Equipping Vascular Interventions with Robotic Wings: A Dialogue Between Academician Yang Guangzhong and Professor Liu Jianmin on the Accelerated Development of Endovascular Robotics

On December 3, 2021, DaoTong Investment held its 2021 Annual Partners Meeting under the theme “Practicing Medicine with Integrity, Achieving Success through Accumulated Strength.”

At this annual conference,Yang Guangzhong, Fellow of the Royal Academy of Engineering (UK), Dean of the School of Biomedical Engineering at Shanghai Jiao Tong UniversityandLiu Jianmin, Director of the Center for Clinical Neurosciences, Changhai Hospital Affiliated to Naval Medical UniversityA dialogue on “Vascular Interventional Surgical Robots” was held, moderated by Cai Wanni, Vice President of DaoTong Investment.

The former is a globally renowned scientist in the field of surgical robotics, while the latter is a leading clinical expert in neurointervention. Both have achieved remarkable accomplishments in their respective specialties. What insights emerged from their dialogue? VCBeat has compiled the following summary based on on-site materials.

Photo from the Daotong Investment Annual Conference (from left to right: Cai Wanni, Yang Guangzhong, Liu Jianmin)

Host: From a technical perspective, how does Academician Yang view the development of surgical robots? Do Chinese surgical robots possess the necessary elements to enter a fast-track development phase?

Yang Guangzhong:Before answering the question, I will first review the development history of surgical robots.To date, surgical robots have undergone four iterations.

First-generation surgical robots were essentially modified industrial robotic arms, capable only of performing tasks such as positioning and cutting. However, surgical procedures involve more than simple cutting and navigation, which spurred the development of second-generation surgical robots, represented by the da Vinci and ZEUS systems. The second-generation surgical robot is designed for general surgery, primarily addressing three key challenges in minimally invasive clinical procedures: first, hand-eye coordination; second, three-dimensional visualization; and third, integrated functionalities including motion scaling, visual magnification, and tremor filtration.

In addressing the pain points of minimally invasive surgery, surgical robots have also identified favorable clinical application scenarios, such as in urology. Surgical procedures vary significantly across different hospital departments. For a surgical robot to be utilized across various departments, it must meet diverse clinical indications. Therefore, third-generation surgical robots are specialized surgical robots.

Currently, we are witnessing the fourth generation of surgical robots, such as the da Vinci SP system. This generation integrates a suite of capabilities, including preoperative and intraoperative image fusion and fluorescence imaging, enabling enhanced visualization, greater depth of field, and more precise manipulation during surgery. From a research and development perspective, we are working on the fifth generation of surgical robots, aiming for a more compact design, higher operational precision, and earlier therapeutic intervention.

"If we want to capture the domestic market and promote our surgical robot products overseas, we must possess our own core proprietary technologies."While the “me-too” model may yield short-term gains, companies seeking successful product commercialization and market penetration must establish their own technological advantages. This will enable Chinese brands to expand into international markets under any circumstances, thereby elevating the overall competitive landscape of China’s medical device industry.

Liu Jianmin:Surgical robots have been widely adopted in clinical practice. Currently, surgical robotics is evolving from laparoscopic surgical robots to vascular interventional surgical robots, with future developments expected to include robots capable of operating under magnetic resonance imaging (MRI) and computed tomography (CT) guidance. By leveraging multiple imaging modalities such as X-ray, MRI, and digital subtraction angiography (DSA), we can enhance the precision of both surgical and interventional procedures.

Surgical robots are undoubtedly a critical direction for the advancement of clinical medicine. Due to the lengthy training process for physicians and significant disparities in competency across hospitals, the level of healthcare standardization remains remarkably low, both in China and worldwide. Greater physician experience translates to enhanced precision and stability in surgical procedures. Consequently, patients universally prefer seeking surgical care at major medical centers under the expertise of highly skilled surgeons.

Surgical robots can enhance the standardization of healthcare delivery within a short period.Doctors will no longer make elementary errors; even after a brief learning curve, they can achieve a stable level of proficiency, significantly enhancing the overall safety of surgical procedures.

Disparities in healthcare standards across China will persist indefinitely.Surgical robots also enable remote operation, rapidly narrowing the gap in medical standards across different regions.Therefore, I believe that surgical robots have a wide range of clinical applications. However, progress varies across different fields. In the field of interventional medicine, I anticipate significant development.

Moderator: Globally, few companies are developing neurointerventional surgical robots. From a clinical perspective, what capabilities do you believe an ideal cerebrovascular robot should possess? Do you have a specific profile or vision in mind for such a system?

Liu Jianmin:The vision in my mind is the fifth-generation surgical robot proposed by Academician Yang.

Interventional surgical treatment has become a highly significant direction in clinical practice.Surgical procedures performed via natural orifices have represented the most significant advancement in clinical medicine over the past two decades, transforming major open surgeries into minimally invasive procedures.However, in vascular interventional procedures, physicians must work under X-ray exposure for extended periods with high intensity. Meanwhile, the training period for these specialists is lengthy, and the level of standardization in medical practice remains low.

Interventional surgical robots must firstSafety, as a founder just mentioned, safety is the top priority in all medical innovations. Interventional robots must be more refined and precise, capable of sub-millimeter-level manipulation, thereby offering greater safety than manual operations by physicians. Secondly, surgical robots need to operateConvenience. Existing vascular interventional surgical robots can already meet basic requirements such as advancement, retraction, rotation, and deployment; however, they are extremely cumbersome and complex to operate, necessitating continuous switching between manual and robotic control during the procedure. Finally, the surgical robot'sEfficacy, which is closely related to the first two points.

"According to the generational classification criteria for robots proposed by Academician Yang just now, I believe that interventional surgical robots may have just entered the second generation, but their development will be very rapid."

