Patients' experience of robotic-assisted surgery: a qualitative study

Ro botic-assisted surgery (RAS) has become widely accepted across several specialties since the introduction of the da Vinci surgical system in 2001 (Dunn, 2022). Dawka (2016) described RAS as a modality that positions a computer-assisted device between surgeon and patient. Movements performed by the surgeon at the console are mirrored by the robotic arms that perform the procedure, ensuring the control of the procedure lies with the operating surgeon. The advantages of RAS are well documented. These include a three-dimensional view, increased dexterity and precision, tremor elimination, motion scaling and improved surgeon ergonomics (Casillas et al, 2014; Trinh et al, 2014; Randell et al, 2016; Sinha et al, 2021).

Use of RAS is increasing, with more than 200 000 RAS procedures performed worldwide by 2009 (Weissman and Zinner, 2013). According to a robotic surgery evaluation in The Lancet (The Lancet, 2016), the number of robotic radical prostatectomies increased in the USA from 1.8% in 2003 to 85% in 2013 and, in the UK, 90% of radical prostatectomies are completed using RAS (Dasgupta, 2022). Maitra and Date (2019) stated that RAS is an accepted modality for several specialties including urology, gynaecology, otolaryngology and general surgery, with a noted upsurge in use. More recently, Mayor et al (2022) stated that there are almost 6000 da Vinci robots now operating worldwide, which have completed 8.5 million surgeries.

Key to any new intervention in healthcare practice is the improvement of the patient experience and outcomes (Klose et al, 2016). However, a review of literature on patient-reported perceptions regarding RAS (Moloney et al, 2020) indicated that although there is research that examined clinical outcomes, there is a dearth of studies focusing on the patient experience.

Evidence from the literature suggested that there was a particular lack of qualitative research exploring patients' experiences of RAS, with the majority of research focused on patient satisfaction using quantitative methodology and data collection instruments not specifically designed for RAS. Furthermore, any studies concerned with the patient's viewpoint indicated that patients appeared to be satisfied with RAS. Given the paucity of qualitative research specific to patient experience, this study aimed to explore the patient experience.

Aim

The aim of this study was to explore patient-reported experiences of RAS.

Methods

Design

The study design was qualitative descriptive, with data collected using semi-structured telephone interviews.

Setting and participants

Study participants were patients aged 18 or over, with the ability to provide informed consent, who had undergone RAS within the specialties of colorectal, urology or gynaecology in one hospital within the previous 6 weeks. The 6-week time frame allowed participants time to recover from the surgery and recollect their experience. Twelve participants met these inclusion criteria and were contacted via their surgeon to ascertain their interest in participating. All expressed interest and were provided with written participant information and consent forms, and were contacted to arrange an interview date. Sample size was not determined before the study, the number of participants necessary was decided when data saturation was achieved.

Data collection

Following ethical approval granted by the hospital ethics committee (Ref 113/18), data were collected using semi-structured telephone interviews supported by an interview guide (Table 1). Interviews were conducted by a researcher trained in interview technique. Individual telephone interviews were chosen to afford convenience to participants who had just undergone surgery and to give them an opportunity to provide forthright descriptions of their experiences (Sandelowski, 2010).

Telephone interviews took place at a time convenient to and chosen by the participants. Participants were asked to describe their experiences of RAS before, during and after surgery and overall. An interview guide was used to direct the progress of the discussion and this was supported by non-directive prompts (Table 1), where necessary. The interviews were audio recorded with the permission of the participants and averaged 18 minutes' duration.

Data analysis

Each interview was transcribed verbatim and analysis was conducted using Braun and Clarke's thematic framework (Clarke and Braun, 2013). This procedure involved repeated listening to each interview to identify themes in the data. Codes were then generated from the data and emergent themes were grouped together, leading to a detailed description of the theme. The trustworthiness of the study was determined using the Lincoln and Guba (1985) criteria for trustworthiness: ‘credibility, confirmability, transferability’. Credibility was achieved by the researcher thoroughly reviewing the interview transcripts and continuously returning to them to ensure that all relevant data were recorded and correct. Confirmability was achieved by recording each stage of data analysis, allowing for an audit trail of analysis. Transferability was achieved by providing an accurate account of all participant characteristics and how they perceived their experience of RAS. This process was discussed by the research team, reviewed and agreed. Finally, two themes emerged and were confirmed as representative of the data.

