Amrita Centre for Robotic Surgery TrainingJune 9, 2019
Technology in surgery has seen several leaps of advances in the past few decades;. from conventional open surgeries to minimally invasive procedures such as laparoscopic techniques, video-assisted thoracoscopic surgeries and more recently, robotic assisted minimally invasive surgeries. These innovations and technological advances are primarily focused on improving surgical procedures so that the final outcome in terms of hospital stay, procedural time, blood-loss, and post-operative complications such as infections and pain, are considerably reduced.
Robot-assisted minimally invasive procedures are a fairly recent development in the field of surgical science. These types of procedures mainly involve the use of computer assistance for performing an array of surgical manipulations through the smallest of incisional openings. The use of robotic assistance has several known benefits, including improved procedural dexterity, ergonomics, safety and ease of surgery, all of which translate to improved patient outcomes. Some of the major surgical specialties that have embraced robotic assisted procedures include gynecology, urology, gastroenterology, and thoracic surgery.
In terms of the actual procedure, one of the primary advantages of using robotic assistance is the magnification of the surgical field that is available to the surgeon. To put this in context, surgical procedures performed under conventional techniques do not allow any magnification of the surgical site, while moderate magnification (2.5 times) is obtained in laparoscopic techniques. However, robotic assisted methods allow up to 10 times magnification, which by far is a significant improvement compared to its predecessors, and also makes a huge difference in how the surgeon makes operative decisions during the procedure. The second and perhaps the most important advantage that robotic assistance provides is the way surgical instruments are negotiated within the surgical site. In open surgeries, the surgeon directly holds the instruments, while in laparoscopic techniques, the surgeon uses the instruments by viewing them through a screen that is connected to a peripheral camera. However, in robotic assisted procedures, the surgeon maneuvers the instruments via a console. This console-based control of surgical instruments, in addition to the enhanced magnification of the surgical site, provides the surgeon with an increased ability to be dexterous and perform difficult surgical maneuvers with ease.
Simple to learn
Considering the advantages offered by the newer, minimally invasive techniques, it would appear that their acceptance would be widespread. However, adapting to viewing through a camera in laparoscopic techniques and maneuvering instruments through an indirect console in robotic assisted techniques is something that needs skill-based adaptation for the surgeons. Even leading surgeons may be unwilling to perform procedures involving newer techniques without training. A well-known example is that of Dr. Robert Cerfolio, previously at University of Alabama and presently Chief of Clinical Thoracic Surgery, NYU Langone Center, New York, who is a leader in the field of thoracic surgery and has performed thousands of thoracic surgical procedures. According to Dr Balasubramoniam K. R., Cardiothoracic Surgeon at Amrita Institute of Medical Sciences, Kochi, “Even though Dr Cerfolio had performed countless open surgeries, he was initially unable to adapt to the video-assisted thoracoscopic surgeries. Nonetheless, Dr. Cerfolio went on to do thousands of robotic assisted surgeries and is currently one of the leading surgeons utilizing robotic assisted techniques in his field.” Dr Balasubramoniam underwent robotic surgery training at the University of Alabama and has since then performed over 150 robotic assisted surgeries in the past few years at Amrita Hospital. He recognizes the true benefits of this technology and highly recommends the need for training and procuring the skills required for performing robotic assisted surgeries.
Such advances in technology undoubtedly come with unique challenges in terms of bringing surgeons up to speed and can require significant training to develop the special skill sets required to use the new technology. While all new techniques require training, some techniques are easier to master. Robotic-assisted techniques are simple to learn, and due to the significant improvements and benefits of using robotic assistance, surgeons worldwide are embracing this technology. However, formal training and competency assessment are required. Many of our renowned, experienced Indian surgeons have had to go abroad to complete training for robotic assisted surgeries, spending money and valuable time out of the country. A training centre in India was a growing need, and this was accomplished in 2016.
