Surgery gets more precise with robots

A week ago in Chennai, media people met a thin young auto driver who had had a major heart surgery a few weeks earlier. The procedure involved replacing both the mitral and aortal valves in his heart, and would normally have left him with a scar that ran all the way down from his chest to his navel, and almost certainly still recuperating. Here he was, however, looking healthy albeit nervous, and showing us a small roughly 5 cm incision scar, and telling us how he was climbing stairs three days after the surgery.

How come? It was because he had been operated on robotically.
And no, that does not mean that a Rajnikanth-like Enthiran cuts you up, repairs and stitches you back again. It just means that a very efficient human surgeon uses an electronic robot with arms to do the surgery. The whole scene looks somewhat as if the surgeon is fooling around with a simulation game as he juggles with joy sticks at a console while the patient lies on a bed some feet away. But he is, in fact, performing some extremely minute manoeuvres using the robot’s arms to wield the minute instruments that actually do the operation.

The person behind the surgery was Dr Ravi Kumar R of the Chennai-based Chettinad Health City (CHC), and it was the first time in the world that a double valve replacement surgery had been attempted using robotics. Earlier, either the mitral or the aortal valve had been replaced using robotics, but this was a first for the simultaneous replacement of both. Robotics began with cardiac procedures in 2000 and has since spread to other fields like urology, gynaecology, and cancer.

Although robotic surgery is fairly widespread in the US, in India it is currently offered in just 4-6 hospitals, including Fortis-Escorts and AIIMS in Delhi, CARE in Pune, and CHC in Chennai.

According to Dr Sudhir Srivastava, CMD of the newly set up Fortis International Centre for Robotic Surgery (ICRS), there are plans to bring the latest robotic surgery procedures to India across the spectrum of heart, lung, urology, gynaecology, head and neck surgeries. Meanwhile, CARE has launched a Centre for Excellence in Minimal Access, and Dr Ravi Kumar says: “With spreading awareness, we could do 30,000 robotic cardiac surgeries a year in CHC alone.” 

So, is robotics really the way of the future? It certainly looks like it, even though like laparoscopy, its predecessor in non-invasive surgery a decade ago, this too is being met with initial scepticism.
Says Dr Srivastava, “Within two-three years, we plan to have 6-10 centres across India, stating with Delhi and moving to Gurgaon, Mumbai, Chennai, Bangalore, and even Tier II cities like Mohali and Jaipur.” 

That last is interesting because da vinci Surgical System, the robot, which is today manufactured only by the US-based Intuitive Surgical, costs about $2 million, and with other costs, the total capital outlay per centre for Fortis ICRS will be around Rs18 crore.

Will centres in Tier II cities attract enough patients to offset this cost? Clearly, Dr Srivastava thinks so. “The scope is huge,” he says, citing the example of the US where roughly 260,000 robotic procedures are performed per year.

For patients, will it cost more? At CHC, a robotic cardiac procedure will cost you about Rs30,000 more than a conventional surgery. CARE plans to charge the patient exactly the same as for a conventional surgery. Thus, a liver cancer operation will cost you roughly Rs1-1.5 lakh, whichever option you choose. At Fortis centres, however, the cost could go up by as much as Rs75,000-1,00,000.

Reduced scarring and recovery times, lesser hospitalisation, lesser pain and blood loss,  and lower chances of post-operative infections may offset the higher cost of the procedure itself for many patients. As for surgeons, the operation becomes more precise, with 3-D imaging, 40 times more magnification, and far lower tremors and surgeon fatigue. “It is like driving down a 10-lane expressway with no traffic!” says Dr Sailesh Puntambaker.

The chief challenges for robotic surgery seem to be the lack of enough trained surgeons, the capital cost of the robot, and a lack of vision in the fraternity, which still views it with distrust.

Some doctors also prefer the tactile sense of conventional surgery. “Around the world, there is a shortage and we are looking to train good surgeons, someone with 500-1,000 robotic operations,” says Dr Ravi Kumar. ICRS plans to bring in a team of 20 world-class surgeons and rotate them across its centres while simultaneously training 16-20 per year, allotting two per specialty.