The rise of robotic assisted surgery
The role of surgery in cancer
Housed in the New York Medical society is a 4.5 metre long papyrus believed to date from around 1600BC. It is most likely a copy of an even older manual of medicine and contains, in hieroglyphs, the description of 48 medical cases. One of these is a ‘bulging tumour of the breast’ which is treated with what is described as a ‘firestick’. This may be the first ever, rather grim, description of cancer surgery.
As clinical understanding improved, so too did the surgeries being performed. Galen, the second century Greek physician spoke of surgery for breast cancer, and the development of early anaesthesia in the 19th century significantly advanced surgery. But it wasn’t until the 1890s that radiation was first used for cancer. Chemotherapy followed many decades later. By 1369, surgeons had their own professional guild.
Surgery remains a vital part of cancer treatment today. In the UK each month, thousands of new patients are referred for an operation as their first cancer treatment. A long history and tradition does not prevent surgery from continuing to innovate, though, as anyone who watched the ‘Super Surgeons’ documentary on Channel 4 (in partnership with Macmillan) will testify.
Benefits of robotic assisted surgery
One of the most important innovations in recent years has been the introduction of the surgical robot. Robotic assisted surgery allows remotely operated tools to access smaller cavities than could normally be reached by a surgeon’s hands and tools.
In 1982, Patrick Walsh at Johns Hopkins performed the first operation to remove the prostate and preserve nerves in the area to help reduce side effects of loss of sexual function and urinary incontinence. Although those first operations were done ‘open’, by the nineties they were being done laparoscopically (using fibreoptic cameras) and were seen as proving ground for a robot-assisted approach.
Around the same time, a group of venture capitalists, engineers and surgeons were establishing Intuitive. Their company manufactured the Da Vinci robot which, in 2000, became the first device authorised by the FDA for robotically assisted surgery. In 2019 the company had over $4 billion in revenue and DaVinci machines have become commonly used for nerve-sparing prostatectomy.
It was a natural step for surgeons to explore the use of robot assisted techniques in other diseases and there are now established procedures in gynaecological, colorectal and thoracic surgery. Lung cancer surgery is often particularly difficult because of the risk of damaging lung tissue in removal of tumours, especially in people with reduced lung capacity from smoking related diseases.
Minimally invasive techniques, such as video assistance to remove lung cancers, have now been shown to be superior to traditional ‘open’ techniques in the UK-led VIOLET trial. Surgeons are now exploring Robotic Assisted Thoracic Surgery to further improve safety.
Rethinking our approach to surgery
Learning to operate safely using new techniques takes time. There’s a necessary learning curve, and it’s vital that these innovations are tested through clinical trials to ensure they truly benefit patients..
One area where robotic surgery showed promise was in the treatment of oropharyngeal cancers (in the tonsil and back of the tongue). These cancers are associated with HPV infection (the same virus that causes cervix cancer) and are occurring more frequently. The cancer can often be treated very successfully with modern radiotherapy, but radiation can cause significant short term and long-term side effects, particularly affecting swallowing.
Transoral Robotic surgery (TORS) appeared to offer the potential to excise these tumours and treat patients more quickly without the side effects of radiotherapy. Long term follow-up of the ORATOR trial, comparing radiotherapy with TORS, sadly appears to show a slight disadvantage in swallowing outcomes with TORS when compared to radiotherapy. There is no clear ‘winner’ here and it shows that both surgeons and radiotherapists need to continue to innovate and test techniques carefully in trials.
There is an old adage that a good surgeon knows when to operate but an excellent surgeon knows when not to. Robots may allow surgeons to do what was not previously possible, but some surgeons are assessing the necessity of procedures previously considered routine.
For example, in breast cancer surgery it has been routine to operate to remove the lymph nodes in the armpit next to the breast (axilla). Removing these nodes allows the cancer team to fully understand the spread of the cancer and remove those cells. But we know that axillary surgery can cause pain, nerve damage and swelling of the arm (lymphedema). Over recent decades, there has been a steady away from taking all the lymph glands (axillary clearance) to a ‘smart’ sample of a small number of ‘sentinel’ nodes.
Initiatives including the UK POSNOC study, are looking at how to safely reduce the extent of axillary surgery without compromising cure rates. These efforts complement UK research, which has already safely reduced radiotherapy treatments in breast cancer.
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