Shrinking the Surgeon into the Body
This week I am talking to Adam Sachs (@AdamSachsVS), CEO and Co-Founder of Vicarious Surgical (@vicarioussurg) a company that is rethinking surgery. Adam is a mechanical engineer by training who studied at MIT focusing on biomedical
engineering and robotics. This is where he met his co-founders Sammy Khalifa, Dr. Barry Green.
They came together to solve some fundamental challenges with surgical approaches that struggles with rigid approaches that are stuck in limited dimensions and with tools that hinder capabilities. Their concept in part was modeled on the movie Fantastic Voyage which miniaturizes a ship and injects it into the human body.
90% humanoid surgical robot, 10% praying mantis pic.twitter.com/ht5sZN3lx5
— Adam Sachs (@AdamSachsVS) April 24, 2021
Sounds to far fetched – not for this company that is approaching this problem not by miniaturization of people but rather a novel approach to robotic design and taking a fresh look at the way in which robots can be used for surgery. Through the experience of their co-founder they saw the difficulties faced by surgeons who use laparoscopic tools to achieve great progress in outcomes but with limits. As described by one commentator, it is as if you put the cardboard tube found on the inside of kitchen paper over the length of your arm from shoulder to wrists and then operated that way.
Adam shares the details of the various forms of surgery and what various robotic tools have brought to improve the experience with an incremental insight of their decoupled actuator technology that brings a whole new capability to their robotic surgical device. Unlike many approaches to innovation Vicarious Surgical believes that you cannot fix the problems in software and solutions must be found in hardware innovation
Listen in to hear the inspiration for one of their incredible advances in robotic approaches that allows for 9 degrees of freedom through a single approach point. The multiple areas of technology that they have advanced from actuators to cables and beyond.
“Our robotic solution has arms that replicate human motion, offering remarkable mobility. Our robot can see, reach, and work anywhere inside the abdomen, which effectively shrinks the surgeon and puts her/him inside the human body.”
Listen live at 4:00 AM, 12:00 Noon or 8:00 PM ET, Monday through Friday for the next week at HealthcareNOW Radio. After that, you can listen on demand (See podcast information below.) Join the conversation on Twitter at #TheIncrementalist.
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Raw Transcript
Nick van Terheyden
Today I’m delighted to be joined by Adam Sachs. He is the CEO and co founder of vicarious surgical. Adam. Thanks for joining me today.
Adam Sachs
Thanks so much for having me excited to be here. So,
Nick van Terheyden
because I do always tell us a little bit about your background and your journey to this point and this company and setting this up.
Adam Sachs
So I am a mechanical engineer by training I studied at MIT and focused primarily on biomedical engineering and robotics while I was studying there. And MIT is also where I met my co founder, Sammy Khalifa, who’s now our CTO. And Sammy and I were working on this project. As a side project with our third co founder, Dr. Barry green, who’s an experienced laparoscopic and general surgeon, we were working through a number of the challenges with minimally invasive surgery today with robotics today, frankly, listening to Dr. Greene talk about his frustrations that with the state of existing tools in the state of existing surgical robots, how challenging they are to learn and to use, and looking toward making something better. And that’s, that’s really where this all came from. We saw at some point, somewhere around there, you know, we were working on this project, and we saw that movie that you and I were just talking about the Fantastic Voyage. And we we were actually I had seen it previously, but I kind of introduced this concept to them. And we were really kind of inspired by this idea that we could shrink the surgeon down and put them inside of the patient. And that combined with the Oculus Rift, Kickstarter, really got us got us thinking and, and onto this track of using our own design of surgical robotics that we had come up with, to create a miniature little human surgeon robot that goes into the patient through one small incision, and a lot of technical challenges that I’m kind of breezing over. And that, that we’ve solved along the way. But that’s, that’s really where it all started.
Nick van Terheyden
So I gotta say, you’re grabbing people’s attention, well, at least you’re grabbing mine, when you say, well, we saw the Fantastic Voyage and thought, Hey, we could do that. I’m sure people go, wow, this is really interesting. So let’s boil this down a little bit, you have sort of talked about some of the challenges. So you know, we’ve got regular surgery that you know, takes place in, you know, the typical field, then you’ve got this minimally invasive through different access ports. And we’ve also got robotic surgery, which is a whole additional layer on top of both of those, and you’re now coming in to do something slightly different. So help us understand and describe a little bit of what it is that you do.
