For robotics of the future - are we talking towers or hubs?

Hubs or Towers for surgical robotics

I’m watching a change happen. The entire architecture of the operating room is changing as we speak. It’s getting way smarter and way more connected. We still see legacy devices that are "indpendent" dumb boxes. But as they get phased out - the next box that replace them is smarter and a little more connected.

Now much of the intelligence in the OR was all looking like it was going to happen by the “walls” of the OR getting smarter and more connected - like an OR1 by Karl Storz or and EndoAlpha by Olympus.

But that is big integrated architectural changes on a fairly slow upgrade cycle. Which will probably not keep pace with the rapid changes we are seeing happening. It requires cahnges to the physical infrastructure and architecture of the operating room. And well - a lot of places can't afford it - want it - or are able to do it.

A second change has been accelerating. The advance of robotics - in many shapes and sizes into the operating room. We see more and more ORs get some form of robotic assistance - be it an Xi, a DV5, a Versius, a Toumai or a Moon Surgical maestro. There are options sprouting up every day.

And that is just the most common soft tissue robots that deal with laparoscopy. There are many other types of robots coming.

I saw the release of the Intuitive da Vinci 5 tower as the start of something. Something different - where much of the ORs power was being embedded into that tower, the console and the “hub” for external communications, video recording etc. Intuitive wanted a self contained ecosystem (another big moat.)

I saw this as a major change from boxes with a function - to structures with modular functional units. And all these modules are connected. It is a very different design philoosophy. But it may just be transient.

The Tower of today

If you look at the classic towers of today - they are a metal rack - where you stack boxy units onto the shelves of the rack - plug them in to the power, and a few of them even talk to each other. But that all depends if it the same manufacturer… and also depends if you use much of that functionality. You may have an insufflator from one company - an imaging chain from another. Your favorite electrosurgery unit from another. That is changing as tower companies move to be integrated box suppliers. One company - one set of boxes - one service contract.

On these systems you might be able to record some video - and some of them talk to the rest of the OR via a control panel embedded in the wall. All signs of where it is going - but not where I think the future ultimately leads.

But in essence the tower is a rack of various units that do various things.

That tower then usually has a ton of cables and wires and light pipes and suction tubes that hang across to the patient. It's a stack of functional boxes.

The primary function of the tower is to deliver light, gas, suction, energy etc etc.

And if you actually go and rip some of those boxes on the tower open - there is a lot of empty space in those boxes. And I know 30 years ago they were that big because of all the electronics that had to fit into them. Plus a lot of cooling - and all the buttons and connecters that needed fit the face. But today as components and electronics have shrunk - we see the same external form factor but lots of space inside.

So we end up with these sort of big 'n heavy and unwieldy tower structures, where the primary function of each box is a specific deliverable to make the laparoscopy work.

For me that concept is now dead (or rather dying.)

The Hub of the Future

As I said before, Intuitive with the DV5 have made a bold step forwards by making a more holistic integrated tower system. It works because every module inside talks to each other. It makes a solution where smarts can help that tower to do more with less.

It also starts to blur the units inside. No longer big boxes that stack on top of each other - but modules that use logical space constraints. It is a more logical layout. It feels more uniform.

Now add to that the number of touch screens and software buttons; and functionality shoots up depending how and when you use it. It is more like a big iPhone than a classic medical device.

But for me - they oddly still have the “Hub” part of the tower out on a separate cart. Maybe a legacy to help backwards integration to the SP or the Xi? But it yet another thing to have footrpint in the OR. And I find it odd in such a well orchestrated system.

But I think we are going to move to a new future or hubs. It's going to be all in one integrated form factor. One footprint - a smaller footprint.

There will still be the need for a physical “tower” structure - but I think that the tower is going to change in how it works and how it is upgraded. And what its primary function is.

For me the core function of the tower will become the hub - an integrated communications platform for the robot, open instruments and laparoscopic instruments. Smart - intelligent instruments no matter what procedure you are doing. All capable to get inputs and outputs from the hub. It will be a two way information exchange for control and data. Even of the most simple instruments.

The hub will be fundamentally about smart computing and smart communications. The secondary function will be seamless delivery of energy, gas, fluids etc etc.

But the primary is compute power and comms. I hope that's clear? I feel I can't explain it well. Maybve later I'll explain it as a computer with peripherals.

A computer in the room

Many will argue that the most important feature of bringing in a surgical robot is that you put an advanced computer into the loop between the surgeon and patient. I think it is bigger and more profound than that. You bring a computer into the health environment to help surgeons - nurses - OR staff - and the hospital in so many ways.

You now have a smart system that is primarily computer based - and functional as secondary. But it is the computer that will do the heavy lifting in the future - be that open - manual lap - robotic - open robotic microsurgery - surgical endoscopy or more.

That powerful computer will be the key to unlocking the power of surgery. The rest around it will be very controlled and monitored accessories that are used in a smart way.

