Interviews

Robotic-Assisted Surgery Has a Bright Future in India

Robotic-assisted surgeries have been there for quite some time. In recent times however, with a growing emphasis on improving the quality of care and with AI making inroads into the medical domain, there is a greater demand for robotic assisted surgeries. The use of robots in the surgical procedure not only enables surgeons perform complex tasks that can be difficult with other methods but also makes the operation more efficient, faster and in the long run cost  effective.

US-based Intuitive Inc., the maker of the popular da Vinci surgical system, and other robotic-assisted tools and technologies for surgery, is seeing a steady rise of robotic assisted surgeries in recent months, especially in the wake of the pandemic. The da Vinci system, which was the first FDA approved system to conduct robotic assisted surgery, has improved the lives of millions worldwide, with outcomes ranging from reduced bleeding, trauma and hospital stays.

In 2018, Intuitive established a direct presence in India although the da Vinci was used for India’s first robotic assisted surgery and treatment since 2002. In a recent interaction with CXOToday, Mandeep Singh Kumar, Vice President and General Manager at Intuitive India, explains how COVID-19 impacted the robotic-assisted surgery landscape, the current challenges and what the future holds.

How has COVID-19 impacted the robotic-assisted surgery landscape?  

COVID-19 has presented some new challenges for surgeons, hospitals, and patients, as healthcare systems around the world adapted and directed resources to respond to and manage the pandemic. Some hospitals and healthcare systems even stalled non-emergency surgeries, including robotic-assisted procedures.  As a company, we have been focused on working with our customers to help them meet their needs and navigate this period. While we saw a backlog of procedures created during the initial phase, the demand for robotic-assisted surgery has been resilient worldwide.

In India, we have been receiving positive feedback from surgeons regarding the usage of robotic-assisted surgery at this time. Many hospitals with robotics programs have resumed operations and successfully carried out a number of surgeries. As the surgery can involve shorter hospital stays and early discharge from the hospital, some surgeons have expressed a preference for RAS in the current environment, as noted in recently published consensus guidelines such as those issued by the ASI (Association of Surgeons of India).

How is India positioned in the robotic-assisted surgery adoption curve compared to developed economies?

Robotic-assisted surgery is being adopted across the globe – currently, there are over 5,500 systems in 67 countries. More than 7.2 million procedures have been performed on our systems, with over 1.2 million taking place in 2019 alone. While individual countries are at different adoption curves, the general trend is towards wider adoption and greater access.

Though it is at a nascent stage when compared to the US, both robotic-assisted surgery and Intuitive have a long history in India and have built a strong foundation with immense potential.  The first procedure performed with a robotic-assisted surgical system took place in India in 2002. Since then, its adoption by Indian surgeons has become more widespread.

The adoption of robotic-assisted surgery has been driven not only by improved patient outcomes but also by the activity and enthusiasm among the growing community of passionate Indian robotic surgeons.  For example, in 2019, the surgeon community held the inaugural meeting of India’s Chapter of the Clinical Robotic Surgery Association (CRSA). More than 250 surgeons from across India attended and met with their peers worldwide to share best practices and resources and discuss the latest advancements in robotic-assisted surgery. These efforts are resulting in wider awareness and adoption.

We are also seeing reimbursement take shape around robotic-assisted surgery in India, which is an important step for the growth of innovative and impactful treatments and innovations in the healthcare space. Private insurers have recognized the clinical value of technology. They are incorporating it into their policies, which will support the development of robotic-assisted surgery in the country both in terms of lowering procedure costs and sending a signal to the healthcare community about the technology’s clinical value and maturity.

What are the specific challenges with robotic-assisted surgery processes? And how can the healthcare sector overcome these challenges?

Robotic-assisted surgery has a bright future in India and has a strong global evidence base. However, at this stage of its adoption, awareness is still spreading among patients and the broader healthcare community in India. There is an existing pool of highly talented, passionate Indian robotic surgeons who not only have a substantial patient flow but are also continuing to educate and engage with their patients, help raise awareness of robotic-assisted surgery among the broader surgeon community, and play a role in training and mentoring new surgeons.

Similar to other countries, the growth of robotic-assisted surgery in India is gaining momentum and will continue to do so over time as patients, surgeons, and hospitals learn more about its potential benefits and impact. This growth process is typically driven by a virtuous cycle. As more surgeons and hospitals adopt the technology, the benefits of robotic-assisted surgery, in terms of the enhanced capabilities it provides for surgeons and the resulting patient outcomes, will continue to become more evident, leading to broader awareness, adoption, and patient access.

