A revolutionary medical technology that lets doctors operate on patients using a robot will be offered in Mumbai for the first time at a Bandra hospital. Demand to be cut up by a four-arm machine is already high among Mumbai's patients, doctors tell Yolande D'Mello
A revolutionary medical technology that lets doctors operate on patients using a robot will be offered in Mumbai for the first time at a Bandra hospital. Demand to be cut up by a four-arm machine is already high among Mumbai's patients, doctors tell Yolande D'Mello
Mumbai cardiac surgeon Dr Ramakanta Panda wears a broad smile and blue scrubs when we meet him on a Friday morning, before he scurries off to attend to surgeries for the day. Happy at the arrival of the latest member on his team at the Asian Heart Institute, Bandra Kurla Complex, he introduces us to da Vinci. 
Dr Ramakanta Panda, cardiac surgeon and vice chairman of Asian Heart
Institute, BKC, has performed over 14,000 heart surgeries. Seen here
with the da Vinci Surgical System that will offer robot-assisted surgery to
patients starting August 1. pic/ Vikas Munipalle
The thought of a handshake is quickly aborted at the sight of a surgical system that is part of a robotic technology that has just arrived at their hospital, the first in Mumbai.
The da Vinci is a $2.5 million machine (Rs 11 crore approx) that will play a crucial role in urological, colorectal, cardiothoracic and gyneacological surgeries.
"The da Vinci will allow us surgeons to operate with greater dexterity, making smaller incisions, thereby reducing blood loss and speeding up recovery. Chances of infection will be low too," says Panda.
Named after the 15th century Italian Renaissance painter and inventor, who dabbled in fields ranging from architecture to botany, the robot is manufactured by Intuitive Surgical Inc, a California-based medical technology firm that created the first da Vinci prototype in 2000 and received the US Food and Drug Administration approval the following year.
Many arms, one machine
Its design includes three componentsu00a0-- one of which is a four-armed machine that stands six-feet tall and looks like it has escaped from a Transformers movie. This component is the 'do-er', working on the patient who lies on a side cart while the four arms hold and manoeuvre instruments, and a laproscopic camera. The arms can extend and rotate 360 degrees around the pivot, and are locked to avoid risks. As the surgeon moves his fingers on the console, the second component, his actions are mimicked by the robot in scaled down movements. The robotic arms filter out hand tremors thereby eliminating the chance of human error. Four arms allow the surgeon to carry out more than one action at a time. The machine makes smaller incisions (called key hole incisions) because of the magnification, and precision allowed.
The pivots are guided by master controls fitted on the surgeon's console. A voice command will recognise the surgeon and even wish him good morning.
The third component is a high definition touch sensitive Vision Screen that allows an assisting surgeon to point to vital areas in a patient's anatomy and make suggestions that the surgeon performing the surgery can see on the screen fitted on his console.u00a0 The HD screen can also be used to explain key steps in the procedure to others in the room. All images are transmitted and received in real time via fibre optic cables. The the surgeon can get to know the pressure he is applying through feedback that the robot relays. The da Vinci currently sits on the second floor of the ICU that is lined with cartoon characters splattered on wallpaper, ever since the paediatric ward was converted to an ICU,u00a0 as a temporary measure. But, the robot is expected to occupy pride of place at the Asian Vattikuti Institute of Robot Surgery, a wing of the hospital that will be inaugurated on August 1 -- the day the first robot assisted surgery will be performed in the city. And the first ones to use it will be the urology department.
The new wing at the BKC hospital is a collaborative venture between the Asian Heart Institute and the Vattikutti Foundation, a Michigan-based NGO involved with charitable programmes in disaster management and scientific education.
"We have four OTs (operation theatres), and a surgery is usually in progress at each of them at all times. I do about six surgeries a day," says Panda's colleague Dr Manoranjan Miska of the Cardiovascular Thoracic Department, as he checks his watch. The surgeon can't help cast a proud look at da Vinci, whose arrival has been eagerly awaited. It is the messiah that's going to take the pressure off Miska and co.u00a0
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Genesis in blood, gore and spacecraft
Unlike Panda and his colleagues, Dr Arvind Kumar, professor of surgery at Delhi's All India Institute of Medical Sciences (AIIMS) has been familiar with robotic technology since 2008 when they received two surgical systems through a government grant. "In the early '90s, the US government, especially through the National Aeronautics and Space Administration (NASA) and the US army were looking for a technological solution to dealing with medical emergencies in far-flung areas, on battlefields and even in space. That is how research on robotic surgery began," says Kumar. At AIIMS, all robot-assisted surgeries are conducted free of cost.
The website of da Vinci's manufacturer, Intuitive Surgical Inc explains how the system was inspired by Defense Advanced Research Projects Agency (DARPA), a US government arm that is also responsible for the first hypertext system. As the technology developed and research grew deeper, it found greater use in Minimal Invasive Surgery and a ready audience among patients worldwide.
New to Mumbai, the da Vinci is widely used in the United States, and makes work easier for surgeons in 1,450 hospitals around the globe.
Its arrival has created quite a stir among the city's medical community, not to mention patients curious about the healing robot.
"They think the robot will be doing all the work without the presence of any surgeon inu00a0the operation theatre.
That's not the case. We will have to prepare the patients before we begin surgery. It is important for them to know that the human connect will be maintained, and the surgeon is still in charge," says Dr Pradyot Kumar Rath, cardiothroracic surgeon at Asian Heart.
