#10 - How Robotic Surgery Is Changing What It Means to Be a Surgeon | Mark Slack

In 10 to 15 years, today's operating theatre may look just as primitive as open surgery did a generation ago. That future is arriving faster than anyone expected.

In this episode of Health in Hyperdrive, Dominic James sits down with Mark Slack, Chief Medical Officer and co-founder of CMR Surgical, for a conversation that genuinely changed how I think about the future of medicine. We cover the crisis in surgical training, why 60% of patients still don't get the surgery they should, how robotic systems are compressing decades of skill development into weeks, and what happens when you combine millions of surgical data points with AI. Mark also shares the remarkable story of building a surgical robot from scratch in five years, and offers a vision of the operating theatre in 2040 that is more radical, and more imminent, than most people realise.

10x faster surgical training. 50% fewer complications with keyhole surgery. Clinical trials at 1/10th the cost using real world evidence. Robotics is how we get there for everyone.

Key Topics Covered

•  Why millions of patients are still getting the wrong surgery, and what it's costing them and the system

•  How robotics is turning a 60 hour training task into 30 minutes, and what that means for the future of surgical skill

•  How five people went from a sketch to operating on a human in five years, one of the fastest robot builds in medical history

•  Why robotic surgery is better for patients, better for surgeons, and better for the bottom line

•  Millions of data points, real world evidence, and just the beginning of what robotics and AI can unlock

•  How AI is creeping into the operating theatre, and how far it might go

•  The 10 to 15 year vision, and why the surgeon of the future might look nothing like the surgeon of today

About Mark

Mark Slack is Chief Medical Officer and co-founder of CMR Surgical. A gynaecological surgeon trained in South Africa and based for most of his career at Cambridge University, Mark spent decades teaching, researching, and pioneering new operations before co-founding CMR in 2014. He is one of the world's foremost voices on the future of robotic and minimally invasive surgery.

Links

•  Mark's LinkedIn - https://www.linkedin.com/in/mark-slack-3b8a2139/

•  CMR Surgical website - https://www.cmrsurgical.com

•  First child in the UK to have robotic surgery - Guy's and St Thomas' NHS - https://www.guysandstthomas.nhs.uk/news/london-first-revolutionary-robotic-surgery-children

•  The IDEAL framework for surgical innovation - BMJ - https://pmc.ncbi.nlm.nih.gov/articles/PMC3685515/

•  The role of Versius in paediatric surgery - PMC research paper - https://pmc.ncbi.nlm.nih.gov/articles/PMC9222178/

•  Dominic's LinkedIn - https://www.linkedin.com/in/dominicjames

•  Health in Hyperdrive website - https://www.healthinhyperdrive.com

•  Socials TikTok / X / Insta / YouTube - @DomJamesHiH

•  Produced by Explosive Brands - https://www.explosivebrands.com/

Transcript

SPEAKER_00 0:00

We are the only robot in the world that completely replicates keyhole surgery. In five years from a drawing to operating on a human, that's something of a record.

SPEAKER_01 0:09

Welcome to Health in Hyperdrive, the podcast where we explore the breakthroughs shaping the future of healthcare. I'm Dominic James, and today I'm joined by Mark Slack, Chief Medical Officer and co-founder of CMR Surgical, and one of the world's leading voices in the evolution of robotic assisted surgery.

SPEAKER_00 0:25

We can get patients up and out of their beds usually on the same day. I really do think that it's going to be a very different world that we see in 10-15 years' time.

SPEAKER_01 0:42

Mark, welcome to Health in Hyperdrive. Hi, thanks for having me. Mark, I think the place I'd love to start this conversation is really let's talk about Verseus. I've been to your website. It looks incredible, really cool. Could you maybe explain in simplistic terms what is kind of Verseus? How does it work? What does it do?

SPEAKER_00 1:01

So Verseus is a robotic-assisted system, and it's designed to help surgeons do keyhole surgery. There have been other robots around, what I call traditional robots. They are different construct from ours. And I think we have some advantages in that we can completely replicate keyhole surgery, but with a whole pile of advantages for the surgeon, such as 3D vision, direct mapping of hand movement instruments, instruments that have wristed ends, so they they do difficult tasks like switching is done better. So the idea behind it is to increase the uptake of keyhole surgery and with all the benefits that it gives patients.

SPEAKER_01 1:45

And um could you describe, like for people who haven't seen it, I know people will go to it, go to your website afterwards, but could you describe a little bit like what does Verseus look like?

SPEAKER_00 1:55

So the the great advantage of Verseus Fus is its size. It's actually quite small, it's only about five foot seven tall, and each um arm has a footprint on the base of 38 by 38 centimetres, so it fits around the table very neatly, also allowing space for other members of the tech team and the medical team to be there. So the surgeon sits at a console with hand controls and a 3D um monitor and actually you know controls the robot. Then at the side of the bed, there are three or four arms. One arm holds the camera, which goes through the trochard into the body, and the other three arms hold the instruments which carry out the task of dissecting and cutting and suturing and so on. So it's it's it's a surgeon still doing it, decision making and um the procedural steps are all still commanded by the surgeon, but with all the advantages of robots over the what we call straight stick um laparoscopy or keyhole surgery, which is incredibly difficult.

SPEAKER_01 2:58

Can you um maybe describe a little bit the the traditional laparoscopic surgery? Because you know, I've I've watched some of the videos. I I actually knew nothing about it. I had an idea in my head, I didn't realize there's like long sticks, and it I I think I read somewhere it was described as like tying a knot with chopsticks while looking in the mirror or something like that. I think it's not a bad analogy, and I've certainly heard that before.

