Can you really trust a ROBOT SURGEON?

With worrying malfunctions and scant evidence that they’re better for patients

EVERY year, millions of us check into hospital for surgery. The doctors who slice us up, mend our broken bodies, then stitch us back together have years of medical training under their belts, not to mention steady hands.

But could an army of robot surgeons do the job even better?

Since the first surgical robot arrived at St Mary’s Hospital, London, in 2000, the number of them in UK hospitals has multiplied rapidly. Most common is the da Vinci robot, a set of three or four robotic arms controlled by a human surgeon sitting a few feet away.

There are currently 58 of these surgical systems in the NHS, undertaking operations for a variety of common complaints, from the removal of kidney and bladder cancers to basic heart surgery — though their main use is in surgical removal of the prostate gland and surrounding tissue i n men with prostate cancer.

In 2012 (the latest year for which figures are available), 1,595 of these operations were carried out using robots — 29 per cent of the total performed.

In future there could be many more robot operations. Last month, Bristol Royal Hospital for Children used a Neuro-Mate robot to drill into the brain of a teenager with epilepsy and implant electrodes to detect the area triggering his seizures. Once located, this scrap of tissue was removed.

Surgeons used a robot to create a 3-D map of the boy’s brain and position the drill bit so it could safely penetrate his skull. This was instead of a human surgeon cutting away a section of the skull and finding the tissue by hand, which carries a greater risk of infection and longer recovery times.

Robotic systems are also being developed that could hand over responsibility for mending broken bones; guide surgeons through the complex twists and turns of our bodies; and slam the brakes on a surgeon if they are about to make a serious error. So should we trust them? Twenty-five years ago, operations generally involved cutting a hole large enough for surgeons to get their hands inside. Then came keyhole surgery, which involves making just two tiny incisions through which the medical instruments are inserted, along with a small camera and a light to guide the surgeon. This usually means less pain for the patient, a shorter recovery time and less risk of infection.

But one problem with keyhole surgery is that the surgeon has a limited range of movement. This is where robots come in.

‘What the da Vinci system has recreated is something like a tiny human wrist at the end of the instruments, so you can theoretically do lots of things you could do with your hands, only through a smaller hole,’ says Justin Vale, a consultant urological surgeon at St Mary’s Hospital in London, who uses robot surgery.

He stresses that the current generation are not ‘true’ surgical robots because they don’t work on their own, but are guided by the THE movement of the surgeon’s hands.

s urgeon sits at a computer console near the operating table, and their movements are translated into highly accurate, tiny movements of the robot’s instruments.

In theory, this should mean greater precision and less accidental tissue damage. But in this respect, the robots have somewhat disappointed.

Take surgery for prostate cancer, which always carries a risk of incontinence and erectile dysfunction because of the close proximity of the nerves controlling the bladder and penis.

‘The hope was that by allowing better visualisation of what you’re operating on, you’d have less urinary incontinence and fewer patients with erectile problems,’ says Mr Vale.

A 2013 review by the National Institute for Health Research comparing standard keyhole surgery with robot-assisted surgery for men with prostate cancer found a slightly lower risk of organ injury and a slightly higher probability that all the cancerous tissue was removed when robots were used.

But there was no difference in the proportion of men suffering urinary incontinence — although lack of data made it difficult to draw firm conclusions.

What’s more, each robot-assisted procedure was estimated to cost an average £1,412 more than a standard keyhole procedure. It only becomes cost-effective when more than 150 such robotic operations are performed each year.

This greater expense is because a da Vinci robot costs about £1.6 million, and each detachable instrument — for example, scalpel, scissors or forceps — can be used only ten times before an implanted chip renders it unusable.

Mr Vale says each instrument costs between £2,000 and £3,000. ‘Scissors tend to blunt after eight to ten uses, so it makes sense to replace them. For some of the other instruments, you’re left pondering why you can’t use them until they break — but that’s the way the system is engineered.’

