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In the era of invasive smart technologies, both personal and professional lives of humans are undergoing a massive change. This electronic evolution is impacting our daily chores from the bedroom to the boardroom. The influence of artificial intelligence (AI) and machine learning is hard to miss in every domain we come across. Some may argue against its aggressive intrusion, while others may call it a boon to mankind for its speed, accuracy, and efficacy. From transportation to banking, retail, fashion, energy and utility sectors to even health, digitalisation is steadily deepening its roots to rule the roost. Robotic surgery is one such breakthrough in medical science that is conspicuously leaving its mark in OTs.
Aided by cutting-edge technology, robot-assisted surgery is making waves in the surgical fraternity. This is applied with the help of small instruments attached to a sophisticated, flexible robotic arm. The surgeon regulates the mechanical arm via a computer. For the uninitiated, a frequently-used standard clinical robotic surgical system comprises a camera arm and mechanical limbs with surgical tools attached to them. The surgeon leading his team of assistants during the operation controls the arms from a computer console in proximity to the operating table to get a high-definition, magnified, 3D (dimensional) view of the surgical site. Robotic surgery enables surgeons to execute the most delicate and complicated procedures, which otherwise look cumbersome with conventional methods.
Surgical robots are specialised machines designed for use in medical procedures to deliver augmented precision, clearer visualisation and decreased invasiveness in surgeries. Some of the types include Da Vinci Surgical System, Versius Surgical System and ROSA Robot. Robot-assisted surgeries are gradually becoming a rage across various major surgical specialties. Studies validate the point that as technology evolves, the list of surgical departments utilising robot-assisted surgery continues to expand. Among these, urology has been a leader in the adoption of robotic surgery so far, with the Da Vinci Surgical System being widely used in prostate surgeries.
AI can uplift robotic surgery by mitigating the surgeons' stress. A slew of AI algorithms used in such innovative surgeries includes machine learning, computer vision and deep learning. This streamlines heavy-duty surgical procedures by zeroing in on the tools, supervising operations and conveying warning signals.
In robot-assisted surgery, AI and machine learning are used for motion planning, computer vision, force sensing, teleoperation and predictive analytics. These algorithms and models optimise the trajectory of the robotic arm, provide real-time feedback to the surgeon, adjust the force applied by the arm, enhance the user interface of the console and guide surgical decisions. “As technology evolves, we can expect to see even more advanced applications of AI and machine learning in robotic surgery,” volunteers Dr. Jaideep Jesson Rayapudi, MBBS, MD, serving as a senior subject matter expert in Healthcare AI at iMerit where he helps create large-scale datasets to power a variety of healthcare AI machine-learning use cases.
Autonomous robotic surgery as Dr. Rayapudi observes – “has the potential to provide increased efficacy, safety and consistency in surgical procedures, irrespective of an individual surgeon's skill and experience. However, the robots currently used in surgery are not truly autonomous and achieving autonomy is a far-reaching goal as it requires addressing various aspects of medical care beyond just technological advancements, such as ethical considerations and regulatory frameworks.”
Nevertheless, technological explosion is witnessing rapid advancements in the AI field and the day won’t be far when slick robots will in reality come completely trained in AI architecture to follow instructions promptly during surgical operations, he suggests, raising a ray of hope.
The Da Vinci robotic system employed in complex surgeries is manufactured by Intuitive Surgical, Inc., an American company that develops, manufactures and markets robotic products designed to upgrade clinical outcomes of patients through minimally invasive surgery, most notable being the Da Vinci Surgical System. It is used in prostatectomy, cardiac valve repair as well as for renal and gynecologic surgical procedures. The system was named after the eminent Italian polymath Leonardo da Vinci, courtesy his invention of a robot, the “mechanical knight”. It was a humanoid automaton, believed to have been designed and constructed by the artist himself in 1495. The teeny-weeny instruments in the aforementioned surgical system move like a human hand but with a wider range of motion. The minute size of the toolkit makes it simple for surgeons to operate smoothly through a single or a very few minor incisions.
