Hand-eye Co-ordination For a New Generation of Medical Technology

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By Tim Lougheed

Sophisticated medical technology often follows a tortuous path into the marketplace. While life-saving devices seem to be indispensable to everyone with a life to be saved, their specific use might actually be limited to relatively few people on relatively rare occasions. That can make these products an expensive proposition for doctors or surgeons, and an uninspiring prospect for entrepreneurs.

Nevertheless, many medical innovations do offer significant advantages, both technical and financial. A new, less invasive surgical technique could call for special equipment and more operating room time, thereby raising the cost to the health-care system; meanwhile, those costs might be more than made up if the patient can leave the hospital in a matter of days, rather than weeks. Similarly, advanced imaging technology might represent an onerous purchase, but it could improve the early detection of some conditions to the point where many patients are kept out of the operating room altogether.

Anyone dealing with just one facet of medical technology could have trouble seeing the larger picture in this way. With this limitation in mind, therefore, a Canadian medical technology conference held last fall in London, Ont., attempted to broaden the view for everyone with an interest in the field.

Called Tech Med 2002, the two-day event brought together medical and assistive technology researchers to showcase their latest work. Organized by the Canadian Medical and Biological Society and hosted by the University of Western Ontario, the audience included research scientists, inventors, medical manufacturing representatives, pharmaceutical company executives, venture capitalists and hospital administrators.

“The greatest success that we could have would be for someone to say ‘I met someone at the show, I built a collaboration with them and we’re having ongoing discussions,’” says Dr. Gordon Campbell, one of Tech Med’s key organizers. “It could be a scientist and a company, scientist and a financing group, or whatever.”

Campbell, a senior research officer with the National Research Council of Canada’s (NRC) London-based Integrated Manufacturing Technologies Institute, spent more than a year ensuring that such interactions would be as varied and beneficial as possible. Members of his institute consulted with people from the NRC’s Industrial Research Assistance Program, the London Economic Development Corp., Medical Devices Canada, the Association of Ontario Medical Manufacturers, the Ontario Rehabilitation Technologies Consortium, the Canadian Institutes for Health Research and the Ontario Ministry of Enterprise, Opportunity and Innovation.

More than 120 people took part in Tech Med, and 42 organizations set up information booths for the occasion. Campbell regards the number and diversity of these participants as an indication that medical manufacturers were able to encounter new ideas to integrate into their wares, while researchers, for their part, could encounter individuals who wanted to know more about their research programs.

Above all, insists Campbell, the entire exercise increased the chances of keeping some of the most promising endeavours in Canada, from bench-top investigation to factory-floor production. As for what those endeavours might entail, the Tech Med agenda revealed a tantalizing assortment of possibilities.

For example, a keynote address by Dr. Richard Malthaner highlighted advances made in robotic surgery. A thoracic surgeon with Canadian Surgical Technologies and Advanced Robotics (CSTAR), he outlined the impact this technology is having for anyone who handles instruments in an operating theatre, as well as anyone who produces those instruments.

That impact cannot be overestimated, says Malthaner’s colleague, Dr. Reiza Rayman. As CSTAR’s director of Research and Business Operations, Rayman describes this $30-million facility as the largest initiative in the history of the London Health Sciences Centre (LHSC). Supported by the Canada Foundation for Innovation, the Ontario Innovation Trust and the Ontario Research and Development Challenge Fund, this interdisciplinary research and training centre will eventually occupy the top two floors of the new Legacy Research Pavilion, which is now being built on the LHSC’s University Campus.

In addition, Rayman has first-hand experience of what this kind of facility can accomplish. In 1999, as part of a team led by Dr. Doug Boyd, he helped perform the world’s first closed-chest, beating-heart coronary bypass. That operation represented a sharp contrast from typical bypass surgery, which begins with cracking open the chest and forcibly spreading the ribs. Instead, the surgeons employed a three-armed robot, which entered the chest cavity through three incisions just five millimetres in diameter. Two of those arms contained instruments for dissecting the old artery and sewing on the new one, while the third arm contained a camera for the operators to see what they were doing.

Since then, Boyd and Rayman have performed more than 90 heart bypass operations in the same way. Patients have been able to undergo the procedure sooner than they might have done, and sicker patients, who might not withstand the trauma of the conventional approach, can be good candidates for this new version. In addition, patients have recovered faster and with fewer complications, suffering less blood loss, spending less time on a ventilator and avoiding the need for long-term use of blood thinners.

CSTAR teams have performed hundreds of other thoracic, urologic and transplant operations with this technology, which relies on a workstation with real-time, 3-D imaging capabilities and hand or voice controls to manipulate the various instruments inside a patient’s body. Software turns the surgeon’s hand movements into precise, tremor-free actions on the part of the robot, which can also be shared by remote users who wish to observe or even take part in controlling the activity.