Dr A K K Unni, Professor and Head, Central Animal Facility, Amrita Institute of Medical Sciences, Kochi, explained to me how it all came about over a cup of tea and cookies. “Intuitive Surgical Inc. reached out to our Medical Director to set up a training center at Amrita hospital. Why Amrita you may ask? One of the major requirements of a training centre is an animal facility where training can be undertaken in large animals. Amrita hospital already had a large animal facility and was able to provide the necessary support required. Being a leading center for postgraduate education and research, we also felt that there was a dire necessity for training potential surgeons in robotic surgical techniques.’
The first and until very recently, the only robotic surgery training center in India, Amrita Centre for Robotic Surgery Training and Animal Cath Lab is a productive collaboration between Intuitive Surgical Inc., and Amrita Institute of Medical Sciences. This is a symbiotic relationship where Intuitive Surgical Inc, which is the only company that makes the da Vinci system for robotic assisted surgeries, provides trainers for the robotic assistance equipment and Amrita Hospital provides the infrastructure, manpower, facilities and the animals required for training.
Dr Unni has laid out some basic requirements for the training programme to ensure that the programme is not misused. He has put in place a minimum academic qualification of MS or MCh for a surgeon to be eligible for this training programme. The surgeon’s affiliation hospital must have their own robotic unit or the surgeon should have prior robotic surgery exposure. Further, the surgeon’s institute must give an assurance that the surgeon would be allowed to pursue and utilize his training skills after the training is completed. Once the surgeon is found to be eligible to undergo the training programme, he/she must first go through an online course before visiting Amrita for a 1-day training session. The session starts with dry training on the state of the art da Vinci surgical system to familiarize the trainee with the system and the instruments, followed by wet training where surgeons get hands-on training on anesthetized pigs. They undergo training that covers a series of exercises, including dissection, ligation of vessels, suturing and energy applications. At the end of the day, the trainees are evaluated and then provided a certificate for this basic training. So far, about 250 surgeons from all over India have been trained and qualified from the Amrita Center for Robotic Surgery Training. The surgeons are also requested to provide feedback on the training facility and the programme, and the feedback has been extremely positive so far. The training does not end there. All surgeons who undergo basic training are recommended to observe real surgeries before performing their first robotic procedure on a patient. Then, to finally complete the training, they are required to perform 3-4 cases in the presence of a proctor. There is however no sign off or certificate provided at this stage.
As of 2017, In addition to the basic training in collaboration with Intuitive Surgical, Amrita also offers an advanced training programme for specialist surgeons that involves training on cadavers. Trained and experienced robotic surgeons with expertise in various specialties provide training for this advanced programme. I was fortunate to catch Dr Anupama R, Robotic Surgeon and Professor in Gynecologic Oncology at Amrita Institute of Medical Sciences, Kochi, between surgeries. She was instrumental in setting up the Minimally Invasive and Robotic Surgery Programme at Department of Gynecologic Oncology in February 2015 and since then has performed over 500 robotic surgeries. She has also been instrumental in the training programme at Amrita and proctors for other trainees across the country as well. When asked how she manages training and proctoring with her busy schedule, Dr Anupama says, ‘‘I was trained at McGill University, Montreal, Canada, and now it’s my turn to train others.’’
While Amrita Centre for Robotic Surgery Training remains the only animal training facility in India, very recently, a basic training center has been started in Ramaiah Medical College, Bengaluru. This new facility is currently equipped only for training on cadaver models. Animal training, however, will remain critical for getting real, hands-on experience as a first step towards patient surgeries.
Based on trainee conversions and surgical outcomes in patients, Amrita Centre for Robotic Surgery Training has been ranked as the best training center outside USA by Intuitive Surgicals, which is a great achievement for all the management and staff involved. Dr Unni has set still higher goals and is in talks with IRCAD, a renowned training center in France, in an effort to make Amrita Centre for Robotic Surgery Training one of the best International training centers in the world.
This is part of a series that features India’s First & Most Unique institutions, facilities, technologies, products etc in the medical and healthcare space.