SPEAKER_00 3:18

Right. Um so keyhole surgery came in in the 90s in real volume. It's incredibly difficult to do, um, and not everybody can. I train people in keyhole surgery for about 25 years, and you know, it's it's an instrument about that long. Um you're standing on the bedside with your arms raised, um you um, you know, your movements are exaggerated. If you move your hand right, the instrument goes left on the on the screen. Um the tips aren't stay rigid. So to tie a knot, if I wanted to teach you to tie a knot with a normal straight stick keyhole, so it would take about 60 hours, whereas the robe will take you about an hour.

SPEAKER_01 3:59

And the um sorry, and and just for people listening rather than watching, when you said that long, that's about like half a meter or something, maybe 40 centimetres. 40 centimetres, yes. Yeah. And um the and as I look at kind of Verseus versus the traditional um instruments, the traditional instant instruments seem they're they're very rigid as you've described, and I've seen like little claws at the end. Whereas Verseus, for people who haven't seen it, there's like lots of actuators. That's probably the wrong term, but it seems incredibly dexterous, both um kind of the arm but also the instrument at the end as well.

SPEAKER_00 4:32

It basically gives you back the human wrist. It's got a wrist on the end, it's got an articulated wrist, which can move through 720 degrees, and and it can flex and it can yaw and everything. So when you come to tie a knot, it's like using your fingers to tie a knot where you can position it appropriately to get the knot tied.

SPEAKER_01 4:50

Um so I I think kind of with that um kind of setting out of the way, and uh it's I'd encourage everyone to just go to your website or watch some videos. It's it's it's really uh it look really looks very cool. Um maybe we can uh kind of jump into your sort of background a little bit, like how how how did you kind of get into this? I I mean you're you you started as a surgeon, you've um you you've done education, you've you've you teach students, you're an inventor, uh, and now you're a co-founder of a very cool surgical robot company.

SPEAKER_00 5:24

Well, I mean, um, as you say, I um trained in medicine in South Africa. Um, I also specialized in gynecology as a gynecological surgeon, and the division of gynea that I worked in is is all surgical. And then I spent most of my career at Cambridge University and both teaching, doing research, and training surgeons. And um I realized I ran a course to train keyhole or minimal access surgery, and realized I couldn't get everybody to the level that I really wanted them to be. And that's when I started to think, well, maybe robots would help close that gap. I mean, keyhole's difficult too. I'm short, so I had to stand on a platform. You got your arms up in the air, you're there for two, three hours. Um, the articulation is incredibly difficult, and uh, some of the tasks some people never master. And that's why I started thinking, could we um use a robot with all the advantages? 3D vision, magnification of the vision, um, depth perception as a consequence of the 3D, the articulated instruments, the direct mapping. I thought that'll be great. Um, and I went and looked at the traditional robots available. I didn't like um what they were on offer. So um with some colleagues decided to build our own.

SPEAKER_01 6:40

And so you made that shift like you made that shift from are you still practicing medicine? No. So you made that shift to kind of help others at scale versus practicing and and being making your difference as a surgeon.

SPEAKER_00 6:57

Yeah, no, it's it's I mean, I I'd sort of done pretty much I'd done a lot of innovation in surgery as well, um, brought in new operations um that were world firsts, and um did some pretty advanced surgery. So I didn't have a lot more to prove to myself in that field, and I thought it would be better to think of something more globally that would mean that more people would get keyhole surgeries. You know, keyhole surgery reduces the complications of the comparative open surgery by about 50%. Uh and you know, a good example is uh a wound infection. If you get a wound infection with a big wound, 50% of those people will have to go back into hospital, and 12 to 20% will need to go back into theater. Now, the incidence of infection in key health surgery is the same, but you treat them as outpatients, saving literally billions of dollars per annum. And so it, you know, I started to think more globally, what could we do that would have a greater impact on health internationally?

SPEAKER_01 7:55

And uh just kind of building on that a little bit, um, I mean, you you you mentioned kind of from a system perspective, but also from the patient perspective, uh you you know, it it feels completely different.

SPEAKER_00 8:05

Well, number one, it's safer.

SPEAKER_01 8:07

Yeah.

SPEAKER_00 8:07

Um, it has lower complication rates, considerably lower, as I said, 50% in some areas. Um, and it's less painful because the robot knows where it goes through the abdominal wall, and it exerts no pressure on the wall at all. And the advantage of our system is that we go through the normal standard trochars, which are five millimeters. Um, so yes, um, we can get patients up and out of their beds usually on the same day.

SPEAKER_01 8:34

Could we um talk maybe a a little bit uh uh about um like the complications around training for surgery? Because I I I think that's um w one one of the kind of the key benefits uh here. Um if I think about um um medical surgeon training or selection, um certainly in the UK you have to be super smart to to be a surgeon, you have to pass really hard exams, you have to have a really uh good understanding, but then dexterity and as you described your a uh an ability to perform is like a completely different skill set and filter. And so uh effectively that becomes a a barrier, or and then training, I think I read, could take up to sort of 10 years for someone to be really competent.

SPEAKER_00 9:26

I think one of the problems in um that's happened. If you go back 20 years in the UK, there were about a third of the doctors um in training that they are now. But with the European Working Time Directive, you've got to limit their hours per week. They all do resident and calls, that's nights, so they have a lot of days off, not due to their own um and that actually limits the ability to train. And to actually, you know, we used to operate four or five times a week. Some of these um operate once a week if they're lucky. So, yes, they've got to pass an exam, they've got to do a lot of studying. Um, but you actually surgery is a craft, and you need to do a lot of it to get good at it. And um, there's some quite scary statistics that about 60 or 70 percent of trainees at the end of their training themselves do not believe they're ready for independent practice. So we do need a radical shake-up of surgical training anyway, but perhaps robot robots will help us. The example I gave you earlier, if to teach somebody to tie a knot 40 to 60 hours well on the robots 30 minutes to 60 minutes and potentially with AI in the future. So um hopefully this will be one of the ways we improve training.

