Look to the future through a keyhole

Urologist Mr Raj Nair (second left) and his Da Vinci robot team at London Bridge Hospital

Mr Jay Chatterjee

HCA Healthcare UK has invested £7m in four new da Vinci Xi robots, confirming its status as the largest provider of robotic surgery in the independent sector with a fleet of seven da Vinci systems across its healthcare system. Mr Jay Chatterjee, consultant gynae-oncologist at HCA UK’s London Bridge Hospital and The Lister Hospital, discusses the rise of robotics.

The progressive adoption and evolution of robotic surgery as the preferred modality for minimal access surgery over the last decade, has many reasons. 

Surgical precision, ergonomics and patient outcome has driven this advanced technology which has now captured the imagination of most surgeons and surgical specialties. 

The most complex minimal-access surgeries are now performed robotically due to the ergonomic advantages over straight-stick laparoscopic surgery, which subsequently translates into better patient outcomes. 

The transformation from open surgery to laparoscopic and robotic surgery has largely been driven by enhanced recovery of patients from their complex surgical procedures and quicker discharges with less hospital stays. 

Greater precision surgery leads to fewer complications. Surgical innovation in recent years, has effectively given rise to surgical possibilities that were never before imagined and thought to be achievable in an operating theatre. 

Skilled laparoscopic surgeons have honed their skills with years of practice. Arms poised like a marionette, but without the benefits of strings to take the strain; these surgeons operate through tiny incisions.  

Lift your elbows up at right angles to your body, and see how long and how comfortably you can sustain this pose. My guess is that it isn’t long. 

Physical fortitude

With years of practice, expert laparoscopic surgeons learn to relax their posture, but operating still requires significant physical fortitude. 

Small incisions are made in the abdomen, through which ports are placed. Slim, crocodile mouth-like instruments provide the means of operating. These tiny mouths can open, close and rotate at the touch of a surgeon’s finger. Moving the surgeon’s hand forward moves the instrument backwards within the body cavity. 

Highly skilled laparoscopic surgeons develop their skills over tens of years, building both skill and stamina. 

Laparoscopic surgery is not a skill that comes easily to all surgeons, with many unable to perfect the necessary skill or 3D depth perception and co-ordination necessary to do more than the most simple of operations. 

As with all levers, small movements at one end translate into large movements at the operating end. Tremors are amplified. 

This demands a skilled steady hand from the surgeon. Despite these challenges, many excellent laparoscopic surgeons perform lengthy and complex surgeries using these instruments. 

Repetitive strains 

Occupational injury, however, in the form of neck, shoulder and repetitive strain injuries can negatively impact on clinical performance, even leading to the premature end of a surgeon’s career.1

Robotic surgery is a progressive development from the world of laparoscopic surgery. It is robot assisted/enhanced laparoscopic surgery. Instruments are again inserted though ports in the abdomen, but are held and supported by robotic arms. 

The surgeon sits comfortably at the surgeon’s console, rather than standing at the bedside, able to relax and concentrate on the detailed surgery in front of them. Microsurgical instruments are controlled by signals translated from the natural movements of the surgeon’s fingers. 

Enhanced and magnified 3D vision supports microsurgical fine dissection. Instead of tremors being magnified, tremor and movement control keep movements fine and precise. 

Some patients may fear that it is the robot performing the surgery, but nothing could be further from the truth; the operation is performed by the surgeon but enhanced by the robotic system.

Robotic surgery is physically less demanding and so supports the use of minimally invasive surgery in longer and more complex surgeries in hard-to-reach areas of the body. 

In our own specialty of gynaecology and gynaecological oncology, we routinely provide robotic surgery for women with endometrial cancer and other complex pathologies, many with significantly raised BMI >50. 

Lower blood loss

Women routinely go home after only one overnight stay or even on the same day following a hysterectomy. Blood loss is known to be much lower with robotic surgery as is the length of stay. 

Before the introduction of robotic surgery to our trust, a woman undergoing a hysterectomy would typically expect to stay in hospital for six days and now routinely stays only one or goes home the same day. Blood loss has also been reduced from an average of half a litre to only 50ml.

Robotic surgery provides the benefit of excellent magnified 3D vision together with microsurgical instruments, providing precision operating. 

Blending surgeons with the technological benefits of the robotic system should be seen as a means of future-proofing.

Image overlay with cross-sectional imaging guides precision surgery, as does the use of fluorescence dyes such as Indocyanine green used in sentinel lymph node and bowel perfusion assessment. 

Remote proctoring/operating provides exciting opportunities to provide the best surgery for our patients not limited by borders of time or travel.

The potential for interspecialty co-operative working using the robotic platform is an exciting prospect. This is increasingly becoming a reality with the expansion of robotic surgery into diverse surgical specialties.

Find out more about minimally invasive robotic assisted surgery at HCA here.

This article was co-authored by subspeciality gynae-oncology fellow Miss Christina Uwins (right)

1. Plerhoples TA, Hernandez-Boussard T, Wren SM. The aching surgeon: a survey of physical discomfort and symptoms following open, laparoscopic, and robotic surgery. J Robot Surg. 2012; 6: 65-72.