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/ 

Surgery in the UK by numbers

An interesting view of surgery in the UK by numbers.  The four largest specialities are Trauma & Orthopaedics, General surgery, Obstetrics & Gynaecology (though the Royal College of Surgeons for some reason don't include those!), and ENT.

A more detailed source of these can be found on the HSCIC website LINK (2015):

• Even more common than the hernia, hip, knee, gall bladder and tonsil surgeries listed above are 
• Skin lesion excision
• Colon lesion extirpation (removal/ablation)
• Joint aspiration
• Caesarean section
• Tooth extraction
• ~500 types of operation are carried out at least 1,000 times each year in the UK
• 60 types of operation are carried out at least 30,000 times each year in the UK
• I'm aiming to see as many of these as I can while I've the capacity in medical school - have seen 30 of the top 60 so far!

Insights from global health conversations

Some global health actors

Have had the good fortune of meeting some people engaged in global health over the last few months.  Some insights:

EB (European health policy).  Indicated some important things that Europe offers us:

• Professional qualifications directive (2005 & 2013): ensures that certification of equivalence is possible for doctors working around Europe.  "Doctors, dentists, pharmacists, nurses, midwives, veterinary surgeons and architects benefit from the automatic recognition of their qualifications, on the basis of harmonised minimum training requirements."
• Working time directive (2003): provides a limit to working hours, which must not exceed 48 hours per week on average. 

SM (WHO, Ebola communications)

• WHO is undergoing a significant restructuring recently in the wake of the Ebola crisis; due to limitations in their logistical capacity to respond effectively to the epidemic.  Improving disease surveillance an important feature.

PF (ILO, disability advocacy)

• Maintains a disability blog - some good core messaging, in that access, rehabilitative therapy, and supported employment are some of the main topics advocated on; these being important topics both in the UK as well as in Bangladesh where much of his recent work has been
• Suggests that getting disabled people into work in developing countries is (1) difficult for many reasons, but (2) possible & going on, and (3) can be developed further through small initiatives rather than the huge investment one might anticipate

EO (Orthopaedic surgeon, Kenya)

• Took the view that any international exposure to different functioning healthcare systems is valuable.  
• Particularly helpful to look up and down the chain of how healthcare is delivered with more resources (and hence some of the latest technology), as well as with less resources (and hence using autoclaves, reusable drapes, etc., and cutting out expensive tech like laminar flow in orthopaedic theatres.
• Indicated that some orthopaedic trainees from Kenya when visiting Europe to train find that they have to relearn a lot of the knowledge - it can be demoralising to be taught badly and have to relearn techniques, although satisfying to bring best practice back

CR (MSF, midwife)

• While wealth levels may vary, the same stories play out in communities all over the world - love, children, infidelity, backscratching, festivities.

Samreen (Indian, FY3)

• The social-care delays on hospital discharge in the UK seem almost inexplicable - in India family will take in dischargeable patients, and middle class Indians can recruit cheap labour to their homes to care for ailing relatives - typically by providing them board & lodgings, and making them one of the family

Hand surgery inspiration

Hand surgery

I've been talking to people about hands.  Here are some of the nuggets that have turned up:

Musicians
- JP Ekins - Piano players' hands have wider reach as the thumb and little finger are sufficiently stretched apart to make a straight line.  Stretching a 9th is a normal reach.  Left hands apparently usually have a larger reach
- Liam Waddle - worried about arthritis.  Seemed to have a hyperextended thumb and middle finger on his right hand
- Dom Pipkin (& the Iko's) - noticeable broadened finger pads; apparently painful after a session of hammering the notes.  Amazing pianist tho
- Patrick (drummer with the Iko's): natural finger cadence is used as a guide when teaching drumming pupils to pick up their sticks

Sports
- Climbers' hands have denser bones, stratified relating to pressures used in their climbing - seen on a Sheffield example BBC documentary about anatomy.  Link to a related paper - one of the authors has surname 'Carpi'

General arts
- Carlo Maria Mariani - "The hand submits to the intellect" - representing the postmodernist 'meta-art' critique: a picture of two men painting each other, indicating that art is self-generated and hermetically sealed.
- Robert / Patrick Scott - Hands are one of the hardest things to get right when painting -> and occasionally palmed off onto the artist's assistant.  The size of hand from distal wrist crease to fingertip is approximately that from chin to hairline.

