“The problem’s plain to see: too much technology.
Machines to save our lives. Machines dehumanize.
The time has come at last
To throw away this mask
So everyone can see
My true identity…”
— Styx, “Mr. Roboto”
Orson Scott Card’s 1985 science-fiction fantasy novel “Ender’s Game” may be set in the distant future (he never discloses a year), but the world he depicts in his book is remarkably similar to the present day.
The story’s protagonist, Andrew “Ender” Wiggin, is a misfit genius bred by a unified planetary government to thwart a repeat invasion of hostile insect-like aliens called Formics, colloquially dubbed “Buggers” by humans. He is sent to an orbital military academy to be molded into a ruthless soldier capable of defeating the Buggers. During his tenure among the world’s scariest child prodigies, Ender masters the art of “machine thinking,” consistently outwitting even the most sophisticated computer systems during simulated war games. Ender’s superior combat and leadership skills make him a frequent target of bullies but they also give him the confidence he needs to single-handedly destroy the Buggers and save humanity from extinction.
Despite his quick ascension to hallowed hero, Ender does not return to Earth; rather, he colonizes a former alien planet and then embarks on an intergalactic mission with his older sister Valentine to find a home for a sole-surviving Bugger queen. Card’s story ends with Ender and Valentine boarding a series of starships and visiting numerous worlds, looking for a safe place to establish the unborn hive queen.
“Wherever they stopped, he was always Andrew Wiggin, itinerant speaker for the dead, and she was always Valentine, historian errant, writing down stories of the living while Ender spoke the stories of the dead,” Card writes in the novel’s concluding paragraph. “And always Ender carried with him a dry white cocoon, looking for the world where the hive-queen could awaken and thrive in peace. He looked a long time.”
Barring cosmic boot camp, interstellar space travel/colonization, political unity and, of course, hostile alien insects, Ender’s life is not much different than our own: His world is a maelstrom of connectivity, a Big Data-driven wonderland of sophisticated video games (some of which border on virtual reality), flying combat drones, civil bloggers, handheld computing tablets and Big Brother-inspired electronic surveillance implants.
The elaborate computer systems Ender uses both professionally and personally are nearly identical to the modern-day Internet—they connect through a worldwide web and are capable of instant communication. “[Ender] was telling his desk to keep sending a message…The message was to everyone, and it was short and to the point,” Card declares in a prescient description of instant messaging.
Ender’s commissionaire, obviously, is not really a traditional desk, but a futuristic forerunner of the laptop computer. Card explains: “Ender doodled on his desk, drawing contour maps of mountainous islands and then telling his desk to display them in three dimensions in every angle…In the corner of his desk a word appeared and began marching around the perimeter of the desk. It was upside down and backward at first, but Ender knew what it said long before it reached the bottom of the desk and turned right side up. THIRD. Ender smiled. He was the one who had figured out how to send messages and make them march—even as his secret enemy called him names, the method of delivery praised him.” At one point in the novel, Ender detaches the “desk” and plays a game on it while holding the device in his lap.
Ender’s world also boasts larger, non-mobile computers (called ansibles). Card doesn’t provide much detail about the systems but they appear to be comparable to current desktop models, replete with voice-over-IP video conferencing capabilities. At the end of the novel, for instance, Ender uses an ansible during his interstellar colonization mission to listen to and record the life story of his ailing older brother Peter. Valentine, on the other hand, taps the machine during that same mission to transmit a seven-volume history of the Bugger Wars back to Earth.
The foresighted innovations in Card’s novel are no less impressive in the book’s 2013 movie adaptation, particularly regarding medical technology. The 114-minute motion picture written and directed by South African filmmaker Gavin Hood begins like Card’s novel with doctors removing a small metallic tracking device from the back of Ender’s neck. As Card explains in the book, the government-issued implants allow military officials to survey practically everything the monitored subject sees and hears, essentially turning the child subordinates into spies.
Card does not describe the equipment used to remove Ender’s implant but Hood’s film shows a high-tech surgical system consisting of three robotic arms with specialized instruments resembling long metal rods. The android surgeons remove Ender’s monitoring device in a matter of minutes, enabling the boy to return to school shortly thereafter.
