A new era in the realm of healthcare has ushered with the integration of robotics in surgeries. With a plethora of advantages, robotics surgeries are benefiting patients and surgeons. Robotic surgeries have transformed patient outcomes to a completely next level. Quick recovery time, reduced hospital stays and less pain and blood loss are its benefits. Robotic-assisted surgeries (RAS), once initiated for urology, are being used across various specialities. Gastro-intestinal and oncological surgeries to bariatric, dental and ENT surgeries are seeing a new ray of light.
By Sonali Patranabish
The 21st century has seen several revolutionary advancements towards surgeries. It has been a significant milestone in the realm of healthcare. Emerging technologies like 3D visualisation, robotics and image-guided surgeries have improved patient outcomes. It is helping surgeons perform surgeries with precision and accuracy like never before.
Robotic instruments and devices are enhancing the capabilities of surgeons today. These are in the form of da Vinci and Intuitive surgical systems. Surgical robots are being used across a spectrum of surgeries. These range from orthopaedic, gynaecology, urology, rectal, colon, hair transplants, dental implants etc.
There has been a transient shift towards robotic-assisted surgeries. These technological advancements cannot refute the role of a surgeon. But they augment the capabilities of a surgeon, by outperforming the basic human performance levels.
Surgical techniques have seen a quantum leap. Laparoscopic surgeries to surgeries that use AI, guided imaging systems and real-time analysis are seeing a .
Hospitals have seen a rapid adoption and integration of surgical systems. It has led to an increased awareness of the advantages of this precise and accurate system. It has also led to the rising need for minimally invasive and complex procedures. And an increased uptake of private health insurance by patients, played a role.
Today India stands at close to 140 surgical units spread across the country. 60,000 robotic surgeries are being performed on an annual basis. This speaks volumes of the immense benefits of this surgical modality. It has been gaining traction both among patients and surgeons alike.
Imminent rise of robotic assisted surgeries (RAS)
Robotic surgeries have seen immense popularity due to the many benefits. Patients see this form of surgery as a better option. This is due to the faster recovery rate, lesser pain and lower blood loss. The realm of surgery in India has seen a paradigm shift. Robotic surgeries enabling surgeons perform complex surgeries with precision ensures better clinical outcomes.
Dr Jaydeep H Palep, Visiting Consultant General Surgery (Robotic Surgery), PD Hinduja Hospital & MRC, Mahim states that robotic technology is a beautiful amalgamation of AI and automation. It has lit up the surgeons’ operating room afire since the last decade, especially in India.
Dr Palep added, “Robotics is now an essential technology recognised by the central insurance regulatory body, IRDAI for various fields like urology, gynaecology, gastrointestinal surgery, thoracic surgery, head and neck surgery, orthopaedic surgery."
Dr Raghu Nagaraj, Director -Orthopedics, Sports medicine and Robotic Joint Replacement - Kauvery Hospitals, Marathahalli, states that the integration of robotics has completely revolutionised both OPD practice and the operation room set-up.
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India boasts 300 surgical robots. It has penetrated even tier II and III cities. Tier II cities in particular are offering world-class advanced surgical procedures to patients. A first in India, PSG hospitals in Coimbatore reached a remarkable milestone. It has completed 10 robotic surgeries in 24 hours.
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He goes on to say that the approach to surgeries has completely changed, robotics gives an in-depth insight and perception of patient problems, and the extent of damage, severity and depth of damage can be precisely assessed. He further adds that robotics has enabled precision and a methodical approach to hip and knee replacement surgeries.
“Even paediatric surgeries, such as pyeloplasty procedures, can be safely performed using robotic technology,” opines Prof Dr Raj Nagarkar, MD and Chief of Surgical Oncology and Robotic Services of HCG Manavata Cancer Centre (HCGMCC) and Hospitals.
Dr Nagarkar mentioned that orthopaedic surgeries such as joint replacements, as well as procedures like hiatus hernia repair and kidney stone removal make use of RAS.
Dr Palep states that even tertiary and quaternary healthcare providers across the country are now offering multi-speciality robotic surgeries.
India boasts 300 surgical robots. It has penetrated even tier II and III cities. Tier II cities in particular are offering world-class advanced surgical procedures to patients. A first in India, PSG hospitals in Coimbatore reached a remarkable milestone. It has completed 10 robotic surgeries in 24 hours.
