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Robotic Cost-effective Surgery 

Robotic and Computer Assisted Surgery: 

delivering the promise 

24 June 2008 

Professor Brian Davies, 

Professor of Medical Robotics 

Mechatronics in Medicine Group 

Department of Mechanical Engineering 

Imperial College, London, SW7 2AZ 

© Imperial College London 

Imperial College 

London

Robotic Surgery: 

Early Autonomous systems 

• Large and costly 

• Is the robot safe? 

• Who is in charge? 

• Is the system cost-effective? 


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ROBODOC 

for Hip 

Surgery: 

an autonomous 

robot 


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I.C. PROBOT for Prostate Surgery 

April 1991 


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I.C. PROBOT for Prostate Surgery 


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The IC Probot: 

An Active Robot 

Used Autonomously 


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Master / Slave Telemanipulators 

for use in surgery 

• Ideal for soft tissue surgery 

• Generally the Master is near to patient in 

O.R. 

• Uses high quality 3D imaging 

• Generally little tactile information 

• Motion scaling of Master to Slave is 

possible 

– Example: da Vinci from Intuitive Surgical 


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Da Vinci telemanipulator System 

Courtesy: Intuitive Surgical 


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Da Vinci: 3 axes Endo-wrist 



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Da Vinci: suturing inside chest cavity 

Frequently used for Radical Prostatectomy 



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Da Vinci: 

Master Console 


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Hansen Medical: Haptic Master controller 


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Hansen Medical: Sensei Slave System 


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Hansen Medical: Artisan Snake Catheter 

www.hansenmedical.com 


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Robotic Surgery can be highly 

Cost-Effective. 

If optimised, it can give: 

• Improved accuracy 

• Consistent performance (no outliers) 

• Rapid learning curve to achieve high 

quality surgery 

• Achieve high quality results for procedures 

difficult conventionally 

• Skin to skin times as good as (or shorter) 

than conventionally 



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MAZOR MARS ROBOT 



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Courtesy: 

Mazor 


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Smaller, low-cost robots. 

MBars: bone-mounted robot for patellar resurfacing 

Courtesy: 

Prof. B. Jaramaz 

Carnegie-Mellon University. 


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The Acrobot Company Limited 

ACROBOT: 

a “Hands-on” Robot 

Used for Uni-Condylar Knee 

Arthroplasty 



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Knee prostheses 

Femoral 

component 

TKR 

UKR 

Tibial 

component 


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Preoperative Planning: CT based 



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Prostheses Alignment 

Segmentation 

Boundary Generation 

Mechanical Axis 

Alignment

ACROBOT; 

being used for MIS 

Uni-knee surgery 


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Uni-condylar knee Surgery 

• A Minimally Invasive procedure 

• Prospective randomised clinical 

trial of robot system 

• Approved by MHRA 

• 15 patients conventional 

& 15 robotic 

• All had a pre-operative plan 



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Acrobot: UKA intra-Operative Procedure 

Intra-Operative system 

Registration 

Implantation 

Cutting 



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Clinical Evidence 


Cobb et al , Hands-on robotic 

unicompartmental knee replacement, 

Journal of Bone and Joint Surgery - 

British Volume, 2006 


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Cost-Effective: 

“Costs”; we need:- 

•Low Capital cost of equipment. 

•Low Maintenance costs, (software and 

hardware) 

•Low Consumable cost per procedure 

•Easy-to-use 

•Short Setup time. 

•Short Training time. 

•Short skin to skin time 


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Cost-Effective: 

Effectiveness 

Effectiveness must be maximised in terms of:- 

•Fast learning curve for a high quality result 

•Accuracy 

•No outliers 

•Short procedures 

•Improved long-term outcomes 

•Fewer tools required 

•Small range of sterilised prostheses required 


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Problems with effectiveness measures 

•There is a lack of evidence-based medicine on accuracy that we 

require due to:- 

•Surgeon error is the greatest variable 

•Planar x-rays are a poor measure of outcomes 

•“Learning curve” is often included in survey of results 

•Orthopaedic standard hip and knee scores are a coarse measure of 

improvements 

•The body is very “forgiving” and adapts over time 

•Standard THR and TKA implants are designed to be very 

“forgiving” 


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What is the solution? 

•Simpler, lower cost robotic systems. E.g., 

“Intelligent Tools” in the hands of the surgeon 

•Minimally invasive, using smaller prostheses 

that cannot be implanted conventionally. 

•Procedures which are difficult to perform by 

conventional means 

•Easy to setup and use 

•Simple training 

•Structured workflow with computer prompts 

•An accurate CT based plan 


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Acrobot’s New Sculptor 

System 

• 3D hands-free sculpting 

• Reduced instrument tray 

• Dynamic constraint control 

• Low encumbrance 

© Imperial College 

London 

• Potential for: 

o Reduced operating time 

o True minimal access 

surgery 


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“Sculptor” for Uni-knee surgery 


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London



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BringingAccuracytotheOperatingRoom 

Sculptor First Evaluation 

Left medial uni-compartmental knee 

replacement 

Tuesday, 22 nd April, Charing Cross 

Hospital 

36 minutes of Sculptor use (average 

time of use during MHRA trial was 56 

minutes) 

7 minutes for registration 

19 minutes for cutting 

••••|Planner|Navigator|Sculptor|•••• 


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SculptorinClinic 




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SculptorinClinic 




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Sculptor Cutting 




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PostoperativeXrays 




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What is the future for Robotics? 

- A Changing Culture : 

• Demand for robotics will be Patient driven 

– Must be real benefit, not just a marketing tool 

• Need to overcome Surgeon reluctance: 

* Hands-on Intelligent tools, not autonomous robots 

* Simple to train, set-up and use 

• Lower-cost systems 

• Time in OR similar to alternatives 

• Used for procedures that are difficult conventionally 

• With clear benefits cf alternatives 



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Acknowledgements 

• Integrated Systems require teamwork…and 

significant funding! 

THANKS TO: 

– The researchers of the Mechatronics in 

Medicine Group 

– Professor Justin Cobb, and the orthopaedic 

team at Imperial College London 

– Support of the Acrobot Company Ltd. 



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THANK YOU 

FOR YOUR 

ATTENTION 


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