Though it fits in perfectly with the movie’s futuristic setting, the robotic system shown at the start of “Ender’s Game” actually is an authentic gizmo developed by the DLR Institute of Robotics and Mechatronics in Weßling, Germany. The organization’s MicroSurge system is capable of performing minimally invasive surgery (MIS) through slender instruments inserted through small openings in a patient’s skin. Several robots mounted around the operating table work together to perform the chosen procedure.
MicroSurge is controlled remotely by a surgeon (who usually is physically separated from the operating room). The system does not replace the doctor but rather augments his skills by replacing lost hand-eye coordination and assisting direct manual contact to the operation area, according to the Institute.
The MicroSurge system’s instruments are held by specialized robot arms and remotely commanded by a sugeon sitting at an input console. The surgeon is able to virtually gain direct access to the operating field through 3-D endoscopic sight, force feedback and restored hand-eye coordination. MicroSurge engineers believe the system possibly could revolutionize cardiac surgery, which traditionally is performed with the help of a heart-lung machine. The robotic system would allow the patient’s heart to continue beating normally while the surgeon watches the procedure on a 3-D screen through an endoscope within the patient’s body (showing an apparently static heart).
“Our ultimate ambition is robot-supported surgery on the beating heart,” Tilo Wüsthoff, an industrial designer at DLR Institute, told the United Kingdom-based architecture and design magazine Dezeen. “For the surgeon, this means that he will see a virtually stabilized video picture of the beating heart. He can focus on his task while the robot follows the motion of the beating heart. The application of the heart-lung machine would become obsolete for a whole variety of procedures that way. Collaterally, the very traumatizing effects of the heart-lung machine on the patient could be avoided [such as] blood contact with extrinsic surfaces, inevitable blood clotting attenuation and typical generalized inflammation reaction.”
Heart surgery isn’t the only frontier DLR engineers hope to conquer, however. The Institute also has deep space ambitions, using the MicoSurge’s tele-manipulation techniques to someday operate on astronauts in outer space. “A key aspect of robot-assisted technology is that it can be used in a telepresence setup, meaning the surgeon can operate in a remote location,” Wüsthoff said. “…This is important in the context of space travel. Ensuring medical assistance for astronauts with tele-manipulated robots is part of different visions for long-term space missions to remote locations such as Mars.”
With interplanetary surgery a distant pipe dream at best, DLR might want to focus its efforts here on Earth, where robotic systems are flourishing. Over the last dozen years, the number of robotic procedures has increased exponentially, going from 1,000 at the start of the millennium to 450,000 in 2012. Industry analysts expect the worldwide robotics market to grow at a 12 percent annual rate through 2018, reaching $18 billion that year and $20 billion in 2020. The Asia-Pacific region is projected to sustain the highest growth, rising a staggering 22.1 percent annually to reach $590.4 million in 2018, statistics from market research firm Frost & Sullivan indicate.
Hospitals have become the technology’s biggest cheerleaders in recent years as they reap the economic benefits of shorter recovery times, expedited healing and less severe tissue damage associated with robotic surgery. In 2012, the Journal for Healthcare Quality reported that 41 percent of hospital websites advertised robotic systems; of those institutions, 37 percent displayed the endorsements on their sites’ homepage.
Research has shown that hospitals with robotic surgical systems are attracting more patients, and in some cases, the robot’s existence actually increases the number of procedures performed. An American Cancer Society study found the number of radical prostatectomies (removal of the prostate gland) has “risen substantially” in the last decade; it also concluded that patients are willing to travel great distances to undergo a robotic procedure. Currently, four out of five prostatectomies are performed robotically.
Indeed, medical robots no longer are the musings of science-fiction enthusiasts. The Age of the Robot has arrived, and hospitals, doctors and patients are scrambling to adapt to this new technology.
“The robotics market is growing significantly. Why? It’s replacing traditional surgical approaches,” noted John T. Hargrove, chairman and CEO of Titan Medical Inc., a Toronto, Canada-based company developing a single-port orifice robotic surgical system. “I have an 8-inch appendectomy scar from an open procedure I had done in high school. Back then, an appendectomy knocked me out for the entire basketball season. That doesn’t happen anymore. These procedures are done minimally invasively now, so the patient is not out of work for a couple of weeks and not in the hospital recuperating for several nights. That has a ripple effect cost-wise. Robotics is here to stay. The technology has applications not only in existing procedures but in most surgical procedures. That’s why everyone is looking at it.”
