Understanding Robotic Assisted Surgical Systems (RAS) in India

By Dr. Ritisha Nadia James

"A great surgeon is one who possesses courage and presence of mind, a hand free from perspiration, tremor less grip of sharp and good instruments and who carries his operations to the success and advantage of his patient who has entrusted his life to the surgeon". An idealism stated by Suśruta in Sushruta Samhita, has stood the test of time since 6th century BC till today, and is even truer with the advent of the robotic-assisted surgical tool.

Complex surgeries do come with their share of risks, mainly due to the inaccessibility of surgical sites with the manual use of the surgeon’s hand. Robotic-assisted surgeries (RAS) have been a boon in such cases because the robot tools are truly an extension of the surgeon’s hand and almost negate any human error. As a result of this precision, surgeons are encouraging the use of RAS because this in turn leads to faster healing time.

While statistics are lacking in India, a study done in the state of Michigan, showed a surge in robotic surgeries from 1.8% in 2012 to 15.1% in 2018 across all general surgeries. From the Surgical Robots Market Size, Share & Growth Report, 2030 - the global surgical robot market was valued at $5.4 Bn in 2020 and is expected to grow at a CAGR of 13.8% to reach $15 Bn in 2028. The market is dominated by North America (57%), Europe (20%), and Asia-Pacific (17%). India, Indonesia, China, and Thailand are the four fastest-growing surgical robot markets, with India being on top.

RAS being a fairly newer surgical concept, the need arose for the surgical techniques to be streamlined across countries; this led to the inception of the "Association of Robotic and Innovative Surgeons" (ARIS) in April 2022. The members of ARIS are leading RAS experts, and in collaboration with international surgeons, are setting the best practices, and providing continuing education to colleagues in any advances.

With the standardization of procedure, and fewer complications with RAS, this will be the surgery of choice in the future.

The popularity of robotic surgery

Speaking to Dr. Shafiq Ahmed, Director – Urology, Robotic Surgery & Renal Transplant, BLK MAX Hospital

"Robot-assisted surgery uses specialized technology that enhances the capabilities of surgeon's hands. It allows surgeons to perform procedures in hard-to-reach areas through small incisions. The robotic technology enables precise movements, and the enhanced magnification provides exactitude and perfection during difficult procedures. The robot can do this due to its 6 degrees of movement.

All states in India have a robotic centre, except for Jammu & Kashmir. The first robotic centre was established at AIIMS in 2007. Multiple centres across India provide training to surgeons, and all procedures are standardized as per protocols accepted worldwide.

In urology, the biggest advantage of a Robot is to operate on the prostate gland and recently we have been doing robotic-assisted kidney transplants in India.

Robotic surgeries are also more popular for reconstructive surgeries. For example – a female patient required to remove an enlarged thyroid gland would rather undergo a robotic surgery with a barely visible nick on the neck than have a long scar across the neck due to open surgery.

RAS is not cost-effective in developing countries due to the high expenses. Besides that, the instruments are not reusable. They are pre-programmed to be used for a specific number of times (usually 10). Since these robots are big ticket items, only large-scale multi-specialty hospitals can afford them, and allows all departments to use the robot to compensate the cost."

The BLK Max Urology department conducts about 20 robotic surgeries per month and overall, more than 100 surgeries a month across all departments.

The Cost Factor

Luckily, some Indian health insurance companies like Max Health, New India Assurance, Oriental Health, IFFCO, United India, Star Health, Reliance Health, Manipal Cigna, Bajaj Allianz, and HDFC Ergo, have started providing coverage for robotic-assisted surgeries.

Dr. Surinder Dabas, a leading oncology surgeon in India, and a member of ARIS, explains the benefit of robotic surgery in terms of oncological and functional outcomes.

"Oncological Outcome” means the cure rate; do you improve the cure rate with robotic surgery? If yes, then by how much? And the second aspect is, if you're not increasing the cure rate, how you can you improve the functions of a patient? Factors like faster recovery, reduced blood loss, early mobilization, early discharge, and early return to activities - all fall under functional outcomes.

For throat cancer, and other surgeries involving the head and neck, the cure rate is increased, and functional outcomes are also improved, like speech, swallowing, neck movements, and shoulder movements. Compared to surgery with chemotherapy plus radiation, robotic surgery is better in terms of both cure and functional outcomes.