Results

The final sample consisted of eight women and four men ranging in age between 40 and 71 years and representing all patients that expressed an interest in participating. All participants had undergone RAS in either colorectal or urological specialties. Participant demographics are shown in Table 2. The following themes and subthemes emerged from the data analysis:

• Factors specific to the robotic modality, with subthemes:
• – Thoughts on RAS
• – Trusting the process
• – Seeking information
• – Mismatched expectations
• Psychological factors, with subthemes:
• – Worry and anticipation
• – RAS within the cancer journey.

Theme 1: Factors specific to the robotic modality

A number of factors specific to the robotic modality were identified as participants discussed the procedure dynamics, their experiences and expectations.

Thoughts on RAS

Several participants in the study reported having thought about how the robot operated. Although the majority accepted that the robot would conduct the surgery, they understood that the robot would be operated by a human.

‘I knew it was going to be clamps rather than actual hands doing the cutting, I knew they [the surgeon] would be operating using hand-held devices.’

Participant 5

Participants were not deterred by the knowledge that a robot would be used. Most viewed this as a positive asset with the surgical team still in control.

‘I knew that there was going to be a person behind it … I know the setting up of it takes a long time so it's obviously very precise.’

Participant 9

The following participant considered the benefits of the robot:

‘With the best will in the world the human hand can be a little shaky, with the robot they [surgeons] are guiding it from outside and its definitely better.’

Participant 7

The appearance of the robot was mainly not a cause of concern.

‘It looks like a big spider, there are arms all over the place but it's not scary.’

Participant 9

‘I saw the robot when I went in all wrapped in plastic, it didn't faze me.’

Participant 12

One participant observed the robot when entering the theatre and seemed to equate its appearance with the seriousness of her condition.

‘I remember looking around at all the machines and asking the nurse: “Am I that sick that I need all these machines?”.’

Participant 1

Another participant was concerned about the extended operating time in RAS and that the surgeon might tire.

‘With it being robotic it was much longer … 6-hour surgery… if it was done non-robotically it would take 3 and a half hours… someone would get tired working on you for 6 hours.’

Participant 4

Overall, participant views of the robotic modality were practical and accepting.

Trusting the process

It was clear from the data that all participants had a great deal of trust in their surgical team and also in the technology used even though they had limited knowledge about RAS. Participants mainly reported accepting the surgical team's advice.

‘He [surgeon] felt robotic surgery was the best option as I would have a colostomy bag if any other method [modality] was used because my tumour was located in an area with only one-eighth of a centimetre to access it so I was happy that it [RAS] was an option.’

Participant 3

Another participant described his surgery as quite delicate, and he had been advised that RAS was the best option for him. Although he was not aware of the detail involved, he felt compelled to take on board the advice of the surgeon.

‘The surgeon said I had to go with robotic surgery as the tumour was among my organs and it would be too much of a risk if they made a mistake in the operation so a steady hand was needed.’

Participant 10

Trust in the surgical team was also evident in the following quotes.

‘I didn't have to think too much about it [RAS], as they [surgeons] offered great reassurance.’

Participant 8

‘My confidence was in the consultant more than the robot and I went with his recommendation to have the robotic surgery.’

Participant 4

Another participant who had experienced a number of RAS procedures explained that he had confidence in the surgeon's ability, even though the surgeon's first RAS was in the early days of the technique being used in the hospital.

‘I never think of asking questions, once I agree to go ahead, I am in their [the surgeon's] hands. I think I was the third robotic case done in the hospital but he knew what he was doing and my family had great confidence in him also.’

Participant 9

The surgeon's confidence allowed another participant to feel at ease with the whole experience.

‘He [surgeon] was quietly confident and this instilled a quiet confidence in me. He shook my hand and said “we've got this”, we've got you, so that was really nice to know.’

