His first patient had obviously overdosed on science fiction. When Dr Arvind Kumar, now professor of surgery, general, laparoscopic, thoracic, thoracoscopic and robotic surgeon at AIIMS (All India Institute of Medical Sciences), New Delhi, explained to the nervous person that his surgery would be done by robots, he was thrown “a very pertinent question”: what if the robot goes haywire and starts doing its own silly movements during the procedure?
Though it was definitely a ‘theoretical’ possibility, Dr Kumar had to do a lot of explaining to the patient about of the security systems in the robot. “Most patients still feel that the robotic surgical system is actually a human-like machine which walks up to the operating table and carries out the surgery with the surgeon looking at the robot, which is actually not the case,” he laughs.
According to Dr Yugal K Mishra, director, department of cardiovascular surgery, Fortis Escorts Heart Institute and Research Centre, New Delhi, “the medical robot available today is from Intuitive Surgical, USA, a company manufacturing robots. It has created the well known ‘da Vinci’ surgical system. The latest version, Da Vinci SI, allows superior 3D high definition vision with the instruments allowing for enhanced dexterity, precision and control. The end result: a breakthrough in surgical capabilities.”
The system consists of three components: a robotic patient cart; a master console and a light source and data processing unit. The patient robotic cart comprises a central tower with three to four arms which move up and down on the tower and have numerous joints simulating the movement of the joints in the human arm – the shoulder, elbow, wrist and the fingers. These multiple joints allow a wide range of movements in the robotic arm. The last part of the arm has a robotic instrument which goes inside the patient’s body though special 8 mm tubes. The central arm has a telescope with video camera inserted into the patient’s body through a 12 mm tube, which transmit images to the video screen in the master console unit. These are high definition images and give a 3D vision to the surgeon sitting at the console. He then manipulates a pair of joysticks on the console, and the movements of his hands and fingers are replicated by the robotic instrument inside the body. This is made possible by the master computer in the console which converts the movements of the joysticks into electrical impulses which pass through the robotic cart and result in movement of various parts of the robotic arm and the instruments. The light source and the data processing unit allow the vision from inside the patient’s body to be transmitted to the master console and the joysticks’ movement to be transmitted to the patient cart.
“Robotic surgery is being applied in a wide range of specialities ranging from general surgery, cardiac surgery, thoracic surgery, vascular surgery, urology, gynaecology to ENT surgery. It is mandatory for a surgeon to be well versed with every step of the procedure and take care of the nuisance of handling a robot,” says Dr Kumar.
The desire to be at the “cutting edge” of keyhole (minimally invasive or robotic) surgery of the chest, had this MS from AIIMS training in robotic chest surgery in Italy and Switzerland. “I started the same at AIIMS in June 2008 and today it’s the only centre in the country which offers robotic chest surgery to its patients free of cost,” he says. Credit goes to Dr Mishra for performing the first cardiac robotic surgery using the da Vinci system in Asia in 2002 at the then Escorts Heart Institute and Research Centre. Since then, he has handled 400 cases, one of the biggest experiences in Asia.
For India it is just the beginning, says Dr Rajiv Yadav, consultant, urologic oncology and robotic surgery, Medanta, The Medicity Hospital in Gurgaon. “We do need well trained and qualified robotic surgeons catering to various surgical subspecialities. There is no fellowship training programme in India for advanced training in robotic surgery. In fact, I am the first fellowship trained robotic surgeon practicing in India. We are in the process of setting up centre of excellence with the aim of providing training in advanced robotic surgery to surgeons in the country,” he adds
The reason Yadav chose this career was because he had the passion for research and desire to keep himself on the forefront of technological advancement in cancer surgery.
“I am sure India will soon serve as a preferred destination for advanced robotic surgery,” says Yadav
What's it about?
