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Robotics in medicine. La robótica en medicina

AuthorsBarrientos, Antonio ; Cerro, Jaime del
KeywordsRobotic technology
Issue Date21-Jun-2019
CitationMedicina Clínica 152 (12): 493-494 (2019)
AbstractIn 1985, at the Long Beach Memorial Medical Centre, a PUMA 200 robot from the company UNIMATE performed what is considered the first ever use of a robot in surgery, accurately guiding a needle to its intended destination in a stereotactic brain biopsy.1 According to Kwoh et al.,1 the reasons justifying the use of a robot in the operating room was its submillimeter accuracy and the precise execution of the plan defined by a surgeon in the preoperative process based on a tomographic image. And indeed, robots can reach precisions of hundredths of a millimetre, countering the small oscillations associated with an inevitable human tremor. Some years after this pioneering experience of applying a robot in the surgical context, in 1993 the Food and Drug Administration (FDA) approved the use of a robotic system in an endoscopic surgical procedure (the Automated Endoscopic System for Optimal Positioning of Computer Motion Inc [AESOP]).2 The combination of the information obtained through a medical image, the computer programmes designed to help with preoperative planning and the ability of the robots to faithfully replicate the plan, are the basis of systems such as ROBODOC3 initially commercialised by CUREXO and currently by Thinsurgical – CASPAR – Ortho MAQUET – and the MAKOplasty® Robotic Arm, whose purpose is to intervene in Total Knee and Total Hip Arthroplasties (TKA and THA). With the same precision that they have when carrying out tasks in a workshop, these robots perform the preparation of bone tissue operations for the correct settlement of the prosthesis. Certain long-term clinical studies carried out on behalf of CUREXO found that robotic TKA and THA interventions show “small but potentially important clinical improvements in patients”4; however, other studies have shown that they generally require an undesirable increase in surgery time. But it is not this ability to accurately replicate a pre-established plan that has given rise to the expansion surgical robotics is currently experiencing. On the contrary, its most widespread systems today fall into the category of telerobotics, which are robots that reproduce instructions coming from a human's movement, rather than having a preloaded programme that they replicate faithfully. In the 1950s, the context of nuclear radiation motivated military research into the development of devices that could be remotely manipulated, in order to work with radioactive substances without risk to the operator. R. Goertz, of the Argon National Laboratory (USA), developed for this purpose the so-called ‘telemanipulators’,5 devices capable of faithfully reproducing the movements that an operator located in an area close-by was making at that moment. The same principle is used in robots such as Intuitive Surgical's da Vinci,6 used today in minimally invasive surgery. In this case, the surgeon – from outside the operating room and through a console – manipulates certain instruments that give orders to the robot arms and instructs them on how to move the endoscopic system used in the intervention. Telesurgery robots improve the surgeon's abilities, and allow them to feel extremely immersed in the act through the use of a stereo endoscope camera that gives a high-quality, three-dimensional amplified image and a control system that increases accuracy, by filtering any possible tremors and translating the amplitude of the endoscopic instruments’ movements into a small fraction of the surgeon's actual movements. In addition, ergonomics are improved by locating the control console in a room outside the operating room, where the surgeon can enjoy a more comfortable posture and a less stressful environment. Despite the high cost of robots for minimally invasive surgery, these systems have been largely adopted and it is not unusual to find them in the surgical units of many healthcare systems. For example, there are currently 52 da Vinci robots in Spanish hospitals,7 in particular in the area of urology. But the participation of robotics in medicine is not only limited to image-guided or minimally invasive surgery. It is also present in radiosurgery, where, again, the advantage of precise positioning, together with the ability to receive and act out orders in real time, in this case from an X-ray capture system, means robots can offer significant help. The CynerKnife8 system, developed by Adler et al.,9 is currently commercialised by Accuray Incorporated. This robot is a similar shape and size to many of those found in automotive manufacturing lines, at the end of which lies the gamma-ray linear accelerator. There is also a stereoscopic X-ray system that provides information on patient's exact position at each moment. With this data, the robot can be continuously repositioned, and the radiation emitter's movements can run parallel to the patient's movements, or more specifically to their organs’ movements, thus maintaining an accurate position and orientation while addressing the tumour. Its implementation in Spain is still limited, and only two units are available in Madrid of the approximately 600 installed in the world. Sánchez's 2014 publication10 analyses the effectiveness and safety of this system. The robotic prostheses that replace arms, hands or legs, or the orthoses that help compensate certain dysfunctions, are all being intensively researched, and certain promising results are fully applicable. Prostheses have experienced significant advances in recent years, partly due to the social demand that has arisen as a result of armed conflicts. The achievements of the LUKE Arms, commercialised by Mobius Bionics,11 developed by DEKA Integrated Solutions Corp. with funding from the Defense Advanced Research Projects Agency, and approved by the FDA, are noteworthy. Its 10 independent movements are controlled from a variety of interface devices in order to better adapt to each individual user. Furthermore, the reinnervation work carried out by Kuiken et al.12 at the Regenstein Centre for Bionic Medicine in Chicago is also worth noting. After fitting a patient who has undergone an amputation with a motorised artificial arm, they give control of the new arm to the patient through restoring the nerves that originally ended in the muscles of the amputated arm, in the patient's chest. By doing this, the nerve signals originating from the mental intention to move the arm become contractions of the chest muscles, which are captured by myoelectric sensors and used to move the prosthesis. In rehabilitation, it is often necessary for the patient to repeat certain movements with a specific amplitude and strength. Robots can reproduce, in a planned and controlled manner, movements that the rehabilitation therapist would normally perform on the patient. Successful cases have been evidenced using the ATLAS system of Marsi Bionics13 or the CPWalker system.14 While the first consists of an exoskeleton that helps in the rehabilitation and mobility of children with neuromuscular diseases, cerebral palsy (CP) and others, the second is a robotic walker, designed to help post-surgical rehabilitation of children with CP. Other systems with an international market are those commercialised by Hocoma: the Lokomat system to rehabilitate walking or the Armeo system for upper limbs. Other needs, such as healthcare assistance, are also beginning to be resolved by robots, which can contribute to providing patients with motor limitations with autonomy in tasks such as cleaning or cooking. The Neater Eater Robotic15 systems and the SECOM Myspoom are examples of this. The purpose of robotic aid is also to improve cognitive or emotional levels. A typical example of this is the PARO robot,16 a furry, robotic seal with multiple sensors and actuators. Their interaction with certain groups has shown improvements in several markers related to those patients’ emotional well-being (hormone levels and specific tests).17 As the aforementioned examples have shown, and in addition to others that have not been cited but are operative (mobile robots for transport in hospitals, robots for hair implants, robotic endoscopic capsules, hospital disinfection robots, etc.), robotics has a remarkable scope of action within the health sector. They are a tool that enhances and expands health personnel's capacities and frees them from having to perform activities, leaving them time for tasks that carry greater responsibility. Current robotic technology has not yet been fully exploited and can be extended to provide additional medical assistance, such as haptic capacity (useful in telesurgery) or self-learning (useful in assistive robotics). These possibilities will be further enhanced by new advances in areas such as micro-robotics, the understanding of natural language, the development of ‘soft’ and hyper-redundant robots, or variable impedance actuators. In any case, the medical profession will in no case be replaced by robots, as evidenced by the study carried out by Frey and Osborne,18 whose synthetic results have been the source of many internet sites predicting the risk of computerisation of certain professions. For doctors, the probability is zero.
Publisher version (URL)http://dx.doi.org/10.1016/j.medcli.2019.02.001
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