Behind-the-scenes of a robot-assisted surgery

Alain Valverde, head of the digestive surgery unit at the Diaconesses Croix Saint Simon hospital (Paris-France), invites us into a 21st century operating theatre, where robots with mechanical arms are no longer in the realm of science fiction.

Meet Si, the remotely-controlled robot with mechanical arms and 3D vision who is here to help you

8:30 am, Diaconesses Croix Saint Simon hospital. In the middle of the operating theatre, a strange-looking machine with mechanical arms is busy operating on a patient with a digestive system cancer. Meet Si, the robot surgeon. Si belongs to the third generation of robots developed by US company da Vinci, the global leader in robotic surgery. Si has four arms: three for holding coelioscopic surgical instruments and a fourth with an optical sensor at its fingertip. The optical sensor sends a 3-D image to a computer console a few metres away from the operating table. Meanwhile, Dr Valverde executes a procedure worthy of a Spielberg film: using joystick-like controls, he operates on the patient by manoeuvring the robot’s arms. Julien, the assistant surgeon who recently joined the gastroenterological ward at the Diaconesses Croix Saint Simon hospital, explains to us that “the robot’s hands control the clamps and the incisions, while its feet control coagulation and the camera movements, sending 3D images in real time.”

alain-valverdeDr Alain Valverde, head of the digestive surgery unit at the Diaconesses Croix Saint Simon hospital, fitting one of the mechanical arms onto Si, the robot created by da Vinci.

A little further away, a da Vinci representative who watched the operation that day spoke to us in greater length about how Si came to be. “It was the U.S. Army that initially came up with the concept of robot surgeons. They wanted to be able to operate on the war-wounded without having to go to the frontline in person. Such projects were eventually adopted by private companies such as da Vinci, which saw solutions that could be more readily implemented in hospitals. Although Si comes with a hefty price tag — an acquisition price of €1 million and €200,000 per year in maintenance – the cost of this technology is likely to decline progressively over the long term, enabling it to be used much more widely in hospitals.

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Julien, assistant surgeon at the Diaconesses Croix Saint Simon hospital

Training is a necessity

 9:55 am. Not content with performing a robot-assisted surgery            to remove a digestive system cancer, Dr Valverde simultaneously explained how he was performing the procedure to an audience of surgeons from Annecy who had come to Paris specifically to watch this operation. Julien didn’t miss a thing. “Alain Valverde is one of France’s foremost robot surgeons. People come from all over the country to train in his techniques. You are witnessing a technically complex procedure far removed from a textbook case. To draw a parallel with football, it’s like watching a clásico between Barcelona and Real Madrid”, he enthused, his eyes riveted to the screen broadcasting the operation live. As with any innovation, robotic surgery requires extensive training. The da Vinci representative confirmed this. “Training in robot-assisted surgery is a four-phase process. The first phase involves familiarising surgeons with the tool. Next, they train in one of our three European centres. After that, they observe their first operation before going on to train in increasingly complex cases with renowned surgeons such as Dr Valverde.

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Dr Alain Valverde, head of the digestive surgery unit at the Diaconesses Croix Saint Simon hospital, preparing to remotely control Si, the da Vinci surgical robot

Robot-assisted surgery, a logical development in the role of a surgeon

2:00 pm. The operation went well. Dr Valverde joins us for coffee and discusses the impact of robots on his profession. “Contrary to what we might believe, robotic surgery is not a revolution but a logical development in the role of a surgeon.” The real revolution in usage in his field of gastroenterology took place 20 years earlier with the development of coelioscopic surgery, a technique that avoids making large incisions by instead using a small coelioscopic camera and special surgical instruments introduced into the abdomen via small incisions. This practice is known as minimally-invasive or keyhole surgery. Robotic surgery is based on this practice, the only difference being that surgical manoeuvres are performed by mechanical arms. So, what are the benefits? “Robot-assisted surgery allows for easier manipulation and greater precision than a conventional coelioscopy.” Although fitting the mechanical arms lengthens preparation time, the operation itself is simpler and faster. And the figures support these claims. “15% of conventional excisions have to be converted to open surgery. In robot-assisted surgery, this falls to 1%.” He did, however, point out that as of today, robot surgery is only useful for the more technically demanding operations that require several hours of surgery (30% of cases). “For more benign operations (70% of cases), it is currently quicker and simpler to perform a traditional coelioscopy.”

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2D view generated by the da Vinci robot Si’s optical sensor

You can’t stop progress … as long as it is economically viable!

“In medicine more than any other field, the steam roller of innovation is unstoppable”, said Dr Valverde. “That said, medical innovations have a much greater deployment time, since patients’ lives are at stake, therefore caution must be exercised. Furthermore, innovation often requires surgeons to change their habits, and they can be fiercely attached to their way of doing things. He drew another parallel, this time with the invention of the coelioscope 30 years earlier. “It took 15 years for this technique to become widely practiced. In its early days, some surgeons regarded it as witchcraft.” He thinks that nowadays robot surgery is better accepted by health professionals, even if the technology does raise a number of questions. “In 2013, I was virtually the only person at conventions defending its use. By 2016, an increasing number of hospitals had decided to take the leap.”

But the principal reason for not adopting the technology is cost. “Robot-assisted surgery is not currently covered by social security. Our hospital is currently operating at a loss on this technology.” Studies must therefore be carried out to scientifically demonstrate the positive effects of this type of surgery on patients. Having performed over 200 robot-assisted operations, Dr Valverde has noted that hospital stays are shorter and less medication is needed, lowering the overall cost of treating the patient. “We need our decision-makers to understand the advantages of this technology. When we see that robot-assisted surgery is used to perform half of prostatectomies, it seems absurd that it is still not reimbursed by the State.”

If robotic surgery offers countless possibilities to develop more efficient and affordable healthcare practices in the long term, it is because it is used alongside other technologies. “Used in conjunction with augmented reality, it could revolutionize the way in which certain pathologies, such as liver cancer, are operated. Coupled with smart devices that remotely measure vital signs, robot-assisted surgery will enable us to promote and improve the safety of outpatient surgery.

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An assistant surgeon looking at the da Vinci robot Si

Any last remarks?

For the time being, the robots that we use are not autonomous, since we control them remotely, but experience in the United States has shown that robots are capable of repairing certain parts of the digestive system. In the long term, our role could consist in supervising operations performed in whole or in part by robots. And I don’t think that’s a bad thing, because as I always say, in the operating theatre, it’s better to have a good brain than excellent dexterity.”

Could surgeons become the future conductors of an orchestra of robots in the operating theatre?

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