Robotic Surgery in Oncology – Breaking Barriers and Redefining Treatment

Summary

Robotic Surgery is breaking barriers and redefining treatment options for a wide range of diseases and conditions that affect different parts of the body. We have already covered Robotic Surgery for Kidney, Liver and Cardiac conditions. When it comes to Cancer treatment, Robotic Surgery has come as a boon and is becoming a popular choice for Oncologists, to treat a wide range of cancers. In this article, we will learn more.

Introduction

Depending on the patient and severity of the condition, the objectives of cancer treatment are one or more of the below:

• Completely removing the tumour and hence curing the condition
• Reducing the size of the tumour (called debulking) and prepare the patient for other therapies such as chemotherapy and radiation
• Reducing symptoms of the cancer such as loss of function or excessive pain

While open-incisional surgery was the only option for cancer treatment in the past, a minimally invasive (MI) procedure called laparoscopy emerged later. As with any MI procedure, laparoscopic cancer surgery comes with less bleeding, less collateral damage to surrounding tissue, less pain and faster recovery. These 2 types of procedures are still used today. However, they come with their own disadvantages. That is why, in recent years, Robotic Surgery has emerged as an excellent option that is becoming more and more popular.

When and why is Robotic Cancer Surgery done?

Not everyone is a candidate for Robotic surgery. It is not used for cancers present on the surface of the body as Robotic procedure in unnecessary, and an open/laparoscopic procedure is good enough in this case. It is preferred for cancers that are deep inside the body, where narrow and confined spaces make access a challenge for the surgeons. Again, depending on the location deep-inside, the stage or severity of disease, size of the growth, and overall health or condition of the patient, the surgeon will take a call on whether open, laparoscopic or robotic surgery will be done. This decision will be made after thorough checkup and diagnostic tests.

Robotic surgery was an inevitable evolution in cancer treatment. One of the characteristics of open cancer surgeries is the large incision, which is required to gain access to the affected, cancerous tissue/organ/gland. However, cancer patients are already immune-compromised (immunity is on the decline) and nutrition-compromised (the cancer is preventing proper absorption of nutrients from food). On top of that, the long recovery time involved in open surgery further compromises immunity, nutrition and overall health of the patient. This further delays the start of other treatment options such as chemotherapy and radiotherapy.

The quick recovery time with Robotic surgery overcomes this drawback of open surgery. Again, laparoscopic procedures have their own limitations around flexibility and control. In contrast, Robot-assisted surgery or just ‘Robotic surgery’ using the da Vinci Surgical System (from Intuitive Surgical) or other competing systems, enables oncological surgeons to perform more complex cancer surgeries than is possible with open surgery. There is more precision, flexibility and control, making it the most superior among all three options.

The highly superior visualization available with robotic cancer surgery is a deciding factor. It helps the surgeon to perform a radical operation (remove the entire cancerous growth, plus metastasized tissue around it) while preserving the nerves and other critical structures intact. This is particularly relevant in gynaecological cancers, rectal and prostate cancers. For example, in prostate cancer surgery, one of the key objectives is to leave the blood-vessels and nerves intact, to minimize the risk of impotency and incontinence for the patient. The highly magnified, 3D view makes this task easy.

Benefits/Advantages of Robotic Surgery

• Minimally invasive procedure
• Significantly less post-operative pain and hence reduced need for analgesics (pain-killers)
• Reduction of infections at the surgical site
• Reduction of blood-loss, and collateral damage to surrounding tissue
• Shorter hospital stays
• Shorter ischemic time: During surgery, blood flow is reduced or halted to the concerned tissue for some time (ischemia). This time can be reduced in robotic surgery.
• Quick recovery, quick resumption of the normal routine
• Highly magnified (10x or 12x), hi-definition (high resolution) 3D images
• Highly precise: the EndoWrist instruments used in the robotic arms offer seven degrees of freedom and 360 degrees rotation going around the structure. This way, there is proper access to hard-to-reach areas, and a superior separation of cancerous tissue from healthy tissue.
• Reduction in the positive surgical margins or PSM. The aim of cancer surgery is to achieve radical resection, or complete removal of cancerous tissue. However, when this does not happen, and there is still some cancerous tissue left behind that is not removed, there is said to be a PSM.
• Enhanced ergonomics and hence less fatigue to the chief surgeon: The robotic system offers fine motion-scaling. That is, small movements of the surgeon’s fingers on the joystick translates into larger, proportional (scaled) movement of the robotic arms, which makes it less tiring for him/her.
• Tremor filtration: Unlike the surgeon’s hands which can tremble while doing the procedure, there is no such tremor or vibration in the robotic surgical instruments.
• Shorter learning curve: Compared to laparoscopic procedures, robotic surgery is easier for new surgeons to pick up and start performing on patients.
• Improved training: The robotic system can also be trained using Artificial Intelligence algorithms. This further reduces the work of the chief surgeon manning the computer console.
• Precise removal of cancerous tissue: The quality of surgical instruments used at the tip of the EndoWrist, combined with the high-quality visualization helps the surgeon to slice off the cancerous tissue completely, without removing any of the surrounding tissue additionally.
• Precise use of energy source to cut and coagulate (stopping blood-loss from damaged blood-vessels, and thereafter repair of) tissues.
• Reduced lymph-node dissection: The short and long-term effects of removing lymph-nodes can be reduced by clearly identifying affected lymph nodes and removing them, leaving the healthy ones intact.

