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At the end of February, Charles Evans was concerned. As the head of gastrointestinal surgery at University Hospital Coventry & Warwickshire NHS Trust (UHCW), the coming wave of Covid-19 was threatening to overwhelm his hospital’s ability to offer urgent surgery to gravely ill cancer patients.
“I had this horrible day where I met about seven patients, newly diagnosed with bowel cancer,” he remembers. “I had to say to them, ‘I’m really sorry, we need to operate on you, but at this moment I can’t promise you a date. I don’t know what’s going to happen.’”
But as the pandemic progressed, Evans and his team found a solution. While open surgery – where the surgeon uses a scalpel to gain access to the internal structures and organs – meant patients would need to recuperate in hospital for several days, putting them at greater risk of contracting Covid-19, using robot assistance to conduct such operations could avoid many of the complications.
Theoretically, this means that the surgeon and the patient don’t need to be anywhere near each other. In 2001, Jacques Marescaux removed the gall bladder of a patient in Strasbourg, France, all the way from New York. Most of the time, however, robotic systems in operating theatres consist of a series of mechanical arms controlled by a surgeon sitting at a console on the other side of the room. This console translates the surgeon’s hand movements in real-time to the instruments attached to the robotic arms, while allowing him to view the operation via a high-definition, 3D video.
The main advantage of robotic surgery over open surgery is it allows surgeons to conduct operations through just the tiniest of incisions in the skin. This drastically reduces the risk of infection, and means patients can return home faster, while it is more precise than manual laparoscopic or keyhole surgery. While UHCW already had one surgical robot on site, it contacted Oxford-based manufacturer Intuitive Surgical to install a second device, making it possible to continue doing urgent cancer operations during the pandemic.
“It seemed like the best way of getting good cancer surgery done safely,” says Evans. “Usually for a prostate cancer operation, they’d be in hospital for four days, but if done robotically, it’s only for a day.”
Such benefits have attracted wider attention over the past six months. The US National Institute of Health has commissioned a collective of surgeons across the UK, including Mark Slack – a former gynaecological surgeon and founder of Cambridge based CMR Surgical – to conduct a study looking at the advantages offered by robotic systems. “There’s a lot of interest because of Covid,” says Slack. “A robot means that the surgeon can be more than two metres away from the patient for the majority of the operation, and you reduce the number of staff around the table.”
But coronavirus has not been a universal boon for the field. With finances stretched, not all hospitals are willing to invest in often bulky and costly robots – the market-leading da Vinci robotic system manufactured by Intuitive Surgical has a price tag in the region of one to two million pounds and two decades after the technology first became available, uptake is still mostly limited to high tier, specialised institutions.
“Right now only two per cent of procedures that could be done robotically, are done robotically,” says Megan Rosengarten, vice president and general manager of Surgical Robotics for global medical device firm Medtronic.
This could change. Robotic surgery has long been regarded as a field of largely untapped potential – some analysts have predicted it could have a market value of $275 billion (£208b) by 2025 if ways can be found to make it more accessible. In recent years, an increasing number of new innovators have entered the market. From CMR Surgical, to Medtronic, Google-founded Verb Surgical, and Californian start-up Auris Health, a fresh wave of robots have begun to emerge, ones that claim to be both sleeker and cheaper.
Earlier this year, NHS surgeons in Edinburgh and Milton Keynes began using CMR’s Versius robot for minimal access surgery for the first time, while Medtronic are intending to launch its own product by the end of the current fiscal year. After gathering the views of hundreds of surgeons and hospital administrators, the main focus has been to make surgical robots that are smaller, and more flexible. “We’ve put together a modular system, so it’s very easy to move, and you can have as many or as little robotic arms as you want in an operation,” says Rosengarten.
These companies are also hoping to boost uptake by finding ways to accelerate the training of new surgeons, saving the healthcare system time and money in the process. Slack says it takes half an hour to teach surgeons how to suture using the Versius robot, compared to 80 hours with manual laparoscopic tools, while the Versius robot comes with inbuilt telemetry, automatically uploading the data of every single movement of the robot during an operation into the cloud. In the coming years, this information could potentially be used to measure when a trainee has reached the level of the average working surgeon. “It could make some of the interpretations of that automatic,” says Slack. “It can also pick up areas for improvement, like if someone has really inefficient hand movements.”
The use of telemetry data could address some of the safety concerns which have dogged robotic surgery in recent years. Inquests, such as that into the death of Stephen Pettitt during a robot-assisted heart valve surgery, have raised question marks as to whether enough surgeons are adequately trained before operating the machines. Slack believes collecting data from surgeons using the Versius robot around the globe can be used to both prevent similar tragedies.
“We want to standardise surgery,” he says. “We can use data to work out the most common procedural steps for different operations, find which get the best results, and then put a menu into our robot, so surgeons have to follow a series of steps. There’s also a patient checklist which surgeons are supposed to go through at the start of operations, which has been shown to reduce complications by 47 per cent. But they don’t always do it, so we’re going to put that in our start-up menu. When you fire up the robot, you have to go through the checklist, before you can proceed.”
Over the coming decade, the ultimate aim for surgical robotics is to introduce a degree of intelligence into these systems to prove real time feedback and enhance decision making mid-operation. During complex procedures such as removing tumours from an organ, image processing and sensors embedded in the robotic tools could be used to guide the surgeon, and detect things that the human eye cannot pick up on its own.
Medtronic and Intuitive are working on developing augmented reality overlaps capable of pointing out structures that the surgeon would want to avoid, or allowing them to pick up changes in temperature or pressure within different tissues or blood vessels.
“We’ll be able to give physicians more information through haptic feedback and other sensing tools to let them touch tissue in new ways, giving them more information to help them make the best choices,” says Brian Miller, Intuitive’s senior vice president of systems, imaging and digital.
This all still very much a work in progress. It is likely to take thousands of hours of surgical videos to train any algorithm to be able to consistently recognise anatomical features from one patient to the next. But there are hopes that one day such technology could even be used to create ‘no-cut zones,’ preventing surgeons from mistakenly slicing into critical nerve bundles.
In the eyes of Slack, the combination of technological advancements and falling costs could see surgical robots becoming more common in general hospitals, and expanding from specialised operations into more routine procedures which are currently carried out as open surgeries. He believes that the use of robots in hospitals such as UHCW during the coronavirus pandemic will help.
“Covid will help in some ways, because with robotics, there are fewer people as close to the patient,” says Slack. “I reckon over the next five years you’ll see an acceleration of robotic surgery to the point where it starts to take over from manual laparoscopic procedures.”
For surgeons who have directly witnessed the benefits of robotic surgery during the pandemic, it is an investment they feel is worth making. “Using robotics has enabled us to do more complex cancer cases immediately which we possibly would have had to delay,” says Evans. “While it costs upfront, there’s increasing evidence that the long term savings from shorter lengths of stay and reduced complications actually help neutralise that. Bed costs are only going up in hospitals, so people are beginning to understand that every saving you make on that is going to help.”
Mark Slack will be one of the speakers at WIRED Health:Tech on September 22 – an event exploring the health trends accelerated by Covid-19. Speakers include Heidi Larson, director and founder of The Vaccine Confidence Project, and CRISPR co-inventor Jennifer Doudna. Tickets start at only £40 + VAT. Book your tickets here.
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