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Robotics in Surgery

Nov 18 | 1:30 PM

The use of robotic surgery has become widespread in nearly every surgical specialty in the 20 years since the US Food and Drug Administration (FDA) approved it. The technical advantages of robotic surgery over traditional laparoscopy are anticipated to be the driving force behind this transition. Robotic surgery is a new minimally invasive surgery method that is gaining popularity among surgeons and patients alike. Let us learn more about this novel trend with Dr. Raj Nagarkar, who will address the importance of robotics in oncology.

[Music] a very good evening everyone i'm doctor and i welcome you all on behalf of team netflix um today we have with us dr raj nagarkar surgical oncologist serving since 21 years so so before being surgical oncologist were an engineering student yeah you heard it right so there came a turn in his life and career it is when sir made a choice of being an oncologist and went on to pursue medicine so i started the first nabh nabl accredited dedicated cancer care hospital in maharashtra call it called as hcg cancer care center a comprehensive technological driven cancer care center whose sole motive is to support and serve cancer patients a very warm welcome sir thank you thank you so much that's it over to you sir uh thank you samantha and i think uh i would say that uh thanks netflix for this opportunity and uh i had in my mind while uh preparing this presentation that what the audience and what should i be addressing around uh i just one of the previous messages which called i think dr shakir he had a emoji saying that he is just an mbbs student so whether he is in the right place or no so dr shakir i would say you are absolutely on the right platform now because probably uh robotic surgery what you are going to talk about is it is going to be there for you for your generation and over the next 40-45 minutes uh all the participants who are there on this particular webinar i'm sure i will take you to the journey of robotic surgery the way it has been over the last two decades and what it has in store for us in the years to come uh friends in the last uh one and a half years the kovild era all of us have seen and realized the importance of health care in fact for those who are from the non-medical fraternity they have realized it much more so in the years to come the importance of technology and in health care is going to increase by leaps and bounds we are already talking about or rather we are already witnessing the era of artificial intelligence we are witnessing the era of personalized medicine we are now talking about cancer-related vaccines which are going to be around the corner very soon so let us start with what is the place of robotic surgery in the surgical armamentarium of every hospital so for those who are unaware about let me start in a way that robotic surgery this novel technology is actually a type of minimal invasive surgery and it is becoming more popular among surgeons as well as among patients quite a few doctors have this in their mind doctors and repeating again that robotic surgery means it is going to be a programmed robo which is going to perform the surgery where the doctor is probably sitting in the coffee lounge and shipping up a cup of coffee friends it is absolutely not that way we are not in a science fiction world robotic surgery is more of an extension of the human hands it is a surgeon who is operating but he has got the robo at his disposable so we really talk about it as a robotic assisted minimally invasive surgeon robotic surgery got fda approval in 2000 it's about 21 years ago 21 years ago robotic surgery got usfd approval and you would be surprised that it was actually got approval for cardiac procedures subsequently its use in neurology mainly prostatectomies and gynecological procedures increase and now it is used in almost every anatomical position in almost every anatomical region uh this if you look at the evolution of surgery i think uh friends i'm not sure how many seniors are there on this particular platform but a couple of messages which i'm reading are about mbbs students who are now part of this wonderful interactive platform i feel that i am blessed to be a surgeon to be born in this era because two decades ago when i started my surgical procedure surgical career i started as an open surgical procedure where i was involved in performing open surgeries subsequently in the last five or seven years i shifted to the laparoscopic platform and for last two years i am now regularly performing robotic assisted surgeries so very few surgeons if you look at our previous generation of surgeons usually they used to start the surgical career with one type of technology and most of them would retire with a similar technology so surgeon who has been doing open surgeries he finishes his entire career doing open surgeries only but in my last two decades of career i have seen best of all three worlds the era of open surgery era of laparoscopic surgery and the era of robotic surgery on this screen you can see three different clippings of videos of the same procedure the one on the left hand side is a open ideo obturator lymphadenectomy for a carcinoma of the endometrium chamber the same procedure in the second frame is being done laparoscopically and the same procedure is done in the third flame by robotic assisted so when we do an open surgery as we are all aware about it is a surgeon who is standing by the side of the patient where you have to have an access to the surgical part so it's usually in this radical hysterectomy so in uh open surgery you are performing either with the electrocautery or with the open set of instruments and directly entering into the patient's cavity and you have a one x magnification because you can unless you are using a loops to have a magnified image but usually in open field with the help of either your forceps or electrocauteries vessel sealing devices and you have to in order to have an access to that particular area you need to have a open procedure may be a long surgery so robotics the open surgery era was where you are opening up the patient's abdomen and operating in laparoscopic surgery it was again what we used to call it as a pinhole surgery values to enter the abdominal cavity with the help of a magne uh with the