[AI] Medibots: The world's smallest surgeons

Sanjay ilovecold at gmail.com
Sat Apr 10 02:22:51 EDT 2010


 Medibots: The world's smallest surgeons

          No more scalpels - tomorrow's lifesaving operations will use
          robots that crawl over your heart, scuttle into your ear and 

swim
          into your eye

by Gaia Vince and Clare Wilson

Editorial: Getting to the heart of robotic surgery
A MAN lies comatose on an operating table. The enormous spider that
hangs above him has plunged four appendages into his belly. The
spider, made of white steel, probes around inside the man's abdomen
then withdraws one of its arms. Held in the machine's claw is a neatly
sealed bag containing a scrap of bloody tissue.

This is a da Vinci robot. It has allowed a surgeon, sitting at a
control desk, to remove the patient's prostate gland in a manner that
has several advantages over conventional methods. Yet the future of
robotic surgery may lie not only with these hulking beasts but also
with devices at the other end of the size spectrum. The surgeons of
tomorrow will include tiny robots that enter our bodies and do their
work from the inside, with no need to open patients up or knock them
out. While nanobots that swim through the blood are still in the realm
of fantasy, several groups are developing devices a few millimetres in
size. The first generation of "mini-medibots" may infiltrate our
bodies through our ears, eyes and lungs, to deliver drugs, take tissue
samples or install medical devices.

The engineering challenges are formidable, including developing new
methods of propulsion and power supply. Nevertheless, the first
prototypes are already being tested in animals and could move into
tests on people in the not-too-distant future. "It's not impossible to
think of this happening in five years," says Brad Nelson, a roboticist
at the Swiss Federal Institute of Technology (EHT) in Zurich. "I'm
convinced it's going to get there."

It was the 1970s that saw the arrival of minimally invasive surgery -
or keyhole surgery as it is also known. Instead of cutting open the
body with large incisions, surgical tools are inserted through holes
as small as 1 centimetre in diameter and controlled with external
handles. Operations from stomach bypass to gall bladder removal are
now done this way, reducing blood loss, pain and recovery time.

Combining keyhole surgery with the da Vinci system means the surgeon
no longer handles the instruments directly, but via a computer
console. This allows greater precision, as large hand gestures can be
scaled down to small instrument movements, and any hand tremor is
eliminated. There are over 1000 da Vincis being used in clinics around
the world.

Heart crawler
There are several ways that such robotic surgery may be further
enhanced. Various articulated, snake-like tools are being developed to
access hard-to-reach areas. One such device, the "i-Snake", is
controlled by a vision-tracking device worn over the surgeon's eyes
(New Scientist, 20 September 2008, p 21). It should be ready for
testing on patients within four years, says developer Guang-Zhong
Yang, a roboticist at Imperial College London.

With further advances in miniaturisation, the opportunities grow for
getting medical devices inside the body in novel ways. One miniature
device that is already tried and tested is a camera in a capsule small
enough to be swallowed.

In conventional endoscopy, a camera on the end of a flexible tube is
inserted either through the mouth or the rectum, but this does not
allow it to reach the middle part of the gut. The 25-millimetre-long
capsule camera, on the other hand, can observe the entire gut on its
journey. More sophisticated versions are being developed that can also
release drugs and take samples.

The capsule camera has no need to propel itself because it is pushed
along by the normal muscle contractions of the gut. For devices used
elsewhere in the body, some of the key challenges are developing new
mechanisms for propulsion and power supply on a miniature scale.

One solution is to have wires connecting the robot to a control unit
that remains on the outside of the body. This is the case for a robot
being developed for heart surgery, called HeartLander.

Operating on the heart has always presented enormous challenges, says
Marco Zenati, a heart surgeon at the University of Pittsburgh,
Pennsylvania, who is one of the device's inventors. Conventionally the
heart is stopped and the patient hooked up to a heart-lung machine. A
more recent approach is to perform keyhole surgery on the beating
heart, but even so several incisions must be made, and the left lung
must be partly deflated to allow access, requiring a general
anaesthetic.

The HeartLander robot is designed to be delivered to the heart through
a single keyhole incision, from where it can crawl to the right spot.
The heart does not have to be stopped, and the left lung need not be
deflated, so the patient could be breathing naturally, with just a
local anaesthetic. "Coronary surgery can become an outpatient
procedure," says Cameron Riviere, the team's roboticist, based at
Carnegie Mellon University in Pittsburgh.

Inchworm
The 20-millimetre-long HeartLander has front and rear foot-pads with
suckers on the bottom, which allow it to inch along like a
caterpillar. The surgeon watches the device with X-ray video or a
magnetic tracker and controls it with a joystick. Alternatively, the
device can navigate its own path to a spot chosen by the surgeon.

The HeartLander has several possible uses. It can be fitted with a
needle attachment to take tissue samples, for example, or used to
inject stem cells or gene therapies directly into heart muscle. There
are several such agents in development, designed to promote the
regrowth of muscle or blood vessels after a heart attack. The team is
testing the device on pigs and has so far shown it can crawl over a
beating heart to inject a marker dye at a target site (Innovations,
vol 1, p 227).

Another use would be to deliver pacemaker electrodes for a procedure
called cardiac resynchronisation therapy, when the heart needs help in
coordinating its rhythm. At the moment, the electrodes are delivered
to the heart by pushing them in through a vein. Riviere's group is
devising electrodes that the HeartLander could attach to the outer
surface of the heart. They have tested this approach successfully on
one live pig, and expect to start trials in people in about four
years. Riviere says there is growing evidence to show that the
technique works best when the electrodes are sited in certain areas
that are hard to access from inside the veins. "The HeartLander can
crawl around to the best position," he notes.

