A Practical Approach to Robotic Surgery Ajit Saxena
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fm1A Practical Approach to ROBOTIC SURGERYfm2
fm3A Practical Approach to ROBOTIC SURGERY
Editor Ajit Saxena MS (Delhi) FRCS (Edin) FICS MNAMS (Urology) Dip Urology (London) Senior Consultant Urologist and Andrologist Indraprastha Apollo Hospitals New Delhi, India Foreword Mahendra Bhandari
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A Practical Approach to Robotic Surgery
First Edition: 2017fm5
Dedicated to
APJ Abdul Kalam
15 October 1931–27 July 2015
A scientist, statesman, poet, visionary, friend
above all, a good human being
“Failure will never overtake me if my determination to succeed is strong enough.”
—APJ Abdul Kalamfm6
fm7Contributors fm13Foreword
It was the summer of 1995, I was ready to leave for Jaipur by road with a friend of mine. While getting into the rear seat of the car, I found a young gentleman already sitting in the car. My friend introduced this smart young gentleman to me as a urologist from Delhi, who was accompanying us to the same conference at Jaipur we were to attend. Within minutes, we were already mutually comfortable, conversing with each other. Soon, I learnt that he was a practicing urologist in Delhi who had returned to India a few years ago after extensive training in urology in the United Kingdom. My fellow passenger's confidence and passion for urology was obvious on his face. Our conversation was so intense that we were totally unaware of how busy and choked the highway was. Our 5-plus hours journey to Jaipur turned into a timeless event. When we stopped over for lunch at the midway, our fascinating conversation continued uninterrupted. Suddenly, we realized that we were already in Jaipur. This was my first meeting with Ajit Saxena. It was the beginning of a durable friendship and mutual professional regard for each other which has extended for the past several years. In Ajit, I found an enthusiastic urologist dedicated to his patients—and to top it up, a compassionate man inside. Even with his aging—and his nagging professional schedule—one could not combat his creativity and enterprising nature. I recall that each time I met him, I found him reinventing himself.
Just a few months ago, he compiled a series of interviews with senior urologists whom he identified to have played significant roles in establishing urology. I had to face him sitting on a hot seat in a studio environment—answering his pointed questions. His latest mission is to publish this book. A Practical Approach to Robotic Surgery is perhaps the first book authored by Asian authors. Myself having also been in the business of editing and publishing over the past four decades, I fully understand the onerous task of editing a multi-author book. This has heightened my respect for Ajit even more—as if there was any scope to do so.
The history of robotic surgery in India dates back to the visionary Dr Naresh Trehan installing the first da Vinci robot at the Escorts Heart Institute, in 2001, and using it for cardiac surgical applications. Following this, other cardiac surgery programs installed robots in different institutions in Asia. Ajit is to be credited for persuading Dr Trehan to grant him permission to organize the very first urology workshop in robotic surgery with live surgical demonstrations at the Escorts Heart Institute.
The Vattikuti Foundation (VF) rolled out its mission in India in 2010, by establishing four multispecialty robotic surgery institutes: one each in Delhi, Mumbai, Bengaluru and Hyderabad. The goal of the VF mission was to revive and foster robotic surgery in Asia. The Foundation had inherited 7 poorly performing robotic surgery programs. When the surgical robots were used, mainly they were called on to perform cardiac and urological procedures.
At the time of my writing this Foreword, robotic surgery has come a long way in the field of multispecialty robotic surgery. We now have 35 plus, and growing, installations. In 2015, Indian surgeons performed a total of 4000 procedures in 8 specialties. To date, 190 trained robotic surgeons are involved in using the robot. It is also important to note that Asian surgeons located the world over, have become the leaders in all forms of robotic surgery.
Asia is at the threshold of growth in the field of robotic surgery. Because of this, I believe, it is the most opportune time to publish a book on robotic surgery—written about Asian patients—by Asian surgeons. The need for such a book is acutely felt, as a large number of young surgeons are beelining to take it up as a career. Ajit has taken the yoke of responsibility for training our next generation surgeons to help fill in this void.
