Latest Da Vinci robotic surgery


Dr Irengbam Mohendra Singh
It sounds notes of a brilliance that Manipur, as far as I know, has at last, one neurosurgeon at JNIMS . His name is Dr S Parkinson, who I took to be an Englishman or American, as a private hospital in Imphal, is in the habit of employing, for immediate fame, retired or semi-retired heart surgeons from Delhi, to come and treat a few minor cardiac conditions, free of cost. Though admirable for short time, how long can these very expensive charitable surgeries go on? This reminds me of a top 1949 Hindi film , starring Suraiya: char din ki chandnni phir andhiyari raat hai (after four days of moonlight there is darkness again). Dr Parkinson is a major talent in neurosurgery for the long haul. I’m an old man, but because of my years of postgraduate training, I keep abreast of the progress in Medical science.
Dr Parkinson’s burr hole surgery in the skull and removal of a ‘sub-dural haematoma’ (see below) from the brain, saving the patient’s life, is the second very delightful news, after I wrote at the backend of last year, about the first Manipur-born heart surgeon Dr Athouba Arambam at Imphal Heart Institute. He shuns publicity when I interviewed him.
The good news came at a time when Robots are revolutionising very complex surgeries, giving hope to many patients who otherwise, would have died. The latest being a 57-year old patient, Bayram Dolukup, who has undergone the latest da Vinci Robotic surgery at University College London Hospital (UCLH) on February 26 2018, to remove his bladder with cancer and be replaced by a reconstructed bladder from a portion of his large intestine.
Imphal isn’t London. Nor was Delhi. It takes time, but healthcare in Imphal is catching up rather too agonisingly. In the early ’60s, when I did my internship at the then Wellington Hospital (now RML Hospital) for central government staff in Delhi, there was a kidney dialysis machine gifted from somewhere in Europe, but it couldn’t be used due to lack of trained doctors. In the 1970s, my elderly friend’s wife had to come to London for heart bypass surgery, known as coronary artery bypass surgery (CABG). I know modern Delhi very well, as I have been visiting and staying there for a week, almost every year en route to Imphal. Delhi, beginning with the Escorts Hospital at Okhla (1988), South Delhi, opposite the old Holy Family Hospital, and Apollo hospital (parent hospital in Chennai) at Indraprastha (1995), South Delhi, on the way to Noida, in conjunction with the Government of Delhi, have been performing CABGY, and more recently, with cutting edge medical technology, Off-pump or Beating-heart bypass surgery (without the heart-lung machine). The operation has become very common and safe. It’s like removing a gall bladder.
A subdural haematoma is a localised collection of blood (clot) from any cause such as a head injury or a stroke (pangthabi in Manipuri) due to a burst of an artery, on the surface of the brain but under the covering membrane called ‘Dura’. Burr hole is a simple surgery for a trained neurosurgeon, but it requires precision. It’s often life-saving, as haematomas can compress the brain tissue and cause life-threatening complications. A small hole is drilled into the skull with an air drill over the area of the clot and a tube is inserted through the hole to help drain the haematoma. But when the subdural haematoma is larger or more severe, an open surgical procedure known as a craniotomy will be required, cutting out a square flap of the cranial bone. Back to the Da Vinci robotic surgery in London. Da Vinci robots were created by the Californian-based ‘Intuitive Surgical’ at whose hospital’s urology department, the first pioneering robotic cystectomy (removal of urinary bladder) was carried out (1995). Thirteen years later, a da Vinci robot arrived at the Royal Marsden Hospital in London (2008). There are now 74 such machines on duty around the country, being used to remove 50% of all prostate, bladder, kidney, womb and tumours. It’s expected that, this year robots will take on an even greater role in Britain’s operating theatres.
Why Robotic surgery? It’s much more accurate. Patient will be left with only a keyhole scar. The robot’s wristed instruments can bend and rotate far greater than human hand. It allows the surgeon’s hand movements to be translated into smaller, and precise movements of tiny instruments inside the patient’s body. In the case of Bayram Dolukup, if he were to undergo an open surgery it would have involved a 7-inch long incision on his stomach, more blood loss and stay in hospital for three weeks, risking an infection. He would have left the operating room with an external bag for bladder to collect urine and manually emptied intermittently.
