Robotics in cancer surgery – The way forward!

Life-saving surgical procedures performed by a robot sounds fascinating - and a wee bit scary! Due to developments in the West, this idea is no longer in the realms of science fiction, but a reality.

Though robotic surgeries have been practiced in the west at a few centers for the past decade, it is only in the last couple of years that their role is being established in cancer surgery. At present, a handful of centers in India are practicing this art and its scope and popularity can only be expected to rise as awareness increases.

The Robotic system is a revolutionary innovation devised for performing surgical procedures in otherwise difficult or impossible locations using specially designed robotic arms.  The robotic arms are controlled by a computer console which the surgeon operates using hand and foot controls - somewhat like a video-game, but a thousand times more precise and sophisticated. The endo-wrist attached to these arms can move in different directions and at multiple angles (270 degrees) - something that the human wrist cannot and therefore can dissect, suture and divide tissues with a precision that even the most dexterous surgeon cannot. 

An endoscopic camera provides a 3-D magnified view of the surgical field when viewed through the console; making structures like nerves, blood vessels etc. much larger and therefore more easily visible enabling faster surgery with more precision. Using small and hidden incisions surgeons can remove complex cancers minimizing tissue damage, hastening recovery and reducing hospitalization. Though the robot facilitates the surgery, it is the operating surgeon’s hand movements that are transmitted to the robotic arms and the surgeon continues to direct the operation. 

The motion scaling with tremor filtration that is incorporated in the newer generation robotic systems (da Vinci Si) eliminate tiny, uncontrolled movements in the surgeon’s arms making cancer surgery much more precise. In certain situations e.g. in Head & Neck surgery - specially designed retractors allow the arms to reach deep-seated tumors and structures using hidden incisions thus avoiding visible scars in the neck

In cancer surgery, the main application of this system has been in head & neck, urologic, gynecological and colo-rectal surgery. The various onco-surgical procedures that are being routinely performed using this state-of-the-art robot include;

Head & Neck:

Robotic Thyroidectomy

The technique of trans-axillary robotic thyroidectomy was first described by Prof Woong Youn Chung, a surgical endocrinologist at the Yonsei University in Seoul, Korea in 2005. The impetus for developing the technique was dictated by the high incidence of thyroid cancers in South Korea. A large number of these patients were young and were reluctant to have a scar on their neck, which a conventional thyroidectomy would result in. Prof. Chung had experimented with the endoscopic technique of removing the thyroid gland from the axilla, but was not happy with it. The procedure was cumbersome and did not offer satisfactory visualization of the thyroid gland. During that time, surgeons were already removing the prostate gland regularly for cancer using the robotic technique with excellent results. Prof Chung devised a special retractor (Chung retractor) to aid in keeping the subcutaneous tunnel created between the axilla and the neck lifted up during the robotic procedure. Between 2005 - 2012, Dr. Chung and his team performed over 3,200 trans-axillary robotic thyroidectomies on patients from across all over the world, majority (over 80%) of them for cancer of the thyroid gland.  Other than the excellent cosmetic results achieved, Dr. Chung also demonstrated the superiority of this technique over both conventional neck and endoscopic techniques in terms of faster recovery and fewer complications.

 

Trans-oral robotic surgery (TORS)

 Surgery for cancer of the throat – primarily the oropharynx (tonsil, base tongue) and supra-glottic larynx via the mouth.

G.I and Colo-rectal:

Robotic gastro-intestinal and colorectal surgeries through tiny abdominal ports avoiding large incisions and extensive mobilization of abdominal organs, thus hastening recovery and minimizing complications from these surgeries

Gynaecological procedures:

Including hysterectomy (removal of uterus for benign and cancerous conditions), myomectomy (removal of fibroids) and other pelvic surgeries.

Robotic radical prostatectomy:

For early and localized cancer of the prostate.

Many other indications are still evolving as the superiority of this technique over open and laparoscopic surgery is being established.  With time, robotic onco-surgery is expected to replace other conventional methods of cancer surgery and can be a real boon to patients suffering from cancer and many other related disorders.  There may come a day in the near future when a surgeon sitting in the convenience of his office may be able operate on a patient at a distant location with the help of the robotic system!

Apollo Hospitals experience

Last year, for the first time in the country, surgeons at the Apollo Hospitals in Chennai and Hyderabad successfully performed a series of ten robotic thyroidectomies through the trans-axillary route for both benign and malignant nodules of the thyroid gland under the supervision and guidance of Prof. Chung. It is expected that this revolutionary technique may be a boon for young patients in India suffering from benign and malignant diseases of the thyroid gland who may wish to have surgery performed without scarring of the neck.

The Head & Neck surgeons also performed a series of TORS procedures for cancer of the tonsil and base tongue.

In addition surgeons are routinely performing other robotic assisted procedures as described above with excellent outcomes.

Dr. Umanath Nayak,

Consultant Head & Neck and Robotic Surgeon, Apollo Cancer Hospitals, Hyderabad, India