Wilson's Blog - Robotic Surgery at Roswell Park Cancer Institute

Hello! I am Wilson Liou a rising senior at Montgomery High School and this summer 2017 I was accepted into the Junior Robotic Surgery Challenge at Roswell Park Cancer Institute to learn about cancer treatment through human-assisted robotic surgery and other methods. This program lasts about a month with around five surgery and other cancer treatment experts leading a group of fifty students. Since I came from far away JRSC was not a paid internship like it was for the local Buffalo participators. Regardless, it was still gave me valuable real-world experience in the operating room and the biology lab. The two major focuses of my blog will be on robotic surgery and cancer treatment so I will split those into two sections. Unfortunately the program did not allow me to take pictures because we were on a medical campus filled with confidentiality-protected patients.

Robotic Surgery

6/24/17

Basic Open Surgery Skills:

Today was the first day of surgical training. We started with basic knot-tying training. We learned the square knot, which is used in tandem with other knots to stitch close wounds. We then learned how to operate with special forceps and scissors with a curved needle so that we could practice suturing. Using the knot tying and needle handling skills we just learned, I was able to use a surgical suture to close a simulated wound.

By placing electrodes on our heads, we could see our brain activity on an EEG moniter.

In the future researchers hope to develop a near-autonomous robot to conduct surgical procedures. Right now robots still make mistakes so humans still need to correct the robot’s mistakes via brain signals. The robot is hooked up to EEG (electroencephalography) monitor which records brain activity through a cap with a bunch of different sensors attached to the brain. The sensors pick up signals from all different parts of the brain but motor neurons mess up the electrical signals so accidental movements have to be filtered out so that the signal from the brain can be accurately read. One brain-assisted robot developed by MIT is called Baxter which is designed to sort paint supplies and wires. The robot by itself works 70% of the time but the other 30% when it messes up, brain activity is sent to correct it.

Roswell’s robotic surgery program uses brain tracking on mentor-learner pairs to help learning surgeon's figure out which tasks need the most improvement. This shortens the learning process of the learner and also these brain patterns are also used to better develop autonomous robots. For more info: http://news.mit.edu/2017/brain-controlled-robots-0306

7/5/17

Solutions to Robotic Surgery Problems:

We were asked to think of major problems with robotic surgery and to think of possible solutions. As a group we thought of four: trocar damages, depth perception, haptic feedback, and RSIs (retained surgical items).

1. A major breakthrough in laparoscopic surgery was retractable trocars. A trocar is the surgical tool used to puncture a small hole through which the laparoscopic tools would enter the body before small incision surgery or robotic surgery. However, this puncturing process is also the most dangerous part of surgeries. This is because at the instant of puncture there is no equal and opposite force to balance the puncturing force and the hand does not react quick enough to pull the trocar back. However, with the design of a mechanism that pulls the trocar back at the instant of puncture, the potential damages can be avoided. In the design below, when the trocar reaches a certain depth, the joints lock against the side which then allows for the spring to pull the trocar back.

2. Another problem with robotic surgery is depth perception and haptic feedback. During robotic surgery, the inside of the body is viewed through a 2D screen so surgeons have to be able to gauge distance carefully so that they do not move their tools recklessly and damage tissue. To improve depth perception, the Da Vinci robot offers three-dimensional (3-D) video on the console for the surgeon.

3. Haptic feedback is the force and tactile feedback that is received when pressing against something. Basically the resistance that you feel. Unfortunately, by operating via robotic machine, haptic feedback is extremely limited and it is hard to measure if too much or too little force is being applied. In response to this, engineers are designing haptic sensors to put on the robot and haptic displays so that surgeons can better gauge the pressure they apply.

4. One of the largest problem in cancer surgical operations are RSIs (retained surgical items). And 69% of all RSIs are retained surgical sponges. We were assigned to think of a solution to this large problem and it turns out the one we though of was extremely similar to an already existing solution created by Stryker known as the SurgiCount Tablet. In this innovation, each of the sponges are uniquely electronically labeled so that it would provide a real-time count/tracker of each sponges location.

7/14/17

Robotic Surgery Simulators

Today was my first day using the robotic surgery simulators. The two used models were the RoSS and the LapSim. The RoSS resembles the DaVinci in design and functionality and is designed to prepare surgeons to use the real thing. But unlike the real surgical machine, the simulators are slightly less responsive. The RoSS contains two triple “jointed” endowrist operating handles to allow for maximum rotation and movement. Additionally, there are four pedals attached to the base: one to control the camera, one to act as a clutch (allows user to rearrange instruments to more comfortable position)/ control the 4th arm, and two to send electrical current through the instruments at the surgeon’s discretion. Cutting tissue with electricity to minimize blood loss is known as bipolar or monopolar cautery, which differ in the way that current runs through the wires.

Using the RoSS, the first exercise required moving the simulated forceps around and pinching them around randomly placed targets without hitting the surrounding tissue. This engaged the use of the clutch pedal to be able to access especially close or far targets. The second simulation required the use of the camera pedal to center the camera around a target. Another simulation practiced the movement and coordination of the fourth arm (if camera arm was counted) to pinch around targets using the clutch/4th-arm pedal. Finally, a challenge involving all three skills was to pick up balls and place them in the highlighted container.

The other simulator, the LapSim was different from the RoSS and DaVinci as it used the maryland dissector instead of the endowrist controller. This one required less motion to rotate as there was a orientation-controlling dial on the side of each dissector. Instead of pedals, there are no clutch controls and there is a third arm used to control the camera. This is a weakness since you will not be able to control both the camera and the two dissectors without letting go of something. Simulations on the LapSim, such as ripping a tissue off from the rest of the body or by cutting tissue at a certain depth, required more pressure gauging than RoSS simulations. As mentioned before, this is really tough because there is very little way to measure tension feedback other than based off of what is seen.

