FAQs On Lap-Robotic Surgery

Open surgeries require large incisions .Major drawback of open surgeries is pain associated with large incisions. This makes post operative recovery relatively prolonged. Patients undergoing open surgeries require more pain killers, stay in hospitals for longer periods when compared to laparoscopic and robotic surgeries. Pain also hinders mobility, respiratory rehabilitation (chest physiotherapy, spirometry, coughing etc.) and bowel function. This may add to the risk of postoperative deep vein thrombosis,pneumonia and delayed return to regular diet.

Open surgeries also lead to more blood loss and induce a relatively more severe form of inflammatory response. Both these act like additive factors to pain and may lead to increased complications after surgery.

Laparoscopy and robotic surgery use several small incisions (5mm-12mm each) to access the abdomen and thorax. Thus the pain, blood loss and inflammatory response of large incisions associated with open surgery are mostly eliminated. With no significant pain after surgery, the patient is more comfortable in the postoperative recovery period. The need for painkillers is minimal.

Getting out of the bed without assistance, accessing the toilet, doing breathing exercises and walking is much easier and happens much earlier with laparoscopic and robotic surgeries as compared to open surgeries. This fastens recovery, reduces hospital stay.

In laparoscopic surgery the surgeon controls the surgical instruments directly and the assistant holds the laparoscope/endoscope/camera.

In laparoscopic surgery the surgeon makes a small incision close to the belly button and inserts a laparoscopic trocar into the abdomen in a controlled manner. This is a short tube through which instruments and camera can be inserted into the abdomen. The trocar can be either a reusable metallic one or a disposable plastic one.

Once the trocar is inserted a laparoscope ( camera) which is a thin long metallic tube with a camera is inserted through it into the abdomen to confirm safe entry. Then the abdomen is inflated with air (this is called pneumoperitoneum). This is necessary to create working space inside. After this step, a few more trocars are inserted for instruments to perform the surgery. Assistant holds the camera while the surgeon operates with two instruments. Sometimes a second assistant is also needed.

The number and placement of other torcars (also called ports) depends on the organ that is being operated upon.

The first steps of robotic surgery are similar to laparoscopy. In robotic surgery , unique robotic ports are available and these are utilized instead of laparoscopic ports.

Instead of a laparoscope, a robotic endoscope is used to inspect the abdomen. This is much heavier and longer than laparoscope. Air is instilled in a similar fashion. Then further ports are established. Once all ports are inserted, the robot is brought in and its arms are connected to the ports.

The robot has to be brought in a direction and orientation that is specific to the surgery and organ. The robot senses all the ports and patient orientation, Then it sets up the range and mobility of each port and instruments. After this step the camera and operating instruments are inserted into the ports and attached to the robot. This whole process is called docking.

The robot is connected to the surgeon console. Once the robot is docked the surgeon takes control of the robot. From the
This is a patient side assistant to give feedback to the surgeon and to change instruments and assist him in the surgery.

Of course!! There is enough scientific evidence to support the use of these methods in cancer surgery.

Since these methods require training, skills and experience only those surgeons who have expertise should perform them.

Laparoscopy and robotic surgeries in cancer require specialized training, skill sets and expertise. Unfortunately this expertise and infrastructure to perform laparoscopic and robotic cancer surgeries is lacking even in high volume cancer centers in the country. Most of the cancer surgeons are not trained in these methods and as a result patients are not offered these options.

A valid fear in applying these techniques is oncological safety. Oncological safety means ability to perform a cancer surgery in such a way that assures optimal results that are at par with prevailing surgical standards endorsed by experts and international guidelines.

Regardless of method of surgery (open or minimal access) the cancer has to be removed with adequate negative margins and adequate number of lymph nodes to assure complete clearance. Contrary to general belief, with proper training and experience this oncological safety can be achieved with laparoscopic and robotic surgeries as well. This has been proved time and again by robust scientific research.

Since laparoscopy and robotic surgery provide a chance for early recovery and reduced complications, patients who need to receive chemotherapy/radiation after surgery may do so on time.

Another distinct advantage is that these techniques produce minimal adhesions inside the abdomen and thorax. Since all cancers have a realistic possibility of recurring, having a cleaner surgical field definitely makes a second surgery relatively easy.

Selection of a patient for laparoscopic/robotic cancer not only depends on the site of tumor and its spread but also depends on several patient factors like comorbidities, BMI, previous surgeries etc. In general large sized Tumours, Tumours with vascular invasions, tumors with extensive spread are contraindications for these methods.

Patients with reduced lung functions ( smoking, COPD, emphysema, interstitial lung disease), patients with heart conditions are not considered as good candidates for laparoscopic or robotic surgery.

Following types of cancers can be operated laparoscopically or using a robotic platform.

• Esophageal Cancers
• Early Stomach Cancers
• Distal pancreatic tumors
• Colon cancer
• Rectal cancer
• Kidney tumors
• Cancer of the uterus and cervix
• Prostate cancer

Yes. There are several other indications where laparoscopy is recommended in cancer treatment.

