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Invited Lecture at the British Association of Indian Anaesthetist Annual Meeting 2014
Citation preview
The invasion of Robotics in Theatre
Mr Nikhil Vasdev
Consultant Urological and Robotic Surgeon Hertfordshire and South Bedfordshire Urological
Cancer Centre Lister Hospital
Senior Visiting Clinical Lecturer in Uro-oncology
University of Hertfordshire
Introduction
Medical Robotics
Robotic Urology • The widespread adoption of robotic technology over the
past decade has resulted in significant changes in the way numerous urological conditions are managed
• Robotic devices continue to evolve and as they become less expensive and more widely disseminated – it is likely they will become more frequently utilized in an increasing number of surgical procedures
• The rapid introduction of robotic procedures in urology
necessitates the need for the development of new training methods
1999 2000 2001 2002 2003
da Vinci® European Installed Base 1999 – 2012
2004 2005 2006 2007 2008 2009 2010-‐‑12
da Vinci® USA Installed Base 1999 – 2012
Surgical Advantages of Robotic Surgery
6 degrees of movement
Surgical Advantages of Robotic Surgery
10 X magnification 3 D vision
Robotic Prostatectomy and Lymph node dissection
Robotic Partial Nephrectomy
Nature Reviews Urology 2004 Technology Insight: surgical robots Expensive toys or the future of urologic surgery? ‘‘A Robot Saved My Life’’: Is It a Myth?
Premature Robotic Surgery: Putting Patients and Professionals at Risk
Robotic Surgery: Hope or Hype? Presidential Debate SAGES 2011
Will the Future of Health Care Lead to the End of the Robotic Golden Years?
• Baseline problems in finding evidence for superiority
o A Randomized clinical trial is not feasible because both expert surgeons and patients have their bias regarding the optimal technique
o No level 1 evidence o Different definitions – Positive margins, biochemical recurrence, urinary
incontinence and sexual function
o Limited to single case series, systematic reviews and meta-analysis
o Selection bias in these studies often from high volume, academic centers
Aim of robotic prostate cancer surgery
ORP / LRP RRP
Trifecta Pentafecta
Disease control Disease control
Potency Potency
Continence Continence
Negative Margins
Complications
Lister Hospital Robotic Urology Experience
• 3 Consultant Robotic Urological Surgeon (NV, JA, TL)
• 2 Consultant Anaesthetists (GMS, VP)
• Theatre Team
• Only National Robotic Urological Fellowship programme accredited by RCSEng / BAUS
Current Achievements Robotic Urology at the Lister
Hospital (2014)
• 1 of 3 trust offering a full range of robotic urological surgery
o Robotic Prostatectomy o Robotic Cystectomy +
Intracorporeal Ileal Conduit / Neobladder formation o Robotic Partial Nephrectomy o Robotic Pyeloplasty o Robotic Nephroureterectomy
Current Achievements Robotic Urology at the Lister Hospital
• Only centre in the UK performing Intra-operative frozen section analysis of the prostate during robotic prostatectomy*
*My Theses for MCh (Urology) – University of Edinburgh / Royal College of Surgeons of Edinburgh 06/2014
Activity and Referral pa[erns
• Increase in Robotic activity by 25% over 12 months
• Increase in 2 week wait cancer referrals by 27% over 12 months
68 73
67 66
79 73
81 78
69
87
72 76
54
86 79
99
85
75
111 114
98
108 114 111
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
2012/13 2013/14
Robotic Urology in the NHS 2020
• Centralization of Cancer Services to 15 – 30 centres in the England [NHS England – Everyone counts (2014)]
• Potential funding gap of £ 30 billion by 2020/21 [A Call to
Action (2013)]
• Variable cost of Robotic system leasing and maintenance contracts [Intuitive Surgical (2014)]
Our experience
Cost
Cost
Cost
Intuitive sales
What makes robotic surgery expensive ? • The initial cost is extremely high, estimated to be about
$1.8 million and the maintenance costs • After ten uses of a robot, the instruments must be replaced • Use of the robot comes with a slower learning curve for
doctors. • When hospitals attempt to balance patient safety with the
high training costs, sometimes poor patient outcomes occur.