Adam Sachs
Yeah, if I can actually back up and even talk a little bit about those you know that the existing systems open, laparoscopic and existing robots, I think it helps give some of the context for what we’re doing. So a open surgery is really obviously as you know, the kind of the classic way of performing an operation you open up the patient with a scalpel. And the surgeon can use their own hands, they can see with their own eyes, but the incision itself to gain access to the abdominal cavity. It’s actually what causes most of the injury to the patient, almost 20% of open abdominal surgical patients have a failure of their incision to heal correctly that results in the need for additional surgery. So that’s what minimally invasive surgery is all about. The idea that having three to five sometimes more small incisions can vastly reduce the injury to the patient at the cost of vastly increased complexity for the surgeon. What is essentially doing is forcing the surgeon to operate from the outside in across the abdominal wall with long slender instruments and a camera that you know is controlled by their surgical assistant. Surgical robots that exist today add some some wrists on the end of those instruments. But still, the fundamental challenge remains which is that with existing multi port surgical robots, as well as with multiport non robotic surgical technique, the surgeon actually has to create the motion profile of the robot for every procedure based on where they put the incisions. Because the main four degrees of freedom, they’re pivoting about the abdominal wall, they, the instruments insert and go out through the incision, they rotate, and they they move and bend in two degrees of freedom about that incision site. So the incision site really defines the robot’s motion for a multi port surgical procedure that adds a ton of training. It also adds a lot of those early procedures, the first 100 procedures that a surgeon performs, they find themselves in the position of choosing the wrong incision sites and having either struggle through the procedure or make more incisions in their patient, leading to a lot of frustration and abandonment of the technique. So to us, that’s what the idea of single incision surgical robots, single port robots is all about. It’s not about the idea that three to five small incisions are really that much worse than one small incision, making the incision small, it’s a huge difference already. It’s about the idea that if you put everything in through one incision, all of the robotics, then the robot can work from the inside out, the joints always move together, the surgeon is not creating a robot. For every procedure, the robot is just inside of the patient. And we’re not the first to think of this, we’re just the first to use our decoupled actuator technology to really achieve it. There are existing single port robots, they’re just far too small and too weak once they’re inside the body. And the smallest incisions that they have are, are 2.5 centimeters, which is quite large. That leads to 8.4% complication rate. So actually less capability than multi port robotics, with complication rates that are actually starting to approach open surgery again.
Nick van Terheyden
So let’s drill down into this a little bit, because it’s important in terms of the value proposition that you’re talking about. So when we talk about open surgery, I think that’s clear, you know, somebody cuts in, you know, there’s a lot of complications associated with those incisions, the repair of the incisions, and so forth. So you remove all of that was minimally invasive. That’s what people typically called keyhole surgery. That’s what you’re referencing. And when you talk about keyhole, unlike your door, it’s like, you’ve got five key holes, if you’re really doing this, or I’m making that number up, it can be a very number, but you have multiples, and you can have robots involved. And I think what’s important out of what you described there is that even if you know, you’re going to approach from five different locations, you’ve got to get those five approaches. I want to say exactly right. I don’t know what the tolerances are. But if you get that approach, right, it’s like drilling in your walls here. You know, if you’re not in the stud, you got to put another study in is that the, that’s what’s going on, even with the robots.
Adam Sachs
That’s That’s exactly it. And, you know, even if you get it, right, right, even if you’re really practiced at doing that gallbladder surgery, you know exactly where to make those incisions, you put them in the right spot, you might find that as happens all the time, that the patient has a hernia in their groin, which is down in the opposite quadrant of the abdomen, and you need to remove your instruments make new incisions, because you’ve set up your system to operate in, you know, the upper right quadrant, and now you need to operate down in the lower left.
Nick van Terheyden
So I that’s just extraordinary. I think lots of people are going to pause for a second ago, what Wait, I thought this whole middle we invasive, you know, at one time, and we’re done, and we’ve got this perfect circumstance. And that’s not the case, even with expert hands. And, you know, knowledge and insight, not least of all, I forget what the numbers are able to be able to remember from my anatomy class, but just pure anatomical variation comes into play with this as well. So that’s an additional layer and again, part of potential complications, poor outcomes, what you’re talking about, and I think it’s important to understand this is a single insertion point, but essentially multiple, I want to say approaches but let’s call the multiple tool sets. It’s like having a Swiss Army Knife going in through one port is that
Adam Sachs
it’s both multiple tool sets, but also multiple approach angles. what you were saying was dead on. So one of the challenges with with some of the historic single port approaches not just that incision size, a lot of them are no little Longer keyhole incisions, they’re actually using open technique. But on top of that they are stuck operating just forward from the incision site. Whereas one of the things that we’ve developed that we’re incredibly proud of is our ability to really flip and face in any direction. And we really believe that by enabling the surgeon to turn around to even work, they can literally flip all the way back and work around the incision site, enabling them, you know, we’ve designed our system to enable them to do that, because we believe that it has incredible potential to offer them the ability to, to do more things and adapt to more challenges during a procedure.
