Jean Claude Durousseaud: We're in the interventional radiology department at Edouard Herriot [HCL, Lyon, France]. We're with you, Professor, so give us a quick tour of the department.  

Pr Laurent Milot: We're located in what's known as the interventional radiology center, which is at the art of the Edouard Herriot hospital's operating theater, in a brand-new building constructed in 2018, so we're lucky enough to have three rooms dedicated to interventional radiology: two latest-generation angiography rooms and a dedicated interventional scanner room. Within this department, we also have access to anesthetic resources, with anesthetists on shift every day and two nurse anesthetists, who always work in two of the three rooms.

Jean Claude Durousseaud: So two angio rooms, a scanner dedicated to interventional, but that's not all, there's also a robotic arm.

Pr Laurent Milot: So, yes, you're quite right! The robotic arm is used exclusively with the scanner. Since last November, we've been lucky enough to be equipped with the Epione robot from the French company Quantum Surgical, which is based in Montpellier, and so we've been lucky and honored of being the second site in the world to be equipped with such a robot, which guides us through our complex tumor ablation procedures.  

Jean Claude Durousseaud: So the second site, one installed, and you now have three in the world.

Pr Laurent Milot: Exactly, so there's the Gustave Roussy Institute in Paris, us at the HCL, and there's actually this third site, which is in Miami, in the United States. So the journey is underway.  

Jean Claude Durousseaud: We beat the Americans

Prof. Laurent Milot: But we're ahead of the Americans, absolutely.

Jean Claude Durousseaud: That's always a pleasure. With several extremely well-equipped rooms, what do you do each day?.  

Prof. Laurent Milot: Well, that's great, because we're lucky enough to be in a department where there are so many different practices. So, we have both people who work in what we call uro-radiology and more vascular radiology, and people like me - I tend to work in hepatobiliary and emergency radiology, where I deal a lot with the liver. But we also have colleagues who do more radiology, who are interested in bones, for example musculoskeletal, in a very advanced way. So, there you have it, we cover the whole interventional radiology spectrum and we also have, as we're a big emergency center, all the emergencies we deal with, people who bleed, acute embolisations. So, I'd say that our range of activities goes from tumor ablation to vascular shunts such as TIPS or emergency embolization, to screwing up broken pelvises in patients.  

Jean Claude Durousseaud: Let's take cryoablation. What are the advantages of this robot, for you, and then for patients?

Pr Laurent Milot: For the physician, the plus of the robot, if we take a classic case, is that it makes the procedure safer. Why? because I can see my trajectory in advance, I can model my ablation zone in advance, and so I can send this information to the robot, which then helps me position myself exactly where I want. So here we can see very clearly an area where my colleague is going to treat this renal lesion on the lower pole, and we can see that she has planned 2 icespheres/ispheres. So, they're pre-entered, which is actually very powerful in the system. The needle is in fact retracted, so depending on various parameters such as temperature, etc., the ablation zone can also change interactively. Basically, here, you have the needle you've chosen, and you go to the parameter you're interested in, and at minus 40. And, in fact, if you put in another type of needle, because these are fixed, that's actually it, that's their zone, not like the microwave.

Yann Lemeur: In fact, that's what we did, we tried to plan with a single needle.

Pr Laurent Milot : If you change, you can use other types of needles, for example this IceRod one, a different one, you can test several needles and see which one is more suitable beforehand. And that's very practical, because you can see not only the tumor destruction area, but also the risk you're taking around it, so in terms of planning, you're much more relevant, because you can anticipate risk and success. And secondly, the transferability of knowledge is very good, because it allows you to think about your type of ablation differently, and to be more precise. So, here, we're more precise in depth, and it allows us to see, for example, the deeper areas. We're not bad at positioning, but depth is often very hard to anticipate. The other advantage for the physician is that it enables him to go beyond certain limits. For example, in extremely complex cases, such as certain examples here of very poorly placed lesions, close to the heart, where you might want to remove the tumor, this is very difficult, you can't see anything, and thanks to the robot, it's a real partner in the destruction of this tumor. So, these are really the big advantages for the physician. The other big advantage is that we can pass on our knowledge much more easily to our teams. For example, I'm very proud that recently, two of my youngest colleagues were able to carry out complex multi-needle electroporation ablations with great success.

Jean Claude Durousseaud : Yes, because it's very visual, and you can quickly see how to adjust the needles and so on.

Pr Laurent Milot : Exactly, and then you can share the planning. It allows you to share the process, whereas otherwise, it's all in your head.

Jean Claude Durousseaud: It's more something you do on your own.

Pr Laurent Milot: You can tell them to "go there, go there", but it's clear that you can make quite fine adjustments, and then you can control the process in real time, review it with them and be in complete control of the process.

Jean Claude Durousseaud : This robotic arm isn't just a robotic arm.

Prof. Laurent Milot: It's made up of an optical camera, the robotic arm itself and a navigation console. In fact, there are three parts. It's used to position the robot in space. So, there's a system [patient reference] that's placed on the patient, which allows you to see where he is in space, and the robot actually positions itself virtually in relation to is position.

Jean Claude Durousseaud: So, for that, you have a particular anesthesia protocol.

Prof. Laurent Milot: Yes, exactly. So, in our center, we make extensive use of what we call jet ventilation, which is ventilation performed by anesthetists, who are absolutely fundamental to this type of procedure. So, you have to imagine that it's very superficial breathing. So the breathing will go like this:”[breathing sound], as if nothing is moving anymore. Imagine there are no more breathing movements. And, of course, this means that there's virtually no difference between the initial information from the scanner and the one we're going to use during our procedure.

Jean Claude Durousseaud: The advantage of having the scanner in the room is that you can go back and forth. So, first, there are different scans for preparation, but there can be several intermediate scans to check how to set the needles, how you're positioned, and whether it worked well.

