Man vs Machine: Technology at its exciting best in medicine, human intervention to take a back seat?

SCI-FI LOVERS will remember the movie, The Island, made by renowned director Michael Bay. Set in the distant future, the movie’s plot revolved around matters such as human clones and organ harvesting.

The use of robots inside the human body might sound like the perfect fit for a sci-fi flick and bizarre in real life. But robotics and automation are, believe it or not, playing a pivotal role in the world of medicine these days.

SCI-FI LOVERS will remember the movie, The Island, made by renowned director Michael Bay. Set in the distant future, the movie’s plot revolved around matters such as human clones and organ harvesting. In one of the scenes, Dr Merrick, the antagonist, realises that Lincoln 6 Echo, a clone and the movie’s primary protagonist, isn’t behaving as anticipated. Merrick then clinically inserts tiny metal robots, the size of salt grains, into Lincoln 6 Echo’s eye to map his brain activity. Later in the movie, these tiny, ant-like robots exit Echo’s body when he uses the toilet.

The use of robots inside the human body might sound like the perfect fit for a sci-fi flick and bizarre in real life. But robotics and automation are, believe it or not, playing a pivotal role in the world of medicine these days. Robotics-assisted surgeries have become a reality now. But what if tiny robots could actually enter our body and heal us of any prevailing ailments? Scientists and researchers are now attempting to unravel the future where this possibility might become a reality.

Pushing boundaries

Picture this: a small capsule, no bigger than your regular medicine, goes inside your body and carries a robot that can be controlled from the outside. Worried about swallowing it? It will be coated in ice and made of biodegradable material, so all you need to do is gulp it down. Sounds impossible? Well, at the Massachusetts Institute of Technology (MIT) in Cambridge, US, researchers are turning the impossible into some fascinating possibilities. Researchers at MIT’s Computer Science and Artificial Intelligence Laboratory (CSAIL) have developed an edible “origami robot” that can unfold itself from a swallowed ice capsule and be steered by external magnetic fields. “In the centre of one of its folds is a permanent magnet that responds to changing magnetic fields outside the body, which control the robot’s motion. The forces applied to the robot are principally rotational. A quick rotation will make it spin in place, but a slower rotation will cause it to pivot around one of its fixed feet,” says a spokesperson for MIT-CSAIL through email.

The researchers explored material like rice paper, sugar paper and hydrogel paper to form the robot’s flexible frame and biodegradable structure. But they settled on dried pig intestine, which is used for sausage casing, since it had the best properties when it came to folding, unfolding and control.

When available in the market, this tiny ‘origami robot’ could be used to patch wounds, deliver medicine to specific areas of the body or dislodge foreign objects like a swallowed button battery. As per the spokesperson for MIT-CSAIL, once its job is done, the robot will dissolve into the bloodstream. However, he adds that it will be at least a decade before this technology could be tested on humans. “It’s really exciting to see small origami robots doing something with potentially important applications in healthcare. For applications inside the body, we need a small, controllable, untethered robot system. It’s really difficult to control and place a robot inside the body if the robot is attached to a tether,” says Daniela Rus, director of CSAIL at MIT.

Another recent advancement is ‘micro-robots’ that are so small they can be seen only under a microscope. These ‘microbots’ have been developed by scientists from the Ecole Polytechnique Federale Lausanne (EPFL) and ETH Zürich (Swiss Federal Institute of Technology Zürich) in Switzerland and resemble a flagella—a spiral-shaped tail that helps a bacterium to swim in fluid. In this case, the micro-robots mimic the bacterium that causes African trypanosomiasis, known as sleeping sickness. “We make these micro-robots using lithographic patterning of hydrogel sheets. Some of these sheets have magnetic particles embedded in them, so they can be moved using magnetic fields. Some of the hydrogel swells with small temperature changes, which we create using infrared light,” says Bradley Nelson, professor of robotics and intelligent systems at ETH Zürich. As per the EPFL website, these micro-robots are soft, flexible and motor-less, unlike other conventional robots.

These microbots can be injected into the body and controlled from the outside using magnetic fields and low-power laser light. While still in development, these microbots could prove effective in performing precise operations inside the body. “We see drug delivery as an important application area. These could also be used to help remove blood clots or plaque in arteries,” says Nelson of ETH Zürich, adding that it’s always difficult to judge how long it will take to move this to clinical application, but if things progress well, it could be possible in the next 5-10 years.

There is no shortage of developments in this field. Some recent news reports talked about researchers at the University of Michigan, who are developing tiny robots that could link together, form chains of minuscule devices that could act as muscles in bigger robots or within the human body. Virtual reality, which has found a useful purpose in many major sectors, is now being used in the field of medicine too, as per reports. The result? A “virtual autopsy”, where a body is put under a CT scanner instead of the pathologist’s knife. The results, say doctors, are reasonably accurate.

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India status

Robotic surgeries are not new to India. Its roots can be traced to almost 10 years back when the All India Institute of Medical Sciences (AIIMS) conducted the country’s first robotics-assisted surgery in 2006. While this surgery happened in urology, the reach and scope of robotics surgery has widened over the years.

As per various reports online, last year alone, nearly 190 robotic surgeons in the country performed over 4,000 procedures in areas like urology, gynaecology, thoracic, paediatric, general surgery, head and neck and weight-loss surgeries. Treatment for various cancers of the prostate, kidney, urinary bladder and reconstructive surgery of the ureter and bladder can be done with the help of robotics today.