SPEAKER_01 10:37

And um we and consequently, I mean, consequently, that gives more people the opportunity to have much better surgery.

SPEAKER_00 10:47

So at the moment, with all the advantages of keyhole surgery, only about 40% of people get it. So you go to the United States of America, supposedly the most sophisticated health system in the world, about 40% of people get keyhole who could could do uh have open. Okay. And uh still the majority get open surgery with all the complications and the consequences. And the NHS last year stated that they wanted to get 80% of the operations in the NHS performed by keyhole surgery.

SPEAKER_01 11:17

And the constraint there is the ability of surgeons to do it for a number of yeah, and they're not going to do that as normal laparoscopy.

SPEAKER_00 11:25

So um we that's where robots will come into the equation.

SPEAKER_01 11:28

I I think that's a that's a really incredible point. In the I mean, that's a doubling, right? Like it's it's it's not a small increment or a small change. It's uh it's it's doubling.

SPEAKER_00 11:41

It's it's um, but the money that it will save the NHS is is incredible. I mean, the the litigation bill in the NHS at the moment is 60 billion. So um we do need to have some radical steps to learn that and so with better training um and um better outcomes, we we suddenly knock a um a lot off that bill.

SPEAKER_01 12:02

I'd like to maybe just expand on the topic, on the kind of the broader landscape of um robotic surgery. Like uh as I you know started investigating this field, I I I guess I had something in my head, maybe something from Star Wars, uh, maybe uh it's the the Elon Musk kind of Tesla Optimus robot replacing the surgeon with a humanoid. Um I didn't really know what robotic surgery is, and you know, in our conversations in in in preparation, I I you gave me a little bit of a an overview that there's there's kind of a a broader spectrum. Um would you mind just kind of sharing a little a little bit like the the the bigger picture of robotic surgery um and maybe the different sort of categories?

SPEAKER_00 12:46

Okay, so at the moment they are literally new robots every week coming out. Okay, and you broadly define them into what we call soft tissue robots that do the equivalent of keyhole surgery, and then you have hard tissue robots that do orthopedic type surgery, knees and hips and and so on, and now spinal surgery as well in this in the heart tissue, and now robots are coming into neurosurgery in the head as well, and in microsurgery for plastic surgeons. So our robot is what we call a soft tissue robot. It's a slave master arrangement. The surgeon drives it, the robot does the technical work for them, but it's not autonomous in any way, it's completely controlled by the surgery. And we replicate all keyhole surgeries, so it's transoral, thoracic, colorectal upper GR, urology, gynecology, and most recently and excitingly, pediatric surgery.

SPEAKER_01 13:38

Uh, what would you say are the kind of the current trends and the innovations that's happening in robotic surgery?

SPEAKER_00 13:44

So the WALS a single robotic system round from about 2001. Um, and its patents sort of started disappearing in about 2018, which has prompted a lot of companies to build robots. Um what we call a traditional robot is what we call a remote sensor, center of motion robot. And there are a lot of them now, and they all hold their um instruments like you'd hold a dagger, and they are on a physical rail arms, and because of that, they need to be very large. So they've very tall, they weigh up to 600 kilograms each, they normally do not fit through doors, so it requires quite a lot of modification in theatre. There are other robotic systems aimed at doing hybrid surgery, so part of the surgery, the surgeon will do traditionally keyhole until they come to the difficult part like tying knots, and then they'll use um two robotic arms. Um, but those robots can't do the whole operation. And then one like ours is a complete replica of keyhole surgery. So we go through the same ports, we use the same size ports, we use the same procedural steps, and we mimic the surgery as it's done handheld laparoscopy. So we probably are the only robot that really can say we replicate um keyhole surgery.

SPEAKER_01 15:04

And could you talk about maybe like some of the um advancements or um some some of the other things that maybe uh robotic surgery unlocks? So for example, I I think when we were speaking previously, you you said, well, actually now you have data so you can understand you've got an a digital recording of how a surgery was was done, and then you would have that on a macro or an aggregated scale, so you can start to do analysis and and make uh make improvements there.

SPEAKER_00 15:35

Robots uh are opening up something. So when you've got surgery, you've got the patient and you've got the surgeon. You can have videos, obviously. With the robot, you've got the robot in between the surgeon and the patient, and it's measuring all sorts of things. So the best example measures telemetry, so it measures the movement of the instruments and move measures the movement of the surgeon's hands. And already on analysis, the robot can distinguish between an expert surgeon and a novice by their hand movements. So that has implications with training one day. When you do your annual appraisal, you might have to go and sit in the robot and tell you whether you're good enough or not, or whether you're inefficient, and whether the areas you could retrain and become more efficient. So those are sort of just the beginning. I mean, we had a surgeon complain that um something had broken when he was taking his instrument out. And we could look at the telemetry and show that he hadn't straightened it before he wanted to take it out. Uh and then a week or two later we we changed the software. So when they press the button to change an instrument, the machine straightens it. So if the surgeon forgets to, that's that's um dealt with.

SPEAKER_01 16:40

And and and I that's like really um quite game shifting, isn't it? The you that you I mean you you you mentioned a little bit like your experience in um innovation in surgery and coming up with new methods, and um, but having the the the data and the tools and being able to see that on a um on a kind of factual and aggregated basis, that feels like it's quite a it's it's quite a transformative thing.

