A Supplement to Design World - October 2021 www.therobotreport.com
Building on success during COVID:
INSIDE: • Inflatable robotic hand gives amputees real-time tactile control ......................................................................... 56
Q&A with Intuitive CEO Gary Guthart page 60
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The Robot Report
Inflatable
robotic hand
gives amputees real-time tactile control
A computer model relates a finger’s desired position to the corresponding pressure a pump would have to apply to achieve that position.
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The smart hand is soft and elastic, weighs about half a pound, and costs a fraction of comparable prosthetics. | Credit: MIT
Steve Crowe
Editorial Director, The Robot Report
For the more than 5 million people in the world who have undergone an upper-limb amputation, prosthetics have come a long way. Beyond traditional mannequin-like appendages, there is a growing number of commercial neuroprosthetics — highly articulated bionic limbs, engineered to sense a user’s residual muscle signals and robotically mimic their intended motions. But this high-tech dexterity comes at a price. Neuroprosthetics can cost tens of thousands of dollars and are built around metal skeletons, with electrical motors that can be heavy and rigid. Now engineers at MIT and Shanghai Jiao Tong University have designed a soft, lightweight, and potentially low-cost neuroprosthetic hand. Amputees who tested the artificial limb performed daily activities, such as zipping a suitcase, pouring a carton of juice, and petting a cat, just as well as — and in some cases better than — those with more rigid neuroprosthetics. The researchers found the prosthetic, designed with a system for tactile feedback, restored some primitive sensation in a volunteer’s residual limb. The new design is also surprisingly durable, quickly recovering after being struck with a hammer or run over with a car. The smart hand is soft and elastic, and weighs about half a pound. Its components total around $500 — a fraction of the weight and material cost associated with more rigid smart limbs.
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The Robot Report “This is not a product yet, but the performance is already similar or superior to existing neuroprosthetics, which we’re excited about,” said Xuanhe Zhao, professor of mechanical engineering and of civil and environmental engineering at MIT. “There’s huge potential to make this soft prosthetic very low cost, for lowincome families who have suffered from amputation.” Zhao and his colleagues have published their work today in Nature Biomedical Engineering. Co-authors include MIT postdoc Shaoting Lin, along with Guoying Gu, Xiangyang Zhu, and collaborators at Shanghai Jiao Tong University in China. Big Hero hand The team’s pliable new design bears an uncanny resemblance to a certain inflatable robot in the animated film “Big Hero 6.” Like the squishy android, the team’s artificial hand is made from soft, stretchy material — in this case, the commercial elastomer EcoFlex. The prosthetic comprises five balloon-like fingers, each embedded with segments of fiber, similar to articulated bones in actual fingers. The bendy digits are connected to a 3-D-printed “palm,” shaped like a human hand.
The smart hand is soft and elastic, and weighs about half a pound. Its components total around $500 — a fraction of the weight and material cost associated with more rigid smart limbs.
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Rather than controlling each finger using mounted electrical motors, as most neuroprosthetics do, the researchers used a simple pneumatic system to precisely inflate fingers and bend them in specific positions. This system, including a small pump and valves, can be worn at the waist, significantly reducing the prosthetic’s weight. Lin developed a computer model to relate a finger’s desired position to the corresponding pressure a pump would have to apply to achieve that position. Using this model, the team developed a controller that directs the pneumatic system to inflate the fingers, in positions that mimic five common grasps, including pinching two and three fingers together, making a balled-up fist, and cupping the palm. The pneumatic system receives signals from EMG sensors — electromyography sensors that measure electrical signals generated by motor neurons to control muscles. The sensors are fitted at the prosthetic’s opening, where it attaches to a user’s limb. In this arrangement, the sensors can pick up signals from a residual limb, such as when an amputee imagines making a fist. The team then used an existing algorithm that “decodes” muscle signals and relates them to common grasp types. They used this algorithm to program the controller for their pneumatic system. When an amputee imagines, for instance, holding a wine glass, the sensors pick up the residual muscle signals, which the controller then translates into corresponding pressures. The pump then applies those pressures to inflate each finger and produce the amputee’s intended grasp. Going a step further in their design, the researchers looked to enable tactile feedback — a feature that is not incorporated in most commercial neuroprosthetics. To do this, they stitched to each fingertip a pressure sensor, which when touched or squeezed produces an electrical signal proportional to the sensed pressure. Each sensor is wired to a specific location on an amputee’s residual limb, so the user can “feel” when the prosthetic’s thumb is pressed, for example, versus the forefinger.