That computer will also be a local - cloud - and site to site communications hub. And the future will be smart modules within the tower that handle all of that.

Local comms will be multifactorial. Communication between the components of the tower - light - gas - smoke - electrosurgery - imaging - all communications to optimise the functionality and then to predict next steps and prepare the system.

It will allow better local in room communication with situational awareness - case progression - planning for the OR suite (see Maestro with Moon). It will create smart communication between health records, PACS, notes, imaging and edge based know how for procedural assistance.

It will allow local predefined user setups - it will know that this surgeon in this procedure likes it all this way - and it will learn and optimise. Itv will set the system for them. (already happening today of course.)

It will have local edge image processing that will give no fly zones, surgical hints and help... and all the good stuff we know AI will do. But AI can only do that if there is a computer in the room. And you might want that computer in the room if it also is the central part of a robot - when you need the robot.

It will act as a hub to take all that rich data, and send it up to the cloud to garner insights for all the users (much like Intuitive does today.) But the future towers (loaded with OR cameras) will do that for open, manual lap (Intuitive and Medtronic are already there) and robotic cases. Giving practical insights - and learning.

It will get more powerful - but will be run by the hub. The computer driven and connected modules on the hub.

That technically means you no longer need a smart OR. Why?

Every OR is now automatically a smart OR

You no longer need an OR1 style infrastructure. Just wheel in a smart hub - and that OR (anywhere in the world) becomes a world class smart OR.

Yes you might like some fancy green lighting - but…. That will be the easy part.

The game changer is that you can now make every (watch that word) every OR - be it in university hospital - a general hospital out in the country side - or a small ASC: each one with the simple wheeling in of a smart hub based tower now becomes a smart and connected OR. No expensive knocking walls down.

And for the companies that see this as the “centre” the Hub and not the robot, not the OR1 or EndoAlpha… they will “own” the OR because they will sell their HUBS on a Pay Per Click usage model. They will own the imaging chain and therefore the video feeds (very valuable).

They will own the kinematics; because of course it would make sense to have their robot in the OR.

But now we go way beyond that. Every robotic stapler and energy device will of course feedback data to the hub. As now every handheld device will have a wi-fi type connection. An RFID tag - and data module. And all that data will go back to the hub. This will pair up with internal and external video and we will start to see a wider underdstanding of everything happening in the OR.

And be assured, that hub will be the reason to switch from Brand A to Brand B supplier of staplers. Not the stapler per se. The smarts coming from and going to the stapler. The data it weaves into and helps the OR with efficiency and outcomes.

The hub will be spitting out analysis of the entire hospitals results - comparing open to lap and robotic and saying where the best gains can be made.

It will be a major network effect. The more hubs the more data the more insights - the more improvemnts. That means every OR should have a hub. Not a robot. A hub. So now your entire hospital is running smart ORs - and you build a powerful network effect. Hell let’s say all the hospitals in your entire hospital network have smart hubs in every OR - now we are talking massive network effects.

And that means - have one supplier across your whole network. And as we see endoscopy, endolumenal robots, endo vascular robots. Don’t you want similar smart hubs working in union? One data set to rule them all?

Every OR is a smart telesurgery - telepresence OR

When you now build your (via your hub) an OR situational awareness system - and cameras - and microphones and speakers - you have a site to site comms tower for all forms of telepresence and telesurgery. All in that one hub (tower.)

And should you have a robot - they will connect through the hubs and now you have all forms of remote robotic surgery you can engage in. No upgrades needed. Any OR any time - anywhere.

So the Hub now makes every one of your ORs telesurgery, and telemedicine ready. Just wheel it in. The bigger your network effect - the more hubs you have - the more they can be used. And it’s not a premium as such… you don’t need to buy new communications system - they are right there working day in and day out in your OR anyway. You just pay a fee when you occasionally need the remote surgery or tele support. An amazing on demand network.

You can’t do that by having to build this in to the walls of the OR. Instead bring the tower to the OR - make it part of the day to day... and that HUB becomes the smart OR. Low infrastructure costs vs building out smart ORs. Anywhere can become smart. Anywhere can be connected.

Speed of upgrade

MedTech does not work at the speed of TechMed. And this will be crucial in the future of smart hubs.

These systems will need to balance design integration with modularity and rack exchange. The DV5 is gorgeous in design but how limited is it for rapid component upgrades? Yet to be seen.

NVIDIA come out with new chips every few weeks. The question will be - how can these hubs be rapid upgradable in the field. Connected racks designs may keep them square and boxy? But some smart industrial designers will for sure work out how to change the heart of the device even if the outer touch screens remain the same. Simple upgrades.

Many of these systems will be software buttons and controls - that change with the needs of the user - the use - the upgrade. Soft menus and soft buttons are becoming the norms now in medical devices.

