Robotics in surgery

Robotic surgical theatre mock-up

I sat with my housemates Sam and Sabrina down in London over dinner one wintery night with Sabrina's lawyer father, and up came the conversation about robotics 'being the future', and the role of human surgeons being in gradual decline.  Challenging!  Could surgeons really be in one country while a robot operates in another, or could the blood-and-guts part of the profession become the realm of programmers?   Something of a career risk as a trainee doctor considering surgery.  How does the marketing hype about robotic surgeons hold up to the evidence?

Usage of robots in surgery: 

The market-leading surgical robot manufacturer (Intuitive Surgical - the Da Vinci robot) report 600,000+ operations per year globally using robots in 2015.  To put this in some context, there were 3.7 million surgical procedures in the UK in 2013/14

Intuitive surgical's marketing is supposedly excellent, and the limited US regulation of medical device advertising means that a market can be built for a product without there necessarily being a patient benefit. In a competitive hospital market, the prospect of robots to do your surgery is a differentiator for the patients. Bloomberg have a good article on this here

Conclusion:
Robot use is growing fast

Potential added value that robots can provide [LINK (2004)]
> Removing operator tremor
> Dexterity
> Technical solutions to microsurgery - operating on tiny blood vessels that might otherwise prove too challenging to reconnect (I find this particularly compelling)
> Ergonomic positioning of the surgeon
> 3D vision (better than on a typical laparoscopy screen)
> Decision support tools (i.e. an MRI overlay helping stereotactic needle placement)

> Automatic movement of instruments in synchrony with a beating heart

Conclusion:
The potential benefits to robot-assisted surgery are significant; but probably dependent on the extent to which the current practical limitations actually impact patient outcomes

Cost implication of robotic laparoscopy compared to conventional laparoscopy:
Per surgery additional cost:
+$200 per cholecystectomy (2014)
+$1,400-$2,200 per hysterectomy (2010)
+$2,500-$3,500 per nephrectomy/partial nephrectomy/pyeleoplasty (2011)
+$800 per radical prostatectomy (2011)

Individual outlay per robot

Net cost of DaVinci robot - $1.75 m, and when factored across their lifespan of use they have implications for the costs of each surgery performed.

Conclusion
Robot-assisted laparoscopy is currently more expensive than conventional laparoscopy.

History of surgical robot development: [LINK]

1983 - Arthrobot (holds limb during surgery)

1985 - PUMA560 (places needle for brain biopsy using CT)
2003 - Intuitive Surgical (DaVinci robot creator) merges with Computer Motion (Zeus/Aesop robot creators). Intuitive Surgical are now the leading robotic surgery technology company.

Conclusion:
Robots aren't a new thing in surgery - they've been around for 30+ years

Patient outcomes of robot use: 
In general for surgery, robots are ​more expensive, have more complications, and outcomes are not improved over laparascopic surgery based on 4000 studies [LINK].  NHS England consider there to be no mortality gains but some quality of life gains in prostate surgery with robots [LINK].  Cancer Research UK consider there to be no advantages yet in prostate surgery with robots [LINK]

Conclusion:
The evidence doesn't currently suggest that there are consistent patient benefits from robotic surgery


General conclusion

Robot use in surgery use is on the rise, and the potential for robots to enhance the quality of surgery certainly sounds impressive.  However, robots are expensive and currently of unproven benefit, so it's not yet time to be requesting your surgeon uses a robot rather than more traditional techniques.

Some videos of robots at work:

Example: Da Vinci Robot: peeling a grape

Animation: radical prostatectomy.
Prostate removal @2:00; bladder-urethra reattachment @ 3:00

Da Vinci Robot: radical prostatectomy

Light ?dark? relief:

Surgical robots in the US Justice system

Medical museums

Recommendations for places to immerse yourself in medicine:

Been to
1) The Wellcome Collection - London (beautiful reading room upstairs with names of the greats on the wall below the gallery.  Huge library and cross-cultural insights into medicine through history.  Obscure collections include African/European statuettes of erotica!

Wellcome Collection Reading room

2) Royal College of Surgeons Hunterian Museum - London (excellent history of surgery, as well as cabinets of surgical devices and obscure pathological cases.

Irish giant at the Hunterian

3) RCS Wellcome Museum of Anatomy & Pathology - London (amazing space, with healthy specimens lined up next to pathological ones.  NB: only open to those in the medical profession, including students; no photos

Study zone at Wellcome Anatomy & Pathology museum - free suturing practice available

4) Semmelweis Museum of Medical History - Budapest (has two collections - a medical history one in memory of Ignaz Semmelweis one of the fathers of antiseptic technique, whose unfortunate approach didn't win him much support while alive, has wonderful full-body medical wax models from the 16th century; second collection is of Hans Selye's extraordinary work into stress / coping / resilience and its effect on the body).

