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Robot-assisted surgery in India: A SWOT analysis

Article in Indian Journal of Urology · January 2020

DOI: 10.4103/iju.IJU_220_19

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Editorial
Robot‑assisted surgery in India: A SWOT analysis
INTRODUCTION major economy, surpassing China.[3] The healthcare sector
has become one of the India’s largest sectors, with healthcare
Sushruta, in his Sushruta Samhita, has said, “A market likely to have threefold jump by 2022, driven
great surgeon is one who possesses courage and by the growing incidence of lifestyle diseases and rising
presence of mind, a hand free from perspiration, demand for affordable healthcare delivery systems.[4] The
tremor less grip of sharp and good instruments growing economy and the rapidly expanding healthcare
and who carries his operations to the success and sector have resulted in decentralization of institutions and
advantage of his patient who has entrusted his life are expected to bring in more hospitals offering robotic
to the surgeon.”[1] The age‑old teachings of Sushruta surgeries, resulting in a decline in the cost of the treatment.
still hold true albeit for the fact that the hands of the
surgeon are slowly being replaced by the tremor less Good laparoscopic surgeons
grip of the robotic arms. The need of laparoscopic experience prior to robotic surgery
is debatable. However, there is no denying the fact that
After the US FDA approval of the da Vinci system in surgeons with excellent laparoscopic skills would have
2000,[2] India got its first urologic robotic installation at an edge and also a shorter learning curve. Laparoscopy
the All India Institute of Medical Sciences, New Delhi, is well established in India. Hence, the transition from a
in 2006. The following decade saw an unprecedented laparoscopic surgeon to a robotic surgeon is smooth, which
growth of robotic surgery in India. There are currently ensures a shorter learning curve and a faster dissipation.
66 centers and 71 robotic installations as on July
2019, with more than 500 trained robotic surgeons in Training and proctorship
our country. More than 12,800 surgeries have been Several institutes in India are offering training programs in
performed with robotic assistance in these 12 years. robotic surgery, mentored by senior consultants at various
The numbers are expected to increase as more robotic government institutions and private hospitals. With the
surgeons get trained and other surgical specialties Vattikuti 1‑year fellowship in robotic surgery, the training
increasingly utilizing this platform. The trend suggests process has been streamlined with increased opportunities
that the rise of robotic surgery in India has been, and is, for upcoming young surgeons.[5] Moreover, the da Vinci
going to be a rapid and huge one; therefore, we scrutinize Basic Surgical Skills Training Center has been started in
this rise of robotic surgery in India, and its future, using India to provide additional training opportunities.[6]
a strength‑weakness‑opportunities‑threats (SWOT)
analysis. Increase in experienced surgeon cohort
Robotic technology has also increased the age of the surgical
STRENGTHS capabilities of surgeons by its improved ergonomics, motion
scaling, and tremor filtration. It is particularly beneficial in
Patient volumes a country like India where the demand of surgeons is ever
The success of any surgical program depends on the increasing.
availability of a large number of cases, standardization
of all surgical steps, and repeated exposure to the Increased insurance (National Health Profile 2018)
same disease reinforcing the stringent management General Budget 2018–2019 brought in the ‘ Ayushman
protocols and ensuring efficient utilization of resources Bharat’ as the National Health Protection Scheme that
in a cost‑effective manner. The alarmingly rising is expected to cover over 10 crore poor and vulnerable
population of India, though a major social concern, families.[7] With the implementation of this insurance, more
results in very large number of patients being treated patients, including those from the lower‑income group, will
by a single surgeon. This blessing in disguise leads to be able to afford robotic Surgery and get benefitted.
an early crossing of the learning curve for most robotic
surgeons and ample learning opportunities. WEAKNESS

Growing economy Huge initial investment

India is the world’s 7th largest economy by nominal The robot currently costs around US $1,500,000 as an initial
gross domestic product and the 3rd largest by purchasing investment with a yearly maintenance cost of US $100,000.
power parity. In the financial year 2015 and 2018, Besides the cost of the machine, the expenditure incurred in
India’s economy became the world’s fastest‑growing setting up a facility dedicated to robotic surgery is also huge.[8]

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Bora, et al.: Robotic surgery in India