Participant 1

Following the procedure one participant was surprised with the short hospital stay but was advised that she was ready for discharge.

‘I was let home after three days. It was very fast but he [surgeon] felt I was doing OK.’

Participant 2

A small number of participants reported that they had trust in the robot and the new technology with one acknowledging:

‘It was the modern way nowadays.’

Participant 6

A male participant with an engineering background acknowledged that challenges can occur with new technologies but he was not concerned in this case.

‘I am a retired engineer so I knew it was just a machine and machines can go wrong but it didn't bother me.’

Participant 11

It is interesting that the majority of participants who first placed their trust in the surgeon were mainly female, whereas those who trusted the robotic modality were all male.

Seeking information

The majority of participants reported receiving little information about their RAS or said that the information received did not meet their needs.

‘I was told on a need-to-know basis. I wasn't told in detail; I am the kind of person who likes to know this is going to happen next.’

Participant 1

Two participants reported that they had conducted their own research to discover more about the procedure.

‘I was looking at videos and information on the internet.’

Participant 1

‘An article in a newspaper discussed robotic surgery and it talked about two surgeons that were doing robotic surgery and it gave a little diagram so it gave me an idea of what the process was like.’

Participant 3

Most would have liked more preparation.

‘I wasn't prepared that much, I met Doctor X and he told me what was going to happen, there wasn't a whole pile of information. There was no counselling or anything like that.’

Participant 11

Participants also reported a lack of time and opportunity to question and discuss their surgery.

‘They didn't explain beforehand what was going to be happening, I didn't know how long the procedure would be … there was so much going on the morning of the surgery.’

Participant 12

‘The doctors and nurses don't have the time to talk to you.’

Participant 10

Mismatched expectations

Participants' experiences of recovery and coping postoperatively did not reflect their expectations. Postoperative pain was an issue raised by a number of participants.

‘I was in a lot of pain for about 4 days … high up in my abdomen just under my breast bone … I didn't know why.’

Participant 1

Another participant reported being unaware of how to use the self-administered pain relief system provided.

‘I was on a morphine pump that was administered by myself. But nobody told me about it, I thought the button was for calling the nurse so I wasn't using it at all, as I didn't want to be calling the nurse.’

Participant 11

Some reported a lack of aftercare advice or that information received did not match the extent of their needs as the following quote suggests:

‘The advice I got (following RAS for hysterectomy and colectomy) had more to do with the ileostomy bag rather than the hysterectomy, I think everyone nearly forgot I had the hysterectomy.’

Participant 12

Another participant did not undertake physiotherapy as advised as she did not understand the benefit to her.

‘I didn't do the physio; I didn't bother because I didn't know if it was going to be any help.’

Participant 2

While discussing their experience following discharge home, it was apparent that experiences and expectations did not often match. Some experiences were unanticipated as described below:

‘There was a bump… It turned out it was a stitch … I had terrible pain in my abdomen and it was getting worse. I didn't know what it was.’

Participant 5

Other participants felt that RAS was a much bigger surgery than they had expected and this subsequently affected their recovery period.

‘It was only when I came home that I realised it was a much bigger operation than I thought.’

Participant 2

‘A person feels so good [immediately after surgery] that you actually think you are better than you are and I think there should be more counselling on that part of it.’

Participant 11

Although most participants expressed dissatisfaction with the information they received before and after RAS, two (one male and one female) of the 12 reported being satisfied and well prepared for their RAS.

‘Before the surgery I thought he was being a bit over the top in explaining all the details but it actually does help, you know exactly how you are progressing if you know what's going to happen.’

Participant 7

‘I was led through the whole thing, there was a leaflet too that explained it, with a photo of the robot. When he explained it to me it was plain sailing and if I had to do it again I would.’

Participant 9

One participant in particular commented positively on the manner in which information was communicated to her.

‘I thought he [surgeon] was very clued in and he spoke English as opposed to medical gobbledygook.’

Participant 3

Nevertheless, a majority of participants in this study described being ill-informed about different aspects of their RAS peri-operative journey.

