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Robot-assisted surgery in India: A SWOT analysis

2020; Medknow; Volume: 36; Issue: 1 Linguagem: Inglês

10.4103/iju.iju_220_19

1998-3824

RavimohanSuryanarayan Mavuduru, GirdharSingh Bora, TusharAditya Narain, AdityaPrakash Sharma, SudheerK Devana, ShrawanK Singh, ArupKumar Mandal,

Global Healthcare and Medical Tourism

INTRODUCTION Sushruta, in his Sushruta Samhita, has said, "A great surgeon is one who possesses courage and presence of mind, a hand free from perspiration, tremor less grip of sharp and good instruments and who carries his operations to the success and advantage of his patient who has entrusted his life to the surgeon."[1] The age-old teachings of Sushruta still hold true albeit for the fact that the hands of the surgeon are slowly being replaced by the tremor less grip of the robotic arms. After the US FDA approval of the da Vinci system in 2000,[2] India got its first urologic robotic installation at the All India Institute of Medical Sciences, New Delhi, in 2006. The following decade saw an unprecedented growth of robotic surgery in India. There are currently 66 centers and 71 robotic installations as on July 2019, with more than 500 trained robotic surgeons in our country. More than 12,800 surgeries have been performed with robotic assistance in these 12 years. The numbers are expected to increase as more robotic surgeons get trained and other surgical specialties increasingly utilizing this platform. The trend suggests that the rise of robotic surgery in India has been, and is, going to be a rapid and huge one; therefore, we scrutinize this rise of robotic surgery in India, and its future, using a strength-weakness-opportunities-threats (SWOT) analysis. STRENGTHS Patient volumes The success of any surgical program depends on the availability of a large number of cases, standardization of all surgical steps, and repeated exposure to the same disease reinforcing the stringent management protocols and ensuring efficient utilization of resources in a cost-effective manner. The alarmingly rising population of India, though a major social concern, results in very large number of patients being treated by a single surgeon. This blessing in disguise leads to an early crossing of the learning curve for most robotic surgeons and ample learning opportunities. Growing economy India is the world's 7th largest economy by nominal gross domestic product and the 3rd largest by purchasing power parity. In the financial year 2015 and 2018, India's economy became the world's fastest-growing major economy, surpassing China.[3] The healthcare sector has become one of the India's largest sectors, with healthcare market likely to have threefold jump by 2022, driven by the growing incidence of lifestyle diseases and rising demand for affordable healthcare delivery systems.[4] The growing economy and the rapidly expanding healthcare sector have resulted in decentralization of institutions and are expected to bring in more hospitals offering robotic surgeries, resulting in a decline in the cost of the treatment. Good laparoscopic surgeons The need of laparoscopic experience prior to robotic surgery is debatable. However, there is no denying the fact that surgeons with excellent laparoscopic skills would have an edge and also a shorter learning curve. Laparoscopy is well established in India. Hence, the transition from a laparoscopic surgeon to a robotic surgeon is smooth, which ensures a shorter learning curve and a faster dissipation. Training and proctorship Several institutes in India are offering training programs in robotic surgery, mentored by senior consultants at various government institutions and private hospitals. With the Vattikuti 1-year fellowship in robotic surgery, the training process has been streamlined with increased opportunities for upcoming young surgeons.[5] Moreover, the da Vinci Basic Surgical Skills Training Center has been started in India to provide additional training opportunities.[6] Increase in experienced surgeon cohort Robotic technology has also increased the age of the surgical capabilities of surgeons by its improved ergonomics, motion scaling, and tremor filtration. It is particularly beneficial in a country like India where the demand of surgeons is ever increasing. Increased insurance (National Health Profile 2018) General Budget 2018–2019 brought in the 'Ayushman Bharat' as the National Health Protection Scheme that is expected to cover over 10 crore poor and vulnerable families.[7] With the implementation of this insurance, more patients, including those from the lower-income group, will be able to afford robotic Surgery and get benefitted. WEAKNESS Huge initial investment The robot currently costs around US $1,500,000 as an initial investment with a yearly maintenance cost of US $100,000. Besides the cost of the machine, the expenditure incurred in setting up a facility dedicated to robotic surgery is also huge.