While the robot could in theory be used in other parts of the body, in
its current incarnation it has to be introduced through a keyhole
incision thanks to its size and because it trails wires to the
external control box. Not so for smaller robots under wireless
control.

One such device in development is 5 millimetres long and just 1
millimetre in diameter, with 16 vibrating legs. Early versions of the
"ViRob" had on-board power, but the developers decided that made
it too bulky. Now it is powered externally, by a nearby electromagnet
whose field fluctuates about 100 times a second, causing the legs to
flick back and forth. The legs on the left and right sides respond
best to different frequencies, so the robot can be steered by
adjusting the frequency.

ViRob's developers at the Technion-Israel Institute of Technology in
Haifa, are investigating several applications including taking tissue
samples, delivering cancer drugs and getting a camera to hard-to-reach
areas, such as deep within the lungs. The size of the camera is a
limiting factor - the smallest models in development are 1.5
millimetres in diameter - but cameras get smaller every year, notes
engineer Moshe Shoham.

The team would like their device to operate inside large blood
vessels, but it is not yet powerful enough to withstand blood flow.
"We don't want it swept away," says Shoham.

The first application for ViRob may benefit people born with
hydrocephaly - fluid on the brain - as it may be able to extend the
life of the shunts placed in the brain to drain the excess fluid. Over
time such shunts tend to get blocked, and so need replacing every five
to 10 years, entailing major brain surgery. Shoham says a
self-cleaning shunt could be made by installing a ViRob permanently
inside. About once a month it would be activated to send the device
scuttling up and down the shunt, which patients might be able to do at
home.

Another possible application might aid the insertion of cochlear
implants. Used by deaf people, these are small electrodes placed
within the delicate spiral-shaped cochlea to stimulate the auditory
nerve. Shoham says ViRob would be able to carry the implant deeper
inside the cochlea than can currently be done, giving patients better
hearing. "The further you go into the cochlea, the more cells you
excite," Shoham explains.
The ViRob would be able to carry a cochlear implant deeper into the
ear

He reckons that tests on people are just a couple of years away. His
team has a proven track record, having already commercialised a robot
the size of a soft-drink can for a type of spinal surgery that
involves fusing two vertebrae together. Called SpineAssist, the
device is clamped over a keyhole incision on the spine, through which
it finds the right spots on the vertebrae for the screws.

While the ViRob can crawl through tubes or over surfaces, it cannot
swim. For that, the Israeli team are designing another device, called
SwiMicRob, which is slightly larger than ViRob at 10 millimetres long
and 3 millimetres in diameter. Powered by an on-board motor, the
device has two tails that twirl like bacteria's flagella. SwiMicRob
may one day be used inside fluid-filled spaces such those within the
spine, although it is at an earlier stage of development than ViRob.

Another group has managed to shrink a medibot significantly further -
down to 0.9 millimetres by 0.3 millimetres - by stripping out all
propulsion and steering mechanisms. It is pulled around by
electromagnets outside the body. The device itself is a metal shell
shaped like a finned American football and it has a spike on the end.

The developers at ETH Zurich are focusing on eye surgery because it
requires such a high level of precision - hand tremor can be a major
problem for surgeons operating here. The other draw is that this
medibot's progress inside the eye can be monitored by viewing the eye
through a microscope.

One application for the ophthalmic robot, as they call it, is to
measure oxygen levels at the surface of the retina, an indication of
its blood supply. For this, the shell is coated with a
photoluminescent chemical, the brightness of which depends on oxygen
concentration.

The device could also be used to treat a major cause of blindness
known as retinal vein occlusion, which occurs when a blood clot blocks
the major vein at the back of the eye. Various drugs are being
investigated as treatments, such as one that dissolves blood clots,
but they are hard to deliver. At the moment a kind of access port
known as a trocar is placed into the surface of the eye, and a needle
is inserted to inject the drug into the vein, but getting the needle
to the hair-thin blood vessel demands great surgical skill.

Once the ophthalmic robot is delivered through the trocar, on the
other hand, it can be guided to the blocked vein by its magnetic
propulsion system. Its spike pierces the blood vessel, and the drug,
which coats the device, diffuses into the vein.

The Swiss team is experimenting with even tinier versions of the
device that fit inside the barrel of a needle and would simply be
injected into the eyeball, avoiding the need for a trocar. "We can
make these smaller, but if we make them too small they cannot exert
enough force to penetrate a vein," says Nelson.
If the device can be shrunk a little further it could simply be
injected into the eye

Another refinement, he says, would be to make a biodegradable device
that would not have to be removed from the eye. The shell would be
made from a polymer, with an embedded metal particle to respond to the
electromagnets. Once the polymer dissolved, the metal particle would
be absorbed into the bloodstream and eventually excreted.

The team has been testing its devices on eyes removed from butchered
pigs, and also on those of chicken embryos incubated in a Petri dish -
a set-up that eye surgeons often practise on. So far they have shown
that the robot can be put into the birds' eyes, steered to the right
place and pierce the retinal vein.

The Swiss team is also among several groups who are trying to develop
medibots at a vastly smaller scale, just nanometres in size, but these
are at a much earlier development stage. Shrinking to this scale
brings a host of new challenges, and it is likely to be some time
before these kinds of devices reach the clinic.

Nelson hopes that if millimetre-sized devices such as his ophthalmic
robot prove their worth, they will attract more funding to kick-start
nanometre-scale research. "If we can show small devices that do
something useful, hopefully that will convince people that it's not
just science fiction."



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