On the cutting edge: how robots are revolutionising surgery
With a new wave of surgical robots entering the market, in DG #37 Rob Orchard investigated the revolution taking place in operating theatres
16th October 2019 (Taken from: #37)
In 2019 a total of 1.2 million people had operations – prostates removed, hernias tamed, tumours excised – with the aid of an American robot called Da Vinci. That’s one patient going under the robotic knife every 26 seconds.
Most of the procedures took place in the US and a decent number were carried out by an enthusiastic surgeon from California called Rockson Liu. “When I sit down at the console I get into the zone; I’m one with the patient, almost,” he rhapsodises in a video promoting Da Vinci surgery. “It’s like a dance, it’s so precise. The robot can augment and amplify my natural abilities. It’s an incredible feeling to be a robotic surgeon… Technology is going to help us get patient outcomes we never thought would be possible.”
Da Vinci has exerted near-total dominance of the robot-assisted surgery market for the last two decades. But this may be about to change. As its initial patents have come to an end over the last few years, new players have prepared to launch their own surgical robots. They are keen to capitalise on a rapidly growing industry which, in its giddier moments, dreams of turning cancer into a readily manageable nuisance rather than an existential threat.
One of the new upstarts is British company CMR Surgical, whose Versius robotic arm went on sale on 16th October 2019. Colorectal surgeon Doug Speake completed the UK’s first operation using Versius in Edinburgh’s Western General Hospital in February 2020. “This is the next revolution in surgical technology…” he said. “We have gone from open surgery, to keyhole surgery, to robotic surgery. This is the future.”
To understand the future of surgery it’s worth casting an eye over its past. It has largely been a squalid affair, a grim parade of ill-informed experimentation with dirty blades and unwashed hands. Until relatively recently surgeons had a poor reputation, thanks to the epic levels of mortality among their patients. In the UK it was not until 1745 that they mustered enough professional pride to break away from the Company of Barbers and Surgeons, their ancient trade association with hairdressers (“Amputation is it today, sir? Or just a short back and sides?”).
In the 19th century, innovations started to arrive that transformed surgery: hygiene, blood transfusions, X-rays and non-booze-based anaesthetics. Although new techniques brought much-improved outcomes, the routine for internal problems was always the same – open up a big enough hole in the patient to reach both hands in, have a feel around, then start cutting.
And then in the 1970s came the first widespread use of keyhole surgery, also known as laparoscopic or minimal-access surgery. A small incision is made in the patient’s belly button and a plastic tube is put in place. Through this are inserted an ‘endoscope’ comprising a light, a camera and a hose which pumps in carbon dioxide to pressurise the abdominal cavity, turning it into a tight, inflated drum and giving the surgeon a clear view of the organs below. Two additional tubes are inserted through 5mm-long cuts in the side of the stomach. This allows for the entry of useful tools on the end of rods – snippers, tweezers, suturing equipment and little bags into which cysts, fibroids and superfluous pieces of entrail can be placed before being vacuum-wrapped and eased out of the body.
He said, ‘I’m not going to have a robot operating on me… I want you to operate on me!’”
The impacts were extraordinary. Keyhole surgery led to radically lower levels of infection, readmission and post-operative addiction to pain-killing opioids. Surgeons could reach into spaces into which their hands would not fit and patients who would previously have had to recover in hospital for several weeks could now head home within a couple of days, sporting dramatically smaller scars.
But it was not all plain sailing. Surgeons who were used to the old ‘open’ procedures had to retrain in the new keyhole techniques. They had to learn to overcome the “fulcrum effect”, in which the rods have to be pushed left outside the body in order to move right within it. Stitching and tying knots, both fairly straightforward in open surgery, became fiddly procedures which had to be re-mastered. Surgeons swapped the dexterity of their fingers for a more limited range of movements and the assessment of the naked eye for a camera display directed by a fellow member of the operating team.
Then, in the 1980s, America’s Defense Advanced Research Projects Agency (Darpa) got involved. It had already played a role in developing inventions as varied as email, lasers, videoconferencing, GPS and stealth bombers. Now it wanted to create a robotic arm for performing keyhole surgery on the battlefield. The hope was that the arm could be operated remotely, perhaps even from a different country, allowing surgeons to concentrate on patching up wounded soldiers without the distraction of being shot at by the enemy.
Darpa prototypes led to the development of commercial versions including the Da Vinci robot, created by US company Intuitive, which was approved by the country’s health authorities in 2000. Under the Da Vinci system, the patient was prepped for surgery and then had a series of robotic-arm-controlled probes inserted into their body. Surgeons would sit next to the operating table at a workstation where they could see a 3D version of the patient’s insides and use joysticks to move the probes, explore the affected sites and snip and stitch them better. Unlike traditional keyhole surgery, the fulcrum effect was eliminated and the instruments were ‘wristed’, meaning they could directly replicate the multiple degrees of motion of a human hand.
