RoboDoc cen­tre stage in the­atre

Ro­bots are play­ing a greater role in Ir­ish hos­pi­tals, de­liv­er­ing pre­ci­sion op­er­a­tions, with min­i­mal blood loss and shorter re­cov­ery times for pa­tients, says Áilín Quin­lan

Irish Examiner - Feelgood - - Cover Story -

THE sur­geon who per­formed what is be­lieved to have been Ire­land’s first min­i­mally-in­va­sive heart by­pass op­er­a­tion us­ing ro­bot­ics, says that within 10 to 15 years ro­bots may be ca­pa­ble of in­de­pen­dently car­ry­ing out cer­tain el­e­ments of an op­er­a­tion — but only un­der su­per­vi­sion.

Cur­rently, many mem­bers of the pub­lic as­sume ro­bots can ‘op­er­ate’ with some in­de­pen­dence, some­what like driver­less cars — but not so, says car­dio­tho­racic sur­geon Vin­cent Young, of Black­rock Clinic, Dublin, who last sum­mer car­ried out what is be­lieved to have been this coun­try’s first robotic coro­nary artery by­pass graft us­ing a da Vinci XI ro­bot and sur­gi­cal sys­tem.

“It’s not like that,” says Young. “Noth­ing hap­pens with­out the sur­geon’s in­put — at the mo­ment it’s just a tool that al­lows us to work through small in­ci­sions.

“The ro­bot is a very clever ma­chine that can trans­late ac­tions out­side the pa­tient to in­side the pa­tient,” he says, adding that a sur­gi­cal ro­bot can work on a pa­tient through an in­ci­sion as small as 8mm.

At the mo­ment the ro­bot does not do any­thing with­out your com­mand. How­ever, with the use of ar­ti­fi­cial in­tel­li­gence, says Young, it is likely that in 10 or 15 years time, cer­tain parts of an op­er­a­tion may be per­formed by a ro­bot, al­beit un­der close su­per­vi­sion.

“Ro­bots are good at stan­dard­ised work — they will not be op­er­at­ing on peo­ple on their own. At the mo­ment they are en­tirely a me­chan­i­cal de­vice,” says Dr Young, adding that down the road, how­ever, they may be­come ca­pa­ble of car­ry­ing out “parts of an op­er­a­tion that are ‘re­pro­duce-able,’ for ex­am­ple join­ing to­gether two parts of a blood ves­sel or parts of the bowel.”

Robotic surgery is car­ried out in hos­pi­tals all over Ire­land. Many pa­tients are happy to have it (see case study op­po­site) be­cause of a grow­ing aware­ness that the pain and re­cov­ery pe­riod will be min­i­mal.

It’s eye-wa­ter­ingly ex­pen­sive, but the re­sults are of­ten very promis­ing — re­search from the Univer­sity of Lim­er­ick Hos­pi­tals Group which be­gan to use state-ofthe-art robotic sur­gi­cal equip­ment two years ago demon­strates that post-op­er­a­tive re­cov­ery is twice as fast with robotic surgery than with stan­dard key­hole surgery, with an av­er­age post­op­er­a­tive hos­pi­tal stay of ap­prox­i­mately four days. This re­search also showed there was also min­i­mal blood loss and a re­duc­tion in post-op­er­a­tive pain with robotic surgery.

“It’s the gold stan­dard of min­i­mally in­va­sive surgery at present,” says Colin Peirce, of the award-win­ning dual con­sole Da Vinci ro­bot­ics pro­gramme at the UL Hos­pi­tals Group. The hos­pi­tal be­came the first pub­lic hos­pi­tal in the coun­try to have the so­phis­ti­cated Da Vinci Xi dual con­sole.

Val­ued at ap­prox­i­mately €2. 6mil­lion, the Da Vinci Xi ro­bot and equip­ment was do­nated by the Mid­west­ern Hos­pi­tals De­vel­op­ment Trust and funded by the JP McManus Benev­o­lent Fund. The Univer­sity of Lim­er­ick, which is the aca­demic part­ner to the UL Hos­pi­tals Group, do­nated €135,000 to the pro­ject for au­dio vis­ual and train­ing equip­ment.