SPEAKER_00 17:10

It's so exciting. I mean, we're just scratching the surface at the moment, but it has implications for training, it has implications for research, it has implications for efficiency. You can also break down the surgery. You could go to the surgeon and say, you know, in that certain stage, you're taking 20% longer than anybody else. What are you doing wrong? What can we improve it? And so, and that's just the beginning. It'd be a bit like your car, which has got um lane control in it. Um when the surgeon, um, you know, if they wanted to use the electrocautery and it wasn't visible on the screen, which is a way people get injured, um, the machine could say, we can't see it. Or if you get to a certain part of the anatomy, say, beware. Um, the ureter is very close to here. Um, so in the beginning, it will be incremental steps. I see it as early warning systems, um, but in time that will grow. Um, and automation will increasingly become part of it as well. So for tying a knot, that may well become an automated process. So the surgeon puts the sutures and then presses a button, and the um machine ties the knot for them.

SPEAKER_01 18:12

And um could we talk about AI? And we're we're gonna have to. Um, it's it's completely transformative. Um, do you do you does it play a role um in the surgical robots or will it in the future?

SPEAKER_00 18:26

Absolutely. I mean, you you can't um you know, you can't do anything at the moment without AI. And there's also an incredible amount of nonsense spoken about AI. And um there have been an awful number of AI apps and so on that have failed already. So I think it's I always tell my my trainees and people, um, I said, imagine if you had an AI app that could reduce your complications by 47% and your um deaths by um 38%, how much you pay for it? And they're all lots. And um, there's a thing called the WHO checklist. If you ask 17 questions before an op, um that will make sure that you're doing the correct things and that will actually take out. So not everything has to be AI or expensive to be good. But with something like that, we're probably going to put it into our startup program. So when you're setting up the robot um before you can start operating, it will make you go through those questions. So AI is going to be um a big change. We've got a huge amount of work going on around, you know, the the the big one at the moment will be first of all to put all your videos on and get the um so the first hundred will be um tagged by humans, pointing out what the various, and then the machines will teach themselves. And so that automatically gives you better anatomical differentiation and understanding. And then as I said, and also you can then look, standardization is what's needed for good surgery. All surgeons do it slightly differently, but when you've got I've got 43,000 telemetry records and a similar number of um videos, and I've got 15,000 clinical outcomes. So all of a sudden you're sitting with a massive data set and can say, you know, oh, Joe blogs over there, gets much better results. And we notice in steps three and four, he or she does something different. Um, and that way you can standardize and you can feed back to certain things that they could do better um in their in their in their um in their execution of their surgical um tools.

SPEAKER_01 20:26

And and you you know, this is the one of the great benefits of AI. It's um it unlocks data, really. Like that's you know, if if if I were to think of a a shortcut, like we've for many, many years, we've had in incredible amounts of data. Um, it's just really hard to know what to do with it, to interpret it, to turn it into something kind of useful and and and insight. So some of the things that like some of the data sets that you're talking about, the telemetry and the video, it's it would be hard for a human, or even there's probably not even analytical tools uh around at the moment that would be able to interpret that. And and so having a a flexible, intelligent machine that can kind of comb through all the all that and link it to good outcomes, that that's gotta be well that that you gets into the into the realm of real world data, which becomes real world evidence.

SPEAKER_00 21:23

And we're sort of tiptoeing into that world, but already you're starting to see papers being published with a million patients in them. I mean, that's transformative. It used to be 120, 130. All and you know, you can't really have any fraud when you've got a million. It's difficult to make it up. Do you know what I mean? Yeah. Um, and you can measure trends. So I to me, the data side is almost as exciting as anything else. So we have a registry which we at the moment getting ready to try and automate. So then you'd have clinical records on every single patient you operate on for every single surgeon that uses the system. And that has so you can see the best surgeons, then you go and watch what they're doing better, mimic their work. If a student's not doing as well, you can review it and perhaps take steps to make them better and safer. So um and the and the data will we will just learn so much from it. And as you correctly say, with um small data sets, there's all sorts of bias in involved in it. With these big data sets, and you know we're talking even, you know, I mean as I said, I've got 43,000 telemetry records. We've only just started to to to peep at those.

SPEAKER_01 22:30

Yeah I I I remember when I first started working in uh pharmaceuticals and you you know I work for a large pharmaceutical company, I was really I started reading clinical trials for the first time and I was really surprised how few people are actually in clinical trials and then you know from from that um you these you know drugs get rolled out kind of globally on on relatively low sample sets.

SPEAKER_00 22:57

And I I I think a lot of people don't actually sort of understand or or or realize that and the the transition from say that as you said you know a few hundred people to millions of records and real world evidence uh in real environments um with real patients not not the kind of the ideal environment um that's just incredible right well I mean pharma is uh we're not discussing pharmacy but it is another interesting area there are very few studies done on women yeah because they have different hormonal fluctuations in the monthly cycle and so the drugs have been tried on men and then prescribed to women you know are they not on different age groups uh um so there's all sorts of reasons why those and it's incredibly expensive um if I was to do a study with 220 patients randomized study in surgery it'll cost me about 1.9 million and we've just finished a study with 150 patients um who we were quoted roughly that by a contract research organization but by using real world data in our registry we've um brought it home for 35000 and that's something in the health service we have to work out as well we've got to try and work out ways to cut costs and make health more affordable and and and you mentioned sort of women but it's just also more broadly inclusive right because it's the the true population of people having surgery uh certainly where there's people very kind of sick or uh in very poor condition quite often they wouldn't be included in in trials sometimes younger people and th things along these lines right it's a very curated group of people that are going to trials and that's where real world evidence does become incredibly exciting because you literally can take all the people that you're operating on in a standardized fashion being collected and having a repository of data that you can then um you can then mine and understand.

SPEAKER_01 24:51

Can we um maybe talk a little bit about uh automation you you started touching on some of these things that you could build into the the system of you know some warnings alerts watch out for this watch out for that is there um a a a world where um the the robots become more automated or they can do some kind of maybe simple procedures on their own or even more complicated ones?