Purchasing a robotic-assisted surgical system is also a significant, long-term decision for a hospital, and it is important to emphasize that installing a system is part of a longer relationship. As a company, we take steps to ensure our customers and partners are able to build a robotics program that will be successful over the long run to maximize this investment. We assess key factors related to starting and maintaining a successful robotics program – that includes the right patient flow, the right skillsets, and the potential to achieve the right clinical outcomes.

As the adoption rate of robotic-assisted surgery increases, hospitals will look for skilled surgeons to perform minimally invasive surgery with da Vinci surgical systems. How is Intuitive helping the healthcare community build these skillsets?

Intuitive has extensive experience in training surgeons worldwide on the technology – to date, more than 52,000 surgeons have been trained on our robotic-assisted surgical system worldwide. In India, over 500 surgeons have been trained so far. There are currently more than 70 of our da Vinci surgical systems in India, which are being utilised by corporate and government hospitals throughout the country.

We believe that training is a journey, not a destination. As part of the ecosystem of programs and solutions we provide our customers, we also aim to provide the best-in-class training and support to surgeons in India throughout their careers – from initial exposure to the technology to progressing to more advanced training, ensuring that they have the skill and experience necessary to perform the procedure using the da Vinci Surgical System. However, Intuitive Surgical trains only on the usage of the da Vinci surgical system, not medical knowledge to perform the procedure. We currently have three training centres in India: Amrita Institute of Medical Sciences and Research Centre in Kochi, Yenepoya Training center in Mangalore and MS Ramaiah Memorial Hospital in Bangalore.

What could be the role of the Government in driving the demand for robotic-assisted surgeries in India?

The Government can take a number of actions, ranging from supporting the establishment of robotics programs at public hospitals and putting policies in place that help facilitate the adoption and access to the technology. We have seen some positive steps over the last few years that will have important long-term implications.

For example, many robotic installations have taken place at various central government institutions such as AIIMS and PGI. A recent example would be the October 2019 establishment of the robotics facility at Safdarjung hospital in Delhi, one of the largest tertiary care central government hospitals.

The penetration of robotic-assisted surgery in government institutions is gaining momentum. State government hospitals too can play a principal role in bringing robotic-assisted surgical technology closer to patients and making it more widely accessible.

Expanded insurance coverage is also an important step in terms of broadening access to robotic-assisted surgery.  We have seen some positive steps from government institutions in this regard.  Last year for example, the IRDAI, India’s insurance regulator, released a circular that required the inclusion of advanced therapies, including robotic surgery, in certain types of insurance policies. Some pioneering insurers are already ahead of the curve and have incorporated RAS into their policies, others are exploring how best to integrate it into their plans.

The Government could also look into bringing about certain changes in the import-duty and categorization of surgical robotics to bring down the cost of ownership. Currently, the government levies import duty on robotic-assisted surgical equipment that falls under Instruments and Appliances, attracting import duty and cess. Although the Government intends to encourage local manufacturing, India does not currently have the required infrastructure to localise surgical robots. The benefits of the reduced or zero import duty will get passed on to customers, encouraging many more of them to adopt robotic-assisted surgery.

What kind of use cases for AI have emerged from robotic-assisted surgery, and what will the future hold? 

A common question we hear is whether surgery will ever be conducted autonomously. Robotic-assisted surgical technology exists to enhance, not replace, the capabilities and experience of surgeons, as well as meet our customers’ needs and create better outcomes for their patients. We see artificial intelligence, augmented reality, and smart instruments as an extension of that line of thought. For example, a smart stapler on a robotic-assisted surgical system can make over 1000 measurements per second, which feeds into an AI algorithm that measures tissue thickness and helps determine if it is safe to fire. These capabilities can optimise stapling and prevent tissue damage in real-time, assisting the surgeon, and keeping the patient safe.

Intraoperative guidance technologies also use augmented reality to help deliver optimal tools to surgeons. For example, through 3D segmented imaging technology, a CT scan – segmented using surgical AI – can be integrated into a virtual environment to help a surgeon see and plan a procedure.

Finally, we see strong utility for surgeon training and benchmarking. Much of the work we are doing in this space is also figuring out how we, as an industry, can enable surgeons to master procedures in order to achieve the best outcomes possible. We can now use video analysis, machine vision, and AI to start comparing existing procedures in a real case to a gold standard so that we can understand best practices, and surgeons can benchmark their performance against their peers.

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Sohini Bagchi
Sohini Bagchi is Editor at CXOToday, a published author and a storyteller. She can be reached at sohini.bagchi@trivone.com