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Technology
MEDICA L R ESE A RCH By Charlie Metcalfe

N
eil Thomas wished he could

The robot have been awake during the

operation to remove a 6cm
cancerous tumour from his

surgeon will
colon. He was one of the first people to
go under the scalpel of University hos-
pital of Wales’s new robotic systems
in June 2022. And, as the founder of

see you now...

Keyhole surgery using robotic arms has
transformed medicine – and advanced devices
coupled with AI might surpass doctors’ skills
a software company, the technology
interested him.
Thomas’s surgeon, James Ansell,
would once have stooped over his
patient’s body to perform the opera-
tion. Instead, he stood behind a con-
sole on another side of the theatre
wearing 3D glasses. His hands grasped
two joysticks, which controlled the
four robotic arms that huddled around
Thomas’s unconscious body.
“My colleague said to me the other
day that this feels like cheating,” Ansell
said. “We’ve done it for so many years:
stood at the bedside at an awkward
angle, sweating because it’s really
physically demanding surgery. [Now,]
sitting down, there’s no pressure on
the surgeon. It’s very straightforward.”
Robots have revolutionised the prac-
tice of surgery since their introduction
to operating theatres in 2001. They can
now be found in hospitals across the
world. The most prolific device, the Da
Vinci, is used in 1.5m operations every
year, according to its California-based
manufacturer, Intuitive Surgical.
Now, combined with AI and other
novel technologies, engineers are
developing advanced robotics to her-
ald another new era for surgery. This
time, the surgeon’s role in the operating
theatre may change altogether. Some
people are referring to it as Surgery 4.0.
Although robots are put to a variety
of tasks in surgery, their use as a tool
in performing laparoscopy – other-
wise known as keyhole surgery – has
attracted the most attention within
and outside medicine. Keyhole sur-
gery reduces the time patients need to
ILLUSTRATION: PHILIP LAY/OBSERVER DESIGN

recover by operating through smaller,

keyhole-like incisions. This reduces the
chance that patients catch infections,
and so accelerates their recoveries.
Without robots, keyhole surgery
requires a very high level of skill. Sur-
geons need to operate at awkward
angles, moving their hands in the oppo-
site direction to that which they want
their instruments to move inside the
body. With robots, they can perform