For pelvic surgery, the pelvis is a deep and narrow structure; hence, laparoscopic surgery is difficult. Even in open surgery, it is a little difficult to handle the tissues. In contrast, the robotic arm can easily access the pelvic region and making the surgery easier. Pelvic surgeries include prostate, rectal, and gynaecological surgeries. The deep suturing is better with robotic instruments.

For kidney surgeries like partial nephrectomy, it is possible to only remove the tumor, and save the rest of the healthy kidney with the robot, unlike an open surgery.

The complication rate is less with robotic surgery; because it is 3 dimensional, 10 times magnified and the robotic instruments have an endo-wrist instrumentation that can move in around 7 degrees, or what we say is about 540 degrees. These 3 factors help the surgery to be more precise and more controlled so that you can handle the small tissues better. If the tissue handling is better, bleeding is less; if bleeding is less, that's why a recovery becomes faster.

In terms of cost, Max group of hospitals has fixed the cost of robotic surgeries between 1.5-2 lakhs. It cannot be more than 2 lakhs. Hospitals in the south, like Bengaluru, are charging less than 2 lakhs. So, it is not as expensive as people imagine it to be."

While robotic surgery does have many benefits, not every patient is fit to undergo a robotic surgery.

Dr. Shashikant Yegnaram, an anaesthetist practicing in the UK, states that it's sometimes not easy to access the patient due to the position of both the patient and the robot. Citing a small excerpt on Anaesthetic implications on Robotic surgery – "Successful and safe Anaesthesia for these patients requires meticulous attention to patient positioning and effects of pneumoperitoneum on patient's physiology. Often patients need a steep head down position anywhere between 25-35 degrees.

First of all, patient selection is important. Not all are suitable for robotic surgery. Any patient with severe cardio-respiratory disease should be considered for standard open surgery or alternative surgical methods. This patient positioning for prolonged periods is associated with increased intraocular and intracranial pressure, hence may not be suitable for patients with glaucoma and central nervous system pathology.

During the surgery, once the patient is positioned, pneumoperitoneum is ensued, and the arms of the da Vinci robot are docked, the anaesthetist ensures that the patient is adequately anaesthetised and paralysed. Any movement at this point can be dangerous. There are also multiple changes to patient physiology intra-operatively, particularly cardiovascular and respiratory systems, which can lead to haemodynamic instability, hypoxemia, and airway oedema. Hence careful fluid management is

necessary. Intraoperative blood loss is usually low in robotic surgeries and postoperative complications are not common.

Lastly, It is really important to have effective closed loop communication amongst all the team members for a successful robotic-assisted surgery."

As in every planned surgical procedure, all pros and cons need to be weighed.

Latest Innovation

In recent news, India has its very own 'Made in India' robotic surgical system. In January 2021, The SSI mantra was launched, which was spearheaded by Dr. Sudhir Srivastava who is a cardiac surgeon based in the US. The system was developed at a government-sponsored Atal Incubation Unit in Andhra Pradesh. The first machine has been installed at Rajiv Gandhi Cancer Institute and Research Centre (RGCI) in New Delhi, and three more machines have been installed at hospitals in Hyderabad and Raipur.

The SSI mantra costs about 5 crores, including maintenance costs, in contrast to the da Vinci robot costing about 15 crores. The maintenance of the da Vinci machine is a separate 1 crore.

Despite the cost of SSI Mantra being so low, it has shown its expertise in the surgeries conducted. Within 6 months of its launch in the market, the SSI completed 100 successful surgeries.

Upon this achievement, a statement was released by Dr. Sudhir Srivastava, Founder, Chairman, and CEO, of SS Innovations, popularly known as The Robo Doctor, "Achieving 100 successful surgeries by SSI Mantra is satisfying both emotionally and professionally for me as it marks a significant milestone in India's quest to redefine the surgical landscape of the country. SSI Mantra costing just one-third of its global competitors has significantly brought down the cost of surgeries making it much more affordable. India can now look forward to high-end medical care and surgeries without having to worry much about the cost factor. It is a reinforcement of our belief in the system, and we are greatly thankful to the medical fraternity for putting confidence in our system and our abilities to provide a surgical option that is at par with its global counterparts."