Robots are changing the world of surgery, including in India
AT Indian Spinal Injuries Centre (ISIC) in New Delhi's Vasant Kunj, a team of spine surgeons led by Dr H.S. Chhabra, Medical Director-cum-Chief of Spine Services, is performing a complex surgery At the centre of action is a robot with four arms. While the patient is surrounded by the surgical team, the surgeon, seated four-five metres away, is directing the robot by moving the sticks on the console. He is focussed on viewfinder, the fourth arm of the robot, which gives a three-dimensional image of the surgical area that is magnified on a screen. The robot has done small incisions, pre-set earlier by the surgeon and his team. Its arms are capable of filtering out any shaking of the surgeon's hands and ensure up to 99 per cent precision. In manual surgeries, which were the only option until two decades ago, this is 70-90 per cent.
Last December, Dr Tejas Patel, a renowned interventional cardiologist and Chairman of Apex Heart Institute in Ahmedabad, created history through telerobotics. He performed angioplasty on a woman while sitting behind a console at the Akshardham temple complex in Gandhinagar, 32 kilometres from Ahmedabad. Apex is said to be among the first hospitals outside the US that use Vascular Robotic Technology for coronary intervention using next-generation robots made by US-based Corindus.
New-age robotic-assisted surgeries are changing the world of health care as roles and skills of surgeons change. And Indian hospital chains are at the forefront of this. Such surgeries can now be done in as many as 100 hospitals in India, including in many Apollo and Fortis hospitals as well as Medanta Medicity in Delhi-NCR.
"The surgeon's hand, wrist and finger movements are transmitted through the computer console to instruments attached to the robot's arms. The movements have the same range of motion as the surgeon, allowing maximum control," says Dr Amolkumar Patil, a Consultant Urologist and Transplant Surgeon at Apollo Hospitals, Navi Mumbai. The robot's arms can work in areas that are difficult to reach by hand such as the pelvic region.
Advantage Surgeon Robot
"Robotic surgeries are going to change the way surgeries are done. We already have eight to nine centres equipped with advanced robotic systems," says Dr Prathap C. Reddy, Chairman, Apollo Hospitals, India's largest hospital chain. He says he has requested executives of Medtronics, a new-age robotic surgery system provider which is likely to launch its advanced robotic surgical units in a year or two, to supply them at least 30 such machines that it is going to produce initially in a year.
The hospitals spend $1-2 million per robot unit. For the patient, these surgeries are expensive by 25-30 per cent. Still, it is a win-win for both. For the hospital, the surgery time is less. Another advantage is less blood loss, less use of life saving machines and ease of planning. And the success rate is high. For the patient, this means higher chances that the surgery will be successful, shorter stay at the hospital as even a complex surgery can be done with a small cut and thus less expenses on medicine, room and post-operative care. The chances of infection are also less.
Suneeta Reddy, Managing Director, Apollo Hospitals, says at least 30 per cent surgeries at Apollo hospitals are now minimally invasive, including robotic surgeries. "We inform patients and relatives in advance about the advantages of robotic surgeries and the cost factor. But mostly these are complex surgeries and, therefore, relatives of patients are usually willing to go for such surgeries," she says. "With more and more machines and options coming in, their price will fall, and help patients and hospitals go for more robotic surgeries," says Suneeta Reddy. She says though the initial investment and cost is higher, early discharge of patients can help hospitals increase their average revenue per occupied bed. "The average length of stay will be less, just two-three days even in case of cardiac surgeries, and there are other advantages such as less bleeding, higher accuracy, speedier recovery and lesser post-operative care," she says.
"Robotics is a recent advancement in spine surgery, which is very complex, and allows surgeons to plan in advance from home or office with higher accuracy," says Dr H.S. Chhabra, President of the Association of Spine Surgeons of India. The latest robots use infrared cameras to track movement of instruments and implants. The customised arms can perform extremely difficult manoeuvring to enable complex procedures with high degree of precision, says Dr Chhabra.
"We now have robotic systems in Chennai, Bangalore, Hyderabad, Kolkata, Delhi and Mumbai hospitals. The Apollo Main Hospital at Greams Road in Chennai performs more than 500 such procedures a year. We have performed more than 320 robotic colorectal surgeries and found that as expertise builds up, patient volume increases and per patient cost comes down," says Dr Venkatesh Munikrishnan, Consultant Gastroenterologist and Robotic Surgeon at Apollo Hospitals in Chennai. "The robot's 'hands' have a high degree of dexterity, allowing surgeons the ability to operate in very tight spaces in the body that will otherwise only be accessible through open (long incision) surgery," says the surgeon.