help of a scope and carbon dioxide or co2 is being used to create the pneumoperitoneum or a pneumothorax to enter into another cavity and and the instruments which were used which are being used for laparoscopy are usually 8 mm or 10 millimeter instruments and they have limitation in the range of movements most important part in laparoscopy is that there is a two dimensional image although recently a three dimensional images uh laparoscope also have come but it's mainly a two dimensional image and there is a restriction about the range of movements which can be performed as against that when you come to the robotic surgery the biggest advantage is that you are using a five millimeter instrument you have a 16 x magnification you are hearing it right you can actually magnify the image 16 times and you have a three dimensional image a three dimensional magnified image is actually what makes the trick because you can see things much better the chances of collateral damage injury to the surrounding structures is significantly less the chances of bleeding go down the risk of infection goes down and these are the major advantages of a robotic error so the era of robotic surgeries as of now there are two commercially available robots for the world on the left hand side what you can see is the davinci or the intuitive uh robot and the right hand side what you can see is the versus system of the cambridge medical robotics you can obviously make out that in robotic surgery the surgeon is actually sitting on a console and operating he is not standing by the bedside so for those young students or young mbbs grads who are aspiring to go into surgical field friends probably robotic surgery has one advantage that you don't really need to be in your scrub suits you don't have to scrub up you don't have to maintain that because you can just change into your ot dress you don't have to be gound you don't have to wear gloves and you can sit on a console and operate but the console is connected to the bedside units where in davinci it is a single vertical boom on which there are four bedside unit whereas in the cmr there are individual three independent bedside units these bedside units are under the control of the console where the surgeon is sitting and operating so you can actually perform the movements much more better here i would like to answer like you know for all those yeah my son is also a final year ambiguous student so for all those youngsters i would like to say most of your life or rather all of you all have been used to ps games you have been used to playing your ps3 ps4 and probably now the ps5 also for you all robotic surgery is more like a cook because it's more of the time like like the way you pay your ps games having your hand controller that is how robotic surgery can be performed this is the versus uh cmr system which i have and i have been i have performed more than 480 surgeries on it in the last two years and as a proud indian i feel that uh cmr has been like you know they always have been kind enough they say that i am the most experienced versus user in the world no other surgeon in the world has performed so many surgeries on the versus system other than me so as of date cambridge medical robotic versus system has performed more than 2000 procedures of which 480 have been performed at hcg monotonous so here as you can see there is a console on which i can see or the surgeon sees page surgeon is sitting in front of the console and he is controlling the entire bedside units using the hand controllers and the patient by the side of the patient there are scrub nurses or your assistant surgeons who is standing over there now what are the key features of any robotic surgery system or if i have to talk about the cmr system it is a portable system you can see the very small uh like no snugly fitting bedside units you can take from one ot to other the learning curve the learning curve is fairly easy as compared to laparoscopic surgery so if you are a good open surgeon you can definitely be a much better robotic surgeon because you have the added advantage of seeing a magnified image seeing a three dimensional image is better it is very easy to set up as usual the entire setup of cmr versus system does not take more than 10 minutes it is very ergonomic ergonomic in the sense that we always have been talking about benefits of any technology for the patients but what about the benefits to the surgeon laparoscopic surgery for those who have been involved in laparoscopic surgery would agree with me it really takes a toll as far as on the surgeon's life is concerned there's lot of strain on your neck on your shoulders and you tend to have backache much early whereas in and when it comes to long prolonged surgeries standing for eight hours ten hours in the over definitely is cumbersome against that the verses or any robotic system you can actually sit down on a chair relax and you can operate there is enhanced dexterity and precision dexter is dexterity in the mean that you can have a range of movements of 360 degrees human hand cannot have that much of range of movements here the versus or the robotic system gives you a 360 degree range of movement and obviously because it is a 5 millimeter scope and a camera which is just 10 mm you can reach into the easily or the less accessible parts of the body very very easily and the open console design which is there it helps to reduce the ache and pain of the surgeon it is ergonomically beneficial as a center is a clear communication between the bedside a team of assistants and the surgeons since there is a enhanced 3d vision you can obviously make out things much better in a much magnified manner the patient optimized port placement because see you cannot have in medicine two plus two is not always four there are every patient is going to be different you can you cannot have do a radical hysterectomy in a with the same port positioning for a patient who is 40 kg or a patient who is 145 kg the port positioning has to be little different for a same procedure in two different set of patients who are who have physically different uh expectations so patient access at all times is also very important and the biggest advantage is it works with your or setup you don't have to have a separate type of operation room you don't need a very big spacious room your normal or is sufficient