Discussing the importance of the Da Vinci's role in hernia surgeries, Dr. Udipta Ray, renowned hernia surgeon, senior consultant and head of GI surgery of Medica Superspecialty Hospital in Kolkata, recommends Abdominal Wall Repair (AWR) as the best approach. “The latest version is the Da Vinci AWR that is perfectly suited to deliver the best shot, thanks to the dexterity of its array of instruments. Add to this, the advantage of a 3D binocular vision, which renders the chromo feedback to segregate the layers beautifully. It’s an apt marriage between machine and surgeon, resulting in clean and correct dissection suturing, defect closure and repair. This, in turn, leads to less bleeding, reduced pain, shorter hospital stay and better post-operative comfort sans any ache induced by tackers (mesh-fixation devices often used for securing the mesh in the laparoscopic repair of complex hernia. Complaints of small gut perforations were earlier reported),” elaborates Dr. Ray. Tackers are avoided in robotic surgery. The Da Vinci system also allows surgeons to effortlessly operate from a stable ergonomic tremor-(a neurological disorder that causes shaking movements in one or more parts of the human body, especially in the surgeons’ hands. This is more common with senior, aged doctors as prolonged surgery often induces fatigue) a filtered platform, which is not the case in general laparoscopy.
Coming to ortho-robotic technologies, the MakoartRobotics platform from Stryker (Stryker Corporation is an American multinational medical technologies conglomerate dealing in medical devices and surgical equipment manufacturing) is available at the Kokilaben Dhirubhai Ambani Hospital (KDAH) in Navi Mumbai. This advanced ortho-robot combines three key components, namely 3D CT-based planning, AccuStop haptic technology and Insightful Data Analytics, into one platform to deliver better results for total knee replacement, partial knee replacement and total hip replacement.
Incidentally, the Stryker Mako is used for robot-assisted joint replacements to attain an exceptional degree of accuracy from the planning stages to the ultimate operation. The patient recommended with robotic surgery undergoes a CT scan, and data accumulated from the same is fed into the robotic system. The system uses an advanced 3-D model to map the anatomy of the patient’s joint and creates a customised plan for the surgery, even before the subject is brought to the operation theatre. This enables the surgeon to conveniently pre-plan the exact cuts or incisions needed to be made before commencing the procedure and tailor those precisely to the patient’s joint.
“During surgery, the surgeon registers the actual anatomical landmarks of the patient with the help of probes and a camera that helps create a 3D model by the computer. By this, the surgeon knows the exact size of the implants, their position and the balancing of soft tissues to preserve the maximum healthy bone and tissue before actually cutting the bones to suit that particular patient. All the sizing of bones and the preparation to receive the implant are done by the robotic arm,” elucidates Dr. Subhash Dhiware, consultant, orthopaedics department, KDAH. At present, no other types of robotic surgeries apart from joint or bone-related operations are conducted at KDAH. However, very soon, a robot will be unveiled for general surgery, urosurgery and gynaecological surgery.
When technology meets human expertise, miracles happens. The use of robots sets a new benchmark in knee-replacement surgery. Robotic arm surgery is one level up from computer-assisted surgery or surgical navigation with its high-power precision. A robotic arm is an indispensable instrument in this surgery. Prior to robot-assisted surgeries, simulation is done on the laptop through 3-D planning and imaging. This involves bone reparation, size of the implant and its placement, how to balance it, plus the final results. The entire mapping is done by the surgeon who’ll operate. This design is then fed into the robotic arm by a pen drive. After starting the surgery, the anatomical points are shown to the robot. Timely knee replacement surgery accelerates the pace of recovery, otherwise an undue delay might weaken the muscles to decelerate the mending process and begin stiffening the knee.
According to Dr Dhananjay Gupta, Director of joint surgeries, Fortis Hospital at Vasant Kunj in Delhi, integration of robotics in orthopaedic surgery is easier than other surgeries like gastric or pelvic organ surgeries. “Robotics brought in high precision required in super major surgeries, such as cancer. The concept of cancer-free margins is quite significant while removing the malign tumour surgically. Therefore, to eliminate human error, the use of robotic surgery makes sense here. In non-cancer cases, the use of robotics is optional,” he states.
Statistics prove that at present, India boasts of 66 robotic surgery centres with 71 robotic systems already installed to implement surgical procedures (confirmed by ClinicSpots holistic healthcare). Some of the top robotic surgery hospitals in India are Apollo Hospitals, Delhi, Hinduja Hospital, Mumbai, Global Hospitals Group India, Fortis Hospital, Delhi, Max Hospital, New Delhi, Medanta Hospital, Gurugram, ILS Hospitals, Kolkata.
It is true that India is steadily embracing AI-aided robotic surgeries and the number of robot-assisted surgery is certainly increasing within the country because of its elevated accuracy levels and highly rewarding outcomes.