The Fortis in Mohali used the da Vinci robotic system to remove kidney tumours. The procedure happened in a record time of 12 minutes which would have otherwise taken half an hour.
Manipal Hospital, Dhakuria in West Bengal conducted 39 advanced ROSA robotic-assisted knee replacement surgeries. It offered patients a less invasive, precision-focussed approach to joint replacement.
Da Vinci systems are becoming a commonality across hospitals at tier II cities. Maharashtra, Karnataka, Andhra Pradesh, Kerala and Telangana have seen an uptick in robotic surgeries.
Krishna Institute of Medical Sciences (KIMS) Hospitals signed an MoU with Intuitive Surgicals. The MoU established 25 robotic surgery programmes incorporating da Vinci systems in these states.
Robotic surgeries are assisting in gynaecology-related surgeries.
“Technological advancements are driving significant changes in the field of medicine, with robotic gynaecology surgery emerging as a true game-changer for women in India,” opines Dr Nageshwar Rao, CEO, Gleneagles Hospital Chennai.
Dr Padmapriya Vivek, Director, Obstetrics and Gynaecology, Gleneagles Hospital Chennai, states that women are becoming aware of their health. According to Dr Vivek, more than 200 women have undergone RAS for gynaecological issues in the last 18 months in the hospital. The hospital conducted hysterectomy, ovarian cystectomies and myomectomies, endometriosis and other complex surgeries using RAS. These surgeries would have otherwise been challenging using the traditional open surgery model.
Dr Ashwin Giridhar, Senior Consultant and Head, Urology, Renal Transplant and Uro-Oncology, Cytecare hospital, Bengaluru, cites a few examples of robotic-assisted partial nephrectomy and, robotic-assisted radical prostatectomy that is used to manage renal and prostate tumours have resulted in improved outcomes lower morbidity and reduced postoperative complications.
“With robotic assistance, techniques such as gap balancing, ligament balancing, and kinematic adjustments during knee joint replacements have become incredibly precise, leading to significantly faster patient recovery,” opines Dr Ritwik Ganguly, Consultant Orthopaedic Surgeon at Manipal Hospital, Dhakuria.
Dr Pradeep Rao - Director and senior consultant, Urology and Renal Transplant, Gleneagles Hospital, Parel, Mumbai adds a word on how robotic surgeries are empowering and enabling surgeons in operation theatres “Surgeons can use critical patient data directly in their field of vision, allowing for real-time visualisation during minimally invasive procedures."
Key drivers: Fuelling the fire
The scope of surgical approaches has seen tremendous growth in the last decade. India is quick to take the advantage of multifarious benefits of RAS. Studies claim that at least 30 per cent of surgeries in India fall under RAS. The demand for surgical robotic systems is at an all time high and the popularity speaks volume.
Growing economy:
The Indian economy touted as the world's 7th largest economy is primarily dominated by the healthcare market that is proving to be bullish due to the demand for quality healthcare services. One of the key drivers behind the dramatic rise of robotic surgeries has been the rising population and the growing incidence of lifestyle diseases.
Robotic Surgical Skill:
India has emerged as a hot hub for advanced robotic procedures.
According to Dr Giridhar, availability of advanced robotic systems and improved accessibility to cutting-edge technology followed by a shorter learning curve for surgeons, compared to traditional laparoscopic techniques, has driven the demand for these technologies.
He further adds that the skill set of surgeons in our country is continuously enhanced through training programmes and hands-on opportunities that give India an edge on the global platform.
da Vinci surgical training centres are helping budding robotic surgeons hone their skills. US-based Vattikuti Foundation, as part of Vatikutti Explorers programme, will hand-pick 20 medical students from India. The programme will help to nurture and provide hands-on training to students.
Intuitive has opened a global capacity centre in Bengaluru. The centre will serve as a platform to drive innovation in robotic-assisted surgeries. It will also train and upskill doctors in RAS.
AIIMS Delhi has entered into an MoU with Intuitive. It has set up a RAS training centre. It will equip surgeons with skills to perform complex surgeries.
Several workshops are being conducted to give surgeons an experiential opportunity. It is helping surgeons to understand the intricacies of robotic surgeries. One workshop was conducted by the Government Medical College and Hospital. The workshop showcased live surgeries that was telecast for health professionals and surgeons. It delved into the technicalities of RAS.
