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Robotic Surgery in Gynecology

Where are we at and what is the future of this technological intervention?
Dr Rohit Ranade,Dr Abhirami GR

Robotic Surgery is the most advanced Minimally Invasive Surgery performed through small (finger size) incisions. There are various advantages of robotic surgery which include faster recovery and quick return to daily routine, less blood loss and less risk of infection, lesser pain and trauma, less blood loss and infection and better access enabling the surgeon to perform complex procedures.

Robotic-assisted surgery is being adopted across the globe. It has a long history in India and has built a strong foundation with immense potential. The first procedure performed with a robotic-assisted surgical system took place in India in 2002.

It is misunderstood as surgery done by a robot. But to be specific, robotic surgery is used to move the instruments while performing surgery. Instead of using the surgery instruments by hand, robotic arms are used which are controlled by efficient surgeons with the help of advanced computers. The movement of surgeons is translated to the robotic arms while observations are made through computer screens. Commonly it is also known as robotic-assisted or computer assisted surgery.

Women are typically put up with painful periods, heavy menstrual bleeding, fibroids, endometriosis, and other conditions for years. Robotic surgery can give these women more control by causing less trauma, hospitalization, and blood loss and improving cosmetics. Today no woman should be subjected to an open surgery and minimal access surgery should be available to all. In spite of minimal access surgery now being available in every hospital including in small towns, but still the skill and infrastructure required for performing complex gynaecology surgeries becomes difficult resulting in inability to provide women with minimal assess surgery.

Robotic assisted surgery can be done in most of the gynaecological condition including few cancerous conditions also. At present most studies do not give significant advantage over conventional laparoscopic surgery in benign gynaecological disease. However robotics do give an edge in more complex surgeries. The conversion rate to open surgery is lesser with robotic assistance when compared to laparoscopy.

The incidence of cancer is rising steadily globally as well as in our country. Cancer not only impacts the person's health but also has social psychological and economical implication. Management of cancer usually involves a multimodality treatment approach with site specific onco-surgery, systemic therapy including chemotherapy, immunotherapy, targeted therapy, hormonal therapy and radiation therapy to achieve the best results in terms of survival as well as quality of life.

Surgery plays an important role in the management of cancer. In early stages it defines the accurate stage of the disease based on which the decision of adjuvant treatment of either systemic therapy or radiation therapy or both is made. Cancer surgery is usually complex and performed caring for oncological principles and precision. Open surgery involves long incisions, Incision related morbidity and delayed recovery. Hence there has been a paradigm shift to robot assisted minimal access surgery in oncology. Robotics offers multiple advantages and has revolutionised the surgical approach in many complex oncological procedures.

In recent years robotic surgery has become a new standard of treatment for many cancers. Oncological outcomes of robotic surgery are similar to open surgery or improved in some with the significantly less perioperative morbidity has led to increased practice of robotic surgery in oncology. India appeared to be a significant destination for robotic surgeries among international patients owing to low cost and low waiting time as compared to other countries.

The practice of robotic surgery is on the rise with the increasing installation of operating robots across the institutions. Change is inevitable, and integrated digital technology and robotics in surgery is driving that change for the better. Technologies and solutions are being developed and used at key centres globally to help reduce the intra-surgeon variability through intelligent/adaptive training tools.

The main reason of non-acceptance of robotic assisted surgery is its cost. Owing to their effectiveness and efficiency, the cost of performing robotic surgeries is a bit higher than regular procedures. The high costs of purchase, disposable supply, and annual maintenance of surgical robots act as significant financial constraints for the adoption. Furthermore, the robot-assisted surgeries are not covered by the Indian medical insurance providers, which leads to mounting economic burden on patients.

We need to address the issues related to the acceptance of robotic assisted surgery. Awareness about robotic assisted surgery should be carried country wide. Availability of robotic assisted surgery at affordable cost should be created at various parts of the country.