We need to continuously optimize vascular interventional robots, primarily in two directions—the first isSensing and Feedback Capabilities of Surgical Robots, the robot must be able to perceive the force exerted by the physician, whether rotational or axial (advancing/retracting), provide relevant data feedback, and automatically identify hazards; secondly,Integrate interventional surgical robots with the surgeon's existing surgical platform, achieving miniaturization, simplification, and integration to make robotic technology more readily accepted by physicians.

Host: In what areas do vascular interventional surgical robots need to innovate, and does our existing technology meet the requirements for such innovation?

Yang Guangzhong:Innovation in vascular interventional surgical robots lies first inMicrosensing, in neurointerventional procedures, physicians perform rotational and advancement maneuvers; the tactile feedback associated with these actions requires extensive experience to master. If surgical robots can acquire such sensing and perceptual capabilities, they can evolve from simple mechanical devices into truly intelligent robotic systems; the second aspect lies inMicro-manipulation, we prefer surgical robots to achieve micrometer-level precision, thereby surpassing the capabilities of the human hand and avoiding vascular trauma caused by tremors and other manual errors.

From a technical perspective, we are capable of implementing all these innovations. However, in the current development of surgical robotic systems, we often overlook a key point, which is toRespect the Protocol of Routine Surgical ProceduresNo matter how much new exploration a company conducts at the technical level, if its surgical robot products do not align with surgeons’ usage habits and surgical workflows, they are destined to fail. Therefore, ergonomic considerations must be incorporated into the design of surgical robots.

Moreover, vascular interventional robots are not designed for use throughout the entire procedure; in the future, they may only be employed during several critical steps of the surgery, while the remaining steps can be performed following standard protocols.

In addition to meeting the requirements for microsensing, micromanipulation, ergonomic design, and respect for surgical workflows, surgical robotics companies must also consider how to leverage their systems to achieve functionalities unattainable through traditional surgery., such as enhancing physicians' tactile perception and providing penetrative visualization. In the field of vascular interventional robotics, many innovative opportunities remain to be explored.

Host: The journey from technology to product, and then to industrial-scale production, involves issues of cost and mass production. Do you believe that current supply chains or manufacturing technologies are capable of producing the vascular interventional surgical robots we desire?

Yang Guangzhong:How can we reduce product costs while enhancing performance? The key lies in materials. When it comes to traditional surgical robots, people tend to think of motors and gears, whereasFor the new generation of surgical robots, the more critical technology lies in materials.

New materials need to meet the requirements of self-driven, sensing, and certain computing functions.Thus, a guidewire fabricated from such multifunctional, all-in-one materials constitutes an intelligent guidewire. Furthermore, by integrating a suite of biophotonic technologies into the material, we can not only perform external visualization but potentially achieve direct cellular imaging, thereby surpassing human visual capabilities.

For instance, the fiber-optic robots we are currently developing involve a highly complex manufacturing process; yet the final product integrates sensing, actuation, and imaging capabilities into a single unit, all at a very low cost.

We hope that investors, when evaluating the surgical robotics sector, will place greater emphasis on original products that achieve breakthroughs from 0 to 1, and provide less encouragement to “me-too” offerings. We aspire for Chinese domestic brands to expand into international markets under any circumstances, thereby elevating the overall standing of China’s medical device industry.

Liu Jianmin:When we speak of innovation, it must be from 0 to 1 to be considered true innovation. Innovations in surgical robots are more focused on engineering and design.Currently, innovation in engineering materials is the most important.China is largely on par with other countries globally in the field of vascular interventional surgical robotics. While material innovations have yet to fully emerge, our innovation efforts may focus on engineering, design, and principles, aiming to make clinical use safer and more convenient.

We should not assume that the launch of surgical robots will immediately unlock a massive market. Among ten thousand physicians, only a small minority will ever be early adopters of new technologies. However, following their successful application over a period of one to two years, a much larger cohort will subsequently adopt the product. This adoption cycle, however, tends to be protracted.

Just as with the promotion of microscopes in China, where only a few young doctors used them in the first five years, a large number of physicians began adopting them after five years, and they became widespread across the country within ten years. I believe the development of surgical robots will follow a similar trajectory.

Host: There is a prevailing view that neurointerventional procedures are where coronary interventions were two decades ago. Professor Liu, what are your thoughts on the future development of neurointervention? Will the integration of surgical robots accelerate this progress?

Liu Jianmin:The development of neurointerventional procedures has had to accelerate rapidly. In China, deaths from cerebrovascular and cardiovascular diseases account for 46% of all deaths. Out of every 100 deaths per day, 46 are attributed to cerebrovascular or cardiovascular diseases, with cerebrovascular diseases accounting for 26% and cardiovascular diseases for 20%.

We should not discuss cardiovascular, cerebrovascular, and peripheral vascular diseases in isolation; in fact, they are the same disease manifesting in different parts of the body, and their prevention, treatment, and health management are identical.。

The slower development of neurointerventional procedures compared to coronary interventions is attributable to two main factors. First, limitations in the historical development of medical imaging in China meant that physicians were previously unable to visualize cerebrovascular diseases effectively. Second, neurointerventions carry higher risks and entail a steeper learning curve for practitioners. While coronary interventions have become widely available even at county-level medical institutions, neurointerventional techniques have not yet achieved widespread adoption at the prefecture-city level. Over the next five years, the highest priority for national health authorities and the industry will be to ensure that 60% to 80% of county-level hospitals master the fundamental techniques of neurointervention.

To date, the growth rate of neurointervention has not been slower than that of coronary intervention. The rapid development of the entire vascular interventional device sector over the past two decades has made neurointerventional procedures simpler and safer, while shortening physicians’ training time. With the integration of surgical robots, neurointervention is poised to accelerate its development even further.