Dec 01

Robotic surgery experiences from Egypt (Part 1/3)

Interview December 1, 2017 800 0 By - Dr Ibrahim Fakhr, AFSA (France), MRCS (Eng), HCMD (AUC)

Interview with Dr Ibrahim Fakhr

Paul: As promised last week, today, we start the first in a three-part series on robotic surgery experiences in Egypt. To guide us on this journey we have Professor Dr. Ibrahim Fakhr, welcome to Robotic Surgery Today!

Image of Dr Ibrahim Fakhr
Dr Ibrahim Fakhr, AFSA, MRCS, HCMD

Dr. Ibrahim Fakhr: Good morning Paul.

 Paul: We are honored to have such a distinguished healthcare professional with us today. Dr Ibrahim Fakhr is a Founder and Board Member of the Egyptian Society of Surgical Oncologists and a Professor of Surgical Oncology at Cairo University. He has studied in Egypt, France and the United Kingdom and speaks Arabic, English and French. He is also a Member of the  Royal College of Surgeons in the United Kingdom.

Dr Fakhr, could you tell us about what attracted you to the field of medicine and share with us some of the challenges that you had to overcome in reaching where you are today?

Dr. Ibrahim Fakhr:  Well, I was attracted to the field of medicine, and specifically surgery when I was quite young because I thought there is a lot of humanity in it. Regardless of how much money you earn, praise you receive, or the positions you attain, at the end of your life you will feel that you have added real value through your work. This is what practicing medicine is all about.  In addition, I always liked doing things with my hands. So surgery gives you the sense that you can make an immediate change.  Therefore, in addition to being able to perform medical diagnoses, I especially appreciated having the skills of a surgeon.

Of course, it was a very, very long journey. Becoming a surgeon means a commitment to lifelong study. At times you have to postpone some of your personal interests because you need to invest more time in your training and with patients. But this is an outlook that I think I share with other healthcare professionals all around the world. Practicing medicine is not like other careers where you receive an education for a few years and then go directly to work. In medicine you will always remain a student, you must always keep learning, and this should keep you modest.

Experiences with surgical robots

 Paul: Could you tell us how you first came to be introduced to robotic surgery? What were your thoughts and expectations?

Dr. Ibrahim Fakhr: My first face to face introduction to robotic surgery occurred when the National Cancer Institute, a faculty of Cairo University, bought a Da Vinci, 3rd generation surgical robot in 2010. However, I first became aware of this technology in 2002 when I attended a medical conference in Lyon, France. During the conference surgical robots were discussed extensively. Robotic surgery had been introduced to France a couple of years before this conference.

At the time there was a huge debate as to how the technology would impact training, the number of junior surgeons and assistants. Would we see a decrease in the number of assistants and surgeons? Would we need to train fewer surgeons? (Dr. Fakhr laughs).

Of course it was an important discussion at that time! Today, the technology has evolved to a point where we can train surgeons on a simulator before allowing them to practice on the real robot. Moreover, the surgical robots now incorporate a training console. The trainee is now able to operate under full control of the surgeon to master the use of the robot. This was not possible before.

Some factors impacting the adoption of surgical robots in Egypt

Paul: About how many surgical robots do you think are being used in Egypt? When were they first introduced?

Dr. Ibrahim Fakhr:  In Egypt we have only one robot which was bought by the National Cancer Institute in 2010. Since then we have not bought anymore robots.  I believe this has to do with the situation after the 2011 revolution, where we have had some financial problems.  The robot is very expensive and following the devaluation of the Egyptian Pound it has become even more expensive.

Also the problem in Egypt is not only with the capital cost but also the running cost.  The running cost is extremely expensive as the instruments are not cheap.  They must be imported and only work for a fixed number of times. These factors  impact and increase the overall cost of the procedures. The robot usage also has a learning curve. So costs are a real challenge especially the combination of a costly learning curve and an expensive machine.