Another technological advancement is tele-guided surgery, where the surgeon is not actually present in the operation theatre. “Cross-continental surgery has also been attempted. A surgeon was in New York and the patient was in France. The surgeon was sitting and operating from New York. The problem was the time lag of three-five seconds. It is risky, but can be done when there is an expert sitting at the other end too. That is the future,” says Narmada Prasad Gupta, chairman, academic and research division, urology, Medanta Kidney & Urology Institute, Gurugram.

Gupta explains that microbots, as mentioned earlier, are used for GI or gastrointestinal endoscopy, where a small camera is swallowed and it takes pictures of the intestine. It comes out of the body the next day.

To the aid of doctors

Going under the knife in a robotics-assisted surgery has its benefits. But these benefits are not restricted just to patients. In some procedures, like oncology surgeries, surgeons are required to stand for prolonged hours. But with the help of robotics, the picture has changed. “Nowadays in the theatre, you don’t need to stand by the side of the patient. You sit comfortably at the end of the room with a console. In the past four years, I have had the experience of conducting over 100 major surgeries with the help of robots,” says Alka Kriplani, professor and head of department, gynaecology and obstetrics, AIIMS, New Delhi. Kriplani adds that with robots, single-port surgeries might become the standard of care in the future.

Gupta of Medanta has handled 400 cases himself and 1,000 cases under supervision at Medanta and AIIMS in radical prostatectomy. He believes robotics-assisted surgery has proved to be a boon for patients in recent times. “Less blood loss, short hospital stay and an early return to work—these are advantages that have been proven all over the world… Today, more than 90% of radical prostatectomy is done through robotics only. This is mostly in the US and Europe,” he adds.

A robotic future?

So are we possibly heading towards a future where operation theatres will not need even the slightest human intervention? Imagine a scenario where the patient enters the theatre on a gurney. A robot picks up the necessary instruments and robotic hands, retro-fitted on the ceiling of the theatre, conduct the surgery. No nurse, no doctors. Or maybe, a surgeon with a console will be operating a robot, which is thousands of miles away in a war field, tending to injured soldiers. Could all this be really possible? “It’s like a dream. But whether it will become practical or not, we don’t know yet,” says Gupta.

When it comes to surgeries—be it through traditional methods or with the help of robots—an element of risk is always prevalent. Gupta says results from robotics-assisted surgeries are much better in comparison to open surgeries, but this is only for select surgeries and not every operation. “I have handled more than 100 surgeries, but I have never had to convert the patient. Conversion means that when you are not able to complete the surgery through robotics, you cut open the patient. So the success (rate) is 100%,” says Kriplani of AIIMS.

But when it comes to results and application of robotics-assisted surgeries, experts say it’s not a case of man versus machine, but master and slave instead. The job of the robot, says Gupta, is to transmit the hand movements of the surgeon through the robotic instruments inside the body.

He adds that robotics surgery is an approach, not a science. Since the principles of the surgery remain the same, be it open or robotics surgery, there is no need for specialised doctors in this field or a separate branch of medicine. “Robotics surgery should be applied wherever it is indicated, not in every case. If a good job can be done by either laparoscopic or open surgery, there is no need for a robot,” he adds.

Access & cost

A possible stumbling block in the adoption of robotics and automation will be the price. Simply put, robotic surgery and technology do not come cheap. “The basic set-up of a robot costs crores—maybe R12-14 crore. Then you have very expensive disposables. Even at

AIIMS, I think one operating theatre costs lakhs of rupees. You are also supposed to change the disposables. The machine counts… after 10 uses, that instrument can’t be reused even if it’s in good shape. So the whole surgery comes out to be pretty expensive,” Kriplani explains.

In some areas in India, where even doctors are not available, such surgeries remain a distant dream. And some latest figures on India’s healthcare situation do not paint a rosy picture. As per an IndiaSpend analysis of government data, India is short of almost five lakh doctors based on the World Health Organization norm of 1:1,000 population.

Kriplani agrees: “Metros might have the best of surgeons and facilities, but the same can’t be said for rural spaces, where even routine laparoscopy facilities are not available. Patients are operated through big surgical cuts. Naturally, the pain and recovery time are more,” she points out.

However, this situation might change when more countries and companies come out with robotics technology. The good news is at least 10 countries are in the pipeline to introduce new robotics systems. The global robotics surgery market, as per research online, is also expected to be worth $20 billion by 2020. So there is hope for the future. “Today, it is limited to a few hospitals in India. There are only 31 robots in the entire country. The moment they enter the market, the price will immediately fall, making this technology accessible to everybody,” Gupta adds.

Bradley Nelson
Professor, robotics & intelligent systems, ETH Zürich, the Swiss Federal Institute of Technology

We make micro-robots using lithographic patterning of hydrogel sheets. Some of these sheets have magnetic particles embedded in them so they can be moved using magnetic fields. We see drug delivery as an important application area. These could also be used to help remove blood clots or plaque in arteries

Daniela Rus
Director, Computer Science and Artificial Intelligence Laboratory, Massachusetts Institute of Technology

It’s really exciting to see small robots doing something with potentially important applications in healthcare. For applications inside the body, we need a small, controllable, untethered robot system. That’s because it’s really difficult to control and place a robot inside the body if it is attached to a tether.

Narmada Prasad Gupta
Chairman, academic & research division, urology, Medanta Kidney & Urology Institute, Gurugram

Cross-continental robotics surgery has been attempted in the past. A surgeon was in New York and the patient was in France. The surgeon was sitting and operating from New York. The problem was the time lag of three to five seconds. It is risky, but can be done when there is an expert sitting at the other end too. That is the future.

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