The da Vinci, man­u­fac­tured by In­tu­itive Sur­gi­cal based in Sun­ny­vale, Cal­i­for­nia, is the only ro­bot on the mar­ket, how­ever, other plat­forms are due to be brought out soon, specif­i­cally by Medtronic and Google, this will in­crease the com­pe­ti­tion and likely drive costs down go­ing for­ward.

Peirce, a colorec­tal and gen­eral sur­geon at Univer­sity Hos­pi­tal Lim­er­ick, says that since the ro­bot­ics pro­gramme was in­tro­duced at Univer­sity Hos­pi­tal Lim­er­ick in Novem­ber 2016 doc- tors us­ing the equip­ment have gen­er­ally found that pa­tients re­cover more quickly from robotic surgery than with ei­ther tra­di­tional open surgery, or key­hole pro­ce­dures.

“We get them home and out of hos­pi­tal more quickly so we’re sav­ing on bed days. It al­lows us to per­form the most pre­cise surgery avail­able world­wide for colorec­tal surgery,” says Peirce.

“It pro­vides a 3D view which is un­sur­passed. The sur­geon has com­plete con­trol of both the cam­era and the in­stru­ments,” says Peirce, who also acts as ad­junct se­nior lec­turer in surgery at the grad­u­ate en­try med­i­cal school at Univer­sity of Lim­er­ick.

He uses the ro­bot for colorec­tal surgery with a spe­cific in­ter­est in rec­tal can­cer, af­ter train­ing in the use of robotic tech­niques in the Cleve­land Clinic in Cleve­land, Ohio.

“The robotic ap­proach is now re­garded as the gold stan­dard ap­proach for op­er­a­tions such as a prosta­te­c­tomy for prostate can­cer and hys­terec­tomy for uter­ine can­cer by many surXi There is data sup­port­ing that pa­tients un­der­go­ing robotic surgery for rec­tal can­cer have bet­ter on­co­log­i­cal (can­cer) out­comes than pa­tients un­der­go­ing tra­di­tional la­paro­scopic (key­hole) surgery for rec­tal can­cer,” he ex­plains.

“Po­ten­tial im­proved on­co­log­i­cal out­comes will add fur­ther to the al­ready known ben­e­fits of re­duced blood loss, re­duced post­op­er­a­tive pain and re­duced length of hos­pi­tal stay which frees up hos­pi­tal beds more quickly, which is es­sen­tial in the un­der-pres­sure Ir­ish health ser­vice.”

The UL ro­bot how­ever, was the fo­cus of some con­tro­versy re­cently af­ter it emerged that na­tional pol­icy does not al­low this cut­ting-edge tech­nol­ogy to be used for the rad­i­cal prosta­te­c­tomy, which is one of the most com­mon op­er­a­tions in urol­ogy.

Dr Barry McGuire, con­sul­tant uro­log­i­cal and robotic sur­geon at St Vin­cent’s Hos­pi­tal Dublin (see cover pic­ture) is equally en­thu­si­as­tic about robotic surgery — as a urol­o­gist, he spent two years train­ing in robotic in the US and now uses the ro­bot for kid­ney can­cer surgery and prostate can­cer surgery.

“The tech­nol­ogy is rel­a­tively new. It’s re­ally only 10-15 years old and has be­come more wide­spread in the last five years.

“It has re­placed the tra­di­tional key­hole surgery in some ar­eas. The lim­its to key­hole surgery is that it is two-di­men­sional and you are watch­ing a screen while us­ing the in­stru­ment and it takes a long time to learn how to do that.”

Ro­bot­ics surgery is much more man­age­able. “You can con­trol it by hand — it moves as your fingers and thumb moves, in a way it is like a vir­tual re­al­ity head­set,” he says.

“The im­age you get is three-di­men­sional, so you can ap­pre­ci­ate depth as op­posed to tra­di­tional key­hole surgery.”

