Explore the breadth of new robotic devices being developed for surgical assistance. See the LinkedIn Robot-of-the-Day (#ROTD) series for an ongoing discussion of this exciting technology.

1. Surgical Robots: Emerging Technologies
Roger Smith, PhD
CTO, AdventHealth Nicholson Center
www.NicholsonCenter.com
Webinar Introduction:
Thank you for joining us for this webinar on Surgical Robots as an important emerging
technology. Our goal in this session is to introduce you to the types of robots that are
already being actively used in your hospital, and then to expose you to the rich diversity of
robotic devices that are on their way to market. It is a really exciting time to be working in
this field. So let’s get started.
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2. 1770 Mechanical Turk plays robotic chess
Wolfgang
von Kempelen
I want to open with a story from 18th century Europe. In 1770 the Hungarian born engineer
and inventor, Wolfgang von Kempelen, created “The Mechanical Turk” as a device to
impress the Empress of Austria. Probably to curry favor and financial support from the
crown, rather than as a romantic gesture. From there he began touring the major cities of
Europe to perform in Opera Houses, City Centers, and the Mansions of the Wealthy. He
opened the cabinet and explained how a very complex system of machinery, gears, pulleys,
wires, an controls allowed this machine to play chess against a human opponent
independently. The challenger would move a piece and the Turk’s arm would then use its
staff to move. This went back and forth until a winner was declared, which was very often
The Turk. Audiences were amazed.
From our perspective in the 21st century we know there has to be a trick to this system.
[Click to reveal graphic] And of course it was a hidden compartment with a small assistant
inside who was actually moving the Turk’s arm. Ingenious. Clever. Wealth building.
This is also the same mechanism that is used to control surgical robots today.
Old Text from a previous Presentation:
Automated robotic performance was actually first suggested by Leonardo da Vinci. In his
notebooks he proposed to insert machinery into a suit of armor to allow it to stand upright
and move on its own. The Mechanical Turk became a sensation in the 1770’s when it
toured Europe playing chess against human opponents. The Turk seemed to have the ability
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3. to make intelligent decisions and move chess pieces without assistance from a human
operator. But, it was actually a stage magician's magic trick. The human player was skillfully
hidden inside the chest beneath the board. When the wooden case was opened, only the
gears that moved the arms could be seen. Audiences were fooled for years before the secret
was revealed.
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4. Robots in the OR Since 2001
Intuitive Surgical’s da Vinci
Standard S Si Xi SP
In the general population, those who are aware of surgical robots usually know about
Intuitive’s da Vinci system which has been in use since 2001 and currently has over 4,000
machines in hospitals around the world. In 2018 over 1 million procedures were performed
with just this one brand of robot. Over the last 15+ years the company has released four
progressively more advanced versions of the machine, and the 5th is just about to be
launched in a big way.
However, the general public is much less aware of all of the other robots that are being
used in their local hospitals.
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5. Today
Today there are over a dozen robotic systems in use for surgical procedures. In early 2018,
the TransEnteix SenHance was approved by the FDA for procedures in the USA, becoming
the first robotic system to compete for procedures directly with the Intuitive da Vinci.
The Stryker Mako robot is used to assist with orthopedic hip and knee procedures. It relies
on a digital surgical plan that is created by the surgeon and his or her team prior to the
procedure. It holds the instruments along with the human surgeon and forces the surgeon’s
hand to adhere to the planned cuts and bone removals, eliminating human error when
executing a great plan.
The Medtronic Mazor X robot uses the same idea to provide a guide for inserting pedicel
screws into the spine. It insures that the screw is placed in exactly the right location and at
exactly the right angle, eliminating the variations or errors that come from human hand
insertion.
Accuray’s Cyberknife delivers energy for cancer treatment. It id guided by a treatment plan
and operates completely without human intervention. It can kill the tumor inside the body
without making any surgical incisions, so less invasive than any other form of surgery.
Stereotaxis Niobe uses two large electromagnets to control the movement of the tip of a
very soft catheter. The catheter is maneuvered inside of the heart, making turns that are
nearly impossible with semirigid manual catheters, and can be held against the surface of a
beating heart with no risk of puncturing the heart wall. It is used to apply electro therapy to
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6. nerves in the heart that are causing eurhythmies.
