Robots check into operating theatres, but they are not making the cut yet

This month, India is at the centre of two landmark developments that could address perhaps the biggest roadblocks in health care delivery today: cost, infrastructure and skilled manpower.

One is the invention of what is arguably the world’s cheapest ventilator. Diwakar Vaish, a 25-year-old robotics engineer in Delhi, claims to have invented a portable ventilator that neither requires oxygen supply nor a skilled technician to operate it. The device, co-developed by Deepak Agarwal, a neurosciences professor at the All India Institute of Medical Sciences (AIIMS), Delhi, is controlled by an Android app and uses a phone or a tablet display. Its models are priced between Rs 20,000 and Rs 70,000 — a fraction of the cost of medical-grade ventilators that start at Rs 300,000 — and are being pilot tested in AIIMS. “The AgVa ventilator uses Artificial Intelligence and machine learning to adapt to a patient’s breathing capability and is comparable to any medical-grade ventilator,” claims Vaish. He says his company has sold over 100 ventilators in a month and these are being tested by major hospital chains around the country.

The other big achievement is the world’s first in-human coronary intervention. Tejas Patel, chief interventional cardiologist at Apex Hospital in Ahmedabad, successfully conducted the surgery through telerobotics sitting kilometres away from the patient. Unlike the ventilator, the robotics system used in the surgery is a highly sophisticated and expensive machine, called CorPath, developed not in India but in the US by Corinder Vascular Robotics. Despite its origin and, therefore, the cost — priced around $65,000 or Rs 400 million — it opens up the possibility of a doctor being able to perform multiple life-saving surgeries sitting at one place. It is especially significant in a country like India where there’s not even 1 doctor for every 1,000 people (0.61) — much lower than the minimum standard prescribed by the World Health Organization.

These events are an indicator that technology — much like in any other industry — is leading the next paradigm shift in health care. And robotics is at the helm of that change. It’s pertinent, therefore, to reflect on where India stands at this juncture. 

According to Global Surgical Robotics Market — Analysis and Forecast, 2017-2025, a report by technology advisory BIS Research, the Indian robotics market is expected to grow from $64.9 million in 2016 to $349.3 million in 2025. Select multi-speciality hospitals in the country have invested in passive (computer-assisted navigation) and semi-active (robotic arm-assisted) systems. But more than the availability of technology and the cost incurred, it is the limited awareness and low adoption both among patients and surgeons that is impeding the growth of surgical robotics.

Blue Belt NAVIO Surgical System

The first published case of a computer-assisted total knee replacement surgery dates back to 1997. And yet, such orthopaedic surgeries have only picked up in India now. In comparison, around 30 per cent of such surgeries in Australia were computer-assisted in 2016, according to the Australian Orthopaedic Association National Joint Replacement Registry. No such formalised data is available for India.

Siddharth Shah, consultant orthopaedic and joint replacement surgeon who specialises in computer-assisted (passive) orthopaedic procedures at S L Raheja Fortis Hospital in Mumbai, says that despite the fact that computer-assisted surgeries are minimally invasive and offer better precision and navigation with 3D imaging, it’s a general perception among patients that an experienced surgeon does not require a machine. “Moreover, experienced surgeons who have spent 30-40 years in the profession have not been sensitised to such technology and are therefore reluctant to adopt it now,” he says.

Shah has taken hands-on training of robotic arm-assisted or semi-active systems designed for orthopaedic surgeries — including Mako by US-based Stryker and Blue Belt NAVIO Surgical System owned by British company Smith & Nephew. In such procedures, robotic arms that perform the surgery are guided by a surgeon operating them through a console. But Shah says that these robotic surgical systems for orthopaedics are rarely available in India and altogether absent in Mumbai. “There’s also a lack of scientific evidence proving that robotic-assisted (semi-active) systems give better results than computer navigation-based (passive) systems,” says Shah. Especially since a robotic system — priced between Rs 80 and Rs 120 million, depending on the brand — is considerably more expensive than a computer-assisted navigation system that costs between Rs 4 and Rs 8 million. Still, a few hospitals — such as the Lokmanya Hospital in Pune — offer robotic arm-assisted total knee replacement procedures.

