Robotic Chest Surgery in India – The Journey so far & the way ahead


The word “Surgery” has traditionally been synonymous with big cuts, blood loss, postoperative pain, numerous postoperative complications including wound infection, several days in the hospital, long time to recovery, prolonged absence from work and in many cases, death also. While many of these were due to the procedure itself, a lot of these problems were due to “opening” made in the body in order to be able to do the surgery. This “opening” or “access” to the target area traditionally required long cuts to go inside, which involved cutting the skin, muscles (as in abdomen) or muscles and bone (as in chest). Traditionally, surgeons have preferred making “long incisions” for wide exposure and hence the saying, “Big Surgeons Make Big Incisions.” While this has been very comfortable for the surgeons, it inflicted lot of trauma on the patient. The patient does get cured of the disease, but the quality of life did not necessarily improve because of the trauma of access (big incisions). The development of technology in the field of surgical sciences has always been with two major aims: “Make it easy for the surgeon” & “Make it least invasive for patient.” This led to the concept of “minimal access surgery” where the “same surgery” can be done without the large cuts and its trauma. With these aims in mind, endoscopy (laparoscopy) came on the horizon.

Third Revolution in Surgery

Endoscopy is a method of “peeping” into a body cavity through a telescopic device. When a miniaturized camera is mounted on its eyepiece, the inside picture can be projected on a TV monitor. The availability of these devices in late 80s gave birth to “Minimal Access Surgery” wherein big incisions were replaced by small incisions with surgeon seeing directly at a much clearer and a magnified image of the target organ on a TV monitor. Instead of operating with hands, the same surgery is done by manipulating 5 to 10 mm size long instruments inserted through small incisions. While this meant total relearning of the procedure and extreme complexity for surgeons, this surgery was “kinder” for the patients as it drastically reduced the trauma of “access.” This translated into lesser blood loss, lesser postoperative pain, quicker recovery, reduced incidence of postoperative complications including wound infections, shorter hospital stay and much faster return to normal life. This minimal access approach has rightly been termed as the “Third Revolution in Surgery” (asepsis and anaesthesia being the first and second revolution) and has been applied to problems in abdomen as well as chest. The term “laparoscopy” is used for surgery in abdomen andthoracoscopy or VATS for surgery in the chest. While this worked extremely well for patients, it did create a new set of problems for the surgeons because of the surgery being done in a 2D environment with no depth perception. All the movements made by the surgeon using these long instruments became much more complex because they had to be performed in a counter-intuitive manner leading to significant stress to the surgeon. This is where Robotic surgery came into being with its 3D vision, which provides depth perception (even better than open surgery), intuitive movements of the instruments making suturing as easy as in open surgery. This gave the surgeon the ability to access the inaccessible areas and perform complex manoeuvres with specialized robotic instruments that are as versatile and dexterous as the human hand.

The Robotic Surgery Revolution

The Robotic surgery revolution started in early 2000s with the performance of robotic radical prostatectomy by Dr. Mani Menon in USA. Thereafter, Robotic surgery spread to other disciplines including Chest Surgery.

The First Application of Robotics in Chest Surgery

The first application of Robotics in Chest surgery was for excision of a small thymoma by Yoshino et al at Fukuoka, Japan in 2001. The same authors reported next year about Robotic excision of a posterior mediastinal tumour. The first Robotic lobectomy was reported by Morgan et al in 2003 and Bodner et al reported the first series of Robotic Chest surgery cases in 2004.

Thoracic Robotic Program in India

In India, the robotic system was initially used for cardiac surgery and thereafter for urology mainly. The “Thoracic Robotic Program” in India was started by our team at the All India Institute of Medical Sciences in the year 2008 under the mentorship of Prof. Jens C. Ruckert, when 8 consecutive thymectomies for myasthenia gravis with or without thymoma were performed. Thereafter, the program continued with over 60 such procedures being performed there till March 2012 when the team moved to Sir Ganga Ram Hospital, New Delhi. The next few months saw expansion of our robotic chest program and procedures like thymectomy for myasthenia gravis and/or thymoma, lobectomy for lung cancer, esophagectomy for esophageal cancer, excision of posterior mediastinal tumours and plication/mesh repair for diaphragmatic eventeration or hernia began to be performed routinely by our team. Another landmark during this period was the performance of “completely robotic aorto-bifemoral bypass for aorto-iliac atherosclerotic obstruction” by the joint effort of the Vascular Surgery & our Robotic Surgery team. We also developed a program of scarless thyroidectomy by trans-axillary robotic approach, which is a huge advantage for patients with thyroid enlargement who want to avoid a scar in the front of the neck. Continuing in our efforts to familiarize more and more chest surgeons in this cutting-edge technology, our group organised “Country’s First Live Robotic Chest Surgery workshop” with live transmission of robotic lobectomy for lung cancer by Prof. Robert J. Cerfolio from University of Birmingham, Alabama, USA on 12th February, 2014. It was attended by the Who’s Who of Thoracic Surgical Community of the country. It is a matter of pride for our Country that large volumes of above-mentioned robotic chest procedures are being performed routinely at Sir Ganga Ram Hospital, New Delhi, and also at some other centres in India.

Advantages of Robotic Chest Surgery

Surgeons using Robotic system in chest surgery have to address certain lingering issues in the mind of conventional surgeons doing either open or VATS chest surgery i.e. Robotic surgery oncologically adequate and is it really beneficial? There is no doubt in my mind that in properly selected patients and in expert hands, Robotic Chest Surgery offers a drastic advantage over open surgery. The difference when compared to VATS, as per currently available literature, is subtle at the best. But with improved magnified 3D vision, natural intuitive movements and far superior ergonomics, I strongly believe that any procedure possible by VATS can be done much better by the “Robotic assistance”. On a long treacherous road, a sports utility vehicle with 4 wheel drive and a plethora of safety features will definitely be more safe than a standard hatch-back. If you do believe in this, then you will have to believe that if cost factor is taken off, all VATS surgeons in due course of time will start using the Robot if and when they can.

Conclusion

Robotic chest surgery is here to stay and will see more and more applications at more and more centres in times to come.


Dr Arvind Kuamr


Comments for “Robotic Chest Surgery in India – The Journey so far & the way ahead”

  1. Reply

    Dear friend,
    Thanks for giving the information. I as alone anaesthesiologist in 2003-06 had a opportunity to be apart of the team in Antigua&Barbuda.I had been associated in VATS ,BARIATRIC & several minimal invasive surgical procedures.

    Thanks once again
    Dr Shankar Rao Burla

    Dr Shankar Rao Burla,
  2. Reply

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