Restoration Robotics’ ARTAS is used in hair transplantation. It is able to see the hair follicles
and automatically extract them as plugs thousands of times over and over. Imagine the
tedium this relieves from the human technician.
These are just six of he robots in use right now. There are at least this many more that we do
not have time to discuss. But how many robots are there and how many new systems are in
product pipelines around the world?
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7. Surgical Robot Landscape
Hair
• Restoration
Robotics
Spine
• Mazor
• Globus
• KB Medical
• Medtech
• Varian
• IMRIS
• Remebot
Eyes
• Cambridge Consult
• Preceyes
ENT
• Medrobotics
• Intuitive
• Medineering
• Galen Robotics
• iotaMotion
Lungs
• Intuitive
• Auris
Skin
• Avra
Abdomen
• Intuitive
• Transenterix
• Accuray
• CMR Surgical
• Titan Medical
• Meere Co.
• Micro Hand S
• Verb Surgical
• Medtronic
• Medicroid
• Virtual Incision
• Vicarious Surgical
• Memic Med
• EndoControl
• USMI
• Avatera
• MST
• AKTORmed
• Human Xtensions
• ACTIV Surgical
• XACT
• Perfint
• Freehand
• Endomaster
• Dexterite Surgical
Knee/Hip
• Stryker/Mako
• THINK Surgical
• Smith & Nephew
• Tinavi
• OmniLife
• Orthotaxy
• AOT
Cardiac Cath
• Stereotaxis
• Corindus
• Robocath
• Catheter
Precision
Dental
• Neocis
67 Companies
Blood
• Veebot
General
• Kuka
• Microsure
• Medical Micro Inst
• Microbot Medical
Transanal
• EDAP TMS
• Medrobotics
• NISI
Urethra
• Procept
Robot‐of‐the‐Day #ROTD
Neuro
• Mazor
• Synaptive
• Medtech
• Monteris
• Elekta
• Renishaw
• Centauri
• BrainLab
Heart
• Heartlander
We have been able to identify 67 companies that are currently selling surgical robots or
that have announced enough details about a future product to make it clear that the
machine is not just a pipedream. Seveal of these companies are actually creating more than
one robot, so there are a few more than 70 unique devices headed our way.
You can see that the biggest share of these machines are targeted at abdominal surgeries
where Intuitive’s da Vinci has been so successful. Many of those machines are attempts to
offer a product that has just a single competitive advantage over the da Vinci. You can also
see a number of machines being offered for neuro surgery, knee & hip surgery, and spinal
procedures. Then there are individual machines targeting microsurgery of the ears and
eyes, skin ablation, dental implants, and transoral and transanal procedures. This market
area is about to explode with new products and opportunities – and with new problems for
healthcare companies to deal with.
If you want more details on any of these machines, we have written a LinkedIn posting on
every one of them and tagged it with #ROTD.
Given such a large number of robots, it would be very helpful to be able to organize these
into categories with similar features and capabilities.
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8. Categories of Functionality
Programmable
Automata (4)
Follow
programmed
plan
• Energy Therapy
• Hair Plugs
Assistive
Guide (20)
Force surgeon
compliance with
plan
• Orthopedic
Knee, Hip, Spine
• Neuro
Surgeon
Waldo (25)
Transfer and
mirror surgeon
movements
• Soft Tissue
Abdomen,
Thoracic, ENT
Motorized
Laparoscopy (13)
Augmented hand
tools
• Soft Tissue
Abdomen,
Thoracic, ENT
Covers 62 of 67, remaining are difficult to categorize
I have made a first pass at categorizing these devices.
The largest category is the “Surgeon Waldo”. The term “Waldo” comes from a 1940’s
science fiction story in which this kind of robot was first described. These are machines that
transfer and mirror the movements of the human surgeon. Human hand and arm
movements are scaled and copied by the robotic device. This is where the da Vinci and all
of its copycats are grouped. They are primarily used for soft tissue procedures in the
abdomen, thoracic cavity, and in ENT procedures.