SPEAKER_00 25:17

So if you'd asked me that three years ago I would have said no um but the acceleration of AI acceleration of LLMs and so on um are making all these things look like they could be very possible. So I'll give you an example every patient's a different size and most of the tables are different and the advantage of our system is having this modularity that you can set up. But that does pose in the early days of experience with it some difficulty for surgeons. So really my team is working on something where they can put in the size of the patient and they'll put in and which operation the patient's going to have and then a visual machine will beam onto the ground where the um bedside units must be placed and you press a button and the arms will come out on their own and pose themselves ready to go into the into the abdomen. So that's a a a good example of just making setup efficient and shorter and so on. But yes automation will come in and there'll be early warning systems warning you that you're near a dangerous structure or that surgeons experience a certain complication relatively commonly at a certain point and and then um it will go on to um warning systems a bit like you're moving your lane in the car and then it will be things automated physical um acts I mean there is a in in in animal work um people have automated a codiosystectomy from beginning to end. Sorry what's one of those? That's taking out the gallbladder and they've automated that in the laboratory. So I mean one of the big challenges in in live um humans is that they're breathing and the organs inside the body don't move in a pattern. If you take a deep breath in your bowel will move in response to it. Your liver will move four centimetres. But again um a few years ago I would have thought that would have been impossible to learn I don't think that anymore and when you see what some of these systems are starting to do. And a lot of this is experimental and there we've got to be very cautious you know these value-based medicines so we mustn't be paying for things that give very marginal gains and these um and value yes the value based and there's evidence based it's got to actually improve things so it will put the onus all these AI claims and so on we've got to go back and say does this genuinely make an improvement and justify the increased cost to get that improvement.

SPEAKER_01 27:49

I'd like to maybe uh I I probably should have done this before I'd like to step back a a little bit um because we kind of skipped over a a a piece of this um story which I I think is really fascinating which is like how do you go from an idea to a robot like that it there seems to be a massive leap so you you you kind of simple you you you painted a very simple picture you you thought robots could help you had a look what was in the market you it none of them were working for you and then you've now ended up with a company and you have a a uh something kind of really incredible like what's that step between I think things should be different and actually building an engineering and coming up with something that actually works.

SPEAKER_00 28:36

So I think we were incredibly um lucky um we had there were five of us though that um got together and each one brought certain skills to the party and um I I think quite differently from from a lot of people I've got quite a lot of lateral thought I'm sure I've got ADHD or something um and um Luke is um incredible he's got um technically vision Paul and Keith two of our other co-founders um likewise technically incredibly talented people and then Martin who was our first CEO um he brought a sort of stability to the team of five of us so it was all incremental um I was thinking about robots as a way but didn't like what was on offer. Luke had done a bit of work on robots as had Paul and and Keith and and when we got together it was a matter of us saying what is it that we want from this robot and one of the things I insisted on was that it's the same size as the instruments you use handheld. So the small ones so they can go into the abdomen less scarring less pain um I wanted the modularity because that gave you the freedom and also meant you could replicate I always say we are the only robot in the world that completely replicates key heart surgery port positioning port size procedural steps so at least from the outset we can claim the same results. What we are starting to show is even better results and this is a journey that we're on at the moment as well. How do you go from A to B?

SPEAKER_01 30:10

I never know it just happens I I I I'm gonna dig in there a little bit so you you have this idea you've like we or you you've outlined some kind of requirements and you're working with uh one of your co-founders who's built robots previously do you sketch it up or you just say I I I want something that does this or so that was a great story.

SPEAKER_00 30:31

Luke had an idea in his head I mean he he has to be praised for the actual design because um you know as I said all other robots hold instruments like a dagger in your fist and ours holds the instruments end on. And that's because Luke designed a wristdown on the robot that could do all the movements and um he always modestly says in a few years time when the patterns ran out all robots will look like ours which is which is probably true. And um but that that you know it's a it's a matter of also respecting people and working well together. So you know we've all made mistakes in the genesis of of the robots and um you know from time to time and and you also have to learn to work as a group so there was a particular fault that I was concerned about um in the beginning with the instruments and that wasn't listened to for quite a while um and then unfortunately I proved to be correct so to be redesigned. But then as you work as a group you learn each other's skills and strengths and um and we also we we had the the the the good fortune of being a city like Cambridge which is wall to wall with young bright um researchers and PhD students and so on. And you know I often say I'm not quite sure we could have done this in many cities other than it we really do have some of the brightest young people working with it. So it's very much collaborative. You've got to listen to each other you've got to learn to respect each other. Paul my co-um founder and I in the beginning used to fight like like crazy and uh Martin would come out on weekends in Karma's both down and then he made some mistakes I made some mistakes I saw him make some wins he saw me make some and you slowly work closer and closer together and Paul and I are incredibly close friends and um I miss working with him at the moment he's with a different robotic company now.

SPEAKER_01 32:29

And um how how long did that process go from say you you know in in you guys coming together to coming up with your first prototype to coming up with something that's kind of um commercially we went from a computer generated image in 2014 um to having a working prototype 18 months later which helped us with our early fundraising we could actually show potential investors what we're doing to first in human in 2019.

SPEAKER_00 32:56

So we went in five years from a drawing to operating on a human that's something of a record.

SPEAKER_01 33:02

And the there's an approval process w with that and it's the first human is that approved or that's still yeah so we we've um introduced something completely different.

