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Robotic-Assisted Surgery (RAS) is a surgical procedure that involves robotic instruments to treat patients with diseases such as colorectal cancer. As opposed to the traditional surgical methods, robotic surgeries are deemed less “painful” with “fewer complications” according to Intuitive India, one of the companies that has been working in this space since 1995. This surgical method is also said to result in less blood loss as well as have a faster recovery rate. Although robotic surgery has been a part of medical science for over 25 years, its demand appears to be increasing owing to the coronavirus pandemic. This is mainly because RAS, unlike traditional surgeries, physically require less doctors or surgeons in the operation theatre. The technology to carry out robotic surgery is also improving with the entry of new players and the introduction of 5G/ 6G networks.

With better connectivity options, experts claim the RAS can transform into telesurgery (or remote surgery) that will further allow the treatment of patients without having the surgeon physically present in the same state or even country.

The demand for robotic-assisted surgery in India is also high, and the country over the years has installed more than 70 robotic instruments across locations such as Delhi, Mumbai, Chennai, and Kolkata. Most of these consoles are provided by the Silicon Valley-based company, Intuitive which pioneered the da Vinci surgical system. Notably, there are 70 da Vinci systems installed in India, according to the company.

In November 2019, the Government also introduced its first public RAS facility at Safdarjung hospital in Delhi. With this development, the Government aims to bring robotic surgery technology at public hospitals to treat patients for free. Similarly, RAS, by its nature is capital intensive, and the cost associated with this procedure is also high. Further, the RAS may likely be useful amid the pandemic; however, the robotic surgical procedure demands highly skilled surgeons.

To learn more about RAS and its growth in India, Gadgets 360 spoke with Dr Venkatesh Munikrishnan, who is a Consultant Colorectal Surgeon at Chennai Colorectal Clinic and The Institute of Colorectal Surgery, Apollo Hospitals Chennai. Dr Munikrishnan has been performing robotic-assisted surgeries for over four years and comes with 23 years of experience. These are the edited excerpts from the conversation.

What happens during robotic surgery, and why is it considered advantageous?

During the RAS procedure, there’s a console where the surgeon sits, and there are joysticks through which he operates. Next to the patient, the robot with arms carries instruments that go into the patient. These instruments are miniaturised that mimic a surgeon’s movements so that it is precise. The robot also gives a ten-times magnification and 3D view.

Those are the advantages of RAS compared to open surgery or laparoscopy.

Why are robotic surgeries important amid the coronavirus pandemic?

The main difference here is being socially distanced. We don’t need that many people around the robot as it has arms that will help in surgery. So, you will need only one [surgeon] instead of three, and the surgeon is also not next to the patient as he is sitting with the console away. This console can be as far as possible from the patient.

In the context of the COVID-19 situation, there were concerns regarding the aerosolisation of the virus as you need to cast an instrument into the abdomen to create the space to operate. Now, that concern has been addressed.

Secondly, infection rates or wound infection rates are fewer compared to laparoscopy or open surgeries. The more contact you have, there are more risks of transmitting virus as well as bacterial infections. You are also moving the team including doctors and support staff away using this technology to do most of the technical work during the surgery.

Is RAS popular in India and what kind of surgeries can this technology perform? Also, how is this going to evolve in the future?

Currently, there are around 80 RAS instruments across India, and Apollo ecosystem probably has the maximum number of robots. Most of it is in the Urology space, but it is also getting popular in general surgeries. Some gynaecology and head and neck surgery usage are there as well.

If this technology were to evolve post-COVID, and we know that the ratio of doctors-to-patients in India is less – that too expertise in areas such as colorectal cancer surgery is not easily available. So, we can place a console next to the patient and send a support team to perform such types of complex surgeries.

Who are the key providers of RAS technology?

We [Apollo Chennai] are using an Intuitive surgical robot, and the latest is the fourth-generation da Vinci Xi model. This is probably the most widely used robot around the world. There are newer ones, such as CMR (Cambridge Medical Robotics) and Medtronic robotic surgery. Johnson & Johnson robotic surgery is also developing one. There are several robots in development too, but I think Intuitive is a front runner because they’ve been in the market for a long time.

What are the challenges associated with robot surgery in India? Are doctors apprehensive about RAS?

One is access to technology as they are expensive. But with more companies coming into the foray, the cost may go down. Also, more insurance is coming to play, insurance companies will cover the cost [associated with this procedure].

But to address cost, you also need to be efficient. It doesn’t matter whether its a private hospital or a government hospital because someone is paying for it. If we become efficient to carry out this procedure, the cost will go down [as more patients are being treated in less amount of time].

We also have a reluctance to anything new, right? And in this profession, you always keep learning. So surgeons have to adapt, adopt, and get trained.

