Cutting edge: Why robotic surgery is the future

Dr Barry McGuire consultant urological and robotic surgeon at St Vincent’s Hospital, Dublin, operates with a Da Vinci surgical system. Picture: Patrick Bolger

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.

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: 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: Alan Place

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.

Mr Vincent Young, cardiothoracic surgeon, who performed Ireland’s first, minimally invasive, robotic coronary artery bypass Graft (CABG) surgery in Blackrock Clinic. Picture : Marc O’Sullivan
Mr Vincent Young, cardiothoracic surgeon, who performed Ireland’s first, minimally invasive, robotic coronary artery bypass Graft (CABG) surgery in Blackrock Clinic. Picture : Marc O’Sullivan

“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-of-the-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 Xi 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 doctors 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 surgeons. 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 surgery 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 instrument. 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, explains 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 14-year 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.

‘Robotic surgery was minimally invasive’

Geraldine Waters at home in Sixmilebridge, Co Clare. Picture: Brian Arthur
Geraldine Waters at home in Sixmilebridge, Co Clare. Picture: Brian Arthur

FOR Geraldine Waters, robotic surgery meant less pain and a much faster recovery.

Waters, a mother-of-two daughters aged 16 and 27 from Sixmilebridge in Co Clare, was diagnosed with bowel cancer in November 2016.

“It was a huge shock,” she recalls, adding that she had gone for tests after experiencing fatigue and blood in her stool,” she says.

The colonoscopy discovered a tumour in her bowel.

“I had chemotherapy and radiotherapy,” she recalls, adding that in April 2017 she underwent robotic surgery.

“I knew robotic surgery was minimally invasive and has left severe effects on your than traditional surgery.

She had a colonoscopy bag fitted, which was removed three weeks ago.

“After the operation, I was up and about the following morning. I was walking around.”

She was out of hospital after a week, and returned home to take it easy for a few days.

“In all, I was only off my feet for two weeks.

“If it had been traditional surgery it would have taken much longer for me to heal.

“I wasn’t pain-free after the robotic surgery, but I was up and about the next day. Traditional surgery would have had much more impact on my system,” she says, adding that her scars are barely visible.

“I know a traditional operation would have left a big scar.”

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