Shahid Akhter, editor, ETHealthworld spoke to Professor Somashekhar, Chairman of Manipal Comprehensive Cancer Centre and the Intuitive Manipal Robotic Institution at Bangalore to know more about the surge in robotic surgeries during the pandemic.
What potential does robotic-assisted surgery hold to become the new normal way of conducting surgeries during Covid and beyond?
These are tough times which the world is facing. India got affected somewhere around March with this pandemic, which is now very rampant worldwide. But, we should look beyond just mourning about it. What is most important is to understand that we need to live with this and make modifications and understand the new normal.
If you look back, what has happened since February is that most of the countries, including India went in lockdown. Remember the mortality of Covid is 0.5% only. But the mortality of untreated other disorders like colon, rectal cancers is 30%. So, we should not ignore the curable, potentially treatable conditions. Which if ignored, will lead to higher rate of mortality. During this pandemic time, we didn’t want to do major open surgeries, mainly because patients stay in the hospital for weeks together, surgeons, assistants, sisters- all together. In an open surgery, there are a lot of instruments that need to be used, lot of vaporization is required, potential complications, pain, ICU stay- all causing risk to patients, their attendants, doctors and healthcare workers.
So, the new normal that all of us have embraced and adopted is minimal access surgery, especially robotic surgery. Because in robotic surgery, we use 2 or 3 instruments only and surgeon sits in the console and 1 bedside assistant with sister. It requires only minimum interaction and provides maximum benefit with minimal invasive nature. So, patients go home the same day or next day, no need for ICU, less complications, less readmissions, less infection, and quality of surgery is also very good. So, it is a boon for patients, who are actually kindred for robotic surgery. So, the new normal is minimal access surgery with keyhole robotic-assisted surgery. Patient comes surgery, goes home faster after recovery, less to no complications, no blood transfusions, no ICU stay and lower complications.
Worldwide now there is a rapid push to robotic-assisted surgeries during this pandemic as it is the preferred option. In this condition, where patients can go home early with less complications and less exposure to- other patients, attendants, healthcare workers, and hospital staff. It is not compromising the outcome and clinical condition of the patient.
How RAS, being a minimally invasive procedure can reduce the transmission of infection?
During this pandemic, the 3 important things we need to consider are, - physical social distancing, which means the closer you are and the more you are interacting, the chances of contracting the virus is high.
In an open surgery, apart from the surgeon and patient, there will be another surgeon, one assistant, and a nurse in the OT. They also come in contact with the body fluids in an open surgery. Because of the cut, the patient takes long time to recover. They are required to stay in the ICU, ward, visit OPD and they will also need dressing.
On the other hand, for minimally invasive robotic-assisted surgery, once you dock the robot and everything is sealed, you don’t have direct contact. Naturally physical distancing is maintained. Because it is minimally invasive, the patient can eat the same day, walk same day, pass urine and motion the same day, and go home the next day. So, there are no wound complications and infections. Features supporting physical distancing, and minimal interactions, is actually inbuilt in the robotic technology. That is why robotic-assisted surgery is the ideal way of performing surgery during the pandemic.
How RAS is proving to be a socially distant surgery during Covid?
This is a very important aspect. In minimal invasive, less human interactive robotic-assisted surgery, surgeons sit on a console not touching the patient and perform the surgery. All keyhole robotic ports are docked before the surgery. Post-surgery, patients are able to recover faster and able to walk around without difficulty. It fulfils all the criteria of natural physical distancing.
What are the various protocols and guidelines in place for surgeons and patients undergoing robotic assisted surgery?
We were unclear on the efficacy and safety of minimal access surgery in the initial guidelines of SAGES. Immediately, the International Society of Robotic Surgery, the SAGES, the International Society of Gyne-Onco, the International Society of Colorectal and Indian Society of Surgical Oncology and AMASO, (Academy of minimal Access Surgery Onco) got together. I wrote a white paper draft for safety, adaption and the precautions that has to be taken to do safe robotic-assisted surgery during pandemic. All these guidelines, helped in bringing together a protocol.
The main protocol- the patient needs to be screened for RT-PCR, HRCT, so that the patient is safe. The surgical OT modification is called Rule number 20. 20 air cycle per hour, and 20 minutes difference between 2 cases, intubation and extubation- 20 minutes to intubate before we enter the OT, and temperature is set at 20. All the pneumo and the smoke that comes out through the robotic ports is vented out through a specific smoke evacuator passed through sodium hypochlorite. So, these are the three modifications which we did and performed robotic-assisted surgeries safely. We have done over 100s of them and not 1 patient became positive, no risk to the patient or any risk to the health worker. Currently, the maximum number of surgeries I perform are robotic-assisted for the benefit of the patient.
What are the various precautionary measures taken by the surgeon in the OR for a robotic assisted surgery to take place?
For any surgery during the pandemic, we need to wear PPE (personal protection equipment). You have to also wear the N95 mask, the visor, P100 respirator, and cover the whole body. The beauty of robotic-assisted surgery is that we don’t have to fully immerse ourself. So, surgeons invariably wear a good personal protection equipment during surgery. The surgeon console and the whole system is regularly cleaned with sodium hypochlorite. Whenever surgeons are shifting from console, we clean the equipment again. These are the precautions that we take.
Why is Robotic assisted surgeries better than laparoscopy and open surgery during Covid?
Primarily robotic-assisted surgery is painless, minimal invasive, provides fast recovery, lesser time required to pass first flatus and faster bowel, early mobilization, lesser complication and early discharge, without compromising the outcome.
How many Robotic surgeries have you performed since the Lockdown ?
During the initial days of lockdown in April, elective surgeries were stopped as per the Government of India guidelines. But, we were able to perform all cancer and other emergency surgeries. Ever since the last week of April, we have not stopped any surgery. Every week we perform robotic-assisted surgery. All over India, around 100s of robotic-assisted surgeries are done every month by surgeons. We can do 2-3 robotic-assisted surgeries on the same day and patients can go home easy and comfortably without complications. The new normal is minimal access surgery with robotics. During this pandemic time people have embraced robotic-assisted surgery even more than before.
Do all patients undergoing surgery at your hospital have to be tested for Covid, how do you carry out the entire procedure?
Such aspects are governed by the guidelines under the rule of the law. Every country has different set of guidelines. In India, it is governed by the Ministry of Health and ICMR. ICMR brought the guidelines in March. They said that only the cancer surgery and immuno-compromised patients should be looked into. Soon, in April- May, the guidelines changed. In our hospital, all the patients undergoing surgery have RTPCR swab testing done. So, we can segregate the patients- patient who are at risk, who are not at risk. We have different OT for positive and negative patients with special protection. So, we are aware of the outcome in a positive patient. Post-op care, lung management requirements, anaesthesia, are all different in positive and negative patients, so we segregate them.
What are the areas of therapies that you have covered under RAS during Covid?
With robotics, we perform gynae cancers, endometrial, uterine cancer, cervical cancer, sentinel lymph node, colorectal surgeries, sphincter preserving LIR. I have done robotic lungs, robotic esophagectomy, food pipe cancer, robotic colon surgeries, robotic thyroidectomy, robotic gastrectomy. My colleague urologists are performing -robotic prostate surgery, kidney surgery. Surgeries are happening with robots, safely like before.