to accommodate this machine so these are the parts of a robotic system which as i said there is a surgeon console which is there with the screen and those are the handheld controllers and these are the bedside cars or what we call it the versus bedside units and if you have noticed closely on your right side the position of the bedside unit is more like a human hand so it has got a elbow it has got a wrist on which and it has also got a the arm region on which you can actually do all the movements of the bedside unit similar to the human hand so obviously it is ergonomically much better now why the cmr system i think here the major part was that it is a robot for all surgical disciplines urology general surgery surgical oncology thoracic surgery gynecology most of the procedures can be done on this journey it is a cost wise someone had raised the question that is it very costly i think it is equivalent cause to most of the other available technologies and it is patient if you look at the cost benefit as far as the reduction in the duration of hospital stay reduction in the pain reduced risk of infection and early return to normalcy if you consider those factors it is definitely not a very costly technology as the usage is going to be more definitely it is going to be more and more cost effective there was an era where mobile phones were considered as a luxury but today it's more of a necessity i think i look upon robotic platform in a similar manner in the meantime mr dr pawan has just a question for me what are the key differences between the davinci robot and this i think the main most concern davinci robot has got a closed system where you actually have to engage your head to the console second thing is the bedside unit is on a single boom on which four uh arms are placed against this the velcro system has an open console where you need not engage your heads all your electro cauteries or your energy devices everything is on two handheld controllers it has got open console and the bedside units are individual bedside unit unlike the single bedside unit of davinci system by insomnia chandrasekharam she has asked a question a suture opportunity will be stolen no it will not be stolen by robot dear in fact you can do the suturing much better with the robotic platform unlike laparoscopic so it's it's not that in fact it's it's a it's a pleasure it is it's a wonderful experience to do the switching post ms yes you can learn robotic surgery i learned robotic surgery 17 years after i completed my mess so why not now so i think these controls i was what i was trying to demonstrate was if you look at the right hand side of the instrument on the screen that is a laparoscopic instrument and the left hand side there is a robotic surgery instrument so actually i was trying to try and demonstrate to you the difference in the range of movements which can be performed with the laparoscopic and the robotic and believe me i have some videos on youtube you all can see the videos there is a great range of movements which can be performed with the robotic instruments unlike the laparoscopic so actually you can see a wide range of movements which can be performed by the robotic instrument and which makes suturing extremely easy particularly in deep parts of the body where otherwise there are limitations for your hand to reach okay these are called as the endo wrist instruments the end of test instruments are fully listed endoscopic instrument and they give you 77 degrees of free freedom you can perform the movements in all directions in and have in a very very precise manner so obviously the suturing or surgical part can be very very easy so this is a slide uh where you can actually see the differences between conventional laparoscopy reserve is the robotic procedure obviously the advantages of robot assisted and the disadvantage also are highlighted over here so as i had mentioned earlier laparoscopy is a two dimensional endoscopic view whereas robotic gives you a three-dimensional endoscopic view in laparoscopy there is a hand-eye coordination has always been a challenge because you need to get tuned for the hand-eye coordination whereas in case of robotic surgery there is a normal hand eye coordination for you right is right whereas in laparoscopy your right is actually the left inside so hand eye coordination has some challenges which are overcoming robotic surgery in laparoscopic surgery there is a fulcrum effect which is nullified in the robotic surgery laparoscopy has five degrees of free freedom here there are seven degrees of freedom the haptic feed feedback haptic feedback you are not able to feel the tissues uh the major thing of open surgery is you can actually palpate you can hold the tissue in your hand you can feel it how it is soft hard or firm that you uh that part gets diminished with a laparoscopic and similarly it gets diminished in a robotic part also but believe me friends what you develop is something called as a visual haptic even if you are not able to palpate it by visualizing and by feeling the tissue with your instrument you can actually make out how firm or how hard it is that just a matter of experience when you get to it poor ergonomic positioning as i said for laparoscopic when the surgeon is performing he has to stand in a very very difficult position and usually it compromises on the health of the surgeon which actually is taken care in the robotic part what are the disadvantages of robotic assistance i think the major disadvantage which has been over the last two decade has been the cost of the instrument because davinci really dominated the market for first two decades and the cost was humongous which really did not make it possible for every hospital or every patient to have the benefit of it absent haptic feedback as i mentioned since there is a loss absence of absolute haptic feedback you can overcome commit by a visual haptic which can be developed the setup was said to be little difficult and position was a challenge however that has now been overcome by the versus system and it has uh the even if you can have a visual haptic feedback and second part what major uh really makes a pay as you go on using it more and more the cost definitely is going to come down for robotic surgery also what are the use of robotics you know the robotics use as i mentioned so uh when we talk about robotic