Amazingly, the world's first robot-assisted surgery was a brain surgery. The PUMA 200, a machine originally designed for industrial use, helped accurately position a needle during a stereotactic biopsy of a deep intracerebral lesion. Despite the success, for the next twenty years, robots were not used frequently in the theatre. But recently their use has become much more widespread. In surgery in general, over 15% of surgeries employ robots. And specifically in neurosurgery, one survey showed that over 50% of surgeons in Europe and North America had experience with robotic technology in clinical practice.
How do robotics in neurosurgery work?
Surgery is a risky business—but the risks of neurosurgery are particularly acute. Traditionally, surgeons have used a skull-based approach to brain surgery, making large incisions and removing large portions of bone to minimise brain retraction. Robots, however, allow surgeons to access hard-to-reach areas of the brain through tiny incisions in the skull. To remove a tumour, for example, surgeons can position a robot at the base of the skull and skillfully manoeuvre it with minimal damage to the patient.
What was once very niche technology is now a fast-moving discipline, and the technology is being quickly adopted. Combined with leaps forward in artificial intelligence and machine learning, robotics is transforming the practice of neurosurgery. Patient experience is being revolutionised thanks to fewer mechanistic errors, reduced operating and recovery time, and fewer surgical complications.
Advances in new surgical robot technology
Until about 2018, one name, da Vinci, created by Intuitive dominated the surgical robot market. While the US company pioneered the technology, electronics have advanced dramatically since the Food and Drug Administration first authorised the use of da Vinci robots in 2000.
Printed circuit boards for medical devices have become better and smaller over the past five years. This means that challengers to Intuitive's dominance have produced smarter circuits into smaller and more versatile robotic arms, causing the market to grow exponentially thanks to the plethora of procedures surgical robots can perform. This has led to the explosion of startups and established companies entering the space and changing medicine with their surgical robot technology.
However, despite this market trend, there are still comparatively few companies developing robots for neurosurgery.
Companies developing robotic brain surgeon robots are creating three types of systems:
- The telesurgical robot: the surgeon remotely controls the robot's actions.
- The supervisory surgeon-controlled robot: the robot assists the surgeon in carrying out precise tasks.
- Handheld shared and controlled systems: the surgeon and the robot jointly control the instruments during brain surgery. This allows a precise robot to be used together with the neurosurgeon's manipulative skills and manual dexterity.
Here's a list of nine exciting companies working on developing robot-assisted brain surgery technology. You don't have to be a brain surgeon to understand them, but it might help.
1. AiM Medical Robots
AiM Medical Robotics is a neurosurgical robotics company that aims to bring high levels of precision, automation, and efficiency, to neurosurgery. The company is currently developing a portable MRI-compatible surgical robot for use in the MRI suite and the operating room. Its mission is to improve outcomes for patients undergoing neurosurgery for functional brain disorders (Parkinson's and Epilepsy, for example) and cancer while providing hospital cost savings by eliminating errors and reducing procedure time by up to 50%.
2. CorPath GRX Vascular Robotic System by Corindus
The CorPath GRX Vascular Robotic System can be used in neurovascular surgeries and is particularly useful in interventional procedures where precise device positioning is a priority.
Its key features that assist neurovascular surgeons include the following: First, its robotic-assisted control of the guide catheter enables adjustments during complex vascular cases. Second, its sub-millimetre measurement allows stents to be positioned exactly where they are needed. Third, it improves workflow through an extended reach arm for radial access and a touchscreen for ease of use. And last, it offers radiation protection to the physician and can potentially reduce radiation exposure for other staff and patients.
3. CyberKnife for brain tumours
The CyberKnife treats many types of cancer, allowing the entire procedure to be executed without direct surgeon-patient contact and with full control from a remote location. It was probably the first true modern application of robotic neurosurgery.
The CyberKnife System is a non-surgical option for treating brain tumours that is useful when working with delicate and complex tissues and structures of the brain, as precision is of the utmost importance. The system delivers stereotactic radiosurgery treatments with sub-millimetre accuracy and provides improved clinical outcomes.
4. NaoTrac by BrainNavi
NaoTrac is a neurosurgical navigation robot that combines high-precision technology with surgical experience. It improves accuracy and results by streamlining surgical procedures, and the autonomous procedure allows the surgeon to plan and let NaoTrac act as an assistant.
