KATHMANDU

Around 2007, a young surgeon stood in a conference hall in Orlando, Florida, the US staring at a magnificent robot operating on a human body. It was then that he decided what he wanted to do - become a robotic surgeon. Dr Pratik Man Singh Gurung was that young surgeon who has ultimately lived his dream, conducting 400-plus robotic surgeries as of now. Upon his return to Nepal from the US after completing his education as well as practising robotic surgeries there, Dr Gurung, 45, looks forward to the beginning of robotic surgery in Nepal. He is probably the only robotic surgeon in the country as of now

Trained to become a doctor

Born and raised in Kathmandu to an army father and a banker mother who wanted him to do something academic, Gurung was a sporty and well-rounded student in his school St Xavier's Godavari.

He later transferred to St Xavier's Jawalakhel where he had to cut down on his sports time and focus on academics.

He joked that he had to get glasses in Class VIII as he spent more time studying.

Hard work paid off and he was the topper of three sections continuously (in Class VIII, IX and X) which made Gurung believe that he could really do whatever he wanted. Thus, he decided to become a doctor.

Gurung went on to pursue his higher education in the UK after his School Leaving Certificate examination here. He received a merit scholarship from the Ardingly College, England, and luckily his father was posted there due to his work, so he completed his A-levels from the said college. After that, Gurung got admission into the highly competitive University College London (UCL), England where he completed his BSc in Cancer Biology in 2001, and MBBS in 2002.

While he knew he wanted to get into medicine from the very beginning of his higher studies, it was only at UCL that he decided on becoming a surgeon.

'The environment, the fact that you can operate, cure some conditions and the results seem to be pretty immediate in terms of outcome, so in medical school I decided to get into surgery,' recalled Dr Gurung.

Upon completing his MBBS, Dr Gurung wanted to become a general surgeon, initially. However, when he was exposed to urology for three months during his MBBS internship, he witnessed a variety of operations.

'In urology, I felt 'Oh! Wow! This feels like a good field' - because it felt very advanced. They were doing some laparoscopic stuff, some endo-urological stuff as well as complex open operations and it looked more varied and interesting as compared to general surgery. That's how I decided to become a urologist,' Dr Gurung chuckled as he shared this change in him.

From urology to robotics

Dr Gurung was already a practising surgeon in the UK in 2006. It was in 2007/8 that he was introduced to robotic surgery at a conference in Orlando, Florida by the American Urological Association where he had gone to present a paper. Upon watching the magnificent machine perform operations on a patient, he was so moved, so amazed by the future of robotics that he decided to pursue robotic surgery.

'Soon after that (conference), robotic surgery started in the UK, probably about 10 years behind the US. I saw a robot face-to-face for the first time in 2011 while pursuing my PhD in UCL,' shared Dr Gurung, who was not allowed to use it. However, he was 'just amazed' by the way others (including his professors) conducted the surgery using robots, and so he chose to learn about robotic surgery after his PhD in bladder cancer.

He started his training in robotic surgery in the UK in 2012.

In 2018, he was awarded an opportunity to explore more about robotic surgery as he got a US robotics fellowship, recognised by the American Urological Association. He was one of the 25 people to get the training in the US where he was allocated to the University of Rochester as a Robotic Fellow for two years.

And once he was fully trained in the field, Dr Gurung started practising it in the US as well. He has done over 400 surgeries in the US and UK combined.

Recalling his experience of operating 'robotically' on a patient for the first time in around 2014, he beamed, 'It was amazing. Even now, compared to open surgery or laparoscopy, robotics is difficult to beat, just because of the level of accuracy, the details that you can appreciate which are not even kind of apparent to the naked eyes, and the complex manoeuvres that you can do with both your hands accurately. It is just amazing.'

He excitedly explained the perks of robotic surgery, 'In surgery done with aid of robots, you can appreciate the nerves because of the tenfold magnification. You can appreciate the blood vessels, also all the muscle fibres in the pelvis, bladder, and neck area, so you can appreciate which ones to keep or your boundaries when you are cutting.

It improves your technical delivery in what you are achieving with the operation, whereas with the naked eye, you're kind of guessing on where to make the cuts.'

Plus his experience as a robotic surgeon has increased Dr Gurung's accuracy as an open surgeon and a laparoscopic surgeon 'because of the appreciation and knowledge of proper location of even deepseated nerves'.

Advantages over laparoscopic and open surgeries

Very passionate about robotic surgery, Dr Gurung argued that there are many-fold advantages of robotic surgery over open surgery.