Prof. Laurent Milot:  Yes, that's exactly it. We're lucky enough to have the scanner in the middle of the operating theatre, so we have this permanent interaction with the anesthetist who's in charge and who can follow the patient through the intermediate control scans. And we can re-launch his intermediate control scans on the robot and make readjustments as we go along, if need be. So, the evolution of the service is interesting, because you need to know that initially in the Edouard Herriot hospital, there were three radiology departments. And so, they each developed separately, and for a few years now, these three services have been brought together. So, when you put together three departments that are well-developed, with great expertise, and you put them all together, you've got all that expertise now at the service of one single department. So that's why we're lucky enough to have these ultra-specialists in osteo-interventional, neurovascular and hepatobiliary surgery. That's what makes our department so unique.

Jean Claude Durousseaud : This versatility means you can switch from robotic arms for cryoablation to TIPS.

Prof. Laurent Milot: In parallel, the two rooms are covered by anesthetists, with tumor removal on one side, and a vascular shunt placed between the suprahepatic vein and the portal trunk on the other, to resolve a rather catastrophic situation for a patient with refractory, multi-infected ascites. In fact, to reduce her ascites with the help of this famous TIPS, a very complex angiography procedure that you've seen for several seniors and that we did together, with mixed guidance using angiography and ultrasound, by placing this little prosthesis that we dropped into this hepatic neo channel.

Jean Claude Durousseaud: So, once again, it's not just the robot arm, but also Quantum Surgical's engineers who are there to discuss and improve. So, it's a rather unique duo. Explain to me what it has been bringing to the both of you.

Pr Laurent Milot : Well, it's true that it was a very nice encounter. Working with the Quantum Surgical team was one of the great aspects of our effort to adopt robotics.. It's important to understand that interventional robotics is quite new. Basically, we're pioneers here, so the idea is that we learn from each other. Every time we do a procedure, what's the idea? There's the robot, there's what it can do. So, of course, the engineer helped us tremendously, if only to make it work. So that we could get through the times when we were stuck, when we didn't know what to do, especially as the platform has improved a lot. In the early days, there was a lot of tweaking going on. It wasn't always easy for us. So, of course, the engineers were there. But what we realized was that we were constantly talking to each other, and as a result, we were constantly understanding each other, and they saw our issues, as they solved them, and basically, my issue became theirs, theirs became mine. We were constantly exchanging ideas to improve the technique.

Jean Claude Durousseaud : So there's this constant ping-pong from one side to the other, which really pushes the system forward. And then, if there are only three sites in the world, it's true that it's good to be close to these sites to get feedback from the field.

Yann Lemeur : Exactly. In fact, as Professor Milot said, application engineer has a bit of a dual role. Let's take the example of the driving license. When you pass your driving license […] frankly you don't know how to drive. So, we provide training on our device. Nevertheless, we support our users in real-life settings, in order to get the most out of the system. That's the first aspect. The second aspect, as Professor Milot described so well, is that we're a start-up company, so we react very quickly to improvements. So, it's very important for us to be present on site too. To capture the way our users utilize the device, and to react immediately, constantly proposing new improvements. I think we release two or three new enhancements a year - which, in the world of medical devices, is quite a lot.  And so, it's also the strength of companies like ours, which are start-ups, to be very responsive to our users. I'm a senior R&D engineer. Being in contact with users is how we get all the ideas for improvement. And it's also important to understand all our users' constraints. It's important to be close to the field. So, at Quantum Surgical we want to have this contact, and in the end they are not our customers, they are our partners.

Prof. Laurent Milot: Yes, I have a concrete example, because it really helps to set the scene. I got the system in November 2022 and already I don't have the same version as the one I had at the start. And, in particular, there has been, in my opinion, a game-changer, the so-called axial mode. It sounds simple enough, but you see, the robot will move, will face the target with a given depth. The problem was that when the needle was inserted, it sometimes inserted the needle a little far from the skin. Well, they've created a mode where you can move the robot forward until it touches the skin, and then you can do the puncture, and then afterwards, you can move the robot back up, and it actually returns to the depth described. The specific “click” you hear afterwards sounds simple, but from an R&D point of view, it's a real new software mode that needs to be coupled with hardware. But for us, it's a real game-changer in terms of our practice, because it's enabled us to be much more precise. We've already seen a significant gain. So we're still seeing this communication, which is totally beneficial, in everyday practice.

Jean Claude Durousseaud : So, when is the next update?

Yann Lemeur : So, the next update. We do have a version in development. I think the next update will probably be before the end of the year. We'll go out with this new version. And we have, for next year, obviously, other new versions with new functionalities, so when we develop new functionalities, people like Professor Milot come to our premises at Quantum Surgical, R&D being in France, in Montpellier. They've just tested mock-ups, quite finalized software. They give us their feedback. In this way, we can adjust the functionality before releasing it into on the market. So, in fact, this support comes afterwards, but obviously also before. So, Pr. Milot, your team, Dr L'Huillier and Dr Gay are coming to Montpellier. 


Pr Laurent Milot : To try and get young people to come along too, because I think young people understand and have a dynamic that is totally in sync with technology. They also see their needs, which enables them to move things forward and test in a totally relevant way. My great mentor Professor Valette, who is really the person who, at first, was excessively skeptical, and we produced a fine patient robotic case. There were very deep lesions and we had to put in a 25 cm needle; we couldn't see a thing. And we did it with the robot, and there, we could see very well, and we put it in one-shot and he told me: “it's really great”. And even Professor Valette was convinced of the benefits of the robot. But it's true that when it comes to interaction and the way in which people project themselves onto the robot, we can see that this generation will be much more inclined, in fact, to adopt it straight away, and indeed they do.