Robotic surgeons

Robot-assisted surgery has come a long way from being a futuristic fantasy; at Bradford Royal Infirmary, it's a frequent occurrence and a successful form of treatment. Sophie Peacock speaks to Dr Sanjai Addla about the crucial impact robotics have had on keyhole surgery, and how financial and technological obstacles are still being overcome.

Initially encountering the Da Vinci robot during his surgical training at the Christie hospital in Manchester, Dr Sanjai Addla quickly discovered his forte. "The moment I performed robotic surgery for the first time on a cadaver in Paris, the moment I sat on the console and started operating, I knew that was what I would be good at," he says. "That was what I'd been trying to work out for the past 17 years, the appropriate use of my skill set."

The ability to perform keyhole surgery with ease of movement, whilst remaining minimally invasive, is no longer an unattainable ideal. The surgical benefits of the robot are manifold: whereas in traditional laparoscopy the surgeon's instruments can only move towards and away from the patient, the robot allows for more effective use of the same entry incisions. This is because the robotic instruments are manipulated by the surgeon's hands via a console, so that every movement he makes is replicated without tremor and with considerably more flexibility; any surgeon who tries to turn his wrist 360° will be unsuccessful. The console's screen also provides a closer and clearer view of the surgery than laparoscopy does.

There's no question that the robot has been revolutionary for what surgeons can offer to their patients. "Before we acquired the robot I would tell patients, 'This is the situation, and depending on how things are inside, this is what we will try to do'," Addla says. "Whereas now I can say, 'This is what you have and this is what I will do.' And in almost nine out of ten cases, I can do it, because I'm operating with the robot that can surpass those limitations."

Having trained as an open surgeon, a laparoscopic surgeon and now a robotic surgeon, Addla is aware of the pros and cons of each method of surgery.

Decreased patient recovery time is an important case made for the financial efficacy of robotic surgery, as patients are able to go home and back to work, and return to full functionality much faster. "The earliest a patient has gone back to work is three weeks after a radical prostatectomy, which is a major operation." After having this procedure with the Da Vinci robot, patients become fully continent again at six weeks, compared with four months without the robot.

Reduced hospital time
"Patients used to be in hospital for eight to ten days, they would need a transfusion of two or three units, they would be incontinent for six months, and they would have no sexual functions. This wasn't so long ago," Addla explains. "Now patients go home the next day, they have the catheter taken out at seven days and they go back to work at around three to four weeks."

In the robot's early days at Bradford Royal Infirmary, Addla's patients were interviewed by news channels, and showed complete faith from the outset. "They were saying, 'I didn't mind being the guinea pig, because what could go wrong?' I thought, thanks for trusting me," Addla says. All the patients expressed feeling absolutely reassured prior to surgery, and that their post-op recovery was better than expected.

Developed by American company Intuitive Surgical, the Da Vinci Surgical System was approved by FDA in 2000. Named after Leonardo Da Vinci's analysis of human anatomy, which led to the invention of the first robot, the Da Vinci robot has brought minimally invasive surgery to over two million patients worldwide in the past decade.

A current drawback of the robot's technology is that it cannot provide tactile feedback. When a surgeon operates manually, they can simply put their fingers directly on the patient. With the laparoscopy, the surgeon has the instrument in their hand and can tell if a surface inside the abdomen is hard or soft.

"In robotic surgery there is no tactile feedback at all," Addla explains. "You have the visual cues of pushing a surface and seeing if it gives way or not. But hopefully the next generation will have that tactile feedback, where, if I am pushing something that I should not, the robot will be able to tell me."

Niche product
There are newer companies entering the robotics market, but the current forerunner has a 15-year headstart with the existing technology. "There isn't any money for other corporations to make out of the robots, because it's not for mass utilisation; it's always going to be a niche product. So that's why the technology hasn't advanced as much as I would have expected it to," he says.

However, Addla points out that similar speculation was made about the MRI scanner, until other manufacturers entered the market and pushed progress forward; now every hospital has one.

