A surgeon has described the tense atmosphere in an operating theatre as a pioneering robotic heart operation went catastrophically 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.
Surgeon Sukumaran Nair (left) has described the tense atmosphere in an operating theatre as a robotic heart operation on patient Stephen Pettitt (right) went catastrophically wrong
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.
The operation using the Da Vinci robot (file image) was the first of its kind conducted in the UK
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.
Mr Nair admitted he was ‘running before he could walk’ in using the Da Vinci robot (file image)
Whilst he could hear Mr Nair’s voice through a microphone, his method of making himself heard if he saw something going wrong was to shout.
He was asked: ‘Was communication difficult?’
He answered: ‘We were not far apart but Mr Nair’s voice comes through a microphone and it is tinny, the acoustics were not very good.
‘There were times when I raised my voice, one was when the sutures were not being placed in an organised fashion and were criss crossed.’
The stitches had to be taken out and replaced, which extended the operating time, the hearing was told.
Mr Pillay said that he raised his voice again when a colleague standing over Mr Pettitt ‘had his arms knocked by the robot.’
He said he called for the proctors to be called in at the point he realised the stitching was criss crossed and when told they were not there he at first assumed they were taking a coffee break.
Consultant cardiothoracic anaesthetist Kevin Brennan said the proctors, supplied by Edwards Lifesciences, had been helpful in setting up the operation.
But he added: ‘I had no idea of their timescale and that they were not staying for the duration.’
He added: ‘The proctors leaving was a crucial moment. The loss of that vital assistance was a major blow at a critical time.’
Northumbria police were called in to investigate after Mr Pettitt’s death, the hearing was told.
Mr Pettitt died at Freeman Hospital in Newcastle (pictured) after the operation went wrong
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.
Dr Anthony George, a consultant anaesthetist in the operation on Mr Pettitt, said that communication problems between the two surgeons were ‘at the core of the failure.’
He also said that Mr Nair was aware the supervising experts – known as proctors – were intending to leave at lunchtime and not return but chose to go ahead without them.
Mr George said: ‘I think the proctors should have stayed for the whole case, their departure is significant.
‘I think communication problems the two surgeons experienced was a core part of the failure of the repair.
‘If they had been able to place those sutures precisely and correctly then the outcome would have been different.’
Mr George said the the anaesthetic proctor told him at the beginning of the operation that they would be leaving at lunchtime.
He said he told that to Mr Nair, who did not seem surprised.
Mr George said: ‘I don’t recall exactly what was said but the implication was that he was happy to continue with the process.’
He said the robotic operation continued after he told them he was concerned that it was going badly.
He was asked by the Pettitt family’s lawyer Georgina Nolan whether he could have indicating his worries more forcefully.
Mr George said: ‘I expressed my concern to both surgeons that things were not going well. The report into this incident said later that it was not my place to harass surgeons and that is not the role I took on.’
Tensions between the surgeons led to shouting between them, he said.
Mr George said that it appeared they were both unable to tell what the other was saying and were also disagreeing over the placing of the stitches in Mr Pettitt’s heart.