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Good grip To test the inflatable hand, the researchers enlisted two volunteers, each with upperlimb amputations. Once outfitted with the neuroprosthetic, the volunteers learned to use it by repeatedly contracting the muscles in their arm while imagining making five common grasps. After completing this 15-minute training, the volunteers were asked to perform a number of standardized tests to demonstrate manual strength and dexterity. These tasks included stacking checkers, turning pages, writing with a pen, lifting heavy balls, and picking up fragile objects like strawberries and bread. They repeated the same tests using a more rigid, commercially available bionic hand and found that the inflatable prosthetic was as good, or even better, at most tasks, compared to its rigid counterpart. One volunteer was also able to intuitively use the soft prosthetic in daily activities, for instance to eat food like crackers, cake, and apples, and to handle objects and tools, such as laptops, bottles, hammers, and pliers. This volunteer could also safely manipulate the squishy prosthetic, for instance to shake someone’s hand, touch a flower, and pet a cat. In a particularly exciting exercise, the researchers blindfolded the volunteer and found he could discern which prosthetic finger they poked and brushed. He was also able to “feel” bottles of different sizes that were placed in the prosthetic hand, and lifted them in response. The team sees these experiments as a promising sign that amputees can regain a form of sensation and real-time control with the inflatable hand. The team has filed a patent on the design, through MIT, and is working to improve its sensing and range of motion. “We now have four grasp types. There can be more,” Zhao said. “This design can be improved, with better decoding technology, higher-density myoelectric arrays, and a more compact pump that could be worn on the wrist. We also want to customize the design for mass production, so we can translate soft robotic technology to benefit society.” RR
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The Robot Report
Building on success during COVID:
Q&A with Intuitive CEO Gary Guthart
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CEO of surgical robotics leader discusses how Intuitive coped with COVID, what must be done to maintain market dominance, and what keeps him up at night. By Joanne Pransky
Gary Guthart is CEO at Intuitive (formally Intuitive Surgical) and a member of the board of directors, roles he has held since 2010. Under Guthart’s leadership, Intuitive, the world’s most successful medical robotics company, has grown to more than 8,000 employees and sold nearly 6,000 da Vinci Surgical Systems. The company’s stock is up more than 600% during his tenure. Guthart is also on the board of directors for Illumina, and a member of the board of directors for the Silicon Leadership Group. Guthart received a bachelor’s degree in engineering physics from University of California, Berkeley. He earned an MS and a PhD in engineering from the California Institute of Technology. Why did you decide to leave SRI International, one of the world’s best nonprofit research institutes, and go work for this new corporate spin-off called Intuitive Surgical Devices in 1996? It was not an obvious decision for me to join Intuitive Surgical when I was offered a position. I am not a roboticist by If we can help surgeons using training; I was formally trained in nonlinear mathematics. physics and some of the new I was introduced to robotics at SRI International when Ajit technologies to illuminate disease Shaw, who ran the SRI Medical Robotics Lab, asked me to as well as the things that surgeons work with their group. My introduction to that work was suturing a femoral artery of a rat, first by hand, and then should not injure during a procedure, using their robotic prototype. I was skilled at assembly such as nerves or deep blood vessels, from building models and other projects that filled my we can substantially improve safety garage growing up. However, it was the first time I was and surgeons’ guidance. exposed to anything medical. I tried suturing by hand, using loops and Castroviejo | Credit: Intuitive needle holders, and it was really difficult. I then tried it on their robotic system and immediately fell in love with the technology.
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The Robot Report Intuitive’s da Vinci Surgical System set up in an operating room.