The robot’s arm automatically inserts the tools into the exact pre-defined position of the lesion with robotic precision while the surgeon remains in control. During the procedure, the surgeon can make the practice safer using non-contact registration, preoperating planning preparation, and choosing the surgery pathway with a 3D vision for precise anatomical location.
NaoTrac uses algorithm software to register the patient's physical anatomic location, which increasing registration accuracy and, thus, the accuracy of the surgery.
5. MAZOR X by MedTronic
MAZOR X is a robotic system that assists physicians during spine surgery. It optimises results while reducing patient recovery time.
The Mazor X is a complete system consisting of three pieces that work together to help surgeons perform precise spine surgery. First, surgeons can use advanced computer tools with 3-D images to help them create a detailed surgical plan. Viewing spinal anatomy pre-surgery helps to plan in more detail, leading to increased precision. Second, during surgery, robotics technology guides the surgical tools and implants, assisting surgeons in becoming more precise. And third, surgeons have visibility as they can see the patient's anatomy with Stealth Navigation, which allows any challenges encountered during the surgery to be efficiently addressed.
Neurosurgeons use Mazor X to treat many spine conditions, including:
- Degenerative disk disease
- Scoliosis or curvature of the spine
- Herniated disk
- Spondylolisthesis
- Stenosis
- Vertebral fractures
6. NeuroArm
NeuroArm is an MRI-compatible image-guided robot for brain surgery. A successful prototype has already been developed, and the technology is currently in the technology assessment stage. Currently, a medical grade system is being built.
The system hopes to transform robot-assisted microsurgery through scientific analysis of surgeon-robot interaction. It offers a human-machine interface, providing the surgeon with an immersive and intricate surgical experience.
NeuroArm is an already-patented inter-connected surgical theatre that relies upon cutting-edge technology, including intelligent software, secure cloud analytics, custom control algorithms, and machine learning. The robot is controlled by the neurosurgeon, who works from a remote workstation outside the operating room, and it is reported to be the first robot that provides the surgeon with tactile feedback.
7. Neuromate by Renishaw
Neuromate is a robotic system for stereotactic neurosurgery. It provides a platform solution for a broad range of functional neurosurgical procedures, including electrode implantation procedures for deep brain stimulation and stereoelectroencephalography. It also has many other stereotactic applications in neuroendoscopy, biopsy, and other research applications.
The Neuromate aims to provide consistent, rapid, and precise targeting in stereotactic procedures. The robot can be used with a stereotactic frame or in a frameless mode for reduced patient trauma. It is also compatible with procedures using both general and local anaesthesia.
8. ROSA ONE Brain by Zimmer Biomet
ROSA ONE Brain is a robotic platform to help surgeons plan and perform complex neurosurgical procedures. It allows for minimally invasive surgery, often without the need to shave the entire head. Once the surgeon sets the trajectory, the rigidity of the robotic arm and secure patient fixation are highly accurate.
The system allows multiple registrations, patient positioning, and head fixation options, which give the surgeon's workflow a degree of flexibility. The software used by the technology enables the surgical plan to be created days before the surgery.
ROSA ONE Brain can increase the speed for multiple trajectory neurosurgical cases, and it can assist in a variety of neurosurgical procedures, including:
- Stereo Electroencephalography (SEEG)
- Deep Brain Stimulation (DBS)
- Stereotactic Biopsy
- Ventricular Endoscopy
- Transnasal Endoscopy
9. Surgivisio platform by eCential Robotics
The Surgivisio platform is an optimised 2D/3D, 5-axis robotic X-ray C-arm, integrating image reconstruction and navigation. It allows surgeons to see a real-time patient image in 2D or 3D. The platform can be used in routine procedures, complex cases, or emergency management.
The Surgivisio platform gives surgeons repeatable precision during surgical procedures, freeing them from constraints and allowing them to focus on the most important aspects of their work.
Conclusion
Over the past five years, many companies have started developing surgical robotics; however, there are comparatively few companies designing robotics for neurosurgery. This is not due to a lack of creativity, vision, or desire but perhaps because of the increased risk and complexity of brain surgery. Neurosurgery requires various steps, including localisation, access, and surgical execution, which requires multiple robotic skills. Therefore, instead of relying on one specific machine, we will likely see several surgical robots being used together in even the 'simplest' surgical procedures. Now really is an exciting time for companies developing robotic neurosurgery systems.