SPEAKER_00 33:15

I followed um a concept called ideal and that's a um a group of surgeons I was one of the earlier um joiners to it who um developed a way of um doing surgical research both ethically and more affordably um and we followed ideal so when we had so in the first phase we worked on um cadavers and we worked on porcine models and we did human factor studies and that was so by the time we got to doing it in a human we pretty much knew how to do every operation um where to put the ports where to put the you know machines in the side and we showed we could replicate key health surgery um and then you go into your first study. So the first study was 30 patients in a hospital with some incredibly skilled surgeons and they do 30 cases and then you stop and you wait 90 days and analyze it and look at the results and then you go to your next phase where you start doing one in operation in the chest one in the upper GI one in the pelvis and so and you start collating that data all the time followed by running a registry alongside it which is collecting a standard set of data on every single patient. And we've published that as well. So it's been an incremental ideal is a great way of introducing new um surgery in a standardized fashion affordably and ethically with the patient in mind. So I knew and if we had a complication an independent committee with no ties to the company of senior surgeons would look at the video and look at the complication and they would score it is it related is it something you'd normally see for that operation? Is it related to the robot in any way? Is it serious or not? And to date we've had no serious complications as a consequence of malfunction of the robot or of a change of procedures with the robot.

SPEAKER_01 35:18

And and yeah I mean that sounds really impressive but I normally with new technology there's a very high bar right a much higher bar than kind of incumbent um technology I mean I think the good thing is that we have replicated keyhole surgery but just with better instrumentation, better cameras and so on.

SPEAKER_00 35:35

I mean operating on 2D, two dimensions is difficult. 3D makes such all the difference in the world you know um and so we're very proud of that um set of statistics. Of course now we're moving to the next phase where we want even bigger data with real world um evidence and huge data sets.

SPEAKER_01 35:51

I mean there's a I obviously I'm a lay a layman a layman here you you know I've watched some videos of more traditional um keyhole surgery and then you look at the um the Verseus robot and you're like holy smoke it looks like we were in the dark ages beforehand it seems like almost almost sorry now I sound like I'm a a pitch man but I I I think you've convinced me but um I it's it's just you can't unsee that right no you can't unsee it and when you see the response of the surgeons on the ground as well and you know training if you can truncate training and get it to a higher level in a shorter time we need that in the world um the there's a a real shortage of skilled surgeons and um so it's it's a way of overcoming a problem. Um maybe that's a good point to talk about um surgeons and their reactions and I do you well well one um I I I'd love to hear just kind of maybe a few sort of I I know you're gonna tell me the good stories um but just kind of a few anecdotes but do you also get resistance as well like you know very skilled surgeons who like a robot can never replace like not never replace me or can never help me or things along those lines as well.

SPEAKER_00 37:08

When we were building the robot one of the things we did is we did a Delphi poll on surgeons who were skilled keyhole surgeons who hadn't converted to robotics and asked them why haven't you done that and they came up with a whole set of um reasons why they hadn't converted. So in the design of our robot we aim to overcome those barriers that surgeons had raised and there are still surgeons now that say well I don't need it that noise is diminishing as the um as the advantage of robotic surgery um come to light but it's it's what we really need to be responsible about is to make sure that we don't think that everything is going to be better by robotic surgery. And so we have to continually produce the the data the evidence and support that what we claim is better. And you know it's um when keyhole surgery came out is a great example the data shows that early stage cervical cancer that's cancer the mouth of the womb had better results in open surgery than in keyhole surgery. Now that work is being repeated and we think we know what the reason was but that's what the data showed. So all the keyhole surgeons in the world doing that sort of surgery went back to doing it open. And that is responsible medical practice you know just because I've got a beautiful robot um I also need to have the data to to show that it is genuinely better than um other ways of doing things.

SPEAKER_01 38:39

And um maybe just on that point a little bit with with the robot and the approval for usage is that by um procedure or do you have to say okay we the we're approved to use the robot for procedure X, procedure Y?

SPEAKER_00 38:56

Do you have to do it case by case and just pretty much um you you know we get the regulatory process differs slightly country to country and in different geographies but basically you've got to first of all prove that it's safe and can work well and then you have to get approval for so in the beginning we did the studies in such a way that we got approval for the whole of the abdomen, the chest um then we've done studies to do transoral surgery busy trying for approval for that then we wanted to do pediatric surgery which is one of the really exciting stories around the robot and we had to do specific studies and then apply specifically for regulatory approval to do children. And so it goes and that's a responsible way of doing things and um you know in the UK they've had quite a shift in in the MHRA which is one of the authorities have appointed new chief executive who's really smart and um very geared up to to improving um the regulatory process and when we did the pediatric study from the finishing of the trial um to getting approval three and a half months that's something of a record in itself. So Lawrence Tallon who's the chief executive needs to be complimented for because what you know what we're showing there is you if you've got something good don't don't put barriers around it. If the data's good get it regular get it approved as soon as possible. And that's not a bad thing. We don't want things being we've seen too many things in the past come to market. Great idea and then the trouble starts and um you know a very good example of that is um transvaginal mesh which they were putting in literally hundreds of thousands of cases and now it's banned because of the complications of cause so regulatory is a necessary um step and it does frustrate people because it slows things down. But at the end of the day the most important thing is the patient on the table and whatever we do has got to be um aimed towards looking after them.

SPEAKER_01 40:54

Yeah I I you know I I'll I'll echo that whenever I worked in pharma I was um massively grateful that we had regulation in in place and that there's the balance there right you you don't want it as you said you don't want it to be a uh a barrier to innovation that you want safety to and effectiveness um to be uh kind of paramount like you you you you don't want kind of rogues kind of enter entering and you just want to make sure everything is safe and regulation helps with that and that's one of the massive advantages and the really exciting areas of real world data and real world evidence.

SPEAKER_00 41:31

You know if we can find a way of collecting that data automatically so the surgeon's not fitting it in just taking it out of the electronic records um and so you pass your regulation that goes into um your routine use and then you start collecting thousands and thousands of data sets. So you make sure that as your numbers grow and as your indications expand that you are genuinely still safe.

