Robots are the latest innovation in the field of surgery. Traditionally, surgery for head and neck disease has relied on making a cut in your neck, your face or splitting the jaw bone (mandible) to reach the disease in order to remove it. Robots have allowed access to these difficult to reach regions of your throat without the need to make a cut in your neck or jaw. At the present there is only one robot, which is approved for head and neck surgery- the Da Vinci Robots that are made by an American company. The Da VinciTransoral Robotic Surgery (TORS) allows the surgeon to operate through your mouth – avoiding a large incision through the jaw and throat. The da Vinci System features a magnified 3D high-definition vision system and special wristed instruments that bend and rotate far greater than the human wrist. This translates the surgeons hand movements into smaller, more precise movements of tiny instruments inside your body. As a result, da Vinci enables us to operate with enhanced vision, precision, dexterity and control.

Robotic surgery is a type of minimally invasive surgery. “Minimally invasive” means that instead of operating on you through large skin cuts, we use special surgical instruments that fit through your mouth for throat disease or use invisible incisions for thyroid disease. When performing surgery with the robots, these miniaturized instruments are mounted on two or three separate robotic arms, allowing us maximum range of motion and precision. The da Vinci’s fourth arm contains a magnified high-definition 3-D camera that allows us to see inside and guides us during the procedure.

We control these instruments and the camera from a console located in the operating room that is connected the actual robot. Placing the fingers into the master controls, we are able to operate all four arms of the da Vinci simultaneously while looking through a stereoscopic high-definition monitor gives us a better, more detailed 3-D view of the operating site than the human eye can provide. Every movement we make with the master controls is replicated precisely by the robot. When necessary, we can even change the scale of the robot’s movements: If we selects a three-to-one scale, the tip of the robot’s arm will move just one inch for every three inches our hands move. And because of the console’s design, our eyes and hands are always perfectly aligned with our view of the surgical site.The ultimate effect is to give us unprecedented control in a minimally invasive environment. In most cases, there is another surgeon at the patient bedside to assist with the operation.

The main benefit of robotic surgery to treat head and neck cancer is the ability to remove the cancer directly at the site, limiting tissue damage. The conventional method requires surgery through the neck, lip or jaw to access the tumor site. With the da Vinci robotic system, we can use a minimally invasive technique through the mouth using the robot’s superior magnification and precise wrist-like action to get to an area without the need for large and disfiguring incisions.

As a result the potential benefits of Robotic Surgery include

• Surgery without neck or jaw scar

• No need to cut normal structures in mouth to reach site of disease

• Less pain and smaller risk of injury to normal nerve or blood vessels

• Shorter hospital stay

• Precise removal of cancer

• Low rate of complications

• Low blood loss

• Minimal need for tracheotomy (breathing tube in windpipe)

• May reduce need for radiation and/or chemotherapy

• Ability to swallow and speak sooner following surgery, usually within 2-3 weeks. This can take 2-3 months after conventional surgery.

Robotic trans-oral surgery – No Incision, No scar
Conventional open surgery – Large incision and scar on your neck and face

No, Robotic surgery is NOT indicated and is NOT beneficial for all head and neck cancer or disease.

The benefit of robotic surgery lies in providing access to certain difficult to reach parts of your throat. For other areas, where access is not a problem, robots do not provide any advantage over traditional open surgery.

Presently, robots are used for the below mentioned surgeries

  • Head and neck tumor or cancer of the following regions
  • i. Oropharynx – Back of tongue and or Tonsil

    ii. Oral cavity – some tongue or roof of mouth cancers

    iii. Larynx (voice box) – limited early stage cancer

  • Thyroid surgery (for avoiding scar in the neck)
  • For small thyroid nodules, less than 5 cm limited to one side, in relatively slim patients – robotic surgery can be done through the armpit to avoid any visible scar in your neck. You can follow this link to learn more about robotic surgery for thyroid cancer or nodule.

  • Surgery for sleep disturbance
  • For resection of the back of tongue (tongue base) where it’s size leads to closing of throat during sleep.

Robotic surgery is very safe, however, its safety is mostly dependent on the experience and skills of the surgeon. As with any other operation technique, robotic surgery has potential complications mentioned below

• Bleeding – This is the commonest complication and can happen anytime during the surgery to up to two weeks after surgery

• Pain

• Throat swelling causing difficulty in breathing

• Injury to your lips, teeth or other structures in your mouth

At the present, robotic head and neck surgery is offered at a handful of hospitals in India. This is because of two main reasons

  • Lack of trained surgeons – At the moment the number of surgeons that are trained in robotic surgery in India can be counted on hand. As mentioned above, the success and possible side effects and complications of robotic surgery is directly linked to the experience and skills of the operating surgeon

  • Lack of robots in hospitals – Da Vinci Robots are very costly. In addition the equipment used during robotic surgery are also costly and need to be replaced at frequent interval. This makes robotic surgery very costly and limits it’s availability to few larger hospitals across India.

