BMJ 2018;363:k4791 doi: 10.1136/bmj.k4791 (Published 12 November 2018)
Page 1 of 1
News
Robot assisted surgery is blamed for heart patient’s
death
Clare Dyer
The BMJ
A coroner overseeing an inquest into the death of a 69 year old
man after a pioneering robotic heart operation went wrong has
concluded that a risk of further deaths will remain unless
additional safeguards are introduced.
The coroner, Karen Dilks, said that the death of retired music
teacher Stephen Pettitt came as a “direct consequence of the
operation and its complications.” She added, “Mr Pettitt died
due to complications of an operation to treat mitral valve disease
and, in part, because the operation was undertaken with robotic
assistance.”
The inquest heard that the operation in February 2015 at the
Freeman Hospital in Newcastle was the first of its kind in the
UK. The surgeon, Sukumaran Nair, had observed other surgeons
using the Da Vinci robot and practised alone on a simulator but
had not had any one to one personal training in its use.
Nair admitted that he had not told Pettitt that he ran a higher
risk as the first patient to undergo robotic mitral valve surgery
than if he had had conventional open heart surgery, which
carried only a 1-2% risk of death in his case.
An expert report concluded that Nair’s cross clamp times in
conventional operations were slow and that moving to robotic
procedures was “a premature step, running before you could
walk.” Two “proctors” (expert doctors) who were experienced
in robotic surgery, supplied by Edwards Lifesciences, had left
the hospital part way through the operation. However, they
could not have intervened in any event because they were not
registered with the General Medical Council, the inquest was
told.
Thasee Pillay, the surgeon assisting in the operation, told the
inquest that he and Nair struggled to concentrate and to talk to
each other because of a “tinny” noise from the robot. He had to
raise his voice when he realised that the stitches were not being
For personal use only: See rights and reprints http://www.bmj.com/permissions
placed in an “organised fashion” after the robot knocked a
theatre assistant’s arm.
Near the end of the operation, when it was discovered that the
sutures needed to be repaired, the aorta had been cross clamped
for a considerable time and the patient developed a bleed that
blinded the robot camera.
The surgeons decided to move to open heart surgery, but Pettitt’s
heart tissue had deteriorated too much, and he died from multiple
organ failure in the next days.
Edwards Lifesciences pointed that it was not the manufacturer
or the supplier of the Da Vinci robot, so was not involved in
the training or proctoring of this device. It was not called to the
inquest and did not comment on the operation.
In a statement to The BMJ it said, “The Edwards Lifesciences
proctors attended in relation to two other devices, manufactured
by our company, which were used early in the procedure. These
devices were both implanted and functioning appropriately when
the proctors left with the agreement of the surgeon. A company
clinical specialist remained in the operating theatre throughout
the procedure and, to our knowledge, these products functioned
as intended.”
Dilks noted that there was “an absence of any benchmark” at
Newcastle Hospitals NHS Foundation Trust for training in new
intervention treatments. Nair had been offered training in
robotics by the gynaecology department but had not taken it up.
The coroner also said that the trust should develop a policy
covering the use of proctors and should ensure that consent
forms detailed the risks of new procedures.
She said that she would ask the Royal College of Surgeons and
the Department of Health and Social Care to consider whether
national guidelines should be introduced in England.
Nair now works in Scotland and no longer does robotic surgery.
Subscribe: http://www.bmj.com/subscribe
BMJ: first published as 10.1136/bmj.k4791 on 12 November 2018. Downloaded from http://www.bmj.com/ on 30 November 2023 by guest. Protected by copyright.
NEWS