Robots are taking on more challenging tasks in today’s medical applications with their improved capabilities. Robotic-assisted surgical procedures, robotic medicine dispensing, and rehabilitation and movement therapy where robotics assist the patient are benefitting from the latest robot technologies. They are improving productivity during procedures, enabling users to perform tasks that are more challenging, improve patient comfort, and reducing costs for medical staff and ultimately patients.
Robotic Gait Rehabilitation with Exoskeleton Assistance
Exoskeleton robot technology keeps getting better. Batteries are smaller, materials are stronger, and computers are hundreds of times smaller and more powerful than in the earliest days of exoskeleton development, which had the weight of a car and never left research labs. Later robots ’motors controlled everything, had knowledge of the world around it, and the ability to make decisions of where it wanted to be and go there. This led to big, bulky systems.
Today’s systems work with the person. Ekso Bionics’ EksoGT™ (Figure 1) is a wearable exoskeleton with improved motion assistance capabilities helping spinal cord injury and stroke patients stand and relearn to walk. It is used in more than 185 rehabilitation centers worldwide.
The robotic suit straps to a wearer’s legs. Portable computers pull sensor and electric motor data from the legs, hips, and knees to decide the motion of the motors and move the patient’s legs. EksoGT™ (Figure 2) provides varying levels of assistance – turned up for full assistance for completely paralyzed patients and turned down for those with more strength – to vary the amount of movement as the leg moves through swing and stance in a normal gait trajectory.
“The robot doesn’t do everything, but makes up for what the person needs. Not as many sensors and motors are needed because the robot isn’t controlling 100 percent of what is going on,” says Adam Zoss, lead engineer and staff scientist at Ekso Bionics. “The person provides situational awareness and decides what they want to do, and the robot leverages the intellectual and physical input.”
Zoss says this mindset produces better rehab outcomes, as patients are constantly involved in what’s going on and part of the process rather than taking a ride. It also improves the rehab process for patients, making steps more consistent, a higher quantity of steps, and more repeatability between sessions, making it easier for patients to stand longer and earlier. It provides strength and coordination to help therapists have more productive sessions and get better results faster.
In addition, the exoskeletons help physical therapists, and reduces the number of therapists needed compared to traditional therapy practices. Typically, a second therapist would crouch down on the ground helping develop muscle memory, balance, or grabbing and moving the legs to help ambulate in cases of limited strength. Instead, the robot does much of the same work of this second therapist, moving consistently and repeatedly while guaranteeing strength and stability so the patient doesn’t collapse during standing. It’s safer and less tiresome for the therapists, and could reduce their own injury rate since they can now stand upright while coaching the patient. It also allows therapists to do more than they could alone, making it safer for a lighter therapist to guide a heavier patient from sitting to standing, which can be taxing.
Zoss’s vision for advanced exoskeletons in the future are to handle more situations, perform more types of activities, and in the long term, get out of the rehab center into the world in less constrained environments. “Exoskeletons will become an expected standard of care after an injury in rehab settings. But the 50-year vision is clear. They will be used for general mobility improvement for anyone with impaired walking or who needs help in daily life, and as an alternative to a wheelchair. Ideally, people will put on an automated suit to recover, and a full suit may not be needed,” he says. Developments are happening now in focused exoskeletons on lower extremities that could bring full leg, knee brace, ankle, or hip brace devices next.
Flexible Surgery Robots
Robotic surgical systems with linear instruments and cameras such as Intuitive Surgical’s DaVinci platform are large and difficult to move from one operating room to another. Hospitals with line-of-sight based robot programs staff up with specialists, dedicated “robot (operating) rooms,” and blocks of time dedicated to robotic surgeries. If a patient cancels or can’t be operated on, the room frequently sits empty, increasing the hospital’s fixed expenditure costs.
Medrobotics’s Flex® Robotic System is a robot-assisted surgical platform (Figure 3) with flexible robotic scopes, flexible instruments, and HD visualization and was designed to efficiently integrate into an operating room. Medrobotics received FDA clearance for Flex for head and neck procedures in July 2015 and colorectal procedures in May 2017. This system translates the surgeon’s hand motions into precise movements that let them access difficult to reach anatomy. The Flex Robotic System is able to do natural orifice surgeries in the colon and at the top of the voice box, which is hard to reach.
The Flex robotic scope’s tight turning radius is small enough to bend within the throat (Figure 4). Surgeons can access and visualize patient anatomy in a way that may be difficult or impossible to achieve with traditional straight laparoscopic or linear robotic approaches, and treat more patients with minimally invasively techniques than is possible with older technologies.