7/15/17

The DaVinci

Today was the day I finally got to use the DaVinci Surgical robot. Unlike the RoSS, it was very responsive and easy to operate and it didn’t have any glitchiness. Using the DaVinci I completed a peg transfer task as well as I performed a suture on a wound-simulating pad. The only difference between the open suture and the surgical one is that the robot has two Maryland Bipolar forceps while in the open one there is a needle driver and Addison forceps in the other. This DaVinci design allows the user to use either hand to of their choosing for each step.

The Davinci consists of a surgeon console (left) and the surgical art cart (right)

Other Cancer Treatments

6/28/2017

Immunotherapy:

We were given three lessons today. The first was on Genetic disorders, more specifically migraines. Migraines are a result of misfiring of neurons in the brain that cause blood vessels to swell, which could be a genetically linked disorder. These specific types of migraines are called familial hemiplegic migraines and are inherited in an autosomal dominant manner, meaning that if one parent carries the dominant trait, the child will most likely have the disorder. On the CACNA1A gene, which controls calcium channels, on chromosome 19p13 is where most of the mutations occur. The Mutations causes increased calcium flow through the channels which causes bursts of pain. This relates to our program because cancer can also be a genetically linked disease and one way to deal with genetic diseases like cancer is through immunotherapy.

We then learned about immunotherapy, a form of treatment that fights disease by stimulating one's own immune system to work harder or smarter. The four types of immunotherapy are:

• 1. Monoclonal antibodies

  2. Checkpoint inhibitor:

  3. Cancer vaccines

  4. Adaptive cellular therapy:

Roswell Park is developing a type of immunotherapeutic vaccine which can be adapted to deal with brain cancer and blood cancers. It is currently in its third phase of testing.

7/5/17

Tumor-Illuminating Dye:

In children textbooks, we often see all different internal parts of the body color coded and easy to identify but sadly that is not how it is in reality.

Everything is red and hard to tell apart. That is why biochemist Roger Tsien created a dye that can make the tumor glow and stand out among other body parts such as necessary tissues. These dyes can be used to expose metastatic lymph nodes and they can also be used to highlight body parts that should be protected such as nerves. By inserting this dye into nerves, surgeons know where to avoid cutting so that they can avoid damages.

There is a dye substance that has additional substances to it a polycation(blue) that sticks to any tissue in the body. However, the polyanion keeps the whole substance neutral and prevents the dye from sticking to tissues. But, if the two pieces are then linked by something that can only be cut if you have the right molecular scissors, such as the kind of protease enzymes that tumors make. Thus, in the presence of the tumor, now there are molecular scissors that can break this molecule apart at the cleavable site and make the tumor fluoresce.

7/10/17

Pharmacogenomics: my first lab experience

Today was my first day in the lab. I got to meet one on one with Dr. Xinjiang Wang who is a professor at Roswell Park Cancer Institute’s Department of Pharmacology and Therapeutics. He particularly specializes in pharmacogenomics, which is the study of the the role of genetics in drug response, and how it affects cancer. He introduced me to his college intern Tyler who I would be assisting during his experimentation. Tyler was in charge of conducting a test known as the IC -50 which basically tests the amount of a drug that needs to be applied to melanoma cells, a type of skin cancer, so that they inhibit 50% of the B-Raf enzyme, which is a mutation. In melanoma, 60% of the cells have the B-Raf mutation and by inhibiting this mutation, the mutated melanoma will die so the goal of this experiment is to see how effectively these drugs can selectively kill skin cancer cells. There would be 6 different drugs tested, one of which was the MAPK inhibitor, to test the different levels of inhibition and there were four different melanoma cell lines tested SK-Mel-19 and SK-Mel-29 as the B-Raf mutated ones, and SK-Mel-163 and SK-Mel-147 as the two cell lines without mutations. Even though they don’t have the mutation, it is still important to include them to see how the drugs would affect the unmutated cancer cells.

The first part of the experiment of adding the MAPK inhibitor drug to the four different cell lines had already been conducted so Tyler and I then begun preparing for the next drug. To begin, the cell lines had to be cleaned by removing all contamination and dead cells. Dead cells had to be removed because dead cells release non-beneficial chemicals. To do this the growth medium, a red liquid substance with nutrients known as eagle’s medium, has to be replaced. This is done with a vacuum which sucks out the medium only and not the cells by not touching the bottom of the dish. PBS is applied to the clean the dirt and contamination before being vacuumed out. The cells are then trypsinized so that clumps of cells can be broken off. The cells+trypsin are then added into a test tube and put in a centrifuge to further isolate the cells from contamination. Next a hemocytometer was used to count the average number of cells by approximating the concentration of cells. This would be used to determine what volume of the cells to split into each sample.

After splitting the proper amount of cells into separate dishes, a dye which was warmed up through a water bath has to be added added to each sample. This dye would react with the mitochondria to produce a color change in the cell. The more alive cells, the greater the amount of cells with changed colors while dead cells would not change. To accurately measure the color change, the cells are read in by a machine that displays the amount of each wavelength emitted. Unfortunately, the machine takes hours to develop the cells and thus I was unable to actually see the machine’s results.

7/18/17

Does Art Cure Cancer?

Today we explored a claim that Roswell is currently exploring: that art is healing and positively affects the recovery of cancer patients. In these studies, some postoperative cancer patients are regularly exposed to artwork in a clinically designed setting while other patients are not. To get first hand experience, Roswell brought us to a special exhibit at the Albright Knox art museum, the sixth oldest art museum in the US, to see what emotions are evoked in us. Hopefully this claim turns out to be true because it would be the easiest and most enjoyable cure to cancer.

Painting: Midnight Peacock Music