The robotic system manufacturers, mostly from the US, see India as a crucial market. Intuitive Surgical, which started selling its robotic surgery units in 2000 after being the first to get the US Food and Drug Administration clearance, has had a distributor in India since 2011 - Vattikuti Technologies, promoted by US-based Indian serial entrepreneur Raj Vattikuti. Sources say India had only about 50 surgical robots and 300 trained robotic surgeons in early 2017. The numbers have doubled in two years. Intuitive's da Vinci Systems, which are now in the fourth generation and cost $1-2 million, had an installed base of 5,270 machines worldwide as on June 30 this year. Of this, 689 were in Asia, including 100-plus in India.
The Market & Future
The global surgical robot market is expected to rise from $3.9 billion in 2018 to $6.5 billion by 2023, growing at a compound annual growth rate of 10.4 per cent, estimate market experts. The major vendors are Intuitive Surgical, Stryker and Mazor Robotics. Market leader Intuitive, a NASDAQ-listed company with revenues of $2.1 billion in the first half of 2019, saw 18 per cent growth during the period.
"We have installed our machines in over 65 hospitals and are getting tremendous response from hospitals across the country, whether metros or Tier-II or Tier-III cities," says Mandeep Singh Kumar, VP and General Manager, India, Intuitive Surgical. Intuitive acquired its Indian distributor Vattikuti Technologies in May last year and started direct operations with Bangalore as its sixth global office. "The adoption and advancement of robotic-assisted surgery have been enabled by critical contributions from professionals from India," Intuitive CEO Gary Guthart had said while announcing direct operations in India last year.
Intuitive has about 5,800 employees across the globe. Close to 100 of them are in India. Numerous Indian doctors in the US and Europe are now well versed in robotic surgeries and are training their juniors across the globe, says Mandeep Singh Kumar, adding that at least 400 surgeons in the country have been trained to carry out complex robotic surgeries. Intuitive has two training centres in the country for surgeons and support staff at Bangalore and Kochi. Singh says Intuitive's Indian business is expected to grow over 25-30 per cent in the coming years, while global growth is predicted to be in the range of 17-19 per cent.
The potential is huge, say experts. About 39,000 surgeons around the world are trained in robotic surgery. Only a fraction are performing such surgeries. More than 5,000 robotic-assisted surgery systems have been installed globally but most are used on less than one case a day on average. Globally, only 2 per cent surgical procedures are being done with the help of robots.
Why No Indian Robots
Robotic surgery was pioneered by US-based Intuitive Surgical in 2000. It has a lion's share of the market. It is now making fourth-generation da Vinci Systems. Patent protection (20 years in the US) was one reason the others could not invest into the area. "The technology is complex and investments required are big. India does not have the ecosystem, technology and scientists in this field and still majority of the companies are in the US, and some in Europe like France," says Mandeep Singh Kumar, VP and General Manager, India, Intuitive Surgical.
Gloabally, once the big pharma and other technology companies saw the opportunity, they started acquiring start-ups in the area. Johnson & Johnson (J&J) made its foray four years ago when it formed Verb Surgical, a joint venture with Google parent Alphabet's subsidiary Verily. Though Verb Surgical is yet to reveal its product platforms, the JV is expected to bring to the market improved and affordable robotic surgery platforms by 2020 and give competition to da Vinci Systems. In last February, J&J had bought a medical technology firm, Auris Health, for about $3.4 billion. Auris has approval for a digital medical device platform called Monarch, which can help physicians access nodules in patients' lungs to diagnose various diseases, cancers and perform robotic surgeries. Earlier, J&J had acquired Orthotaxy, a privately held developer of robotic-assisted surgery software. Last year, another global medical device major Medtronic bought Mazor Robotics, which makes spine surgery robots, for $1.6 billion. In September, Medtronic unveiled its robotic surgery platform Hugo-RAS, likely to come to the market within two years. This modular upgradable system has four robotic arms with surgical tools. Each arm, mounted on a separate cart, can be wheeled to different operation theatres for different surgeries. The FDA recently cleared medical device maker Stryker's Mako robot for total knee reconstruction. Stryker had acquired Mako Surgical in 2013 for $1.65 billion.