surgery now everyone questions that is it really good because see or is it market driven is it that the market is actually pushing the hospitals to perform more and more robotic surgery so what is the evidence now if you look at the evidence over the last two decades there are certain areas where definitely it has been proven that robotic surgery has uh like you know comparable results to laparoscopic surgery in fact in some places where it is even better the for example in lower rectal resections when we do low low anterior resections actually a robot assisted a procedure a systematic review and a metal analysis which has been published to look at the functional outcome they said the return to normalcy particularly the bladder function is much better with robotic surgery as compared to laparoscopic surgery yeah perfect right yeah okay so friend this is a robotic low anterior resection video which is there so what i have done is uh what you can it is a lady who is a case of carcinoma rectum who has undergone new adjoint chemo radiation and now i'm planning a robotic low air so while you are seeing that on the left hand side i'm having a bipolar grasper and the second right side i'm using a hook which is a monopolar hook and you can see i'm just going on smoothly dissecting out the instruments my assistant is actually sitting on a chair and the entire procedure is being controlled by me the camera is under my control i don't have to tell my assistant show me this is the area where i'm operating that is the posterior tme plane which i am taking if you can see closely because of the magnified image such small blood vessels can be so clearly so closely been seen there is hardly any bleeding you can dissect out one advantage of having a pneumoperitoneum with a carbon co2 is that there is a increased intraperitoneal pressure so obviously small small breeders with the pressure gradient can be controlled very very easily and you go on smoothly performing i am just this is the posterior tma dissection as we call taking away all the tissue from the dissecting the tme plane in rectal cancer or in any cancer surgery it is extremely important that your plane your dissection has to be clear it should not be a blunt dissection where you are just thrusting your hands inside the patient's body if you have noticed closely how smoothly i change the direction of the tip of my hook from left side to right side and i continue doing so that is the anterior dissection close to the uterus as i mentioned it's a female patient and that is the dissection going into the right para actually at my screen i'm seeing the screen little whitish but actually when i operate you can see a beautiful 3d something like a 4k image which is there on your screen and all the blood vessels can be easily be tackled the dissection continues anteriorly that is the dissection in the between the rectum and the vagina and that dissection is anteriorly that's a vagina being dissected anteriorly the entire tumor with the tme plane which is a good circumferential resection margin crm has to be clear because if you do not have a clear crm you are compromising on the oncological principles and the same dissection continues now on the left side usually for doing a low anterior resection of rectum using a robotic technology it takes about two to two and a half hours of procedure here i am taking the inferior eccentric medical the imei the blood vessels are being taken it can be taken initially along with the nodal dissection however because this lady had a very redundant sigmoid colon which is common in indian patients hence i preferred doing the paradise section earlier and once the vessels are being dissected here i take the benefit or the advantage of my bedside colleague i request them for putting a clip so here my bedside colleague has just put in clips at the imei and i will be cutting the iron with the monopolar or there is a hot scissors as we call it we can comfortably cut it continuing with the dissection uh we dissect out the left ureter if you notice over there there's a left urethra which is coming out and we continue for the dissection of the pararectal tissue earlier uh for rectal resection now in this particular patient the tumor is hardly about four to four and a half centimeter from my inner verge where abdominal perineal resection and a permanent colostomy was thought to be mandatory however now you can safely perform a low anterior resection using a stapler anastomosis so patient does not need to move around with a permanent stoma so that's how if you have noticed the entire dissection on the pelvis is complete now i am dissecting out the sigmoid colon i identify the level at which i want to transact the sigmoid colon after mobilizing the descending colon from the splenic fracture and at that point once i know that i can safely smoothly take this part of the sigmoid colon into the pelvis i now dissect identify the area and i use an endo stapler this is a endo stapling device where i will be stapling the rectum below the tumor and at the same time i will also be cutting it so that if you have noticed it that's the endo stapler it while it when you fire it as we call it it cuts and it also puts in three layers of staples on either side so here this is the second stapler which is being fired and you can see the entire insta the colon can be brought out from the ileostomy side the proposed ideo certain stomy side this is the distal part of the rectal pouch which is there and now a circular stapler is being put from the inner canal and the proximal part of the large bowel is now being announced most to the low rectum if you notice it is below the periperitoneal fold so the anastomosis is around in the range of four to four and a half centimeters from the inner verge once you fire that the anastomotis anastomosis is checked by installation of saline under pressure from the inner region i usually do not open up the procedure patient the entire tumor is delivered outside the body from the ileostomy side and from the same side the eyelid stomach is being done so no major scar on the abdomen patient can be made to walk after six to eight hours on the second day of like the first day after surgery patient can be started on oral liquids and usually by third day patient can be discharged the ileostomy which has been done to safeguard the anastomosis can be