SPEAKER_01 41:56

Yeah but it's it's it's incredible.

SPEAKER_00 41:59

You talked a little bit I about pediatric surgery and I'd just like to explore that a a little bit um I'm guessing it's a lot more complicated because children's bodies are smaller is is is is that it so um you know I I have enormous um enormous um respect for pediatric surgeons it's difficult they're tiny some of them I mean obviously pediatric runs from 18 years of age downwards so there are pediatric patients bigger than me but as you get down towards the babies the in the the the um the organs are tiny and one of the big operations having to be done for children is where the pipe between the kidney and the bladder is narrow and the kidney swirls up and they do an operation called a piloplasty and the diameter of that pipe the ureter is about the size of a little finger and you're standing with these long instruments this is in routine keyhole trying to suture end to end and only a tiny percentage of people can actually do that. So we went into three sites in Southampton in Guys and Thomas's in London and Manchester um and we've just finished a prospective formal um trial um with the surgeons at the end of it all applied for ethical approval to continue to use the robots um before it got regulatory approval because they ethically believed they couldn't go back to doing handheld surgery. And there were also other exciting ones there's a surgeon at one of the hospitals who had tried keyhole surgery and failed at it then he got a younger colleague joined him and he would refer all those patients to the younger colleague. That is one of our sights when we went to do the study he asked if he could try and train on the robot which we allowed him to do and it is put him good enough to participate in the study. So that's a and that's where really robotics is you know we know keyhole is good. We know a lot of people can't do it. So if we Can actually enable people who can't do keyhole surgery to convert to doing keyhole robotically, we've really made a big step. And we saw that in the pediatric study, and we've seen it in a in a Ghanaian study as well. So PEADS is exciting, and the results are proportionately better than the published literature. So it's a very exciting area for us.

SPEAKER_01 44:29

It's almost um an articulation of a real articulation of what I saw on, you know, when I've been watching the YouTube videos. You know, I see the older instruments and then I see this like fancy robot, and I'm like, how can you go back? And the example you gave with the pediatric surgeons was after they had used robotics ethically, they couldn't, they didn't want to go back to doing it the traditional way. Um, and then I'm just repeating what you're saying, it's because I I it's so important and I think it takes a little bit of time to sink in as well. Um, and then the other point you made is there was a really experienced surgeon who just didn't have the the skills to do um keyhole surgery, but with a robot he could. So you have all of his experience. Um and he's and you've given him the skills.

SPEAKER_00 45:22

And we've looked at his times. Uh you know, he's not far different from his younger colleague. And we had a similar one in gynecology in one of our centers in in Europe where we did a gynee study, was a surgeon who had tried keyhole, really couldn't master it, had given it up, was doing open surgery, and then his young colleague we recruited to do a study, he also said, could he have a go at the robot? And he also put so not only did he get good enough to do it, he was good enough to participate in the study. And so that to me is very exciting. If we can shorten training and get more people doing it and get them doing it at a higher level, we truly are getting towards solving the problem of increasing the surgery up to 80%.

SPEAKER_01 46:04

Can I just quickly ask you that point? What does it mean what's the difference between being able to do it and being included in the study? Is it a higher level of skills that you can do?

SPEAKER_00 46:11

No, we that that's also changing as well now for all our American studies. They insist we have um young, new surgeons inexperienced. They insist we have ones with a sort of a moderate level of experience and ones with a high level of experience. So that is a change. But typically you would only include surgeons um to in a study um who can do the procedure, um, so that it's not about the surgeon, it's about the procedure and the results that you get as a result of it. But that's changing as well now. And that's again where um so our keyhole surgeons um that did the um that did the um pediatric study, one of them was an open surgeon as well, who learned from the robots. So the first keyhole surgery robotic cases he did are all in the study. So, and they did 150 patients with seven surgeons, so ultimately it means they're all pretty much still in their learning curve. And yet, despite that, they still got better results.

SPEAKER_01 47:10

Are there um scenarios where um the traditional tools for keyhole surgery would be used versus a robot, or do you is is the future the robot can circumvent all of that now? But I think I'm thinking a little bit like is the future the way this is done 100% or you know 99.9%?

SPEAKER_00 47:36

That's a great question. That's a great question because there are three scenarios, and and the one is that you do the entire thing robotically, but there may also be a role um in doing part of it handheld and then the more complex bit robotically, um, as a way of holding down cost. Um and then there's another argument that's not all the instruments in robotics necessarily need to have a wrist in them and be articulated. Some could also be rigid, and that would reduce the cost of production. Um, and and that's what you know, we all our instruments are multi-use, and we spend a lot of time just increasing the lives. You know, they started at about three lives per instrument, now we're up at around about 20. And again, this is part of this pursuit of value-based medicine of getting the same or better results, but uh on on controlling cost. So there will be people that do, you know, some of the operation handheld and then go to robotics. There'll be some people who do it beginning to end robotically. Um, one of the things that drives the surgeons to complete robotic is their personal comfort. And when you do keyhole surgery, you're standing, you've got two arms in the air in a very awkward pose. When you want to use the foot pedals that you use, you put all your weight onto one leg, which curves your back slightly. And by the end of the day of keyhole surgery, you're absolutely shattered and exhausted. On the robot, you're sitting or standing in a neutral position, your neck is straight, your arms are resting on a bar, and your hand movements are far less because you have touches and these articulated. And so the ergonomic injuries to robotic surgeons are hugely reduced compared with laparoscopic surgeons. Oh wow. Can I just quickly, what are the foot pedals for? That is in we don't have foot pedals. Um in in traditional lafaroscopy, they use foot pedals for other functions like diathermy, when you want to hit the instrument that burns or closes the blood vessels. Okay. They use it as a foot pedal. Um, we've made ours completely hand controlled um because we looked at the gaming industry. Some of the older surgeons still say they'd like a foot pedal. The younger ones, the younger ones don't. They they they're used to playing, you know, with instruments using the hands only.