“Availability of advanced robotic systems and improved accessibility to cutting-edge technology followed by a shorter learning curve for surgeons, compared to traditional laparoscopic techniques, has driven the demand for these technologies.” Dr. Ashwin Giridhar, Senior Consultant and Head , Urology, Renal transplant and UroOncology, Cytecare hospital, Bengaluru.
Self reliance:
SS Innovations International has installed the Make-in-India robots. The robots were installed in several hospitals spread across 13 cities in the country. Several central government hospitals have also integrated the SSI surgical robotic systems. A first in Haryana, ESIC Medical College and Hospital, Faridabad.
“The introduction of pioneering systems like the Intuitive Da Vinci system over two decades ago, followed by newer technologies such as the Medtronic Hugo RAS system, SSI Mantra, and Versius CMR RAS, has created a diverse and competitive market,” opines Dr Giridhar.
Cost-effectiveness:
The cost-effectiveness of RAS in India makes it a prime destination for domestic as well as international patients. The cost of RAS in India is anywhere between $2000 and $15,000 as compared to the US. India comes as a lucrative option to opt for such advanced surgeries.
Competitive edge:
Robotic surgeries are still considered to be in their nascent stage in India. But several hospitals in India are tapping into the transformative potential of RAS. Kokilaben Dhirubhai Ambani Hospital, Apollo Hospitals, Fortis and Max Healthcare have all joined the bandwagon.
RAS is gaining popularity in India due to the reduced waiting time to avail robotic surgery in India. This is when compared to the US and Canada.
Mandeep Singh Kumar, VP, Intuitive India has stated that the pandemic has also given a major push to the RAS market in India.
Advancements in surgical techniques
India is witnessing a revolution in the domain of surgical techniques in the last decade. Advanced technologies and innovative approaches are enhancing surgical capabilities in India. From high-risk cases to invasive procedures, RAS are a go-to for surgeons and patients alike. India has come a long way since the first surgical robot. AIIMS Delhi has its own surgical robot in 2000.
Several domestic medical devices players are taking part in R&D to innovate surgical robots. It aims to improve patient outcomes.
Vapi, Gujarat-based Meril has introduced the state-of-the-art joint robotic surgery system CUVIS. This fully-automated joint surgery robot ensures flexibility and precision. It enables surgeons to get an in-depth insight into the patient's anatomy. It also gives the surgeon cues to pre-plan the incisions made by the robotic system.
The hand-held robot Handx developed by Meril also aids surgeons during laparoscopic surgeries. The device replicates the wrist movements of surgeons. It enables surgeons to manoeuvre during surgeries.
Meril has the following robots in the R&D stage. These are third-generation robots, bioinspired bots and fourth-generation MicroBot.
A complete spectrum of 3-dimensional images produced through MRI, computer tomography and ultrasound make preoperative and intraoperative navigation effortless for surgeons.
Raj Vatikutti, Founder, Vattikuti Foundation states that generative AI and other emerging technologies are going to further enhance RAS capabilities.
"Surgeons can now perform complex procedures with accuracy through 3D visualisation,” opines Dr Rao.
Dr Rao feels that artificial intelligence (AI) is set to revolutionise the field of robotics. He states that today's innovations like robotic wrists e with 360 degrees of movement improve in precision in minimal access surgery.
"Other innovations like 3D vision and 4k surgical systems offer an added layer of precision to robotic surgeries," opines Dr Giridhar.
While throwing more light on the innovations in RAS, Giridhar adds that the development of surgical 3D printing and intraoperative ultrasound imaging has allowed surgeons to make real-time decisions due to the detailed anatomical reconstructions.
Laparoscopic and endoscopic surgeries were one of the very first advancements in surgery. Over time, surgeons realised that natural abilities were getting more mechanised and automated. Surgeons were reliant on a video monitor to perform surgeries. Rather than following their senses of perception and intuition.
This drawback has been resolved with systems like 3D visualisation, teleoperation and computer-assisted imaging. Surgeons can even utilise the natural hand movements to manoeuvre during surgeries.
RAS is enhancing various branches of medicine. It enhances precision and accuracy.
Cardiovascular conditions like CAD are being managed by RAS.