As the editor, he has been fortunate to find some of the top Indian surgical talent—who have built in their expertise in their respective specialties. He has deservedly invited them to contribute their hard-earned experience to this effort.
The book is complete in all aspects, having 7 sections: Robot and Surgery, General Surgery, Thoracic and Vascular Surgery, Gynecology, Urogynecology, Pediatric Urology and, Adult Urology. The chapter on Ergonomics is especially designed to assist the hospitals which are desirous of establishing robotic surgery—from square one.fm14
I congratulate Dr Ajit Saxena for undertaking the arduous task of editing this very important and timely book. It is my sincere hope that this will be just the first milestone on his path of editing. I am confident he will continue updating the contents of this book periodically, keeping pace with the unprecedented growth of robotic surgery worldwide.
I sincerely hope that this book will be a useful companion not only to the growing Indian surgical fraternity but also globally—irrespective of their specialty—as they continue on their journey to surgical excellence. Furthermore, I hope it serves as a guide in their sincere efforts to give their very best to all patients. The contents of this book reinforce what the Vattikuti Foundation embarked on only a few years ago—and continue to this day. I thank Dr Saxena immensely for that.
Mahendra Bhandari
MS MCh (Urology) FAMS FNA SC DSc (Hon) MBA
Robotic Surgery Education and Research
Vattikuti Urology Institute
Henry Ford Hospital
Detroit, USA
Vattikuti Foundation
fm15From the Editor's Desk
The rules must change…
When we were students, the dictum was ‘big surgeons make big incisions’. Barely two decades later, with the advent of first laparoscopy and, now, have robotic surgery, the entire concept has been changed. With these technological advancements, even the biggest of surgery can be done through smallest of incision. Thus, in the new millennium, the dictum must be revised as ‘bigger the surgeon, smaller the incision’. The rules must change…
Another feature that has changed with the advent of robot, is the recognition of the ureter as a gateway to retroperitoneal and pelvic surgery. Beginners in robotic surgery will be well advised to identify the ureter as it crosses the bifurcation of common iliac artery at the pelvic brim.
This is the easiest structure to identify even in the most obese person. Squeeze the structure with a pair of non-tooth forceps to confirm the ureter by its wriggly movements. Trace the ureter upwards, and it leads one to the renal hilum. Trace the ureter downwards from the pelvic brim and it leads you to the urinary bladder. In the females, the ureter provides a solid landmark for ovarian and uterine vessels. These vessels can be safety ligated once the ureter is identified.
In short, in the current-day robotic surgery for retroperitoneal and pelvic structures, robotic surgeons will be well advised to spend an extra time in identifying the ureter and tracing it prior to embarking on surgery of the diseased tissue. Tracing the ureter after identifying it initially and respecting the relations of various structures especially pertaining to the large vessels, will go a long way in preventing catastrophic complications. The rules must change…fm16
‘From Mars to India’ was the caption we used for the first-ever robotic surgery workshop held in this giant subcontinent. The year was 2005 and the surgeon was a jolly young chap by the name of Vipul Patel. Thanks to his midas touch, the conference transpired like a dream and is remembered to this date as one of the memorable seminars.
It took almost ten years for the robot to gain a foothold on Indian soil, and one of the chapters, in this book, traces the development of robotic surgery globally.
As regards the book, I am excited because the best of Asian talent has put the best foot forward to contribute toward this venture. A unique feature of the book is that all the authors are from Asia and that each chapter ends with the author's now-significant experience.
The book has been divided into seven sections encompassing the major specialties using the robot. Section 1 is a ‘must-read’ not only because it deals with the historical landmarks, but also because it emphasizes the importance of ergonomics in robotic surgery. Do go through it; it is particularly relevant for the younger generation. The small pointers tucked throughout the primary chapter might prolong your surgical career by leaps and bounds. Also included are anesthesia details, which underscore the vital role anesthetists play in the overall early recovery of the patient.