closed after two to three weeks or after completion of chemotherapy if you look at the number of publications in robotic rectal surgery you will realize that from 2011 till 2016 in five years the number of publications had increased by leaps and bounds indicating clearly that there is an increase place for robotic surgery in rectal surgeries this is another video of a robotic assisted esophagectomy esophagectomy was always thought about as a very very morbid and a major procedure so the in thoracic this is the esophagectomy three stages usually start with the thoracic part after the completion of radiation six weeks after radiation the patient is placed in a semi-prone uh dorso lateral position these are the four ports which we put the two ports are 5 mm two ports are 10 mm and this is how the esophagus as you can see starts mobilizing it from the inferior pulmonary vein the dissection is being done and you clear off all the lung ligament lung attachments take up the mediastinal pleura start dissecting it from the aorta oh yeah if you can see that posteriorly that's the aorta that's the descending the posterior dissection is being done ensuring that all the fibro fatty tissue the nodal tissue comes along with the main specimen you should not be keeping it back that's been the major advantage of robotic as i have been saying that since you can see things very clearly because things can be visualized well and a magnified image you can obviously do much more justice to the dissection see small nodes actually the node is sub centimetric but because of the magnified image it looks like a huge boulder sitting over there and the dissection is done in such a way that the esophagus along with the fibro fatty tissue is taken away from the aorta at the back from the heart in the front the pericardium is there lower down that's the dissection at the cardia where the gastroesophageal junction is dissected then you just loop the esophagus to retract it this retraction is done by the assistant and the dissection continues up towards the infra azygos part of the dissection as we would called it now because we can see things well small blood vessels also can be magnified if you can see just at the upper part over there there is a thoracic duct which is running along the entire course so you can take care of the thoracic duct make sure that you do not injure it yeah dr jashim wants a gynecological procedure well i have a video of a radical hysterectomy i'll play it after this i know it becomes really harsh for gynecologist to see use of effective videos but please bear with me for another five days so there is a azygos part of the dissection where the azygos mean is being dissected you ensure that all the nodes the parallel nodes uh are being dissected and taken away yeah and once you have dissected the azaleas will add the suprasight as part of the dissection then i request my assistant to clip the zygas okay because it becomes slightly safer particularly when you have a large size of the tumor to dissect it down and now the dissection continues right up to the root of the neck ensuring that we do not damage the recurrent line is non-recurrent laryngeal now and also do not damage any the other the inferior subclavian over there that is the hiatal dissection that is the thoracic duct as i just demonstrated over there uh in the initial part i was not doing it but now i regularly clip the thoracic duct do not want to take risk of a high leak over there once the thoracic part is completed we place the patient in the supine position and start the abdominal part of the dissection and my assistant my colleague he starts the neck dissection where we open up the neck and do the neck lymphadenectomy and prepare the esophagus fine once the hyatt dissection is being done you can see that is the left gastric vessels which have to be clipped and [Music] once the left gastric vessels are clipped and the body side is clipped the specimen side you can use a harmonic or ligasure that is the node at the celiac which has been done that's the greater momentum [Music] which is being dissected as the left is the short gastric vessels which are taken and when the entire stomach is freed from that you make a small incision in the epicastic region deliver the stomach outside along with the esophagus over there's a tumor prepare a stomach tube and you anastomosis in the neck so it can be so comfortably done where patient can be made no need of long term ventilation patient can be excavated on the table and after extubation you shift the patient to the icu next day i start ambulating the patient and you can patient can be ambulated on day one uh day one i usually start the patient on nasojanal feeding or jejunostomy feedings can be started day five we do a oral contrast ct scan to assess if the healing has occurred and if the healing is fine pressure all the tubes can be removed and patient can be started on oral and discharge so because you are avoiding a thoracotomy the pain definitely goes away the risk of atelectasis the risk of pulmonary infections go down significantly and obviously the morbidity of patients comes down each other and with the cross protocol and the multidisciplinary team approach in management of malignancies now the survival advantages also have been immense now what are the robotic surgeries which have got a definite benefit carcinoma prostate where there is a nerve sparing prostatectomy i think best one or if i have to say the indication for robotic surgery it would be a nerve-sparing robotic prostatectomy because i i think hardly anyone does laparoscopic robotic radical prostatectomies because the nerve swelling have very good results even for partial nephrectomies for renal cell carcinomas robotic surgery is the best technology which should be used when it comes to the thoracic cases you can metastatic medicine for ca lung veg resections lobectomies can be done very well by rats or video assisted thoracoscopic surgery and in using the using the robotic arm this is a thymoma which had operated using the robot versus robot and you can see that it is a very very uh comfortable procedure for the patient because within 48 hours the patient can be discharged from the hospital surgery for carcinoma of the endometrium is one of the best procedures uh which should be done this is the video of robotic radical hysterectomy robotic assisted