Operating theatre of the future

The University of Twente is developing a new generation of surgical robots. Ivo Broeders, one of the project leaders, expects to see a breakthrough in minimally invasive surgery. "The University of Twente is making a big commitment to the Operating Theatre of the Future".

He was the first surgeon in the Netherlands to perform an operation with the use of a robot. Now, ten years later, he is helping to design one. Ivo Broeders (46) works as a gastro-intestinal surgeon at the Meander Medical Centre in Amersfoort, and since 2007 he has been professor of robotics and minimally invasive interventions at the University of Twente. In his study at the university he sketches out the contours of the TeleFLEX robot project, and how it could enable the University of Twente to capitalize on a promising medical technique: minimally invasive surgery.

"My profession has already been experimenting with keyhole surgery for about twenty years. A few years ago we have entered a new phase. We are currently working on a technique with only a small entry at the navel (single incision surgery) instead of three or four incisions in the body, but in due course we aim to be able to enter a body cavity through natural body openings (natural orifice surgery, or NOTES)."

"Very little scarring: that's what makes the new keyhole operations attractive. For the patient, that is, because as a surgeon, with techniques as they are now, you wouldn't like to see them become standard practice for gall bladder or hernia operations. Those are routine interventions that we carry out tens of thousands of times every year. With single incision surgery and NOTES your position at the operating table is very awkward: in a career of some 35 years that would place too much of a strain on your back and neck."

Cockpit

"It is also for that reason that we are developing our surgical robot. It has three components. At the front is the cockpit, which is where the surgeon sits, and at the other end are the instruments to manipulate tissue, with the electro-mechanical connector between the two. At the University of Twente we are focussing on the platform: the cockpit and the connector. That was delivered to us at the beginning of March by the German firm K. Storz, which is making thirty experimental instruments available for NOTES. The University of Twente is one of the first ten institutions to receive the instrument. Now it's our move."

"The great thing about our platform is that it enables complex, computer-driven manipulation of the instruments in an ergonomically acceptable way, because the cockpit is placed at a distance. What is more, the surgeon can carry out high-tech diagnostics from the cockpit. Endomicroscopy, for instance, or an echo head that can see straight through a body wall, or even light and colour techniques that distinguish healthy and diseased tissue. In short, the working environment is perfect, both surgically and diagnostically."

Teleflex

"The applications for NOTES and the single incision robot? For the time being they will be restricted to minor interventions, not so much in body cavities as inside of organs: in the stomach, in the large intestine, but not in the abdominal cavity. And it will mainly involve the removal of polyps and mucous membrane with pre-malignant characteristics. After all, with the introduction of screening programmes we will be able to identify more and more malignant conditions of the alimentary canal at an early stage. They can then be treated with a limited resection rather than a major operation. In our view this will be the main market for this technology."

"Our TeleFLEX project brings four faculties together, with Technical Medicine playing a key role. This project gives a good impression of what this degree programme - which is unique in the Netherlands - stands for. You have to understand the patient who is receiving healthcare, and look at the technology from that perspective, and then decide on the technology that can be helpful in optimizing the diagnostics and therapy. Bringing the worlds of medical technology and healthcare together, so we can design and develop new technology: that is my central role in this project. And that will also be the role of our students who are going into healthcare on this basis."

Thanks to a robot the surgeon can work by touch Surgeons often use a flexible endoscope for diagnosing conditions in the digestive tract. Using this manoeuvrable tube, with a light source and a camera at its end, they can see inside the body without having to operate. Simple operations, such as removing polyps or taking tissue samples, can also be carried out in this way. But the flexible endoscope is becoming increasingly difficult to operate as it acquires more functions and is fitted with more and more instruments. It also works in a counter-intuitive way: to operate it the surgeon has to turn two wheels. "But with the help of robotics we can make the operation intuitive", says Rob Reilink, who is involved in the control engineering aspects of the TeleFLEX robot project at the University of Twente. "Telemanipulation is a promising technique", says Reilink. "The surgeon operates a kind of joystick, which in turn directs the endoscope. If we can provide an optimum connection between the joystick and the endoscope, the surgeon can work more quickly and accurately. And by means of force feedback the surgeon can also feel what is happening: the joystick will give a feeling of resistance if the endoscope presses against something in the body." "A further step is to integrate the joystick control with an HD monitor in a single cockpit. Then the surgeon will see the medical instruments on a monitor, moving just like his hands do: as if he is really inside the patient's body."

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