The future of surgery, today
After revolutionising the way we treat patients, The Royal Marsden’s robotic surgery programme now tackles more cancer types than ever before
Mr Declan Cahill, Consultant Urological Surgeon, at the da Vinci Xi's console
robotic surgical procedures have been performed using The Royal Marsden's da Vinci Xi since 2015
For more than a decade, The Royal Marsden has been performing robotically assisted surgical procedures for patients with a variety of tumour types, having introduced the groundbreaking da Vinci S machine in 2007 and the latest da Vinci Xi model in 2015 thanks to supporters of The Royal Marsden Cancer Charity.
With this technology, a surgeon uses a control console to manoeuvre the da Vinci’s robotic arms, which cut and manipulate tissue in much the same way a surgeon would when carrying out open surgery. However, the system means that complex procedures can be performed using minimally invasive laparoscopic surgery, also known as keyhole surgery.
“The combination of the brightly illuminated, high-definition magnified image and instrument dexterity facilitates better-quality surgery, and allows for more ambitious and inventive procedures,” says Mr Declan Cahill, Consultant Urological Surgeon.
“For our patients, this means they lose less blood, experience less pain, recover quicker and leave hospital sooner.”
Surgeons performing robotically assisted surgery require specialised training. But thanks to the dual console of the da Vinci Xi – which allows consultants to supervise trainees during live surgery, at no risk to the patient – The Royal Marsden is training future robotic surgeons through the UK’s first cross-speciality robotic fellowship programme, funded by The Royal Marsden Cancer Charity.
Head and neck
Professor Vinidh Paleri, Consultant Head and Neck Surgeon, joined The Royal Marsden to set up a transoral robotic surgery programme, using the da Vinci Xi to remove tumours from the mouth or throat.
“We can now offer selected patients a minimally invasive alternative to open surgery with the robot,” says Professor Paleri.
“This pioneering work is providing very good outcomes, even in the long term for patients with recurrent head and neck cancer.”
Reaching and removing throat and neck tumours normally involves extensive surgery, which can often require long hospital stays and extensive rehabilitation.
“The da Vinci Xi provides greater access and visualisation at the very back of the mouth and lower down the throat, avoiding large incisions to the neck and jaw,” says Professor Paleri.
“Like other minimally invasive procedures, transoral robotic surgery enhances patient care as it involves less disruption to normal structures, thus leading to quicker recovery and a shorter stay in hospital.”
Robotic surgery is now routinely used for urological cancers that were previously treated with open surgery. A number of bladder and kidney cancer procedures are now performed robotically, and the technique is regularly used for men with prostate cancer who require a radical prostatectomy. In addition, our surgeons can use the robots to perform salvage operations on patients with recurrent cancer, avoiding or delaying the need for chemotherapy.
“During the past 10 years, robotic surgery has facilitated a change in how a number of urological cancers are treated,” says Professor David Nicol, Consultant Urologist and Chief of Surgery.
“In younger patients with testicular cancer that has spread to the lymph nodes, robotic surgery can now be used as an alternative to radiotherapy. Previously, surgery would not have been used due to the large incision that would have been required.”
Cystectomies (the removal of the bladder) can now be performed as a minimally invasive technique, while small kidney tumours can also be removed without the need for a large incision or to remove the entire kidney.
“Our patients’ quality of life has improved,” says Professor Nicol. “As a large abdominal incision is not needed, they can return to work and normal activity a lot sooner.”
The da Vinci Xi surgical robot has a built-in fluoroscope that enables surgeons to use a fluorescent green dye to identify sentinel lymph nodes (SLNs) in patients with early cervical or endometrial cancer.
“The standard course of action for women with these early cancers is a total pelvic lymphadenectomy – where all the lymph nodes are removed to assess the spread of the disease,” says Ms Marielle Nobbenhuis, Consultant Gynaecological Oncology Surgeon.
“However, most patients have negative nodes, and the total lymphadenectomy may expose them to the risk of lymphoedema. We’ve launched the FRIENDS feasibility study to carry out an SLN biopsy using the da Vinci Xi and a green dye, to better identify women who do not require a radical lymphadenectomy.”
As one of a few national proctors in robotic surgery, Ms Nobbenhuis trains other surgeons on performing and setting up a robotic surgery programme. Gynaecological oncologists from across the UK and Europe come to The Royal Marsden to observe and learn from her procedures, and she visits other centres to provide one-on-one teaching.
The da Vinci Xi gives surgeons enhanced vision, precision and control
As the technology for surgical robots continues to advance, robotic surgery for colorectal cancer has evolved and is now regarded as a treatment option for patients with the disease.
“The da Vinci Xi gives surgeons a three-dimensional, high- definition view inside a patient’s body, and the controls offer a far greater range of movements than the human hand,” says Professor Paris Tekkis, Professor of Colorectal Surgery, who is leading on the establishment of a national registry for colorectal robotic surgery to ensure that the highest standards are maintained across the country. During conventional keyhole surgery, the camera is held by hand rather than in a steady position by the robot, the manoeuvrability of instruments is limited, and the surgeon only has a two-dimensional view.
“The robotic surgeon operates via tiny incisions in the body and controls the machine’s movements from the comfort of a seat at the console,” says Professor Tekkis.
“This is a benefit for surgeons, as conducting lengthy conventional surgical procedures can be physically demanding and lead to neck, shoulder or back problems.”
“Because the da Vinci system provides improved access to hard-to-reach areas as well as enhanced vision, precision and control, the patient has less post-operative pain, a reduced risk of infection, less time in hospital and an earlier return of urinary and sexual function.”