Could an army of high-tech robots help to tackle Britain’s surgery backlog crisis? It may sound like the stuff of science fiction, but at least one senior NHS figure believes robots could help speed up waiting times.
Official figures show a record 6.07million patients are now on NHS waiting lists for operations. And an unprecedented 20,000 people are having to endure waits of more than two years.
The Government recently announced targets to eliminate waits of more than 18 months by spring 2023. But even achieving such limited improvements is a ‘big challenge’, says the Royal College of Surgeons in England, given the chronic shortages of nurses and doctors in the health service. So could robot surgeons step in to help?
Evidence suggests patients will take much convincing before they trust a robot to operate on them
The NHS has more than 60 robotic surgery machines in service — often used for urological surgery, such as prostate cancer operations — with experts predicting many more to come.
The national medical director of NHS England, Professor Stephen Powis, last year forecast that they will ‘play an increasingly pivotal role’ in reducing patient wait times for surgery.
The machines, which resemble giant, multi-armed insects suspended over operating tables, currently have to be guided by expert human surgeons. But in January, U.S. researchers allowed a surgical robot to operate free from human control for the first time.
Experts at Johns Hopkins University in Baltimore created an autonomous machine they say performed a complex laparoscopic (keyhole) gastric operation on a pig, thought to be surgically as challenging to work on as a human.
The Smart Tissue Autonomous Robot (STAR) performed one of stomach surgery’s toughest tasks: reconnecting two ends of an intestine. And, according to results published in the journal Science Robotics, it did the job better than a human might have done.
The task demands extremely accurate control — the slightest tremor or misplaced stitch can result in catastrophic leaking of the stomach contents. But an autonomous robot surgeon needs more than just steady ‘hands’. Like its human counterparts, it needs to be able to change plans when unexpected problems arise.
The STAR, with its 3D-camera eyes and computer-algorithm brain, can do this just as a human surgeon would, says Axel Krieger, the mechanical engineering professor who led the study.
‘It is the first robotic system to plan, adapt and execute a surgical plan in soft tissue with minimal human intervention,’ he says.
However, evidence suggests patients will take much convincing before they trust a robot to operate on them.
In November, for example, a study by the University of Catalonia, Spain, involving 28,000 people across Europe and published in the International Journal of Environmental Research and Public Health, found high levels of misgivings about being on the receiving end of robot-assisted surgery.
Such fears in the UK have been fuelled by an inquest in 2018 into the death of Stephen Pettitt, 69, following a heart operation involving robotic surgery. He was the first UK patient to have the pioneering treatment, which he underwent at the Freeman Hospital, Newcastle, in 2015.
Official figures show a record 6.07million patients are now on NHS waiting lists for operations. And an unprecedented 20,000 people are having to endure waits of more than two years
The operation was to treat mitral valve disease, a problem with the valve between the two chambers on the heart’s left side and which can cause fatigue, an irregular heartbeat and breathlessness.
The coroner’s investigation found significant deficiencies in the training and competence of Sukumaran Nair, the surgeon who performed the robot procedure.
The inquest heard Mr Nair had received no one-to-one training on the Da Vinci robot device involved, and had been ‘running before he could walk’. It was ‘more likely than not’ that Mr Pettitt would have survived had conventional open-heart surgery been used, with a chance of him dying of about 1.5 per cent, the court was told.
The coroner warned in the light of the evidence that there ‘remains a risk of further deaths’ from robotic heart surgery.
Newcastle Hospitals NHS Trust paused its robotic heart programme and told the coroner’s court that significant changes had been made to improve safety.
A year after Mr Pettitt’s death, a study in the journal PLoS, of hospital incident reports made to U.S. regulator the Food and Drug Administration, found robots had been involved in 144 patient deaths and 1,391 injuries.
However, for most reports involving death, little information had been recorded for why the patient died, making it difficult to say whether it was human error, a problem with the robot or the risks inherent in surgery. Nevertheless the study, led by the Massachusetts Institute of Technology, found cause for concern. ‘Despite widespread adoption of robotic systems for minimally invasive surgery, a non-negligible number of technical difficulties and complications are still being experienced during procedures,’ it said.
Errors included burnt or broken pieces of tools falling into the patient (14.7 per cent of errors), electrical sparking that could injure patients (10.5 per cent) and robots making unintended movements (8.6 per cent) — alarmingly, the latter resulted in 52 injuries and two deaths.