Theme 2: Psychological factors

Worry and apprehension

Participants expressed worry and apprehension regarding several aspects of the RAS procedure. Before the surgery, one participant reported contemplating all the potential consequences of her forthcoming surgery.

‘The things they [doctors] tell you the night before that can go wrong aren't great but I was lucky and they were very nice to me in theatre.’

Participant 7

Similarly, another participant reported feeling anxious regarding the surgery due to her lack of detail about RAS.

‘I was worried about it [RAS] and Googling things on the internet but if you don't know the detail then you are always hoping that “I may be one of the lucky ones”. You are really worried and thinking “am I on the way out?”.’

Participant 1

Not unexpectedly, the general worry about surgery was evident.

‘I was so worried; I was even asking would someone give me something to knock me out.’

Participant 11

Anxiety reported before the RAS included concern about the robot.

‘I was wondering about the robot in the surgery. I was feeling anxious about the operation, I just wanted it over.’

Participant 2

Yet another participant was more concerned about being anaesthetised, as she explained below.

‘For me the scariest part was being put under [anaesthetised]. The idea that these drugs are being put into your system, you are completely out and need to trust that they [anaesthetist] can bring you back again. That was scarier than the robotic surgery for me.’

Participant 3

Fear and anxiety were prevalent experiences reported by participants while discussing their RAS peri-operative experience. Natural anxiety about surgery was apparent within the majority of participant reports. However, few had any direct association between their anxiety and the RAS modality itself.

Of note was that the majority of participants had undergone RAS for the treatment of cancer and viewed their experience as another episode in the management of their disease.

RAS within the cancer journey

Participants who had undergone RAS as a treatment for cancer, all spoke in similar terms about their individual experiences, intimating that the RAS experience was only a minor detail in their long cancer journey. Participants reported on the added strain the cancer diagnosis had on them, with little or no mention of the RAS modality.

‘There's so much going on … I was going down to the hospital for 5 days a week for 6 weeks. Then I was taking my chemotherapy tablets to try and boost the radiotherapy to try and kill the tumour in the pelvis.’

Participant 1

It is evident from many of these participants that the RAS was necessary for their survival.

‘I was very happy and confident going into the surgery, I just made my peace with the whole thing.’

Participant 1

‘I had to get it done as I was told there was only 6 months [to live] if I didn't.’

Participant 4

Participants discussed not having a choice regarding their RAS.

‘When you are dealing with cancer you can never be back to yourself. I have had three operations in the last year and a half so this is just another stage of it.’

Participant 6

‘I am just a passenger [on this cancer journey] along for the ride.’

Participant 11

Participants who had multiple RAS surgeries for cancer agreed that RAS was less invasive but the modality did not make a difference to the psychological impact of their diagnosis.

‘It's such a mental and emotional process. I remember I was praying like I never prayed before promising that I would never be bad again.’

Participant 1

‘I remember sitting in the waiting area looking up at God, saying “why me?”.’

Participant 12

Although participants with a cancer diagnosis tended not to focus on the RAS procedure, one participant recounted receiving additional support from the clinical nurse specialist (CNS) aiding her experience.

‘The CNS is an excellent person to have, she listened and she would ring you back, that was really important. She would say, “I will get an answer for you”.’

Participant 4

It was clear from the data that, for those who had undergone RAS as a treatment for cancer, the overall cancer experience overwhelmed their experience and perceptions of the RAS modality.

Discussion

The aim of this study was to explore patient experiences of RAS. Although the sample of participants was drawn from one hospital, there was representation from different types of surgical specialties. Overall, the participant experiences of RAS were dependent on the reason for RAS. However, there was evidence of discrepancy between the actual patient experiences and their expectations of RAS. Participants in this study described a lack of preparation for RAS and for the postoperative period. Although preparation for surgery is an imperative element of care (Levett et al, 2016), length of stay may have an influence on the time allocated to pre-operative preparation.

