“Robotic surgery has huge benefits for surgeons”August 7, 2021
Dr Rani Bhat is Head & Senior Consultant – (Robotic & Laparoscopic) at Apollo Hospitals, Bangalore. She has performed close to 90 robotic-assisted surgeries for complex gynaecologic procedures and has been treating gynaecological malignancies like cervical, endometrial, ovarian, vaginal and vulval cancers, uterine fibroid, adenomyosis and endometriosis for over two decades now.
Dr Bhat has been involved in educating healthcare providers about the latest gynae-onco medical technology. She mentors sub-specialty registrars in surgical, medical and radiation oncology selected by National Board of Examinations (NBE), under the union ministry of health.
In an interaction with Divya Choyikutty, she speaks about the latest medical technologies in gynaec-oncology and the new programmes she is involved with for creating qualified gynaecologists, and shares her experience in the field.
What is the current level of application of robotics in gynae-oncology worldwide vis-à-vis India?
The application of robotic surgery is quite low in India due to two major possible reasons, but primarily, due to the lack of availability of the da Vinci / robotic surgical system. The first roadblock is the lack of infrastructure and the lack of robotic surgical system installations in the country. Even today, not many hospitals are equipped to perform robotic, assisted surgeries.
Secondly, we see very few surgeons trained to perform robotic surgeries, when it comes to well-equipped hospitals.
These are the two major reasons why robotic surgery in gynae-onco is lower than in Western countries.
Can you elaborate on the nature and scope of the current training module you offer to gynec surgeons?
When I started, I went to Hong Kong Queen Mary
hospital for my training certificate because India didn’t have any training center during those days. Now, we do have a few training centers for the certificate course in robotic surgery.
To-date, the interest towards laparoscopic or robotic surgery is very low among surgeons. I cannot outline definite reasons for the same. But the number of trained surgeons [required] to train junior doctors and the low number of robotic surgical system installations and training centres in the country could be some of the reasons.
Surgeons who undergo training would need a mentor to supervise and guide them through a few procedures initially. One challenge we face is getting the mentor to the centre. When there are limited trained mentors in a particular specialty, there is a logistic challenge. This can be resolved with more trained surgeons in robotic-assisted surgery and more robotic installations. The easy availability of a mentor during a procedure can also encourage junior doctors to take up robotic surgery as a specialisation in their careers.
On the other side, HCPs from other specialties lack awareness on the capabilities of robotic-assisted surgery. Usually, a patient’s first point of contact is a physician when they face any health-related issue and are referred to a higher centre for treatment. Now, when the physician is not aware of the latest treatment approaches, it limits their ability to advise patients on the various surgical modalities. Today, it is still rare that a patient enquires about robotic-assisted surgery as a treatment approach unless a doctor recommends it.
Hence, educational programmes on robotic-assisted surgery become imperative to drive awareness amongst HCPs. Realizing the need, we at Apollo organised one such programme before the lockdown for general physicians on robotic-assisted surgery, wherein we took them through videos on RAS and patient testimonials to help them better understand the advantages of such procedures in complex cases. This practice will also help clarify the common myths around RAS, such as the robot performs the surgery, whereas, in fact, it is the surgeon who operates with the help of a robot.
You are involved in upskilling health care providing (HCP) communities, including young gynaecology students, with the latest gynae-onco medical technology. What are those programmes?
Yes, I have been involved in upskilling gynae-oncology surgeons and training young gynecologists with the latest in medical technology. I teach sub-specialty registrars in surgical, medical, and radiation oncology selected by National Board of Examinations (NBE), under the Union ministry of health, to undergo Diplomate in National Board (DNB) training at the institution. I was the founder of a one-year sub-specialty gynecological oncology fellowship programme directed towards qualified gynecologists interested in gynae-oncology at HCG cancer hospital in Feb 2016. The program, well appreciated by the medical community, has continuously received high-quality applicants from all over the country every year since its inception. This fellowship programme is ongoing even at Apollo hospitals in Bangalore.
Currently, we have initiated a minimally invasive training programme (laparoscopic & robotics surgery) for young gynecologists and gynae-oncologists at Apollo hospital. We have also established an oncofertility program at all Apollo centers to provide fertility preservation options for cancer patients of reproductive age. We are basically providing the training in minimally-invasive surgery (MIS) because we are well trained in open surgery right from our post-graduation but do not have much exposure to MIS, both in laparoscopy and robotic.