1. Staging laparoscopy-

This is a surgical procedure where the entire abdominal cavity is inspected with the help of 2 or 3 incisions (ports) to map the spread of the disease beyond the concerned organ. This is needed whenever the cancer has reached the outermost layers (muscular is propriety and serosa) of an abdominal organ as seen on CT scan or MRI scan. Studies have shown that such advanced diseases have the risk of spreading to the peritoneum in 20-30% cases and even the best of the CT/PET/MRI scans can miss it.

Staging laparoscopy is recommended in stomach cancer, cancer of the esophagogastric junction, colon and rectal cancers, ovarian cancers, primary peritoneal cancers.

The information obtained by this procedure helps us in deciding whether the disease is amenable for surgical treatment and whether any additional treatment in the form of chemotherapy should be considered before surgery.

2. IP port insertion-

IP port is inserted to administer chemotherapy directly into the abdomen to treat cancers that have spread to the peritoneum.

3. Risk reducing salpingo-oophorectomy:

Patients suffering from breast cancers may have genetic mutations –BRCA1 or BRCA2. These genetic mutations put them at high risk of developing ovarian cancer in future. Hence it is recommended to consider risk reducing salpingo-oophorectomy for such patients and this can be performed very easily using laparoscopy.

4. Ovarian transposition:

In females who need to receive radiation for rectal cancer the ovaries need to be taken out of the radiation field to preserve their function. If not done the ovaries stop functioning due to radiation induced damage. This will lead to early menopause and adverse effects associated with it.

5. Diagnostic laparoscopy and biopsy:

Many a time’s patients present with intra-abdominal masses/lumps that are suspected to be malignant. Some of them would have even undergone CT guided biopsies with inconclusive results. Ovarian masses frequently present in this manner.

A diagnostic laparoscopy in such scenarios gives us the best chance to arrive at a correct diagnosis because of two reasons. One, the entire abdominal cavity can be inspected under direct vision. Two, biopsies can be taken from all the suspicious and representative areas with practically zero chance of miss.

6. Retroperitoneal lymph node dissections by extra peritoneal approach.

Majority of the cervix cancers are treated by chemoradiation. But in select patients the retroperitoneal nodes need to be sampled before chemoradiation to make sure that they are not involved. With laparoscopy this can be achieved easily with early patient recovery so that further treatment can be initiated on time.

Nowadays almost all hospitals have good laparoscopic units and routinely perform gynecological and general surgical procedures. The same setup can be used for most laparoscopic cancer surgeries as well.

The need to perform a cancer surgery in a higher center is not dependent solely on the method of surgery but also on several patient factors like age, comorbidity, need for postoperative intensive care etc.

Numerous scientific trials have been conducted world over to answer this question and found that laparoscopic surgery is not inferior to robotic surgery. However we feel, in certain types of cancer surgeries robotic surgery scores better than laparoscopy. For e.g.:

(a) Mobilization of the esophagus in the chest in bulky esophageal cancer,

(b) mediastinal nodal clearance

(c) rectal cancer that requires en bloc removal of adjacent structures –seminal vesicle, prostatic capsule

(d) prostate cancer.

Previous open surgeries are a contraindication for lap and robotic surgeries. But a previous open surgery in the pelvis is not a contraindication for a robotic /laparoscopic surgery of the upper abdomen and vice versa.

Even in those who have had Cesarean sections, open hysterectomy, appendectomy -laparoscopic and robotic pelvic surgeries can be performed safely as the risk of adhesions in these procedures is minimal.

The risks and complications primarily depend on the type of surgery and not just on how it is done i.e open vs laparoscopic vs.robotic

The risks specific to laparoscopic and robotic techniques are

1. Bowel/organ or vessel injury during the entry into abdomen or thorax.
2. Thermo electric injury during the usage of energy devices.

These risks can be mitigated by following standard protocols and proper instrumentation

Yes. These techniques generally take a little longer than open surgery.

Robotic surgery platform has undergone extensive safety evaluation and it can be considered completely fail safe. There are checkpoints at every step of robotic surgery to ensure patient safety. For eg. The robot does not receive a sharp edged instrument directly.

The range of the instruments is also predefined. In critical areas, a surgeon can scale down his movements so that the robotic arm travels proportionately smaller distances compared to surgeon’s hand movements, etc.

Warning alarms, voice intimations are incorporated into the surgeon console as well as patient side monitors to alert potential problems. All the problems are logged and reviewed centrally.

It may appear so when only the surgical costs are considered. However, when the hospital stay, cost of additional medications are also taken into account the cost laparoscopic surgery is similar to open surgery.

The cost of a robotic surgery varies depending on the type of surgery and policies of the institution. But generally it is costlier than laparoscopic and open surgeries.

Hence we recommend robotic surgery only when it has distinct advantages compared to laparoscopic or open surgery.