radical hysterectomy what is the scope for versus neurosurgical procedures uh dr prasanna at this point of time i do not feel any of the neurosurgical procedures are being done on the robotic platform what we do is gynecological urological thoracic gi all gi procedures i have done a weapons also where i do usually as a hybrid procedure i have done esophagectomies thymectomys taurus transoral robotic surgery is also possible with the robotic procedures particularly for based on tumors posterior pharyngeal wall tumors recurrent shear tonsils small areas where they can be very beautiful and very nicely been done by the robotic procedures yeah rosa robot is available for neurophysical procedures i think that what we are talking about is the either davinci or cmr uh i would be very honest i do not have much information on knowledge about the rosa robot so it will be wrong for me to comment about it i have another two short videos one is about a radical hysterectomy and one is of a simple cholecystectomy in fact that's one procedure i have although as a surgical oncologist i was not doing very frequently but on the report i have been doing it cholecystectomy as well as inguinal hernia procedures simple procedures but they really can be done wonderfully and it becomes more like a daycare procedure hardly any analgesic requirement for the patients i've seen one thing between laparoscopic and robotic procedures the pain require the pain post-operative pain at the port site is extremely less in robotic surgery probably because the traction is less what is the time taken for a total hysterectomy benign hysterectomy 35 minutes i was just answering dr krishna priya for a benign total hysterectomy it is 35 minutes patient can be discharged next day evening for a radical hysterectomy it takes around two to two and a half hours because in radical hystectomy the major domain becomes the lymphadenectomy as well as the entire para being cleared how does a doctor get to learn robotic surgery it's like you know now uh i think when i graduated when i did my masters and my super specialization there were there were no robots available in india or very few it was like you know it was only for a selected group of consultants in some major institutes only but now robotic surgery is gaining there are close to 100 robots in india now and i i think it should be part of a routine curriculum where students are exposed to robotic surgery i have my dnb surgical oncology residents who are working with me i make sure that they take care of majority of the procedures related the pre-pressure the docking the port placements as of now i have not given them independent free hand to operate but the final year residents they would be going through the robotic surgical training program on the it's like you know virtual trainer it's called as a vt on virtual training you spend about close to six to ten hours on the virtual trainer then you do it on the animal models and once you do then followed by that you can do pasha perform on uh patients it the learning curve there is definitely a learning curve on the robotic surgery it took me about 30 to 35 cases my surgeries to get used to robotic procedures so if earlier i was taking about one hour for a hysterectomy now i can do it in 30-35 minutes cholecystectomy it takes hardly 12 to 15 minutes to perform a cholecystectomy esophagectomy the thoracic part of each of the economy can be easily completed in 45 minutes so uh it is it is there anything you use repeatedly you use diligently keeping your ethics and protocols in place in the interest of the patient i think almighty will always bless us and we'll make sure that we excel in our own specialities at the same time while i was talking about all the advantages of robotic surgery there are certain alarming facts also colon surgery gastric cancer surgeries robotic surgery and laparoscopic surgery have shown to be having a equivalent results similar outcomes but there are some surgeries where there are alarming results for example cervical cancer cervical cancer that was the ramirez study which was a major whistleblower and raised a red flag whether we should be doing minimal invasive surgery in cs cervix so as of now we are not doing uh radical hysterectomies for carcinoma cervix without proper consent of the patient because there have been risk of unusual site of recurrences similarly in bladder cancers there have been evidence of a typical recurrences after robot assisted radically structured radical systems now what are the barriers for a body i think most of you all who have been sending messages have been are mbbs residents i think these are these four questions or this slide is for you what are the barriers for robotic surgery to be part of routine surgical armament i think the first important barrier is difference in opinion among surgeons involved in cancer care second one is the high cost the third one is the translation of immediate benefit from the resulting long-term surgical outcomes and fourth one is suitability of robotics in advanced diseases these barriers can definitely be overcome by increasing the enthusiasm in young surgeons i think all senior surgeons all middle age surgeons should uh promote they should support uh junior surgeons to and get them involved in the learning processes and the surgical techniques because believe me i feel that my younger generation is definitely going to be more smarter much better than me until and unless i involve them along with me in surgeries i am not be able going to be a better surgeon the second barrier about the cost is definitely going to be overcome in the years to come because of more number of robots and in fact again i would be saying that i am a proud indian because in our own delhi we have dr srivastav who is doing who has planned for making india robotic procedure uh well dr ketul there is a question how important is haptic feedback in robotic surgery honestly speaking not much because the visual haptic actually takes over the advantage of a haptic feedback the third barrier about the use of robotic surgery in cancer surgery can be overcome by proper long-term documentation until unless we document we will not be able to improve and the last barrier like you know is the caution for robotic surgeries because over enthusiasm in anything not only in robotic surgery over enthusiasm is going