The surgeon drives the robotic scope into position to visualize the surgical field then advances instruments through guide tubes along its length to reach the surgical site. The design and ease of use allows more surgeons to perform robot-assisted procedures, and they don’t have to think about how to use the robot allowing them to focus on the surgery itself.
Line-of-sight robots from Intuitive Surgical and TransEnterix Surgical are mainly used in urology, OBGyn, and minimally invasive colorectal and head/neck procedures. Their straight-line systems are in large, dedicated suites and require surgeons to sit at remote consoles. Contrastingly, the Flex surgical robot is highly mobile, and its integrated cameras and instruments allow surgeons to directly access the patient with their hands while sitting or standing next to their surgical assistant and patient. This access can save time in an emergency and lets surgeons operate in their preferred manner.
Medrobotics President and CEO Samuel Straface, Ph.D., says “Compared to open surgeries to remove tumors or other diseases such as cancer in those spaces, recovery time drops from a month to going home in one or two days, and back to work in a week. This leads to quicker wound healing, less scarring, and less pain during recovery which is better for the patient. The difference is huge.”
The small mobile platform of the Flex can be wheeled into a new room and set up or reconfigured in five to six minutes. No special rooms are needed for robotic surgeries. Now, if the robot is available, any properly trained surgeon in any surgical suite can have access to it.
Cost savings may come from shorter hospital stays from reduced infection rates and other complications. Its efficiency also allows hospitals to perform more procedures per operating room since set-up times are short and the robot can move from room to room “just in time” for the next procedure.
“Large ambulatory centers in the United States are starting to deploy robots for major surgeries providing day care only, where patients enter and leave the same day without overnight stays. Advanced surgical systems like this could start to shift resources away from expensive operating rooms to much less costly, more efficient surgi-center places. It’s promising,” says Dr. Straface.
Future product development and regulatory clearances for the Flex may expand the types of transoral procedures to go deeper in the airway or digestive tract such as in the trachea or espohagus. Additional transanal product development may extend the surgeon’s reach further into the colon where they may be able to treat up to 50 percent of all bowel cancer without a skin incision. Less invasive, Scarfree™, trans-vaginal surgeries may also be possible, providing quicker recovery and less pain compared with open, multi-port, or multi-trocar procedures. Work also continues on qualifying single-site abdominal surgeries with umbilical entry providing a less invasive option than multi-site entry.
Latest Robotic Pharmacy Systems
Pharmacy inventory management in most hospitals is largely a manual process today. Medications sit on shelves, and as the pharmacy receives orders for patients or to refill automated dispensing cabinets or satellite locations, technicians pick medications, put them into bags, and pharmacists are required to check everything leaving the pharmacy. The new Omnicell XR2 Automated Central Pharmacy System is a self-contained robotic warehouse that stores and dispenses medications, automating the repetitive logistical tasks of inventory storage and management without requiring human involvement.
Medications come in all shapes and sizes. Storing and manipulating an endless variety of packets, vials, syringes, ampules, blisters, cups, boxes, and IV bags has historically been a daunting challenge for automation. Older and competitor robots required overwrapping or repackaging medications to be stored and picked, which added extra time, labor, equipment and cost.
The XR2 has a patented storage architecture and vision guidance capabilities, making it the only robot on the market able to handle medications in their original form, without repackaging. It scans manufacturer’s barcodes on any medication regardless of size or shape. “Using the manufacturer’s barcode is the safest, most reliable approach to storing and dispensing medications. This translates into saving time and money.” says Michael Guidry, Senior Director of Central Pharmacy Products at Omnicell.
The XR2 has the unique ability to scan every package into and out of the system and can track the expiration date of every dose stored inside. This allows the system to dispense the earliest-to-expire medications first, helping pharmacies with the complexity of managing expiration dates for every medication and reducing the expense and waste of unusable inventory.
“This level of safety and control will allow hospitals to pursue approval from state pharmacy boards allowing pharmacists to check only a sample, usually five to 10 percent, rather than 100 percent of medications leaving the pharmacy. This frees up tremendous amounts of pharmacists’ time, making them more available to be part of patient care teams and elevating their level of practice. Hospitals can see a payback of two to ten times their cost by having pharmacists involved in other clinical activities,” Guidry says.
Other than restocking and moving output to its final destination, pharmacy technician time is also freed up to support more value added activities. The system creates a 24 hour work window where XR2 can work through the night when pharmacies typically have limited staff.
Guidry expects future versions to have refrigeration and additional layers of security to allow handling different classes of medicines such as controlled substances.
For More Information:
Videos of EksoGT in Action
Medrobotics Video: Flexible robotic surgery at University of Pittsburgh Medical Center
Video of Omnicell XR2 in Action