Surgical Robotics in India Grows but Could Use Help

The impact of surgical robotics in India is increasing as the number of facilities performing robotic surgeries continues to grow.

The first robot-assisted surgical procedure in India took place at a Delhi hospital in 2002. It used a da Vinci surgical system from Sunnyvale, Calif.-based Intuitive Surgical Inc.

Today, the technology is used in both government and private hospitals, with an estimated 120 surgeons performing a wide range of robotic surgeries, according to the Vattikuti Foundation. The Southfield, Mich.-based nonprofit was founded in 1997 to serve health care causes in India and other parts of the world.

The foundation plans to help increase the number of surgeons trained to use robotics to 300 by 2020. When the foundation started its work in India in 2009, there were only five or six surgeons trained to carry out robotic surgeries in the country.

In 2015, approximately 190 surgeons in India performing more than 4,000 robot-aided procedures in the areas of cardiac, urology, thoracic, gynecology, head and neck, vascular, pediatric, bariatric (weight loss), and general surgery.

Surgical robotics offers clear benefits

“Robotic surgery assures a healthier post-operative life, causing minimal loss of blood, quicker healing of wounds, and shorter hospital stays for those suffering from life-threatening conditions in digestive, respiratory, urinary, reproductive, and other vital body systems,” observed Mahendra Bhandari, a kidney transplant surgeon and the director of robotic surgery research and education at Henry Ford Hospital in Detroit.

Surgical patients, like their counterparts worldwide, can expect to receive an array of benefits from surgical robotics in India. They include reduced pain and discomfort, a faster recovery time/return to normal activities, and minimal scarring. Smaller incisions also reduce the risk of infection.

During surgery, the surgeon sits at a console several feet away from the patient. Looking through a powerful lens, the surgeon has a view of the surgical site that is 10 times more powerful than the human eye, and it includes high-definition images and 3-D capabilities. In fact, the visual is so clear, the surgeon can see the weave of the suture thread. Operating through tiny incisions, the surgeon can control the system’s robotic arms with a high degree of precision and steadiness. The arms can make finer movements than a human arm and reach areas of the body that no human hand can access.

Deployments expand …

As of this year, approximately 30 Indian health facilities are performing high-end robotic surgeries. Of these facilities, 12 are in northern India, including AIIMS, Apollo, Max Hospital, Rajiv Gandhi Cancer Institute, Sir Ganga Ram Hospital, Fortis, and Medanta.

Eight hospitals using surgical robotics are in western India, including Jaslok Hospital, Kokilaben Dhirubhai Ambani Hospital, Sir HN Reliance Foundation Hospital, and Tata Memorial Hospital.

The Krishna Institute of Medical Sciences (KIMS) in Hyderabad. Photo Credit: KIMS

Seven are in southern India, including Apollo Hospital — in Chennai and Hyderabad– the Krishna Institute of Medical Sciences (KIMS), the Amrita Institute of Medical Sciences, and Aster Medicity, Kochi. One surgical robotics user, Apollo Gleneagles Hospital, is in Kolkata.

Yet while the number of Indian health facilities offering robotic surgical procedures has grown impressively over the past several years, numerous challenges remain. Physicians and clinicians need to be more aware of the technology, training needs to be more accessible, and costs are still high.

“Robotic surgeries are a new concept in India, and not all departments across hospitals are using this effectively,” said G. Suresh Kumar, a gastrointestinal surgeon at the Hyderabad-based Krishna Institute of Medical Sciences (KIMS). “Many times, it has been noted that even the doctors treating patients for critical conditions are not aware of benefits of robotic surgeries in certain fields or its availability in India.”

Kumar added that it is “unfortunate that the patients are not aware of the availability of robotic surgeries in certain specializations like ENT [ear, nose, and throat] because very few hospitals in the country offer these services.”

Qualifying surgeons for use on robotic surgery remains a major roadblock to adoption. According to Kumar, surgeons require specialized training and certification from Intuitive Surgical. For surgeons based in India, these services that aren’t particularly easy to obtain–or affordable.