There is evidence from this study that the robotic modality itself was not of great concern to participants because most trusted that humans were in control and their trust in the competence of the surgical team was paramount. Similar findings were reported in McDermott et al's (2020) qualitative study with 25 participants in the UK where participants felt having trust in the surgeon provided reassurance regarding their RAS experience. The findings of the present study show that any negative experiences of RAS related directly to a lack of information and communication about it. Gaps in the provision of information may be caused by wide-ranging issues such as a lack of written information, lack of specialist nursing staff available, the type of surgery being performed and the reason for surgery.

The importance of pre-operative patient education is stressed in the literature and clinical guidance for peri-operative care (Collin et al, 2015). Recently, Asokan et al (2021) reiterated that pre-operative patient education is imperative to meet patient expectations and limit challenges in their rehabilitation period. The present study's participants experienced a lack of awareness of what to expect immediately following RAS or in the recovery period at home and they also reported a lack of opportunity for questions and discussion pre-operatively. This finding is in contrast to a service evaluation in the UK to determine patient satisfaction with gynaecological RAS by Long and Kew (2018) where findings from a survey of 100 participants suggested that they were pleased with the content and level of information received.

The median length of stay (LOS) in this study was 5 days and participants reported that this was too short, resulting in their unpreparedness for their discharge and recovery period at home. This is similar to a survey of RAS patients in the UK (Long and Kew, 2018) where 18% of respondents felt that their LOS after RAS was too short. According to Backes et al (2016) LOS was 4 days for laparotomy patients and 1 day for RAS patients. When participants in this study experienced a longer LOS (participant 1 in particular, the youngest participant, spent 14 days in hospital) this was primarily due to unexpected complications experienced postoperatively. The longer LOS did not negatively impact on this participant's experience as she spoke with great contentment. Where no complications occurred, the minimum LOS was 2 days. Most participants perceived their length of stay as too short, possibly due to being insufficiently educated pre-operatively regarding the shorter LOS post-RAS, which is major aim of this modality. However, Ahmad et al (2017) suggested that the average LOS is determined by several factors, including the type of RAS procedure, the facility at which surgery was completed and the duration before discharge.

There is evidence from this study that RAS was viewed by participants as a less invasive minor procedure and expectations about recovery differed from their actual experience. Similar expectations about recovery from RAS were found in previous research. In a qualitative study conducted in Denmark, women (n=12) who underwent gynaecological RAS were surprised at their rapid postoperative recovery, but did not understand their lack of energy and why they could not complete daily activities as they expected at home (Herling et al, 2016). Furthermore, they found that patients had unanticipated normal postoperative occurrences such as various postoperative pains and vaginal bleeding. Similar to these findings, patients in the present study appeared to equate RAS with a minor procedure so recovery expectations were higher and much of their experiences were unanticipated. The development of patient-led information in this instance could be important as it may impact the patients' expectations of their recovery period. Patient expectations and experiences are clearly linked to their understanding and awareness of RAS. Evidence from international research consistently supports this. For example, in a large public survey of more than 1000 people in Kuwait by Buabbas et al (2020), there was a lack of awareness and limited understanding of RAS regarding the modality among the general public, which is fundamental to decision making.

The positive expectations related to trust in the surgeon, greater precision and increased dexterity, which subsequently offered a greater degree of safety, are well documented (BenMessaoud et al, 2011; De Wilde and Herrmann, 2013; Casillas et al, 2014; Trinh et al, 2014; McDermott et al, 2020; Torrent-Sellens et al, 2021). However, expectations of the postoperative period were clouded by the perception that RAS is minor surgery. More information and patient preparation is required.

Unsurprisingly, participants in this study expressed worry and apprehension at different stages of their surgery. This was mainly general concern about their condition, or the prospect of having a general anaesthetic and the length of surgery rather than specifically related to the robotic modality or surgeon's performance of the procedure. These findings are in contrast to a study in the USA by Irani et al (2016), where 67.5% of patients did not understand the surgeon's role and RAS was considered frightening by those who witnessed the robot.