Nick van Terheyden
So we’ve we’ve gone from open to keyhole, or minimally invasive to single approach, I think you recognize those, you know, not brand new in terms of its approach, but you’ve obviously managed to find some success in that tell us, what was it that allowed you to be successful, whether some learning points or some differences in the way that you approached it? How did you make this work?
Adam Sachs
So it’s all about the robotic actuator technology, there’s a there have been a number of attempts to replicate success of previous surgical robotics companies by copying their existing technology in this industry, that is really hard, you need something really disruptive and very different to a in order to make an impact. And one of the main challenges you know, it’s interesting, we is always the saying and engineering that will fix it in software. And as a mechanical engineer, I really believe that you need to fix it in hardware first, and then adapt any software that you need. So flexible robots that people use for existing single port, that they’re ironically, they’re just they’re too flexible, they don’t have the force capability. And yet, they also don’t have they’re, they’re too large, and don’t have the number of joints that you need inside of the body to provide the total motion, that we’re able to provide rigid robots like what are used in most most surgical robotic procedures today, and multiport procedures. There, they all have something called coupled motions. So within the robot, when you move one joint, all the other joints distal that down toward the tip of the robotic arm also moved through their full range of motion because of the way the cables passed through the joints. So what that means is, is that legacy systems would just arrest on the end of a stick, they end up needing thick steel control cables in order to drive that wrist. Whereas our system, we’ve invented and patented and spent many years perfecting decoupled robotic actuators that allow us to remove any connection. So so you know, with these legacy systems with their coupled motion, they’ve they’ve essentially fixed it in software, they have a mechanically coupled system that they then use complex software to move all the control cables in unison to produce motion of just one joint. But that’s that’s why they still have that mechanical exponential buildup of force. Whereas we’ve fixed it in hardware, we’ve invented the decoupled actuators, and our system has no linking between each of the joints, we have half millimeter diameter, advanced polymer cables driving our system, and nine degrees of freedom per arm. And that’s, that’s what gives our system so much capability. And then the one other innovation that I’m really proud of is everybody else and not even just surgical robotics and robotics focuses on six degrees of freedom plus an end effector seven total typically, the six joints are you know in Cartesian and Euler that’s that’s x, y, z plus yaw pitch roll. It gives you full position and orientation control. But it doesn’t give you a choice of how to get there. So what what we pretty quickly realized is that humans actually have two extra joints, the most obvious for, you know, everyone listening, you can hold your hand in one spot and raise your elbow up and down. And that’s part of what gives humans such incredible dexterity. If you remove those elbows like legacy multiport robots, you’re stuck with your arms colliding all the time, which really just goes to show how important port placement incision placement is for legacy systems and how how perfect it needs to be every time we’ve recreated those elbows, giving that natural human dexterity, the ability to reach around things. To address tissue from multiple angles.
Nick van Terheyden
So for those of you just joining, I’m Dr. Nick the incrementalist today I’m talking to Adam Sachs, the CEO and co founder of vicarious surgical. We are knee deep in robotics in robotic actuator technology. That’s the essentially the muscles I think it’s, it’s how I would sort of describe it. We’re talking degrees of freedom. from six, I think I heard you say, nine degrees. And I want to go back to something that you talked about the, you know, just extraordinary idea that you can insert a robot into the, into the abdomen facing, let’s say, down to the pelvis. And what I heard you say was you can essentially turn that around and face up towards the head as part of the technology that you’ve built. And maybe that’s one of your degrees of freedom, because visually on my mind’s blown, it’s exploded, if you can see me on the screen right now. Help me understand that and what’s going on there?
Adam Sachs
Yeah, I’ll uh, you know, I’ll actually share something that I am not sure I have shared previously. But the inspiration for that one was the movie The Exorcist. It’s a, the idea that, yeah, it’s super human flexibility. And we allow the surgeon to do exactly that, to spin all the way back around and operate back at their own incision site through which the robot was inserted. And that’s, you know, as I was mentioning, that is incredibly important, because, of course, surgeons do not get the incision location that wrong, right, they don’t pick the entirely opposite side of the abdomen from where they wanted to operate. They do discover things, as you mentioned, that they didn’t expect during the procedure, and suddenly need to operate on the opposite side to repair something or address something or even just to look at something in detail that they didn’t see previously on on preoperative imager, or in the patient’s history. So all of that’s an incredibly important addition to what the surgeon can provide.
Nick van Terheyden
Let’s be clear, just in one fell swoop, you have wiped out a whole surgical activity of the exploratory abdominal surgery for somebody that has unexplained symptoms where we have to open up a huge incision, and essentially look around and you said, we can now do that effectively with one small keyhole incision. That’s extraordinary. I mean, just that I know, that’s not one of your focus areas. But Wow,
Adam Sachs
I’ll say I’ll say that’s, that’s the goal. That one, you know, we this is still in design, and I do want to kind of be cautious about making it clear that, you know, we are in the final stages of our design and need to take this to the FDA and prove all of that, but that is absolutely part of the goal.
