Robots get under your skin

Three months ago, Dr Anshumala Kulkarni, consultant gynaecology, laparoscopic and robotic surgeon at Kokilaben Dhirubhai Ambani Hospital at Andheri (W), recommended Robot-assisted hysterectomy - removal of the uterus - to Poonam Bagwe (name changed on request) from Pune. Twenty eight year-old Bagwe had been suffering from fibroids (non-cancerous tumours) in her uterus and endometriosis (thickening of uterus lining) since the age of 18, but preferred to ignore the side effects, such as pain and heavy bleeding during her menses, instead of opting for surgery to have the fibroids removed.

"I was really scared of undergoing surgery at that age. I didn't want any scars either. Eight years later, however, she had no choice. She finally went for her first surgery to get rid of the multiple fibroids.

At Kokilaben Dhirubhai Ambani Hospital, Andheri (West). The u00a0robotic system has four arms, which the doctor manipulates to form an incision on the patient. The remote console has foot gears that help the doctor zoom in and zoom out of the 3D camera. Pic Courtesy / Kokilaben Dhirubhai Ambani Hospital

This gave her solace for three years, after which the problem recurred. In 2007, she underwent a surgery again. This time, the fibroids with endometriosis resurfaced within six to eight months. In 2008, she underwent her third surgery. By now, she was married, and doctors suggested that she would be able to conceive a child through invitro fertilisation (IVF) treatment.

Unfortunately, the recurrent fibroids had affected her ovaries and the uterus. "First they told me that there was a 70 per cent chance of having a baby, but later they told me that the chances were as low as five per cent," says Bagwe. "The multiple fibroids were pushing against my kidneys which had caused a swelling. There was no alternative to a hysterectomy," says Bagwe.

Dr Anshumala Kulkarni on the remote console of the Da Vinci Robotic system

Today, Bagwe regrets delaying the removal of her fibroids due to her fear of undergoing surgery, which has left her unable to conceive. She needn't have postponed the surgery if the MRfGUS (MR guided focused ultrasound surgery) had existed at the time.

Introduced in 2010 at Jaslok Hospital, the procedure takes approximately three hours, requires no incisions and therefore leaves no scars, and allows the patient to "resume work within an hour of the surgery," as 54 year-old Sandhya Dhuru, at Jaslok Hospital, describes. Like Bagwe, Dhuru bore the painful side effects of multiple fibroids for 10 years, because she did not want to undergo surgery. Today, she's glad she went in for the procedure.

Non-invasive surgery
Dr Shrinivas Desai, director - department of imaging and interventional radiology, Jaslok Hospital, oversaw the installation of the MRgFUS. "MRgFUS has an MR table with a high intensity ultrasound fitted below it. The source maps the tumour, and sound waves are targeted towards the area with sub-mm precision and removed. The process is non-invasive. In the past one-and-a-half years, we have treated 300 cases of fibroids," explains Desai.

Dr Shrinivas Desai, director - department of imaging and interventional radiology, Jaslok Hospital u00a0and Dr Rishma Dhillon Pai, consultant gynaecologist at Jaslok and Lilavati Hospital study a case of MRfGUS (MR guided focused ultrasound surgery) . Pic/Sunil Tiwari

This is a good alternative to myomectomy conducted on patients by doctors on an operating table. "When patients opt for this treatment, they don't need to starve as there is no anesthesia involved. We give a little sedation to make the patient feel comfortable and attach a catheter."

"MRgFUS is used to treat uterine fibroids, prostrate cancer, metastatis of the bones, bone tumour and soft tissue tumour," he adds. So easy is the procedure that "the cases have upped by 20 per cent this year," informs Pai, adding that they actually call it the ‘walk in, walk out' surgery'.

Better than before
According to Dr Kulkarni, 20 per cent women in India suffer from fibroids in the uterus - a form of benign tumour. And more than 50 per cent sit on the condition, for the fear of surgery. To address this issue, on May 28 this year, Kokilaben Dhirubhai Ambani Hospital introduced the Da Vinci Robotic system - a series of computer-controlled instrument arms connected to cables and a remote console from where the doctor controls the procedure. In the past six months, Dr Kulkarni has treated 70 such cases using the machine at Kokilaben Dhirubhai Ambani Hospital, which she claims is the fastest in India.

MRfGUS (MR guided focused ultrasound surgery) machine at Jaslok Hospital. Pic/Sunil Tiwari

While the machine conducts the same procedure as a normal surgery, biotechnological advancements are proving to be a great relief from post-operative pains, as the procedure is almost painless, which in turn hastens the recovery period, says Dr Kulkarni.

Since the Robodoc was launched in India two years ago, it is being used for gynaecological surgeries such as a hysterectomy, endometriosis, fibroid cancer, uterine and cervical cancer. It is also used for cancer surgeries of the kidney, bladder and adrenals. "Other specialities include surgeries of the oesophagus, head and neck, thoracic and ENT (Ear-nose-throat) surgeries," Dr Kulkarni.