Second is the “Motorized Laparoscopy” devices. These are modifications of traditional
laparoscopic instruments which have been augmented with capabilities that are typically
only available on a Surgeon Waldo device – most commonly the addition of a wrist joint at
the end of the instrument.
Third is the “Assistive Guide” category. We described two of these earlier. They follow a
presurgical plan and force the human surgeon to be more accurate in following that plan.
They are most common in orthopedic hard tissue procedures of the hip, knee, and spine –
and also in neuro cases in which the skull and brain remain very static and stable during a
procedure.
Finally, there is the “Programmable Automata” which executes a pre‐programmed plan
entirely without the intervention of the human surgeon. Such as the Cyberknife described
earlier. You can see that this last category only has four items in it. So you might comment
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9. that it is not very useful as a category. But I have kept it for now because several of the
“Assistive Guide” robot manufacturers have comments that they actually could have enabled
their machine to perform parts of the operation as an automata without human assistance.
But they did not go that route because the surgical specialty and the healthcare system are
not ready to cede that much control right now.
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10. Surgical Robot HQs
29
3
4
1
1 1
1
6
1
6
1
5 2
1
5
USA 29
France 6
Germany 6
Israel 5
UK 5
China 4
Canada 3
Netherlands 2
Italy 1
Sweden 1
Switzerland 1
India 1
Japan 1
South Korea 1
Singapore 1
Robot‐of‐the‐Day #ROTD
67 Companies in 15 Countries
So where do all of these robots come from? As you might have expected, most of them are
from the United States, with majority of those coming from California and Massachusetts.
France and Germany are tied for second with 6 each. Followed by Israel and the UK with 5
each. There is an entire story to be told about what is happening in those two countries.
Then you can see the numbers scale down from there.
One interesting fact is that a year ago several of the countries with one robot would not
have even been on this list. The family of surgical robot building countries is on the rise.
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11. Surgeon Waldo
• Intuitive
• Transenterix
• Medrobotics
• Auris Health
• Stereotaxis
• Meere Co.
• Micro Hand S
• Corindus
• Robocath
• Catheter Precision
• EDAP TMS
• CMR Surgical
• Titan Medical
• Verb Surgical
• Medtronic
• Medicroid
• Memic Med
• Virtual Incision
• Preceyes
• Medineering
• Galen Robotics
• Vicarious Surgical
• Cambridge Consult
• iotaMotion
• NISI
In case you were not clear on what a Surgeon Waldo category looks like, these are a few of
the machines that fall into that category. They usually have at least two separate pieces of
equipment, one for the surgeon to control and a second holding the instruments, with an
data cable between the two. Many also used a third console as the intermediary for
compute power, light source, energy and other supporting capabilities.
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12. Motorized Laparoscopy
• EndoControl
• USMI
• Avatera
• TransEnterix/MST
• AKTORmed
• Human Xtensions
• XACT
• Perfint
• Freehand
• Endomaster
• Dexterite Surgical
• Synaptive
Motorized Laparoscopy devices are being created which use several different clever
techniques to add a wristed joint at the end of the instrument, something that has been
unique and exclusive to the Surgeon Waldo machines for years. Each of these companies
markets its device as a small robot and I include them in this list because they place that
label on the product. A couple on this list offer a different capabilities, but we can’t go into
those details right now. You can read about them in #ROTD if you want to know more.
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13. Assistive Guide
• Medtronic/Mazor
• Stryker/Mako
• Zimmer/Medtech
• Globus
• THINK Surgical
• Smith & Nephew
• Tinavi
• OmniLife
• J&J/Orthotaxy
• AOT
• Monteris
• Elekta
• Renishaw
• Centauri
• BrainLab
• Varian
• Remebot
• Neocis
Assistive Guide robots offer active intervention in the procedure. You can see in every one
of these pictures that the surgical instrument is being held simultaneously by both the
robot and the human surgeon. The point is that the robot’s job is to make the surgeon
more accurate in his or her movements, actions, and interventions with the patient.
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14. Programmable Automata
• Accuray
• Restoration Robotics
• Veebot
• ACTIV Surgical
Finally, the Programmable Automata are able to carry out some or all of procedure without
assistance from the human. Accuray delivers energy in a precise, pre‐programmed pattern,
Restoration Robotics accurately extracts hair plugs, and Veebot can draw blood. The Veebot
looks like a high tech version of a blood pressure machine that you might see at a CVS or
Wal‐Mart. But it possesses a visual scanner that can actually see the blood vessels beneath
the surface of your skin, select the best one as a source of blood, and plunge the needle in.