Bangalore-based Vattikuti Technologies Pvt. Ltd. is the sole distributor of da Vinci systems in India. At the present time, Intuitive has no plan to directly sell its technology to hospitals in India.

… But costs hold back surgical robotics in India

Overall system cost is another major reason why robotic surgery in India has not progressed at a faster rate. According to P.N. Dogra, head of the Department of Urology at the New Delhi-based All India Institute of Medical Sciences (AIIMS), a basic da Vinci system currently sells for about $1.2 million.

A complete da Vinci surgical robotics system. Photo credit: Intuitive Surgical

Meanwhile, a high-end da Vinci SI costs approximately $1.75 million. Dogra noted that the robot’s base price, along with annual maintenance and disposable supply costs — about $1,500 per procedure — place the technology beyond the reach of many Indian health care systems.

The only way of addressing the cost problem and making robotic surgery financially feasible for use in India is to drive robotic systems to their fullest potential, said Dogra.

“The maintenance costs remain the same whether one case or six cases are done in a day,” he said. “So it is logical that if more cases were generated out of a robotic system, the cost per case would automatically decrease.”

Government support is also necessary to distribute robotic surgical technology to qualified institutions so that it can become available to patients at an affordable, subsidized rate.

“The media also has an important role to play in spreading awareness among the public about this new technology,” Dogra noted. “Similarly, the primary care physicians need to be made aware so that they can refer the cases to the robotic centers.”

How to harness homegrown talent?

Another approach to cutting costs is encouraging Indian companies to develop their own surgical robots. Developing a system as sophisticated as the da Vinci would be a Herculean task for the typical small and underfunded Indian robotics developer.

However, the department of biomedical engineering at the Indian Institute of Technology has “made some headway in the goal of developing our very own Indian prototype,” Dogra said.

A lack of robotic surgery fellowships is also hindering surgical robot research in India, according to Dogra. Since robotic technology has not entered the mainstream healthcare infrastructure, there is a lack of access to the technology and a deficit in educational opportunities.

As things currently stand, young Indian physicians hoping to specialize in robotic surgery must travel abroad to become trained in the technology’s practices and nuances.

“How many of these surgeons do actually come back [home] after their training?” Dogra asked. “Robotic surgery fellowships are the need of the hour at present if we wish to take robotic surgery to the next level in India.”

Another concern is the lack of evidence-based evaluation of robotic surgery outcomes from the high-volume Indian medical facilities. “Critical evaluation of our results is necessary to understand our shortcomings and help in progress,” Dogra said.

Yet he is generally optimistic about the future of Indian surgical robotics. Dogra pointed to recent developments, including multi-image stereo viewers, the incorporation of haptic feedback, and miniature surgical robots, as signs that the field is advancing rapidly.

“India now stands at the cusp of a robotic revolution,” Dogra stated. “Robotic surgery in India is here to stay, and it is up to us as minimally invasive surgeons across different specialties to lead the way and make maximum use of robotic surgery.”

Spreading the word about surgical robotics in India

A final, yet important step toward greater use of surgical robotics in India is convincing skeptical patients and their families that the service is a proven technology and that robotic-assisted surgery outcomes typically equal or exceed the results of traditional surgeries.

To commemorate the completion of its 600th surgery using the da Vinci system, KIMS earlier this year established a robotic counseling center in its hospital to encourage patients to opt for robotic surgeries for treating serious and life-threatening diseases such as cancers and other chronic ailments.

While inaugurating the robotic counseling center, B. Bhaskar Rao, the hospital’s CEO, said that the KIMS facility will serve as a platform to educate patients and their families on the advantages of robotic surgeries, enabling them to make informed decisions.

“With the setting up of this counseling center, we want to bridge the gap of understanding of advanced technology to the common man,” he said. “This will not just help improve the quality and efficiency in medical standards, but also help in evolving newer treatment procedures using the advanced technology in the coming days.”