Introduction
The story of the operating surgeon
relinquishing his hallowed position beside an operating table to a chair
positioned a few feet away began in the 1980’s in the USA when NASA, Stanford
Research Institute, and the US Department of Defence developed the SRI
Telepresence Surgery System, which was intended to aid the wounded in a battle
by surgeon’s miles away from the frontline (1). Although it did not accomplish
the intended objective, this surgical system eventually led to the development
of the present day Da Vinci Robotic System.
Robotic surgery is the latest cutting-edge
technological advancement in the surgeon’s armamentarium. Almost like science fiction
to the uninitiated, the surgeon sitting at a console controlling a robotic arms
assembly has revolutionized the surgical approach to many procedures which were
hitherto either very complicated or fraught with prohibitive complications.
Although newer modifications of the Da
Vinci robot are on the anvil, the present configuration is likely to remain the
mainstay in the Indian scenario for the foreseeable future.
The Da Vinci Surgical System was released
in April 1997 and received FDA approval in 2000 for laparoscopic surgeries.(2)
Today it is being used in increasing number of specialities including gynaecology,
ENT, Cardiac Surgery, General Surgery, Orthopaedics and Urology.
In its present configuration Da Vinci
Surgical System can be used in most contemporary operating suites. It has 3
major components
·
Robotic Tower: Assembly where
instruments are attached and mechanically manipulated within the patient
·
Surgeon’s console: Workstation
where the surgeon sits and manipulates the instruments
Advantages
Any technical advancement is a tool for execution
of the basic technique of surgery and hence must be examined with the question
- Does this further aid, simplify or facilitate our adherence to our time
honoured basic surgical steps and their outcomes?
The answer for the robot is probably a resounding
“Yes”. It unquestionably offers some distinct advantages. (3)
1.
3D
vision and depth perception: One of the biggest
hindrances of Laparoscopic surgery has been a 2 dimensional representation of a
3 dimensional operating field. The incorporation of binocular optics in the
operating console offers the operating surgeon a 3 dimensional simulation and
thereby improves depth perception which is invaluable when operating in the
limited confines of areas like the pelvis.
2.
Elimination
of hand tremors and field magnification: Robotic
arms eliminate tremors and help in movement scaling. This increases the
precision of the surgical steps and helps define difficult anatomical
landmarks.
3.
Ergonomically
superior and cause less fatigue to the surgeon:
Better operating posture and surgeon’s comfort translates into better surgical
outcomes.
4.
Reduces
the learning curve of Laparoscopic surgery: The
exposure to robotic surgery offers a chance for surgeons who are not
laparoscopically trained to offer a minimally invasive surgery option. (4)
The additional advantages of minimally
invasive surgery like lesser post-operative pain, shorter convalescence period,
lesser bleeding and more cosmetic incisions unarguably further the case of
robotic assisted surgery. (5)
Disadvantages
The biggest and possibly the only
uncontested disadvantage of the Robotic Surgery is the incurred cost. The Da
Vinci Surgical systems robot costs a considerable $ 2 million with a further $
100,000 required for annual maintenance. (6, 7)
Undoubtedly the higher costs involved
translate into higher cost of Surgery which is principally borne by the
patient. In the Indian context this is a very pertinent consideration where a
vast majority of the population cannot afford such high costs. Another uniquely
piquant condition in India is that even in patients who have medical insurance;
the companies refuse to cover surgeries done using the robotic technology.
The Indian Scenario
Major diseases causing maximum number of
deaths in India are still TB and infectious diseases like malaria. (8) A
question that is most frequently and arguably the most aptly asked in this
scenario is – Can we afford it?
At present this question is akin to asking
- Can India afford to market a Mercedes Benz or an Audi car?
The reply to the question, as written in an
essay by Vipul et al is, that the Robot is already there in India and the question
is becoming increasingly redundant.
Role of Urology
In July 2006, India witnessed its first
Robotic Assisted Surgery at AIIMS. Fittingly, it was pioneered by the
Department of Urology and a Robotic radical prostatectomy was completed
successfully (5). We have indeed come a long way since then. As PN Dogra et al
have analyzed, the results of a series of 190 cases performed at their centre
compare very favourably with the western figures. The number of Robots in India
has also been steadily increasing and although the precise number is not
available, there are about 21 centres, across the country, which are regularly
performing Robotic surgeries (10).
