Topic: Robotic surgery: From Skepticism to standard of care

Speaker: Dr JS Rajkumar, Chairman & Chief Surgeon, Lifeline Hospitals, Chennai

29th January, 2023, Saturday

9.30-10.30 am

• Robotic surgery, when it first burst upon the scene, was regarded with skepticism. Initially it was economically driven. But now it has become the standard of care in many areas. 
• The surgeon utilizes the mechanical robotic arm bearing surgical instruments and a camera to enter the surgical field and uses the computer to be able to high precision surgery and avoid the need for large incisions. Surgeons have the master control to manipulate the instruments and the instruments translate the movement of surgeons into precise movements inside the body. It makes use of a unique set of circuits called master slave circuit. All robots are color coded.
• Robotic surgery is not new; it is nearly five decades old. The first robotic surgery was done in 1985 to obtain brain biopsy. In 2019, around 6 million surgeries have been performed globally.
• The types of robotic surgery systems include the Zeus (the first robotic system), intuitive surgical (da Vinci, which replaced the Zeus system), CMR (earlier called Cambridge Medical Robotics) and the Hugo systems. 
• In June 1997, the da Vinci surgical system became the first assisting surgical robot to get FDA approval. On October 9, 2001, the Zeus robotic surgical system from Computer Motion received regulatory clearance. 
• On September 7, 2001, Zeus was the first commercially available surgical robot to complete a trans-Atlantic surgery when a doctor in New York removed the diseases gallbladder of a 68-year-old patient in Strasbourg, France. It is also known as the “Lindbergh” operation. 
• In laparoscopic surgery, the movements are counterintuitive; with robotics, the movements are intuitive. 
• Robotics improves hand movements and facility of hand gestures tremendously. 
• Robotic surgery is going to become feasible in a few years from now and not take decades. Surgery will become geography agnostic and this will happen in the next few years itself.
• Robots have been used in eye surgery, minimally invasive surgery, micro surgery and also as scope holder in minimally invasive surgery.
• The first prototype of the Da Vinci robot developed by Intuitive was Lenny (abbreviated from Leonardo). Then came Mona (named after Leonardo da Vinci’s Mona Lisa), which in 1997 was the first robotic surgical system to move to human trials. The Vattikuti Institute of Detroit, Michigan was the first to document the process for robotic prostatectomy, which today has become the standard of care for carcinoma prostate.
• CMR is the least expensive robot. The robot from CMR is called Versius. It has been used across the UK, France and India over the past year. 
• Robotics has made a huge difference in urology and also general surgery. Now robotic assisted partial nephrectomy can be done for carcinoma kidney. The entire kidney need not be removed. Now nephron-sparing robotic radical surgery for carcinoma kidney is feasible. Other operations that can be done with robotic assistance are cholecystectomy, Nissen fundoplication, esophagectomy, radical hysterectomy. 
• Robotics is soon going to become a useful adjunct to surgery in general surgery, gyne and urology. Orthopedics is increasingly utilizing robotic help.
• So far robotic surgery has found no application in nasal and ear surgery. 
• Robotics is not the greatest thing to happen in cardiac bypass surgery; less than 2-3% cardiothoracic surgeons are using robotic surgery. But it is the greatest thing to happen for radical prostatectomy, radical hysterectomy and radical colorectal surgery. Most radical prostatectomies are being done robotically.
• It can also be done for other surgeries like modified neck dissection, robotic thoracoscopic surgery. 
• Advantages of robotics include far superior precision, depth perception, 3D vision, less bleeding, less pain vs lap surgery leading to much smoother recovery process. 
• Onco surgery and lymph node dissection are much better with robotic surgery.
• The more complex the surgery, the more the role of robotics.
• The disadvantages are the high cost, though the cost has come down tremendously over the last two decades. It takes time to dock a robot (to get it started), this prevents its use for emergency surgery. But this is a system that is work in progress.
• The learning curve for laparoscopic surgery from open surgery is very steep. The jump from open surgery to robotic surgery is very smooth. Laparoscopic surgery has bimodal learning curve for simple and complex surgeries. For robotics, the learning curve is flatter for simple and complex surgeries.
• Covid-19 had a huge impact on bariatric surgery in India. 
• Future of robotic surgery includes better energy devices, staplers, haptic feedback and nanorobots. 
• Nanorobots can be used in surgery, diagnosis and testing, gene therapy, cancer detection and treatment.
• Now people are working with artificial intelligence to work on human cells and make them function like robots “xenobots”.
• The possibilities are numerous. There are biologically inspired nanobots (planar flexible tail nanobots, helical rigid tail nanobots and cilia tail nanobots) and non-biologically inspired nanobots (magnetic nanobots, light/temperature/chemical sensitive nanobots).
• Light/laser, ultrasound or magnet can be used to guide the robots (external stimuli based propulsion). There are bio-hybrid carrier propulsion solutions (mammalian cell based and microbe based) and internal or self-propulsion (lipoprotein, protein/genetic, chemical/signaling factor).
• One advantage of robotic surgery is that the nerves and blood vessels will not be damaged.

Participants

Member National Medical Associations

Dr Wasiq Qazi, Pakistan, President CMAAO

Dr Yeh Woei Chong, Singapore, Chair of Council CMAAO

Dr Kar Chai Koh, Malaysia, Vice Chair of Counsel, CMAAO

Dr Marthanda Pillai, India, Advisor CMAAO

Dr Ravi Naidu, Malaysia

Dr Prakash Budhathoki, Nepal

Dr Akhtar Hussain, South Africa

Prof Ashraf Nizami, Pakistan

Dr Qaiser Sajjad, Pakistan

Dr Mulazim Hussain Bukhari, Pakistan

Invitees

Dr Monica Vasudev, USA

Dr Arun Jamkar, India

Dr Jan Muhammed Agha, Pakistan

Dr Neeraj Gupta

Dr Long Tuan

Dr S Sharma, Editor IJCP Group

Moderator

Mr Saurabh Aggarwal