The challenge then for a company like ours, is not a question of where do we find opportunity to work on, but how do we choose a productive pathway? How do we advance as a company and remain as dedicated, passionate and committed as when we were a small company? Larger companies do not have a problem with hiring intelligent people, or securing financing and resources. But sometimes they forget their mission, and mediocrity creeps in. I worry a great deal about keeping focused, vibrant, and continuing to strive toward excellence.
| Credit: Intuitive
I loved working on the SRI team and initially declined the job offer from one of the three founders of Intuitive. Thankfully, Rob Younge, the founder who was recruiting me said, “Let’s have another conversation. Talk to the other founder, John Freund, a venture capitalist and a brilliant man.” John came out and we sat down at a local coffee shop. I was about 28 at the time and I knew nothing about the startup world. John, on the other hand, was quite experienced. He said the following to me, and it really stuck, “Regardless of whether you want to be a commercial technology person or not,” (I was just quite happy with the view of myself as an applied researcher) “you’ll be a better researcher if you see what it really takes to try to make these prototypes commercial. Succeed or fail, you’ll be better for it and SRI will still be there, but you will be more valuable to them having seen what the process really is.” I went home and I talked to my wife Dawn about it. Dawn’s an adventurer and she said, “He’s right. Go for it!” So I said yes and thankfully, I listened to them both. When you made that transition, was it on your mind to become a CEO? I joined Intuitive in April 1996 as a controls system analyst, and I met the CEO of Intuitive, Lonnie Smith in early 1997. Lonnie is a spectacular human being as well as a fantastic businessperson. Those two attributes are not always found in the same person, and fortunately, he is both. Lonnie had a lot of diverse experiences. He was an electrical engineer by training (BSEE) and then went to Harvard Business School (MBA), then went to the BCG (Boston Consulting Group) … a classic business leader background. A couple of years in, Lonnie said to me, “Gary, I think you have skills and attributes beyond what
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you think you might.” Lonnie planted the seed in me that I might be capable of doing more, even though I hadn’t aspired to at that time. I loved seeing the direction of Intuitive, but I did not feel like I had to be the person leading the company, and I did not have a burning ambition to be the CEO. I still don’t. But Lonnie invested his personal coaching and drive in me. As CEO of the world’s most successful medical robotics company, what keeps you up at night? Two different things. In a pandemic year, there have been a lot of “up-at” nights. At Intuitive, we have had both a massive challenge and a sacred obligation to being both healthcare experts and technologists. The obligation has been, how do we help our customers? How do we help our staff be safe and productive? How do we help our supply chain stay fresh, whetted and full? How do we help communities? At Intuitive, we have manufacturing and healthcare capabilities. We do not traditionally make personal protective equipment (PPE), but when demand was lacking for our products because of COVID, we converted our factories to create PPE and we donated it. There is no sense in having medical device factories idle when you can make something that people need. These activities and others kept us busy in 2020 and I think it aligned our company toward our values. Outside of the pandemic, I think the opportunity for better healthcare is just massive. Our generation and the next generation will continue to work on it. www.therobotreport.com
For years, Intuitive’s position in the marketplace has been protected by patents that have now come to an end. Do you think that this has encouraged Intuitive to push technical boundaries even more? For one thing, competition is natural. If we were at this for 25 years and did not have competition, you would be worried that we were not doing something of interest or importance. We have not stopped innovating at Intuitive. While it’s true that our early systems are off-patent, we continue to invent new technologies, along with several thousands of new patents and patent applications. I do not think [competition is] robot versus robot. I think it’s about ecosystem versus ecosystem. The technologies and services that deliver better outcomes and experiences for the patient, and better experiences for the care teams, with lower total treatment costs. If you could solve one technical problem today, what would it be? I think there are two places that are really interesting. One is that there has been enormous variability between care teams. Surgery has a large standard deviation between its care team of four or five people – surgeon, physician’s assistant, anesthesiologist, circulating nurse – who are orchestrating that procedure. The variance between the good ones and the less good ones is quite high due to factors such as experience, training and level of competency. I believe imaging, cloud computing, the Internet of Things (IoT), sensing, and machine learning can really start driving closure of those gaps. THE ROBOT REPORT
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2 Conceptual rendering of the multi-jointed robotic arm of a surgical system.
