Prototype robotic wrist joint optimised for surgery
Ready for surgery: the Cambridge Medical Robotics 'wrist'

The surgical equipment developed by UK-based Cambridge Medical Robotics has “shoulders”, “elbows” and “wrists” and mimics the movements of a human arm. It allows surgeons to work with greater accuracy and precision, according to the company.

But as the next generation of robot technology enters the operating theatre, practitioners stress that surgeons still control what happens during procedures.

Predictions that robot technology would enable surgeons to perform operations on the other side of the world have not come to pass. “That has not happened and one of the reasons has to do with the speed of light,” says Martin Frost, chief executive of Cambridge Medical Robotics. “You can’t transmit the amount of data you need over a communications network fast enough to give the surgeon the feedback he or she needs.”

Even though telesurgery has not yet materialised, surgeons say robot technology is improving their work. “Your vision is better and your movements are more refined,” says Maurice Lau, a consultant urological surgeon.

“The evidence and our anecdotal experience show that you have a lower complication rate and a lower blood transfusion rate — and blood is an expensive and rare commodity,” says Mr Lau, a specialist at the Christie Clinic, a leading UK cancer centre. In August, the clinic bought two da Vinci Si Surgical System robots, the latest technology from Intuitive Surgical of the US, the market leader.

While lower blood transfusion rates save money, the increased cost of the machine, its maintenance and the disposable devices it requires make robot surgery more expensive than standard operations. This means its cost benefits will depend on achieving economies of scale.

Some have tried to calculate this. Research funded by the UK’s National Institute for Health Research’s Health Technology Assessment programme found the extra cost could be offset if each robot system conducted at least 100 to 150 procedures a year.

Mr Frost argues that, to make these procedures cost effective, the price of the equipment must be reduced, something he says his company has achieved by taking a modular approach in the design and by building greater flexibility into the robotic arms.

Minimally invasive surgery has long been possible using laparoscopic or keyhole techniques. However, surgeons say robot surgery takes minimally invasive surgery to another level.

Rakesh Suri, a cardiac surgeon at the Cleveland Clinic, says traditional laparoscopic equipment lacks the wrist-like movements made possible by robot technology. “It is like eating with chopsticks as opposed to eating with your fingers, and imagine peeling a shrimp with chopsticks,” he says.

Not everyone views robot surgery as a cure-all. Peter Dunn, perioperative medical director at Massachusetts General Hospital, argues that claims about the benefits to patients over other techniques have been overstated.

“Our robotic programme is at a low level because our surgeons want to individualise the care for each patient, whatever the right device or technique, not to advocate for one technique over another just for the sake of using a device,” says Dr Dunn.

Surgeons stress that robotic tools are just that — machines that extend the capabilities and precision of the surgeon, rather than replacing human skills. In fact, when applied to surgery, the term “robot” can be misleading. Rather than referring to automatons such as those used in car manufacturing, the term refers to robotic tele-manipulation.

“It is merely taking the surgeon’s hand, replacing it with a robot arm,” says Dr Suri. “Every single movement is conceived and carried out by the surgeon.”

Some operations continue to require open surgery. Mr Lau cites the case of procedures to remove large tumours, sometimes weighing 15 kilogrammes. “You don’t have enough space in an abdomen to do a keyhole procedure,” he says. “So there will always be certain operations that cannot be done because of physical limitations.”

This poses a conundrum when it comes to training surgeons. In the past, all surgeons would have had experience with open surgery, but the take-up of robot technology could create a cohort of surgeons trained only to operate laparoscopic or robot equipment.

This could be problematic in cases where an operation needs to be converted to an open procedure. “That is an issue that we are all grappling with at the moment,” says Mr Lau.

But if the kind of training surgeons will receive in future has yet to be determined, Mr Frost is confident that the use of robot surgery is set to increase. He predicts a tenfold rise in its use over the next decade.

“We will see robotics becoming commonplace,” he says.

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