We will not see whole “hubs” upgraded in the way we have seen to date - we will see Hifi style rack upgrades as a new smoke unit comes out - a new light unit - a new comms unit - a new AI chip set etc etc. That component will simply be switched out - or software upgraded or component exchanged. It's not going to be whole tower after whole tower upgrades.

MedTech is going to have to work this out - and fast - as the speed of upgrades will be fast and furious. It's faster than most regulatory cycles - so medtech will need to play smart in architecture.

It means that legacy OR companies cannot and will not keep pace if they stick with the old paradigms. I think they need to completely rethink their entire smart OR business and strategy. Or potentially be left in the 90s and 2000s. Are most hopsitals really going to rebuild their OR in that way any more? Or is the future - climate controlled and light controlled rooms where you switch out the hub and change the functionality?

Could we see the move to wireless and micro sized system?

Most of us have an iPhone or Android phone in our pocket. The power packed into that small brick is more than most medical imaging systems from the 2000s.

Micro electronics and shaped PCBs have changed everything - including power consumption and heat creation.

I’ve seen entire electrosurgery units with monopolar and bipolar as small as a deck of cards. I’ve played with 4K wireless imaging systems. They have LED lights that are in the handle - no cables. No big boxes.

What we might see is the miniaturisation of these hubs. More and more power fitted into smaller and smaller designs. Much of the comms will be wireless - so no need for wired connectors - which take up a lot of space. And are failure points. Put the comms in the hub - and micro control units in the instrument.

If we move much of the functionality towards the bedside - hanging CO2 units on the bed - with the pump on the bed - or in the robot. Lights by LED inside the robot arms - or even in the next generation scopes (see Integrated endsocopy). If we see small battery powered and wireless energy units, or even robot arms....

All of this can be controlled by the hub via wireless connection. Less and less spaghetti across the OR. Better designs around the bed - that communicate with the hub. Or bring the micro component hub to the bed - to the instrument.

In my experience one of the biggest complaints about modern ORs is the layout and all the wires that become trip hazards. Just laying out all the cabling - and setting it up right takes a lot of time. The next generation of hubs and towers will work this out. The technology stacks will come together to “unwire” and “Reduce size” and that will then completely change the games for sites of care.

Micro - connected smart OR Hubs that have tiny footprints in the ASC.

Small, compact, light, portable and wireless. It’s coming at a speed most don’t get yet.

“But what about the screens Steve. You still need big screens!!”

No. Very soon smaller glasses with amazing heads up displays and AR and mixed reality that use “group spacial computing” will put virtual screens anywhere in the room. Everyone will have a pair of lightweight glasses - and they will also have noise cancelling headsets built in - so that verbal communication is clear between everyone. Smart AI will make that comms easier by filtering out unwanted noises and amplifying the audio that is case critical.

Everyone can choose to have a common place to see screens placed virtually - - or they can override and choose the move the screen where is convenient for them.

ORs  will eventually be just rooms. With air conditioning - air filtering - ambient lighting. But all the tech and hardware. X-ray images - EHRs and everything you have cluttering the place today with trip wires could be reduced by these micro hubs and smart glasses.

(Anaesthesia will also change dramatically but that’s for another day.)

Smaller systems - wireless systems - connected systems are going to change the face of the hubs. Today they will be glorified towers - but in the future they could have a very very different form factor.

The path to the future

I know many will be rolling their eyes and saying “Steve - wind your neck in.” (Scouse saying)

But I see we are already on the path to this future. Intuitive - Medtronic, JNJ will all have their own towers on the market. All focused on their robots. All having some form of connectivity to hand instruments.

That means that three of the biggest forces in healthcare will determine that towers are a critical part of “owning the OR.” This is an inevitable move. And we are on the path.,

The da Vinci 5 tower is out in the wild now; and coming to Europe - NOW. Medtronic has towers out in Europe in use today - and USA around the corner. JNJ has Dualto on the market today and Ottava in trials. Which has a tower.

Two of these behemoths own the stapling and energy (hand held) and they will not let that go. Defence will not be around just staple formation but data networking.

Micro electronic systems are here and now. CREO has small systems available now with Kamaptive. Integrated endoscopy has an entire imaging system that fits in a small backpack. And it has no servicing. It breaks - you replace - it’s cheaper.

DV5 has shown a level of integration that shocked most of the imaging companies. And they really have only just stared. But they are taking manual laparoscopic procedures - today.

Telesurgery and telepresence is real - and now and growing.

We are here and now - and the robots are driving it - but the hub will be the star - it’s not going to be about towers for insufflation and imaging and electrosurgery. It will be about connected ultra smart computers and comms hubs that run those things as peripherals.

It is that change from the “main units” today, to becoming the peripherals run by a computer that will be the big change. Any OR becomes smart the second you roll in the hub.

These are just forward looking visions by the author for education purposes only.