The human phlebotomist is standing by to change out the vials, but is not involved in the
actual blood draw itself.
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15. Positive Forces
Fidelity: Improve the fine movements of the surgeon
Robots like the da Vinci Surgical System are used to aid the surgeon’s precision and stability
during surgery. The da Vinci Surgical System features tiny wristed instruments that are able
to address tissue at a much finer resolution than the unaided human hand. When coupled
with the robot’s image magnification and hand‐to‐instrument motion scaling, these precise
movements seem to be much larger and smoother than they actually are. The robot also
uses tremor filtering to remove small unintended tremors in the surgeon’s hands, so those
tremors do not appear as much larger instrument movements during the surgery.
Accuracy: Reduce variation in surgeon and procedure actions
Robotic systems like the Mazor X and Stryker Mako are guided by patient anatomy scans
and a programmed plan of the surgery. With the aid of the robot, the actions performed by
the human surgeon are guided such that they follow the plan precisely, removing any
unplanned variations that would reduce the outcome of the procedure for the patient.
With the robot’s help pedicle screws in the spine (Mazor) are placed exactly as planned,
and bone removal for hip or knee implants (Mako) are exact fits for the prosthetic implant
that will be used.
Safety: Reduce exposure to radiation and improve ergonomics
In manual Percutaneous Coronary Intervention (PCI), there is a high level of exposure to
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16. radiation that is potentially dangerous to the doctors and nurses assisting in the procedure.
Robotic devices, similar to the CorPath GRX, allow the surgeon and OR team to perform their
functions from outside of the radiation field, reducing the long‐term damages from radiation
exposure. This also allows them to work without wearing heavy lead jackets that lead to
career ending spinal nerve injuries. Robots also allow a surgeon to work from an
ergonomically proper position, eliminating the muscle and nerve stresses that come from
leaning over a patient on an OR bed when providing service.
Less Invasive: Reduce impact on the patient
The CyberKnife Robotic Radiosurgery can address cancer tumors without requiring surgical
incisions. It uses computer and robotically controlled focused energy to kill cells inside the
body without ever cutting through the surface of the skin. The EDAP TMS system uses this
same concept to steer high frequency ultrasound to kill cancerous tissue in the prostrate.
Efficiency: Improve OR throughput
The adoption of complex new technologies always requires changes in the processes for
applying it. Experiences with robotic devices has proven that to be true for these as well.
However, once processes are aligned with the capabilities of the device and surgeons master
the new technology, they report that they are able to deliver care more efficiently than using
the older methods. This means the advantages listed above can be delivered to more
patients in a shorter period of time, and that surgeons experience less mental and physical
fatigue in the process.
National Interest: Build an in‐country capability to eliminate dependence on the USA
Recently, scientists in South Korea developed and reveals the Revo‐I robot which has all of
the appearances of the da Vinci robot. The country’s ministry of health released a statement
which made it very clear that the objective of the device was to reduce dependence on USA‐
based robots, as well as the significant loss of funds required to import these into the
country. This robot is meant to make the device more accessible to the citizens of the host
country and to reduce the negative impacts of expensive imports.
As the Nicholson Center continues to be a leader in bioskills training, we believe it’s
important to keep a pulse on the surgical robotics industry as a whole. Follow Dr. Smith’s
ROTD feature to stay up‐to‐date on the latest in surgical devices.
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17. Negative Forces
Along with the positive forces, there are countervailing negative forces. The first and most
obvious is the cost of the robotic system. The Waldo systems are always north of $1 million.
This is a capital investment that has usually been achievable only for large hospitals with
significant revenue and sufficient patient volume to be able to project Following that is the
price of instruments which have a limited lifetime. These add a cost to each procedure in
which they are used, so they either increase the cost to the patient or reduce the profits to
the hospital.
