About one month ago, the headlines flashed, ‘Gujarat doctor makes history’, crediting cardiac surgeon Dr Tejas Patel with conducting the world’s first telerobotic surgery on a patient in Ahmedabad. Sitting 32 kilometres away from his patient, a middle-aged woman with a blocked artery at Apex Hospital, Dr Patel guided the robotic arms through a joystick to perform the coronary intervention. The surgery sounded rumblings of a shift in healthcare. Is robotics the way to go?
The ‘what’ of it
When the trauma caused by incisions in traditional open surgeries started becoming a point of concern, laparoscopic surgeries started becoming popular, in the ’90s. “Even though the surgeries would be successful, the recovery time would be longer, and the scars would add trauma,” says Detroit-based Dr Mahendra Bhandari, Director, Robotic Surgery Research and Education, Vattikuti Urology Institute, Henry Ford Hospital.
A laparoscopic surgery, on the other hand, was minimally invasive: instead of a single major incision, it created multiple micro incisions, one of which was for a camera, through which the surgeon could see what he was doing.
Think of robotic surgeries as one step further. Instead of operating on the body himself, the surgeon can guide the robot to do so through a controller in a master-slave system: whatever the surgeon motions, the robot mimics. “Currently, in the Indian market, robotic surgeries are not technically done by robots,” says Dr Bhandari. A robot, by definition, replicates human tasks on its own (autonomous). Right now, they are ‘dumb’.
This, then, is a robot-assisted laparoscopy, that can be used in different fields of surgery such as urology, oncology, gynaecology, gastroenterology, bariatric, thyroid, colon, and rectal. All major hospitals, such as AIIMS, Apollo, Fortis, Medanta and more have this facility. However, urology and cancer surgeries are the ones that most see robotic assistance, due to their cost-effectiveness. Cardiac surgery hasn’t found much use, given the likely complications.
The ‘why’ of it
Robot hands can move 360 degrees, and provide better dexterity and precision
“In surgeries at crictical locations, there’s something called the fulcrum effect,” explains Dr Srivatsan Gurumurthy, consultant surgical gastroenterologist, GEM Hospital, Coimbatore. Given the limited area of access, the human hand finds it difficult to manoeuvre tools.
When working in difficult areas, especially in the abdomen and pelvic regions, “the robot hand can move 360 degrees, and provide better dexterity and precision,” he says. “Moreover, it minimises fatigue: the surgeon need not stand for hours for one surgery.”
The camera, moreover, provides a 3D magnified real -time visualisation of what the surgeon is operating on. Adds Dr Bhandari, “The camera makes visible the smallest structures and blood vessels that our naked eyes can’t see.”
Easier access, and less tissue damage also helps reduce blood loss and the need for transfusion, and correspondingly, the chances of infection: all in all, making recovery quicker.
The only disadvantage? A surgical robot such as da Vinci Xi (the most prevalent in India) costs upward of ₹14 lakh — something that will undoubtedly translate into costlier surgeries for patients. A complex robotic surgery is likely to be nearly ₹2 lakh costlier than a laparoscopic one.
From the past…
The Vattikuti Foundation, set up in 1997 by Raj and Padma Vattikuti in Detroit, Michigan, has been responsible for training over 300 surgeons in robotics, and helping set up approximately 70 robots from California, US to India. .
“When we came to India in 2009, there were six robots in the whole country,” recalls Dr Bhandari, who is also the CEO of the foundation. Their challenges were two-fold: the doctors here didn’t believe that robotic surgeries would be cost-effective, and the young tech-friendly ones that did, did not handle enough patient volumes to support a robotic programme.
“We handpicked four centres that we financed robots for: Medanta, Gurugram; KIMS, Hyderabad; Manipal Hospital, Bengaluru; and Asian Heart Institute, Mumbai,” he says. The foundation would bring experts from around the world to train young surgeons and facilitate surgeons going to other countries for training. The ones who showed potential were then trained as trainers, and so the local community of skill-sharing grew.
The foundation has also established the Robotics Surgeons Council of India, and organises biannual meetings for knowledge-sharing and skill-enhancement.
To the future…
T Jayakrishnan has been toiling away at his prototype, the Cranio Bot. The founder of ASIMOV, a Kochi-based robotics company that focuses on healthcare solutions, has invented this bot to assist in surgeries to correct craniosynostosis (a birth defect that gives the head a misshapen appearance). He has received a grant under BIRAC, by the Government of India for this. However, for the product to come out of its prototype stage, and be commercialised, it will take seven more years.
One of the problems causing the delay is getting the patent. His technique clashes with global leader Intuitive Surgical’s. For a long time now, Intuitive has had the monopoly over the market, and so, over the cost. However, most of Intuitive Surgical’s patents are likely to end by 2022.
“Da Vinci robots (from Intuitive Surgical) are the pioneers. The cost of the robot is high, purely because they have invested a lot of money in research. And because there aren’t many major competitors right now, they won’t compromise on the cost,” says Dr Bhandari.
Under the US Patent system, the patent owner has the right to exclude competition for a limited period of time for the invention covered by the patent, generally 20 years since filing.
Dr Deepak Subramanian, laparoscopic and bariatric surgeon, Fortis Malar, Chennai, is excited about what the future holds. “When I was in the US, I tried out a robot by TransEnterix. Everyone’s trying to break into the market once the patents are over. The future is robotic surgery!” he exclaims. Even Alphabet (Google) and J&J are joining hands to create robots with their platform, Verb Surgical.
Will India have space in this new world too? Says Jayakrishnan, “We need to create an environment conducive for research, where experts from engineering, and the medical world work together.”
The Vattikutu Foundation has provided thirty Vattikuti Fellowships in Robotic Surgery to Indian surgeons, and are accepting new applications currently. Visit https://vfrsi.vattikutifoundation.com/2019-vf-fellowships-