A big ad­van­tage, ex­plains McGuire, is the sur­geon’s abil­ity to “have depth of per­cep­tion and mi­cro­scopic move­ment”.

“It al­most feels as if you are ma­nip­u­lat­ing your own hands rather than an in­stru­geons. ment. I find it very good for work­ing in small places within the body.

“Robotic surgery has al­lowed us to match what you would have been able to do with your hands with small in­stru­ments, so that a pa­tient gets a high-qual­ity op­er­a­tion but re­cov­ers much more quickly.”

Ro­bots are now used in ev­ery spe­cial­ity through­out the world, ex­plains Peirce, who adds that ev­ery sur­geon us­ing a ro­bot­ics pro­gramme is, cru­cially, backed up by a team of highly trained col­leagues.

“Robotic surgery be­gan with car­dio-thoracic surgery and is now used to per­form all the surgery we al­ready per­form.”

For him, its best use lies in pelvic surgery, gy­nae­col­ogy and the colorec­tal field, where, he ex­plains, it has had proven ben­e­fits.

“We can po­ten­tially use the ro­bot for any­thing but we’re very fo­cused on us­ing it in fields where the ben­e­fits to the pa­tient has been shown com­pared to key­hole or tra­di­tional surgery.”

Here’s how they work — in tra­di­tional surgery, ex­surgery

plains Peirce, a sur­geon op­er­at­ing on a pa­tient he or she is es­sen­tially “mak­ing a big cut” and han­dling the or­gans within the body.

“In key­hole surgery, we use spe­cial ports that go through the wall of the ab­domen, and we use a cam­era and in­stru­ments through the ports.”

The sur­geon’s hands are not on the pa­tient, but on the in­stru­ments, he ex­plains.

“In robotic surgery, we take all of this a step fur­ther — we dock the ro­bot up to the ports, and the robotic in­stru­ments are con­trolled by a sur­geon sit­ting at a nearby con­sole.”

Ro­bot­ics surgery has def­i­nite ad­van­tages over its pre­de­ces­sor, he says — there is less blood loss than in other surg­eries, pa­tients re­cover more quickly, and the length of hos­pi­tal stay is sig­nif­i­cantly re­duced.

“The up­side is that the pa­tient re­cov­ers more quickly and is out of hos­pi­tal more quickly, and as a re­sult, there is less risk of in­fec­tion and com­pli­ca­tions,” says McGuire.

The length of hos­pi­tal stay for pa­tients who have un­der­gone kid­ney and prostate surgery by ro­bot has ac­tu­ally been halved at St Vin­cent’s, a huge sav­ing for the health ser­vices,

“Most pa­tients af­ter a kid­ney surgery will now get back to work af­ter about three weeks, where pre­vi­ously it would have been six weeks or so.”

How­ever, there are some down­sides,” says McGuire. “There is no sen­sa­tion of touch,” he says, adding that train­ing can take a long time and the cost of a hos­pi­tal ro­bot­ics pro­gramme is high.

“The ro­bot it­self costs around €2m and run­ning costs and main­te­nance are also very ex­pen­sive,” he says, adding that it costs about €150,000 an­nu­ally to have a qual­i­fied tech­ni­cian on call 24/7.

On top of that, the in­stru­ments used with the ro­bot are very ex­pen­sive, as they can only be used a cer­tain num­ber of times.

Also train­ing takes a long time as sur­geons need to be very highly skilled.

“I spent two years train­ing in the USA. It’s ex­tremely im­por­tant to have peo­ple who are well trained to do op­er­a­tions in high num­bers.”

The skill and train­ing of the sur­geon are crit­i­cal to the suc­cess of robotic surgery — a re­cent in­quest in the UK was told that a mu­sic teacher who died af­ter robotic heart surgery would have had a 98%-99% chance of sur­vival had the pro­ce­dure been done con­ven­tion­ally.