AgVa Advanced ventilator

The use of robotic arm-assisted systems, however, is prevalent in thoracic (organs in the chest), ENT (ear, nose and throat) and head and neck surgeries. Kalpana Nagpal, senior consultant and robotic surgeon, Department of ENT and Head & Neck Surgery at Indraprastha Apollo Hospital in Delhi, has performed over 100 successful robotic surgeries, including for sleep apnea, parathyroid, vascular tumours and cancers. But it will still take at least five more years for robotic surgeries to become routine, she says.

The da Vinci Si Surgical System — developed by California-based Intuitive Surgical — that Nagpal uses at Apollo is one of the most sophisticated robotic systems available worldwide. It’s a machine with three robotic arms (including one for the camera) and costs around Rs 1.3 billion.

In many cases such as those of throat cancers, a traditional or endoscopic surgery cannot be performed without cutting through the jaw. Besides permanent dislocation of the jaw, it also causes severe blood loss. This also means a recovery time of weeks at the hospital and permanent scars. “Still, a lot of people in India do not even know that robotic surgery is even an option,” says Nagpal.

In another example, Nagpal says that most doctors don’t even attempt the traditional surgery of the parathyroid gland, because there is a high chance of the patient losing his or her voice. “But with robotics, physicians have 3D vision and 10x magnification, and there’s no chance of injury,” she says. The robotic arm, which is guided by the surgeon, navigates through the throat avoiding the need to make incisions. The duration of the surgery also comes down from four to five hours to one-and-a-half hours. 

Nagpal recently operated on a 16-year-old girl from Nepal for lingual thyroid (tumour at the base of the tongue) without a scar. The patient was discharged within four days. “Once the surgeon believes in the technology, it’s not difficult to convince the patients of its advantages,” she says.

Surgical robotics have obvious advantages. Minimal or no incisions, faster recovery and minimum blood loss. But for some, it could also be the only option.

Some 10 years ago, Mahavira Prasad, now 70, was operated for cancer in the base of his tongue on the right, which was followed by seven weeks of chemotherapy. The disease resurfaced and he was operated again for a tumour on the left of his tongue followed by more chemotherapy six years ago. “But a patient can’t be put on chemotherapy for the third time,” says Surender Dabas, director (Surgical Oncology) and chief of robotics surgery at BLK Super Specialty Hospital in Delhi. So when the tumour did not respond to radiation, in traditional practice, it was the end of the line for Prasad. Except this time, the tumour was removed using the robotic surgery, and the patient has been well for three years since.

“A traditional surgery would have meant cutting through his mandible, which is very morbid, and it could have failed badly,” says Dabas. The robotic arm can move in seven directions, which a surgeon’s wrist can’t. “But it’s not the robot performing the surgery as some people believe,” he adds. It’s the doctor guiding the robot.

With robotic surgery, while a patient’s chances of survival can improve drastically, the cost is not much of a barrier either. A robotic surgery — depending on the number of arms that will come into use — costs between Rs 40,000 and Rs 80,000 more than a traditional surgery in a private hospital and less in government ones. “In many cancer cases, robotic surgery also eliminates the need for chemotherapy,” says Shah. This, along with a shorter hospital stay, could actually make robotic surgery cheaper in some cases.

The next best thing in surgical robotics — currently available in South Korea and the US and expected to arrive in India by 2020 — is an advanced, single port unit da Vinci that will also communicate with the surgeon through haptic feedback (the sense of touch).

While adoption remains a big challenge, it’s clear that robots and AI-powered devices are quickly learning to size up a patient. But we are still far away from a future when these machines can work without human intervention.

For now, a helping hand is needed to get the job done.