How robotic assisted surgery is transforming lives and cutting recovery times
This special report delves into how robotics has changed the world of surgery. Just ask Carolyn Wilkinson, who had two hip replacements, along with knee surgery, due to arthritis. This is how it changed her life.
Victoria
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In the two decades since the first robotic surgery was performed in Australia, both the computers that drive them and the surgeons who guide them have come of age.
Australia was in on the ground floor of the surgical revolution that is Robotic Assisted Surgery (RAS) and is now considered a global-leader in not just the technique, but also training and research.
Today more than 60,000 Australians have had RAS, most commonly for a radical prostatectomy – the removal of the prostate due to cancer – but increasingly for knee and hip replacements and now complex cancers and some general surgeries.
Assisted is the key word, robots are not replacing surgeons.
Andrew Tang is the associate director for robotic orthopaedic surgery at Epworth Healthcare in Victoria.
He says the concept of a robot that the public thinks of, which is an autonomously functioning device, is not what robotics is.
“In every robotic platform available in orthopaedic surgery the surgeon is still controlling the cutting tool,” Tang says.
He says some of the guidance was provided by the robotic system and in other models it’s the cutting block that’s positioned with the robotic system.
“But either way it’s the surgeon who is using the power tool to cut, saw or mill a bony surface in preparation for implantation of a prosthetic device,” Tang says.
“That’s one thing that the public needs to understand because I know some of my patients have asked me if I am actually going to do anything. In fact the surgeon is actively involved in performing the operation.”
Robotics for surgery is a system of mechanical “arms” holding cameras and surgical instruments that are controlled by a skilled surgical team.
Where the robot comes in to its own is that it allows surgeons to do more complex procedures less invasively because it can typically be done through smaller incisions. This can mean less blood loss, less scarring, less pain and potentially a quicker recovery.
The latter is what attracted Melbourne mum Tanaya Paradkar to the technique. She travelled to India to investigate how her complex surgery was routinely being performed using RAS, and then found a surgeon in Melbourne who could do the same.
Paradkar was diagnosed with rare congenital anomaly, a choledochal cyst in the common bile duct, that untreated can lead to liver damage.
“I was told the only option, because of the complexity of the surgery, was open surgery which will take around eight weeks to recover and the incision will be just below my ribcage causing a bit of discomfort,” Paradkar says.
A busy working mum with a young family, Paradkar says eight weeks to recover was not ideal.
Key, she says, was finding a surgeon in Melbourne who would do it via RAS. She found general surgeon Dr Osamu Yoshino.
“To remove the cyst the portion of the common bile duct had to be removed along with the gall bladder and requires reconstruction of the bile duct to flow bile to the digestive tract,” Paradkar says. “The recovery time post-surgery was just 10 days.”
She says it delivered “100 per cent” on her expectations.
Flying high
The next generation of Australian surgeons to master RAS are flying high thanks in part to a unique program that includes a former Qantas director of training Matt Gray.
Gray has more than 40 years’ experience as a pilot and was encouraged to bring those skills to the International Medical Robotics Academy (IMRA).
It has collaborated with the University of Melbourne, making it the first university in the world to offer a medical student immersive program in robotics. The program is using simulation techniques similar to that used to train pilots to respond to emergency situations.
The program’s senior lecturer Dr Helen Mohan says it’s vital for students to be aware of the technology that is coming.
“Because the reality is that by the time most of today’s medical students are in practice robotics is going to be very much part of their day-to-day professional life,” Mohan says.
She is also the director of clinical research at IMRA.
“We developed hydrogel models that can use to dissect in a realistic manner,” Mohan says. “It gives those new to robotics an immersive workshop during the four-week module where they can practise training on the hydrogel models and they can practise the technical components of the robot.”
Gray, Mohan says, was brought on board as there were a lot of parallels with high-stakes industries like aviation.
“Aviation has used simulation and simulation labs to train to reduce error and to reduce fatalities and they’ve had a big impact in making aviation safety safer over the past 20 years.”
Mohan says the program also has PhD and masters’ students working on evidence around robotic surgery. It was a PhD student, Dr Jade El Mohamed, who spearheaded the medical student robotic program.
Not all who sign up for the training want to become surgeons.