Cancers that can be treated by Robotic Surgery

Central Nervous System

Glioma is a type of tumour that starts in the brain stem and spreads to the spinal column. Robotic Surgery makes it easy to remove gliomas, and with minimal complications.

Head and Neck

The Head and Neck is a tightly-packed space with multiple organs, tissues, glands, muscles, nerves and vasculature. This area is vulnerable to cancer from the HPV virus or metastasized cancers from other parts of the body. Previously, open surgery would be done by making long incisions through the throat, cheeks and jaw, and repositioning of the lower-jaw-bone in order to access hard-to-reach areas or cancers. This led to ugly scars, difficulty in swallowing or breathing, and a lengthy recovery. In contrast, Robotic Transoral Surgery (TORS) uses the natural mouth cavity to access the cancer. This is very effective to do resection (removal of) cancers of the throat, tongue, tonsils, larynx (voice box) and salivary-glands and perform an occasional glossectomy or partial removal of the tongue. The more precise resection means, the frequency and dosage of radiation therapy, if required subsequently, can be reduced, leading to fewer complications from radiotherapy.

Thyroid

Previously, open surgery for removing cancer in the thyroid glands would require long incisions to be made in the neck followed by a complex procedure. This led to visible scars and mixed results (not very effective always). In contrast, in Robotic Thyroidectomy, the surgical system accesses the cancer by making small incisions behind the ear or under the arm. The procedure has a high success rate. Healing is fast, and scars are almost invisible.

Thoracic

Cancers that affect the thoracic cavity and mediastinal or middle-chest area include those of the esophagus, lung and thymus, among others. People suffering from early stages of small cell lung cancer, non-small cell lung cancer and posterior mediastinal tumours can first undergo chemotherapy or radiation, and based on the success, go in for Robotic Surgery for a complete resection (removal).  There are minimal to no complications this way.

Hepatobiliary

Robotic surgery is very effective for partial or total resection (called radical surgery) of cancers of the pancreas, liver, gall-bladder and bile ducts.

Gynaecologic

Robotic surgery is very effective for blood-less resection of cancers of the uterus, cervix, ovaries and endometrium.  It is also used to treat benign (non-cancerous) conditions such as excessive menstrual bleeding, fibroids, pelvic prolapse and endometriosis.

Urologic

Robotic surgery is being used to treat cancers of the adrenal glands, bladder, kidneys, penis, prostate, testicles and ureters. In fact, it’s the standardized procedure for treating prostate cancer. When it comes to kidney cancer, the entire kidney would be removed using open surgery, previously (called as radical nephrectomy). Now, robotic surgery is used to precisely remove the affected part of the kidney and leave the rest of it which is healthy – intact. For bladder cancer, once the bladder is removed, robotic surgery also helps rebuild an alternate mechanism to hold the urine.

Gastro-intestinal / Colorectal

Gastrectomy or partial removal of the stomach affected by cancer, is done robotically today. Treating cancers of the intestine, colon and rectum used to be a complex procedure using open surgery, previously. Today, Robotic surgery is being increasingly preferred by surgeons and patients alike for these and sigmoid cancers. Robotic Surgery makes it easy to use nerve-sparing techniques whenever possible. This helps preserve the bladder, sphincter and sexual function of the patient.

Kauvery Hospital is globally known for its multidisciplinary services at all its Centers of Excellence, and for its comprehensive, Avant-Grade technology, especially in diagnostics and remedial care in heart diseases, transplantation, vascular and neurosciences medicine. Located in the heart of Trichy (Tennur, Royal Road and Alexandria Road (Cantonment), Chennai, Hosur, Salem, Tirunelveli and Bengaluru, the hospital also renders adult and pediatric trauma care.

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