Surgical robots have been used to perform more than 600 surgeries at two Cape Town public hospitals, beacons of excellence offering a glimmer of hope. Spotlight’s Biénne Huisman visited Dr Tim Forgan at Tygerberg Hospital to learn more.
The Da Vinci Xi systems enable surgeons to control operations from a console – steering three arms with steel “hands” equipped with tiny surgical instruments; plus a fourth arm bearing a video camera (the laparoscope). The system translates a surgeon’s hand movements in real time, with enhanced precision, range and visuals, compared with manual surgery.
“It really is next level, it feels as if you’re inside the patient,” said colorectal specialist Dr Tim Forgan, Tygerberg Hospital’s Da Vinci robotics co-ordinator.
“You can see 10 times better with this robot than with the naked eye; you can see tiny, tiny nerves you wouldn’t normally see. And you can manoeuvre surgical instruments so much better. Because of that, people have way better function after the procedure.”
The technology allows major surgery to be completed through small incisions, instead of larger cuts made by a doctor’s hand, leading to less bleeding and faster recovery.
Hundreds of surgeries in two years
On 22 February 2022, cancer patient Lorraine Gys (65) from Phillipstown, Northern Cape, became the first person to undergo Va Vinci robotic surgery in the public sector.
Forgan was behind the console at Tygerberg Hospital.
“My recovery was very quick,” said Gys, who had a cancerous rectal tumour removed. “I was up and about in no time, while the other patients had to be assisted. I was discharged on day four, and back at home I could continue doing my own chores.”
On the day of the surgery, Forgan was joined in theatre by several onlookers including former Western Cape MEC of Health & Wellness Nomafrench Mbombo.
“It was a circus,” said Forgan. “A whole bunch of people watching me operate.”
Also in the operating room was colorectal surgeon Dr Roger Gerjy, a leading Swedish robotic surgeon who works in Dubai.
“If there had been a problem, Roger would’ve taken over,” said Forgan “He was also there to impart tips and tricks: move the instrument like this, shape it like a hockey stick; because with the robot it’s like having your whole arm inside (the body). He’d give me advice on what to do with my extra floating arm – where to place it and how to manipulate it – because remember, you’re controlling three arms at a time.”
Since 2022, the Da Vinci robots at Groote Schuur and Tygerberg have enabled more than 600 minimally invasive surgeries, including colorectal operations, prostatectomies, cystectomies (bladder removal surgery), and gynaecological procedures to treat endometriosis.
A spokesperson for the Western Cape Ministry of Health & Wellness, under former MEC Mbombo, Luke Albert said: “We can see the immense impact it has for patients and the health system. For example, a traditional open cystectomy patient would require three days of ICU stay, as well as two weeks of hospital stay to recuperate.
“During this time, on average, 42% of patients require blood transfusions and almost 20% need total parenteral nutrition (intravenous feeding). After robotic surgery for a cystectomy, patients don’t need an ICU stay and go straight to a general ward for no more than six days on average, needing no blood transfusions at all.”
The money …
Asked how the department could afford R40m per system for these machines in the context of severe budget cuts, Albert says: “The purchase was applicable to 2021/22 and not the current financial year; with all provincial Health Departments currently managing the effects of budget cuts.”
Forgan said the investment was derived from surplus budget discovered within the throes of the pandemic: “There was a surplus because certain services just couldn’t be done. I mean, for us, we couldn’t do elective surgery. And how state funding works; if you don’t spend your (provincial) budget within the financial year, it goes back to central government.”
What it looks like
Forgan points out the three core components of the system. There is a console with two control levers similar to refined joysticks – he demonstrates how to delicately hold them between forefingers and thumbs – a patient-side cart with four interactive metal arms (they are disposable; each arm can be used on 12 patients), and another trolley with a TV screen. All are connected by blue fibre-optic cables.
He expands on his passion for colorectal surgery.
“With colorectal surgery, there’s a high rate of complications … but when you have a successful outcome, saving a person from their cancer and prolonging their life through your intervention, that is the reward. It is a very unpleasant disease, and operating like this can make one hell of a difference in a patient’s life.”
He said colorectal cancer was on the increase: “There aren’t many colorectal surgeons in South Africa, and there’s a dire need for them. I mean, there are so few of us, we’re all on a WhatsApp group.”
Colorectal or colon cancer is the second most common cancer in South African men (after prostate cancer), and the third most common cancer in women (after breast and cervical cancer).
Forgan attended medical school at the University of the Witwatersrand and qualified as a general surgeon at Stellenbosch University, sub-specialising in colorectal surgery at the University of Cape Town before studying minimally invasive colorectal surgery at the Academic Medical Centre in Amsterdam.
He is president of the South African Colorectal Society and runs a part-time private practice with his Tygerberg colleague, Dr Imraan Mia, at Cape Town’s Christiaan Barnard Hospital.
‘Practise makes perfect’
Forgan said learning to use the Da Vinci system did not happen overnight, and training was done on a simulator, which is on the surgical console.
“You spend hours and days and days doing procedures, over and over again on the simulator. You have to get more than 95% for each procedure before you can move on to the next skill.
“Then it’s how to use the machine, how to put it together, what to do in an emergency; what if there’s a power failure and the machine stops working? How to safely remove it from the person? Then we went to the University of Lyon (in France) for two days of hands-on robotics training. And then a proctor – an international expert – comes to your theatre and does the procedures with you. So that was Dr Roger Gerjy, and that’s when we did Lorraine…”
First introduced by American biotechnology company Intuitive Surgical in 1999, the Da Vinci systems have sparked some liability lawsuits. An article from the Tampa Bay Times in February cites a lawsuit filed at a US District Court with a man claiming a stray electrical arc from a surgical robot burned his wife’s small intestine during a colon cancer procedure, causing her death.
The article quotes Intuitive Surgical’s 2023 financial report, which notes that 8 606 da Vinci systems are in use worldwide, having performed 2 286 000 procedures in 2023. The financial report mentions an undisclosed number of pending lawsuits, which the company disputes.
Nevertheless, Forgan, who describes himself as a “glorified plumber”, remains an advocate.
See more from MedicalBrief archives:
Robotic surgery reduces Cape backlog by 70%
SA surgeons welcome robot’s extraordinary precision
Robotic surgical system introduced at Eastern Cape hospital
SA cancer cases climb as unequal treatment causes ‘needless deaths’