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
- Ancillary Vision Cart: Supports a flat screen monitor
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 feasible is for multidisciplinary utilization
of the robotic system to its fullest potential. The maintenance cost
remains the same whether one case or 6 cases are done in a day. So it is
logical that if more cases were generated out of a robotic 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 Indian
Institute of Technology have made some headway in the goal of developing
our 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 of
robotic 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
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