Quaternary care is the highest level of patient-care after primary, secondary and tertiary care. It involves various specialists, hi-tech devices and surgical interventions. In the past, open surgery was the norm, and the final resort. Today, one can avail the benefits of minimally-invasive surgery, robotic surgery, microrobots, nanorobots, remote and telesurgery, AI-driven predictions, haptic feedback and 3D printing. In this article, we will learn more.
Quaternary care refers to highly specialized and advanced therapies or treatments required to resolve the patient’s condition. Quaternary care is the highest level of patient-care that is possible, and sits at the top of a pyramid made of 4 layers namely – primary care at the bottom followed by secondary, tertiary and quaternary care as one goes upwards. Quaternary care involves specialists at the highest level as well as a host of surgical interventions. These interventions have evolved in the last 3-4 decades and are getting more reliable, more sophisticated. They harness various technologies, tools, devices and equipment to achieve positive outcomes. This is a constantly-evolving field, with interesting possibilities emerging every day. In this article, we will trace this evolution, and look at possibilities available today.
Open, incisional surgery has been around for hundreds of years. It was the final resort when the problem could not be resolved through medication. However, open-surgery (the name comes from the fact that the body is opened-up widely to access organs inside) came with its own risks. As a result, there are several categories of patients for whom open-surgery poses great risk. To minimize the risk for such patients, doctors in the US came up with the practise of ‘Minimally Invasive Surgery’ (MIS) in the 1980s. In this type, a thin, flexible tube called catheter is fitted with surgical instruments, light and camera at the end and pushed gently into the body, up to the site of operation. The robotic surgeon then achieves the desired intervention by manipulating the catheter. The length or number of cuts made on the skin to introduce the catheter are fewer and shorter. This results in less trauma to tissues in the body, fewer or smaller scars, quick recovery, reduced hospitalization and reduced risk from anaesthesia.
MIS became increasingly popular throughout the 90s and 2000s. Thereafter, it became the default option for many procedures, with open-incisional surgery being used only when inevitable. Today, MIS is used for a wide range of procedures including organ transplantation.
Some examples are:
Surgery, whether it’s the open-incisional type or the minimally-invasive type comes with a small risk of ‘surgeon tremor’. That is, due to fatigue and other conditions, the hands of the surgeon(s) operating on the patient can tremble. This can cause unwanted deviations in the movement of the surgeon’s hands, resulting in errors during the procedure. These errors can compound into poor outcomes for the patient, and increase the risk of complications.
In the early-1980s, several experiments were conducted in the US to take the assistance of robotic devices that will take over some of the complicated manoeuvres from the surgeon, during a surgical procedure. The outcome was very encouraging and within a decade, robotic surgery became a new offering from leading hospitals, and an entirely new sub-category under medicine. As a natural outcome, technology companies and vendors jumped into the fray to design robotic surgical assistants that can dominate the market. One such successful product, and market-leader is the da Vinci Surgical System from Intuitive, founded in 1995, in Sunnyvale, California, USA.
The da Vinci surgical system is made up of a robot with 4 or 5 large metallic arms that are fitted with surgical instruments at the tips. One arm is fitted with the light and camera at the tip. The camera and lens relay images of the inside of the body to a computer console placed close to the patient’s bed. A surgeon sitting at the console operates the robotic arms using controls available on it, while looking at the imagery on a monitor attached to it. The fingers of the arms and the arms themselves move in various directions, offering a lot of flexibility, dexterity and precision.
Today, there are competing systems to da Vinci, which have all made robotic surgery more and more popular, more and more reliable. Today, Robotic Surgery is used for:
This device is a fine combination of radiation therapy and robotic surgery, and is an example of ‘Image-guided Radio-surgery’. It is used to treat both cancerous and non-cancerous tumours in the brain, head, neck, lungs, liver, spine, pancreas, kidneys and prostate. This device consists of a robot that has a linear accelerator directly mounted on it. The linear accelerator delivers high-energy X-rays or photons of the type used in radiation therapy. The robot is capable of moving, bending and delivering radiation in thousands of unique positions. This increases the precision of radiation delivered to the tumour and minimizes damage to healthy cells in the vicinity.
While previously, surgery (whether open or MIS) could only be done in person by the concerned surgeon, today, they are being performed remotely. A surgeon sitting in a remote location can see imagery on his laptop or computer monitor, using an internet connection. Then he/she can orally guide other surgeons present in the OT suitably, so that they make the desired intervention. In the case of robotic surgery, the remote surgeon can even operate the robot remotely using a software that delivers instructions via an internet connection to the robot in the OT.
Surgeries, irrespective of the type and purpose have different outcomes. So, over the years, the medical community has been compiling data around the patient, the nature of surgery and the accrued outcome, captured from millions of patients. This databank can be used to predict what kind of procedure will have better outcomes for what kind of patient. Previously, these analyses used to be done by doctors themselves, after spending hundreds of hours on it. Today, all such data can be fed into an AI-powered, ML-based system. Such a system can make more reliable predictions, in a much shorter period of time.
Haptic Technology is the ability to replicate the natural experience of touch, by using various forces, pressure, vibrations and motions, which are fed to the user. When haptic feedback is incorporated into robotic surgery, the surgeon can ‘feel’ the resistance to robotic movement inside the body, presented by one or more tissues. In contrast, the imagery on the computer console can only present the visuals, but cannot replicate the feel. This new ability helps the surgeon get a better idea of the operating environment, also called ‘field’. This helps the surgeons achieve better manipulation, whether it is for resecting an organ, dissecting a tissue or putting sutures on an incision/tear.
Sensory augmentation takes the above abilities to the next level by incorporating AR (augmented reality) and VR (virtual reality) features in the computer console used in robotic surgery. The surgeon can enjoy the benefits of 3D visualization, real-time data from haptic feedback, and navigation guides, to make highly-precise manipulation and interventions.
3D printers can replicate the patient’s unique anatomy and the specific operating field. A robotic surgeon in Alwerpet, Chennai can then practise complex procedures on these 3D models. That will help him/her evaluate the potential-challenges better, and refine their approach or strategy towards the procedure concerned.
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 (Alwarpet & Vadapalani), Hosur, Salem, Tirunelveli and Bengaluru, the hospital also renders adult and pediatric trauma care.
Chennai Alwarpet – 044 4000 6000 • Chennai Vadapalani – 044 4000 6000 • Trichy – Cantonment – 0431 4077777 • Trichy – Heartcity – 0431 4003500 • Trichy – Tennur – 0431 4022555 • Hosur – 04344 272727 • Salem – 0427 2677777 • Tirunelveli – 0462 4006000 • Bengaluru – 080 6801 6801
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