What is robotic surgery?

Robotic surgery is a form of keyhole surgery where the surgeon carries out the procedure by controlling miniaturised surgical instruments through a series of robotic arms. Sitting in front of a console, the surgeon’s hands are secured to the controls by Velcro straps. The surgeon then controls both the robotic arms and surgical instruments while viewing the procedure on a high-definition video screen.

From a prostate surgeon’s perspective, what is the benefit of using robots?

With traditional open surgery, we made one cut long enough to allow access to the prostate. The patient often lost quite a bit of blood. This meant more time in hospital and more pain for the patient. With a robot, we make six small holes, so there is much less trauma for the patient. The robot’s tiny instruments give you better access and also allow you to be much more precise with your cuts. Also, no matter how good a surgeon is, there may be a slight amount of tremor at the tip of a cutting instrument; the robot can filter this out completely.

We first talked about this field in 2015. How has it progressed since then?

While the idea behind the technology remains very similar, there have been real improvements. The 3D HD screens provide even clearer images, magnified by a factor of 10, giving us a wonderful view. The prostate, which is the size of little chestnut, looks the size a football. There has also been the development of image guided surgery. We transfer scans of the prostate into the robot and plan the best route for accessing and removing the tumour before the procedure starts. The ability to 3D print the prostate from very accurate scans is hugely beneficial in planning tumour removal. It gives me a very accurate reproduction of how the tumour is located and where I need to go to make sure I get all the cancer. The combination of image guided surgery and 3D printing had led to very intelligent surgery.

What else has improved?

Connectivity has taken a major step forward. By this, I mean the ability to virtually transport an expert surgeon from one part of the world to the other. This is made possible by the development of low-latency, high-speed lines of communication. A technology which does that very well is called PROXIMIE, an augmented reality secure platform for virtual surgical collaboration. It has already been used during the pandemic to allow a surgeon from Seattle to guide a very complex procedure here in London. Finally, there is artificial intelligence (AI), which was not available to us back in 2015. One extremely useful use of this is assessing a procedure. We attach what is essentially a small computer to the robot, which tracks the surgeon’s movements. Having tracked a series of procedures, it can see which surgeon is making the most economical movements. It can also be linked to how the patient does after the procedure. For example, if I remove someone’s prostate, they’re concerned about losing erections or bladder control for a period of time. AI allows us to determine which movements lead to better patient outcomes, to a level you couldn’t do with the human eye, which leads to better surgical practice.

What is the state of play with automated operations?

The principle of automating part of a procedure has been around for a while. There is a robot called STAR which has been shown to stitch bowels far more accurately than any human can. But we are nowhere near a point whereby I press a button and robots in parallel rooms do the procedure. We will need human judgement for a very long time to come, as there is always the potential for something unexpected to occur. The robots are getting better at carrying out some techniques, but they are still carrying out a set of predetermined steps. You still need a human to deal with the unexpected, sometimes quite quickly, during a procedure. There is also the fact that machines fail, and when they do, a surgeon needs to be able to take over.

This interface between robot and human seems to be a complex area.

Yes, we call this branch of thinking ‘humanics’. It is the science of understanding what a machine can do better than a human, but equally and more importantly, what a human can do better than a machine. Many people worry that these machines are going to replace surgeons completely. A time will come when with machine learning we can train the robots to do more and more complex surgical procedures, but I’m not certain that this will happen very soon because there can be so many judgement calls about which direction to take during any single operation. That’s why you go to an expert surgeon: to make the correct judgment call in real time at the operating table. It’s about building a synergy between the surgeon and the robot, with increased patient welfare being the ultimate aim.

Does robotics make it easier to operate on obese people?

Yes and no. Physically, it is easier, no question: you can access the organs more easily. But that does not mean that we should. The correct thing to do is help the patient lose weight and get optimised for surgery, because this is not just about their cancer, but their overall health. If a man is obese, his risk of dying from heart disease, diabetes or other obesity-related illness can be much higher than the risk from prostate cancer. To say, “I’ll cure you of your cancer and not tackle your weight” is not the right thing to do. Getting ready for robotics procedures is not a walk in the park. The operating table is at an angle which has the feet elevated above the head. This leads to pressure on the heart and lungs during the procedure. The fitter the patient, the better they come through it. You need to stop drinking alcohol, stop smoking and lose excessive weight.

What percentage of prostate operations are done robotically?

When I started, it was one per cent. There were two robots in the whole country, at Guy’s hospital and St Mary’s, both NHS hospitals. The London Clinic was the first private hospital to invest in robotics, which was a very bold, forward-thinking move. The Royal College of Surgeons recently released data saying that the percentage is now up to 90.

That is an extraordinary uptake. Is it value for money as well as clinically effective?

That is an extremely good question, which has taken an extraordinary amount of time to answer. I have been heavily involved with pushing the boundaries of robotic surgery and have seen great progress, but as a scientist, you constantly question yourself as to whether these advances are a cost-effective way to improve patient safety. This is extremely expensive technology, and shorter patient stays in hospital is not enough in itself. So, what is cost effectiveness? You look at the greater societal costs known as ‘out of pocket costs’, of people being off work and unable to engage in their normal economic and cultural activities. Earlier this year, I was involved in a publishing a paper in the JAMA Network Open journal, looking at patients who had undergone either an open or robotic radical prostatectomy, hysterectomy, partial colectomy, radical nephrectomy, or partial nephrectomy for a solid-organ cancer. Having looked at huge amounts of data, we found out that for treating prostate, gynaecological and bowel cancer, the out of pocket costs were lower with robotic surgery than they were with traditional open surgery. After many years, I feel relieved!

Are you still involved in robotics research?

Luckily, I have managed to remain at the cutting edge, and there are some really exciting developments coming through. There’s something called hyper-spectral imaging, where you can analyse high resolution scans using computerised algorithms with such accuracy that you would not have to stain a biopsy to determine the presence or level of a tumour. That would be an incredible advance. Then we have some very exciting work based on machine learning, whereby if you are doing a robotic colonoscopy—examining the bowel with a robotic colonoscope—you can train a machine to spot tumours or polyps which the human eye would miss. I’m also involved with the National Clinical Entrepreneurship Programme, and along with colleagues I mentor a number of biomedical start-ups. One is an AI company called Jiva.ai who have worked with us here at The London Clinic. They are developing AI algorithms that can lead to more consistently accurate interpretations of MRI scans. At the moment, the algorithms are around 87 per cent accurate and getting better. It’s an incredibly exciting time to be involved in medical robot technologies.

How do you see the field changing in the next five years?

For the benefits of robotic surgery to reach many more patients, the costs have to come down. If prices continue to rise, I don’t think this is sustainable even for the wealthier nations. The machines are also becoming smaller and more modular, which is good. Connectivity means ultra-low latency connections, allowing us to virtually transport surgical expertise to more areas of the world more easily. We can use 5G to shorten lag times and then AI to cut it even further. Thirdly, there is AI itself. This is a very interesting space. At the moment, I would characterise its future direction as a bag of unknown unknowns. There is such enormous potential, but we have to ensure what we do is of real benefit to patients, not just satisfying scientific curiosity. Otherwise you get wonderful technical advances gathering dust in libraries. Humanics will play a crucial role in the direction of surgical AI. Ultimately, there will be an increasing degree of automation in many procedures, but the surgeon will still play the central role for a long time to come.

For the full article please click here.