Medical lectures
- Morgan X / Louise Hickey - greater density of nerve fibres in fingertips enables more effective tactile discrimination.  Morgan (as an architect) talked of being able to 'grasp' a design - only engaging with a building design once he had physically felt it.  Haptic object recognition (stereognosis) enables us to generate a virtual image of an object without seeing it.
- Hand transplants: 80% of tactile function may be achievable with appropriate patient concordance with physiotherapy (from Blood and Guts, the History of Surgery).  Choosing an appropriately hairy / sized / gendered hand is important.  Immunosuppressant anti-rejection drugs may reduce patient lifespan.
- Carer: massive functional loss that occurred when his wife finally lost the ability to move both hands.  Even the basics like television remote and panic button use.  Preserving hand function is v important (perhaps a point for voice control).  Story was told by a 70+ y/o carer who's part of the MS society.


[To be added to]

Some Lessons in Development Management - Places Visited (Kenya)

Kenya visit - August 2015

 2 weeks' clinical shadowing!  Set at a PCEA Kikuyu district hospital, as well as the Kivuli medical clinic, Miliki Afya clinic, Mid Hills hospital and a health project operating with HIV/AIDS patients.

Health data: Major health problems faced: diarrhoea, malaria, HIV/AIDS (5.6% prevalence), TB, other respiratory problems.  Major exports are coffee / tea / cut flowers / refined petroleum.  There are approx 1 doctor per 10,000 people (compared to 30x that number in the UK), under 5 mortality is 71 per 1000 live births.  User fees have been levied for healthcare, since 1989 ?structural adjustment.  50% of doctors practice in the capital, and only 10% of doctors across the country work in the public sector.  Per capita expenditure on healthcare is $72 (as compared to $3,400 in the UK). 

Health facilities: Vary from the very upmarket (Gertrude's, Aga Khan) through smaller hospitals (including some mission hospitals), to local poorly regulated clinics.  Word of mouth reputation is important as clinical excellence data is not routinely collected.

Kenya is a financial centre for East Africa; strong trade links with India, China, UK as well as its Ugandan / Tanzanian neighbours.

Cost effectiveness of basic medical interventions in the developing world

Vaccination programme

Figures provided are per DALY (2001 data).  I've highlighted up the areas I've thought of working in, both pre-medicine and now I'm in medicine (latest view in bold).

·        Vaccination (e.g. diphtheria, polio, pertussis, river blindness, measles & deworming) ($3-6)
·        Hygiene promotion against diarrhoeal disease ($5)

·        Emergency medical care by training first aiders ($6)

·        Identification/treatment/control of leishmaniasis (~$10)

·        Malaria bednet provision and residual spraying ($6-11)

·        Acute MI management with aspirin and beta-blockers ($14)

·        Malaria treatment ($19)

·        RTA reduction interventions, e.g. speed bumps, media campaigns, speed penalties ($21)

·        Clean cookstoves - swapping out for LPG (~$50)          

·        Child nutrition / breastfeeding advice ($42)

·        Water sector regulation for clean water supplies ($47)
·        Integrated child health management (~$70)

·        HIV/AIDS education; routine counselling/testing; condom distribution ($37/$47/$82)

·        Ante/postnatal midwifery and obstetric emergency care ($87)
·        BCG vaccination against TB (~$100)

·        Epilepsy (Phenobarbital) & CHF (ACE + beta blocker + diuretic) basic treatment (~$100)

·        Family planning / contraception ($117)

·        Trauma surgery ($136)

·        Basic sanitation provision ($141)

·        Emergency medical care by training ambulance service (~$150)

·        TB treatment (~$150)

·        Cataract surgery ($183)

·        Vaccination (e.g. Chagas, Flu, HepB, diphtheria, pertussis, tetanus) ($300)

·        Alcohol & tobacco disincentivisation ($300-1000)
·        Oral rehydration therapy package for diarrhoeal disease ($1,000)

Source: http://www.ncbi.nlm.nih.gov/books/NBK11784/ 

Medical literature/arts

Crucial Interventions - an arty book of surgery

So, with a view to a broader take on medicine, I'm trying to read a few novels and absorb a little medical culture in between the scores of facts that I'm learning in the weeks.