It should be said that in NHS hospitals, in most (possibly all) cases, robots have been bought using charitable donations and endowments, not public money.

Meanwhile, safety concerns have been raised in the U.S., where several lawsuits have been filed against Intuitive Surgical, which makes the da Vinci robot. In some cases, such as that of a Chicago man who died from an infection after his intestines were punctured during a spleen operation, the injuries were the result of poor training — that is, the doctors hadn’t been trained how to use the robot properly. In others, a robot malfunctioned during surgery and staff didn’t know how to fix it.

According to data presented to the Society of Thoracic Surgeons, 144 deaths, 1,391 patient injuries and 8,061 device malfunctions related to robotic surgery were reported to the U.S. Food and Drugs Administration between January 2000 and December 2013. As yet, there are no UK figures available.

‘For uncomplicated procedures such as prostate or hysterectomy, where there’s not too much blood supply, robotic surgery works very well,’ says Professor Jai Raman, a cardiac surgeon at Rush University Medical Centre, Chicago, who car- ried out the U.S. research. ‘Where it gets difficult is when you are dealing with the heart or lungs or in a confined space where there’s a large bl ood supply a nd a l ot of small vessels.’

This is because the likelihood of accidentally cutting through a vessel is much higher. But the main problem, he says, is lack of training in how to deal with any problems that come up during surgery, such as the equipment malfunctioning, resulting in burns or uncontrolled movements.

According to Professor Raman, this sort of scenario isn’t covered by standard training and doctors aren’t given enough experience on the system before being allowed to operate on patients.

Intuitive Surgical points out that its robots weren’t the only ones mentioned in Raman’s report. Neither did the report compare the rate of adverse events with those of conventional keyhole surgery. ‘Robotic-assisted surgery is safe and effective when used appropriately and with proper training,’ a spokesman said.

Surgeons learn to use the system in a training simulator, and are then initially supervised by an experienced robotic-assisted surgeon. ‘Ultimately, the surgeon’s hospital grants surgical privileges, not the device manufacturer,’ the spokesman adds.

Intuitive also offers a free service that remotely monitors operations, and may be able to diagnose and fix any problems with the system before they harm patients.

One benefit of using a robot is that it can make performing surgery less arduous. ‘If using a robot makes it easier and more comfortable for the surgeon, which it does, then in the long run — particularly as the technology becomes cheaper, smaller and more accessible — people will elect to use it,’ says Mr Vale.

So robots are probably here to stay, and the next generation could extend their surgical reach: systems are being developed that would monitor what a surgeon was cutting into and limit their movement if they got close to a major nerve or blood vessel.

Other innovations include developing robotic arms that can go around corners — currently they KASPAR can only move in a straight line.

Althoefer, professor of robotics and intelligent systems at King’s College London, is working on such a device. He explains: ‘ We have taken inspiration from the octopus, which has very flexible arms that can be squeezed into tight spaces.’

And fully automated surgical robots are coming. At Bristol Robotics Lab, Sanja Dogramadzi and her colleagues have developed a robot to heal fractured bones without the need for open surgery (usually required to see all the broken bits and fit them back together), meaning a quicker recovery for patients.

A surgeon would plan the operation on a computer using CT scans of the bones, but the robot would carry out the procedure by itself. The robot is expected to be tested on human cadavers for the first time this year.

It’s more difficult to automate operations involving soft tissue because it is more complex than bone.

So will we ever do away with human surgeons?

‘Theoretically, yes,’ says Mr Vale. ‘The question is, whether we will even be operating at that point?’

For instance, he suggests, we might be able to localise radiotherapy to the extent that it could be given in far bigger doses and there would be no need for surgical incisions, effectively vaporising diseased tissue instead.

Dr Dogramadzi disagrees, though: ‘Even if the robot can do all the preplanning and carry out the operation, I think we would always like a human surgeon in the room, just in case.’