Robotic surgery is be­ing car­ried out in Cork Univer­sity Ma­ter­nity Hos­pi­tal, Lim­er­ick Univer­sity Hos­pi­tal, Gal­way Univer­sity Hos­pi­tal and St Vin­cent’s and it is also avail­able in many of the pri­vate hos­pi­tals, says Dr McGuire.

We’re well into a whole new wave of modern medicine now, though the US has led the way since hands-off surgery was first de­vel­oped by the US mil­i­tary at the end of the last cen­tury.

Like ev­ery­thing else, how­ever, ro­bots have a fi­nite life-span, CUMH, which pi­o­neered robotic surgery in Ire­land in 2008 — the hos­pi­tal’s orig­i­nal Da Vinci ro­bot, which was fa­mously launched on RTÉ’s The Late

Late Show, has re­cently re­placed its ro­bot.

“Cork Univer­sity Ma­ter­nity Hos­pi­tal opened with an am­bi­tion to lead the de­vel­op­ment of clin­i­cal prac­tice in ma­ter­nity ser­vices; the use of robotic sur­gi­cal sys­tems is one ex­am­ple of this. We are thrilled that the HSE has funded a re­place­ment ro­bot — it’s a true vote of con­fi­dence in Cork Univer­sity Ma­ter­nity Hos­pi­tal,” says the hos­pi­tal’s clin­i­cal direc­tor of ma­ter­nity ser­vices Prof John Hig­gins.

ROBOTIC surgery has been in­creas­ingly used since the 1990s when the Pen­tagon wanted to ex­plore ways in which op­er­a­tions in field hos­pi­tals might be per­formed by ro­bots con­trolled by sur­geons at a safe dis­tance from the bat­tle­field. Are we get­ting to a point where ro­bots will com­pletely take over in Ir­ish op­er­at­ing the­atres?

Doubt­ful, says Peirce, who like Young, does not fore­see ro­bots be­ing able to carry out surgery in­de­pen­dently. “I don’t see the role of sur­geons be­com­ing re­dun­dant any time soon,” he com­ments. “Po­ten­tially ro­bots could be pro­grammed to per­form an op­er­a­tion, but ev­ery op­er­a­tion, and ev­ery pa­tient is unique, so I be­lieve it will al­ways need hu­man in­put. I don’t see a ro­bot per­form­ing colorec­tal surgery on its own any time soon.”

But does it ever go wrong? A re­cent study into the safety of sur­gi­cal ro­bots has linked the ma­chines use to at least 144 deaths and more than 1,000 in­juries over a 14year pe­riod in the US. The study showed that when prob­lems do oc­cur, peo­ple were sev­eral times more likely to die if the surgery in­volves their heart, lungs, head and/or neck rather than gy­nae­co­log­i­cal and uro­log­i­cal pro­ce­dures.

The au­thors of the re­port sug­gested it was be­cause the for­mer were more com­plex op­er­a­tions for which ro­bots are less com­monly used, so that less ex­pe­ri­ence and ex­per­tise was avail­able.

They in­di­cated one way to tackle such prob­lems would be to give sur­gi­cal teams more trou­bleshoot­ing train­ing — to help them learn how to restart surgery more quickly af­ter in­ter­rup­tions.

While train­ing con­tin­ues to be cen­tral in the suc­cess­ful use of ro­bots in the op­er­at­ing the­atre, it’s clear these finely-tuned ma­chines are here to stay.

Pic­ture: Alan Place

Mr Colin Peirce with the Da Vinci Xi Dual Con­sole Ro­bot. Univer­sity Hos­pi­tal Lim­er­ick; how­ever he does not fore­see ro­bots be­ing able to carry out surgery in­de­pen­dently.

Pic­ture : Marc O’Sul­li­van Pic­ture: Patrick Bol­ger

Above: Mr Vin­cent Young, car­dio­tho­racic sur­geon, who per­formed Ire­land’s first, min­i­mally in­va­sive, robotic coro­nary artery by­pass Graft (CABG) surgery in Black­rock Clinic. Dr Barry McGuire uses a ro­bot for kid­ney can­cer surgery and prostate can­cer surgery.

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