Innovation in robotic surgery: the Indian scenario.

Robotics is the science. In scientific words a "Robot" is an electromechanical arm device with a computer interface, a combination of electrical, mechanical, and computer engineering. It is a mechanical arm that performs tasks in Industries, space exploration, and science. One such idea was to make an automated arm - A robot - In laparoscopy to control the telescope-camera unit electromechanically and then with a computer interface using voice control. It took us 5 long years from 2004 to bring it to the level of obtaining a patent. That was the birth of the Swarup Robotic Arm (SWARM) which is the first and the only Indian contribution in the field of robotics in laparoscopy as a total voice controlled camera holding robotic arm developed without any support by industry or research institutes.

INTRODUCTION

It has been said that “need is the mother of innovation.” The journey may start with any idea and lead to a need-based approach in application, design, development, and implementation till prototype level. This can be a long journey with many hurdles. Actual clinical application and acceptance is the step next. Can such ideas come from small set ups? In a way, the demands and needs in smaller set ups are more. An enthusiastic surgeon with a background knowledge of engineering can dream of bringing his ideas in reality.

Making an automated arm or a robot in laparoscopy to control the telescope-camera unit, initially electromechanically and then with a computer interface using voice control, took us 5 long years from 2004. This article traces the birth of SWARM which is the first and only Indian contribution in the field of robotics in laparoscopy as a totally voice-controlled camera holding robotic arm developed without any support from the industry or research institutes.

Early surgical robots were developed with the help of computer-aided design/manufacturing (CAD/CAM) systems.[12] As defined by Richard Satawa[34] “A robot is not a machine; it is an information system with arms (manipulators), legs (locomotion), eyes (vision systems), and so forth.” The playwright Karel Capek coined the term “robot” in his satirical drama Rossum's Universal Robots, the word robot derived from the Czech robota (slave labor), “Master Slave” system as was introduced in the west or “Surgeon's Friend” in India.

Robots have a number of advantages over humans in performing remote manipulation tasks.[5] Their accuracy and repeatability allowed robots to penetrate the market in the industrial sector in the 1970s with clear economic benefit. However, in surgery the environment was often far less structured than in the industry, highlighting some of the weaknesses in current robotic devices, such as substantial loss of force feedback (haptics) and a lack of adaptability and exhorbitant cost. Currently it is not possible to “program” a robot to autonomously perform a surgery like the industrial robots which can carry out autonomous tasks. Surgical robots can then be viewed as providing “extension or enhancement of human capabilities” rather than replacing humans, in contrast to the example of industrial automation. Other applications for robotics invoke the “tele” part of telerobotics, which permits viewing, monitoring, collaborating, and even performing surgery from a distance.[678910]

In this article we have described pre-existing robotic arms with brief description of their mechanics and critically compared SWARM to them.

Commercially available robots

There are two types of robots:

Motion controlled and

Voice-activated.[11] Motion-controlled camera holders currently in use are the Endo Assist® camera holding robot, the camera arm of the da Vinci® robotic system and the Zeus® surgical system. The voice-activated device currently in use is the AESOP® device.

AESOP-Automated Endoscopic System for Optimal Positioning

Is developed by Computer Motion, Inc. It played a very important role in developing early surgical robotic technology, using continuous input from surgeons to change their movements according to input in real time. They made a significant contribution to the fields of minimally invasive surgical robotics. AESOP™ [Figure 1] was the first arm used for holding an endoscopic camera in minimal invasive surgery. It is operated by foot pedals which avoided problems due to hand tremors. In 1993, the AESOP1000 system was certified by the FDA. The foot pedals, although easy to control for well-trained surgeons, were a problem for new users as they had to look down on the pedals every time. AESOP2000 launched in 1996 had a voice control and the AESOP3000 launched in 1998 added another degree of freedom in the arm. Thousands of surgical procedures were performed using AESOP robots.[121314151617]