In India, robot-assisted surgeries have been conducted for more than two decades now, primarily utilizing the Da Vinci system. More recently, machines by Medtronic and Stryker are also introduced.
Considering hernia operation to be complicated, a query that inevitably crops up in mind is about the chances of survival in robot-assisted surgery. “Death due to complications in robot-assisted hernia repair, even for the most critical hernia surgery is extremely rare. Patients collapsing or succumbing during and immediately after such surgeries is largely due to cardiac or respiratory diseases and bowel injury at the time of being operated on. However, this hardly happens in a robotic surgery than in either an open or a laparoscopic surgery. The former is essentially safer than other procedures,” warrants Dr. Ray.
When enquired if these surgeries are susceptible to high risks and what happens if a robot suffers a technical breakdown in the middle of a surgery, to that, Dr. Subhash Dhiware, consultant, orthopaedics department, KDAH, assures that “there is no extra risk involved in robot-backed surgeries. If the robot hits a snag, the surgeon present around can immediately take over and complete the remaining job in standard fashion. But chances of such emergencies and unpredictable circumstances are extremely low as every piece of equipment is tested before initiating a surgery”.
“All surgical procedures are risk-prone to some degree, including robotic surgeries”, Dr. Rayapudi accepts this fact. “However, in the event of any issue, say a technical failure in the middle of a surgery, a team of surgeons is present to take over from the robotic system and intervene if necessary,” he reminds to retain faith in the technological breakthrough in medical science that is under discussion.
Technical glitches can occur anytime, even amidst a surgery. A surgeon overseeing the procedure should be prepared enough to take over the surgery manually and finish it off if such an uncalled-for episode ever happens. “Robots are very costly and it’s not possible to keep one on a standby mode. But chances of such a mishap are very rare,” chips in Dr. Dhananjay Gupta, director of joint surgeries, Fortis Hospital at Vasant Kunj in Delhi.
Admitting that robotic surgery is paving a new revolutionary path for advancement in medical science, the surgeon enlightens that “we are already in the 4th generation of the Da Vinci evolution. From a deep pelvic region, it has already travelled to broader indications. Moreover, vital clinical data derived from the Da Vinci platforms collected from different corners of the globe shows better patient outcomes.”
Robot-assisted surgery has a proven track record for general surgery, gynaecology, urology, cardiac, H&N (head and neck), oncology, GI (Gastrointestinal), transplant, vascular and thoracic procedures, and so on. Apart from Da Vinci, other robots are unleashing disruptive technology even in cardiology, orthopaedic joint replacement and lung biopsy. Robotics with an impressive success ratio in surgical procedures could unlock its significant value and is definitely here to stay with a promise of greater evolution in the coming days.
Robots can acquire 100 per cent accuracy at the execution level. For example, the Mako’s robotic arm can operate within a fraction of a millimetre. But it cannot replace human surgeons as the latter is required to make incisions and expose the joint. “Robotic surgery is actually robot-aided surgery. A surgeon has to take precautions to protect the soft tissues and decide on the soft tissue tension while balancing the joint. The robotic platform’s software provides a visual path for the surgeon as he makes the planned incisions and fixes the implant, while the arm uses tactile resistance to prevent any movement outside the planned boundaries. The surgeon is required to close the wound, check the bleeding and take care of pain management,” reasons Dr. Dhiware.
It is important to note that a highly dedicated team of remote surgeons and AI experts play a pivotal role in a robot-aided surgery. They coordinate to design and strategise the surgery using superior imaging techniques and computer simulations. They can use this material to create a detailed surgical plan that takes into account the patient's unique anatomy and any potential complications. During the surgery, distant surgeons and AI exponents can provide real-time support to the on-site surgical team. They can use sensors to monitor the patient's vital signs, provide guidance on the use of the robotic system and make adjustments to the surgical plan as and when required. After the surgery, this crucial data can be utilised to optimise the patient's health and well-being and ensure to address any issue or complication instantly.
Robotic surgery as of now is not autonomous or fully automated. The robot does not perform the surgery on its own but serves as an extension of the surgeon's hands, allowing more correct and controlled movements. Though the surgeon typically regulates the robotic arms from a console, located near the operating room but remote operation is also possible. Interestingly, robotic arms can perform common surgical procedures, such as excision and suturing with greater deftness than human hands. Autonomous robots are still largely experimental, and their successful functioning relies heavily on advanced computer vision and movement detection technologies.