“The skills that we teach are useful to apply into their practice because no matter what aspect of medicine they’re going to practice in the future, being familiar with new technology, being familiar with what the potential advantages are, what the challenges are, and being familiar with the kind of principles of robotic surgery is relevant for our graduates to future-proof them for their future practice,” she says.
I’m 81 and I back to running after my hip replacements
Judi Herkes says having RAS to replace both hips has given her back her life.
The 81-year-old returned not just to competing, but winning the country’s most prestigious masters orienteering events six months after she had her second hip replacement using the method.
Would she have recovered as well if her orthopaedic surgeon had used traditional hip arthroplasty to replace the damaged parts with artificial joints?
“I have no comparison, but I just know it was very, very successful,” Herkes says.
“I won all three of my events. I just had a purple patch.”
Whether it was a run of good luck, robotics to the rescue or the fact Herkes has always been pretty fit she can’t say.
What is without doubt is that she took on the best in the country in a sport that demands physical and mental agility, and won.
The first RAS in Australia was a prostatectomy, performed at the Epworth Hospital in Melbourne in 2003.
Radical prostatectomy, the removal of the prostate, remains the most common robotic procedure in Australia with more than 50,000 performed in the last two decades.
Declan Murphy is director of robotic surgery at the Peter MacCallum Cancer Centre and one of the most experienced robotic prostatectomy surgeons in the world.
With urologist Dr Renu Eapen he also hosts a podcast called GU Cast. It is a genito-urinary (GU) podcast “for all things prostate, kidney, bladder, testis and penile cancer”.
One of its most popular episodes is called A Touchy Subject with intimacy specialist Victoria Cullen on normalising conversations about sexual dysfunction following treatment for prostate cancer.
Prostate cancer is the most commonly diagnosed cancer in Australian men with around 25,000 diagnosed every year.
Murphy performed the first robotic prostatectomy in the public system in Victoria at the Peter Mac and also does the surgery privately at Epworth Healthcare in Richmond.
He says while there has been good access to RAS for patients in the private system, there has been limited access in the public system in Australia.
That is changing, particularly in Victoria where a change in government policy last year took the brakes off public hospitals investing in the technology.
“In the past 12 months, there’s been a really a dramatic shift in that rather unequal situation and many public hospitals are now installing robots, which is fantastic news,” Murphy says. “It means the patients access robotic surgery, and also we can train young surgeons.”
He says there’s a decade of data showing robotic surgery could be cost effective in large public hospitals with big volume surgical lists.
Murphy’s team at the Peter Mac did the research showing robotic surgery gave prostate cancer patients better health results, reduced their hospital stay, and saved the health system money.
“One of my PhD students, Marnique Basto, did a PhD on the health economics of robotic surgery in the public system in Victoria,” he says.
“What we showed is that due to the savings in terms of early discharge from hospital, less blood loss and better cancer results, better positive margins, that these benefits offset the cost of robotic surgery provided you were doing about 120 cases a year.
“We therefore were very encouraged by that, because it meant that you could create high volume centres where this technology was going to be cost effective, and the patients would get those benefits of going home earlier, back to work earlier, less blood loss, better cancer results.”
Orthopaedic surgeon Dirk van Bavelperformed the first robotic surgery for a knee replacement in Victoria in 2017, also at the Epworth Hospital.
Van Bavel says like mobile phones and laptops, the technology supporting robotic surgery systems has quickly caught up.
Today cameras can magnify an area by 10 times and offer surgeons a three-dimensional view allowing a more personalised, precise surgery for patients.
Van Bavel also trains surgeons in RAS methods and runs workshops for one of the robotic companies used in Australia.
He is also an executive board member of the Australian Medical Association and has completed a Masters in clinical research at the University of Melbourne that he says will complement his interest in clinical research into the use of robots in joint replacement surgery.
So is RAS better than other surgical methods? Van Bavel chooses his words carefully.
“I’m a believer in it,” he says. “All my patients in the last seven years have had robotics, and I wouldn’t do the operation without robotics, because I think it’s more accurate.”
Asked which patients would be better candidates for RAS he says it’s a matter of surgeon preference.
For now robotics are used in orthopaedic surgery in Australia for joint replacement surgery. The most common is a full knee replacement, but coming soon will be RAS shoulder replacement.