Figure 1

AESOP-automated endoscopic system for optimal positioning

Limitations of AESOP

It was not claimed that every surgeon achieves time savings and cost advantages with AESOP. It demands specific modifications to accommodate the surgeon's operating style. Voice control of AESOP requires constant chattering by the surgeon, other members of the team finding it distracting. At times the voice control is slow, compared to the rapid camera movements of a practiced and attentive assistant. Mettler et al,[17] found that AESOP showed some inadvertent movements, rotations and contacts with adjacent organs than did a human assistant during laparoscopic gynaecological operations. Considering all these facts we decided to develop robotic arm having better manuverability, more functions, and faster execution of commands (without a voice card).

The Indian Scenario

The typical Indian mindset takes a long time to accept newer versions and adopts a viewpoint of “what is wrong with the existing system and available facility?” The reasons why robotic technology is not widely accepted in India are the cost, time required for setup, applicability in all cases and the learning curve. It is a fact that often the camera assistant available to surgeons in smaller towns is an untrained, unskilled person. He is trained by us to suit our requirements in and out of the operation theatre. He may serve multiple roles such as the manager, driver, housekeeper, and theatre assistant and that too at a low wage. Then why do we need to invest crores of rupees in a robotic machine? We forget that the “human” assistant may be absent from work for one reason or the other, and a novice assistant, although well trained, can hinder progress of the operation by inappropriate camera movements. He ages, gets fatigued and has tremors; a “machine” is devoid of all these shortcomings. This is what led us to think of having a robotic arm in our theatre. We realized that if one such machine becomes available at an affordable cost, there would be no reason to criticize robots.

When I saw AESOP for the first time, during an international conference in Rome in 1998, it did not accept my commands; the reason given was my Indian accent. That spurred me to develop a robotic arm that would accept commands in any accent. This, of course has been a long journey starting from a “hand-operated” to a “foot-controlled” machine. To add “voice recognition” was an enjoyable exercise as it was frustrating. Working with the “speech” machine was a steep track. It was exhausting, sometimes frustrating and often discouraging. To choose the exact frequency for the syllables of needed command was not an easy job. It took us a full year and at the end we were successful in adding the “voice control” feature to SWARM for all its six commands. We were able to eliminate the voice card as was used in AESOP so that any person is easily able to use it without any problems with voice recognition or delay in booting. We succeeded in adding this feature in 2006.

Now we needed smoother mechanics, combination of movements, and online speed selection for which we toiled hard and succeeded. We processed this technology in “Windows 98” which was no more in existence at the end of 2006. We again had to work with a new challenge. A newer version of Windows operating system made us to have a software which will work with any given system like Windows 98, Window 2000, Windows XP, and still further. The sophisticated headphone with the inbuilt software does not allow any command beyond 6 in distance from operator's mouth. It works in any “Noisy” atmosphere of the operation theatre and recognizes the voice accuretaly over 95% of the times.

Machine, Design, and Mechanism of SWARM

SWARM, developed by Swarup Robotic Research centre, consists of a compact camera holder robot by the side of the operation table (wheeled on the ground), and a control unit in the base cabin which contains the electricity supply, CPU that controls the robot and drivers of the motors. The robotic arm directly holds the endoscope to guide and move it in all 8 rays of directions. Four back-driveable motors are integrated, one motor is used to control the endoscope to move along its length (right/left), the second motor takes the arm in its perpendicular axis (up/down), and the third motor rotates the endoscope pan-tilt (zoom/back). Gears system is used to control the rotations. No cables or springs are used, as they can give way reducing their life and often needing a repair. The fourth motor can rotate an angled telescope in 270 degree axis.

SWARM has four ranges of movement: 120 degree rotation around the vertical axis, a 30 cm arm length for the vertical position, and 20 cm to cover horizontal journey, with 270 degree axial rotation. The base cabin contains a CPU with a Voice Recognition Software presently wired headphone assembly (wireless in near future) and a control box for the motors. Also driven by a foot pedal the arm works on regular electric current.

