Robotic revolution in the NHS
October 2007
Surgical robots, in the past, were viewed as expensive “toys for the boys”. Now they are rapidly becoming accepted for routine procedures, while playing an important role in the development of the latest pioneering techniques. LOUISE FRAMPTON talks to Prosurgics about the adoption of the technology.
Robots offer the ability to deliver shorter operating times, improve accuracy in localising surgical targets, reduce collateral damage and can reliably repeat complex movements. Furthermore, they don’t get tired during lengthy surgical procedures. Perhaps most exciting of all is the potential they offer for the development of new surgical techniques that can increase life expectancy in patients who would normally be considered untreatable.
In recent years, considerable excitement has been generated by reports of a “caterpillar robot” being developed which crawls across the surface of the heart to deliver treatment, while gall bladder surgery has already been performed using remote control robots, by surgeons located thousands of miles away from the patient. Robots are also being used for nonsurgical applications. A new hospital being built at Larbert in Stirlingshire will be the first in the UK to use a fleet of robots to transport goods and equipment – such as linen, waste and medical equipment around a network of separate corridors, using magnetic strips or infra-red technology. At the Royal Lancaster Infirmary a robot is already being used to dispense medicines, eliminating human error. Patients needing physiotherapy could also soon find themselves being treated by robots carrying out repeated limb movements.
ROBOTIC INCREASE
At first, robotic technology was slow to be accepted by surgeons, however. The technology has been available since the 1980s, but adoption started to “take off” in recent years, according to Paul Moraviec – the new chief executive of Prosurgics.
He told The Clinical Services Journal: “Robotic technology is at an embryonic stage, but it is set to explode. There are very few companies in this field at the moment but robotic surgery is gaining more and more acceptance. The number of robots being used has rapidly grown in the last year, and over the last few months we have seen a significant increase in the number of applications, as surgeons are becoming more comfortable with the technology.”
He estimates there are around 1000 university projects currently in progress around world, looking at different robot technologies, but added that many will not materialise into commercial solutions. However, one company in particular has driven the demand for robotic technology forward – Intuitive Surgical, the US company which developed the da Vinci robot.
This system comprises a surgeon’s viewing and control console, a 3-D high definition vision system, a patient-side cart consisting of three or four robotic arms that position an endoscope and various articulating instruments. It has paved the way for robotic technology and generated significant excitement within the surgical community.
“Second quarter 2007, da Vinci Surgical Systems revenue increased 54% to $74.1 million, which goes to show the interest in the market for robotics. The majority of growth has been built around a particular procedure (radical prostatectomy) using the da Vinci robot. It has proven clinical outcomes data, showing superior patient and economic outcomes – which are significant drivers for medical device technology,” he commented.
The da Vinci has been marketed primarily to patients rather than clinicians in the US, where there is greater “patient power” than the UK according to Colin Robertson, sales and marketing director at Prosurgics.
The message to patients has been that if they have their prostate removed using this robot they will have less impotence and incontinence post-operatively. More than 50% of prostates removed in the US are now being performed by a robot – which has been largely driven by patients demanding that hospitals acquire the technology. “The technology has very quickly disseminated throughout the market,”
Colin Robertson said. “Even in countries where there isn’t the same level of healthcare funding such as the UK, there has been a marked increase in the last couple of years. It is an expensive piece of kit to invest in, but it’s successful because it is proven to deliver successful outcomes.”
CAPITAL COST
The limiting factor, with robotics in his view is the fact that they are considered an “expensive luxury”, however. Some can cost around £1.2 m to purchase, approximately £100,000 per year to maintain and £5000 per procedure. When such a high level of investment is required, such robots can only be used for specific procedures where easily quantifiable benefits can be demonstrated. Yet 95% of other procedures could benefit if the technology was more affordable. He claimed that 70%–80% of surgeons become “converts” to robotic technology after using it for a few hours, but only 5% of the surgeons will succeed in securing the funding.
There is a need to develop robots with lower capital cost and lower cost of ownership, he believes. R&D is therefore focused on developing a cost-effective approach that will ensure robots are more general in their application with a lower capital outlay. EndoAssist, the company’s robotic camera holding technology, currently costs around £40,000 but there are plans to develop a new entry-level solution to make the technology more widely accessible.