Van Bavel says the potential is its precision in the positioning of the two new parts of the shoulder: the glenoid part of the scapula (the shoulder blade) and the humerus (the upper arm bone).
“Spine surgery will also come,” he says. “It is one of the more challenging surgeries. Really good spine surgeons are great at it, but you have to put screws into part of the spine called the pedicle. And if you miss that screw, you can get the nerve or the spinal cord. So the idea is to make the insertion of those screws more accurate (with robotic spinal surgery).
“I’m not sure about brain surgery, but I wouldn’t be surprised if that comes in the not too distant future. You know, anything where you want that accuracy, that precision, robots are better than humans.”
A new frontier
Surgeon Tang says in orthopaedics robotics is a development on computer aided navigation which came along in the early 2000s and the genesis of that was for knee replacement.
“Orthopaedic surgery is a wide variety of devices that are used to enhance the positioning of the implants for the best balance and the best function,” Tang says.
“What we are discovering is that it may well play a role in reducing the so-called revision rate, which is the rate at which the implants loosen and need changing over.”
He says the data was promising that the precision of robotic surgery was going to reduce the revision rates.
“We are on the forefront of that in the development of future applications for robotics. In the long term we believe it will be enhanced by the use of robotics.”
Tang says the way the knee joint moves is complex and still being investigated, but robotics has allowed surgeons to look at different ways in which the knee moves.
“We believe that if we can accurately restore or replace the way the knee moves that we’re also going to get better functional outcomes and better longevity of implants so it’s a whole new frontier.”
I have a new lease on life after my hip replacements
It may have been the aerobics craze of the ’80s or a passion for walking; whatever the cause Carolyn Wilkinson ended up with pain in her right knee that led to a knee and two hip replacements all by RAS.
“I did a lot of hill walking and probably put a lot of pressure on my knees going downhill,” Wilkinson says. “I started to have pain in my right knee. Nothing I could do with pilates or stretching or anything seemed to work.
Initially she was disappointed with the result of her knee replacement, but it was discovered later that both hips needed to be replaced because of arthritis and no cartilage to cushion fragile bones.
“I was in England in 2022 (after the knee surgery) and it was becoming very obvious that the knee was okay but the right hip was a problem,” Wilkinson says.
RAS surgery for that hip followed but her surgeon told Wilkinson she would also need her left hip replaced “fairly soon”. She put it off as her late husband Collin had been diagnosed with melanoma and she was caring for him.
“That was a traumatic time and so my left hip, I put off for quite a while and I managed to keep going for a while but it was becoming unstable and so last year I had it done,” she says.
“I got over that very quickly. It has been remarkable.”
Wilkinson puts that down to RAS, a lot of rehab with pilates and being “evened up” by having the two hips done.
She says it has given her a new lease on life. “Oh goodness it really has.”
What’s next?
Murphy says RAS systems are still expensive and health providers need to be pragmatic about which procedures make sense to offer it.
“So certain complex cancer procedures like prostatectomy, rectal cancer surgery, kidney cancer surgery, head and neck surgery are a good example of high value proposition. It is good for cancers in the mouth where you can put these robots in and spare patients from having big, destructive surgery,” he says.
“But for example, a hernia repair, I would argue, an appendectomy, gall bladder surgery, these are surgeries where it’s difficult to justify the extra expense of the robot.
“So I think we still have to be pragmatic about how we use what are still quite expensive technologies to make sure that it’s all valued, not just to the patients, but also to the health system.”
He says it’s key for patients is to be reassured RAS is safe and that the surgeon has not given over control to a robot.
“It is still a surgeon driving it,” Murphy says.
“These tools are great, they have really helped us do better quality surgery. We see better, we can cut better with these machines, but it’s still important to know that we still need humans to be just as well skilled and well equipped to do the highest quality surgery with these machines.”
The cost
Some privately-insured patients will be out-of-pocket for RAS performed in private hospitals across Australia.
The CEO of Private Healthcare Australia Rachel David, the peak body representing health insurers, says patients concerned about out-of-pocket costs could speak to their GP before they get a referral.
The federal government’s Medical Costs Finder website also provides information on fees.
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Originally published as How robotic assisted surgery is transforming lives and cutting recovery times
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