Recurring cost of consumables for intuitive surgical, which may lead to a decreased cost
Much more concerning is the recurring cost of the of initial investment as well as maintenance, thereby
instruments. A number of procedure‑wise cost‑effectiveness increasing the affordability and widespread use for Indian
studies have shown that open/laparoscopic surgeries are much population.
more cost‑effective than robotic surgeries for pyeloplasty
and prostatectomy.[9] Large burden of communicable diseases THREATS
such as tuberculosis, malaria etc., take priority in the health
sector budget of India.[10] The expenditure on robotic surgery Fear of missing out
will increase the load on the health sector expenditure. Increasing popularity of robotic surgery can lead
to an increase in irrational demand by the patients,
Considerable reliance on technology: device malfunction mounting an undue pressure upon the surgeon. This
Robot, being a machine, is prone to break downs and may lead to the irrational use of robotic surgery in view
malfunctions. FDA data on adverse events in robotic of fear of missing out. This is especially true in India
surgery found that there were 1535 (14.4%) adverse where the literacy rates and awareness about health are
events with significant negative patient impacts, poor and belief systems are more prevalent. In addition,
including injuries (1391 cases) and deaths (144 cases), hospitals are more likely to buy a robot for commercial
and over 8061 (75.9%) device malfunction. [11] publicity and superiority, and subsequently, to regain
Manufacturer and User facility Device Experience, which expenses, push surgeons into recruiting patients for
is an independent voluntary database for reporting robotic surgery.[17]
robotic malfunction, is also plagued by a significant
under‑reporting and remains an imprecise tool for Compromise in training
reporting such malfunction.[11] India is currently in need of trained taskforce which can
cater to millions of people, not limited to cities. Due to the
True benefit of robotic surgery: No data in India limited availability of robotic systems, a trained surgeon/
Systematic reviews/meta‑analyses comparing robotic surgery urologist capable of performing an open or a laparoscopic
to conventional surgery have failed to show superiority surgery is desirable. However, in academic institutions with
of robotic surgery, thus questioning its true benefit.[12‑14] robotic facility, the exposure of residents/fellows to open/
Contrary to the West where there is a strict quality control laparoscopic procedures is decreased. This can lead to a
in place by keeping a tab on the readmissions, prolonged vacuum in the training of these new residents who will have
stay, and re‑exploration rates for every surgeon, Indian to perform open/laparoscopic procedures on their own as
hospitals do not have such robust checks and balances. they go and work in hospitals where robot‑assisted facility
Therefore, the assessment of actual benefit of robotic surgery is not available.
in our population becomes more difficult.
Risk of infection
OPPORTUNITIES Although not pertinent only to India, there is a definite
possibility of the increased risk of infection by robotic
Scope for expansion instruments and ample data are available, suggesting
As other specialties are slowly accepting the role of this incomplete sterilization of robotic instruments due to
technology in India, the multidisciplinary use of robotic a complex pulley system run by thin wires. Saito et al.
surgery creates an opportunity to decrease the maintenance reported higher levels of contamination of proteins and
cost associated with it, making it much more cost‑effective.[6] residue in robotic instruments as compared to other
instruments.[18] They concluded that the complex robotic
Medical tourism surgical instruments necessitate the establishment of
The availability of excellent physicians and surgeons new standards of cleaning and novel classification.
providing care at par with any nation of the West, coupled It is virtually impossible to completely remove the
with the Indian hospitality, low cost, and short waiting protein from surgical instruments and, with increasing
time, makes India a sought‑after destination for patients all complexity of the instrument such as the robotic one,
over the world.[15] Currently, medical tourism in India is a endangers the patients for unknown organisms and
2 billion USD industry.[16] Availability of robotic surgery prion‑based diseases.
would attract more foreign patients who may be requiring
not only robotic procedures but also other nonrobotic CONCLUSION
surgeries.
Having taken into consideration, various facts and practical,
Newer robotic systems logistic, and economic aspects, we believe that spread of
Newer robotic systems are currently underway for clinical robotic surgery in India is possible with its judicious use
applications. These systems usher a competitive market and standardized reporting of outcomes.

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Bora, et al.: Robotic surgery in India

Girdhar Singh Bora, Tushar Aditya Narain, Versus Robotic Radical Cystectomy: Analysis from the RAZOR Trial with
a 3‑Year Follow‑Up. The Journal of urology. 2019 Sep 24:10‑97.
Aditya Prakash Sharma, Ravimohan 13. Chang KD, Abdel Raheem A, Kim KH, Oh CK, Park SY, Kim YS, et al. Functional
Suryanarayan Mavuduru*, Sudheer K. Devana, and oncological outcomes of open, laparoscopic and robot‑assisted partial
Shrawan K. Singh, Arup Kumar Mandal nephrectomy: A multicentre comparative matched‑pair analyses with a
median of 5 years’ follow‑up. BJU Int 2018;122:618‑26.
Department of Urology, PGIMER, Chandigarh, India 14. Ilic D, Evans SM, Allan CA, Jung JH, Murphy D, Frydenberg M.
*E‑mail: ravismi2003@yahoo.com Laparoscopic and robot‑assisted vs. open radical prostatectomy for the
treatment of localized prostate cancer: A Cochrane systematic review.
BJU Int 2018;121:845‑53.3.
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