more complex operations that might
otherwise demand open surgery, they
suffer less physical strain, and they
require less training time. Surgeons
are becoming better at using them, too.
“Some of those patients who have
ultra-advanced diseases involving
blood vessels at the back of the pelvis
might still get an open operation,” said
Deena Harji, a colorectal surgeon in
Manchester, “but we’re starting to see
some very early case studies coming
out where they’re starting to have
robotic approaches applied to them, at
least in part. When robotics started 20
years ago, that group would not have
been eligible for robotic operation. But
as we have developed experience and
knowledge, we can offer really com-
plex patients robotic surgery.”
Surgeons are physically limited by
their bodies. Their minds are limited
in their capacity to learn and improve.
That’s why engineers are hoping
robotic systems combined with AI
might be able to surpass the skills of
human surgeons to produce more
consistent results – with fewer errors.
Last year, engineers at Johns Hop-
kins University in the US came one step
closer to realising that goal. In what
they described as one of the most
delicate procedures in the practice of
surgery, their Smart Tissue Autono-
mous Robot (Star) sutured the ends
of a severed intestine together in four
pigs – while they were under anaes-
thetic. According to the engineers, it
performed better than a human sur-
geon would have.
“Our findings show that we can
automate one of the most intricate and
delicate tasks in surgery,” Axel Krieger,
an assistant professor of mechanical
engineering, and the project’s director,
said at the time.
The Star’s procedure was not the first
time a robot had performed with a level
of autonomy in surgery. The TSolution-
One device (formerly called RoboDoc),
for example, is approved by the US Food
and Drug Administration to prepare
human limbs for joint replacements
according to a surgeon’s plan. What
makes the Star’s procedure special was
that it performed its task using keyhole
surgery – a world first.
Surgical robotics presents a good
opportunity for engineers to introduce
autonomy because of the vast volume
of data that devices can collect. An
intelligent system, once developed, can
use this data to teach itself. In theory,
it could even become better with each
operation that it performs as it gathers
more and more data. This could help
healthcare organisations “standardise”
the results of operations.
Mark Slack, the chief medical officer
at CMR Surgical, which manufactures
another surgical robot, Versius, says
manufacturers have failed to exploit
this data until now. That’s why they
and researchers such as those involved
in the Star project are scrambling
to collect and process as much as
possible. “Data, data, data,” Slack
said. “This data has had significant
untapped potential.”
Despite the Star team’s success, it’s
still too early to forecast autonomous
surgery in hospitals any time soon. Engi-
neers talk about “levels of autonomy”.
For a robotic device, the question is not
whether it is autonomous or not; the
question is how autonomous it can be.
And the Star system performed only
a small section of a complete surgery
without human help. In fact, it even
needed humans to apply a fluorescent
marker to guide its movements.
“You’re not supposed to call it
autonomous surgery,” said Tamás
Haidegger, an associate professor of
intelligent robotics at Óbuda Univer-
sity in Budapest. “This is automating
one particular surgical subtask.”
H
aidegger makes what he
believes is another impor-
tant distinction – between
the kind of complexity
required for a system like the Star and
the devices used in hospitals. Standard
laboratory best practice in research
environments often falls short of the
safety and design standards of clinical
settings, he says.
For use in clinical environments,
manufacturers need to be able to
explain exactly how their devices
work, which continues to prove a
challenge for people who develop
AI. There’s also the impending intro-
duction of AI-specific regulation that
governments across the world, includ-
ing the UK and EU, are developing.
Autonomous surgical robots will need
to comply with those too.
According to Haidegger, this all
amounts to a very expensive pro-
cess for manufacturers to prove that
their devices meet the regulatory
requirements. Each device needs
to gain approval for each new field
of surgery, one at a time, which has
already decelerated the adoption
of the human-operated robots used
CMR Surgical’s Versius
robot. The technology
takes much of the
physical strain out
of an operation for
the surgeon, and is
particularly useful in
keyhole surgery
‘Surgeons’ today. It will take a lot more work for
a commercial manufacturer to decide
minds are that the potential profit justifies the
limited cost of research and development. “It’s
in their not going to radically change medical
devices overnight,” Haidegger said.
capacity to For health organisations with strict
learn and budgets, the cost of surgical robots has
remained a prohibitive factor. The Da
improve’ Vinci costs about $2m (the company
would not confirm a specific price,
stating that it depends on the buyer’s
individual requirements). CMR Sur-
gical’s Versius costs between $1.5m
and $1.9m. This does not include the
added cost of training and mainte-
nance, which can be 10% of the initial
investment every year.
1.5m
Whether they prove cost-effective
or not, surgeons agree that robotic sys-
tems have made it easier for them to
The number of perform more complex procedures,
operations the while minimising scarring for their
manufacturer of patients. Neil Thomas, the former tech
the most prolific entrepreneur with a tumour that was
surgical robot, removed from his colon in June 2022,
the Da Vinci, was able to leave hospital only two
says it is used days after his operation.
in each year Thomas had been training for an
Ironman triathlon at the time of the
$2m
diagnosis. Three months after the
operation (on doctor’s orders), he
was able to return to training. First a
Approximate 1.5km run, and then a few more three
cost of the Da days later. The robot used in his opera-
Vinci (the firm tion had left only a small collection
would not quote of almost imperceptible scars across
a specific price, his abdomen. “You can’t see a thing,”
saying it depends he said. “And recovery, I thought, was
on buyers’ excellent.” Observer
requirements) CHARLIE METCALFE WRITES ABOUT
SCIENCE, HEALTH AND TECHNOLOGY
23 June 2023 The Guardian Weekly