The rise of the robotic surgeon.

By Sophie Wright

Washed and scrubbed, check; gloves, check; protective apron, check; face mask, check.

Every surgeon and their team, typically comprised of an assistant; a scrub technician; and a circulating nurse, must run through a basic checklist of hygienic practice before performing surgery on a patient. Amid the times of the coronavirus pandemic, where personal protective equipment (PPE) is no longer confined to operating theatres, the protective surgical practice has been heightened still with additional components to mitigate the risk of intraoperative viral transmission. Indeed, the danger for the patient lies not on the operating table, but in the wards where they must recuperate in an environment where front-line healthcare workers are at an increased risk (compared to the general population) for testing positive for COVID-19. 

Coronavirus not only presents a risk to post-operative success, but it has also impacted the survival rates of cancer patients. This is due to suspended cancer screening, postponed routine diagnostic work, and prioritisation of only the most urgent symptomatic cases for investigation. Compared to pre-pandemic figures, medical journal, The Lancet, published a study in July 2020, which estimated a 7·9–9·6% increase in the number of breast cancer-related deaths in the five years following diagnosis. The study also reported a 15·3–16·6% increase for colorectal cancer; a 4·8–5·3% increase for lung cancer; and for oesophageal cancer, a 5·8–6·0% increase up to 5 years post-diagnosis. Thus, many clinicians have been struggling as they attempt to strike a balance between undertaking urgent operations and protecting the already immunosuppressed patients from the infection. 

Cue the robot. 

Although the idea of robotic assistance in hospitals seems to be something akin to the stuff of science fiction, there have been mutterings surrounding the potential of robotic surgery in the corridors of hospital wards and leading research institutes since 1985. Robots have already been operating behind the scenes in hospitals to perform menial tasks such as sterilising medical equipment, use in highly technical orthopaedic and neurological procedures, and to monitor real-time patient data. Robotics has not only saved clinicians time, but has also offered the potential for surgeons to perform precise and complex surgery through minute incisions – cutting the risk of infection and recovery time. 

Most recently, a Taiwanese MedTech start-up ‘Brain Navi’ has pushed its agenda for the widespread roll-out of an autonomous nasal swab robot which allows clinicians to delegate the risky procedure for COVID-19 testing to this mechanical aid. For the benefit of those unfamiliar with the pleasantries of nasal swabbing, the protocol involves a clinician pushing a long-handled cotton swab up the nose. When it reaches the nasal cavity, mucous secretions are collected before removal of the swab for testing. One only need a description of the procedure to appreciate the discomfort of nasal swabbing. Pair that with the knowledge that this robot has no pressure sensors and approaches the patient with inefficient (and slightly unnerving) slowness, it seems fairly obvious why there is a degree of reluctance within the medical community to adopt the design. Furthermore, the margin for error must also be discussed as, should the angle of the swab be incorrect, severe damage could be inflicted upon the patient. However, Brain Navi offered some comfort in stating that medical staff use a pedal to control the robot’s movements and that the soft plastic swab would bend before inflicting any tissue damage. Is everyone feeling reassured?…

Luckily, there is more confidence in the surgical robotics already in use which has offered many tangible advantages, such as requiring less than 10mmHg of pressure compared to conventional laparoscopy which demands 10–15mmHg of abdominal pressure. This lower pressure, combined with the distance created between the surgeon controller and the robotic cart; and the subsequently smaller surgical team, is associated with a reduced risk of viral particle transmission. This would likely have a markedly beneficial impact on patient outcome post-surgery during the pandemic.

Despite having established a strong market presence over two decades, the leading robotic system, da Vinci, manufactured by Intuitive Surgical, still floats around the one to two-million-pound benchmark, resulting in the technology remaining largely out of reach for the publicly funded NHS. However, with increased interest in robotically assisted surgery, especially during the pandemic, increased competition will likely extend accessibility with a predicted market value of US$13.7 billion by 2026 and a CAGR of 10.4%. Additionally, robotically assisted surgery may well prove a strategically beneficial long-term investment for the NHS. Some research has found a statistically higher significant difference in clinical patient outcome in robotically assisted surgeries compared to non-robotically assisted surgeries. This, in turn, reduces the length of stay – an attractive means of decreasing costly bed occupancy, which averaged at 90.2% for general and acute cases in 2018/9 and surged to dangerously high occupancy rates of 100% in winter months. However, research on this subject remains in its infancy with many studies still lacking in standardised controls and some degree of quantitative analysis. 

With the inevitable progression towards a more technologically savvy healthcare system, alongside the ushering in of telehealth, the COVID-19 adage of ‘the new normal’ is certainly applicable in the context of robotic surgery. Indeed, technology continues to prove a more efficient means of performing highly skilled and complex work. However, the idea of being met with a metal automaton in lieu of a kindly-faced doctor to perform highly technical procedures, for many patients, is accompanied with an air of unease.

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