“The next step forward is to produce a robot that is designed for a wide range of procedures, providing simpler tools that are less sophisticated but more general purpose,” Paul Moraviec commented. “The company’s mission is to take robotics from what is a very small niche to something that is far more ubiquitous in operating theatres. Our aim is to bring the technology to the masses, to put an end to the perception of robots as high tech ‘toys for the boys’. Robots should be available as standard tools for every surgeon. There is a need to make the technology more accessible – not just for leading teaching institutions but for routine jobbing surgeons carrying out the vast majority of procedures.”
Surgeons are already performing an increasing variety of procedures using EndoAssist which is being marketed as a “routine tool for routine surgery”. As the robot can be used with any laparoscope, it can be used across a whole range of procedures from relatively complex urological cases such as prostates to simple general surgical cases such as gall bladder removal.
LAPAROSCOPIC SURGERY
To date, twenty EndoAssist laparoscopic robots are being used for procedures such as radical prostatectomy, nephrectomy and pyloplasty, as well as cholecystectomy and hernia repair. New applications such as arthroscopy, port access mitral valves and bowel resection are also emerging. The technology is designed to eliminate the need for hand held endoscopes ensuring a completely steady visualisation of the target treatment area. An assistant would normally be required to move the hand held camera, but if they become tired, or they are inexperienced, the stability of the image can present problems for the surgeon. As more and more complex procedures are being carried using laparoscopy, the average duration of the procedure has increased.
Colin Robertson explained the advantages of using a robot to replace hand held endoscopes: “Some prostate operations can take 3-4 hours and inevitably the assistant becomes tired. Surgeons do not always work with the same assistant, most are junior doctors and there has been a reduction in junior doctors’ working hours. Surgeons often complain that every time they enter the operating room there is a different assistant holding the camera.
“Many of them are inexperienced which means the procedure can take longer. Moreover, after five years of medical training, who wants to stand there for hours simply responding to left/right, up/down commands?”
The robot can replace the assistant, give a completely stable image and offers the potential for solo surgery to take place in routine day surgery cases. Surgeons can control the camera themselves, without an assistant and without using their hands. A sensor is attached to a headset (or with Velcro to the surgeon’s cap for extra comfort) which detects head movements to indicate the direction of the camera, while a foot pedal activates the system to avoid unintentional movements.
“The surgeon has a better view of what they are doing which results in better suturing and a better operation. Operating time is reduced, benefiting the patient through reduced time under anaesthetic and there is also a benefit to the hospital – by potentially increasing the number of operations performed in one day,” Paul Moraviec pointed out.
In a series of more than 100 laparoscopic chole cases, the robot reduced total operating time by 10% compared to hand held cameras. Clearer visualisation allows minimal invasive surgery to be performed in a wider range of procedures – for example, in cardio thoracic surgery sternotomy can be avoided. The taking out or replacement of mitral valves can be performed through small ports rather than large incisions. The patient benefits from reduced pain, shorter recovery times and improved cosmesis.
“The UK has been slower than virtually every country in Europe in adopting laparoscopic surgery. But for the adoption of this type of robotic camera holding technology, the UK is ahead of the rest of Europe. To change the way an operation is done is extremely challenging but, with this technology, no change to clinical practice is required. It simply facilitates an existing procedure, making it easier for the surgeon to do their job,” he commented.
Surgeons tend to be relatively conservative when it comes to adopting new technology, in his view, which presents a challenge for smaller companies like Prosurgics. One of the important factors has been the securing of good reference sites.
“The robot is now being used by key opinion leaders in laparoscopy surgery – people like Philippe Grange at King’s College Hospital who are now spreading the word,” Paul Moraviec said.
NEUROSURGERY
PathFinder, a neurological positioning robot, is also now in beta form and has been installed in five centres around Europe. At Ninewells hospital and medical school, in Dundee, M S Eljamel, a consultant neurosurgeon, has used the robotic technology in epilepsy surgery. He found that 40-50 minutes were saved in operating time compared to previous experiences without the robot.
PathFinder is designed for precise localisation in neurosurgery and allows the positioning of stereotactic instruments to at least an accuracy of 1 mm. A camera mounted on the robot’s arm searches for fiducial skin markers that are positioned on the patient’s head completely removing the need to fit a stereotactic frame. This can result in savings in set-up time of more than an hour and can improve the efficiency of scanner usage.