Indeed, a growing number of companies have been looking at the technology in recent years in an effort to break Intuitive Surgical Inc.’s stranglehold on the market. The publicly held Silicon Valley-based company turned traditional surgery into a futuristic endeavor with the 1999 launch of the da Vinci system, a surgical platform that enables doctors to perform delicate and complex procedures through several small incisions. da Vinci consists of an ergonomically designed console, interactive robotic arms, a patient-side cart (for positioning during surgery), a 3-D high-definition vision system and instruments. The system can cost up to $2.3 million and is powered by technology that allows the surgeon’s hand movements to be scaled, filtered and translated into precise movements of the instruments working inside the patient’s body.
Since receiving U.S. Food and Drug Administration (FDA) clearance for general laparoscopic surgery in 2000, the da Vinci platform has dominated the worldwide robotics market, having sold more than 2,585 systems to 2,025 hospitals to date. Overall procedure volume grew 16 percent last year, driven mostly by the use of da Vinci in general surgery and gynecology in the United States, according to the company’s 2013 annual report. Foreign procedures swelled 21 percent compared with 2012, boosting the company’s total revenue 4 percent to $2.26 billion.
Over the last 15 years, the FDA has approved the da Vinci system for thoracoscopic (chest), urologic, gynecologic, pediatric and transoral otolaryngology surgery as well as cardiac procedures performed with adjunctive incisions. Like the company’s name suggests, the da Vinci is an extremely intuitive system: Recent research suggests that children adept at video games are better at using the system than most surgeons new to the interface (Ender would be a natural at the technique).
To use the da Vinci, surgeons hook their thumb, middle finger and forefingers through two flexible controllers and tap on one of seven pedals to engage different tools. The system’s $63,000 video camera provides physicians with an immersive view of the surgical field, capturing anatomical structures in high definition and natural colors. Fortune magazine dubbed the da Vinci the “iPhone of its category” last year, citing its design and ease of use.
Like Apple, Intuitive Surgical employs a closed innovation model to control all aspects of the da Vinci’s commercial production and develop new projects. The Sunnyvale, Calif., company has improved upon the original da Vinci a half-dozen times since its market debut, releasing a single-site system, which uses curved tools to enter the body through a single incision in the bellybutton; and fluorescent imaging to identify cancer.
The latest addition to Intuitive’s da Vinci portfolio is the fourth-generation Xi, a system optimized for complex procedures with more capabilities than previous models. The Xi features a new overhead instrument arm designed to facilitate anatomical access from virtually any position; a new digital endoscope that produces a simpler, more compact design with improved visual definition and clarity; the ability to attach the endoscope to any arm (providing flexibility for visualizing the surgical site); smaller, thinner arms with newly designed joints that offer a greater range of motion; and longer instrument shafts for better operative reach. In addition, the da Vinci Xi system is compatible with the company’s Firefly Fluorescence Imaging System.
“Our goal is to develop technology that enhances surgical performance,” Intuitive Surgical President/CEO Gary Guthart said in the Xi’s official announcement last month. “The da Vinci Xi System’s new overhead architecture means that multi-quadrant surgery can be preformed without repositioning the system, an innovation long sought by surgeons who perform [these] procedures.”
Taking on Goliath
It seems only logical that Intuitive Surgical would name its robotics platform after mankind’s most diversely talented individual. Italian Renaissance polymath Leonardo da Vinci—painter, sculptor, architect, musician, mathematician, engineer, inventor, anatomist, geologist, cartographer, botanist and writer extraordinaire—designed the first known robot in history, an animated suit of armor operated by a series of pulleys and cables.
Intuitive’s robots are not suits or armor per se, although the company’s shield of more than 200 U.S. and foreign patents has successfully warded off competitive assaults on its business. Consequently, the firm has monopolized the robotic surgery market for most of its existence.
Intuitive’s market domination may not last much longer, though. Concerns about the da Vinci’s safety, clinical benefits and high cost are beginning to sour public (and hospital) opinion about the technology (the “wow!” factor is quickly wearing off, according to some doctors), and many key patents in the company’s massive portfolio will expire over the next two years, thus lowering the barriers of entry for competition.
