Robotic surgery is now being pushed by several hospitals in India. Is it really beneficial, or are there pitfalls that patients need to know about?.
It’s been over a decade now since robot-assisted surgery moved out of the realm of science fiction and into the operation theatre in the United States; so it was only a matter of time before the technology reached hospitals here. Although the All India Institute of Medical Sciences in Delhi was the first in the country to perform robotic surgery in 2008, the push now seems to be coming from the private sector with at least seven major private hospitals across the country, including rival hospital chains Fortis and Apollo, having started robotic surgery in the past one year.
In its present form, robotic surgery, or more accurately robot-assisted surgery, is not a process that eliminates the surgeon — here, instead of bending over the patient, the surgeon is seated at a console nearby, controlling with what seems like joysticks the robot’s three or four arms that do the actual cutting and stitching up. The robot’s cameras relay 3D images of the procedure to the surgeon at his console and the visuals can also be projected on a big screen for the entire operation theatre. Proponents who call this the future of surgery say there are various benefits for both patient and surgeon. “With a robot, the size of the incision is smaller, around two inches, and because the robotic arm is much more dexterous and steadier than the human hand, there is less damage to the tissue, resulting in very little loss of blood, less trauma and swifter recovery,” says Sudarshan Ballal, the managing director of Bangalore-based Manipal Hospitals, which recently launched a robotic surgery wing.
Seventy-year-old Jagshi Jagani, who underwent surgery in August, is a convert. Jagani opted to go the robotic way for his prostatectomy (removal of the prostate gland) at the robotic surgery centre of Mumbai’s Asian Heart Institute on the suggestion of his doctor. “I was in the hospital only for four days — and there were no cuts made for the surgery, just six holes,” says Jagani over the phone from Mumbai, adding that he has more or less regained bladder control.
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Both Manipal and Asian Heart, as well as Apollo in Chennai and Kolkata, Medanta in Gurgaon and KIMS in Hyderabad have tied up with US-based Vattikuti Foundation, which supports robotic surgery, to launch their robotic surgery centres. Mani Menon, the director of Vattikuti Urology Institute at Henry Ford Hospital in Detroit and the first surgeon in the US to perform a robotic prostatectomy in 2001, says we are just scratching the surface as far as robotic surgery is concerned. “Ironically, it was my best open prostatectomy patients who encouraged me to explore robotic surgery because they felt shorter recovery periods would have been of great help even considering that they recovered excellently,” says Menon who is on a whistle-stop tour through the country, performing robotic surgeries and delivering public lectures.
But the benefits that robot-assisted surgeries reportedly offer come at a hefty price. A robotic surgery costs at least a lakh more than the same procedure done through laparoscopy. Doctors may tell you that this will be offset by the money you save from a shorter stay at the hospital and the fact that you can return to work sooner (and experience less blood loss, etc) but then again, remember that hospitals have invested Rs 7-10 crore to buy the robot. That’s not all. “All robotic surgery equipment have to use disposable or single-use instruments which are tailor-made for the robot and are actively marketed by the manufacturers of the robot. This pushes up the cost of individual surgery,” says a laparoscopic surgeon who is developing indigenous robotics for laparoscopic surgery, speaking off the record. Vijay D’Silva, director of Asian Heart Institute, says volumes will eventually bring down costs, but that might be easier said than done. The surgical robot market is dominated by one player, US-based Intuitive Surgical, and its da Vinci surgical system. Da Vinci has several advantages; it was the first to receive US Food & Drug Administration approval, holds a clutch of patents and has taken over its biggest competitor. With global sales of close to 2,000 systems and a market capitalisation that has ballooned to over $16 billion, Intuitive Surgical is under no immediate compulsion to reduces prices. However, Raj Vattikuti, founder of Vattikuti Foundation, says his foundation is currently negotiating for better prices for India.
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Cost might not be the only factor you need to weigh. In the US, studies have questioned the tendency of hospitals to promote the procedure. Research by The Johns Hopkins University published earlier this year says that an estimated four in 10 hospital websites in the US publicise robotic surgery, with promotional material that overestimates its benefits and is strongly influenced by the product’s manufacturer, while largely ignoring the risks. Marty Makary, associate professor of surgery at the university and the study’s leader, is quoted as saying that there are no randomised, controlled studies showing patient benefit in robotic surgery, adding that robotic surgeries take more time, keep patients under anaesthesia longer and are more costly, none of which is mentioned on the hospital websites. Menon, however, says various peer-reviewed research papers have highlighted the benefits of robot-assisted surgery, adding that the biggest risk is an inexperienced surgeon; while D’Silva says the time spent under anaesthesia depends on the skill of the surgeon and not on the tool, i.e. the robot. Another study, also published this year, by New York University’s Langone Medical Centre and Yale School of Medicine found that when hospitals acquire surgical robotic technology, men in that region are more likely to have prostate cancer surgery. Patients should be aware that if they seek care at a hospital with a new piece of surgical technology, they may be more likely to have surgery and should inquire about its risks as well as its benefits, says Danil V Makarov, lead author of the study and assistant professor, department of urology at NYU Langone Medical Centre.
Nevertheless, considering the enthusiasm with which doctors are welcoming robotic surgery at the hospitals that have adopted it, the technology is likely to find takers. Sudhir Srivastava of Fortis International Centre for Robotic Surgery, for instance, says the company plans to set up centres in Mumbai, Bangalore, Kolkata and even smaller cities like Mohali and Jaipur. And apart from Indian patients willing to go under a robot-wielded scalpel, there is likely to be an influx of foreign patients familiar with the procedure and attracted by the cheaper costs here. So the procedure is undoubtedly here to say. But it might be a long while before it comes within the reach of the common man.