SWARM is designed in such a way that it never interferes with the surgeon's field nor it compels the surgeon to change his style or the position of ports.[1314] It does not hamper the surgeon's movements. The total set-up time is hardly 1-2 minutes (just as needed for booting time of a computer). The arm needs to be covered by routine sterile camera cover during its use. The robots which were directly put[18] on the patient's abdomen (animal study only), after several hours of surgery, the device left marks on the animals’ skin. This does not happen with SWARM. The voice recognition software allows eight basic commands SWARM — up, down, right, left, zoom in and zoom out, rotate right and rotate left with nearly 95% reliability in terms of recognition of voice commands. This is true even with noncomputer savvy and inexperienced surgeons. Recently we have added combinations of movement commands such as left-up, left-down, right-up, and right-down. It has an online voice selection of speed i.e. slow, normal and fast. The noisy environment of the operation theatre does not affect the voice recognition in comparison to other similar systems.[16] Training is not an issue at all as there is no voice card. The surgeon wishing to use the SWARM can get accustomed to the “read and reciprocate” commands on the touch screen monitor and get started immediately. There is a vocal feedback from the system that it has executed the commands. Many a times while talking with anaesthesiologist or other staff in the theatre certain words can match the frequency of the commands forcing the machine to move. To avoid this a safety measure — a pause function — is provided which locks the SWARM temporarily so that it does not take any command, when needed a “resume” command recativates the SWARM to take further commands.

Set-up and Removal Time for SWARM

SWARM has the quickest set up time of hardly 1-2 min and little less removal time[1819] irrespective of type of surgery and the surgeon's experience. We recommend adjusting the position of the arm primarily with the foot pedal as per the need of each surgical field and then switch over to the voice control so as to reduce the time taken in set up. SWARM can move the telescope in all quadrants as done by a camera person.

In its first version, SWARM [Figure 2] had an angular movement taking the scope through 7-9 degree with every command. Now we have been successful to move it in all directions on centimetre basis. One can either select a single command mode, wherein the arm covers the specified distance (this range can also be changed) and stops, otherwise with a single command it starts moving in the specified direction and can be stopped by the “stop” command.

Figure 2

Original look of SWARM

SWARM, as seen in the Figure 3, is a on a wheel cart for easy manuverability, the arm lying by the side at the basic height of 120 cm and it finally traverses to 150 cm in upward direction. It is kept at 22 cm from the umbilicus to finally move to 42 cm in the transverse direction.

Figure 3

SWARM today

The advantages[20] of SWARM are its robst design, reliable and precise action due to voice-controlled computer interface, stable continued vision, absence of tremors, fatigue and soiling of telescope lens, ease of training, reduced learning curve, and absence of any hidden costs of disposable consumables such as voice card. The SWARM also lends itself to SOLO surgery.[21]

Clinical utility

Table 1 shows the clinical applications of SWARM since April 2005.

Table 1

Clinical application of SWARM

Comparison with Other Similar Robotic Systems

The aim of this study was to compare SWARM with available robotic arms like AESOP and ViKY system (Vision Kontrol for endoscopY; France)[18] in vivo in a porcine model, performing successfully surgeries in four different parts. Setup time was compared[22] on the same platform SWARM was compared with VIKY and AESOP using the similar criteria. Table 2 provides the comparative data.

Table 2

Comparison of the ViKY system in animal studies compared with AESOP and SWARM in human subjects[1922]

CONCLUSION

Any innovation must be tested and coined with 5 As: It should be affordable, accessible, available, appropriate, and acceptable. As worldwide availability is concerned AESOP is no more in existence today. A camera holding robot that is comparable or better and cost effective than the existing technologies, is the need of all Indian surgeons and we feel that SWARM has fulfilled all these criteria as an Indian innovation.