• There are also increased costs to the patient per surgery, estimated at around $2,500 per procedure compared to traditional methods
Robotic prostatectomy will always be more costly to the NHS because of the fixed capital and maintenance charges for the robotic system Our modelling showed that this excess cost can be reduced if capital costs of equipment are minimised and by maintaining a high case volume for each robotic system of at least 100–150 procedures per year. This finding was primarily driven by a difference in positive margin rate
How can we improve robotic theatre efficiency
Theatre Robotic Urology Utilization
Audit Urology – N Vasdev, S Cashman, S Elands,
S Brooks, D Hanbury, T Lane, G Boustead, J Adshead
Anaesthetics – Gowrie Mohan S, Venkat Prasad
Urology Theatre – J Ocampo, L Jones
Urology Robotic Theatre Cycle
Time patient sent for theatre
Time from preoperative area to theatre
Anaesthetic start time to theatre
Operative time
Time second patient sent for second patient
Time list finishes
Patient and Methods • N = 43 Robotic Urological Cases
• August 2013 until February 2014
• 2 Groups of patients
o Group 1 – List on which 1 Robotic Urological Case was performed (n=18) [40%]
o Group 2 – List on which 2 Robotic Urological Cases were performed (n=25) [60%]
Time from “patient sent” to arrival in theatre
pre-‐‑operative area
• Mean = 29.8 minutes • Range = 10 – 95 minutes
20 20 15 15
18 15
65
14 18
15 15 10 10
13 20 19
72 78
90 95
10
30 25 25
20
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
Time from Pre-‐‑operative area to Anaesthetic
Room
• Mean = 65.4 minutes • Range = 10 – 126 minutes
10
30 15 20
67
95
115 125
95 95
126
73
11
62 78
87
12 28 25 22
10
70 80 85
100
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
Comparison of total time in pre-‐‑operative area
when patient arrives before 8 am or after 8 am
67
95
115
125
95 95
126
73
110
62
78
87
70
80 85
100
28 25
10
22 20 15
30
10 12
0
20
40
60
80
100
120
140
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Before 8 am
After 8 am
Anaesthetic Time
Mean Anaesthetic Time = 61.8 minutes (Range 20 – 110)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
95
11
93
30 65 59 50
29
70
40 67
20
99 74 65 72 75
105
20 23
70 65 72
38 39
Operative Time
(Surgery + Time to recovery) for first case
Mean operative time + Time to recovery = 3.6 hours (Range 2.45-4.5)
4.75
3.80
3.15
3.88 4.10
3.95 3.95
4.55 4.45
3.15
4.05 3.85
3.40
4.20
3.10
3.98
3.15
2.45
4.05 4.24
3.90
3.25
2.45
3.15 3.25
0.00 0.50 1.00 1.50 2.00 2.50 3.00 3.50 4.00 4.50 5.00
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
Comparison of Anaesthetic times
0
20
40
60
80
100
120
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
AM case
PM Case
One Robotic Case
78%
Two Robotic Cases
20%
Details of robotic cases completed by 5 pm
Time of completion of theatre list
(Patient leaves theatre at 5 for recovery)
20%
68%
8%
4%
By five
By six
By six.thirty
By eight
Areas of improvement • When 2 Robotic cases are performed only
20% of cases finish at or before 5 pm
• There is significant variability in the following areas
o Waiting time from pre-operative area to theatre before 8 am
o Issues with nursing handover and time of sending for theatre need to be addressed (Swift Ward)
o Theatre turn around time between cases needs to be evaluated
How can we improve robotic surgical outcomes • Regulation of Training (National guidelines being
prepared - 2015)
How can we improve robotic surgical outcomes • Simulation
o Simulation and Technology enhanced Learning Initiative (STeLI) project o SAGES / RAST (Robotic assisted surgical training) programme
• Formal Fellowship training o 6 robotic fellowships in the UK o Only one recognized by the RCS/BAUS
• Strict audit of outcomes
How can we improve robotic surgical outcomes
STOP COWBOY ROBOTIC SURGEONS
Latest developments • Robotic image integration surgery (Imris)
medical)
Latest Developments • Haptic Feedback
Latest Developments
Robotic Surgery-‐‑ Is the jury out ?
Conclusion • Patients undergoing Robotic Urological Surgery appear to
have o Lower blood loss o Reduced surgical morbidity o Equivalent oncological outcome
• There is likely to be in an increase in robotic surgical procedures o Functional and quality of life benefits to patients o Demand to provide service
Conclusion “The Surgeon, Anaesthetist and
Theatre Team are most important determinant of robotic surgical
patient outcomes of peri-operative complications and length of stay”
L Klotz
“The aim now should be to evaluate the cost of robotic
surgery results in long term gain for patient”
J Meeks
“Efficiency is doing things right; effectiveness is doing
the right things”