[8] Recurring cost of consumables Much more concerning is the recurring cost of the instruments. A number of procedure-wise cost-effectiveness studies have shown that open/laparoscopic surgeries are much more cost-effective than robotic surgeries for pyeloplasty and prostatectomy.[9] Large burden of communicable diseases such as tuberculosis, malaria etc., take priority in the health sector budget of India.[10] The expenditure on robotic surgery will increase the load on the health sector expenditure. Considerable reliance on technology: device malfunction Robot, being a machine, is prone to break downs and malfunctions. FDA data on adverse events in robotic surgery found that there were 1535 (14.4%) adverse events with significant negative patient impacts, including injuries (1391 cases) and deaths (144 cases), and over 8061 (75.9%) device malfunction.[11] Manufacturer and User facility Device Experience, which is an independent voluntary database for reporting robotic malfunction, is also plagued by a significant under-reporting and remains an imprecise tool for reporting such malfunction.[11] True benefit of robotic surgery: No data in India Systematic reviews/meta-analyses comparing robotic surgery to conventional surgery have failed to show superiority of robotic surgery, thus questioning its true benefit.[121314] Contrary to the West where there is a strict quality control in place by keeping a tab on the readmissions, prolonged stay, and re-exploration rates for every surgeon, Indian hospitals do not have such robust checks and balances. Therefore, the assessment of actual benefit of robotic surgery in our population becomes more difficult. OPPORTUNITIES Scope for expansion As other specialties are slowly accepting the role of this technology in India, the multidisciplinary use of robotic surgery creates an opportunity to decrease the maintenance cost associated with it, making it much more cost-effective.[6] Medical tourism The availability of excellent physicians and surgeons providing care at par with any nation of the West, coupled with the Indian hospitality, low cost, and short waiting time, makes India a sought-after destination for patients all over the world.[15] Currently, medical tourism in India is a 2 billion USD industry.[16] Availability of robotic surgery would attract more foreign patients who may be requiring not only robotic procedures but also other nonrobotic surgeries. Newer robotic systems Newer robotic systems are currently underway for clinical applications. These systems usher a competitive market for intuitive surgical, which may lead to a decreased cost of initial investment as well as maintenance, thereby increasing the affordability and widespread use for Indian population. THREATS Fear of missing out Increasing popularity of robotic surgery can lead to an increase in irrational demand by the patients, mounting an undue pressure upon the surgeon. This may lead to the irrational use of robotic surgery in view of fear of missing out. This is especially true in India where the literacy rates and awareness about health are poor and belief systems are more prevalent. In addition, hospitals are more likely to buy a robot for commercial publicity and superiority, and subsequently, to regain expenses, push surgeons into recruiting patients for robotic surgery.[17] Compromise in training India is currently in need of trained taskforce which can cater to millions of people, not limited to cities. Due to the limited availability of robotic systems, a trained surgeon/urologist capable of performing an open or a laparoscopic surgery is desirable. However, in academic institutions with robotic facility, the exposure of residents/fellows to open/laparoscopic procedures is decreased. This can lead to a vacuum in the training of these new residents who will have to perform open/laparoscopic procedures on their own as they go and work in hospitals where robot-assisted facility is not available. Risk of infection Although not pertinent only to India, there is a definite possibility of the increased risk of infection by robotic instruments and ample data are available, suggesting incomplete sterilization of robotic instruments due to a complex pulley system run by thin wires. Saito et al. reported higher levels of contamination of proteins and residue in robotic instruments as compared to other instruments.[18] They concluded that the complex robotic surgical instruments necessitate the establishment of new standards of cleaning and novel classification. It is virtually impossible to completely remove the protein from surgical instruments and, with increasing complexity of the instrument such as the robotic one, endangers the patients for unknown organisms and prion-based diseases. CONCLUSION Having taken into consideration, various facts and practical, logistic, and economic aspects, we believe that spread of robotic surgery in India is possible with its judicious use and standardized reporting of outcomes.