-term functionality. Furthermore, for those implants that provide temporary physiological support, designing the implant to be resorbable could eliminate the need for surgery to remove the device. Implants must also be designed to react to changing conditions, such as exercise, and extreme reliability is a necessity because malfunction could quickly lead to death. Although remote programming to provide software updates is advantageous, security is critically important to prevent one’s organ from being hacked. Last, because the power requirements of a robotic device are high in comparison to, e.g., a pacemaker, the capability for wireless power transfer will be crucial. An other emerging area of medical robotics is micro- and nanorobotics, with increasing numbers of groups maintaining high-profile research efforts. The field has made impressive strides over the past decade as researchers have created a variety of small devices capable of locomotion within liquid environments (94). Robust fabrication techniques have been developed, some devices have been functionalized for potential applications (95), and therapies are being actively considered (96). Although excitement remains high for this field, it faces a number of significant challenges that must be addressed head-on to make continued progress toward clinical relevance. The primary roadblocks to overcome include the development of biodegradable and noncytotoxic microrobots, development of autonomous devices capable of self-directed targeting, catheter-based delivery of microrobots near the target, tracking and control of swarms of devices in vivo, and the pursuit of clinically relevant therapies."
Source: Science Robotics
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