It is my dream to see India as the hub of robotic tourism in the immediate future…and a vision of a robotic surgeon performing surgery, sitting anywhere on earth, on persons living in outer space in the near future!
In the end, if you have any suggestion/comment, please do not hesitate to write to me at ajitsaxena@hotmail.com.
Friends, together we can do it!
Ajit Saxenafm18
K Subramaniam, who was widely known as ‘KS’, was instrumental in taking the benefits of robotic surgery, a cutting-edge technology, to a host of surgeons and hospital administrators in India. He diligently created tie-ups with a wide range of institutions to fulfil the dream of taking India to the next level of surgery. KS put into place a series of programs that helped more and more hospitals acquire robotic systems, and also assisted surgeons get trained and certified in robotics to help create immensely successful robotic centers.
KS also painstakingly set up the functions of an organization and a team that could support the sales and service and technical maintenance required to seamlessly run da Vinci robotic surgery systems installed across the length and breadth of the country. At the organizational level, KS was an inspirational leader who led by example. Indeed, he was a powerhouse of energy who would always find solutions to any problem and drive execution with great passion and zeal.
The robotic surgery fraternity knew him as an ever-active, hardworking workaholic and as a soft compassionate man who would make friends for life in an interaction of a few minutes, while at the same time, with a straightforward approach and a code of integrity—a man who always promised what he could deliver. The vacuum created by his loss shall remain.
KS will always be remembered as a leader, a great friend and a good human being.
First of all, I am grateful to my publishers, who not only gave me a long rope but also contributed actively in making this ‘one of its kind’ book possible.
I would be failing in my duty if I do not thank my team, Ms Swati Thapar, Mr Anuj Ahuja, Ms Shuchita Singh, Mr Amit Rana and Ms Chandani Alaudhin, for their untiring efforts. I sincerely thank my wife Dr Neeta, who has become a virtual robotic surgeon in her untiring effort to get the book published on schedule. My thanks also go to my two lovely daughters Pooja and Roopa, who lifted my spirits when the chips were down.fm22
fm23Hello Mr Robot
The only robotic system so far available is the da Vinci Surgical System (Intuitive Surgical, Mountain View, California, United States).
This consists of a console at some distance from the patient where the surgeon sits while operating, and the robotic cart with its three or four robotic arms, which is in close proximity to the patient. Various instruments attached to the robotic arms, are inserted into the patient through small incisions. The console provides a magnified high-definition three-dimensional view of the operating field through a stereo endoscope fitted to one of the robotic arms, whose visual field and angle of vision are adjustable. The surgeon manipulates two-finger joysticks (finger and wrist movements) at the console while watching the surgical field through the visual system. Movements of the surgeon's hands are transmitted through the robot to the robotic arms, so that equivalent but scaled movements of the surgical instruments are made within the surgical field. The instruments have 7 degrees of movement freedom and hand tremor is filtered out. The da Vinci system appears able to overcome many of the problems that characterize laparoscopic resection. Initially, the three-dimensional high-definition camera is under the direct control of the surgeon, and the double optical system makes consistently clear vision more likely. Furthermore, the tremor-filtered, multiple-degree-of-movement instruments, which can be scaled relative to the surgeon's hand movements, permit more precise dissection in narrow spaces and render the more difficult steps of the operation easier. Tissue retraction with the robot is also easier, since the third arm can be used as a fixed retractor, and is always manipulated by the surgeon. These potential advantages within the narrow space of the pelvis have been shown to be translated into concrete advantages for robotic radical prostatectomy, and in our opinion, the excellent ergonomics and precise dissection offered by the robotic system can be helpful in colorectal surgery also for vessel ligation and flexure mobilization amongst other surgeries. This is why there is a standardized ‘fully robotic’ technique for left colon and rectal resection. The robot allows for 7 degrees of motion versus the limited 4 degrees of motion in laparoscopy.