1 Nov 2010
As an increasing number of surgeons are being forced to operate without an assistant, could robotic assistance help to address the impact of the European Working Time Directive? The Clinical Services Journal reports on the latest developments in robot-assisted laparoscopic surgery.
The Royal College of Surgeons has recently carried out research into how the European Working Time Directive (EWTD) has impacted the NHS, one year since it was implemented. One of the most important conclusions from the study showed that almost two-thirds of surgeons are now forced to operate without an assistant, as there are simply not enough junior doctors to go round. However, last year, a new robotic device used to assist laparoscopic surgeons was approved for use in Europe and the US, which not only made robotic technology affordable, but offered the potential to overcome the unintended consequences of limiting junior doctors’ hours. The FreeHand robotic system puts the surgeon in complete control of the camera by enabling him to guide it using simple head movements. The scope is moved by a hands-free controller, worn on a headband, or attached to a surgical cap and an activation pedal. Surgeons can control the tilt and pan movements, zoom in and out, and control the speed of the camera’s movement. In simple procedures, this removes the need for an assistant, often a junior surgeon, to hold the camera, reducing the number of surgeons required for the operation. Consultant urological surgeon, Mr Anand Kelkar, is one of the surgeons to have introduced the robotic camera controller (developed by UK robotics company Freehand Surgical) to three hospitals in Essex. Mr Kelkar, who specialises in urological cancer and laparoscopic surgery, has recently had FreeHand installed at King George Hospital in Goodmayes (part of Barking, Havering and Redbridge University Hospitals NHS Trust); has used it at the Nuffield Health Brentwood Hospital and Spire Hartswood Hospital; and will shortly be using it at Spire Roding Hospital. He explained: “I have carried out over 60 laparoscopic operations using this technology and can now carry out kidney surgery alone, without the need for an assistant. Previously, a prostatectomy required two assistants, now I only need one, thereby saving hours of work, time and money. I am able to focus on training my junior surgeon better and can concentrate more on the operation without needing to hold the camera.” Mike Parker, consultant surgeon at Darent Valley Hospital in Dartford and council member of the Royal College of Surgeons, would like to see the EWTD abolished, but believes the device could offer a solution for surgeons who are required to carry out operations on their own: “FreeHand is very quick to learn, easy to use and you can perform the operation single-handed without fear,” he commented, adding: “Controlling the device becomes second nature very quickly – it gives me a superb view, unhindered by shake or tremor. It is also very affordable. Every surgery department in the NHS should consider investing in FreeHand, especially now, with the increasing shortage of junior doctors.” Affordability In the current financial climate, however, capital investment in new technologies can prove difficult to secure. UK robotics company, FreeHand Surgical, has sought to address this barrier to adoption. Instead of demanding significant up-front capital, the company is finding surgeons who are likely to carry out a reasonable number of laparoscopic operations on a weekly basis and places the robotic system in their hospital without charge. Revenue for FreeHand is then achieved from the disposable zoom module and sterile sleeve which need to be replaced before each operation. These disposable components cost £125 per patient, making the venture profitable for FreeHand Surgical and affordable by the hospital. The FreeHand device has also proved to speed up the operation time. According to a controlled study carried out on the use of the robotic arm with laparoscopic cholecystectomy procedures, a 10% time saving was demonstrated when compared with surgery with an expert human assistant. Users report that greater savings are possible in more complex cases. Mr Kelkar commented: “During a long procedure, the assistant’s hand becomes tired and shaky, the visual clarity gradually reduces, and the operation becomes more tedious to perform. This presents a risk to the patient and can lengthen the surgery. A precise and efficient operation requires a completely clear view of the operative field. The stability and clarity of the image that FreeHand provides is incomparable to handheld scopes and is a major advancement for laparoscopic surgery. I am becoming increasingly dependent on this technology.” According to the company, FreeHand can save hospitals an estimated £160 for each routine procedure by eliminating the need for extra surgeons. Reducing the number of required staff can reduce the number of operation cancellations which are caused by staff unavailability. This helps hospitals to reach the 18-week waiting time targets, while saving up to £8,000 per year in theatre costs if one cancellation per week is avoided. Alan Briggs, a retired Thames Waterman from Hornchurch in Essex, was diagnosed with low level prostate cancer in April 2010 and underwent a laparoscopic prostatectomy with Mr Kelkar and the FreeHand device in May 2010 at King George Hospital. He commented: “At the time of diagnosis, the consultant gave me three options; he said that I could either be kept under observation for a further three months, I could undergo radiotherapy, or I could have the prostate removed. I went to a private physician to gain a second opinion, but the consultant agreed with me that surgery was the best option. “When I came round, I felt as if no operation had taken place. In fact, the nurse had to reassure me that it had. When the painkillers had worn off I felt stiff, but I was up and about by myself within a week. I had just five incisions in my stomach and the scars have almost vanished in just three months. I healed very quickly and my PSA count is now 0.1%. The operation was a great success.” In addition to the surgical benefits, Mr Philippe Grange, consultant at King’s College Hospital in London, has noted the advancements the system brings in the field of training: “When a junior surgeon is holding the camera during laparoscopic surgery, he does not learn the procedure – just how to hold the camera. When the FreeHand system is used to train junior surgeons, it creates a more relaxing experience. Trainees benefit because the lead surgeon can let them operate, providing guidance and assistance, rather than them having to simply hold the camera.” Mr Grange teaches surgeons laparoscopic surgery in over 30 hospitals throughout the UK, Europe and China, and has carried out over 200 procedures as a solo surgeon using the system. He has taken part in developing and designing the FreeHand device and stated: “I have been convinced by the technology from an early stage. It has been a great success in a whole range of procedures including prostate cancer, renal surgery, general surgery, gallbladder removal and in the emerging field of scarless single port surgery. “With kidney surgery, the conversion rate [from keyhole surgery to open surgery] is far below 1% in our hospital using the FreeHand. In other hospitals in the UK, it is between 2% to 5%. This is probably because in those few difficult cases, when as assistant is needed, the camera robot frees both of the assistant’s hands and the assistant can help the surgeon more efficiently in the actual procedure.”
Last updated: 12 Nov 2010, 6:40 PM
