Umamaheswar Duvvuri, M.D., an otolaryngologist at UPMC in Pittsburgh, Pennsylvania, talks about a revolutionary new robotic device that is giving surgeons a minimally invasive way to perform delicate, life-saving procedures.
Interview conducted by Ivanhoe Broadcast News in September 2016.
Let’s talk a little bit about the flexible robot? Can you describe it for me, describe its origins?
Dr. Duvvuri: The flexible robotic system that we use now, which is called the Flex System by Medrobotics, is actually as a snake like device, which was meant to get access to different parts of the human body in non-linear trajectory. Basically we know that the human body is in a straight line. We know that we have to force a straight stick instruments to get into the body to find appropriate places in the anatomy, but it’s really not ideal. We have known for a very long time that if you could have flexible instruments, it would make laparoscopic surgery or any sort of minimal-invasive surgery much more accessible and hopeful more efficient for the surgery, therefore, safer and easier for the patient. But we never had that technology in hand so more recently are colleagues at Carnegie Mellon University thought to tackle this problem by really developing a highly articulated probe, initially they called it the HARP, Highly Articulated Robotic Probe, H-A-R-P. The concept was that if you had a, much like a snake, where the body of the snake follows the head, if you direct where the head of this device was pointed to then the rest of the instrument will follow in its place.
Doctor I wanted to ask you again about the idea of HARP.
Dr. Duvvuri: Our colleagues at Carnegie Mellon University had design this concept of, Highly Articulated Robotic Probe, which is what they called it and HARP being the acronym and the concept of HARP is that much like a snake, the body of the snake follows the head. If you can direct the head of this instrument to whichever point in space you want to be pointed in, then the body of the instrument will then follow its natural course. This means you can take any trajectory in space that you wanted, then have to just be a straight line or just a curve, you can have multiple curves, it could be an ‘s’ shape, it can turn and basically in all degrees of freedom. What this really let us do now is get access to hard to reach places in the body by controlling just the tip of this device, which is what makes it unique.
How does this work, is there a camera? Can you describe for me, for our viewers who would not be familiar on how this actual works?
Dr. Duvvuri: The initial concept was that this HARP of this Highly Articulated Robotic Probe would be able to certainly navigate the heart, actually. By going in through a very small incision in the chest, this probe will be able to literally crawl around surfaces of the heart and be able to map the parts of the heart muscle that maybe causing atrial fibrillation or irregular heartbeats of some sort. Then the initial concept was that you would be able to see a particular point in space by mapping it with the electrical activity and then you would be able to let’s say ablated, therefore, have a small probe come out in the front and ablated for that, the vision would be just what’s necessary. It wouldn’t have to be surgical vision if you want to think of it that way. But, clearly in other parts of the body such as the head and neck, or the abdomen, the vision is really important because if you can’t see; you can’t operate. We really wanted to be able to get a really, really high-definition camera at the tip of this instrument so you can actually see the anatomy in the appropriate fashion. Then right next to the camera bring our instruments that can then be used to perform surgery. Then they will be to grasp, or cut, or dissect and so this allows us to have great vision, as well as, triangulation, which much like a standard surgery, our hands come out in front of our eyes. The left and right hands have to be triangulating to a point in space so then you can actually perform the task. Well there’s something as simple as signing your name or something that’s complex as performing delicate surgery triangulating is a key aspect of that and so the FLEX system incorporate all of these elements. There’s a high definition camera that gives the surgeon an excellent view, as well as, articulate instruments that come out at just the right angles that allow surgeons to be able to operate on a particular part of the anatomy.
Talk to me about using this for head and neck surgery, your specialty? Why is it critical again to be able to have that flexibility?
Dr. Duvvuri: The head and neck is clearly an area that is very delicate and very sensitive in the sense that there are a lot of structures in a very small part of the anatomy. The neck has critical blood vessels that take blood to the brain, as well as, nerves that give us a sensation and taste and speed, and vision, etc. All of these critical neurovascular structures existence in a relatively small space and so we really want to be able to perform delicate surgery in this area. This area is very visible; it’s part of what defines us as humans. Having large incisions or disfiguring incisions, really brings with it a cost, which is more than medical. It’s social, it’s emotional and patients would like to avoid these disfiguring incisions if all possible; rightfully so. Head and neck has always been a field that has to perform surgeries in a cosmetic way, while not compromising on oncologic efficacy and safety of doing the procedures. That’s the introduction but the real meat of the matter is that getting access to critical areas of the head and neck through a natural orifice, for example, the oral cavity is obviously very intriguing and an obvious solution to this problem. But the problem once again is that humans aren’t straight lines, right? Our mouth isn’t directly connected in a straight line to our back of our throat, or to our voice box or larynx, or our esophagus and so we have to go around the corner, we have to go around the curve which is basically, the tongue base in the back the tongue. To have an instrument to navigate this tongue base, is ideal for us. It makes a lot of intuitive senses very logically that we would use a nonlinear system to be able to provide access to a critical area such as the tongue base, the tonsils, pharyngeal wall or the pharyngeal space.
