COVID-19 pandemic has put India’s health care system to test and caused significant pressure on the frontline workers. While the healthcare sector is trying its best to cope with the situation, there are several patients who are at the receiving end. This intensity of the situation can be gauged by the fact that a recent study conducted by an international consortium found that more than 5,80,000 planned surgeries in India are scheduled to be canceled or delayed.
In a situation like this most surgeons and hospitals are leaning towards minimally invasive robotic-assisted surgeries as it has proved to provide successful clinical outcomes during COVID-19. According to many surgeons, robotic-assisted surgery (RAS) can provide them with the ability to perform many types of complex surgical procedures with precision and flexibility. Owing to the many benefits it offers over traditional open surgery and laparoscopic surgery, robotic-assisted surgeries is considered to be the most viable option for surgeries during COVID -19 and beyond.
Dr. Somashekhar, Chairman and HOD, Surgical Oncology, Manipal Hospital, Bangalore Chairman and HOD, Surgical Oncology, Manipal Hospital, Bangalore spoke to HealthWire in length about how this procedure is going to be the new normal surgical procedure during and beyond COVID.
What is robotic-assisted surgery (RAS) and how crucial it could be when it comes to conducting surgery in the coming days?
Since the first phase of lockdown in April, hospital services for non Covid patients have been disrupted causing a significant strain on the Indian health care system. Studies suggest that nearly 5.8 lac surgeries were delayed due to the nation- wide lockdown since April. Elective surgeries can be conducted by either open, laparoscopy or robotic surgery. With new advancements in technology, the Indian health care system is equipped with a minimally invasive procedure such as robotics as an alternative to open and laparoscopic surgeries. Today, many complex surgeries can be conducted successfully with the help of robots. The surgeon community has embraced robotics in the field of surgery and have found several reasons to shift from traditional to robotic assisted surgeries.
It is important to analyse why hospitals and surgeons put elective surgeries at hold during the lockdown. Conducting an open surgery requires a large team of medical staff and the usage of several instruments. These procedures involve invasive cutting of the organ leading to pain, scarring, excessive blood loss and post – surgery infections. Also, the medical staff present in the OR has to be in close contact with the patient while performing the surgery. Such surgeries were possible in a Covid free world, but with the ongoing pandemic such surgeries pose a huge risk to both the patient and the medical staff present in the OR. While the best decision to curb the spread of coronavirus at hospitals was to stop elective procedures, an extended lockdown meant accumulation of patients awaiting immediate treatment and surgery. Also, as there were no uniform guidelines in place for hospitals to follow, many hospitals were apprehensive of restarting such procedures. There was also a growing fear amongst patients with respect to the pandemic. They feared contracting the virus whilst getting treatment.
RAS on the other hand is being preferred by surgeons during Covid as it requires less operating time, shorter hospital stays and faster recoveries leading to early discharge of patients. Also, transmission of infection rates is fewer compared to laparoscopy or open surgeries. The more contact a surgeon has with the patient, the more there are risks of transmitting infections. In case of robotic surgery there is no direct contact of the surgeon with the patient thus protecting both in the OR. Owing to all the benefits it offers, RAS is proving to be a safer way of conducting surgeries going forward. Essentially placing a computer between the doctor and the patient, this cutting- edge technology comes with advanced features like 3D visualisation and robotic precision that aids surgeons to see the target anatomy with an increased magnification thus allowing them to complete intricate surgeries with much ease.
What are the benefits of robotic-assisted surgery?
Robotic assisted surgery has proved to be beneficial in many complex cases, where a minimally invasive approach is required, providing exceptional functional outcomes to the patient. The procedure has several short- term benefits that it offers to the patient. It requires smaller and fewer incisions which cause less pain, less tissue damage, reduced risk of infection, reduced dependence on medicines and an early rehabilitation to life post- surgery.
Robotic-assisted surgery also benefits surgeons by allowing them to perform minimally invasive surgical procedures with utmost precision. The procedure is a remarkable improvement over traditional methods of surgery where the surgeon has to operate for long hours and has problems manoeuvring instruments in constricted spaces of the anatomy. In the case of traditional procedures, the surgeon must look up and away from the instruments to a 2D monitor to see an image of the target anatomy. But in the case of robotics, the surgeons are equipped with advanced technology enabling them to view the anatomy in 3D, thus making it possible for them to perform minimally invasive procedures with enhanced precision and dexterity. Also, as the procedure requires shorter hospital stays, patients get discharged in 24-48 hours allowing the hospital to accommodate and treat more patients thereby reducing the backlog of patients awaiting surgeries.
How RAS is proving to be a socially distant surgery in times of COVID?
Robotic assisted surgeries has definitely become a new normal way of performing surgeries as the procedure has several benefits over conventional methods of surgery, especially during the pandemic. RAS is being preferred over open surgery as the procedure allows surgeons to perform a minimally invasive procedure successfully without coming into contact with the patient in the OR. Open surgery requires nearly 3-4 surgeons to operate simultaneously on the patient, whereas RAS requires only one surgeon that operates on the patient using a robotic console. This console can be placed as far as possible from the patient ensuring safety to both the surgeon and patient. Another reason why RAS is better than the conventional method is because RAS requires very few instruments during surgery whereas in an open surgery nearly 400 instruments have to be used to conduct a single surgery. This solves the problem of sanitization after surgery as a smaller number of instruments have to be sanitized.
What are the guidelines and protocols for patients and surgeons if someone wants to undergo RAS?
Initially there were no guidelines from the Government as to whether non-Covid surgeries should be continued. The hospitals were worried of conducting cancer surgeries amidst the ongoing pandemic. Also, several cancer patients were getting affected as hospitals put elective surgeries at hold.
With the onset of the pandemic we at Manipal Hospitals decided that minimal invasive surgery should be the way forward. It took us roughly 3-4 weeks to overcome these challenges. I have been instrumental in forming guidelines for the medical fraternity in India. I have a white paper published in the Indian Journal of Surgical Oncology. The paper discusses the precautionary measures a hospital must keep in mind while conducting RAS. We follow the same guidelines in our hospital. Seeing the success rate of the guideline system in place, the National Associations and Body of Minimal Access Surgery, Surgical Oncology, and Association of Surgeons of India approached me to contribute my expertise to publish another paper. Each hospital in India follows the same protocols and guidelines as mentioned in the published paper.
We have prepared a Covid task force team which triages patients and segregates them into different wards. We have separate guidelines for the hospital, patients and for the procedure itself. The precautionary measures for a patient involve them filling a questionnaire where they are asked several questions in order to understand if they come from a Covid hotspot or not. We follow the same question pattern as issued by the Government of India. Each cancer patient requiring RAS has to undergo a RTPCR test, and patients coming from a Covid hotspot have to undergo an antibody test. Also, each patient is assigned one hospital attendant that takes care of them throughout the surgery. Once the patient gets admitted, no visitors are allowed in the hospital.
To ensure maximum safety during the surgery, the entire medical team equips themselves with PPE and N95 masks. We also follow a strict guideline called the rule of 20 which means 20 cycles of air circulation in the OR. After every 20 minutes of intubation and extubation, no medical staff is allowed in the OR apart from the anaesthetist. After 20 minutes, we clean the OR with sodium hypochlorite. Robotic assisted surgery allows us to keep minimum staff during the surgery.
We segregate patients into different wards based on their symptoms- Covid susceptible, High Covid, Covid negative. The hospital ensures that the guidelines are followed by all. Following such guidelines has allowed us to complete several robotic-assisted surgeries with safety during the lockdown. I have performed about 368 robotic surgeries and in the last 5 months and all 368 surgeries have been successful.
