A surgeon has described the tense atmosphere in an operating theatre as a pioneering robotic heart operation went disastrously wrong.
At one point one of the assisting medics had his arms knocked by the robot which was being used to repair retired music teacher and conductor Stephen Pettitt’s heart valve, an inquest was told.
Communication between lead surgeon Sukumaran Nair and his assisting surgeon Thasee Pillay was difficult because of the ‘tinny’ sound quality coming from the robot console being operated by Nair.
“Robot surgeon ‘spiralled out of control’ after hitting nurse while doctors shouted at each other during pioneering operation that went catastrophically wrong and led to death of father of three, inquest hears”
Mr Pillay told how he had to raise his voice as the robot knocked one of the theatre assistants and when he realised that stitches in 69-year-old Mr Pettitt’s heart were not being placed in ‘an organised fashion.’
At the hearing in Newcastle, Mr Nair admitted he was ‘running before he could walk’ in using the robot because he lacked experience in using the robot in a training capacity.
He missed a training session in Paris using a cadaver and another session at his own hospital because he was busy with other surgery.
Despite that he conducted the operation to repair Mr Pettitt’s leaking mitral valve using the Da Vinci robot for the first time, which was also the first operation of its kind conducted in the UK.
When things started to go wrong, two proctors – supervisory experts trained to take over in a crisis – had left
Mr Pillay said he thought they had ‘gone to the coffee shop’ for a break when in fact they had left Newcastle’s Freeman Hospital and gone home part of the way through the procedure in February 2015.
They were not on hand to help when father-of-three Mr Pettitt’s intra aortic septum was damaged and Mr Nair was no longer able to see clearly when blood spattered the robot’s camera.
The robotic operation was abandoned and open chest surgery began, by which time Mr Pettitt’s heart was functioning ‘very poorly.’
He died a few days later on March 3rd after going into multiple organ failure.
Consultant cardiothoracic surgeon Mr Pillay told the hearing he was standing a few feet away from Mr Nair facing the patient while the lead surgeon had his head in a console facing away from him.
Northumbria police were called in to investigate after Mr Pettitt’s death, the hearing was told.
Giving evidence on Tuesday, 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’.
Mr Nair said: ‘At the time, I should have gained more experience and my clamp times would have been shorter with time.’
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, who trained in India and London and previously worked at Papworth Hospital in Cambridgeshire, said he now works in Scotland and no longer does robotic surgery.