to be bad and any like no uh or poor oncological outcomes just for the sake of doing robotic surgery should be condemned and there should be proper guidelines for do's and don'ts in robotic surgery in advanced cancer what are the benign conditions in which robotic surgery definitely has a role i think as i mentioned simple cholecystectomy extremely good though now majority of our gi's colleagues and general surgeons do laparoscopic cholesterol is very well but yet there is that odd chance of risk of injury to the cbd or necrosis i think when you have a good magnified image a 3d image that risk of injury to the adjacent structures can be taken away and there is robotic surgery for cholecystectomy is there this is a robot the cholecystectomy video i think that's yeah okay thank you so much so that's a uh cholecystectomy video for a year this was a young guy who is basically i.t engineer who one wanted to be back on his uh desktop uh within fastest possible time so you can see that this is a robotic surgery for being done for a simple cholecystectomy with the robotic assistant and because of the magnification and three-dimensional image it can be done so beautifully without causing any damage to the surrounding structures and you can dissect out the cbd there's a cystic duct which can be so clearly the cystic eye tree can be uh identified separated clipped properly so like you know you can rest assured after doing the procedure that you have not caused any harm to the surrounding structures for this patient that's the scissors and once you have the we have taken the duct and clipped then you go on for the dissection of the rest of the gallbladder from the your bed there's hardly any bleeding there's hardly any pain usually the patient can be discharged the same day patient can be made to walk after four hours and started on overalls after four hours and that that's actually what we are looking forward to risk of anti infection is less risk of bleeding is less pain is less this is a case of endometrial adenocarcinoma uh 66 years old lady that's the opening up of the right pelvic peritoneum i think uh as a uh the madam who requested for a hysterectomy video gynecologist i am sure she must be doing his laparoscopic procedures uh the biggest part or advantage of robotic is like you know you have the camera under your own control so you don't have to depend upon your assistant no wonder how good your assistant is but that's a unit of you can see very clearly very closely you go on dissecting that's the round ligament which is being taken and you continue with the dissection anteriorly and the para vesicle area that's the all the tissue over the external eye like artery vein is taken that is the nodes between the artery and the vein can be taken so smoothly beautifully yeah minimally invasive surgery or robotic surgery has to be better than open surgery you cannot be compromising on the quality of radicality of your procedure as i mentioned particularly in case of cancer because here it's not about cosmesis or pinhole it is about first part is your survival advantage yeah that's a resection of is a bright parabolic uh ideological dissection the vein is being dissected completely and while you just pull with your grasper on one side it just starts falling away from the vein so you don't really have to take efforts to dissect out the or retract the vein that's the obliterated umbilical intelligent tree which is there yeah there's obturator nerve you can see being dissected c endometrium large nodes that's the uterine artery which should be clipped at the origin it's obviously obliterated umbilical ligament dr marzi mehta has a question what is your experience with robotic say honestly at this point of time cmr versus does not have robotic stables so we are using the laparoscopic staplers only that's the separation from the bladder here we do not because it's a ca endometrium uh it is just a vaginal manipulator has been put there is no uterine manipulator which has been placed because we do not wish to manipulate the tumor unless it can cause a seedling from the fallopian tubes you can go down dissecting the bladder and then we continue by opening on the left pelvic peritoneum and the same procedure continues on the left side now complete the entire lymphadenectomy on the left side so i will not play the entire video of the left this section because we were like yeah this part is mentioning look at just i think just observe the way in which the movement of the instruments is being done if you look at the range of movement which the instrument offers this type of movements cannot be done with the laparoscopic instruments and i think that is what is the advantage plus you can do low down deep i am going into the pelvic floor all the lymph areolar tissue emphatic tissue comes out as obturator now which is popping up over there now usually follow the no touch technique we do not touch the object now at all only hold the surrounding tissue there's the paraviginal tissue and we've opened up the vaginal world and that's the as i mentioned the vaginal manipulator under vision we can close surely see that having a good margin is important once it is being cut then the specimen is delivered vaginally once the specimen has been delivered by generally then the suturing of the vaginal wall starts the patient can be made to walk around after six hours once and discharge after 48 hours usually in radical hysterectomy one simple instruction which they have to follow is for at least seven days we ask them not to squat not to sit down another very good procedure which can be done robotically is a robotic healers myotomy which can be done again a wonderful procedure robotic fund application can be done very very nicely as i mentioned earlier in vinyl hernias as compared to standard laparoscopic harness rafi robotic surgery definitely gives a wonderful experience another procedure is the robotic the transferal approach the robotic thyroidectomy unlike the trans axillary approach young patients a small size thyroid nodule who are reluctant to have a next car you can do a very good robotic transfer thyroidectomy benign gynecology as i mentioned that mainly for hysterectomies ovarian cystectomy endometriosis endometriosis is one such procedure where usually gynecologists are little careful cautious mainly because of the anatomy and the dissection