While doctors here may have received inquiries from curious patients eager to try the procedure, only suitable candidates will be considered, say doctors.
"The technology for robot-assisted surgery is still evolving. I wouldn't suggest it for an infant. It wouldn't work for a very risky cardiac procedure that involves more than blocked arteries. It is also not advisable for someone who is undergoing a second surgery," saysu00a0 Panda.
Kumar agrees. "Can the robot be used for all kinds of operations? Perhaps, but that's true at research level. It can even perform the simplest hernia operation but the argument is, what's the need for that? Gall bladder surgeries are complicated, requiring a large incision that would take months to heal. About 15 years ago, laparoscopic surgery made the procedure simpler and safer. So, I don't see the need for robotic assistance here either.u00a0 It's the surgeon who takes a call if it's needed," he says, admitting that the technology has been slow to penetrate Indian hospitals on account of a large initial investment. The initial cost covers the machine, and the first set of instruments. Between three and four instruments are used on an average in every procedure, and they have a life span.
"This means they can only be used for a set number of surgeries, and would need to be replaced. This implies a recurring cost of Rs one lakh every year," says Kumar.
Surgeons must go back to school
All surgeons using the equipment are required to undergo training at two global centres located in Strasburg in France and California, US. Rath who is back from a two-day training at the Strasburg says, "First we learn how to use the console. The next step is practicing on an animal, and finally on a cadaver."
For Panda, it's "like learning to drive a car."
He says, to start with, the surgeries will take longer than conventional operations, but this is owing more to the learning curve than anything else. "The more often you drive, the better you get," he says, continuing the
analogy.
New Delhi resident Kalpana Arora (name changed) went under the knife for a thymectomy, a surgery to remove the thymus, a gland in her chest, at AIIMS on July 14.
"When they mentioned it would be a robotic surgery, I imagined an android performing the procedure. I requested Dr Kumar to stay in the room. He then explained how exactly the procedure would be carried out.
Hearing about why the procedure made better sense, made me feel better," says Arora.
The first step then, it seems, is to shed da Vinci's android image. "The robot is a brainless machine. It is dictated by the mind and the actions of the surgeon," says Kumar.
A thymectomy that usually requires an incision that runs from the neck right down to the chest, was done through robotic-assisted surgery via three one centimetre-large incisions under her arm. Three days after surgery, Arora was free to go home. Two weeks later, life is back to normal.
"They put me under at 8 am and they were done by 1.30 pm. It takes a while to set things up but all the equipment looks spic and modern," says Arora, who had been troubled by the gland for two years.
It doesn't come cheap
The cost is unlikely to leave patients as happy, though. While a conventional urology surgery, like a prostrate operation, will cost between Rs 1.5 and Rs 2 lakh, the cost of robotic-assisted surgery is an additional Rs 1 lakh. Cardiac surgeries that cost between Rs 2 and Rs 4 lakh could jump up to Rs 6 lakh when a robot steps in.
Even at inflated costs, it still remains competitive to medical costs in the US. The new technology is therefore expected to aid medical tourism in India.
"Earlier, patients would travel to the US for assisted surgeries. We wanted to offer Indians the latest in medical breakthrough, and the best of what's available," says Panda.
Bengaluru-based Manipal Hospital has conducted over 25 robot-assisted surgeries in the last two weeks alone, tackling urology, non-pregnancy related gynecological issues, oncology and paediatric concerns. Dr Sudarshan Ballal, director, Manipal Hospital calls it a giant technological leap.
"Here's the comparisonu00a0-- blood loss in robot-assisted surgery is about is 30 ml. It's over 200 ml in regular procedures. And the reduced period of recovery makes it worth the cost. We only make a suggestion. It's patients who take the final call."
Kumar says this is just the beginning. "It's like the first computer that occupied an entire room, and was affordable to an elite few. The technology has a long way to go. The market will open up, and costs will go down. The possibilities are vast. It's only a matter of time."u00a0u00a0
How is Robot-Assisted Surgery different from Laparoscopic Surgery?
Laparoscopic surgery initiated key-hole surgery with smaller incisions, and belongs to the broader field of endoscopy. It followed open surgery and offered the advantage of reduced pain and hemorrhaging, and shorter recovery time.
Laparoscopic cholecystectomy is the most common laparoscopic procedure performed. Here, 5-10mm diameter instruments (graspers, scissors, clip applier) can be introduced by the surgeon into the abdomen through trocars (hollow tubes with a seal to keep the CO2 from leaking). With multiple incisions, a camera is inserted to give the surgeon a 2D view of the body segment. He views this on a monitor but the operation is performed by hand.
Learning with the robot
A collaboration between the Centre for Robotic Surgery at Roswell Park Cancer Institute and the Buffalo's School of Engineering and Applied Sciences has led to the formation of Simulated Surgical Systems that produced one of the world's first simulators that closely approximates the "touch and feel" of the da Vinci robotic surgical system. The RoSS is a robotic surgical simulator, which uses virtual reality to train medical students in robotic surgery. A stand-alone machine comes at a minimal cost and can record results for further evaluation. The console allows surgeons to rehearse complete procedures and the external screen is for tutors to observe and monitor in real time. The module seeks to improve hand-eye co-ordination and basic dexterity.
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