Furthermore, you have to keep in mind that in Egypt the average income of surgeons is not that high. The running cost of the machine is more expensive than traditional surgery whether open or laparoscopic. However, we think the coming Italian surgical robot with reusable instruments will substantially decrease running costs.  We are also expecting that due to competition, the next generation of surgical robots will be cheaper, at least we hope so.

Paul: Are there any special authorizations required to use this technology in Egypt?

Dr. Ibrahim Fakhr: The surgical robot did not require any special authorizations. We cannot have legislation when there is only one machine in Egypt. Actually, as I mentioned earlier, in addition to being the only surgical robot in Egypt, to my knowledge, it is the only robot in North Africa.  So on the African continent we have one in South Africa and another in North Africa, so it’s not a technology that is widespread in the region. I believe other countries in this region also face similar challenges to Egypt. In the end, the ability to acquire this technology depends on the size of the initial capital investment and running costs relative to the average cost of medical treatment. So clearly, the rate of the adoption of this technology is strongly influenced by the socio-economic status of the country.

Physician training and public demand for robotic surgery

Paul: About how many doctors do you think are there in Egypt that have been trained to use surgical robots? Is this a skill that is highly demanded or sought out by patients?

Dr. Ibrahim Fakhr: At the National Cancer Institute we have trained quite a good number of surgeon, we have around 10 or 12 surgeons who are either trained or undergoing training.  Of this group two have completed their training.  Acquiring the skill takes some time and the level of demand from the public for robotic surgery interventions is not very high.

There are two main factors for the low level of demand and awareness. Firstly, this service is being offered by the National Cancer Institute which is a teaching Governmental Institute. It is not in the private sector where a large capital investment in equipment would be accompanied by a commensurate marketing campaign. We are a public sector, teaching hospital, with the only machine in the country and limited operating resources. A successful marketing campaign that  raises public awareness and interest in the technology would generate a huge demand. However, the high cost of robotic surgery compared to what patients can afford, would make providing this service too expensive.

In  Europe and the United States, hospitals are conducting up to five procedures daily, this requires a large number of instruments.  This is not economically possible in Egypt at this time. On the other hand, the laparoscopic and open procedures are very efficient, are faster, and we have surgeons who can perform these procedures.

As I mentioned, we are in the process of training 8 to 10 surgeons and this takes a long time given the training procedures and learning curve. So in fact, we are not enthusiastic, at this time, about increased patient demand for robotic surgery. Nevertheless, we are informing the Egyptian population of our efforts to ensure that our surgeons and healthcare services are up-to-date with the rest of the world.

Paul: Thank you Dr. Ibrahim Fakhr for sharing these insights with us.

Coming next week, part 2 of our interview: 

We will continue our discussion with Dr. Ibrahim Fakhr next week. Join us to hear about the new developments taking place in Egypt, like the construction of a state-of-the-art 1000-bed cancer hospital.

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Dr Ibrahim Fakhr, AFSA (France), MRCS (Eng), HCMD (AUC)
Dr Ibrahim Fakhr, AFSA (France), MRCS (Eng), HCMD (AUC)
Prof. Dr. Ibrahim Mohamed Yehia FAKHR is a professor of surgical oncology at the National Cancer Institute, Cairo University, Egypt, where he helps to train the next generation of surgeons, he is also a practicing surgeon. In his capacity as the Deputy Manager and Owner's representative, he has oversight for the new state of the art 1000-bed specialized cancer hospital and research center being developed by the National Cancer Institute. This world-class facility will on its completion be amongst the largest and most advanced of its kind. Ibrahim has studied at prestigious institution in Egypt, and France. He is a Member of the Royal College of Surgery (MRCS) in the United Kingdom and the European Society of Surgical Oncology. He is also active in a number of national professional bodies, including the Egyptian Society of Surgical Oncology (EGSSO) and the Egyptian Society of Peritoneal Surface Malignancies (EgSPSM) which he was instrumental in establishing and where he continues to serve as Board Members. Ibrahim has authored over 20 peer reviewed journal papers and has presented papers, posters and other substantive contributions at conferences in Egypt, Europe and the United States of America. Ibrahim is a fluent speaker of Arabic, English and French.

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