A Spotlight on a Researcher

Dafna Gold Malchior

A Surgeon’s Right Hand… A Robot

 

The Israel Robotics Association had the privilege of reviewing the latest exciting developments in medical robotics research with Professor Leo Joskowitz, Head of the Computer-Assisted Surgery and Medical Image Processing Laboratory at the School of Engineering and Computer Science, Edmond and Lily Safra Center for Brain Sciences – ELSC, Hebrew University, Jerusalem. Prof. Joskowitz, a recognized world leader for his many innovations and technical contributions in mechanical kinematic design and computer-assisted surgery, shared his insights on smart tools, orthopedic haptic devices, customization and miniaturization in medical robotics

 

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The research passions of Professor Leo Joskowitz, a seasoned, multidisciplinary computer scientist, span a variety of fields, including computer-aided mechanical design, computational geometry, computer-assisted surgery and medical robotics, especially for orthopedics, neurosurgery, and radiology. He’s involved in developing a clinical support system for radiologists -  a large bank of scans that will become “the Google of radiology imaging”; He’s working on developing a method to reduce the harmful exposure of patients to accumulative radiation in repeat CT scans by an order of magnitude, through software that identifies the slight changes that occurred since the previous scan. And – perhaps of most interest to our Israel Robotics Association readers – Professor Joskowitz is developing orthopedic systems using haptic – sensory - devices.     

“Our team has been studying orthopedic fractures for a long time. Caused by accidents, falls or osteoporosis. When seeking to heal a fracture and put the pieces back together, orthopedic surgeons are faced with a challenge: often there are very small pieces of bone to reassemble, sometimes even missing parts. To date, planning the reassembly has been carried out on a two dimensional screen, while the fragments are three dimensional. Our team has developed a system that creates 3D models of the fractures, providing orthopedic surgeons with a more intuitive manipulation which allows tactile feedback, simulating a more realistic situation for them.”

 

What additional directions are currently being pursued in medical robotics?

“We’re seeing a lot of work in development of smart tools – equipped with sensors and implementing sensed information to improve precision in surgery. For example, sensors that can identify a blocked blood vessel and retract the scalpel mid-surgery accordingly, or a drill with a tip that retracts automatically if the surgeon deviates from the planned surgery. We’ll also see smart tools customized to personal needs: in rehabilitative medicine, for example, for Parkinson’s patients - micro motors and sensors are being embedded into spoons to neutralize the typical tremor associated with this disease and stabilize the patient’s hand to enable independent eating. The needs are diverse across conditions.”

“Secondly, much effort is being invested in the development of robotics for assisting laparoscopic surgery. For example: the Da Vinci system. Over 1 million laparoscopic procedures have been performed with it. It’s a large robot, priced at over 1 million dollars per unit. It’s a major, multi-purpose machine. It’s used in surgery for treating organs as diverse as prostate, ovaries and heart. It was designed to be generic, with many buttons and features, with massive hardware and varied software. The cost of development was immense. The direction we’re seeing now is towards more customization, to lower costs and specialize for specific tasks. We’ll also see more autonomy. There will be a wider variety of more targeted systems that will be smaller and less expensive. The goal of these robots is to provide a better support system, supporting surgical gestures, providing guidance, a steady hand, holding the instrument or laparoscopic camera, for more precise navigation as well as enhanced stereo vision.”

 

“A third direction we’re seeing is miniaturization nano-robots, that will end up being inserted into the body, crawling inside clogged arteries to remove plaque, for example. We’re probably 5-10 years away from these research projects becoming a clinical reality. There are currently research projects underway at Tel-Aviv University and at Technion, investigating these issues and already working on some prototypes.”

 

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Visualization  of a child's MRI head and brain scan showing the optimal insertion trajectory for keyhole neurosurgey (yellow line) and possible insertion starting points (green -- safe; red -- risk of hemorrage).

Surface model of muti-fragment fractured femur automatically generated from CT scan showing its reduction and fixation with a plate and screws for visualization and Finite Element Analysis.

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Schematic view of the FP7 ROBOCAST keyhole neurosurgery concept consisting of a standard robot arm for coarse positioning holding a a small parallel robot for fine positioning.

Visulaization of two needle insertion trajectories (yellow and green) for keyhole eurosurgery.  The goal is to find the trajectory that is furthest from blood vessels (shown in red).

 

Will medical robots end up replacing surgeons altogether?

“This talk of replacing surgeons – it’s not happening. There are so many ethical, legal, and other complex issues to take into consideration. Medical robots are a means of support, assistance and precision for doctors. I don’t foresee an entirely autonomous system becoming a reality. In medical robotics, especially in the operating room, there are many players: surgeons, the hospital, insurance company, regulators. National and international initiatives in medical robotics are welcome and useful, but they’ll have to be led by the medical field. The changes are usually driven by surgeons. Experienced surgeons, “high volume” surgeons, defined as those who perform specific surgery a few times a week, these are the ones most able to define the intricacies of where robotic help could be most instrumental in supporting surgeons and increasing precision.“

 

How is Israel doing in medical robotics on a global scale?

“Israel is certainly attracting much interest in this field. There are start-ups, a few successful Israeli medical robotics companies with a success ratio of 1-10, which is not unusual in high tech. But in medicine there are no shortcuts. It’s like a marathon. There is no prototype on a site for customers to experience. Development processes are long and complex.”

 

How did you choose this exciting field of medical robotics for your research?

“I took advantage of some very special opportunities that came my way at just the right time. In the early nineties, I had finished my Ph.D. (Professor Joskowitz earned his first degree in computer science at the Technion and his masters and PhD at NYU) and was working in geometry artificial intelligence at IBM research. I developed a preoperative planning system for total hip replacement for ROBODOC, the first medical robot developed by Ross Taylor at the IBM T.J. Watson Research Center, NY. I was both lucky and privileged to work with Ross Taylor, to be there from the very beginning and I seized the opportunity. Later, I was further privileged to work with Prof. Moshe Shoham, the father of the Mazor surgery system, including software for registration, robot-patient interaction and a prototype for spine surgery. For the past two and a half decades, medical robotics has become one of my major passions and research pursuits. I’m proud of the recognition my work has been receiving – I have been elected fellow of two major scientific societies - the IEEE - Institute for Electric and Electronic Engineers and the ASME – American Society of Mechanical Engineers, as well as the International Society of Computer Aided Orthopedic Surgery which awarded my work a major research prize.”

 

What do you foresee in Medical Robotics 10 years down the road?

“We’ll see a proliferation of more ergonomic systems and smart tools to help surgeons do a better job, and more leveraging of sensors and robotic technology. Delivering improved care for patients is ultimately the goal. That’s what we’re working so hard to achieve.”

 

What is most needed at this point to further develop robotics in Israel?

“We need much more support for applied (and not just basic) research. Engineering research. We need to increase awareness of its importance and support of it. We’re seeing plenty of popular competitions in high schools, and it’s easy to create excitement around this field as robots are attractive and engaging. It’s easy to sell and you can capitalize on it. We have great science museums. This is all part of the backdrop for increasing positive hype about the field. You also need the basis of high skills in math and physics and there’s more awareness to this need as well. Students are being encouraged in these directions, and we’re seeing encouragement of women and minorities to enter the field. Now there’s a need for a lot more concrete funding so that we can leverage this fantastic foundation to develop a strong robotics industry in Israel.”

 

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