Rise of the machines: Surgical edition
Never in her wildest dreams had 62-year-old Meena Kumari thought she would be in an operating theatre with surgeons bent over her, cutting into her abdomen. “I had never had even stitches before and was so afraid,” Kumari, who lives in north-east Delhi’s Chander Nagar, says. So, when she was diagnosed with endometrial cancer (cancer in the inner lining of the uterus) about a year ago, she was prepared for her worst fears to come true. Luckily, Kumari underwent an operation that didn’t require invasive open surgery and caused very little blood loss, pain, and discomfort. The only difference was that a huge robot, controlled by a surgeon from a distance, towered over her, doing almost everything the latter could do, only more artfully and with greater precision.
The robot that was used in the operation was the da Vinci surgical system, one of the most advanced medical robots, which enables surgeons by making a few centimetre-long incisions, and thus getting rid of the need for open surgeries. The robot has four arms—three of which can hold different surgical instruments and a fourth that has a 3D camera attached. The three arms, controlled by a computer, replicate the movement of the surgeon who sits on a console a short distance away in the room and can view the organ being operated upon through a 3D, high-definition image on a screen attached to the console.
“It’s like a video game,” says Dr Rama Joshi, a gynae-oncologist at Fortis Hospital in the city, who has performed close to 250 robot-assisted surgeries in the four years since she completed training. With two joystick-like controls in both her hands and clutch controls at her feet, Joshi operates on Kumari by looking through the 3D screen, which has a view of the uterus and the ovaries. Moving the joystick, she cuts the cancerous cells in the lining of the uterus.
The da Vinci is one among several surgical robots that are increasingly becoming a familiar presence in operating theatres. India’s surgical robotics market is estimated to expand at a compound annual growth rate of 20% between 2017 and 2025 to hit a net worth of $350 million, compared with a net worth of $64.9 million in 2016, according to a report by BIS Research, a technology research and advisory firm. Robotic surgeries in Gurugram first began in a couple of its private hospitals around 2015-16, even though the technology was brought in a few years earlier. In 2018, more than 400 robotic surgeries in the fields of urology, general surgery, gynaecology, and paediatrics were conducted in the city’s hospitals, a rise of around 50% from the number of surgeries in 2016.
Kumari’s surgery to remove the uterus went on for around five hours. She was discharged a day later. She then resumed walking and could relieve herself on her own, she says. According to experts, an open or laparoscopic surgery (through thin, long tubes) would have taken her at least a week of bed rest to recover. “Recovery is a lot faster this way because the operation is very precise. Patients have joined their workplaces in less than 10 days after being operated upon,” Joshi says. Robotic surgeries also lead to lesser blood loss—a laparoscopic surgery would cause an average blood loss of 150-300ml, while a robotic surgery leads to a loss of around 30ml—as well as reduces the risk of infection as the incisions are tiny. Not to mention doctors’ movements in robotic surgery are intuitive.
However, robotic surgery isn’t is the preferred method in all types of surgeries, say experts, adding that such a surgery is performed particularly on difficult-to-access parts of the body, such as near the spinal cord, and on patients who are morbidly obese. Kumari, for instance, weighs 117 kilograms and a laparoscopic surgery would have been difficult as the length of the instruments used in the surgery would be shorter than those used in robotic surgery.
While the first robot-assisted, minimally-invasive surgery was performed for the first time in India in 2002 in a Delhi hospital, the technology took years to become more common. Robotic surgeries were becoming more popular in western countries around the early aughts, as per various published papers on the history of robotic surgeries, but the practice picked up in India almost a decade later. “Back then, very few people in the country knew of robotics in medicine. They were afraid as they thought a robot would be operating on them by itself, which isn’t true,” says Joshi, adding it took some time for patients to adjust to the idea.
Ridhi Naik, 67, who underwent robotic surgery in the city to remove the thyroid gland in April 2015, says she was terrified to hear something like that was even possible. “I was opposed to the idea from the start. Aren’t robots capable of making mistakes? It took quite a lot of convincing by my family that it wasn’t all that bad,” she says.
However, another patient, 65-year-old Shakuntala Bindal, who weighed 106kg and had a uterine robotic surgery done this April, says she did a lot of research before going ahead with the decision. “I had to mentally prepare myself. I had not heard of robotic surgery before, and watched a lot of videos and read articles to learn about how it is done,” Bindal says.
According to surgeons, more people are opting for robotic surgeries, thanks to more information available about the process among the general public. They say many patients reach out to them, specifically demanding robotic surgery, which wasn’t the case three or four years ago.
For spinal, cranial, orthopedic, ENT and trauma-related surgeries, city hospitals have a surgical robot called the O-arm which provides real-time, intra-operative 3D imaging of a patient’s anatomy. According to experts, the robot is best used for complex spine surgeries. “During complicated spinal instrumentations (implanting screws into the spine), there is a high chance of the screw being misplaced, which can lead to complications such as weakness in the legs,” says Dr V. Anand Naik, orthopedist at Medanta Hospital in Sector 38, adding that an O-arm, through the scan it generates, can even help pre-plan the trajectory of the screw and ensure precision.
Naik also does robotic surgeries on children in the city. Paediatrics robotic surgeries remain far less common in India, and only a handful of surgeons are trained in the field, he says. Even in western countries, since robotic surgery was introduced in children in 2001, it has been employed by select paediatric laparoscopic surgeons, but not to the same degree as adult surgical specialists. According to a 2015 study in Frontiers in Paediatrics, due to size constraints (typically, surgical area in children is smaller than that of adults’), the tight financial margins that paediatric hospitals face, and the lack of high-level data proving robotic surgery is more beneficial compared to conventional laparoscopic surgery, it may be some time before the robotic surgical platform is widely embraced in paediatric practice.
While the number of hospitals offering robotic surgeries and the number of people opting for it has grown in the country, several challenges remain. A major impediment is the high cost. According to experts in the field, robotic surgeries, on an average, cost between ₹1-1.5 lakh more than regular procedures. Moreover, robotic surgeries are not covered under most insurance plans. “Many patients still don’t opt for robotic surgeries, mainly because there is no insurance cover for them,” says Dr Anil Mandhani, a urologist at Medanta Hospital, who was one of the first few surgeons to be trained in robotic surgery in 2007. He says that until costs come down and insurance policies start covering robotic surgeries, they will be an alternative, not the first choice.
A basic da Vinci system costs between ₹10 crore and ₹15 crore, and the annual maintenance can be around ₹4.5 lakh, according to hospitals using the robot. The high costs of the robot also place the technology out of the reach of many public health facilities. “The maintenance costs remain the same; whether surgeons conduct one surgery or multiple surgeries in a day. So when more surgeries are conducted, the cost per surgery automatically comes down,” Dr Mandhani explains, adding this is why most hospitals with the system push for robotic surgeries.
Yet, experts are optimistic about the future of Indian surgical robotics. The BIS Research report says the next level of technological advances might completely remove human contact during surgeries. Future robotic surgery systems might allow surgeons to conduct robotic surgeries on a patient in a nearby clean room without any human contact or interference. Mixed reality —the convergence of virtual reality and robotics—where surgery can be performed by looking at the patient’s anatomy and the scans simultaneously, is something surgeons in the city are eager to test. Recent developments in the field of robotics, such as miniature surgical robots and technology through which surgeons can feel the interaction of the instrument with the patient’s body are a sign that robotic surgery is here to stay, they say.