So far:
Morris Gibson - One Man's Medicine (James Herriott-esque tale of working in Hull as a GP)
Atul Gawande - Complications (learning on the job as a surgeon)
Jed Mercurio - Cardiac Arrest (1990s TV dark drama/comedy series of horrific hours on the NHS wards)
BBC - Inside Harley Street (2015; exploring the world of complimentary therapies, private consultants; plastic surgery etc. in London)
Thomas Lilti - Hippocrate (2015: Film about a French intern dealing with his mistakes, seeing that experience counts more than rank, the food&cultural underpinning in a French hospital, the importance of good clinical skills with the patients)
Samuel Shem - House of God (cynically written, reminds me of Catch-22 and Catcher in the Rye, actually too cynically written for me to finish)
Atul Gawande - Reith Lectures (more on the theme of learning and making mistakes in medicine)

Matthew Syed - Bounce (a helpful take on the benefits of practice and how to avoid becoming preoccupied with notions of talent)
Richard Hollingham - Blood and Guts (a history of surgery, including a great take on the 19th century developments of anaesthesia, haemostasis and aseptic technique)
Henry Marsh - Do no Harm (memoirs of a neurosurgeon, including the thrill of the operating microscope, dealing with dying patients, greiving relatives, challenging NHS managers, and the decline of the doctor's omnipotence)
Steven Soderbergh - The Knick (surgical drama set in 1900; main protagonist played by Clive Owen - a cocaine addicted creative surgeon)
Mark Porter on BBC R4 - Inside Health (picking a local health topic each week; Tuesdays at 9pm, not particularly challenging, has a British GP feel to it)
Claudia Hammond on BBC World Service - Health Check (picking a global health topic each week; Wednesdays at 8.30pm, has an international feel to it)
Lisa Sanders - Every Patient Tells a Story (from the technical advisor to House, MD - insight into the medical life)
Kevin McKidd - Grey's Anatomy (remarkably well-scripted drama about surgeons starting out on their internship rotations in the US)
Victoria Pile - Green Wing (sitcom from 2004-7, dead funny, set in an NHS hospital)
Dan Sefton - Trust Me (drama from 2017, nurse posing as a doctor)
James Wood - Quacks (comedy from 2017, surgeons set in Victorian Britain, moderate at best)

In the planning:
BBC3 - Junior Doctors (2011-2013; exploring the trouble around being an F1)
Max Pemberton - Trust Me I'm a junior doctor (columnist)
Daniel Kahnemann - Thinking Fast and Slow (on human rationality and irrationality)
Atul Gawande - Better (a surgeon's broad visits to and review of what improves medical interventions - from Iraq to India)

>>list updated as it grows<<

Porto Hostel

Gallery Hostel - Porto

Can't recommend this hostel enough:
http://www.gallery-hostel.com/en/

Particularly - an art gallery on the inside (and over the road from another gallery), communal three course delicious meals served with the staff and their wine; a substantial DVD collection with a cinema-room, guitars, bikes and a terrace.  What's not to like?!

+ Breiner '85 gig venue
+ Muralhas wine
+ Liveria Lello & Imao
+ Restaurante Salta-O-Muro (Matosinhos district)

Spent a lovely few days there with Nick & Jon at Easter, before partying in Bairro Alto, Lisbon and visiting Braga for their pre-Easter build up.

Social psychology of relationships

A helpful management / social psychology site covering relationships
http://www.changingminds.org/

Particularly interesting to read the section on transitions in relationships. Would have stood me in good stead working with some of the pscyh patients; and may well be helpful in some of the relationship crises that our medical patients get wrapped into.
http://changingminds.org/explanations/relationships/devito_stages.htm

The sections on group dynamics also useful @ work.
http://changingminds.org/explanations/groups/groups.htm