Nick van Terheyden
That’s just fantastic. I mean, that’s such a huge operation quite, you know, has major impacts for all sorts of reasons. But it’s, you know, it’s a valuable diagnostic tool, but we don’t use it because of all the complications that potentially ensue for something that you know, is diagnostic in in approach so fantastic. So I know a lot of time left, but there’s something that’s burning inside me now as I think about all this. I already understand my ineptitude when it comes to this. So I had an experience where my daughter went and she trained on a laparoscopic robotic system. To do gall bladders. She literally blew through the seven or eight steps in 30 minutes. I couldn’t get past that one. I just didn’t have the wiring. She was wired that way. But I think you’re at a whole different level, how are you going to train or allow people to operate that this seems like a really complex area? Or have you thought about that as well.
Adam Sachs
So we’ve definitely spent a lot of time on it. I actually if I before I address that. I do think it’s worth noting that your experience, I breezed over it in the story at the beginning about you know, what Dr. Greene was frustrated with and what he was complaining about but that was actually one of his biggest complaints was that and there are surgeons who they go through all this this training like like you have they go through, you know, medical school and then residency and some of them just still are not natural said they’re brilliant, they’re dedicated they care. But laparoscopic surgery is it’s an incredibly complex technique that takes a level of hand eye coordination, they may be excellent and operating open and just never got good at that backwards or First motion that his laparoscopic surgery and that’s, that’s part of the value proposition of providing a system that’s that that can frankly allow the surgeon to go back and focus on what they’re good at again, instead of all of this technique. So of course, we spent a lot of time on training. But I guess the point I’m really trying to make here is that the inspiration of what we’re trying to do, and what what we’re designing our system to do is to not require all of that training to just work like the surgeons own body, instead of teaching the surgeon to press a clutch pedal and drag the camera around with, like, with legacy surgical robots, you move the camera by looking around, you just look, you know, you tilt your head, and you look, you move your arms by moving around, you can sort of reposition your robot just as if you were sitting in a chair by grabbing and scooting around, like, like you would if you were in a swivel chair, like I’m sitting in now. It’s all you know, it’s all designed to be much, much easier, much more natural for surgeons to use. And we believe that the training profile will reflect that.
Nick van Terheyden
So I mean, that’s just extraordinarily exciting. I mean, I think you’ll resonate with lots of clinicians that, you know, it’s a different set of techniques to do minimally invasive, you’re sort of looking at something else versus at the field. And you know, that hand eye coordination is completely defunct. And, you know, we’ve failed at delivering a system that enables you to sort of work naturally, because that’s, that’s what we spend our whole lives up to that point until we choose minimally invasive surgery, you know, working in that way. So you’ve essentially turned the system on its head to create, I want to say the natural use case for surgery. So in the closing minutes, that we have, tell us where this is going, and what you’re excited about.
Adam Sachs
So the next steps for our company are to go through the final stages of design, the technology all works, we’re going through beta testing right now, in house, we’ll be doing another round of beta testing next year, finalizing and locking our design, and then going through all the regulatory testing that it’s necessary for us to prepare and submit our application to the FDA, we’re incredibly proud to be the first robotics company to have a breakthrough designation from the FDA. Meaning that, you know, the agency has reviewed what we’re doing in detail, and they believe that we are quite likely to have clinical benefit where nobody else has succeeded. And they’re going to provide us a ton of support working with us to make sure our device is safe, effective, and get it to market as quickly as possible. And all of that makes us incredibly excited about the next two years, we’re also working on building out partnerships with surgeons and hospitals across the US and across the world, have major hospital chains, both in and outside the US that we’re working with that have invested in our company, and are devoting time and resources to help us go through these final stages of design to make sure that our device is exactly what they need. Once it’s on market.
Nick van Terheyden
I think exciting times I want to just sort of emphasize a couple of points here before we close out one, you’re looking for sites, you know, test beta sites, you’re looking for people, you’re actually hiring folks to come in and participate in that. And you know, this is right at an inflection point, which for those that don’t know, getting de novo status with the FDA is a big big hill to climb. So kudos to you and for the innovation. I imagine you’re going to have other people knocking on your door from other industries and potentially out of this world, possibly I would imagine, as well. So exciting times. Unfortunately, as usual, we’ve run out of time, it just remains for me to thank you for joining me on the show, sharing this exciting vision and you know, looking forward to hearing more more about it. Adam, thanks for joining me.
Adam Sachs
Thanks so much for making the time
