CANCER AND SURGERY
Surgery clearly dates back millennia, but the era of cancer surgery really dates back to the development of effective anaesthesia in the mid-19th century, which moved surgery from the ghastly, last-ditch ‘gore-fest’ of emergency amputations to controlled dissections. Surgery to remove a tumour is one of the mainstays of cancer therapy (together with radiotherapy), and despite advances in drug treatment seems set to remain so for the foreseeable future. Increasingly, surgeons are developing minimally invasive (often called keyhole) techniques to operate without performing large incisions. These have the advantage of the rapid postoperative recovery, but do increase operation times and are technically challenging. These techniques do allow older, frailer patients to be operated on due to the faster recovery times. They are also more generally attractive to all patient groups as they are less painful in the recovery period and rehabilitation to full normal function is quicker. Against this, operating via long metal tubes whilst peering down a modified telescope has been likened to tying your shoelaces with chopsticks, making exponents of open surgery claim that the key cancer outcomes – completeness of tumour removal, for example – may be compromised. Assessment of this aspect of care is made by the pathologist – a key member of the cancer team.
A recent development in minimal access surgery is the robot-assisted procedure. In a robotic operation, the instruments are inserted manually and then fixed into the robot arms. Viewing ports are inserted and the surgeon operates at a console separate from the patient – essentially using computer games technology to manipulate the instruments remotely. There are potential downsides to this exciting technology – for example, the set-up time for the robot instruments is longer than directly manipulated ‘keyhole’ instruments. Also, the machines themselves cost around £1,000,000 to buy and approximately £150,000 per year to run. This is a considerable additional outlay over and above all the general infrastructure of operating theatres, wards, anaesthetic departments, and so on. Whether ultimately this will turn out to be both clinically and cost effective clearly remains to be seen. Certainly, in the USA, there is now very strong consumer/patient demand for robotic surgery that may ultimately override the colder clinical considerations.