i think that part can be taken care with the robotic assisted procedure neurology majority of the urology procedures beat piloplasties donor nephrectomy cystectomy adrenalectomies the vvf repairs read implantation bladder augmentations urinary diversions i think most of them can be done in benign neurology when it comes to malignancy the robotic prostatectomy does remain a gold standard along with all of the procedures so greetings from hcg manota cancer center which is situated at nasik and i would say that thanks for giving this opportunity i in this short time i i think i tried to do some justice to the topic which is a very vast topic and i'm sure all those mbbs residents it would add some value in inspiring you all to take up robotic surgery career because in the years to come kids i would say that that is the future and please keep your eyes open because the future is bright and robotic cannot be shied away it is going to be part of every surgeon's hand thank you so much thank you sir so there is a question uh from dr sakshi what's the scope of robotics in pediatric search pediatric surgery as i mentioned pyloplastys can be done very well particularly pediatric urology but at present the versus system which is there the cambridge medical robotic the challenge is that the arm in the instrument arm they cannot be used for a small site like you know for pediatric patients usually you need very short instruments so it is not being done but pediatric robotic procedures on the dimension system are definitely being done so um so there's a question from dr norman uh the robotic system and bedside unit used for abdominal procedures can be used for doors or heads the same bedside units will be used in fact there are four bedside units one bedside unit is used for the monopolar arm one is used for the bipolar cautery one is used for the retraction or for the grasp and fourth one is your camera the endoscopic bedside unit so they can be used for thoracic procedures abdominal waste procedures pelvic procedures transferable procedures also so dr mano is saying great session sir doctor satan is also saying thanks so very great session very informative has a question i just missed out on that about trichostomy there was a question yes sir how it will help in trichostomy and ota procedure and it's equivalent and triggers for me it will not help because trichostomy is something which has to be done either trans it has transcutaneous either you can do the uh like railroading technique or a open trigger so robotic intercostal so there is a question from dr shivam um so can we expect ai assisted robotic surgery anywhere near definitely yes yes in fact i'm working on an app where we are now looking at we are starting with oral malignancies like you know we are trying to accumulate the data of more than 100 000 images of oral malignancies and it is going to be put on an ai platform and i am sure it will see the light of the day where a patient can actually click the photograph of his oral cavity and put it on that app and tell self-diagnose whether this is a pre-malignant condition or a benign oral leukoplakia or is it a malignancy so ai is definitely there and i think as i mentioned initially last two years the way uh healthcare has seemed like it's gone through a turmoil there were people who were raising fingers against us but now we realize the importance of healthcare and it's going to be a boom it's like we always used to talk about the i.t sector boom and all this i think as doctors let us be proud enough to say now it's going to be a healthcare boom which is coming for for good healthcare boom for the benefit of society that's very interesting so that's great um so we have a question from um dr pawan has are the robotic arm instruments of cmr versus i'm sorry i could not read the whole thing can you please read it up for me uh yes sir are the robotic arm instruments of cmr versus reusable or single use compared to that it can be used for up to 13 to 14 surgeries right so so dr sanchita is saying honored to be a part of this amazing explosion very well experienced dr umbal is saying it's very informative presentation so so we have a question from dr radi uh so she wants to know about the views on robotic tonsillectomy ah not for benign condition because i think see as such with the advent of better antibiotics our oral hygiene has improved so the need of tonsillectomies as such has gone down significantly like you know for those who need tonsillectomies or trans oral transplectomy can be very easily cost effectively performed i would reserve my indication as translectomy by robotic only for that group of patients who have got a carcinoma of the tonsil post radiation patient has completed radiation and yet there is a residual small tumor that who has got an adequate mouth opening that's group of patient i would advise a transferal robotic surgery otherwise it would be a waste of resources see you have a good technology but the technology is good only in the right hands you should not misuse it yeah right so um so can we take one or two questions i think there was one question i missed out i think it was uh someone was asking what is the role for paramedics what they would like to do yes sir i think there are quite a few surgeons who are enthusiastic to learn robotic surgery perform robotic surgery however there is a dearth of paramedics who would be supporting and assisting in robotic surgery so in fact i would i i missed out the name i think dr or mr guy please if you are keen if you are a paramedic please take up an either a nurse's training program in robotic surgery or ot assistant training program in robotic surgery believe me you will be more sought after than other than doctors so thank you so much for a wonderful session i'm looking forward for your next session thank you so much look forward thank you thank you wish you all the best thank you so much

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Dr. Darius Justus & 861 others

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dr. Raj Nagarkar

Dr. Raj Nagarkar

Managing Director & Chief of Surgical Oncology and Robotic Services, HCG Manavata Cancer Centre

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dr. Raj Nagarkar

Dr. Raj Nagarkar

Managing Director & Chief of Surgical Oncolog...

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