Robotic surgeries pick up pace in India after Covid-19 pandemic lull

Small number of trained surgeons, robots remain a challenge

Last month, a middle-aged sweet stall owner from Kolkata underwent a robotic surgery in Chennai that removed cancerous tumours from both his kidneys. All it took was two interventions — a minimal invasive procedure on March 22 to allow robotic instruments access to his abdomen, followed by a four-hour robotic surgery two weeks later.

Vasantharaja Ramasamy, associate consultant, Urology, Uro-oncology and Robotic Surgery, Rela Hospital, who led the procedure, says he achieved what the surgery aimed for with no side effects for the patient. The tumours were removed while saving the kidneys as far as possible, otherwise the patient would have required kidney transplantation or life-long dialysis, he says. “With open endoscopic surgery, this would be very difficult.”

There are several plusses to robotic surgery, a hi-tech alternative to traditional operations that is gaining momentum in India after a lull of nearly two years owing to the Covid-19 pandemic. Besides the ease of it, “the post-operative period in robotic surgery is very brief. A patient has to stay in hospital only for one or two days,” says Ramasamy.

While official data is not available for the number of robotic procedures carried out annually, as of July 2019, India had 66 centres, 71 robotic installations and had conducted over 12,800 surgeries with robotic assistance in 12 years, according to an article titled “Robot-assisted surgery in India: A SWOT analysis” (Indian Journal of Urology, 2020).

India has just a little over 500 robotic surgeons, which is a small number, points out Ramasamy, and only 70-odd robots. Compare that to the US, which has 4,000-5,000 robots with one-third the population.

Kalpana Nagpal, senior consultant, department of ENT and head and neck surgery, Indraprastha Apollo Hospitals, New Delhi, who has done over 200 robotic surgeries since 2017, says that cases and volumes are increasing for surgeons in India despite an expected dip during the pandemic.

The hospital, adds Arun Prasad, senior consultant, gastrointestinal, bariatric and robotic surgery, has carried out 2,063 robotic surgeries in the last 10 years. As against 300-350 surgeries annually earlier, the average fell to about 200 per year in 2020 and 2021.

Among a handful of ENT robotic surgeons in the country, Nagpal does six-seven such surgeries a month. “People come from far and wide. Two doctors came from Malaysia for treatment of sleep apnea,” she says.

Recently, she removed a parapharyngeal space mass, a benign tumour of over 5 cm in size, without any external incision in a 28-year-old man. The youth who plans to get married soon was very pleased, especially because it left no scar.

For cancers of the tongue, tonsils or epiglottis, traditional surgeries “involve major morbidity such as cutting open of the jaw and cosmetic disfigurement, all of which can be avoided in robotics”, she points out.

The ENT surgeon is able to take up cancer cases that are not in advanced stages, besides other procedures such as scarless thyroid surgery.

India currently has facilities to train general surgeons, urologists and gynaecologists. Nagpal, who got trained in South Korea, wishes for a training centre for ENT robotics, too.

“If you go to Korea or the US, you have to spend $3,000 for three days, and only for observation. India could be a hub of affordable training. We have already had international observers from Africa, Iraq, Dubai etc. who we haven’t even charged,” she adds.

 For the surgeons, the robotic experience is akin to playing a video game with a joystick — an analogy both Nagpal and Ramasamy prefer.

The 3D vision helps navigate better and direct the instrument specifically to the organ of concern, without disturbing any other part of the body. Another luxury is that the surgeon, seated in a console next to the patient and transmitting all movements through the robotic instrument, does not have to operate for hours.

“I can do five surgeries at a stretch and not get tired. The robotic system has a backrest and armrest, several foot pedals that I can operate (to start a surgery, for control of motion scaling and tremors), and buttons that I can push to zoom in or out. It can go to inaccessible areas, and you can rotate the arm 180 degrees whereas human arms have their own limitations,” explains Nagpal.

Robotic surgery came to India in 2006, when the All In­dia Institute of Medical Sciences got the first equipment. In the last three to four years, it has gained more prominence bec­ause of newer robotic systems and growing demand, as well as insurance reimbursements for robotic surgeries, says Vivek Bindal, member of Clinical Robotic Surgery Association (CRSA) India, and head of department, Max Institute of Minimal Access Bariatric and Robotic Surgery, New Delhi.

Bindal, who has been performing robotic surgeries for 11 years, says that training surgeons is a big gap that needs to be filled in India with demand expected to grow again after the lockdown months. CRSA’s India chapter, which was set up in 2019 and has a membership of around 200 surgeons, also conducts training sessions in medical institutes.

Urology, including treatm­ent of prostate and kidney cancers, is one of the principal areas catered to by robotics, followed by bariatric surgeries, complex hernias and gynaecological surgeries, Bindal says, adding that operations for head and neck cancers is an emerging area.

For patients, while there are obvious advantages such as less blood loss and pain, faster recovery and minimal scarring compared to open surgeries, costs remain high. According to doctors, patients have to spend an additional Rs 1 lakh to Rs 1.5 lakh as compared to open surgery, because of instrument costs.

At present, the da Vinci equipment, which is the world’s first FDA-approved robotic surgical procedure invented by US-based Intuitive Surgical, is used in India.

On Wednesday, Mumbai-based Kokilaben Dhirubhai Ambani Hospital announced the launch of its third da Vinci robotic surgical system, becoming the first in the country with three such equipment. Since June 2012, the hospital has completed over 4,500 robotic-assisted surgeries. It is also the first hospital in India to conduct over 2,600 robotic surgeries in uro-oncology.

While the da Vinci robot remains the go-to solution, Nagpal says the surgery costs could come down drastically once an indigenous robot becomes available to surgeons.