Robotic Surgery

It is not robotic; it is robot assisted surgery

Recently I came across a patient who asked me not to do robot assisted surgery for his prostate gland removal due to prostate cancer! I was surprised to know that his notion was beyond the question of affordability, which usually is the scenario when it comes to having robot assisted surgery. This gentleman’s perspective baffled me! It was an absolutely misconceived opinion, which he had formed.. His understanding was that robot assisted surgery is done by a robot and he could not risk his life to a machine!
So it is not the robot, which does surgery, but it is still surgeon behind the machine, who does the work with the help of robotic arms carrying the instruments. It is a common adage in surgical literature that robot does not make a bad surgeon do one particular surgery with a better outcome. Therefore the correct phrase used should be robot assisted surgery not the robotic surgery!

In evolution of surgery as a specialty, transformation of concept i.e. "big surgeons make big incision" to "big surgeons make smaller incision" was a very significant step forward. Laparoscopic surgery is a form of minimally invasive surgery where in multiple holes are made strategically to enter the site of proposed surgery and desired goal is achieved by following the same surgical steps as done in open surgery.

Minimally invasive surgery as name suggest is aimed at causing less surgical trauma to the patient undergoing a major surgery, which eventually spring back patient to life soon. Therefore the purported perception about minimally invasive surgery, that it is only cosmetically better surgery is ill fated. The da Vinci System enables surgeons to perform even the most complex and delicate procedures through very small incisions with unmatched precision, significantly less pain, less blood loss, shorter recovery time, faster return to normal daily activities and in some situations, better clinical outcomes.

Despite advantages of minimal invasion, laparoscopic surgery has limitations of lack of 3- dimensional vision and limited movement of surgical instruments. Instruments used in laparoscopic surgery are rigid like a rod and devoid of movements like surgeon’s hand.
These advantages result in better precision and accuracy of the dissection and reconstruction of deep-seated organ in the pelvis like prostate gland. Robot assisted surgery has been useful in few of the indications across Urology, Cardiac, Thoracic, Gyene, ENT, Colorectal, Pediatric and General surgical disciplines.

The first robotic radical prostatectomy in India was performed in A.I.I.M.S, New Delhi in July 2006. Since then there has been 80 installations in India and about 11 in NCR region only. Most of the high-end work in urology surgery is being done by robot assistance. The most commonly performed surgeries by robot assistance are, radical prostatectomy for prostate cancer, radical cystectomy for bladder cancer (in some patients) , partial nephrectomy for renal cell cancer, reconstructive surgery for defects in kidney and ureters etc. Robot gives a definite advantage in obese patients of maneuverability.

Robotic Surgical System:

The current equipment is known as “da Vinci Xi model” which is manufactured by Intuitive surgical, California USA. There are four main components to da Vinci: the surgeon console, patient-side cart, Endo Wrist Instruments, and Vision System with high resolution 3D Endoscope and Image Processing Equipment. The surgeon sits at the console several feet away from the operating table, where he gets a magnified three- dimensional view of the surgical field with a real-time progression of the instruments. The latest version of the system has 4 arms, which are much sleeker and have wider range of motion.

The Intuitive Masters technology also has the ability to filter out hand tremors and control movements. The endoscope is programmed to regulate the temperature of the endoscope tip automatically to prevent fogging during the operation. Unlike The Navigator Control, it also enables surgeon to quickly switch views through the use of a simple foot pedal.

Epilogue

The da Vinci Surgical System provides surgeons with an alternative to both traditional open surgery and laparoscopy, a platform to use instruments like his hands. But we must not forget that the robot is there to facilitate the surgeon and it may not reduce the inherent potential complications associated with any surgery, anesthesia and equipment failure. Apart from the cost, another disadvantage, which is being looked in to is the lack of touch sensation; termed as tactile feedback. This loss of touch sensation could be overcome by magnification and 3D vision and of course by the expertise of a surgeon.
William Gibson, the famous cyberpunk science fiction writer once said that "The future is already here - it's just not very evenly distributed". The same is true for robot assisted surgery. The criticism against it is that, when in India most of our patients are deprived of access to basic health facility, should we acquire such an expensive technology at larger scale! I think change is the only constant and as in space technology, where we have become self sufficient, we could work towards providing what is best for health of our citizen by producing indigenous technology to gain the same results.