By: 17 July 2023
Royal College of Surgeons of England ‘lays out the pathway to achieving and maintaining safe robotic assisted surgery’ in the UK

Robotic-assisted surgery (RAS) is here to stay and comes with the potential to completely transform the way aspects of surgical care are delivered.

It is already being used in many types of operations across the spectrum of surgical specialties. Some of its reported benefits include reduced peri-operative blood loss, reduced peri-operative pain, more efficient use of anaesthetics and shorter hospital stays.  Used well and for the right patients, RAS has the potential to give greater precision during operations, result in fewer blood transfusions, free up hospital beds, increase patient satisfaction and help with a faster return to work and family, together with the potential for lower rates of return to theatre.

Studies across a variety of surgical procedures have shown some significant advantages of robotic-assisted surgery, particularly when performed by experienced robotic surgeons and on appropriately selected patients.

However, despite the recent rapid growth in RAS, there are no formal processes for providing robotic training in the UK or Europe, or introducing RAS to hospitals.  Unregulated adoption has the potential to lead to varied accessibility, variable outcomes and possible patient harm.

The Royal College of Surgeons of England (RCS England) has published a new guide that discusses some of the challenges – and promises – of robotic surgery.  ‘Robotic assisted surgery – A pathway to the future’ also looks at the potential future application of robotics and makes recommendations to encourage sound governance practices that can lead to the safe adoption and expansion of robotic surgery in UK hospitals.

The guidance proposes a structured pathway for established surgeons who want to transition to robotic-assisted surgery. It identifies the relevant roles and responsibilities of key stakeholders for ensuring and maintaining safe autonomous practice in robotic surgery.

Despite the centralised approaches in Wales and Scotland, the current lack of a national strategy in England and Northern Ireland has meant that the use of robotics is often based on local availability, resources and expertise, rather than patient suitability and care.

Also, there are currently no nationally recognised standards for established surgeons and surgical teams.  Services who wish to transition from open or conventional minimally invasive surgery to an autonomous robotic assisted surgical practice do not have consistent guidance. There is also limited access to the required training, assessment, feedback and support necessary to perform robotic surgical procedures competently and safely.  There is no clear definition of roles and responsibilities for hospitals, health boards, surgeons, robotic companies, proctors (observe the procedure and intervene if needed), and the regulators.

With the publication of the new guidance, RCS England is looking forward to working with all relevant parties to develop a set of national training standards and enhance the readiness of the workforce to meet the rapidly expanding robotic technology.

The new guidance also emphasises the importance of proper and cautious research and evaluation, defined outcome-measures and transparency of processes, while at the same time ensuring patient privacy and confidentiality.

Decisions need to be based on objective research that considers the full implications of using new technologies, not just at the individual level but also at a systemic and societal level.  It is also recognised that there are no established protocols or minimum requirements for robotic training of either established surgeons or surgeons in training, although a number of organisations have developed curricula to expose surgeons to basic robotic technology.Miss Nuha Yassin, Consultant Colorectal Surgeon, robotics and minimally invasive surgery & RCS England Council Lead for the Future of Surgery, Robotics and Digital Surgery said: This timely new guidance will support the safe and structured introduction of robotic assisted surgery – and the fruitful collaboration between hospitals, surgeons and industry. It’s important for the surgical profession, led by RCS England, in collaboration with the surgical speciality associations, to take charge of all processes, accredit training centres and pathways and facilitate equity in access and training. To benefit from the potential advantages, any investment in purchasing robots needs to be accompanied by proper planning for its introduction into the service with a focus on training, quality assurance and efficiency. This also needs to acknowledge the variable learning curve which can be long for some surgeons and theatre teams before these efficiencies can be observed at a large scale.

“In addition to being a tool in the surgeon’s toolkit, robotics and computer assisted technology have the potential to provide a pathway to the future not just by improving the technical or mechanical aspects of surgery, but also by providing enhanced vision around preoperative or intra-operative imaging which aids with operative planning and accuracy.  Incoming technologies in surgery can support intra-operative decision making. For example, through rapid pattern recognition and by converting data to information in a way that can support the operating surgeon’s judgement and perception – and steer them away from danger or error.”

Professor Neil Mortensen, outgoing President of the Royal College of Surgeons of England (RCS England) said: “The 21st century has brought an increasing variety of less invasive ways to treat disease and to carry out surgery. It is possible that robotic surgery will eventually reach an era where a robot could perform pre-programmed tasks, complementing human performance.  This is likely a long way in the future and it comes with significant additional ethical and systemic considerations.  It is also important to establish the right relationship with industry, being clear and transparent around what constitutes conflict of interest and creating an effective dialogue that will benefit both patients and surgical education.

“At a time when there is less exposure of trainee surgeons to theatre time, robotic-assisted surgery simulation could be an opportunity to safely expose them to the spectrum of case complexity and expand the capacity of the surgical workforce.”