In November 2022, Guy’s and St Thomas’ NHS Foundation Trust grabbed headlines when it completed a week’s worth of robotic-assisted radical prostatectomy procedures in one day to help reduce NHS waiting lists. This was the latest impressive feat for the Trust which boasts the largest robotic surgery programme in the UK carrying out around 1,400 cases per year.
Ben Challacombe is the Trust clinical lead for robotic surgery and chairs its robotics steering committee. Ben has completed over 2000 robotic procedures and is the highest volume surgeon for robotic partial nephrectomy in the UK with over 750 cases.
In this interview, Ben provides an overview to Guy’s and St Thomas’ robotic surgery programme, how the Trust identifies and adopts new robotic systems, the benefits of robotic surgery compared to traditional and how he thinks the Trust’s robotic surgery programme will look in the future.
Can you give an overview to your journey in robotic surgery and the programme offered by the Trust?
I was a surgical trainee in 2001 working for Professor Prokar Dasgupta and we decided to do a research project into robotics. We proved that putting a needle into a kidney to take out a kidney stone was more accurate with a robot than the human way. That was how we got into the research side of things and at that time Prokar started putting in some grant applications for getting one of the earlier da Vinci® systems. We first got the da Vinci system at Guy’s in 2004 which was the second one in the UK. We had that single robot until 2010 doing prostate and bladder surgeries.
In the last five years, we’ve gone up to two robots, then three and then during COVID, we went up to five. Most recently, in December 2021, we bought CMR Surgical’s Versius®. So, we currently have seven specialties on two sites with six robots of two types, five da Vinci® and one Versius®. We are looking to expand to some other types of robots when they become available.
The specialties we’ve got are urology, then thoracic, who are the biggest user of thoracic robotics in Europe, they do 500 lung resections a year. Then ENT do something called TORS (TransOral Robotic Surgery) to remove cancerous lymph nodes and diagnose tumours right down the back of the mouth and throat. This often prevents people from having large face opening surgeries because they can get much further in than people can with just their hands. Then, more recently, we’ve had renal medicine and transplant and we do donor nephrectomy. We’ve done a pilot study in putting it in with the robot which is trickier but is something we are looking into getting more impetus behind in this upcoming year. Then we’ve had gynaecology start on the St Thomas site and finally, upper and lower gastrointestinal surgery who are doing brilliantly.
How do you identify new systems and specialties?
If it is in my area, then I might know about it through medical meetings, journals, publications, etc. However, what must happen is if a surgeon states that they really want to start robotics, they will have to present their need to our robotics steering group. They tell us what they think the advantages are and we will then get them to identify what system they like. I then work with some amazing people within our administration team, and we will bring in the commercial team who are the experts in doing the deals.
The deal is quite complicated because you can buy it, lease it and you can lease it with a view to buying it. But, what people are doing now is more of a managed service. So, they will give you a quote for what a certain amount of cases will cost with that system, and we will see whether that is viable, and they will then provide the kit to do that, but you won’t own it. The advantage is that these things get upgraded a lot, so they should upgrade during that process for you.
How much research is needed before the surgeon presents their need?
This is the reason why we’ve got a structure and it must go through the robotics steering group. Everyone has a say in that group, because we’ve got academics, and the managers of the Trust who run the robots. They must be clear that this is the strategy we are looking to go through, and I will work with the manager and the commercial team. You’ve got to have a strategy.
As a very early adopter of Versius®, what was that process?
CMR Surgical is a UK company and we’d known Mark Slack, and I’d been up and done some labs in Cambridge. We’d shown the lab videos at a meeting about 4 years ago to show that it was coming. Then, naturally when it became clinically approved, CMR was keen for us to get involved with it. If you sell a robot to a hospital that’s done 18 years of robotics and almost 10,000 cases it may be safer, but it also may be more difficult as everyone is set in their ways with the original system. Therefore, you need to be open-minded. They thought we’d be quite a good place to go to because we’ve got a system and we’re only changing one thing and that is the robot, everything else is standard in terms of the assistants and the anaesthetists that are used to doing robotic surgery, so I think that made it a good partnership.
What is the general perception from patients of robotic surgery and is this changing as awareness increases?
When we started, people were unsure as there wasn’t a lot of awareness around it. But, nowadays the patient awareness is much stronger and everyone is generally very positive about it. Some of our specialties are moving to robotics and a major factor of that has been wanting to avoid missing out on a referral practice.
What benefits have you seen from robotic surgery compared to traditional methods?
Quality of operation: Doing an operation to an extremely high quality is easier with robotics. For example, it provides surgeons with the ability to minimise trauma to other tissues.
Faster patient recovery: Although standard laparoscopic surgery has got a quick recovery; we are finding gains in most of the specialties converting to robotics. There is often reduced pain and reduced time spent in hospital.
Reduces the chance of major complications: What we’d previously called conversion to open surgery, would happen in laparoscopy at least 2-3% of the time. Although it still happens, it is very unusual in robotics.
Reduced cost: You can often fix intra-operative issues in robotic surgery before it gets out of hand, and perform more cases per day than in laparoscopy, hence reducing the overall cost.
In terms of Guy’s and St Thomas’ robotic surgery programme, what does it look like in 5-10 years’ time?
There are three strands: the research, the clinical excellence and wider use, and the training.
The vision is that pretty much all laparoscopic surgeries will be done robotically. I would foresee that we need at least a robot for gynaecology on its own, a robot for general surgery, maybe upper, and lower, two robots for thoracic, one for transplant and ENT and four for urology.
Having a robotic training centre and training our own junior surgeons. We currently haven’t got that, and I’d like to see a national training centre for robotics.
I am now chairing the robotics steering group and we have all sorts of areas in the pipeline that I hadn’t even dreamt of when we started this. This includes robots to help with orthopaedics, plastic surgery, micro dissection of blood vessels and spinal surgery. Those robots are different to the da Vinci® and Versius® type body cavity robots, but we are looking at expanding into that. So, I think my job is to get as much robotic access to as many specialties as possible and improve patient care with this technology.
Pictured: Ben Challacombe with the da Vinci Xi system