WHY THIS MATTERS IN BRIEF
Surgery is getting the robotic treatment, and it could mean better working conditions for doctors, and better outcomes for patients.
When Luke Hares met with gynecological surgeon Mark Slack four years ago to talk him through his idea of Versius, the first UK built surgical robot, the latter’s first reaction was naturally one of scepticism. A machine for assisting him in performing surgery, he thought, was not useful. As a first class surgeon, Slack believed, and with good reason, that there was nothing a robot would do that he couldn’t, in spite of the fact that increasingly surgical robots are setting new records in neurosurgery, dentistry, and eye surgery, and being used by the US military to remotely operate on soldiers injured on the battlefield on the front lines while the surgeons themselves are based thousands of miles away back home in the US.
Slack was in his mid fifties at the time, and at the end of an eight-hour day standing in stress positions while he was operating, he felt exhausted. So when Hares asked him about the hardest parts of his profession, Slack was adamant: the difficulty came from physical fatigue.
“By speaking to experienced surgeons like Mark Slack I was able to understand the need,” says Hares. “While they are able to do a lot, surgeons can’t do everything. That’s where robotics can bring solutions.”
Four years later, Hares seems to have completed the challenge he set for himself. Cambridge-based medtech CMR Surgical, after raising £75 million in June 2018 from a number of investors including LGT and ABB Robotics, has launched his surgical robot – one that hopes to revolutionise medical robotics. It goes by the name of Versius, and it is likely to be rummaging through your abdomen with tiny scissors and graspers pretty soon.
All metal and no heart, meet your new surgeon
The concept may sound off putting, but it is not new. Guy’s and St Thomas’ NHS Foundation Trust in London was the first NHS trust to use a robotic system to help surgeons, and that was all the way back in 2003.
Robots have been used since then in the UK to perform Minimal Access Surgery (MAS), also called keyhole surgery – a type of operation that is done using small, keyhole incisions rather than open surgery, a longer established way of operating, which consists of making a large cut across the body to allow the surgeon to look directly at what he is doing.
Smaller cuts mean smaller wounds, and smaller wounds mean less blood loss, less complications and less recovery time spent in a hospital bed funded by the NHS – two days on average, in fact, instead of two weeks. Essentially, MAS makes everyone happy.
But as Prokar Dasgupta, Professor of Urology at the London Clinic – a private hospital and charity – and at Guy’s and St Thomas’ NHS Trust explains, the growing patient demand for keyhole surgery cannot be met.
“There is an increasing need for surgeons to learn how to perform this type of surgery,” he says. “But MAS surgery is hard to learn and too strenuous to carry out on a large scale. Not enough surgeons can do it, and therefore not enough patients can get it.”
To perform manual MAS, surgeons use small instruments at the end of long sticks that they insert through keyhole incisions into the patient’s body. What is happening at the end of the stick, they can see on a TV screen linked to a camera that is also inserted through a keyhole.
Standing for a couple of hours watching a screen to check that you are correctly manipulating forceps and needles inside a patient’s body is no easy job. Enter the da Vinci surgical system, which I’ve also talked about before, created by American company Intuitive in 2000. This 750 kg “robot” allowed the surgeon to sit down watching the screen and control, from a distance, moving frameworks attached to the machine and which carried the different instruments necessary for keyhole surgery.
Imagine a surgical video game, where the surgeon has a console controller. Just a left-hand push, and down go the scissors through the tiny incision on the patient’s body. Dasgupta, who was the first doctor in the UK to perform robotic surgery using the da Vinci, asserts that the system was revolutionary.
“The surgeon could be comfortably seated and that completely changed the way we perform surgery,” he says. “When I look back on the past 15 years, I would say the da Vinci has been largely a success story. It made MAS more accessible to surgeons and therefore to patients.”
Luke Hares, inventor and designer of CMR’s Versius robot, believes on the other hand that Intuitive’s machine has not solved the most important problem linked to keyhole surgery.
“Today, about 12 million surgical procedures are performed every year. Half of them are done with MAS, and the vast majority of the other half should be but aren’t. And among the six million procedures that are done with keyhole surgery, only 800,000 are done robotically with the da Vinci system. That’s after 15 years since Intuitive launched their product,” he said.
Dasgupta agrees that as ground breaking as the da Vinci was, it is still not accessible enough.
“Worldwide, only 5 to 10 per cent of operations are robotic. The da Vinci’s successes must be tempered with an element of reality. That reality is that it is not as available as it should be,” he said.
The reason for the da Vinci’s lack of availability lies in it cost. Not only is the machine really expensive, but it’s not designed to be flexible either and its weight and size mean that it is assigned to one operating room and cannot be moved. On average, a da Vinci system operates once every other day. Hares argues that this lack of productivity explains why hospitals cannot justify investing in the system.
“The big challenge is to find out how to make a sophisticated tool available at a reasonable price and the answer to that is utilisation. If the robot is busy three or four times a day, it becomes much more cost effective. This is why we came up with Versius.”
Versius’ added value lies in its flexibility, continues Hares. Instead of one central pillar holding all the instruments, CMR designed several separate robot arms, each with their own surgical instrument, each on their own pillar, and all still controlled by the surgeon from his console. The arms can be set up a lot of faster – and therefore much more easily carried from one operating room to another.
“We focused on making Versius easy to set up, tear down and reconfigure, because that directly impacts the robot’s productivity,” says Hares. “We designed it to be as flexible and mobile as possible. This way, it can be kept constantly busy and it becomes more affordable.”
The CMR team, driven by the idea of building a system that would be as productive as possible, also dramatically rethought the robot’s design to make it an ergonomic tool for surgeons – thus enabling them to tire less easily and operate more patients every day.
“We looked at the requirements of surgery and we realised that we had to build a robot arm that would mimic exactly the human arm,” says Hares. “Industrial robot arms today can’t do that. They only have six degrees of freedom: when they hold an instrument, they can only go upward, downward, forward, backward, left and right.”
“We invented a robot arm with a seventh degree of freedom,” he continues, “by adding extra joints in the arm and the wrist. The elbow can pivot, adding a lot more capacity to what the wrist can do.”
In other words, the CMR team’s robot arm could probably dab. But even more crucially, it provides for a much more intuitive and comfortable tool for the surgeon to use.
Hares expects that an experienced surgeon could operate up to eight hours a day instead of two with the help of Versius – another boost in productivity that would make the treatment accessible to more people.
And it is not only about opening access to keyhole surgery. By storing data after each operation, the system will also enable surgeons to refine their technique. The information recorded by the robot about how it has been used can be analysed, compared and fed back to surgeons. A potential to contribute to the improvement of surgery that Luke Hares describes as “tremendously exciting”.
Some of us may feel reluctant that robot surgeons may become the new norm for operating. But Dasgupta firmly dismisses distrust in robotic surgery as grounded in misconceptions.
“A fool with a tool is still a fool,” he says. “There is no question that the quality of the surgeon is more critical than the machine, and the outcome of the operation still relies on a human brain. Surgical expertise is still key.”
For the moment, it looks like it is. But for Luke Hares, we are only at the start of the surgical journey that could potentially lead to robots one day operating on human bodies in a completely autonomous way.
In the meantime, Versius is only waiting for its CE mark, which should be secured in the next six months, before it can be sold to hospitals – or rather, offered as a managed service. The CMR team is planning on arranging for clinics to be able to pay smaller sums of money each year to use Versius, with access to all of its instruments, rather than having to pay at once for an expensive system that needs to be regularly refreshed with new instruments.
Hares and his team hope to make Versius more accessible this way – keeping in mind, always, that technology is only revolutionising if it is economical.