As we have the infrastructure and resources at Apollo hospital, we have started an MIS fellowship programme wherein we provide training in both laparoscopic and robotic surgeries for both general gynecologists and gynae-oncologists. For now, RAS training is an observership that is theoretical in nature. Our future plan is to convert Apollo robotic center as a centre of excellence for the certification course and train the young gynecologist and gynae-oncologists in robotic surgery by providing them hands-on training.
What are the gynaec malignancies which can be better managed by robotic surgery compared to conventional techniques?
The latest technology in gynae-oncology in the surgical field is robotic-assisted surgery (RAS).
The advancement in da Vinci is notable, especially in the case of endometrial cancers, as the incidence of endometrial cancers is in women with high BMI. In my practice, 50%-53% of women with endometrial cancer are obese or morbidly obese. Patients with high BMI benefit immensely from minimally invasive surgeries such as laparoscopy and robotic surgery. Between laparoscopic and robotic surgery, the latter is helpful in obese and morbidly obese patients because performing laparoscopy procedures for such patients can be challenging, and therefore, the conversion rates for RAS from laparoscopy to open surgery can be very high. Consequently, I would say RAS has a huge advantage in gynae-oncology because we can now efficiently perform endometrial cancer surgery in high BMI patients and give them the benefits of minimally invasive surgery without compromising on the outcome.
Please share your experience in having performed several robotic-assisted surgeries for complex gynaecologic procedures. Do you think robotic-assisted surgeries could become an ineludible technique in treating gynaecological malignancies in the future?
Yes, robotic surgery, as I mentioned above, has huge benefits for surgeons. Since I’m trained in both laparoscopic and robotic surgery, I can perform equally well in both. But when you ask me the real difference with robotic surgery, the depth of field is limited in laparoscopic surgery as it has a 2D view. But the depth of perception is superior during robotic surgery due to its 3D view. In a gynae-oncology procedure, we are operating very close to major blood vessels and vital organs. So, when we have a proper depth perspective, the safety is much higher, and the margin for error is small.
Secondly, if you ask any laparoscopic surgeon, they will always say that they are dependent and, kind of, at the mercy of their assistants. Because of equipment demands for laparoscopic surgery, the first assistant needs to be well acquainted with the operative suite arrangements. Often, the most important role of the first assistant is operating the camera. Never overstated – the camera assistant plays a vital role in the success of the laparoscopic procedure. The optical dynamics during laparoscopic surgery requires momentary camera adjustments to accommodate operative maneuvers, be it for simple or complex surgeries. Prior training and familiarity will help the assistant to assist better. When the assistant doesn’t have experience, the camera is not stable, surgeries tend to get prolonged, exhaustion sets in, and the incidence for conversions to open surgery tends to be high. So basically, for laparoscopic surgeries, you are dependent on the efficiency of the team.
After performing robotic-assisted surgery (RAS) for many years now, the most important safety measure for a gynae-oncology surgeon is camera stability where the camera is under the surgeon’s control and also the assistant arm, which is a major advantage for us, especially when we are doing lymph node dissection or any suturing of vessels to control the bleeding deep in the narrow pelvis. The robot has wristed arms with great instrumental mobility for fine suturing, which is not available in laparoscopic instruments. These become the major advantages of RAS.
Cervical cancer, which is currently the second most common cancer among Indian women, is also one of the top ten causes of death in the country. What contributes to the high level of mortality of this cancer which is considered a preventable malignancy to a great extent?
Cervical cancer is a highly preventable cancer. But even in this era, the mortality rate due to cervical cancer is high as these are diagnosed at a late stage. Unfortunately, even today, patients come to us in advanced stages.
In urban areas, the incidence of cervical cancer has decreased because they are aware of cervical cancer screening and human papillomavirus vaccination,
which is available to prevent cervical cancer. But in the rural setup, the screening is bare minimum because of the lack of awareness and, more importantly, lack of facilities.
In rural areas, another prominent reason for the higher number of instances is early marriages, which leads to early sexual activity, early pregnancies, and multiple pregnancies. Basically, cervical cancer is caused by HPV, a sexually transmitted virus. Another cause noted in rural setup is lower levels of hygiene which opens the door to sexually transmitted infections, including HPV.
For that matter, when we look across the world, being sexually active at an early age with multiple sexual partners is one of the most prominent risk factors of cervical cancer. So, in the rural areas, early marriage, poor hygiene, lack of facilities, and lack of awareness and education are the reasons behind the higher incidences of cervical cancer compared to urban cities. And that is the reason why most of the cases that come from rural areas are in more advanced stages leading to the high mortality rate of a preventable cancer like cervical cancer.