A robotic surgeon carries out minimally invasive surgical procedures through use of medical devices and systems. The robotic systems are equipped with arms for optics and camera which are inserted into the body and send images to video screens on a console where the surgeon sits. He then manipulates a pair of joysticks on the console connected to instruments inserted in the patient’s body which replicate his movements and carry out the surgery. Robotic surgery has been utilised in cardiac surgery, thoracic surgery, urology, gynaecology, general surgery, bariatric surgery etc
5.30am: Wake up and get ready and connect with OT staff to ensure if patient has been readied for surgery
6.30am: Leave for hospital
7am: Reach OT, check preparations for surgery, do checks of equipment
10am: Patient wheeled in. Get ready for surgery
3pm: Finish surgery, monitor patient for post-op care and wait for him to regain consciousness
6pm: Prepare report on robotic system to send to manufacturer
At a government-aided institute like the AIIMS, the take-home salary for someone at a senior position of professor is approximately Rs1 lakh a month. His or her counterpart in a private hospital could be making ten times more depending on the hospital or city he or she is working in
. Finely tuned surgical skills with some technological orientation to be able to understand the workings of the robotic systems
. Dealing with high-tech systems which are upgraded constantly means you have to remain updated on everything that’s happening in your field
. A desire to achieve cutting-edge excellence in your field and developed ability to network with the best brains
How do i get there?
Any medical student who completes a masters in surgery should first develop proficiency in open surgery before training with the robotic devices. Robotic surgery is a new and more precise method of doing surgery using the keyhole method with minimal invasion - thus ensuring quick recovery time. Surgeons are now able to perform complex manoeuvers in a small operative area
Institutes & urls
. India does not have any dedicated training centre for robotic surgery. Various universities in the US offer fellowship programmes in this discipline which is for two-three years. Dr Pier Cristoforo Giulianotti, MD, one of the pioneers robotic technology, and currently chief of the division of general, minimally invasive and robotic surgery, trains surgeons at the University of Chicago (www.uic.edu). However one needs to clear United States Medical Licensure Examination (USMLE) in order to apply for these fellowship training programmes. International bodies like the Endourological Society (www.endourology.org) and the Society of Urologic Oncology (www.societyofurologiconcology.org) provide accreditation to institutes in Europe and Asia which offer the relevant programmes
Pros & cons
Greatly respected profession and an exciting field to be in
You save lives, what could be better than that?
Tough profession to be in - surgery can be risky for a patient and dealing with his or her death could be tough
The benefits are significant
India could become the preferred destination for advanced robotic surgery in the future
What does a robotic surgeon do?
A robotic surgeon performs advanced laparoscopic surgery for both cancerous and noncancerous conditions using a surgical robot. With the use of robots there is enhanced surgical precision, minimal blood loss, lesser pain, smaller surgical scars, faster recovery and earlier return to work.
How much does robotic surgery contribute to reducing risks? Although the robot is merely a surgical tool and the skill of a surgeon is paramount, it allows a surgeon to perform a more precise surgery, which transforms into lesser blood loss, better reconstruction of tissue architecture and thus better overall outcomes.
Specialisations required? Do surgeons have to look after the maintenance of the machines?
Robotic surgery is a superspeciality. One needs to have basic surgical training and then undergo fellowship training for two to three years in a high-volume centre before one is qualified to perform independent surgeries.
Maintenance of the equipment is handled by biomechanical engineers who are specially trained to look after the machines.
Does one need knowlege of engineering to operate the machines? Although the surgeon need not have any specific knowledge of engineering, he or she should be well versed with the machine and about the problems usually encountered with the use of hardware. This helps in case there are problems during surgery.
Does a surgeon also contribute to the development of surgical devices/robotic systems? Robotic surgeons do take part in the development of the device by giving valuable feedback about the instruments. The development of suitable instruments is a continuous process. Regular changes are done in the type of robotic instruments used in various types of surgeries by utilising the feedback given by surgeons. For example, specific instruments are designed for use in cardiothoracic surgery which can used only for heart surgery. Better designs of instruments are available for more efficiency. Similarly, now various energy sources like Lasers, Harmonic and Electrocautery have also been incorporated into surgical robots, making surgery safer and efficient.
When is robotic surgery recommended?
Robotic surgery is done for a variety of cancerous and noncancerous conditions among various specialities. In urology it is primarily used to treat prostate cancer, urinary bladder cancers, kidney cancers and certain congenital conditions of kidneys.
The Indian scenario?
Regarding the scenario for robotic surgery in India, there are three main limitations: There are limited number of surgical robots primarily because of high initial and recurring cost of maintenance. Secondly, there is lack of awareness among the general public as well as physicians regarding the benefits of robotic surgery. Thirdly, there is also lack of a referral system. Despite the highly expensive instruments, the benefits of robotic surgery are significant enough in certain conditions such as prostate cancer so as to justify its wider application. The need of the hour is to create greater awareness among physicians and surgeons regarding the benefits of robotic surgery.
Dr Rajiv Yadav, consultant urologic oncology and robotic surgery interviewed by Ayesha Banerjee