Getting to grips with robotic surgery

When it comes to medicine, robotics is becoming very big business: the venture we’re about to hear from are industry “unicorns” - these are start up companies that have been valued at over a billion - thanks to their technology that can make the benefits of keyhole surgery available to everyone who needs it. Tricia Smith spoke with chief medical officer and co-founder Mark Slack, and implementation executive Mario Bento, to find out more...

Tricia - I'm at CMR surgical, which is a medical robotics company based in Cambridge. I'm here to have a demo of, and have a look around the Versius system, which is a medical robot that assists surgeons in performing laparoscopic surgery. Hopefully I don't break anything. What's the difference between normal laparoscopic surgery and that where you've got a robot assisting you?

Mark - Normal laparoscopic surgery is keyhole surgery, and that's doing your surgery through tiny little holes. Now these huge advantages of keyhole surgery over open surgery, to you give you one statistic, you reduce surgical complications by 50% doing exactly the same operation by keyhole rather than by open surgery. However, in the world, only about 30 to 40% of people who could have keyhole surgery, do get it. The reason for that is it's really difficult to do. If you bring in robotic keyhole surgery, the end of the instrument is articulated. It behaves like a hand or like a wrist. In conventional keyhole surgery, the slang term for it is 'straight stick surgery' because the instruments have no articulation. That makes it incredibly difficult to do; That's where the difficulty comes.

Tricia - What's different about the Versius system compared to other robot assisted laparoscopic devices?

Mark - We've got a very different design from the other ones that makes us able to have a smaller robot. It's able to be placed more efficiently around the table. We can get better reach and that just widens the scope of what we can do. We can do surgery everywhere from the chest to anywhere in the abdomen.

Tricia - Is there anything that's automatic or does the surgeon have complete control over everything?

Mark - If I had a person standing next to the table and they wanted to get close to do something, they could push the arm across and I won't know that the arm's been moved because it adjusts automatically. The tip, where it's working and what it's doing, stays exactly where it was.

Tricia - And the tip staying exactly where it was is important because the surgeon needs to have complete control over what's happening in the patient.

Mark - The word is precision. That's what you want. You want absolute accuracy and precision in surgery. And that's what the robot gives us.

Harry - Yeah. It's time to get up close and personal with the equipment and Tricia got that chance to play surgeon with implementation executive Mario Bento.

Tricia - I can see clearly that at the bottom of this plywood prototype, there's a joint that looks like a shoulder further up, something looks like an elbow. You can see a wrist and then it's perhaps got a hand that's holding a long rod.

Mario - The system consists of the Versius console, which is the brain of the system and consists of four Versius arms. The console itself is where the surgeon would sit or stand.

Tricia - Attached to this rolling brain of the operation, which has a very large screen, it basically looks like there are two little nunchucks which have joysticks and a couple of buttons attached to these arms that then have a freedom to move around. I'm assuming that that's how the surgeon then operates the robotic arms.

Mario - Yes. As we can see when the console is turned on, the controllers actually float. Also, there's just enough space between where the surgeon sits to where the screen actually is, which maximizes that 3D view that the console has. You'll always need your 3D glasses to actually see the 3D screen, of course.

Tricia - Oh gosh. That's amazing. I'm leaning forwards and backwards and I'm looking at this screen and the field of view is getting closer and further away, but it's definitely three dimensional.

Mario - The controllers themselves have 3 sensors on each controller that detect someone's hand. It's a safety feature of the robot itself. It knows if I am holding the controller appropriately, it allows me to use the instrument. But as soon as I let go, or if it doesn't recognize my hands, if I'm not holding it properly, it won't let me move the instruments.

Tricia - Okay. I have to hold these joysticks to engage, so I'm allowed to move. I press a button with my thumb that says, 'start using this arm'. And then if I press my first finger, it's kind of like the trigger on a joystick and I can close and open the instruments. Hopefully I won't collide with anything.

Machine - [beeps]

Tricia - There we go. I've gone wrong. I've got something flashing on the screen in front of me and also the robotic arm by the operating table is flashing too.

Harry - It's not to worry. Mario got the kit up and running again eventually, but Tricia thought she would leave the robotics with the professionals. Just enough time though, to revisit Mark and discuss her experience.

Tricia - I had a go. I wasn't very good, I have to say. But one thing I noticed was how ergonomic the setup is when you're operating and the support that you have, and the fact that you can let go and everything pauses, it's like pausing a video game. Why is that important in terms of the safety to the patient and also in terms of the comfort and the safety to the surgeon?

Mark - There are multiple sides to that. Fatigue during normal keyhole surgery means that you're struggling and you're probably more prone to make errors. There's a little known fact that many senior surgeons get a lot of musculoskeletal difficulty from operating. That's one big area. A lot of the instruments that are made are too big for female surgeons to use because their hands tend to be smaller. Those are all things that the robot can help overcome. We pay a lot of attention to the ergonomics. I don't want to see surgeons being injured and then having to end their careers because of neck problems, so we see that as a very important part of the program. They are more rested while they're operating, which means better outcomes, and they remain able to operate for longer.

Tricia - Do you think that in the future, we are gonna have fully autonomous robotic surgeons?

Mark - I don't think in our lifetime. But what I do see the robot introducing is a system between the surgeon and the patient. That allows us to do all sorts of other exciting things. We can actually standardize surgery. We can put checklists onto it. Every time they arm moves, the computer is registering its movements. Every high end movement to the surgeon is measured as well and we started to correlate that with outcomes. When you go and have your operation, wouldn't it be nice to know how good your surgeon is?

Tricia - These robots not only are tools that allow us to access the body in a minimally invasive manner. They also give feedback that wouldn't otherwise be recorded if you did a manual laparoscopy.

Mark - All the data that is got through there, when you talk about AI and things like that, that's where we are going to mine a lot of data. And potentially we'll come to a point where it can warn you that you're about to make a mistake. Those are the sort of things that I'm looking towards as being futuristic.

Harry - Tricia Smith, speaking to Mark Slack and Mario Bento from CMR Surgical there. We're discussing some of the novel ways robots are pushing the boundaries of human endeavour.