In safe hands

Robots reduce errors during surgery,leave no scars and shorten patients recovery period. However,doctors say,they are not ideal for all procedures

The face of Indian operation theatres has changed over the years. Strides in technology,detection of new disease patterns and increasing attention to cosmetic detail have accelerated the transition. Due to free access to vital information,patients are increasingly informed these days,say doctors. For surgeries,patients main concern is to ensure quick recovery and minimise scars.

In India,there was a sharp increase in the number of laparoscopic procedures two decades ago. In the last decade,that kind of growth was seen in navigational or radiological image-guided surgeries. The latest developments are with respect to robots,and manoeuvrable tools like the Spider. A robot with four arms,each with attached wrists and magnified 3D vision,performs the procedure,controlled by a surgeon at its console. The robot enters the body through four tiny incisions,cutting down chances of human error. Tools like the Spider,which enter the body through the umbilicus,open up inside the body like an umbrella and perform the procedure. The scars,doctors say,are undetectable. With minimal access,surgery is now becoming single port,with no scars.

Dr Pradeep Chaubey,chief of minimal access surgery at Max Super Speciality Hospital,feels newer technologies like the robot may dumb down the doctor. He says,I think the robot can make a below-average surgeon look average.

Dr M C Misra,head of surgical disciplines at AIIMS,feels technology is good if it justifies additional costs. A robot is a boon for procedures like urology because the pelvic region always had an access problem. For problems like prostrate and gastrointestinal surgeries,which had huge access issues the robot has shown good results worldwide. But in other disciplines,the benefits even out due to the costs.

IN CARDIAC SURGERY

At Escorts Hospital,a 35-year-old IT professional was diagnosed with a problem in his aortic valve. The valve between the key pumping area of the heart and the key vessel which supplies blood from the heart to the rest of the body,had stopped working properly. His company allowed him three weeks of leave to repair the damaged valve by surgery. Dr Y K Mishra,director cardiac surgery at Escorts,said,If we had done an open procedure,he would need at least three months to recover. Due to robotic surgery,he was back to office in three weeks. Many young patients are diagnosed with heart problems,and spending powers are going up. If we can replace a 12-inch surgical incision,the minimum in an open procedure to access the heart,with a 3-inch one,patients are willing to pay anything for it.

Minimal access surgeries in cardiac procedures involve accessing the heart through incisions near the hip or groin region,with small cuts,eliminating the use of the heart and lung machine that is used to perform beating heart surgeries when heart function has to be temporarily stopped while it is being operated upon. Accessing the heart through a small incision itself is a problem,and other organs like the lung are situated in close proximity,so a lot of things to be considered, Dr Mishra said.

In 2002,doctors begun performing robotic procedures on the heart,but doctors say it has not really caught on. Robot is good for lateral heart calves. Its main problem is that it cannot be tilted,so it cannot be used for bypass and other procedures, Mishra said. But with the patent of the Da Vinci robot set to expire by the end of this year,surgeons expect newer robots more suited to heart procedures to enter the market. Till date,Da Vinci was the only company producing robots globally.

NOT ALWAYS IDEAL

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Many doctors say they find themselves counselling patients who come with demands of pin hole surgeries where the condition may not warrant it. There is an obsession for scarless surgeries,but if the size of a tumour is too huge,or spinal deformity extremely chronic,we can expect better results by opening up the body. It is always better to be safe rather than play to patients cosmetic concerns, Dr H S Chabra,medical director at Delhi-based Indian Spinal Injury Centre,said.

Dr Punita Bharadwaj,senior gynaecology consultant,says,If there is a defect in the fallopian tubes or uterus,or a tumour is accessible through the vaginal route,there is no need to access it through the abdomen just because patients feels pinhole surgery is safer. Doctors need to make the decision where to use it based on the location,size and possible number of problems. There should not be any adventurism involved.

THE COST BARRIER

For cancer surgeries,doctors say the robot will prove to be a boon only when its costs are brought down. We have a gross shortage of cancer surgeons in our country. The problem with laparoscopic procedures was its very steep learning curve. With the robot,a doctor learns much faster, Dr Sudhir Rawal,surgical oncology head at Delhis Rajiv Gandhi Cancer Institute,says. In case of obese patients,access to disease areas in the abdomen during surgeries has reportedly become much easier with the robot. I have operated on prostrate and gynaecological cancers with the laparoscope for almost 15 years,and 275 patients with the robot. I can say access is much easier using the robot, Dr Rawal said. However,he admitted that with large tumours,doctors would have to master the art of traditional open surgeries.

In spinal surgeries,doctors say the advent of minimal access has only come up in the last 3-4 years. We are correcting slipped disc problems,the most common cause of back pain,doing disc replacements,corrections of problems like spondylitis and inserting screws within vertebra to stabilise spines with an endoscope. We are using navigational techniques: image-guided procedures with minimal invasion, said Dr H S Chabra,from Indian Spinal Injury Centre.

QUICK RECOVERY

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At Sir Ganga Ram Hospital in New Delhi,barely three months after the installation of the robot,doctors have used it in different kind of surgeries like vascular,thoracic,head and neck,and the highest numbers in bariatric procedures. Doctors say the results speak for themselves. Take the example of Mukesh Singhal 42. With a body mass index BMI of 54,Singhal was in the super obese category,and had several associated co-morbidities: severe diabetes,hypertension and sleep apnoea. After consulting surgeons at various hospitals,he reportedly zeroed in at Sir Ganga Ram Hospital for its robotic equipment. A day after the surgery,though still admitted,Singhal is already walking,eating normally. Dr Praveen Bhatia,chief of the bariatric surgery at Sir Ganga Ram Hospital,said,After I operated on him,his wife told me Doctor,I hope the robot performed the surgery,not you.

While Dr Bhatia says that the robot is no good without the surgeon at its console,he admits technology instils faith in people,and that ensures a quick recovery. Where a patient operated on a laparoscope would take 3-4 days to get back to normal,we have patients walking out of operation theatres after surgery. The biggest advantage is it removes chances of human error. There is minimum blood loss,so we do not have to transfuse the patient. Associated risks of blood transfusion like the spread of blood-to-blood infections like HIV are eliminated, Dr Bhatia says.

A study published in the July issue of the Indian Journal of Urology documented 190 cases of robotic surgeries on prostrate cancers at AIIMS since 2006. It noted that pelvic surgeries for Indians warranted greater use of robots,despite the cost,because Indians have a smaller pelvis as compared to Caucasians. Indian population presents certain unique characteristics which may affect the outcomes of Robot Assisted Laparoscopic Procedures RALP. It allows transition from open to minimally invasive surgery with a small learning curve, noted the study,led by head of urology at AIIMS,Dr P N Dogra.