SPEAKER_01 49:54

Okay, fantastic. I think this is a good good point to maybe talk about the future. So I I'd love to um uh maybe use our or your imagination a little bit and um you know, think about what could the future look like? Um, you know, say we project 10, 15 years forward. Um, what does the future of robotic surgery look like? What are the advances? What would be different for patients? What would be different for surgeons?

SPEAKER_00 50:20

So the one will be the data management, so we'll know a lot more about them and a lot more about the differences between different racial groups, different sexes, etc. So that will be uh, you know, we can have great knowledge acquisition as we go into the next 10 years. There will be automation, restarting it. Um, so um where that ends, I don't know yet. Um, I suspect that um operations will get faster. Um, I suspect that people do even more complex surgery in some areas because they'll be enabled to do it and um would have this constant feedback loop. Um and that means that we may need less highly skilled surgeons. And you could almost envisage a technical surgeon who the decision to operate is made by um a highly skilled diagnostician surgeon, and even there the in the um large language models may intervene. And then the person operating may be not always a fully trained surgeon um who is there to put the ports in and but the robots to do a large percentage of the complex side of the surgery. And and I uh three years ago I would have never said that. Um I really do think that it's going to be a very different world that we see in 10, 15 years' time.

SPEAKER_01 51:39

And can I ask you, um, you know, when I first got into this topic of robotic surgery, uh uh you you you can see there are a lot of misconceptions. I I I I I I I think maybe they're quite common. Um in my head, I was thinking the robot could be fully autonomous. I was thinking a lot about telesurgery, and you know, you've got a surgeon in I I don't know, Chicago operating on someone in Mumbai or vice versa. Um and then I I never really got into the the the the Tesla humanoid robot, but you know, replacing a surgeon, but you know that that that's kind of a little bit of a um a meme. Are any of these things kind of real or are they all red herrings?

SPEAKER_00 52:25

So telesurgery is a real um issue at the moment. So uh many robots um are if you have a robot in one city and a robot in another city, you can operate from one city to the next. And they used to say it was a problem with the latent phase. If your latent phase got to 250 milliseconds, then you couldn't operate across a certain distance, but that's all been overcome as well. Um so you can certainly operate with some robots in, you know, say London or somebody in Munich. Um now that means both hostels have to have the same quality of robot. Um, it also means they have to have the same quality of perioperative care. You can't suddenly bring this highly skilled doctor from New York who does a massively complicated operation in a low and middle-income country if they don't have an ITU to go to afterwards and they don't have the nurses to look after them. And one of the big problems that in the world at the moment is that 90% of complex surgery is carried out in geographies that serve 10% of the world's population. So there's a real pressing need to improve surgery, and it's something I'm actually very interested in. Whether telesurgery sells that is unlikely, I believe. You know, if you've been operating in New York all day from seven in the morning till eight in the evening, do you really want to go and get on a robot at nine at night and operate in somebody on the other side of the world? So I'm not that sure. Way telesurgery, I think, will have a really big role is I'm a surgeon, I have my robot, and you have your robot. They're both the same, and you're doing an operation that I can't do. And I read up on it, and I think, yeah, I can probably do that, but I'd like some supervision. So without you having to get in a plane, you sit on your robot and I sit on mine, and I start the operation and you talk me through it because you're watching it. And with telesurgery, you could come to a point where you could say, Mark, can I just take over for two minutes? This is how I would do it. So I think from a training point of view in supervision, because when I was a younger surgeon when I was doing some fairly rare operations, people would either fly to see me in my hospital or I would fly across the world to demonstrate it. And that's not nice either, because then you're working in a theater with different nurses, maybe don't speak the same language. And um, so so in terms of teaching surgery, I see telesurgery as something. In terms of solving the world's problems of a shortage of surgeons in certain geographies, I don't see it. I mean, there are things that in in the low and middle income countries are running water, adequate electrical supply for the hospitals, pipe gases. You know, there's so many other things that need to be to be sorted out. And what I would love to see is the device industry and the pharmaceutic industry getting together to see what could be done on a global sta scale to improve medicine for people in these low and middle income countries.

SPEAKER_01 55:30

Um I think maybe my uh I mean you've you've you've painted a uh a really exciting and optimistic um future, right? Um hopefully realistic. What are the sort of the headwinds and what are the tailwinds? Like what what needs to go right for some of these things to happen or to happen sooner?

SPEAKER_00 55:50

So we do have to get a handle on regulation um worldwide. And I'm not gonna point a finger at any specific geography, but but regulation can also be used as a bit of a negative tool. So um, you know, you'll see with the diathermy machines, and these are machines that are used to seal blood vessels when you want to cut them. And the advertising will say it seals to 10 times the blood pressure. Now, when your blood pressure is 10 times higher than normal, the last thing that you're worried about in the world is bleeding. You know, so it's a completely false um standard, but it's being set there to make the bar high and keep other people out. So things like that need to, we need to get a maturity in it, at the same time looking at cost, um, because trials are expensive. So things like ideal are amazing. So we we've we've got to constantly work at better ways of doing research, more affordable ways of doing research, and better ways of of actually disseminating the work. Um, I'm an idealist, and um I'm afraid, you know, um at the end of the day, companies also need to make a profit to survive. Um but I am a believer that you can build a company and you can deliver health ethically and affordably. Um, but um it needs a slight change in political thinking.

SPEAKER_01 57:19

Mark, thank you so much. It's been a really incredible conversation. Thanks, Tom. It's been a pleasure being here,