The first operation using Da Vinci on UK soil was a gallbladder removal performed by Iraqi-British surgeon Ara Darzi, now Baron Darzi of Denham, in 2000. “The most striking and memorable thing about that first case was not the operation – it was consenting the patient for the operation,” he recalled in 2017 at an event at London’s Science Museum. Darzi spent half an hour explaining to the patient that he would be operating on him using robot assistance. “You should have seen his face, he nearly flipped,” said Darzi. “He said, ‘I’m not going to have a robot operating on me… I want you to operate on me!’” After Darzi reassured him that the robot would in no way be acting independently, the operation went ahead and was a success.
Then on 7th September 2001 came a true ta-da moment. Professor Jacques Marescaux, a French surgeon in New York, used a surgical robot called Zeus to remove the gallbladder of a 68-year-old female patient in Strasbourg, almost 4,000 miles away. The procedure employed a high-speed optical fibre link to transmit the surgeon’s instructions between continents. It was dubbed the Lindbergh Operation in tribute to Charles Lindbergh, the first man to fly solo across the Atlantic. Flushed with success at a post-op press conference, Marescaux said that, “We can’t even begin to imagine the implications for medicine… The barriers of space and distance have fallen.” The achievement, he said, “lays the foundations for the globalisation of surgical procedures, making it possible to imagine that a surgeon could perform an operation on a patient anywhere in the world.”
The Zeus robot is no more – the company which created it merged with Intuitive in 2003 – and Marescaux’s grand vision has not become a reality. While the technology exists to operate at a distance, a series of administrative and practical issues seem to have blocked progress.
“If the surgeon’s sitting in one country and the patient’s sitting in another, how does that work in terms of malpractice insurance?” asks Jaime Wong, VP and senior medical officer of Intuitive. “If something happens during the procedure and [things] need to be done differently, how does that happen if the surgeon is sitting hundreds of kilometres away? The safety of the patient is the most important thing to us.” He also points out, fairly, that most patients would prefer to meet their surgeon face to face before they start slicing away at their insides. And even if that weren’t an issue, there’s always the thorny question of internet connections dropping off at crucial points. What may catch on, Wong tells me, is remote telementoring – surgeons calling in expertise from international colleagues during surgery, who could log on to the robot-assisted system, assess the situation and make recommendations.
At the company’s UK base in Oxford, clinical affairs manager James Grainger shows me Da Vinci, which is now on its fourth generation. It is an impressive beast. There are 34 instruments that can be clipped to the end of its robotic arms, from the Maryland Bipolar Forceps to the Tip-Up Fenestrated Grasper, a Dickensian-sounding tool used for manipulating delicate tissue. There’s a laser-targeting system to make sure the boom from which the arms hang is positioned in the perfect spot above the patient. Pedals beneath the surgeon’s feet control the camera and can also be used to send high-frequency electrical currents into the surgical instruments, to destroy unhealthy tissue or seal bleeding vessels. Should the surgeon wish, the patient can be injected with special fluorescent dye: if ‘Firefly’ mode is deployed, the patient’s blood vessels will then show up green on the screen, making it much easier to avoid giving one an accidental nick with a scalpel.
Visiting surgeons can try out the system in the Da Vinci showroom by stitching chicken breasts. Visiting squeamish laymen, meanwhile, get to have a rummage around in a soft-play practice abdomen, a springy green surface dotted with multicoloured foam hillocks. Grainger encourages me to use the robotic arms to remove some black rubber hoops from the hillocks, a satisfyingly straightforward manoeuvre. He then suggests I use robotic tweezers to pick up what looks like a sizeable piece of metal: I do so and he brings it over to me. It is absolutely tiny. A combination of the ten-times magnification of the high definition cameras and the ‘motion scaling’ conversion of broad moves of the hand to delicate moves of the instruments enables surgeons to be much more precise in their actions.
While the system does not currently offer Britons the opportunity to have their gallbladders ejected at a 4,000-mile remove, it does have a range of other, less glamorous benefits.
“For me the things that are better about Da Vinci than manual keyhole surgery are the acuity of the visual system and the fact that you can get a 3D reconstruction of the anatomy instead of 2D,” says consultant colorectal surgeon Kathryn McCarthy, who also works for the UK’s National Institute for Health Research.
“There’s also the fact that as the robotic user, the picture is under your control. Given that us surgeons can be control freaks, it’s quite challenging in manual keyhole surgery to have someone assisting you not following your vision or who can’t predict where you might want to go next. For surgeons who’ve got a little bit of a tremor, robotic systems also eliminate it because you’re on a console and you’ve not got your hands on the body.”