Potential adversaries already are lining up for their chance to dethrone Intuitive and expand the market. Among the top contenders is North Carolina robotics firm TransEnterix Inc., which currently is preparing an FDA 510(k) application for a mobile, single-site surgical platform called SurgiBot that features high-definition 3-D vision, a smaller footprint, a cheaper price, and a design that allows physicians to remain in direct contact with patients during procedures.
TransEnterix’s device is inserted into the body through a small, single incision in the patient’s abdomen (usually hidden inside the naval). Once inside, the SurgiBot opens like an umbrella, extending articulating instruments controlled by the surgeon; its 3-D visualization restores depth perception lost in traditional laparoscopic procedures.
“The platform automates what have been manual laparoscopic tasks in meaningful ways with added strength, precision and visualization,” said Juan-Carlos Verdeja, M.D., medical director for general surgery at Baptist Health South Florida and an investigator who used the SurgiBot in prototype pre-clinical testing. “It also allows me to scrub in and work at the patient’s side, and maintains and tactile feel that I want as a surgeon.”
Titan Medical also has developed a single-site robotic system that has a 3-D vision system, interactive MIS instruments, a smaller footprint and less expensive price (less than $1 million). The company plans to target the release of its Single Port Orifice Robotic Technology (SPORT) Surgical System to mid-size hospitals at first, though the device theoretically could be used in a variety of settings, from ambulatory surgery centers to large healthcare institutions, given its lighter weight and mobility.
Despite the inevitable comparisons, however, Hargove does not expect the SPORT to compete directly with the da Vinci system. “Initially, we are focusing on less complex procedures—those that are more common to current robotic surgery,” he told Medical Product Outsourcing. “This particular venture started off because of the procedural opportunities and the limited choice in the robotic surgery market.”
The choices, however, are about to explode: A host of entities are developing or currently selling robotic surgical systems, including:
• Privately held Medrobotics Corp. of Raynham, Mass., which received the CE Mark in March for its Flex System, a platform to access and visualize hard-to-reach locations such as the oropharynx and endolarynx. The single-access site system has “wristed” 3-millimeter Flex instruments that enable surgeons to operate in confined spaces.
• Mazor Robotics, an Israeli firm with a monopoly on robot-guided, minimally invasive spinal surgery. The company’s Renaissance Guidance System has been used to place more than 45,000 implants in thousands of spinal procedures worldwide, ranging from minimally invasive one-level fusions to complex deformity reconstructions. Several months ago, Mazor entered the brain surgery market, performing an Asleep Deep Brain Stimulation procedure on a 65-year-old Parkinson’s patient in Littleton, Colo.
• The ARAKNES (Array of Robots Augmenting the KiNematics of Endoluminal Surgery) project in Europe, which is pursuing several designs for surgical robots. The idea closest to the da Vinci is the single-port Sprint system, a platform featuring two robotic arms and a smaller overall footprint. ARAKNES has conducted animal studies on the Sprint, boosting its prospects for eventually winning European regulatory approval.
• SOFAR S.p.A., an Italian pharmaceutical firm that designed and developed the Telelap ALF-X, a telesurgical system with tactile sensing capabilities. The device’s haptic feedback feature allows surgeons to indirectly “feel” the tissues being manipulated, the company claims. The system also tracks the physician’s eye movements, positioning the camera so the field of view is centered on the eyes’ focus.
• Plymouth, Minn.-based Blue Belt Technologies Inc., inventor of the NavioPFS surgical system. The combination platform provides orthopedic surgeons with a detailed virtual cutting guide as well as robotic control through a handheld, computer-assisted bone-cutting tool. The Navio handpiece lets surgeons precisely resurface bone based on a pre-defined plan that uses the limb’s natural landmarks to map the cutting parameters. The technology is built on an open implant-architecture platform and supports multiple implant systems, executives claim. “We view our technology as applying intelligence to existing instrumentation in the orthopedic O.R. [operating room],” marketing director Adam J. Simone noted. “Our brand of robotics is focused on minimizing the disruption to typical workflows and empowering surgeons’ hands/movements with the level of accuracy and precision that can be afforded by smart instrumentation. It was inevitable that robotic techniques would find themselves in the operating room as practitioners and industry team up to advance the state of the art.”
