Robot doctors moving in a new direction

​Robotic surgery is becoming more common at Rigshospitalet. The Department of Surgical Gastroenterology will soon be performing all cancer surgery on the oesophagus and stomach with robots and will test new treatments. And at the same time, a new public-private collaboration is well on the way to optimising robotic surgery workflows.

With Steen Kofoed, Consultant, in charge in front of a screen, control pedals and handles, the robot moves part of the stomach up and connects it to the healthy part of the oesophagus deep in the thoracic cavity, a procedure that previously would have required open surgery.

Four small incisions in the abdomen and thorax and a single umbilical incision is all Rigshospitalet’s experienced gastrointestinal surgeons need to be able to insert robotic arms into the abdominal cavity and operate on vital organs in the gastrointestinal region if the cancer has spread.

“We’ve been using the Department of Urology’s robot since 2013 when we do surgery on the stomach and oesophagus. Now we’ve got our own robot, and it’s time we consider what other types of surgery might benefit from robots. For example, we would like to be able to develop techniques for removing cancerous tissue with the robot when performing certain types surgery of the liver and pancreas,” said Steen Kofoed, a consultant at Rigshospitalet, who, together with his colleagues at the Department of Surgical Gastroenterology, was one of the first surgeons in Europe to introduce robotic surgery on the stomach and oesophagus more than five years ago.

3D cameras enhance reality

In 2018, 120 patients underwent surgery for oesophageal cancer where the new, less invasive robot-assisted technology was used. Using this technology allows the surgeon to perform the surgery with the least possible pain and discomfort for the patient. The ambition is that, in the future, the robot will be used when performing surgery on all patients with oesophageal cancer and stomach cancer unless scar tissue or other issues prevent this.

“When we use the robot as an assistant, we not only have the benefit of four arms and wrists that can move in all possible and impossible directions, we also have the benefit of a sophisticated camera that lets us see everything in 3D. This is a great advantage as it enhances the images due to the fluorescent substances, thereby making the cancer cells much easier to see during the operation. This allows us to be very precise when we operate deep in the abdominal cavity and under the thorax,” said Steen Kofoed, and he continued: 

“As surgeons we're all used to using our hands and leading the knife ourselves. Robotic surgery breaks with this. Even though we don’t have the same tactile sensation that we have when we perform traditional open surgery where we touch everything with our hands and can feel what we’re doing as we go along, we need to constantly consider what will give the best result and cause the least possible pain and discomfort for the patient. The advantage of robotic surgery is that the patient recovers much quicker and will be back to eating and drinking normally within a very short period of time. 

Robots are the future at Rigshospitalet

Rigshospitalet's specialists have been conducting robotic surgery for more than ten years, and they have some of Denmark's oldest robots. Especially the great experience held by the Department of Gynaecology and the Department of Urology has benefitted the gastrointestinal surgeons in the transition from traditional surgery to robotic surgery. An innovation project conducted in collaboration with the medico company Medtronic is to take the hospital to the next level.

“It’s been a great advantage for us to learn how to use the technology from our good colleagues at Rigshospitalet who started using the robot several years before we did. Now that we’ve got our own robot, we would like to expand to other areas within gastrointestinal surgery. And we’ve also initiated an exciting collaboration with Medtronic, who will be helping us with the logistics, planning and documentation of workflows. This will help us develop the technology and quality-assure good guidelines for several parameters, for example, how to set up and prepare for all types of robotic surgery,” said Jens Hillingsø, Head of Department, Department of Surgical Gastroenterology. 

Jens Hillingsø has great ambitions for introducing robotic surgery across specialist areas and would like for all minimum invasive surgery to be performed by the same section.

"If it were up to me, we would collect all robotic surgery at Rigshospitalet once and for all in one central section, so that we could make the most of the robots we have across all sections. For example, we could set up a joint section for robotic surgery when we move to the North Wing. The robots are very expensive, and we need to ensure that they’re used as much as possible so there’s no waste. They shouldn’t be kept idle in surgical wards when they’re not in use,” said Jens Hillingsø.

Training in robotic surgery

The Capital Region of Denmark has recently established a training programme in robotic surgery for specialist doctors to ensure that they all participate in the same tested and highly specialised training programme. The programme is a joint offer from CAMES, Rigshospitalet and Centre for Robotic Surgery at Herlev Hospital. 

“Training is essential and it’s good that everyone follows the same programme. We know from experience that surgeons typically have to perform more than 100 operations with supervision before they have perfected their keyhole surgery skills, whereas it only takes 10-20 operations before a surgeon is ready to perform robotic surgery without supervision. This is also a factor worth remembering when assessing the costs of the different types of operation. And you mustn’t forget, the robots will most probably be cheaper to buy once there is more competition on the market. Robots are here to stay whether we like it or not, and by collaborating with Medtronic we can collect data to find evidence that robotic surgery creates the necessary value for patients,” said Jens Hillingsø.

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