Operating time and consequently anaesthetic time are considerably longer in RAS when compared with other modalities (Elias et al, 2018) and therefore participants worried about the surgeon's ability to perform such a lengthy operation. However, Hubert et al (2013) reported that laparoscopic procedures are in fact more taxing on the surgeon when compared with RAS. Mäenpää et al (2016) considered the robot in this instance was of benefit because it is fatigue resistant. Clearly, providing pre-operative education can reduce anxiety and aid postoperative recovery through creating realistic expectations and awareness of potential outcomes (Collin et al, 2015).

Interestingly, there were gender differences in perceptions of RAS. Female participants tended to place their trust in the surgeon and males tended to trust the robot. This finding is similar to a study with 25 women and men in the UK, where McDermott et al (2020) found that females voiced concerns regarding the technology associated with the new modality, whereas their male counterparts felt content with this aspect. A new finding in this study was the dissimilarity in experiences reported by participants undergoing RAS for cancer treatment and those undergoing RAS for benign conditions. Participants with cancer were clearly more invested in the surgical outcome rather than the robotic modality. Nine out of the 12 participants had undergone RAS for cancer treatment and were solely concerned with achieving a disease-free status and did not appear to be too concerned about the means of achieving this. For these participants the RAS was only a short juncture in the broader cancer journey. These findings support those of Reynolds et al (2018), whose survey results found there was 97% satisfaction with RAS for radical prostate cancer but qualitative data emphasised the importance of outcome, reporting that the only subject that mattered was becoming cancer free. The CNS has an important role in supporting these patients and may require additional education and support regarding RAS to continue this role.

The strengths of the study are the patient-reported experiences with RAS rather than medical outcome or complication, and it is one of very few qualitative studies with this focus. Although limited to two RAS specialties (colorectal and urological), one study site and a small sample, findings support existing research but also highlight an urgent need for a focus on patient preparation for RAS and information to support patient expectations of the post-RAS period. There is strong evidence that there is a lack of patient education and preparation pre-operatively for RAS, leading to misunderstandings about the surgery process and outcomes. The lack of patient understanding of RAS was compounded by the lack of time due to a shorter length of stay in hospital and also misconceptions in relation to recovery from the minimally invasive nature of the RAS modality. Patient preparation for surgery is of huge importance in order to reduce anxiety and create the foundations for an easier recovery due to forming realistic expectations. The role of the nurse in providing this education is a very important part of the peri-operative patient experience.

Conclusion

This study is one of the few studies that has explored patient experience of RAS. Key findings from the study were that participants' expectations did not match the reality of experience and this is potentially due to a lack of preparedness pre-operatively. This warrants intervention, with the need to create awareness of the indications for RAS, the type of surgery RAS is, and assisting patients with decision making. The correct timing of this information needs to be established and factored into the holistic care of the peri-operative patient. If timely and relevant information is not provided pre-operatively this can lead to misconceptions about the surgery and postoperative recovery. In addition, patients may get information from sources that are not evidence based. Nurses play a major role in preparing the patient for surgery and patient education and information provision are considered key parts of their role. Therefore nurses are best placed to work with patients and develop information that suits their needs. The authors are unaware if nurses involved in the study participants' care received dedicated information and/or teaching about RAS to care for their patients peri-operatively. Further research is needed to explore nurses' experience of preparing patients for RAS and to identify barriers and facilitators to preparing patients for the RAS peri-operative experience and recovery period from a nursing care perspective.

KEY POINTS

• The majority of participants reported that the amount of information they received in relation to their robotic-assisted surgery (RAS) was sparse and mainly did not meet their needs
• Participants' postoperative experiences were not reflective of their expectations due to patient unpreparedness
• For participants who had undergone RAS as a treatment for cancer, the overall cancer experience overwhelmed their experience or perceptions of the RAS modality

CPD reflective questions

• Do robotic-assisted surgery (RAS) patients require a specific RAS pathway to address the shortcomings regarding information provision and education, preventing mismatched expectations and poorer recovery? What form should this take?
• Does the nurse's role in the peri-operative pathway for RAS need to be evaluated?
• How can nurses prepare patients for recovery after RAS, especially as the majority of their recovery time will be spent at home?