Israel's Robot oasis

Israel’s Negev desert appears to be the opposite of futuristic.

It is drab, dusty and desolate. It is far from the center of Israel where international hi-tech conglomerates have built their top research and development facilities outside of the United States.

But within that desert there is an oasis of technology that facilitates robotics envied by the world.

In each of several laboratories at Ben- Gurion University of the Negev (BGU), humans and robots interact, working hand in hand in an effort to solve medical problems previously thought impenetrable. Several interdisciplinary teams at BGU are actively working to advance medical robotics.

From brain researchers to mechanical and electrical engineers, computer scientists and philosophers, BGU has hundreds of faculty and students researching, building, testing and using robots.

“You name it, and we are working on it,” Prof. Hugo Guterman, head of the Laboratory of Autonomous Robotics at BGU tells The Jerusalem Report.

Admittedly, “the technology of robotics advances slower than expected,” says Prof.

Amir Shapiro, a faculty member of BGU’s Department of Mechanical Engineering.

“What we believed would be with robotics in the year 2000 does not exist. But there is always promise – and it’s looking good,” Shapiro tells The Report.

Guterman says he got into robotics “by mistake.” But there are two reasons he sticks with it: “One is the possibility that we can improve how things we used to accept as ‘Mother Nature’ are really done,” he explains. “The second is that you can solve problems and actually help people.”

There are a handful of well-known medical robots that have been invented throughout the world. The most famous from the Start-Up Nation, Mazor Robotics, invented in the robotics laboratory of the Faculty of Mechanical Engineering at the Technion, is today transforming spine surgery with its Renaissance Guidance System. The robotic system allows surgeons to plan operations in a virtual 3D environment, and during procedures, it helps guide tools and implants to their planned location with uncanny accuracy.

Mazor was founded by Eli Zehavi and Prof. Moshe Shoham; the latter served as PhD supervisor for Prof. David Zarrouk, today the head of BGU’s Bio-Inspired and Medical Robotics Laboratory.

Shapiro’s Balance Tutor, invented with Prof. Itzik Melzer from the Physical Therapy Department, measures the level of balance in elderly people and then trains them to balance better. It is the only rehabilitation system that employs an advanced 4D perturbation patented treadmill, multiple force and movement sensors and customized motivational video games. The technology was licensed to Netanya-based MediTouch and is now sold to physical therapy clinics around the world.

BGU and Cincinnati Children’s Hospital combined efforts to launch Xact Medical earlier this year and bring to market the Fast Intelligent Needle Delivery (FIND) system, which uses robotics and ultrasound to better guide and insert a needle into a patient’s body. Guterman also worked on that project.

Prof. Hugo Guterman believes robotics allows us to intervene in areas once considered the sole province of ‘Mother Nature’ (DANI MACHLIS/BGU)

“It is very common to make mistakes when trying to introduce a needle into a vein,” explains Guterman. “There is only about a 70 percent first-try success rate and as many as 300 people die per year in the US from complications of misplaced needles.”

FIND puts the needle and the ultrasound into a singular robot, which both identifies the best location to insert the needle and automatically inserts it. The whole process takes less than 30 seconds.

Guterman says that his team is now working on expanding the use of the technology for other medical uses, including biopsy, chemotherapy and the administration of intravenous drugs.

“ONE OF the huge problems we have today is not being able to know exactly where we are injecting drugs, which makes them less effective,” Guterman says. “If you deliver the drug to the exact same place time after time, you can reduce the amount of drug needed and make the treatment more successful.”

Another one of Guterman’s projects centers on physical therapy. He says there is a shortage of physical therapists today.

As such, patients in need of care have to wait too long to get appointments and are charged with doing PT exercises at home without any feedback from their therapist.

Therefore, many people fail to do the required exercises, delaying or even inhibiting recovery.

“Now, suppose you were able to do those exercises in your house, but you had a system that continuously transferred information from you to your therapist in real time?” asks Guterman. “What if your therapist could respond and change your program in reaction to how you are doing? This would improve the quality of service and reduce the time until recovery.”

Guterman says the technology to make such a system work already exists. His lab is trying to determine the best way to leverage it.

What other robots are in the works in the labs of BGU? Remember the PillCam Capsule Endoscopy, developed by Israel’s Given Imaging? Zarrouk is working on the next generation: a self-propelled camera capsule that will assist doctors in seeing the small intestine. A patient will swallow the device, which will work its way through the system and come out the other end. But rather than passively moving through the body, Zarrouk’s capsule will be controlled by the doctor, perhaps even with a joystick.

“The doctor will be able to halt the device and get a more optimized view,” says Zarrouk, explaining that the camera would likewise be connected to a screen.

Shapiro is working on improving the functioning of robotic hands – not the kinds humans use if they are born without a hand or lose one in an accident, but the hands of the robots themselves. Currently, most robots have very simple grippers at the end of their arms that are used to grasp specific objects. Shapiro is hoping to design a hand that will allow the robot to better manipulate its hand movements and grasp more detailed and diverse items.

From a medical standpoint, this could mean grasping internal organs for a doctor during surgery or holding the stomach during a sleeve gastrectomy, surgery conducted for weight loss.

