Your life in the hands of a robot

The doctors watch on TV as a programmed 'cyber-surgeon' operates. Roger Dobson reports on the cutting edge of surgery

A robot is being prepared to operate on patients at Guy's Hospital in London. It is being programmed to carry out delicate operations automatically, with consultant urologist John Wickham and a team of surgeons standing by, hands off, watching and following its progress on a TV screen.

It is also being programmed to operate, all by itself, on a particularly anxiety provoking part of the male anatomy: the genitalia.

"There are multiple safety controls," Mr Wickham, a leading specialists in keyhole surgery, is quick to point out. "What makes this unique is that it is not directly under the manual control of the surgeon. It is programmed to operate automatically."

Almost exactly one year after new training centres were established in Leeds, London and Dundee to train surgeons tn keyhole techniques, hospitals like Guy's and the Hammersmith Hospital, west London, are involved in perfecting some of the most advanced techniques in the world.

Senthil Nathan, senior registrar in minimal invasive therapy at Guy's, who was involved in the development of the robot, says: "When you need to do something with a lot of precision, that is when robots come into play. I see a big future for robotics. Whether we like it or not, as technology improves, computers and robots are coming more and more into medicine."

For the Guy's operation a three-dimensional image will be displayed on the screen showing the progress of the robot as it vaporises sections of the prostate gland. The equipment is made up of a 2ft diameter gantry or frame, erected above the patient, around which the robot can move in any direction to follow the contours of a 3D image. Once it gets to the prostate it vaporises the part identified for removal with a high powered electric current.

"A series of scans of the patient will be taken first to build up a 3D image of the area where the robotic device will be operating. Details from each of the scans are programmed into a computer which then recreates the image," says Dr Nathan. The robotic device is positioned within the frame. By taking reference points between the frame and the computer image the device knows exactly where it is in relation to the patient.

"The device then moves itself into position, moves down the penis and removes sections of the prostate by vaporising them. There in no tissue to bring out, it just disappears," he says.

The advantage of using the robot is that it halves the time for the operation from one hour to around 25 minutes. It is also more accurate in what it does because it follows its programmed instructions precisely and any room for human error is eliminated.

These robotic operations, planned for a series of patients in the near future, are at the leading edge of developments in minimal access or keyhole surgery in the UK. "There are a number of procedures where robotic arms are moved about by surgeons, but this is the only case where ethical approval has been given to use a robot device not directly controlled by the surgeons," says Mr Wickham.

At the Hammersmith Hospital clinicians have developed a technique for "seeing" under the skin of the patient before an incision is made. When their scalpels, needles and other instruments touch the skin of the patient, images taken earlier by a scanner are shown on a screen and reveal what is beneath. As the instruments move through the tissue they show various images of what lies ahead or just around the corner.

At the Hammersmith the doctors are actually working inside the magnetic resonance imaging (MRI) scanner performing breast tissue biopsies and prostate surgery. The MRI scanner, the modern equivalent of the X-ray machine, takes 3D images of regions of the body as the patient passes through it.

"In a breast biopsy, for example, markers are put around the area that we are interested in. By using these as reference points we can programme a computer to tell us where the clinician's instrument is in relation to those markers," says Professor Ian Young, physicist at the hospital.

"So when the biopsy needle touches the skin we can bring up an image of what lies beneath on to the screen. Working with the MRI means that the clinician can get constantly updated pictures.

"The advantage is that the surgeon is no longer working blind. One section of the screen can show what is in front of the instrument through a camera looking down the instrument, while the other will show what is out of sight."

Despite mistakes made by inexperienced and unskilled surgeons, keyhole surgery in the UK is increasing. Some predict that by the end of the century open surgical operations will be outnumbered by keyhole procedures in most specialities. Minimal access technique more than halves the time spent in hospital, reduces rehabilitation periods by three quarters, gives less after-pain and prevents big surgical wounds and scars.

In keyhole surgery a one-inch incision is made and the surgeon manipulates instruments inside the body through this porthole. While his hands move the instruments his eyes are on a TV screen which displays pictures of how the operation is progressing. These pictures are taken by fibre-optic cameras connected to the instruments or inserted through another small incision, close by.

To allow greater movement inside the body the region under investigation is inflated with carbon dioxide. "Minimal access surgery is a bit like playing the piano while looking at the sheet of music. It is a totally different technique from open surgery, where you are looking down at your hands as you work. With minimal access, you have to look at the screen all the time," says Mr Wickham.

These new techniques are being taught at the three main centres funded as part of a Departmant of Health initiative at St James's Hospital in Leeds, the Royal College of Surgeons in London, and in Dundee, where another pioneering unit has already been established.

But despite the enthusiasm of most surgeons for the advancement of keyhole surgery, there is concern among others.

In a recent report from the US, a team from Brooklyn says that cases of cancers being transplanted during keyhole surgery are increasing. They looked at 13 cases where cancers had spread as a result of being "re-seeded" as tissue is pulled out. When malignant tumours are removed with keyhole surgery, they are manipulated into a little pouch that is sealed and pulled out. If cancerous cells leak from the bag they can re-seed the cancer wherever they land, particularly when the tissue is being pulled through the abdominal wall. The Brooklyn team says, in a report in the journal Surgery: "These cases raise the question of whether cancer cell seeding is facilitated by the laparoscopic technique and cast doubt on its safety."

Mr Wickham responds: "The number of these cases is very small. This re-seeding went on with open surgery too but no one made much of a fuss about it."

He believes we are only at the threshold of this surgical revolution. "Microscopic instruments could be put into body cavities to perform operations that at present are impossible. There are minute tractors which could, for instance, crawl along the gastro-intestinal tract taking photographs or biopsy samples. Compared to such instruments - which we will soon have - what we use now is as crude as agricultural machinery."

Our article on knock knees will appear in the near future.