As an engineer working in British Leyland car plants in the 1970s, John Gurney
learnt much about the intricate relationship between man and machine. His
unit in Hertfordshire — which had created Malcolm Campbell’s
speed-record-breaking Bluebird vehicle decades earlier — specialised in
suspension, brake and steering gear components, combining precision
manufacturing and “big grinding machines that went like billy-o”. As a
process planner, Gurney was responsible for calculating speeds and flows: he
made sure the right levers were pumping at the right times.
Almost four decades later, the same issues of automation — attaining the
exhilarating and unnerving balance between human master and mechanical slave
— have made a very personal return. Last year John Gurney was told he had
prostate cancer. Tests suggested that the tumour was low-grade: the disease
affected a small volume within the gland and did not appear to have spread
to other organs. His specialist suggested a wait-and-watch approach. But at
the age of 67, and with the prospect of having to live with the disease for
years, Gurney decided that the uncertainty was going to be less bearable
than surgery. “Everyone I had met said it wasn’t going to kill me till I was
80, but if you are waiting around like that you want to do something. I had
to get on the robot.”
The robot in question is the da Vinci Surgical System, and one Monday a few
weeks back, John Gurney got on it — or more precisely was manoeuvred under
it. A mass of mechanical joints wrapped in transparent sheeting, the da
Vinci is a spider-like unit the size of a double fridge, with four
overhanging limbs. Once rolled into place, it loomed over the operating
table in Theatre 5, St Mary’s Hospital, Paddington. Gurney was placed on his
back and tilted slightly upside down to allow gravity to pull his organs
towards his ribcage. The surgeon marked out four small incisions on his
stomach and after using his scalpel “for the first and only time”, started
screwing a camera port into place. “Goes in just like a cleat on a boat,”
Justin Vale, consultant urologist and pre-eminent robotic surgeon, said as
his team made final preparations. “You can pull things in and out without
any yanking.” Two of the robotic arms were lowered into place, and after a
top-up of carbon dioxide to inflate Gurney’s abdomen, Vale took up his
operating position: on a stool in the opposite corner of the room, his head
deep inside a monitor unit, fingers pinching and swivelling small joysticks
and feet tapping intermittently on a pair of pedals like a pianist. Within a
few minutes, the two robotic arms were busying away with the clinical cut
and thrust of removing John Gurney’s prostate.
A surgeon operating on a patient from three metres away may sound like
something from the sketchbook of Hieronymus Bosch, but this kind of
arrangement is now at the forefront of 21st-century healthcare. Over the
past decade, robotics has driven forward the concept of minimally invasive
surgery, building on the skills developed in keyhole (laparoscopic) surgery
and moving away from open-body operations. Slicing through chunks of healthy
tissue was once thought inevitable; now, with the control and visual
feedback offered by robots, it has begun to look like mutilation. The
reduction in trauma that can be achieved using such machines means a quicker
recovery for patients, faster discharge from hospital and the prospect of a
better quality of life after surgery. For the last five years da Vinci
systems have, in a handful of hospitals, been the norm for quick and clean
prostatectomies.
Peering through stereoscopic lenses, his hands tweaking and twitching in
precise rhythms, Vale worked his way round the depths of John Gurney’s
pelvis. The camera, inserted into an incision on the belly button, relayed
images of soft tissue, bladder and bowel, veins, arteries and nerve bundles,
while the two robotic arms — one ending in multi-jointed pincers, the other
a cauterising hook — cut and stitched in response to Vale’s movements at the
console. Another arm assisted with attaching clips and sucking up fluids.
Every motion is steadied and scaled as the surgeon chooses, turning a
five-centimetre twitch of the joystick into a smooth one-centimetre shift of
a blade, for example. According to Vale, “clutching” is key — using the foot
pedals to disengage and realign joysticks and arms, allowing the surgeon
vital moments of rest during a two or three-hour session.
The changing patterns of Vale’s surgical output say much about the rise of the
robot. In 2001, more than 80 per cent of his urological work was open
surgery, with some laparoscopic operations using small incisions, cameras
and probes, under hands-on control of the surgeon. By 2004, half of his work
was laparoscopic, 40 per cent open surgery and 10 per cent robotic. Five
years on, and fully half of his procedures are robotic, while laparoscopic
work accounts for 40 per cent.
Where robotic operations have the edge on keyhole surgery is in the degree of
dexterity and visual enhancement they offer. Robotic instruments are
“wristed”, offering seven degrees of movement (the human wrist has six; when
the hand is out flat the thumb and little finger cannot be bent to touch the
forearm). Laparoscopic instruments are more rigid and have only four degrees
of freedom.
Keyhole surgery also creates a disorientating effect: a tool in the surgeon’s
left hand will appear on the right of the field of view as relayed by the
camera. This requires considerable visual-spatial co‑ordination, like riding
a bicycle with the steering back to front. Robotics can not only realign
this “visual-motor axis”, but also magnify, scale and stabilise it.
While the very best surgeons can be equally proficient in either discipline,
Vale believes that robotic procedures offer better prospects for a patient
under the care of the average practitioner. In prostate surgery, the
stereoscopic view afforded by robotics can mean sparing more nerves — which
protects against erection difficulties and incontinence — and a reduction in
damage to nearby structures such as the anal sphincter. Compare that with
keyhole surgery where, as Vale puts it, “If you only have two-dimensional
vision [from a monitor], a needle moving at 30 degrees away from you can
look like it’s coming at 30 degrees towards you. When you are operating in a
deep, dark hole, it can get quite difficult”.
Yet robots can be awkwardly cumbersome and expensive. A single da Vinci system
costs around £1 million, while tools such as cauterising scissors have to be
replaced every dozen uses, at £3,000 a go. At present, there are only 19 da
Vinci units around the country — reportedly fewer than on Long Island — and
with the NHS facing a period of parsimony, the situation is unlikely to
improve. Robotic surgery, experts concur, is still in a clunky infancy
comparable to the advent of costly, bulky home computers in the 1980s.
If robot surgeons are about to come of age, then the Bill Gates and Steve Jobs
of the field are Ara Darzi and Guang-Zhong Yang, though both men are
self-effacing about their achievements (Darzi says he is a “failed
engineer”, while Yang hopes to become a “moderate surgeon”). Darzi,
professor of surgery at Imperial College London, knight, peer and, until
July this year, junior health minister, has steered surgery’s progress for
the best part of twenty years. What Darzi brings in clinical expertise,
Yang, a computer scientist, gives in engineering knowhow.
While Darzi compares the current limitations of robotic surgery to Henry
Ford’s attitude to Model T cars — “you can have any colour you like, as long
as it’s black” — he believes the extraordinary potential of robotics is now
being realised. Advances in imaging will bring about the greatest change.
You need only wander round Yang’s lab on Imperial College’s campus in
Kensington, West London, to begin to grasp what imaging can do. Computer
visuals show how tissue could be rendered transparent, allowing a surgeon to
see behind it. There is a rubbery silicone heart, created by an American
artist for a whispered £5,000, for exploring 3D visualisation and ways of
removing tremor. There is even talk of performing an operation using a
simulator that allows a surgeon to try out various options before the robot
replicates the optimum procedure on the patient.
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