Experience at Mahatma Gandhi Cancer Hospital & Research Institute (MGCHRI)

One fine morning, we had a call from a patient inquiring about the feasibility of a Robotic Hysterectomy for a 140 kg female patient. Given the complications associated with morbid obesity during surgery, they advised her to attend the centers outside Visakhapatnam. By then, the hospital had performed over a hundred successful surgeries , but the problem was that they needed bariatric (long) robotic trocars and table extensions for such a patient. The anaesthesia implications because of the patient’s condition for the procedure (reverse Trendelenburg position) were a challenge. With thorough planning and an excellent anaesthesia and surgical team, they successfully performed the surgery. The patient was jubilant and grateful. She got discharged and went home on postoperative day 3.

In another instance, a young, nulliparous working lady diagnosed with rectal malignancy received neoadjuvant treatment planned for Low Anterior Resection (LAR). The patient wanted robotic surgery. The weight of the patient at 34 kgs with a BMI of 16.4 (underweight) and a petite frame became an issue. With unwavering confidence, they completed the multi quadrant surgery with careful Port placement. The team performed the surgery with no complications.

These are a couple of challenging surgeries among many others where the latest technology fared exceptionally.

Robotic Surgical SystemThe journey started in 2017. Being a standalone, comprehensive state-of-the-art cancer hospital on the East Coast, the management at MGCHRI wanted to induct the latest technology of the time into the system and provide the best services to cancer patients. Despite the exuberant procuring costs involved, they installed the first da Vinci® Si™ Robotic Surgery Technology in Andhra Pradesh at MGCHRI.

As only trained and certified surgeons from Intuitive Surgical could operate on the system, doctors from MGCHRI completed a meticulously planned basic training programme in India and advanced training in the world-famous institute for GI Surgery, Research Institute against Digestive Cancer (IRCAD) at Strasbourg, France.

robo testimonyThe first few cases were a hassle, but thanks to the intuitiveness and many well trained senior and professional proctors from all over India, who made it easy to steer through the initial phase. They enabled them to perform the procedure independently. Getting accustomed to the system and technology was the first hurdle. The excellent 3D vision with 10x magnification combined with the 8 mm wrist instrument with 7 degrees of motion, tremor elimination and motion scaling capacity enabled dissection of vital structures - even in the narrow pelvis precisely. Initially, they started with Extra fascial Hysterectomy and Pelvic Lymphadenectomy and later moved on to Radical Hysterectomy with Pelvic Lymph Node Dissection (PLND).

Especially, dissection of the ureters from ureteric funnels becomes much easier with the wrist instruments. Rectal resection needs mobilization of the large bowel both in the abdomen and pelvis while maintaining a clear circumferential margin. They must preserve the nerve which supplies the bladder and sexual function. The third arm retraction along with a dual-camera preventing fogging has enabled their resection with no complications. The same goes with prostatic resection where it is the gold standard.

The transthoracic oesophageal mobilization has to be done in a narrow space with zero margins of error without which it is a major catastrophe. The best part of the system comes when resecting a thymic man on a beating heart - timing the cuts without injury to the phrenic nerves and completing thymic tissue excision.

In all these cases, there were no intraoperative events. Minimal tissue handling along with minimal blood loss eliminated the need for blood transfusion. From a small postoperative pain to early recovery and discharge in 2-4 days comfortably became a norm. USFDA has approved a host of procedures, and these are the various procedures they have done.

They had a few postoperative complications like one scar neural, two incisional hernia at Specimen extraction site and two recurrences mainly because of one company. The cost of the procedure is another hurdle, which the patient can mitigate by decreasing the hospital stay and quickly resuming work. As more companies come up, the cost of instruments decreases and competitive pricing would help in bringing the costs down.

Author's Bio: 

With the current experience of more refinements in techniques and technology, ease of learning and performing without many complications, after completing 200 surgeries, Dr Kalyan says, Robotics will lead the new era and for sure, it is here to stay.