Specialized training applies to multiple members of the surgical staff, which divides them
into those who can assist with robotic cases and those who cannot. That is a small split
where these is just one robot, but when a hospital has two or three in the same specialty,
the staff is further subdivided into those who understand robot A, robot B, or robot C.
This same specialized training applies to the staff in instrument processing who must learn
the unique techniques and tools for cleaning the robots’ instruments.
Finally, there is the challenge for a hospital system to communicate the advantages of
robotic‐assisted procedure to their potential customers/patients. This has become
relatively straight‐forward for the da Vinci robot, but is much more complicated when there
are a dozen robots, each of which is used in a different specialty and each of which conveys
a different set of advantages. Creating an accurate and clear message to the patient
population is difficult.
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18. Tomorrow
CMR Surgical Versius (UK) uses anthropomorphic arms with shoulder, elbow, wrist, and
endowrist joints.
Titan SPORT single port (Canada) offers flexible instrumentation via a single port.
Cambridge Consultants eye surgery robot (UK)
Auris Health’s (USA) flexible catheter for lung cancer biopsies.
Children’s National Hospital’s (USA) automatic suturing device, which may someday
become part of a larger system via the ACTIV Surgical company.
Vicarious Surgical’s (USA) miniature robotic arms what can be inserted into the patient
abdomen along the shaft of a laparoscopic instrument shaft.
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19. The Soft Side of Robotics
Surgical Apps
Standard O/S
Cloud Connected
AI Enhanced
Up to this point we have discussed surgical robots as pieces of hardware. But we have not
thought about the future structure of the software that will e used to animate these
machines. Today each robotic system O/S is a unique package of software that is created
for just one robot. But imagine a evolution of software ecosystem similar to that used for
smartphones. It would be possible and advantageous to create a shared and standardized
O/S that could be used in multiple robotic systems. The more this operating system was
used, the most stable it would become. It could even be a separate product created by a
different company than the robot itself.
Imagine that, like your smartphone, the robot O/S was connected to the cloud where it
would upload records of each procedure for storage and later analysis. Information about
the instruments used, the specific manipulations applied, and video of the procedure are
all logged. These could become the basis of cloud‐based AI or machine learning so that the
experience from millions of procedures could be condensed, understood, and made
available as teaching material or intra‐operative intelligent guidance to a new generation of
surgeons. What could be learned from millions of procedures every year?
And imagine that the O/S provided an app store for software that could further enhance
the capabilities of both the robot and the surgeon. Every machine would not have to have
installed every application, but only those that are useful to the surgeons who are using it.
Also, every application would not have to be built by a single company, limited by their
internal resources and schedules. One app might improve visibility of blood vessels,
another might delver better integration between the visual scene and pre‐operative
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20. imagery, a third might contain anatomical guidance and warnings for new surgeons. The
number of potential applications is almost as extensive as the number of applications on a
smartphone.
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21. Potential Players in the Soft Ecosystem
The companies that can deliver an extensive software O/S and ecosystem are not the
medical device companies. That expertise lies at companies like Google, Microsoft,
Amazon, and Facebook. There would have to be partnerships between the traditional
medical device companies and the IT companies that know how to construct cloud‐based
ecosystems, installable applications that can co‐exist, and tools for improved user
interfaces.
If we are not so USA‐centric, we would also expect to see partnerships with Chinese
companies like Tencent, Alibaba, and Bai‐du.
Cooperation and partnership can cerate some really impressive capabilities far beyond
what we are used to.
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22. Exciting Robotic Horizon
Robotic surgery has a very bright future ahead of it. There are exciting opportunities for the
hardware, software, and ecosystem that are just beginning to be realized. Today is a very
exciting time to be part of what is happening in this field.
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23. Thank You & Discussion
Copy of the presentation:
www.LinkedIn.com/in/rogersmithcto/
Recording of this webinar:
blog.NicholsonCenter.com
Discuss concepts and collaborations:
Contact author via LinkedIn
Thank you for joining us in this webinar. I would like to invite the participants to submit
questions that we can all discuss for the remainder of the time. While we are waiting, I
wanted to let you know that these slides are available via my LinkedIn profile at
“rogersmithcto”. A recording of the presentation with audio will be posted on the
Nicholson Center web site at the link shown. You will also receive an email with these links
soon after we are finished here.
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