In total, 12 patients from a wide demographic range participated in an interview (Table 1). The mean duration of interview was 26 minutes, with a range from 16 to 42 minutes. Four main themes and 14 subthemes were identified (Fig. 1).
Acceptability of robotic surgery
Although all the participants had undergone RS the factors that determined their decision to go ahead with RS varied between participants.
1) Diagnosis of cancer: A cancer diagnosis provoked feelings of fear and apprehension with participants reporting that they were more concerned with having their surgery performed as soon as possible rather than the route of surgery: “I wanted the surgery done and it didn’t matter how it was done as long as it was done and now” (P8, 57 years old).
2) Benefits of Robotic Surgery: The prospect of robotic surgery being associated with a shorter recovery time compared to open surgery was appealing to many participants to accept robotic surgery: “I was told about it and it’s a quicker recovery, which appealed to me” (P8, 57 years old).
3) Confidence in technological advancements: Accepting robotic surgery as a new technological advancement was appealing to some participants who described RS as futuristic, and possibly with a higher level of precision and efficiency, and less prone to human errors: “I think we are in the 21st century, so I think we should move forward isn't it? Instead of sticking to the old technologies and everything” (P9, 66 years old)
4) Patient-Doctor trust: Many participants reported that their relationship with their surgeon was the main factor that influenced their decision to undergo RS. Confidence in the surgical team significantly minimised feelings of anxiety and apprehension about RS: “I wasn’t frightened because I completely trust [consultant], I didn’t want anybody else to be involved, I just wanted [them], so [they] could have said anything to me, and I would have just gone along with it” (P2, 51 years old).
5) Patient demographics: Younger participants were more prepared to accept RS and other forms of new technology in medicine as they thought it will be less prone to human errors, and it functions with greater efficiency, accuracy and precision. However, the presence of a surgeon remained necessary for "peace of mind" so that the surgeon can intervene if any system error or malfunction occurs. A 36 years old when was offered robotic surgery responded: ‘’….I’m like “oh brilliant”, I wasn’t nervous, it I was like, okay, it must be normal, that’s the way it’s done these days. My mum said, “oh, we’ve looked at the YouTube where they do this robotic surgery so, obviously I had to have a look and thought, oh wow, so yeah I thought it was amazing’’ (P10, 36 years old). On the other hand; older patients were more anxious about the robotic use in surgery and more concerned about system errors and malfunctions rather than the potential advantages of its use, for example:‘’… that was the only time I got nervous because, then nobody is in the room and what happens if something happens’’ (P8, 57 years old).
Concerns surrounding RS
1) Misconceptions: A lack of understanding of the RS set up raised questions as to the role of the surgical robot during the procedure and left participants relying on their imagination and stereotypical images of robots presented in the media. This significantly impacted acceptance of RS. A 52 year old participant when she was asked about her thoughts when she was first offered RS stated: “I’ve never come across anything like that before. I think it was just “a robot is going to do your surgery”… “a robot?” after discussing with her friends she said “We (Herself and her friends) went from the smash potato advert from years ago to the “oh yeah, I don’t think I’d let anybody do that to me.” (P2, 51 years old).
Many participants who assumed that RS was an automated procedure displayed more hesitancy towards robotic surgery, compared to those who assumed that it remained under the control of a surgeon. There was also a lack of understanding about RS theatre set-up and staff: “that was the thing that was bothering me all along. That if anything happens to me, they’re behind the screen” (P8, 57 years old). This theme indicates that knowledge gives reassurance and eventually acceptance of RS since participants who had no previous knowledge and initially misunderstood RS and appeared to be the most anxious.
2) Surgical safety: The fear of mechanical malfunction was one of the leading causes of distrust of RS: “I thought somebody’s going to put this programme in and this robot is going to be there and do whatever it needs to do and then somebody will come in the room when it’s all done and I’m thinking, what if it goes wrong?” (P2, 51 years old).
3) Lack of commonality: Participants usually perceived conventional surgeries (open or SS) with comfort, whereas some participants perceived RS with some hesitancy. It was felt that there was a lack of awareness of RS among the general public due to the technology not being used or implemented widely in the NHS: “We mention it to people, and they don't know anything about it. It’s just something that they think is from Mars or something. People don't know anything about it, it’s strange!” (P11, 57 years old)
Information resources
1) Printed leaflets: The majority of participants described printed patient information leaflets as not a reliable source of information for RS, and instead many preferred to carry out their own research using other methods, e.g. Internet, advice from family and friends, media and professional face-to-face advice: “I know all information is on the leaflets, but people nowadays don't tend to read them as much as they used to, there’s more important things like phones, but you may find that visual impact sticks in people’s minds, so a bit more visual awareness” (P11, 57 years old).
2) Internet: Participants acknowledged that the accuracy of the information available on the internet was not always reliable and it could be sometimes misleading, especially if the information source was not recognised as trustworthy. Nevertheless, many participants attempted to overcome anxieties concerning the procedure by seeking more information using the internet. In our study; it was highlighted the commonality and normality of using the internet for seeking further information about RS rather than the provided leaflets: “I’m not a massive fan of leaflets particularly, I can see that they have their use but I guess in this current digital age, for me it’s online” (P5, 37 years old).
3) Advice: A proportion of participants reported seeking advice from relatives and friends to help them making an informed decision regarding RS, however, again there was a lack of knowledge and commonality of RS: “when I said about robotic surgery, not one person knew anything about it, not one person. Even where I work in a school, none of the staff knew, none of my friends or my relatives or anybody that works with, not one person had heard of it” (P2, 51 years old).
4)Visualisation: One of the key pieces of information the majority of the participants reported that was lacking pre-operatively was ‘what does the robot look like?’ and ‘how robotic the surgery will be performed?’. The majority of the participants described the use of a picture, model or video that demonstrated the interaction between the surgeon and the robot as a highly essential piece of information that should be offered before their surgery, as it was felt that it would help to allay their fears towards the procedure: “After I left the clinic, I was straight on Youtube and googled it (RS) and I watched the video of it, cutting the grape,. it did reassure me actually because I didn’t know what the robot was” (P1, 32 years old).
A visual model of RS set-up through the official NHS website reportedly could have prevented some patients’ attempts to seek information from unreliable resources, which might have adversely affected some patients psychologically preoperatively: “I think the model would be enough because I remember while I was waiting to go into surgery, a woman was panicking because she’d seen something, and she didn’t want to see it again, just do it and don’t show me anything and she heightened my fear as well, I think seeing a model prior to surgery would probably be better” (P8, 57 years old).