Supporters argue protocols have since been tightened so the approach is at least as safe as human-performed surgery.
But separately, are robots really better surgeons — in terms of achieving faster and more effective patient recovery? Such benefits are essential, if not only in patients’ interests, but in making robots worth the money. For, as the Royal College of Surgeons points out, robot-assisted surgery ‘costs a lot more than surgery without robots’ — an additional £400 per case, plus the purchase cost of the robot, which is approximately £1 million.
Unless they achieve markedly better patient outcomes, such as faster recovery, fewer complications and fewer long-term disabilities, they can’t pay their way.
To find out if they can, the NHS is running trials of robot surgery on patients’ knees and hips, looking at arthroplasty, a common type of knee surgery performed on tens of thousands of people every year in the UK.
The trials, which cost £3 million to run, will involve more than 600 patients and compare results of those who have robot-assisted surgery with those who have conventional operations. The earliest results are not expected until next year, however.
Other studies have yet to prove robots’ advantage: an analysis in the Annals of Internal Medicine last year of the results from 50 studies, involving nearly 5,000 robotic surgery patients, found ‘no difference’ in complications and long-term outcomes between robot and human surgeons.
The review also found the robots can take longer to perform surgery — as much as 41 per cent longer in gynaecological operations, for instance.
But enthusiasts for the technology remain optimistic. Dr Philip Scott, chairman of health and care at British Computer Society, The Chartered Institute for IT (which promotes economic progress through the use of science and technology), argues that evidence showing no difference between robotic and human surgery outcomes ‘is actually very impressive’.
He told Good Health: ‘It’s part of a trend that has seen the increasingly successful adoption of digital tools across healthcare. At the end of the day, it is a matter of persuading people that robots can do the job as well as humans.’
Furthermore, Dr Christos Bergeles, a medical robotics developer and leader of the Robotics and Vision in Medicine Laboratory at King’s College London, predicts that in five years’ time there will be many more robots in NHS operating rooms.
He also believes that robots will soon be able to perform operations that are too intricate for human surgeons. ‘They are being developed for things that humans just can’t do with their bare hands,’ he told Good Health.
‘Robots’ enhanced dexterity, vision and sensory perception could make them able to perform tasks with unprecedented levels of accuracy and consistency.’
Dr Bergeles predicts further, that ‘in ten years we will start seeing some robots becoming automated as intelligent assistants, helping the surgeon by suggesting where to cut or how to do the operation better’.
‘Some robots already have aspects of automation, such as using their sensors and computing power to measure the best way to remove complex tumours,’ he says. The ‘holy grail’ he adds, would be robots that automatically learn how to perform operations better each time, and carry out routine surgery autonomously.
‘The whole classification of ‘routine’ would become much wider, so that many types of surgery currently considered very difficult will instead be quite easily doable by robots.’
Such revolutionary changes remain a long way off, however, according to Professor Subramanian Ramamoorthy, chairman of robot learning and autonomy at the University of Edinburgh.
‘In ten years, the fundamental landscape will not look very different,’ he told Good Health. ‘I’d be amazed if robots displaced any surgeons from their jobs at this point. Instead, there will be a long period of shared work.’
Professor Ramamoorthy believes the benefits of robots will lie in enabling more surgeons to perform intricate tasks that are currently beyond their skill sets.
‘With robots you may no longer need to be a specialist surgeon to do, say, brain cancer operations, where the slightest mistake may paralyse the patient,’ he says. ‘Robots may enable more surgeons to do them.’ As for the NHS’s enormous backlog of routine operations, even the most enthusiastic proponents of robot surgery agree: the only answer is to recruit and train more human surgeons.
Dr Jonathan Clarke, a postdoctoral fellow at the Imperial College London Centre for Mathematics of Precision Healthcare, has studied the introduction of robot surgeons across the NHS.
He says: ‘While we need to invest in robots as a technology for the future, right now it’s a human thing that we need.’
Robert MacLaren, a professor of ophthalmology at The University of Oxford, performed the world’s first robotic eye operation in 2016, to surgically repair the retina of a 70-year-old patient.
He told Good Health: ‘Robots can certainly help with improved precision and patient safety when doing complicated operations.
‘What I do not understand, however, is how a robot could replace the surgeon completely.’
And he stressed: ‘We should never lose track of the fact that there is a human patient at the centre of all this — and most would wish a surgeon to be present.’