The most important thing is that it is minimally invasive unlike open surgery, which ultimately lessens the chance of infection in patients, he said. Along with being hasslefree to operate on, it also allows for better anastomosis (the surgical connection between two structures) and lets patients recover faster, informed the doctor.

Elaborating on the advantages compared to laparoscopic surgery, he said, 'In robotic surgery, you get 3D vision (laparoscopic surgery gives 2D vision), ten-fold magnification and your movements are within millimeters of accuracy. As there is no element of tremor, the degree of freedom of movement in this surgery is more than the degree of freedom while operating using hands. So, when you need to make very fine and delicate cuts, it is accurate within millimeters in robotic surgery. It makes complex operations easier as you can see even small details like small blood vessels, and nerves.'

He passionately explained, 'Those technical advantages translate into better, finer outcomes for the patient. You have the advantage of minimally invasive surgery like laparoscopic surgery, unlike open surgeries which have patients hanging in pain. The patients go home a lot quicker. In due course, the outcomes are also more accurate in terms of making/ leaving things cancer-free, joining things accurately.'

Since the surgery is done by a surgeon operating on a console, it is less draining and tiresome for the surgeon too. 'It feels easier on the eyes and the operation is less stressful,' he said.

Cost-effectiveness Dr Gurung also called robotic surgery economical in the long run. He emphasised how once doctors are trained to use it, the surgery would be more economical considering the accuracy of the operations done by the robot.

It would also stop the government health fund from getting drained, he remarked and gave an example, 'Taking any big hospital into consideration - it is easily observable how clogged up the beds are. For diseases like cancer and kidney failure, the government funds the treatment with a certain amount of money. When patients recover in the first attempt (that is possible through robotic surgery), it helps clear up the queue of patients needing treatment faster, and the government does not have to keep funding the treatment, while hospitals can treat more patients in the meantime.'

He remarked that the treatment would cost more than open or laparoscopic surgery but it would not cost more than what Nepalis are paying in India for their treatment, which would, in turn, save people's money.

Why are we hesitating?

Sadly, Nepal is yet to begin robotic surgery despite there being a scope for it because people are going to other countries to get their surgery done robotically, remarked the doctor.

'Why cannot there be two or three robots to start off?' he questioned considering how robotic surgery is growing exponentially around the globe.

While robotic surgery is a huge commitment because of an initial cost of Rs 30 crores to buy the da Vinci surgical system via which the robotic surgery is done, the budget is not as magnanimous as it sounds to the government, he remarked.

At the same time, the robot can easily perform two operations a day, said the doctor and revealed that even if it performs four to five operations a week to break even, conducting the operation via the robot would be profitable.

Dr Gurung emphasised how once doctors are trained, it would be more economical considering the accuracy of the operations done by the robot.

The other setback is that Dr Gurung is currently the only robotic surgeon in Nepal, and it takes a couple of years for surgeons to train in the field.

Dr Gurung talked about how, if we could do this in Nepal, families will also benefit because they would be closer to their families, rather than having to travel abroad to get their robotic treatment.

'It will not only benefit the Nepali people but also the country because then you are on par with the quality and level of surgical care that you expect in a good hospital, good country. So from a country's standpoint, from a hospital's standpoint, and from a healthcare standpoint, it is a necessity to bring robotic surgery into the country,' he added.

How does it work?

Robotic surgery is done using the da Vinci surgical system. The surgical robot generally has three to four arms - one arm has a camera and two arms are used to hold scissors, diathermy instruments, suction instruments, and suture instruments, as per Dr Pratik Man Singh Gurung. The fourth arm does the retraction, the doctor said explaining the technology of robotic surgery.

The operating doctor uses a foot pedal that has a camera button to move the camera situated in the robot's arm.

The camera gives the operating doctor a 3D view of the part to be operated on, plus ten-fold magnification, as per him.

'The operation utilises ports - small cuts on the body - to do the surgery. Usually, four cuts are made in the human body, and sometimes up to five for big operations. The robotic arm with a camera enters the body from one port and gives the doctor the vision as s/he sits on the console - placed either in the same room with the patient or in the next. The doctor can move the camera inside the patient's body by moving the controls on the console and seeing the inside of the body. Likewise, once the other robotic arms are docked onto the robotic ports, the doctor synchronises them via the console. Every movement the surgeon makes in the console translates through the instrument inside the body.'

He further explained, 'The body is inflated in a process called insufflation using carbon dioxide. This creates a dome of skin adjusting the instruments inside the body and you can work with the organs.'

A version of this article appears in the print on July 10, 2022, of The Himalayan Times.