An advanced surgical platform

Robot assisted surgery has replaced most but not all of the open and laparoscopic surgeries.

It is not robotic surgery, it is robot assisted surgery

By Dr Anil Mandhani

Recently I came across a patient who asked me not to perform robot assisted surgery for his prostate cancer problem! His notion was not due to unaffordability, which usually is the scenario when it comes to having a robot assisted surgery. This gentleman’s perspective baffled me as he had misconceived information about robot assisted surgery.  In other words, his understanding was that robot assisted surgery is done by a robot! And that the surgeon himself takes a backseat!

To clear the misconception, it is not the robot which performs surgery. Rather it is the surgeon himself who takes the help of robotic arms carrying precision instruments and executes the procedure. It is a widely known fact that robot does not make a bad surgeon any better. Therefore the correct terminology used is robot assisted surgery not robotic surgery! In evolution of surgery as a specialty, transformation of concept i.e. ‘big surgeons make big incisions’ to ‘big surgeons make smaller incisions’ took place with the advent of key hole or laparoscopic surgery. This was a very significant step forward.

Laparoscopic surgery is a form of minimally invasive surgery, wherein multiple holes are made on the abdominal surface to enter the site of proposed surgery and desired goal is achieved by following the same surgical steps as in open surgery. This achieves the advantage of causing less surgical trauma, lesser pain and lesser time away from his or her occupation or daily routine, even for major surgeries. This advantage is further magnified in obese patients who stand to have higher incidence of wound-related complications following major ‘open’ surgery.

Despite advantages of minimal invasion, laparoscopic surgery has limitations of lack of 3-dimensional vision and limited movement of surgical instruments. Instruments used in laparoscopic surgery are rigid like a rod and devoid of movements like that of a surgeon’s hand. Robot assisted surgery provides a technologically advanced platform to perform conceptually similar surgery by using advance robotic instruments, which is more precise and has intuitive movements. These instruments also replicate the movements of a human hand. The surgeon sits in a console and has the advantage of magnified 3D vision.

Apart from it being cosmetically superior, the da Vinci System enables surgeons to perform even the most complex and delicate procedures through very small incisions with unmatched precision, significantly less pain, less blood loss, shorter recovery time, faster return to normal daily activities and, in many cases, better clinical outcomes.

Robot-assisted surgery provides a technologically advanced platform to perform conceptually similar surgery by using advance robotic instruments.

These advantages result in better precision and accuracy of the dissection and re-construction of deep-seated organ in the pelvis. Robot assisted surgery has replaced most but not all of the open and laparoscopic surgery across urology, cardiac, thoracic, gynaecologic, ENT, colorectal, paediatric and general surgical disciplines.

The first robotic installation in India was done in 2001 at Escorts Hospital, which is now Fortis Escorts and then it came to All India Institute of Medical Sciences and the first surgery performed was prostate removal for prostate cancer in the department of urology in 2006.  Since then there have been 52 installations in India and about 11 in NCR region itself. Most of the high-end work in urologic surgery is being done by robot assistance.  The most commonly performed surgeries by robot assistance are radical pros-tatectomy for prostate cancer, radical cystectomy for bladder cancer, partial nephrectomy for kidney cancer , reconstructive surgery for defects in kidney and ureters and lately even for kidney transplantation. Robot gives a definite advantage in obese patients, particularly in kidney transplant.

Robot is there to facilitate a surgery but it may reduce the inherent potential complications associated with surgery itself.
• Da Vinchi robotic system was first approved by US FDA in 2000. The current equipment used is known as the da Vinci Xi model, which is manufactured by Intuitive Surgical, California USA. There are four main components of da Vinci: the surgeon console, patient-side cart, Endo Wrist instruments, and vision system with high resolution 3D endoscope and image processing equipment. The surgeon sits at the console several feet away from the operating table where he gets a magnified three- dimensional image of the surgical field with a real-time progression of the instruments. The latest version of the system has four arms, which are much sleeker and have wider range of motion.
The Intuitive Masters technology also has the ability to filter out hand tremors and scale movements. The endoscope is programmed to regulate the temperature of the endoscope tip automatically to prevent fogging during the operation. Unlike the navigator control, it also enables the surgeon to quickly switch views through the use of a simple foot pedal.
The da Vinci Surgical System provides surgeons with an alternative to both tradi-tional open surgery and conventional laparoscopy, putting a surgeon’s hands at the controls of a state-of-the-art robotic platform.

We must remember that robot is there to facilitate surgery and it may not reduce the inherent potential complications associated with surgery itself, anaesthesia and equip-ment failure. Apart from the cost, another disadvantage, which is being looked into, is the lack of touch sensation also termed as haptic feedback. Though it is a desirable virtue, most of the surgeons using robot assistance can overcome this by better magnification and 3D vision provided to them.

Dr Anil Mandhani is director ,uro-oncolgy,Fortis Escorts Kidney and Urology Institute.

William Gibson, the famous cyberpunk science fiction writer once said: “The future is already here – it’s just not very evenly distributed”. The same is true for robot assisted surgery. The critique against the robotic platform is that in India most of the people are deprived of access to basic healthcare facilities. Is it worthwhile to adopt such an expensive technology?  I think we should always welcome and embrace change. As in space technology, where we have become self-sufficient and benefited millions of people in day-to-day life, we can work towards providing what is best for our patients when it comes to adopting newer technology!

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