Susini's Anatomical Venus @ Semmelweis - c. 1790s.  Body hasn't changed much!

5) The Old Operating Theatre & Herb Garret - London (history of surgery in London - an example of how things were done in the past, and how lessons were learned from the mistakes)

Old Operating Theatre by Guy's Hospital - looks just like that featured in The Knick

6) Body Worlds - the one of Gunther von Haagens pedigree, currently on tour the USA, Germany, Poland, Netherlands (excellent for anatomical insight, a mixture of human and animal plastinated models)

Body Worlds - exhibition full of curious poses

Future plans!
Freud Museum - London
Maguro Parasitological Museum - Japan

Links:
London Medical Museums: http://medicalmuseums.org
Medical Museums of the world: http://www.mnn.com/lifestyle/arts-culture/photos/7-unusual-medical-museums/weird-science
Semmelweis Meseum: http://www.semmelweis.museum.hu/muzeum/index_en.html

[will keep this updated]

Hand surgery - an introduction

Since having shadowed a hand surgeon in Derby, which got me excited about the profession, I thought I'd review how hand surgery is organised, and just what hand surgeons do.

Hand surgery governing body - the BSSH
The British Society for Surgery of the Hand (BSSH), est 1952, formally 1968.  Its first president was Irish-born 'Guy Pulvertaft' (1907-1986).  The Pulvertaft Hand Centre at the Royal Derby Hospital of the Royal College of Surgeons (internationally recognised) is named after him.

Commonest hand surgeries
I was informed during shadowing at the Pulvertaft that there are 250 hand surgeries that can be mastered.  BSSH list the commonest as (2006 UK figures):
- Carpal tunnel decompression (38,000)
- Palmar fasciotomy for Dupuytrens disease (11,000)
- Surgical removal of Ganglion cysts (6,400)

Carpal Tunnel Release

Ganglion cyst

Dupuytrens

Further surgeries
These include the following - it would be good to find a resource with a list including statistics
- Trigger finger release
- Post-traumatic reconstructive surgery of the hand, including scaphoid (wrist bone) fracture
- Ruptured tendon repair, often secondary to rheumatoid arthritis - plus tendon transfer
- Trapeziectomy (removal of a bone in the wrist) at the base of the thumb
- Joint fusions (PIP, DIP, carpal fusion in the wrist)
- Arthroplasty (e.g. resurfacing joints - commonly MCP, PIP)
- Treatment for ligament injuries in the wrist
- Wrist replacement, nerve ablation, very specialised centres conduct hand transplants, etc. unclear how common all these are

Referrals to hand units
Referrals to hand units don't all require surgical intervention - common referrals are below:

Links:
BSSH Hand surgery report: http://www.bssh.ac.uk/members/documents/ukhandsurgreport.pdf
Introduction to common hand surgeries for junior doctors: http://bit.ly/1m7pTNJ

Upper extremity prostheses

I was interested to see what was available in prosthetic devices for upper limb injury, after having visited a prosthesis manufacture workshop in Nairobi in summer 2015, and also since I have an interest in hands.

Prosthesis options:
Passive prosthetics - cosmetically helpful but without significant functional use (some can be reshaped into a pincer grip) http://biomed.brown.edu/Courses/BI108/BI108_2003_Groups/Hand_Transplantation/altern2.html

Functional prosthetics 1 - simple mechanical cable operated - can operate by motion to close the gripping device, which would reopen by an elastic mechanism (e.g. rubber banding).  Limited in those patients with limited movement.  Paired claws and pincers are remarkably functional and offer good visual feedback of what the hand is doing, thus enhancing their use.  Cheaper to produce.



Functional prosthetics 2 - myoelectric - skin-based electrodes sense muscle contraction, and thus enable the device to be controlled.  Devices tend to be heavy, expensive and battery duration can be an issue.   https://www.youtube.com/watch?v=_qUPnnROxvY


Particularly impressive is the variety of grips with the advanced versions of these prostheses:

o    Handshake

o    Power grip

o    Precision grip

o    Mouse grip (e.g. to point and click)

o    Trigger operated device grip

o    Index finger use for PIN number entry

o    Key-holding grip

Notable figures with upper extremity prostheses:

Rick Allen – Def Leppard drummer (RTA amputee)

Aron Ralston – Adventure writer featured in 127 hours film (amputated his own right arm after becoming trapped by a boulder)

Abu Hamza – radical Islamic cleric known for using a pair of hooks (explosives accident)

Matthew Scott - first recipient of a lasting hand transplant, which is still functional more than a decade later (firework explosion).

Blog link 
Great thoughts on prosthetics and exoskeletons
https://forrestbrown.co.uk/news/we-are-all-cyborgs/