“Now there’s a high level of interest from all the other surgical disciplines, because we all see robotics as a new, revolutionary way to provide surgical care in a very minimally invasive fashion,” says Rayman. “Even in their first generation as they are now, with fairly rudimentary levels of dexterity, robots really do show great potential in performing complex procedures with very small incisions.”

Moreover, the basic elements of these tools are already in place, having been created for use in fields such as aerospace. Rayman argues that such high-profile items as the Canadarm, which is being used to assemble the International Space Station, represent much of the technological innovation that surgeons are seeking.

“We just need to refine it and make the engineers understand what particular applications are needed,” he explains. In fact, applications to enhance the haptic potential of robotic surgical tools — improving the degree of comfort and natural feeling surgeons will enjoy with those tools — is high on CSTAR’s list of research objectives.

“It makes me think of the cyborg soldier, except it’s a medical application,” he says, referring to a system that functions as a mechanical extension of the user’s body. Learning to use this kind of hardware still requires some practice, but Rayman says refining the technology itself will solve this problem.

“As the ergonomics and control systems get better, it will essentially be a non-training item,” he says. “It will be as natural as using your own hands.”

By comparison, medical practitioners are unlikely to be using anything as natural as their own eyes for such work. Tech Med participants were updated on the latest imaging technology that will be necessary to make the most of these robotic systems. Dr. Aaron Fenster, director of LHSC’s Robarts Imaging Laboratory, described innovations that build on techniques that have become well established in the medical community. In particular, he outlined his own group’s success in literally adding a new dimension to the all-too-familiar methods of ultrasound monitoring.

“Although ultrasound has been used all over the world for 50 years, we invented a technical 3-D ultrasound,” he says. Dramatic improvements in computing power over the last decade have made it possible to handle the considerable amounts of data that must be processed to generate such images in real time. In addition, he and his colleagues have patented the software responsible for such processing.

Moreover, this work is focused on immediate medical applications, including minimally invasive strategies for treating the prostate. Their approach, called the transrectal ultrasound (TRUS) shows great promise in overcoming the anatomical complexities of any surgery in this region. The prostate is buried amid a group of important, vulnerable structures, including the bladder, the urethra, the rectum and major nerves and arteries linked with such basic functions as continence and erections. Damage to any of these structures can have serious consequences for a patient’s overall well-being, making it necessary for surgeons to know exactly where they are working.

By way of example, Fenster describes brachytherapy, the implanting of radioactive seeds within a cancerous prostate. This low-level radiation kills the tumour cells in their immediate vicinity, while avoiding the negative effects of traditional radiotherapy.

“For early-stage prostate cancer, this is becoming the preferred technique,” he says. “Instead of having to shoot radiation from outside the body to destroy the cancer, traversing healthy normal tissues, you can embed these radioactive seeds right beside the cancer.”

As enticing as that goal might be, getting those seeds in position remains a tricky business, one that calls for the detail offered by TRUS 3-D imaging.

“We’re talking about inserting a needle into the prostate, delivering something with a fraction of a millimetre accuracy,” says Fenster.

The Robarts Imaging Laboratory, which has evolved from a handful of researchers in 1987 to some 160 today, continues to develop these kinds of applications for cardiovascular, neural and musculoskeletal work. Besides setting new standards for image-guided surgery and therapy, this research contributes to pre-operative diagnoses and post-operative assessments. Orthopedic specialists can track the status of a joint implant, gauging how well it is performing after installation. Conversely, a heart specialist can take stock of the buildup of plaque on blood vessel walls, a condition that regularly precedes incidence of stroke.

Robotics and imaging were among several key themes addressed by Tech Med, which looked well beyond purely technical accomplishments associated with research. Four panels dealt with business issues surrounding the development of medical manufacturing, including the path to commercialization, how to finance a venture, adopting new technology and creating innovation within Canada.

Gordon Campbell regards this inaugural edition of Tech Med as an unqualified success, and he would like to see it repeated elsewhere in Canada in two years’ time. The interest should be there, he points out, noting that upwards of 30,000 Canadians are employed in 1,200 firms that conduct medical R&D in this country. As those firms look to improve their products, they can enlist the help of scientists in places like CSTAR and the Robarts Imaging Laboratory in order to do so.

Other parts of Tech Med displayed equally enticing incentives for these parties to continue seeking partners and advisors to match their technical or marketing ambitions. For instance, the conference presented material on assistive medical devices, such as more versatile wheelchairs, which will be needed to meet the demands of a market that expands with the demographic trend of an aging population.

Above all, adds Campbell, there is never a better time than the present to begin working on all aspects of this field. Among other things, he emphasizes the need to consider therapeutic deployment technologies along with the therapies themselves.

“Let’s get rolling now on those delivery mechanisms,” he says, referring to such daring notions as microscopic robots that could deliver altered genetic material directly into the body’s cells. “If you have to wait for the gene therapy to be developed before you develop the mechanism for delivering it, you’ve doubled the time.”