Instead of having tools, is it flexible enough if the surgeon is in the wrong place will it come out, move away?
Dr. Duvvuri: Absolutely, this is some of the questions the FDA had before the system was brought to market. There was extensive testing that was performed by the company on animal models and cadavers to show that even if you purposely drove the snake into a part of anatomy; it was not strong enough to be able to hurt the anatomy. Of course, you may have a bruise, but it’s not strong enough to cause permanent damage, for example.
No perforation?
Dr. Duvvuri: Correct, there won’t be any perforation, nor will there be any damages or any consequences of putting the robotic system into place. Of course, the FDA was very concerned about this concept of autonomous or selling autonomous surgery so this system will only move where the surgeon directs it to go, it doesn’t do anything itself. It doesn’t have any memory, or it doesn’t move in any particular place mainly of itself. When put together it’s really the surgeon in charge of deploying the system and using the system. It’s really a very cool and new technology that allows the surgeons to be able to do the things we couldn’t typically do it before.
A couple of questions just about the system again. UPMC is the first in the nation to use it for this, head and neck?
Dr. Duvvuri: Well, we were the first in the nation to use it for anything. The system is actually FDA approved for head and neck because I had the good fortune to work with a company as they were deciding what their space was going to be that they would really focus on and I was able to convince them that the head and neck was an area of great need for patients. Therefore, the company invested a lot of effort to have the FDA approval for the head and neck commonly this system is FDA approved for treating diseases and process of the head and neck in the U.S. In Europe it can be used in other parts of the body, but to my knowledge it has not been used anywhere else yet.
When was the FDA approval?
Dr. Duvvuri: FDA approval was in the fall. It was early fall in 2015.
How many patients have you used this on?
Dr. Duvvuri: To date we have done about seven patients. We have a robotic surgery program here that quite robust. We have done over four hundred patients with different types of robotic surgery but since this technology is out, we knew we’ve only had it at our disposal for a couple of months. We’ve tackled seven patients with it and we have another three patients that are scheduled to undergo the procedures.
Is there anything I didn’t ask you about this that you think people should know?
Dr. Duvvuri: It’s a novel technology. This is the first flexible robotic technology that exists in the world. I think it’s going to set a pyridine for the future for how we use instruments to move forward I think that it’s a novel technology, but in and of itself, it’s not a panacea, it doesn’t fix all the problems, the surgeon is still critically important then, therefore, the surgeons that patients choose have to be qualified to perform these procedures along those veins. Complications can happen with any system and luckily we have not had any complications with the system in my hands. There are a handful of surgeons in the world that are using it to my knowledge and there haven’t been any complications from that end either but clearly training and surgical training is really important and so that’s part of where we are moving forward in getting people trained and as more surgeons want to offer this technology to their patients throughout the country.
Any ties to the company disclosures?
Dr. Duvvuri: I have no conflict of interest in the company. This was all done for the academic glory of it.
Did you say you are able to use it in other areas of the body? We talked initially about using it in the heart.
Dr. Duvvuri: Yes, so because the system was actually designed for cardiac surgery and that was the initial thrust of the company and subsequently, they have refocused their desire and really focused paid attention to the next phase, there is still great interest to deploy the system in other parts of the body. Since it is the first flexible robotic system our colorectal surgeons are interested in applying it for natural orifice surgery for colorectal diseases. In fact, our thoracic surgeons and cadaver labs have. Instead to perform partial sections of the lung through a small incision in the neck because you can then get access to parts of the anatomy that you typically couldn’t again with straight instruments. Our gynecologic surgeons colleagues have considered using this to perform transvaginal approaches through the pelvis so I think that while he TNT head and neck accomplishes the first frontier and we are privileged to have the opportunity to bring this to the medical market, so to speak, and to alert our colleagues about it; I see a really, really bright future for this serving others to be used in other parts of the body by many different specialties
END OF INTERVIEW
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