Surgeons no longer have to spend the long hours of an operation standing in contorted positions over their patients, but can operate in comfort. “It improves the musculoskeletal system of the surgeon because it allows you to sit back in a more ergonomic position,” says McCarthy. It could make a big difference – a recent survey suggested that one in five surgeons in the UK say they may need to retire early due to the physical impact of conducting traditional keyhole surgery.
When it comes to training, as well as offering realistic computer simulations to practise procedures, Da Vinci also sells a dual control console, which works like a driving instructor’s car. Trainees can work away on a body and experienced surgeons can jump in and take back control of the instruments from them with the flick of a switch. In the future, says Wong, surgeons could have example videos of the “surgeon hero of their choice” screened in their display as they train, much like a golfer might watch footage of Tiger Woods to help them with their swing.
While the technology is exciting, Da Vinci is not without its critics. The main issue is cost – the system sets hospitals back well over £1 million, with sizeable additional bills for servicing and supplies, which is part of the reason it has been taken up much more widely in the private hospitals of the US than in the UK. While it has been shown to have substantial benefits over traditional keyhole surgery in terms of speed of operation and recovery time in some fields, notably urology – a significant percentage of prostatectomies carried out on the NHS are now performed with the aid of Da Vinci – when it comes to many specialisms the jury is still out.
In her own field of colorectal surgery, says McCarthy, “I haven’t yet seen robust evidence to show that the operating time and the quality of the surgery is substantially better than what we do already.” In its ‘Future of Surgery’ report in 2018, the Royal College of Surgeons highlighted many of the benefits of robot-assisted surgery but also cited “insufficient evidence of [its] effectiveness… studies of robot-assisted procedures over a number of years are often unhelpful, due to rapid advances in the design of the robots.”
The problem with surgery is that surgeons do like new toys”
McCarthy also sounds a note of caution about the lure of sparkly new technology. “The problem with surgery is that surgeons do like new toys,” she says. “It’s like getting a new phone. They can see the difficulties in the surgeries they’re doing so they’ll give it a go without necessarily being fully reassured of the evidence or the cost benefit.” In the US, hospitals have been criticised for marketing Da Vinci technology direct to consumers, which has led to patients demanding robotic-assisted treatment, regardless of whether it will lead to a better outcome for them on the table.
The great new hope for British robotic surgery started life as a prototype knocked up from PVC pipes and glued-together bits of board. After five years of development, pre-clinical research and painstaking studies on cadavers, the finished version will begin work in hospitals across the world in 2020. I meet its co-creator Mark Slack, now chief medical officer of CMR Surgical, at the company’s headquarters in a Cambridgeshire business park where the pipe-and-board arm is proudly on display.
“Versius doesn’t resemble any other robot on the market,” says Slack, an energetic character who bobs up and down to scribble enthusiastically on a flipchart as we speak. “It’s smaller, it’s completely different, a very sexy little thing.”
Despite Da Vinci’s 20-year headstart, its 52,000 trained surgeons and its six million completed operations, Slack is not daunted. His aim is for CMR to become “the biggest company in England” within the next decade. “Intuitive, the market leaders, occupy five to seven percent of the keyhole surgery market. They’ve got a market capitalisation of $69 billion. I only need ten percent of the market and this will be a $100 billion company,” he says.
Versius is being sold on its versatility and portability. Unlike Da Vinci, whose four arms are connected by an overhead boom which requires a decent ceiling height and strong floors, each cart-mounted Versius arm is separate, making it easier to swiftly convert any hospital room into a theatre and fit the robot into existing workflows. Although CMR refuses to reveal its prices, it also claims that the system will be cheaper than Da Vinci – “closer to manual keyhole surgery”, in part because, it believes, the ease of set-up will lead to higher use and greater cost effectiveness.
Some surgeons have this concept of being artists: rubbish!”
But the biggest weapon in its arsenal may be data. “I’ve built a registry,” says Slack. “Every single patient that gets operated on by Versius gets entered into it. It is completely unique.” Every twist and turn of every robotic instrument – along with every beat of the patient’s heart, every frame of footage and all their post-op measurements – will be stored digitally in Versius’s data stack. The colossal amounts of data generated by each operation can then be combed through algorithmically.
This, says Slack, will help surgical techniques to be refined and surgeons to excel by giving clear proof of what brings the best outcomes for patients. “Some surgeons have this concept of being artists: rubbish!” he says. “You want a surgeon who’s a data-obsessed obsessive-compulsive, who does everything the same way every time.” He is dismissive of surgeons who aren’t comfortable with being transparent. “As a profession, the time to be hidden has passed,” he says. “We need to be accountable. And if a surgeon doesn’t want to put their data [on our system], I’d rather not send them a robot.”