The robot compares the marker positions on the patient’s head to those on the pre-operative scan and performs an intelligent and flexible map-reading exercise of the patient’s head automatically. The robot moves a cannula to a position above the required target, then locks its arm – providing a rigid platform for the surgeon to insert instruments accurately into the brain.
It provides benefits across a wide range of procedures. Tumour biopsies can be performed with superior accuracy, but in a fraction of the time, while the robot is ideally suited to accessing deep-seated structures for functional neurosurgery. It also offers the potential for less invasive procedures, resulting in shorter recovery times.
“PathFinder is very different to the EndoAssist technology. It will significantly change the way surgeons currently work in neurosurgery and significantly impact on patient outcomes,” Colin Robertson explained.
Over the last 15 years medical imaging has gone from very crude x-rays to very sophisticated, high resolution CT, MR and ultrasound. But the problem exists of converting the knowledge on the scan to what presents itself in the operating table. “In the case of Parkinson’s, the surgeon can see the problem area on an MRI scan.
If an electrode can be accurately inserted into that area, a stimulator can be implanted into that part of the brain to reduce the symptoms. Traditionally, a stereotactic frame provided a mechanical guide, which is clinically proven and offers 1mm accuracy. However, patients hate having a ‘medieval’ frame bolted to their head, which is uncomfortable and inconvenient to fit. Furthermore, it can get in the way of the surgery,” Colin Robertson continued.
“Very high resolution scans are used to plan the operation but the clinician must then convert this to coordinates written on a wipe board – with the associated risk of human error. There is something bizarre about juxtaposing a mechanical solution with the sophistication of the MRI technology being used – there is a mismatch between the imaging process and the way that information is converted.”
NEW PROCEDURES
For procedures such as biopsies, where the clinician wants to take a sample of a deepseated brain tumour, the technology is also much quicker. With deep-seated brain stimulation the surgeon can also have a higher level of confidence that the procedure is going to have a good outcome. However, a particularly interesting aspect of PathFinder is its ability to enable new neurosurgery procedures. Toxic agents are now being used for brain tumours, allowing them to be treated in situ, which requires the drug to be injected in a grid pattern throughout the tumour. In theory, this could be performed with a stereotatic frame. However, every time a need arose to change location, it would take 10-15 minutes to reset. The process would take hours, making it impractical, while the robot simply goes straight to the next grid location.
An experimental treatment in Berlin, using magnetic nanoparticales to destroy a tumour from within has also been made possible. The technique is being developed to treat some of some of the most malignant brain tumours, where survival rate is normally measured in weeks or months – even after surgery.
Colin Robertson revealed: “The hospital is getting very good results with a 50% life expectancy increase, but the only way that the treatment can be delivered reliably is through a robot.”
The technology is also being used during the insertion of percutaneous pedicle screws into the vertebrae to correct curvature of the spine or injuries. It is extremely important to get the positioning right or there is a risk of damage to the spinal cord. Traditionally, this was performed with a large open incision, but surgeons are now trying to move away from this traumatic procedure by inserting the screws through the skin.
“It is very difficult for surgeons to ‘see where they are going’. As a result, there is a higher rate of collateral damage and misplaced screws when the procedure is performed percutaneously. We are currently working with a leading spinal surgeon at a hospital in Blackheath on trials of a new technique using the robot to ensure the screw is inserted in the correct position to get a result that is at least as good as if it had been performed with a large incision.”
In Finland, stem cells are also being used in trials to treat Parkinson’s by repeated injections into the brain using the PathFinder to facilitate the operation.
The potential for robots to have a significant impact on surgical innovation is particularly exciting, but they also offer the potential to provide surgical expertise in remote areas or to share skills across locations within a Trust. One example of telesurgery systems is in Norway where an EndoAssist telemanipulator can be controlled remotely by a joystick communicating over a telephone line. This enables an expert surgeon at a central city hospital to assist colleagues in an outlying clinic using a normal teleconferencing facility.
“The technology has the potential to revolutionise both the way surgery is performed and indeed where,” Paul Moraviec concluded.
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