One of the main reasons for my decision to leave my consultant position in Britain and move to USA was to get experience in use of robotic surgery. I have spent considerable time and effort gaining this skill and experience at one of the most reputed hospital in USA. By choosing me as your surgeon; you will be placing your care in the hands one of the most experienced and well-trained robotic surgeon in India.

How is robotic thyroid surgery different from normal thyroid surgery?

Traditional thyroid surgery usually involves a fairly long cut in your skin at the base of the neck. A permanent visible scar in the neck is possible. The visual appearance of thyroid scars has certainly improved to a large extent, but thyroidectomy with a neck incision still leaves a visible scar.

With robotic surgery, the skin cut is made under the arm, in your armpit (called axilla) and from this incision the robotic arms are introduced under the skin to reach the thyroid gland and the operation is carried out.

The main benefit is that robotic surgery does not result in a visible, permanent neck scar. The scar in your armpit is made in such manner that it will not be visible from the front.

From a safety standpoint, in robotic thyroid surgery, the use of the high-definition robotic equipment with 10X magnification of the field and 3D vision allows us to perform a very precise operation. This means that there is a reduced likelihood of nerve damage and less risk of trauma to the nearby structures like the laryngeal nerve or parathyroid glands. It's very hard to injure the nearby structures if we can visualize the field at ten times their normal size. Pain after the operation tends to be significantly less. This is likely due to the fewer number of nerve endings under the arm, compared to the sensitive skin of the neck.

No. Not all patients are suitable for robotic thyroid surgery.

The main constraint is the anatomy, the size and shape of your body and your thyroid disease as these aspects play a critical role in allowing the robotic arm to reach thyroid gland and for surgeons to get a good view during the operation.

In addition, robotic surgery is ONLY suitable if ONE thyroid lobe needs to be removed. This is because access from your armpit on one side allows the robot to reach thyroid lobe only on that side.

Generally speaking, presence of any of the following condition will make robotic thyroid surgery less practicable –

• If you are very overweight or obese

• If you have a limited range of motion in your shoulder

• If the Thyroid lobe is large (usually if more than 5 cm)

• If the thyroid extends into the chest

• If you have a short neck

Thyroid surgery, like any other surgery has known possible complications and you can learn more about those by following this link. There are some unique potential complications associated with robotic thyroid surgery as we enter through your armpit. The most common of this is bleeding and / or collection of blood in your armpit. If this is small, your body will absorb it in a week or two. However, if this is large, we may need to carry a small second surgery to find the blood vessel that is bleeding and control it. In addition, as elsewhere, the skin around the cut in your armpit will be numb and it can take a year or two for this sensation to return partially.

In addition, generally speaking robotic thyroid surgery takes 3-4 hours while conventional surgery through your neck takes half of this time. It will also be more costly because of costly equipment and extra time required for the operation.

In suitable cases, robotic surgery can be the best mode of treatment. However, at the moment robotic surgery has the following constraint

• It is indicated in limited number of head and neck cancer or thyroid cases that have been mentioned. In addition to these, it is also of tremendous utility in patients with sleep apnoea. You can follow this link to learn about it here

• Robotic surgery is costly. This is because the robot itself and the instruments that needs to be replaced frequently after operation; both are costly. In addition some operations such as thyroid surgery takes longer with robot compared to conventional surgery.

• It is not widely available, not only in India but also abroad. For example there are only a handful of hospitals that have robots in UK (as of 2014)!

At the present, robotic head and neck surgery is offered at a handful of hospitals in India. This is because of two main reasons

  • Lack of trained surgeons – At the moment the number of surgeons that are trained in robotic surgery in India can be counted on hand. As mentioned above, the success and possible side effects and complications of robotic surgery is directly linked to the experience and skills of the operating surgeon.

  • Lack of robots in hospitals – Da Vinci Robots are very costly. In addition the equipment used during robotic surgery are also costly and need to be replaced at frequent interval. This makes robotic surgery very costly and limits it’s availability to few larger hospitals across India.

One of the main reasons for my decision to leave my consultant position in Britain and move to USA was to get experience in the use of robotic surgery. I have spent considerable time and effort gaining this skill and experience at one of the most reputed hospital in USA. By choosing me as your surgeon; you will be placing your care in the hands one of the most experienced and well-trained robotic thyroid surgeon in India.

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