Like any expensive state-of-the-art technology, there are many factors to consider when evaluating the financial benefits of the Da Vinci robot. Funded by charitable donations from the Bradford Hospital Charity Fund and Sovereign Healthcare, Bradford Hospital was able to apply to purchase the robot in 2012, and succeeded.

Proof that the money has been well spent is evident in the feedback from the patients who have been treated by the robot. Addla's initial thoughts were that patients would be hesitant to accept this new treatment, but not a single case out of the 470 he offered it to refused. "I was totally stunned. I was telling them, 'You are my first case, you are my second case...'. It's not that we were telling them we had done loads of these procedures already," he says. "They said they never felt like they were in unsafe hands."

Cheaper technology
Addla predicts that in the future, the robot will become cheaper and therefore more widely used. "Currently the only restriction to every laparoscopic or keyhole operation being carried out robotically is the price," he says. "For every robotic operation that I'm doing, I'm spending an extra £2,500 or £3,000."

As Addla's patients are all over 18 years old, the majority of them are of working age, he believes the speedy recovery that the robot can afford them is worth investing in. "The earlier we get them back on their feet, the better," he explains. "So yes we can look at the upfront cost of £2,500 but the amount of money that we get back from them contributing to society is huge."

The patient feedback has been overwhelming in its positivity; all patients said post surgery that they would have the same method of procedure again, with 95% saying it was "excellent" and 5% saying it was "good". All agreed that it was a worthy use of money.
So how feasible is it to implement robots across all hospitals in the near future? The financial benefits of robotic surgery are only worthwhile, in Addla's view, if the robot can perform more than 150 procedures and therefore "earn back" its cost. "If a robot is bought at £1.5 million, and it costs £140,000 to maintain, and you do ten procedures a year, that doesn't justify the amount of charity money it was bought with."

Addla estimates that out of the 2,000 or so surgical robots in the world, the first hundred do 90% of the work. An interesting question arises as to whether wider distribution of the robots is vital, given that transatlantic surgery has been completed with a patient in the US and a surgeon in the UK performing the operation remotely. Keeping the robots in prime condition isn't cheap; a maintenance contract for the Da Vinci robot is £40,000 a year and with only one leading robot manufacturer providing this service, there is a monopoly preventing any price reduction on such a contract.

The current dynamic of the Da Vinci robot is master/slave technology, wherein the robot responds accordingly to the surgeon's movements and instructions. The structure of the robot itself relies on pulleys, with the instruments being manipulated via wires. Addla wonders about more advanced technologies and says: We don't know what the limit is."

After a certain amount of time, the wires get stretched when they need to be taut, and the fine instruments used on the patient will only work for ten operations. As each of these instruments costs £2,500, every operation requires at least £1,500 worth of finite consumables. "With the evolution of technology, when we stop using pulleys, there might be some other mode of transmission of the signals," Addla suggests. "Then they will be running for longer and the cost will come down in that way."

Valuable learning tool
Another factor to consider when financially investing in robots, is that they are extremely valuable learning tools for trainee surgeons. Dual-console robotic surgery allows the surgeon to operate with the trainee assisting; this adds £200,000 to the robot's cost, however. The single-console robot is also conducive to successful mentoring, as it comes with an interactive training module wherein the instructing surgeon can draw on the console's screen and speak to the trainee through a microphone. "What I do, is I draw on the screen and say, 'This is where you need to be cutting, this is how far you would go and then stop there,'" Addla says. "This helps the assistant because he can see what the surgeon is seeing. Whereas if I was doing open surgery, the only way you can demonstrate like that, is by taking over and saying, 'This is the way to do it.'"

It's doubtless that the Da Vinci robot has dramatically increased the efficacy of keyhole surgeries, but until greater distribution of the robot is possible, access remains limited to the hospitals that can afford it and put it to regular use. Addla says that the momentum of robotic-surgery technology that has already begun will almost certainly continue. "Robotic surgery is not the future," he explains, "It is the current standard of care."