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The Robot Report It’s not that “everybody is the same.” The difference between a lowest quartile care team versus the upper quartile care team in complex procedures can result in about two to three times the likelihood of patient complications or readmissions to the hospital. That’s an enormous opportunity for improvement and I think imaging, machine learning and cloud computing can make a powerful difference. The second technical need is a collection of sensors that can construct a view of the world that allows for successful surgical navigation. In most cases, surgeons cannot see a cancer when they’re doing cancer procedures. They have a preoperative image that guides them, but some cancers are totally invisible to the unaided human eye. If we can help surgeons using physics and some of the new technologies to illuminate
Intuitive’s da Vinci Xi surgical system. | Credit: Intuitive
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disease as well as the things that surgeons should not injure during a procedure, such as nerves or deep blood vessels, we can substantially improve safety and surgeons’ guidance. These are two massive opportunities, [that if addressed will] change the conversation and outcomes. What is the greatest lesson or largest mistake you have made? There are plenty of lessons and mistakes. My mom was a high school science teacher and my father was an electrical engineer who later in his career became a startup leader for a small defense company. Science is in my blood. Literally. The Physics of Fluids was a magazine on my parents’ coffee table. When I came out of school, I was really excited about technology first. Then I learned pretty quickly that healthcare is a “human-first” endeavor. If you go ask the surgical experts and do the workflow analysis, it’s about 60 human beings who have to do the right thing the day of surgery for that patient to have an optimal chance of a good outcome. Approaching medical challenges as human first, and anchoring on patients’ needs with technology as an aide, was really something that was super important. My most challenging lessons were viewing through the eyes of the patient first, then viewing through the eyes of the care team and then viewing through the eyes of the healthcare organization. If we invert that order and fall in love with a particular technology, we find that it actually carries us a little bit in the wrong direction. Hospitals have to look at the overall costs of treatment, reducing length of hospital stays, and reduction in complications as the major selling point for robotic technologies. What can be done to reduce the cost per operation of using robotics like the da Vinci surgical system? I think the core economics that matters most to the healthcare system www.therobotreport.com
is the total cost-to-treat per patient episode. In terms of the hierarchy of costs, it turns out that the robot itself is the part that everybody focuses on, but actually is not the costliest item on a per procedure basis. The cost of the parts, service and capital allocation for the robot are a small fraction, about 10% of the total cost expenses. Furthermore, over time, we have had a chance to refine our design and manufacturing prowess. We have used advanced manufacturing techniques to create lower costs for our instrumentation. We have recently also implemented some scale advantages in terms of our supply chain and our manufacturing capabilities that likewise lower costs. The highest cost is human staff, the second highest is the time in the OR, and the third is the operating room consumables. Single-use sterile instruments, used once and thrown out, are typically more expensive, not less expensive. Sometimes you can get higher performance in something that is used only once, but in general, it is not a great idea. It increases costs, medical waste and transportation costs, and also leaves a carbon footprint. In general, reuse is a better idea than single use, with the exception of very few things where waste costs can be managed. Is it possible for hospitals to do two operations a day every day of the year? How much downtime should they assume for routine maintenance? What drives utilization has little to do with the robotic system and almost everything to do with the kind of surgery. We have hospital customers who do benign surgeries, such as gallbladder surgery or hernia repair. They can do seven to eight per day, every day. On the other hand, if you are performing a complex colorectal cancer procedure, you may only do two a day because of total surgical time and the uncertainty of the procedure. In general, the amount of time the system is decommissioned for maintenance is less than 2% of the total operating time available to it in a year. Reliability is quite high. In industrial settings, people talk about mean time before failure, but it is somewhat different in our setting. In our setting, the assistant is right on top of the robot, right there with the patient. It is not automation in that sense. System availability to complete a case is greater than 99.9%. RR THE ROBOT REPORT
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