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Smaller, gentler, minimally invasive: that has been the credo of surgery in the last few decades.
In the future, robotic assistance systems will increasingly support surgeons.
The advantages: procedures become safer for the patient.
In medicine, the robot-assisted systems are called “robotically assisted surgical systems” (RASS).
There are now around 45 systems for diagnosis and surgery.
The next 40 systems are about to be launched in the short and medium term.
Professor Thomas Hoffmann, Medical Director of the ENT / Head and Neck Surgery Clinic, is developing such systems on an interdisciplinary basis with a robotics research group at the Ulm University Hospital.
He is certain: "In many specialist areas we are only at the beginning."
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The most well-known system so far is “Da Vinci” from Intuitive Surgical.
Around 135 Da Vinci systems are currently installed in Germany.
Major patents will expire this year.
At the start are competitors from North America, Asia and Europe.
This could also reduce the cost of 750,000 to 2.3 million euros per device.
Urologists now operate routinely with Da Vinci, especially on the prostate.
“Yes,” says Hoffmann, “we head and neck surgeons have a different perspective on interventions.
The Da Vinci instruments have a diameter of five to eight millimeters and rigid axes - that poses a problem for us. ”In the throat there is a curved, narrow anatomy.
System with up to four robot arms
That is why Hoffmann and his colleagues switched to a flexible, curved robotic arm for ENT.
The “Flex-System” from MedRobotics lies like a “snake” in the neck, so that structures that were previously hidden can be reached.
Cancer surgery is particularly demanding.
There every millimeter counts, says Hoffmann.
The Ulm robotics group recently developed tubular systems with a working group in Hanover that can adapt to curves.
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The German Aerospace Center is heavily involved in surgical robotics research.
At the Institute for Robotics and Mechatronics there, research is being carried out on a modular system with up to four robot arms called “Miro”.
Medtronic licensed portions of this technology.
The new robot-assisted system is slated to hit the market next year.
The surgeon can control the operating theater remotely from a console, but does not only look at the virtual console, but has a look into the operating room across the screen.
Julian Klodmann, head of the medical robotics research group at DLR: “The doctor is then not completely lost in the 'patient's interior', but can follow the entire surgical process.
This is better for communication in the OR. "
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Medical colleagues are already sharing such systems.
Like at the Berlin Charité.
In urology, surgery, thoracic surgery, gynecology and ENT, cancer operations are performed with several Da Vinci systems, explains Professor Thorsten Schlomm, director of the Urology Clinic.
Around half of prostate cancer operations across Germany are done this way.
"The new technology is particularly helpful for overweight patients, in whom we would find it difficult to reach the deep structures through the abdominal wall," assures Schlomm.
Because the prostate is very close to the bladder, urinary sphincter and erectile nerves, surgeons must be extremely careful.
Schlomm: "We have developed surgical methods for maintaining continence and potency and optimized them for use with the robot system".
New generation of surgical systems
The benefits are also evident in kidney cancer operations, where the aim is to only remove the tumor and leave the kidney intact.
Several companies with the expertise of surgeons from the Charité and Eppendorf University Hospital are currently working on a new generation of digitally supported surgery systems.
“That goes far beyond what we have known so far.
As with cars, digital assistance systems will make their way into operations, making operations even more precise.
Artificial intelligence and semi-autonomous operational steps will also play a role. "
At the Ludwig Maximilians University in Munich, among others, Professor Martin Canis, Director of the ENT Clinic, and Professor Christoph Reichel, Coordinator of the Head and Neck Tumor Center at the Comprehensive Cancer Center, are dedicated to the topic of robot-assisted systems.
Da Vinci is currently also being used there, especially for malignant tumors on the base of the tongue and in the throat.
Canis: "We can operate with it through the mouth, similar to the laser, without leaving external wounds."
More precise than any scalpel: robotic operations can be planned extremely precisely.
Source: pa / obs SWR
While the laser light can only reach tumors tangentially, the filigree arms of the robot system have a higher degree of freedom.
“We can work even more precisely, and important functions such as swallowing, speaking and breathing are better preserved.” Reichel adds: “At the moment, research is being carried out at the LMU-Klinikum to improve robotics with imaging processes, augmented reality, artificial intelligence and the use of fluorescence-marked, Combine tumor-specific antibodies. "
Great advantages in neurosurgery
Doctors should recognize tumor boundaries more precisely.
This should be standard in five to ten years.
RASS are particularly valuable in neurosurgery, for example for the operation of brain tumors, aneurysms or the placement of electrodes for deep brain stimulation.
Professor Rainer Christian Wirtz, medical director of the neurosurgical clinics in Günzburg and Ulm, explains: “Zeiss Kinevo 900 is a visualization system with many additional functions.
The robotic microscope shows me where to operate.
With the integrated micro-inspection tool, you can effortlessly 'see around the corner' without having to give up the microscope view. ”With this look behind the pathological bulge, he can see that no other important vessel is impaired.
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Kinevo, with the microscope and two joysticks attached to its arm, is a platform made up of more than 100 individual patents.
“During the operations, we also access the integrated vascular imaging method.
Tumors stained by contrast media or blood flow in blood vessels can now be displayed much more clearly. ”This is intended to make difficult brain operations safer.
The expert emphasizes: "In the future we will move away from the microscope and towards cameras, video glasses and 3-D screens." For the surgeons, it is like looking through a pane of glass at the structure, with extended contours being faded in - as in the 3- D cinema.
Olympus, Zeiss, Storz and Brainlab are developing systems and are close to approval.
But robots will not replace the surgeon: "The device does not operate, it is controlled by us."
Robots are much more precise than humans
Professor Ulrich Nöth, Clinic Director of Orthopedics and Trauma Surgery at the Evangelical Forest Hospital in Spandau, is also convinced of the support provided by robot-like systems.
A semi-active robot called "Rosa" from Zimmer Biomet helps to fit knee prostheses in the correct position.
After an exact x-ray and operational planning, the robot is fed with data.
Software transmits the spatial position of the leg to the navigation unit.
The robot then holds a cutting plane over the leg so that the surgeon has to move within it.
Nöth: “We don't have any more deviations.
The aim is a straight leg axis that is accurate to the millimeter.
Robots can do this much more precisely than humans. ”The robot will also be available for partial knee and hip replacements from 2021/22, developed by Nöth and a Canadian team.
In addition, a lot of research is currently being carried out in spinal surgery on assistance systems for vertebral body blocking.
In cardiovascular surgery, on the other hand, RASS is intended to achieve greater precision in the placement of stents.
Da Vinci has also been available in general and visceral surgery at the Ulm University Hospital since October 2020.
"The system, which can be operated intuitively, gives us guard rails for the operating theater," says Medical Director Professor Christoph Michalski.
The development, especially in imaging, is picking up speed.
MRI images could soon be displayed in 3-D on the console.
Cannulas are inserted through tiny holes in the abdominal wall and the robot arms are attached to them.
A laser marks the area to be operated on, the robot aligns itself accordingly.
Systems should soon become cheaper
The system is now also suitable for the surgery of tumors in the abdomen, but also for reflux (heartburn) surgery, for cysts and in pediatric surgery.
Michalski and his colleagues designed a program for interdisciplinary training on the robot-assisted system.
Practice is carried out on the simulator - it's "like getting your driver's license".
Michalski: “The systems will soon be cheaper, better, and easier to use.
Hybrid robotics in wide-ranging supply will come. "