Despite scare stories, robotic surgery, in the hands of well trained, experienced and highly skilled surgeons, can produce amazing patient outcomes, writes Ben Challacombe
I recently read with interest an article in the Daily Mail that heavily criticised the use of robotic surgery. The article was sensationalist, basing its claims on a couple of cases where surgery had reportedly gone wrong and patients’ lives had been severely affected. It failed to mention some of the tremendous success stories made possible by the use of robotics.
‘Although the number of robotic operations has increased, the proportion of cases where there has been a problem has significantly decreased’
However, as a consultant urological surgeon at Guy’s Hospital who uses a robot to remove prostates and kidneys on almost a daily basis, it led me to question whether there was any merit to the article’s claims.
There are now more than 2,500 Da Vinci surgical machines in clinical use on patients worldwide including 31 in the UK. In many countries they now carry out significant proportions of certain types of surgery including radical prostatectomy − removing the prostate for cancer. As a new type of surgical system/tool there are quite rightly some concerns about any reports of patient harm during Da Vinci surgery.
Reassuringly, however, although the number of robotic operations has increased, the proportion of cases where there has been a problem has significantly decreased.
The system itself offers high quality 3D vision, unlike most laparoscopic systems with 2D screens. It also has fantastically controlled instruments that filter out hand tremors, whereas long laparoscopic tools only enhance tremor. Movement can also be scaled from the console arms to the patient arms meaning increased movement precision.
There are two kinds of patient harm or complication that can occur when using a new technology such as robotics.
First, there might be complications caused by the actions of the surgeon themselves. This could happen regardless of the technique used to perform the operation, but might be greater with a new approach. Second, there is the risk that things could go wrong specifically due to a fault or problem with the new equipment, potentially related to design or component faults.
To use a driving analogy, if there is a car crash it might be due to the driver speeding (type 1 complication) or due to the brakes failing (type 2 complication) and only the second type is potentially the fault of the car manufacturer.
Robotic surgery by numbers
- There are 31 Da Vinci systems across England.
- In the US, approximately 80 per cent of all radical prostatectomies are now carried out by robotic-assisted surgery. In the UK, Intuitive Surgical quoted the proportion of Da Vinci prostatectomies to be more than 50 per cent in 2012.
- About 5,000 radical prostatectomies are carried out in England each year.
- The installation cost of a Da Vinci surgical system is £1.5m.
The second type of complication remains a key concern for both patients and surgeons but thankfully these faults, after 1.5 million clinical cases, are extremely rare. One example of a robot-induced problem is unintended burns due to electric current arcing abnormally from the robot’s cauterising tools. This seemed to be a particular issue in gynaecology procedures in the US. Intuitive Surgical, which makes the robot, responded by introducing a new type of robotic arm cover with improved insulation that rectified this issue. Indeed, each new version of the robot incorporates several small but significant improvements reducing the risk of patient harm.
However, complications resulting from surgical error due to of the inexperience of a surgeon using a robot are still a major issue. While Intuitive Surgical, which built the technology, runs a introductory users course and is actively involved in sponsoring larger master classes and courses internationally, it is not in a position to accredit surgeons and nor should it be as producer and vendor of the systems. Therefore it is likely that some errors arise from surgical inexperience with the system itself and how to safely control it.
Many advocate a fellowship year of dedicated training at the end of conventional specialist surgical training to really acquire the best technical skills to work in this area. While this works for many younger surgeons, unfortunately for many practising consultants this is not feasible and they must acquire skills while still working as a full-time consultant. Most procedures have a shallow learning curve indicating a large number of cases are required to reach proficiency.
‘Each new version of the robot incorporates several small but significant improvements reducing the risk of patient harm’
This leads to the issue of who is really best to teach and mentor robotic surgery and who is going to act as the accrediting body?
For urology, which is the biggest user of robotic surgery in the UK, particularly for radical prostatectomies, a cadre of experienced robotic surgeons who are independently adjudged to be excellent trainers is needed. The trainers and the trainees would be accredited by the British Association of Urological Surgeons, which would hold an updated list and provide certification.
The UK should also have an accurate list of how many procedures are actually performed with the robotic system each year. A new curriculum is being trialled and validated by an international collaboration to describe the most effective way of acquiring proficiency of the robotic system.
It is clear from many peer reviewed papers that the Da Vinci robotic system is an excellent tool that can produce amazing patient outcomes but which ultimately requires its surgeons to be well trained, experienced and highly skilled. I am in no doubt that it truly adds quality to every operation I use it for.
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Ben Challacombe is consultant urological surgeon and honorary senior lecturer at Guy’s and St Thomas’ Hospitals and King’s College Hospital