Dr Rishma Dhillon Pai, consultant gynaecologist at Jaslok and Lilavati Hospital, says multiple fibrosis affects 20 per cent of Indian women, causing painful and heavy menstruation. "The tumour is recurrent. But women who are petrified of surgeries, now have an option. Who would have imagined curing fibroids without any incision, anesthesia and radiation? In certain cases, MRgFUS is a good alternative. But some cases may require a regular myomectomy or hyterectomy, she says.

Faster, cleaner
The Robotic system has company. In the past two years, India has witnessed the entry of many advanced machines and equipments such as the MRgFUS and 3D laproscopy.

Twenty two Da Vinci Robodocs have been installed in hospitals in major metros in this period. Delhi has 10 machines and the western region has four, out of which two are in Mumbai, and one in Pune. Given its advantages, the number ought to be higher, but Mohammed Pervez, clinical sales, manager, Da Vinci India, believes that the prohibitive factor is the cost of the machine - Rs 12 crore.

However, he believes, "The response is quite positive and with the rise in medical tourism, surgeons and oncologists will resort to its use more often," adding that patients today are well read and is open to trying new procedures and scientific breakthroughs.

Da Vinci India has thus charted a five-year plan, which is to install over 100 machines all over the country. "The biggest advantage is that the patient can go home within 24 hours, instead of being kept under observation during recovery. The blood loss is minimal and the incisions are precise and controlled. The recovery is much, much faster than a regular surgery," says Pervez.

The results speak for themselves. It has been two months since Bagwe's hysterectomy, and follow-up reports are normal. "The surgery was supposed to end in three hours, but continued for nine hours, since my condition was bad. Now, there is no pain," she says.

This month, Jaslok Hospital also launched the Automated Breast Volume Scanner (ABVS), which helps analyse detailed sonographic volumes of intricate breast anatomy and pathology. "It helps spot the rigidity and detect early legions and breast preservation. Some women find getting a mammogram, painful, and the ABVS is a great relief," explains Dr Desai.

First in India
Asian Heart Hospital at Bandra Kurla Complex has performed around 111 robo-assisted surgeries, says Dr Ramesh Juvekar, a urologist who is on the robotic surgery panel at the hospital. "Once the cost comes down, robotics will soon replace laparoscopic surgeries. Rob-assisted surgeries reduce tremors, and the magnification of images is excellent. In 3D laparoscopy, the fulcrum is far away, and the handler has to manually adjust the camera. In Robotics, the camera does the job of zooming in and out."

Dr Mangesh Patil, consulting urologist and robotic surgeon at Asian Heart Hospital, has been part of the robotic team since the time the first machine in India was launched a year and a half ago. "Of all the cases that were treated via robot-assisted surgeries, 97 per cent have been urology cases."

Jagshi Jagani, a 72 year-old patient from Vile Parle (East), who underwent robotic surgery on August 12 for prostratectomy - cancer of the prostrate gland - recounts, "In May, I was diagnosed with prostate cancer. We took several opinions and I was asked to meet Dr Mangesh Patil at Asian Heart Hospital. He told me that going for a robot-assisted surgery meant that the procedure would be safer, less painful and there would be no blood loss. I decided to go for it, considering my age."

It helped, because Jagani says he had to stay at the hospital for four days, instead of the usual 15 days. "Within seven days, I was off the catheter and today, I lead a normal life, as if there was never any problem. New technology is changing the way we do anything and everything, especially in medicine," he feels.u00a0

Machines for IVF
Dr Hrishikesh Pai, IVF expert, who has five centres in India, brought the first Embryoscope, which allows the study of eggs that are reared in the incubator last November. Since its launch in Delhi, there have been 150 successful IVF treatments. "Thirty years ago, the success rate was 5 per cent. But with the Embryoscope, it has risen to 40 per cent. The machine helps keep a close watch on the eggs, by capturing a film every 15 seconds. You can actually time the rate at which the cells divide. So, this allows you to pick the fastest performing egg to be implanted in the uterus. This cuts out the need to implant three to four eggs at a time, which is done to better the patient's chances, but can also lead to multiple pregnancies that may not be what she wants."

Robotic surgeries vs normal surgeries
>>u00a0The Robotic system makes a smaller incision, and reduces blood loss
>>The robotic arms have 580 degrees of rotation. It has wristed movements at the ends with seven types of movements called ‘7 degrees of freedom', as compared to the comparatively-restricted movements of a human hand or laparoscopic instruments.
>>u00a0Team required during the surgery remains the same - two nurses, one doctor, one assistant doctor and a technician
>>A robot-assisted surgery costs Rs 1 lakh more than routine laparoscopic surgery
>>u00a0The view on the console screen is in 3D. The image is 12 times magnified and clearer, compared to traditional 2D screens, allowing for better precision
>>u00a0The robot filters motions and tremors, making precise and fine movements easier