The data gleaned by Versius could be used to highlight variations in quality which might mean a surgeon needs extra training or time off work. It could flag up outliers – for example if someone has decided, as Birmingham surgeon Simon Bramhall did in 2013, to start initialling their patients’ livers with an argon beam. While Bramhall’s signatory flourishes did not harm the patients concerned, if rigorous data collection and analysis were applied more broadly across a range of clinical professions, says Slack, it could catch out the truly bad actors who occasionally pop up. “Would this sort of database have caught Harold Shipman? Yeah, in three months,” he claims.
Universal data collection could also bring the Hawthorne effect into play. This principle, first identified through efficiency studies at a telephone equipment factory in Illinois in the 1930s, states that when people know they are being monitored, their performance improves. Samer Nashef, the surgeon who created EuroSCORE, a revolutionary system for evaluating risk in heart operations, believes Versius could have this effect, improving results for patients. “Any collection of data and measurement of outcomes that is then made available for the people who are producing these outcomes automatically brings in the Hawthorne effect,” he tells me. “There is no doubt in my mind that if you measure and feed back performance people get better.”
While Da Vinci doesn’t have Versius’s grand unified database, Intuitive is alive to the opportunities of big data. One possibility mooted by Wong in a speech in February 2020 is the alleviation of stress for patients’ relatives. “Algorithms are being used in research to identify features in a surgical video and parse them into surgical steps,” he said. “What if we’re able to use this information in real time to show us when certain tasks occur?”
Such a development would allow robot systems to send messages to anxious family members in hospital waiting rooms – or anywhere around the world – telling them as each stage of their loved one’s procedure is successfully completed and giving them an estimate of when it will end. It could also mean a quantum leap in hospital efficiency: automated messages could be sent to pre-op teams saying when a surgery is an hour from being completed and asking them to prep the next patient. Big data could help administrators plot bed occupancy and schedule operations with laser-like accuracy, leading to major savings.
The robot-assisted operations of the future may look very different to today. In a speech in 2015 Catherine Mohr, VP of strategy at Intuitive, sketched out a world in which a series of technological innovations have converged. New regular tests using biomarkers in our breath enable us to detect the presence of cancer when it’s still at stage one, small and contained. Agents injected into the body bind preferentially onto cancer cells “so instead of looking in an abdomen and trying to think where in this pinky mess is the cancer… you light it up [like a] starry night and if it’s bright you take it out.” Improvements in optics and ‘nano-surgery’ allow surgeons to “drill a hole in a single cell with a laser… so now you start to think about being able to unwind these small cancers from a neurovascular bundle, not hacking something out with a large margin but just taking out the parts that you really need to take out and leaving everything else behind.”
After revolutionising cancer treatment, Mohr envisages that robotic surgery will go into “the spare parts business”. As regenerative medicine begins to allow for the creation of new blood vessels, nerves and organs, robots will be used to put them in place with extreme precision. “It is the augmentation of the surgeon,” concluded Mohr. “We are going to be able to give the surgeon surgical superpowers.”
When it was my dad with bowel cancer, I asked for the older cancer surgeon who wasn’t going to use any technology”
It’s not just Da Vinci and Versius that aim to supply these superpowers. There’s also Verb Surgical, a megabucks collaboration between Google and Johnson & Johnson, featuring robots connected online so they can learn from one another. Auris Health’s Monarch platform has been specifically developed to tackle lung cancer. Meanwhile Italian-made robot Senhance aims to solve one of the big problems of keyhole surgery – that surgeons don’t get to physically touch the tissue they’re operating on. To do this their robot includes ‘haptic feedback technology’ which sends tactile information to the surgeon through the console handles. It can also track the surgeon’s eyeballs, moving the camera to focus on the spot they are looking at.
The Royal College of Surgeons predicts that before long new products will be brought to market which fully automate some surgical procedures including simple stitching and closing wounds. “Mediated control” systems may also be introduced, which could warn the surgeon about potentially dangerous movements they are making in real time.
But for all the grand hopes, excitement and potentially monster profits of the robotic arms making their way to an operating table near you, the indispensable part of the equation remains the highly trained human. McCarthy cites American software engineer Grady Booch. “A fool with a tool is still a fool,” she says. “When it was my dad with bowel cancer, I asked for the older cancer surgeon who wasn’t going to use any technology. Competence, confidence and outcomes are all about the highly skilled individual surgeon sitting in front of you. As long as you’re a good surgeon, it doesn’t matter what you use – you could use a knife and fork if you wanted.”
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