Siemens Healthineers, a medical technology company, has devised COBOTS. The collaborative robots enhance outcomes of minimally invasive surgeries, especially for cardiovascular issues.
“In urology, the integration of advanced energy sources such as Holmium and Thulium lasers, along with tools like vessel sealers and advanced dissectors, have significantly improved surgical outcomes. These technologies reduce blood loss, minimise tissue damage, and promote quicker healing,” opines Dr Giridhar.
“Realigning leg after severe arthritis (post-traumatic, age-related, bone loss, severe alignment issues in the leg) can be addressed in a more precise manner due to RAS. Surgeons understand the degree of knee bending and angle of alignment of the leg, all this information is conveyed to the surgeon in real-time, which enables them to take better control of patient discomfort and recovery time." Dr Nagaraj.
Telesurgeries ensure the accessibility of robotic surgeries to underserved regions. The amalgamation of robotic surgery with advanced tele-communication technology have led to improved accessibility to quality surgical care irrespective of geographical barriers.
Rajiv Gandhi Cancer Institute & Research Centre conducted the first tele-surgery. It was conducted by using India's first surgical robot mantra. The surgery happened across a distance of 40 km for a case of urinary bladder cancer.
Challenges
Ethical concerns
Despite the immense benefits, ethical concerns around the safety and lack of human touch remains. Questions arise around accountability - in the event of a mistake during surgery.
Capacity building
Dr Rao feels that there’s an urgent need for ongoing education as technology is evolving. This is even for operational efficiency. Lack of technical know-how can hinder staff from maximising the potential benefits of robot-assisted surgeries.
Dr Giridhar states that skill development is a significant hurdle.
“It’s not just the surgeon who requires training, but the entire operating room team - nurses, technicians, and support staff -must also become proficient with the robotic systems, which takes time and dedicated effort. The learning curve can result in longer operating room durations initially, as the team adapts to the new technology,” opines Dr Giridhar.
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Despite the immense benefits, ethical concerns around the safety and lack of human touch remains. Questions arise around accountability - in the event of a mistake during surgery.
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Dependency on imported infrastructure
Dr Rao shares his opinion on how as a nation we are yet to become self-reliant w.r.t robotic technology manufacturing, “While the country has made strides in developing Indigenous robotic technologies, fostering innovations, and securing investment in the sector, it often relies on imported components and expertise to sustain its ambitions.”
“While many robotic surgical systems can be found in some urban hospitals, the country remains underdeveloped in this sector. The absence of local robots’ construction and overdependence on external sourcing for systems escalates the expenses, making such surgeries the reserve for a few individuals,” opines Dr Manisha Karmarkar, CEO, DPU Super Specialty Hospital, Pimpri, Pune.
Market monopoly
The robotic surgery market has been dominated by players like Intuitive Surgical. The da Vinci robotic surgical system costs around Rs 15 crores, while its maintenance goes up to as much as $100,000. This is a major factor impeding the further growth of robotic surgeries in India.
Financial burden:
“One of the primary obstacles is the high capital and maintenance costs associated with robotic systems. For many hospitals, especially smaller setups, the initial investment can be prohibitive, and the ongoing maintenance expenses can strain resources,” opines Dr Giridhar.
Nagaraj states that shield robots and bone robots come at a high cost. Investing in these robots is a challenge, as there is no data on the cost-benefit ratio.
The lack of volume in early adoption phases often makes it difficult to justify the costs. And the return on investment may take time.
Regulatory issues
Insurance companies consider robotic surgeries as luxury surgeries. Hence, the approval of insurance for such surgeries is being declined. Insurance companies need to look at RAS as tool to reduce
Reluctance and Resistance:
Dr Giridhar shares his opinion on the resistance displayed by surgeons in a forthright manner.
He states, "Some experienced laparoscopic surgeons may resist adopting robotics, perceiving it as unnecessary given their expertise. This reluctance, along with the need for specialised infrastructure and market-ready operating rooms, can further delay widespread integration.”
The future
The robotic surgery space in India is poised for significant growth in the coming future. Robots are enabling surgeons to think on their feet and make quick decisions. This especially holds where quick turnaround times have become the need of the hour. Next-generation robotic surgeries are set to mechanise a surgeon's skills and hand movements. Robotic surgeries are becoming a norm and a mainstay in mainstream surgical procedures. In the next few years, this market is bound to grow by several manifolds.