In terms of departments, Urology is quite
definitely the forerunner in the use of Robotic technology. The number of
radical prostatectomies being performed has gone up tremendously as compared to
the open era. The improved continence results (some patients at our centre
report continence at day 1 or day 2 post catheter removal) and the lesser
erectile dysfunctions attributable to better nerve sparing achieved due to the
robotic technology, have gone a long way in establishing radical prostatectomy
as the flagship surgery of robotics worldwide and in India. The advantages have
also been extended to procedures requiring precision and accuracy like partial
nephrectomy which has enabled efficient nephron sparing surgery with resultant
renal function preservation. Robotic assisted adrenalectomy, pyeloplasty,
radical nephrectomy and donor nephrectomy are being performed with increased
frequency as the Surgeon is getting more and more acclimatized to the Robot. A
further testament to the proficiency of the Indian surgeon with the robot is
the increasing number of Robotic Renal Transplant surgeries being performed
successfully at some centres.
Other Surgical departments in India are
also joining the Robotic revolution in increasing numbers. Gynaecology, ENT,
Cardiac Surgery and General Surgery are using the Robot in a wide variety of
cases.
The challenges
As Dr Mani Menon, of the Vattikutti
Institute said in an interview to Express Healthcare, - “India is ideally
suited for robotic surgery as the surgeons are skilled, the patient volume is
high and a full spectrum of complex diseases are encountered. In India
particularly, multispecialty robotic surgery has a great future.”
Even with this well recognized potential,
Robotic surgery is still in its infancy in India.
As mentioned earlier the inherent costs
associated with it remain the biggest challenge to be overcome for a more
uniform dispersion of this technology throughout the country. The only way to
tackle this and to make robotic surgery financially feasibleis for
multidisciplinary utilization of the robotic system to its fullest potential.
The maintenance cost remains the same whether one case or 6 cases aredone in a
day. So it is logical that if more cases were generated out of arobotic system,
the cost per case would automatically decrease. Government support is also of
paramount importance in making this technology available to more people at a
subsidized rate.
With Indians at the forefront of Robotics
worldwide, it is not unreasonable to anticipate the development of an
indigenous robotic surgical system in the future. The department of biomedical
engineering at the IndianInstitute of Technology have made some headway in the
goal of developingour very own Indian prototype. (5) Needless to say, such a
system will go a long way in making this technology come within reach of a
majority of our population.
Another major drawback with the current
Indian scenario is the lack ofrobotic surgery fellowships in India. With
increasing number of centres attaining competence in performing surgeries, it
is expected that a number of them shall make the logical transition of
imparting Robotic training also.
Conclusion
India today, is gaining momentum in the
process of becoming a very competent Robotic Surgery destination. Our costs
still remain lower than most western counterparts while our skills match up to
the world’s standards.
Steve Jobs famously said at the
inauguration ceremony of the Macintosh – “Everyone here has the sense that
right now is one of those moments when we are influencing the future”. Witnessing and actively participating in the rapid growth
and spread of Robotic technology in India, one cannot help having the same
sense of shaping the future of health delivery in India
References
- Nguyen MM, Das S. The evolution of robotic urological surgery. UrolClin North Am. 2004 Nov; 31(4):653–8. vii. Review. [PubMed]
- 5. Carpentier A, Loulmet D, Aupecle B, Berrebi A, Relland J. Computer Assisted cardiac surgery. Lancet.1999; 353:379–80. [PubMed]
- Cathelineau X, Rozet F, Vallancien G. Robotic radical prostatectomy: The European experience. UrolClin North Am. 2004 Nov;31 (4):693–9.
- Menon M, Shrivastava A, Tewari A, Sarle R, Hemal A, Peabody JO, et al. Laparoscopic and robot assisted Radical prostatectomy: Establishment of a structured program and preliminary analysis of outcomes.J Urol. 2002;168:945–9.
- Dogra PN, Current status of Robotic surgery in India. JIMSA July-September 2012 Vol. 25 No. 3; 145
- www.modernhealthcare.com/article/20140419/magazine/304199985
- Morgan JA, Thornton BA, Peacock JC, Hollingsworth KW, Smith CR, Oz MC, et al. Does robotic technology make minimally invasive cardiac surgery too expensive? A hospital cost analysis of robotic and conventional techniques. J Card Surg. 2005;20:246–51.
- Girish G. Nelivigi, Robotic surgery: India is not ready yet. Indian J Urol. 2007 JulSep; 23(3): 240–244. doi:10.4103/09701591.33443
- Vipul Patel, Robotic surgery: India is not ready yet. J Urol. 2007 JulSep;23(3): 244–245.
- Jain S, Gautam G. Robotics in urologic oncology. J Minim Access Surg. 2015 JanMar;11(1): 40–44.
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