• IMRIS Inc., a Minnetonka, Minn., company engineering the design of a neurosurgical robot. The firm claims its SYMBIS Surgical System evolved from Project NeuroArm, a robotic concept conceived as a method to optimize outcomes for neurosurgical patients during intraoperative imaging.
• The University of California-Santa Cruz and the University of Washington’s Biorobotics Laboratory, which collaborated on robotic technology originally intended for the military. The partners’ Raven II system consists of two robot arms, a camera, a surgeon interface and open-source robotics code software that allow university research laboratories to connect the platform to other devices and share ideas. It can be used for online telesurgery, but some of the more intriguing plans for the Raven II include operating on a beating heart by moving in sync with its motion, and having the robot perform autonomously by imitating surgeons. Built by spinoff firm Applied Dexterity of Seattle, Wash., the Raven II is used strictly by universities to design and test new hardware and software for tele-surgery procedures. “A lot of computer science and bioengineering researchers want to work in the surgical robotics field. If you want to study and innovate in surgical robotics, the only way to do that has been to build your own robot from scratch, which not many laboratories want to do,” said Blake Hannaford, a University of Washington electrical engineering professor involved with the robotics project. “Our robot is a platform in which you can build your own software, and add your own devices as you wish. The only other option is the da Vinci system from Intuitive [Surgical Inc.] that is $1.8 million and the software is closed so you can’t change the code. For computer science researchers, it’s not very useful. It’s great for the clinic, but it’s not designed for engineering research.” Last fall, the Raven II was featured in the film “Ender’s Game,” operating on a bullying soldier who sustained brain trauma during a brutal beating from the movie’s main character.
• Excelsius Surgical, (now owned by Audubon, Pa.-based Globus Medical Inc.), architect of a robotic positioning platform for spine and brain procedures. The Excelsius system is designed to integrate intra-operative digital imaging with a robotic surgery device to hold patients in place during surgeries with “sub-millimeter accuracy.” Globus expects the Excelsius system to win FDA clearance next year and hit the market in 2016.
• MAKO Surgical Corp., the most significant player in the robotic surgery market next to Intuitive. The two are not considered rivals, though, because they compete in different medical arenas. Bought late last year by orthopedic device behemoth Stryker Corp., MAKO’s RIO Robotic Arm Interactive Orthopedic System uses computed tomography (CT) scans and 3-D imagery to guide the surgical removal of bone and implant placement. “First, a patient’s CT scan is converted into a 3-D computer model. The surgeon positions the implants where the patient can benefit most from joint alignment, motion through flexion and soft tissue balancing,” explained Robert Cohen, vice president and general manager of Stryker-MAKO. “The patient’s virtual plan is then loaded onto the robot. With the touch and feel of the surgeon’s skilled hand, the virtual plan is executed in the operating room with the technology providing consistent bone preparation and implant placement in both partial knee resurfacing and total hip arthroplasty procedures.” Despite the lengthy list of potential contenders-in-waiting, Intuitive Surgical’s market-leading position is safe, at least for the near future. Other than Titan Medical’s SPORT system and Excelsius Surgical’s device, the possible alternatives to the da Vinci are still several years away (at best) from final designs, clinical trials, FDA approval and commercialization.
The lapse, of course, gives Intuitive more time to improve upon its product. But latecomers to the robotics game still may find their way into the market via cost-conscious hospitals and health systems. With a price tag of $1.5 million-$2.3 million, an annual service contract ranging from $175,000 to $230,000 and replacement instruments that run between $2,000 and $3,000 per procedure, the da Vinci is a significant investment. Hospitals that once considered augmenting their cutting-edge technology now are more likely scrutinize ways to maximize the effectiveness of their equipment, industry analysts contend.
Similarly, studies questioning the da Vinci’s clinical outcomes are prompting some healthcare institutions to re-examine the efficacy of their robotic systems at their facilities.
Nevertheless, few, if any, hospitals are willing to turn their backs on robotic medical technology despite its high cost. As one industry insider noted: “If a patient goes into a hospital and has a robotic procedure done it might end up costing X amount of money out of his or her own pocket. Is that worth it to the family? Or would it have been better to have laparoscopic surgery that is more invasive but is covered by insurance? The bottom line is robotic surgery currently is not cost-effective for hospitals. But they continue to invest in it. And the end of the day, robotic surgery is here to stay.”
Ender’s future has finally arrived.