How is telesurgery going to help and where is it leading at the moment?

As I said that the expertise level is limited, so the technology has to evolve. You will plug this [RAS console] to 5G/6G network and bring this expertise across the country. The only thing you need to figure out is to how many this [telesurgery] cheaper so that every patient can benefit from it.

Also, the next thing with this technology is that you can get augmented reality to come and assist you. It’s just a matter of time.

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Open source: Why governments need to go further

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Commentary: Yes, governments should open source their custom code. But more than that is needed.

Image: lucky-photographer, Getty Images/iStockphoto

For Drupal (and Acquia) founder Dries Buytaert, “the default [in government] should be ‘developed with public money, make it public code.'” That is, if a government is paying for software to be created, that software should be available under an open source license. While he acknowledged there might be exceptions (e.g., for military applications, as I’ve called out), his suggestion makes sense.

Years ago I argued that government mandates of open source made no sense. I still feel that way. Governments (and enterprises) should use whatever software best enables them to get work done. Increasingly, that software will be open source. But when good open source alternatives don’t yet exist, it makes no sense to mandate the use of suboptimal software. 

But software that governments create? There’s no compelling citizen-focused reason for closing it off. Instead, there are many reasons to open it up.

SEE: How to build a successful developer career (free PDF) (TechRepublic)

Of the people, by the people, for the people

This topic of why countries should embrace open source is an easy argument to make. As Buytaert pointed out, if public money pays for the code to be developed, why wouldn’t that code be available to the public (except, as mentioned, in the case of sensitive military software)? 

Some countries have already gone this route. As I detailed in 2016, Bulgaria is one of them. A few years later, Bulgaria has been preparing its own national source code repository, based on Git (as required by law: “administrative authorities shall use public storage and control systems for the source code and technical documentation for development, upgrading or deployment of information systems or electronic services”). 

This is a significant step toward greater transparency. However, it’s not enough.

SEE: Open source can thrive in a recession says Drupal creator Dries Buytaert (TechRepublic)

Collaborating on common government issues

As much as I understand Bulgaria’s desire to build its own source code repository, there’s even greater need for governments to collaborate on code beyond their borders. Think about it: Governments tend to do the same things, like collecting taxes, issuing parking tickets, etc. Currently, each government builds (or buys) software to tackle these tasks. Obscene quantities of custom code are created each year by government organizations operating in silos.

Why isn’t the city of Bogota sharing software with London, which shares software with Lagos, which shares software with Pocatello (that’s in Idaho, by the way)? 

As IBM president (and former Red Hat CEO) Jim Whitehurst said way back in 2009, “The waste in IT software development is extraordinary….Ultimately, for open source to provide value to all of our customers worldwide, we need to get our customers not only as users of open source products but truly engaged in open source and taking part in the development community.” This is particularly true in government, where there isn’t even the competitive pressure (e.g., Bogota doesn’t compete with Pocatello) that might prevent large financial institutions from collaborating (though even they partner on open source).

So, yes, we need governments to open source the software they pay to have built, to Buytaert’s point. But we also need those same governments to share that code beyond their borders, thereby driving greater innovation at lower cost for their citizens. 

Disclosure: I work for AWS but the views expressed herein are mine, not those of my employer.

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Elastica: A Compliant Mechanics Environment for Soft Robotic Control

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Soft robots can be used in various spheres, such as agriculture, medicine, and defense. However, their complex physics means that they are hard to control. Current simulation testbeds are insufficient for taking the full advantage of elasticity.

A recent paper on arXiv.org proposes Elastica, a simulation environment tailored to soft robot context. It tries to fill the gap between conventional rigid body solvers, which are incapable to model complex continuum mechanics, and high-fidelity finite elements methods, which are mathematically cumbersome. Elastica can be used to simulate assemblies of soft, slender, and compliant rods and interface with major reinforcement learning packages. It is shown how most reinforcement learning models can learn to control a soft arm and to complete successively challenging tasks, like 3D tracking of a target, or maneuvering between structured and unstructured obstacles.

Soft robots are notoriously hard to control. This is partly due to the scarcity of models able to capture their complex continuum mechanics, resulting in a lack of control methodologies that take full advantage of body compliance. Currently available simulation methods are either too computational demanding or overly simplistic in their physical assumptions, leading to a paucity of available simulation resources for developing such control schemes. To address this, we introduce Elastica, a free, open-source simulation environment for soft, slender rods that can bend, twist, shear and stretch. We demonstrate how Elastica can be coupled with five state-of-the-art reinforcement learning algorithms to successfully control a soft, compliant robotic arm and complete increasingly challenging tasks.

Link: https://arxiv.org/abs/2009.08422