With precise scalpel work of the robot, controlled by a trained surgeon, he was up and about the next day and out of hospital within a week. He will have less pain, needing no more than paracetamol. He will have a working bladder within 5 months of leaving the hospital. He will have a better chance of retaining erectile function and continence.
The operation was performed by professor John Kelly, clinical lead at the UCLH urology department. He sat in one corner of the theatre in the first stage of the 5-hour operation to remove the bladder. On the operating table lay the anaesthetised patient, with his abdomen bloated with gas to give the surgeons maximum room to manoeuvre inside. Plugged into his abdomen was the robot’s thick, grey arms, three of which held surgical instruments, such as scalpel and cauterising scissors (that prevents internal bleeding), while the other a 3-D camera.
The surgeon has his eyes pressed to a 3-D screen and controls the Robot’s every move using not only his hands, but also his bare feet. He actually moves the instruments as he would in an open surgery. Only that he does it through a console that gives him a finer control and precision. Robotic surgery is labour-intensive. Mastering the robot to perform a keyhole surgery is in itself very difficult. Surgeons view the inside of the patient using mirrors. That means they perform everything backwards. Manoeuvring the robotic arms during the operation is very uncomfortable for the surgeon. They can only work for a couple of hours per day task. They often develop physical problems such as tennis elbow.
Professor Kelly says, after UCLH bought its first da Vinci robot in 2008 at the cost of £1.7 million, it was set to work removing cancer patients’ prostates and bladders. The procedure became so popular that, Sundays are Robot’s only day off. After Britain’s National Health Service (NHS) have bought a second da Vinci machine at half the cost, robotic surgery has become very widespread in almost all disciplines in the UK. “Today, I don’t tie a suture or use a knife to cut skin. It’s done with lasers and special devices. We are working with engineers to bring X-ray and MRI images onto the robotic screen. We are exploring energy devices that can see blood vessels and little probes that can tell us if there’s cancer elsewhere than the bladder.”
Robotic surgery is about only 12 years old. The idea originated at the National Air and Space Administration (NASA) in 1990s, which teamed with researchers at the Stanford Research Institute, US, to develop ways to provide surgical intervention to astronauts from a remote hospital.
Meanwhile, US Army surgeons taking cue from NASA, were thinking of developing such a system for remote operations on wounded soldiers under the direction of a surgeon who would be located at a safe zone, while researchers were also planning to expand the use of robots to civilian practice as well.
In 1995, a US company called Intuitive Surgical from California, developed a three-dimensional vision system and patient safety sensor monitors to create a trial product called the da Vinci surgical system. In 1997, Surgeons in Belgium, first utilized the machine for robotic cholecystectomy (removal of gallbladder). The system is so named because it is the first known robot in history like Leonardo da Vinci’s first study of human anatomy.
There is now the fourth generation da Vinci robotic system, used all over the world, in many specialities, and is specifically indicated for micro and complex minimally invasive surgeries in cardiac, colorectal, gynaecological, thoracic, urology and Head & neck surgeries.
As for Imphal, with one highly trained neurosurgeon and one super cardiac surgeon, I’m very optimistic about saving lives in Manipur. It’s pretty cool. What these surgeons need is public enthusiasm and a keen government interest in medical care, to save lives of thousands of people in Manipur. I recall my old days in Imphal, when diabetic and patients with tuberculosis died because they couldn’t afford to buy long term medications.
In this year 2018, beyond counting corpses, renaissance man, CM Biren with his luminous HM Jayantakumar, should set them apart from the other romantics in their ‘leap forward’, by sending native-born doctors with post-graduate degrees, for more specialist training. Perhaps I may draw them to Ho Chin Min who said: “To reap a return in ten years, plant trees. To reap a return in 100, cultivate the people.”
(The writer is based in the UK. Email; irengbammsingh Website: www.drimsingh.co.uk)

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