Can robotic surgery work in India?

Day 3 of AAPI’s Global Healthcare Summit.

Dr. GhaniKOCHI: Day 3 kicked off with a special session on robotic surgery. Dr. Mani Menon, widely regarded as the godfather of robotic surgery, introduced the Indian audience to its concepts and how his team established the world’s first robotic surgery program at Henry Ford Hospital in 2001.

The ‘robot’ consists of a 3 or 4-armed machine placed beside the patient with instruments in each arm extending into the body cavity of interest. The instruments, including a camera, are controlled by the surgeon within an immersive 3D virtual-reality style console. The dexterity, magnification and precision afforded by this system, called the da Vinci, is breathtaking. Most doctors who use it for the first time comment on how intuitive it is. No surprise then that the company in California who make it call themselves ‘Intuitive Surgical’.

Dr. Menon showed a fascinating graph demonstrating the speed with which new technologies have been adopted over time; the uptake of robotic surgery for prostate cancer has exceeded that of even the Internet. In the U.S., over 80% of prostates removed for cancer are now done using the da Vinci, and Dr. Menon pioneered its use. Proven advantages include lower blood loss, complications, and a rapid recovery for the patient. The robot is now used in other fields such as gynecology, cardiac, head and neck, and thoracic surgery.

But robotic surgery has its critics and rightly so. The stumbling block for its dissemination in markets outside the U.S. and Europe is its cost. Produced by a single manufacturer with a complete monopoly and priced at $1.5 million, it is prohibitive in countries like India. Add to this, the instruments have a limited life span such that the cost for disposables may be as high as $2000 per operation. Not accounting for hospital stay and other charges, robotic surgery is therefore beyond the reach of the average Indian patient.

Despite these drawbacks, there are already 20 da Vinci systems in India (compared to 1900 in the U.S.). Its middle class population of 60 million (increasing to 200 million in 2015), with its rising living standards demands the latest advances in medicine be available to them too. In fact, over the next few weeks I will be visiting a few of these centers in India with Dr. Menon, with the aim of introducing new robotic surgeries suited to the healthcare needs of India (unlike the U.S. prostate cancer is not common because screening is not health policy).

Other speakers at this session also included Dr. Palanivelu, a world-renowned laparoscopic surgeon who owns one of India’s largest laparoscopy (keyhole surgery) centers in Coimbatore, and Dr. Paul, who runs a specialist gynecological center in Kochi. These are remarkable men who have been able to achieve high standards of surgical practice within the restrictions of the Indian market. They were the dissenting voices of reason when it came to the robot: everything boiled down to cost. Think how costly CT scans would be if it were manufactured and controlled by one company? In medicine, competition is vital.

Another member of the panel, Dr. Srivastava, head of the International Center for Robotic Surgery in Delhi, agreed. The monopoly needs to be broken and competition established for this type of surgery to break even in India. This highly respected doctor is putting his money where his mouth is; he is currently leading a consortium developing a new robot suited to the Indian market. My only concern is: will this robot run on Indian time?

(Dr. Khurshid R. Ghani is a Fellow at the Vattikuti Urology Institute, Henry Ford Hospital, Detroit, MI, with interests in Robotic Surgery and Endourology. A UK Board qualified Urologist who studied Medicine and Psychology at the University of Leeds, he was awarded The Urology Foundation Robotic Urologic Surgery Fellowship from the British Association of Urological Surgeons. He is the co-author of the textbook, Endourology: A Practical Handbook. He spent time as a junior surgeon in Zimbabwe and was awarded the Lindsay Stewart Prize from the Association of Surgeons of East Africa. He is married to Muna, who is the Manager of Executive Communications at General Motors, Detroit. They have two daughters, Hana, 3 years, and Sofia, 1 month.)

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