英國首例機器人心瓣手術失敗 機器人「亂放心臟」病人死亡

(倫敦9日綜合電)3年前的英國首例機器人心瓣修復手術以失敗告終,病人死亡,11月5日起到9日召開的聽證會顯示,在機器人「暴走」的背後,可能還有人為因素。

英國在2015年2月進行了該國首例機器人心瓣修復手術,期間「達文西」機器人手臂把病人的心臟「放錯位置」,還戳穿大動脈,但主刀醫生未能第一時間搶救,導致病人佩蒂特(Stephen Pettitt)死亡。

主刀印度裔醫生納伊爾(Sukumaran Nair)說,自己曾錯過兩次機器人手術培訓課程,其中一次是因為自己還有另一台手術太忙,抽不了身。」而當天是他本人第一次使用該型號的機器人進行心瓣手術。

手術中,醫生間的交流原本是通過話筒進行,但因機器人主機發出「刺耳」的聲音,很難進行溝通。

當時他發現機器人把病人的心臟「放錯位置」後,必須向其助手佩萊(Thasee Pillay)大叫才行。他隨後還看到機械臂「亂碰」助理醫生的手,當場又一次大叫。

結果,機器人把病人的大動脈戳破,血濺到機器人的攝像頭上,導致這台機器「失明」。這時,納伊爾準備向在場的2名醫用機器人專家求助,但兩人不見了。

調查發現,這兩人當時已離開手術室,稱「不想打擾醫生工作」而且兩人已回家。

醫生不得不關掉機器,開始親手操刀修復病人動脈。但病人的心跳已「相當微弱」。

手術結束後不到1周,病人就在醫院去世。納伊爾說,從那次事件以後自己主刀的手術再也沒有使用過機器人。

「達文西」手術機器人系統。

主刀印度裔醫生納伊爾。

病人佩蒂特

文:英國 每日郵報、英國 每日電訊報

圖:英國 每日郵報

Robot killed patient when it knocked doctor’s hand during heart operation

A dad-of-three died after a robot knocked a doctor’s hand during a pioneering operation with the new technology, an inquest heard.

Heart surgeon Sukumaran Nair and his assistant doctor Thasee Pillay were struggling to concentrate and talk to each other due to a 『tinny』 noise from the robot while operating on Stephen Pettitt’s heart valve.

Mr Pillay said he had to raise his voice when he realised the stitches on Mr Pettitt’s heart were not being placed in an 『organised fashion』, after the robot knocked a theatre assistant’s arm.

Mr Nair agreed with an official report that his use of robot surgery, the first of its kind in the UK, was like 『running before you could walk』.

He also said he told the 69-year-old father about the risks, but admitted: 『I did not tell him he ran a higher risk being the first robotic mitral valve patient.』Mr Nair, who told the hearing he no longer carries out robotic surgery, agreed with coroner Karen Dilks that it was 『more likely than not』 that Mr Pettitt would have survived had conventional, open heart surgery been used.

The surgeon told the inquest in Newcastle that when he undertook the operation in February 2015 at the Freeman Hospital, he had not had any one-to-one personal training on the use of the Da Vinci robot, but had observed others and practised on it alone.

Mr Nair said: 『At the time, I should have gained more experience and my clamp times would have been shorter with time.』

Sukumaran Nair said he did not tell the patient he ran a higher risk being the first robotic mitral valve patient.

When it started to go drastically wrong, medical experts, known as proctors, who were flown in to oversee and take over in crisis, had left the theatre.

Mr Pillay told the inquest he believed they had gone on a coffee break, it was later revealed that they had left Newcastle’s Freeman Hospital before the surgery was successfully completed.

Mr Pettitt was diagnosed with a mitral valve leak after experiencing palpitations and, being tall and not overweight, was considered a good candidate for the new, robotic technique.

But near the expected conclusion of the long operation, it was discovered that sutures inside the heart had criss-crossed and needed to be repaired.

By this time Mr Pettitt’s aorta had been cross-clamped for a considerable time, and the robot camera was blinded by leaking blood.

Thasee Pillay said he had to raise his voice when he realised the stitches on Mr Pettitt’s heart were not being placed in an 『organised fashion』.

The doctors decided to convert to open heart surgery, but the patient could not be saved and died from multiple organ failure in the following days.

Mr Nair agreed when Barry Speker, for the Newcastle Hospitals NHS Trust, read from an official report by a professor that his cross-clamp times in non-robotic operations were slow and moving to robotic procedures was 『a premature step, running before you could walk』.

Speaking about gaining patient consent, Mr Nair said: 『I made it clear to him that he is going to be the first robotic mitral valve repair patient.

『I had explained to him about risks. I agree, I did not tell him he ran a higher risk being the first robotic mitral valve patient.』

Asked if he was keen to get the robotic mitral valve replacement surgery up and running, he said: 『Developing it in a country is something an innovative surgeon would be looking to do.』

Mr Nair had not had any one-to-one personal training on the use of the Da Vinci robot, but had observed others and practised on it alone

He was asked if he was considering switching to open surgery when the proctors unexpectedly left the theatre.

He replied: 『At the stage when they left the operation was progressing well.

『It didn』t cross my mind that the proctors [leaving] should have been an indication to convert immediately.

『I was not foreseeing a problem at that stage.』

Georgina Nolan, representing the family, asked whether Mr Nair had any face-to-face training on using the robot.

The inquest heard Mr Nair shadowed US surgeons carrying out four robotic mitral valve repairs, and one in Holland, and that he practised alone on a simulator, but had no individual hands-on training.

When it started to go drastically wrong, medical experts, known as proctors, who were flown in to oversee and take over in crisis, had left the theatre

He said he was offered training in robotic surgery with the gynaecology department but he had his own list of operations to perform on that day.

Mr Nair, who trained in India and London and previously worked at the Papworth Hospital in Cambridgeshire, told the inquest: 『With this experience behind me and reflection, [the way we] started the robotic programme would be very different and the way I conducted the operation would be very different.』

Earlier, cardiac surgeon Professor Stephen Clark was asked what he thought about the proctors leaving Mr Nair’s operation.

He said: 『If the proctor leaves, that safety net has gone and you are left with an operation that is outside your normal experience and remit.

『I would feel very nervous and exposed, I am quite a cautious and conservative surgeon.』

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