Dr. Ilana Nisky’s Biomedical Robotics Lab at BGU is using robots, haptic devices and other mechatronic devices as a platform to understand the human sensorimotor system in real-life tasks like surgery. Practically, this means that she is trying to understand “how our brain succeeds in controlling the motions of our hands and how we process information that we acquire through our sense of touch,” she tells the Report. The goal is to design software that will give surgeons conducting robot-assisted procedures physical information about what they are touching and how they are touching it.

Dr. Ilana Nisky is developing technologies that will give surgeons conducting robotassisted procedures information about what they are touching and how they are touching it (DANI MACHLIS/BGU)

THERE ARE multiple advantages to such software. For starters, it will improve the time needed for surgeons to become experienced robotic surgeons, since the transition will feel more natural. It will also make conducting minimally invasive surgeries easier.

“During standard laparoscopic surgery, the surgeon needs to work with long instruments that impose strong challenges on their motor system,” Nisky says. “The doctors have limited freedom of motion and that makes it very difficult. The assistant holds the camera, and you hold the instruments, and you need to ask the assistant to move the camera where you want to look.

“With robotic surgery you gain a more natural motion and more freedom, plus you get better 3D visualization, but you still cannot feel what you are doing.” Her technology would change that.

Further, Nisky says that as robotic surgery advances, she sees no reason why the surgeon and patient would need to be in the same location, because the surgeon would simply be manipulating a robot through an external device.

Nisky said it has happened before. On September 7, 2001, a 68-year-old woman walked into Strasbourg Civil Hospital in eastern France to have her gallbladder removed.

It was a standard procedure like any other, with one exception: her surgeon, Prof. Jacques Marescaux, performed the operation from New York.

“I think that this demonstration of the feasibility of a completely safe, remotely performed surgical procedure ushers in the third revolution we’ve seen in the field of surgery in the past 10 years,” Marescaux said at the time.

Marescaux conducted the surgery, known as the Lindbergh Operation – named for aviator Charles Lindbergh because he was the first person to fly solo across the Atlantic Ocean – by controlling the arms of the ZEUS Robotic Surgical System, designed by Computer Motion. The link between the robotic system and the surgeon was provided by a high-speed fiber-optic service deployed by France Telecom.

Visiting Nisky’s laboratory feels like entering a life-size, virtual-reality video game.

Those who come are invited to test a joystick, feeling its movements, as it simulates surgery.

She envisions that procedures like the Lindbergh Operation could become commonplace.

“There is nothing really preventing it,” says Nisky.

Nevertheless, there are issues that get in the way, which are not technological, but rather bureaucratic, economic and ethical.

“I don’t think we are in a medical revolution,” says Guterman. “It’s really slow and difficult for robotic devices to enter the marketplace and get accepted.”

HE SAYS there are several barriers to entry, and the first is money. It costs a lot to do enough clinical trials to prove that a medical device is both useful and safe. And he says once you actually do that, new technology also tends to be expensive, which means few doctors or their clinics can afford to use it.

Other challenges are the long and unpredictable amounts of time it takes to get medical devices FDA approved – anywhere from six months to several years. Furthermore, traditionally trained doctors find it difficult to transition to robotics.

There is also a fear among some doctors that robotics will put them out of work. At this, Guterman laughs.

“Robots cannot replace doctors because there is a lot of know-how that is not well defined,” he says. “In many cases, doctors treat not solely based on the knowledge they get from a test or a textbook, but based on information they receive from conversations with patients.”

Guterman says robots will save doctors time and diminish human error with well-defined mechanical procedures.

“I think doctors will ultimately prefer to have free time to talk with patients, rather than wasting their time making cuts or doing procedures that could just as well be done by a machine,” he says.

Anyway, it is unlikely that doctors will have a choice. Just as print newspapers need websites, and college students require computers, the medical robot train has already left the station. Instead of trying to stop medical robots, he says, doctors, politicians and philosophers should use this time to tackle ethical questions tied to their use.

Today, robots are not sophisticated enough to make life-and-death decisions, Guterman explains. “We have to ask ourselves if in the future we will allow robots to make such decisions. It may seem like it is in the distant future, but we are not too far off from having to decide, for example, if we will allow robots to implant not only embryos but also define or decide which embryos to implant.”

He continues, “What if we have another September 11, and you send in robots to remove the people? And the robots discover that some of the people have more of a possibility of surviving and they go to those with the greater possibility – will we allow robots to make such decisions?” In cases of remote surgery, Nisky says, questions such as where does the doctor need to be certified to perform the remote operation, who is responsible if something goes wrong (the engineer or the surgeon) and who pays will all come up. She says countries will have to enact legislation to deal with these challenges.

And even as far as testing out medical robots, such as the kind Zarrouk is working on that involve digesting machines, at some point he will eventually need to test his creation on living animals.

“Do we want to harm animals before we know for a fact that the robot has a good chance of working?” Zarrouk asks.

Such moral and philosophical debates appear to be a better fit for the Biblical swath of land in the Negev than the technology currently being developed in the area. But for pioneers like these, the old and the new go hand in hand.

“We don’t know what is in the future for us,” says Guterman, but the bottom line is that “society has much to gain from medical robots.”