Govt support necessary to increase penetration of robotic surgery in tier 2, 3 cities: Dr. Sudhir P. Srivastava, SS Innovations

For robotic surgery to enter the mainstream healthcare infrastructure, the government should introduce robotic surgery at educational institutions.

Despite decades of successful robotic-assisted surgeries globally that have positively impacted millions of patients, the access is scarce at large. The dominant current robotic system is expensive and associated with a steep learning curve, resulting in the limited availability across the world of over six billion people. In an exclusive conversation with Financial Express Online Dr. Sudhir P. Srivastava, Founder, Chairman & CEO, SS Innovations said that robotics shall be the future of surgery, and he aims to create a technologically advanced system that will be cost-effective, easy to use, and can be applied to all surgical specialties. Thus, benefitting most patients around the world. Compared to conventional surgery, robotic surgery results in smaller incisions, that reduces pain, scarring and leads to quicker recovery, he added. Excerpts:

What is the current state of the latest innovation and technology in medical and healthcare, please elaborate.

Over the last 70 years, medicine has advanced significantly because of new discoveries, developments and newer technologies from a plain X-Ray to CT Scans, MRIs, ECHOs and 3D imaging to give more details about the disease process.  Various Artificial Intelligence and algorithms can determine very quickly in relation to differential diagnoses.  There are machines that can give quick interpretations in remote areas where there are no doctors present, for example to generate an EKG report with interpretation utilizing AI and machine learning.  The utilization of technology in the field of medicine has always been important with the goal of advancing science.  A perfect example of this is the comparison between minimally invasive surgery and traditional open surgical techniques.  The traditional techniques carried with them an increased risk of infection, slower recovery times and post-operative pain which ultimately affected the quality of life of the patient.

There was an evolution of surgery from these open techniques to laparoscopic, or keyhole, surgery and today robotic assisted surgery.  Additionally, various treatment methodologies have changed, instead of excision, now ablation of cancers within the body is done to prevent systemic side effects of various treatments.  Nanotechnology is now being used in relation to drug delivery in targeted therapy for various systemic diseases.  Stem cell research is ongoing with regards to the regeneration of organs and 3D printing is now being used for modelling of organs to better understand the disease processes.  Lastly, telemedicine has come to the forefront with astonishing advancements where medical diagnosis and care can be done remotely and telesurgery, where surgery can be done remotely utilizing technological advancements in connection speeds and bandwidth.

How far has medical robotic surgery come from its origin?

In the 1980s the United States Defense Department and NASA funded research to develop technologies to be able to treat patients in space and the battlefield, however, at that time the technology was not mature and bandwidth was not available for telesurgery.  Early robotic companies came into existence in 1988 with the PROBOT which was developed at the Imperial College of London to perform prostate surgery, then ROBODOC from Integrated Surgical Systems in 1992 to mill out precise fittings in the femur for hip replacement.  IN 1998 a Trans-Atlantic surgery was done with the Zeus system, however, there was significant latency and the cost was prohibitive but it did show that a telesurgery Proof of Concept could be achieved. Robotic surgery started at the patient level in 1998 and over the last 20 plus years, over 7 million robotic operations have been performed globally.  Even though so many procedures have been done, when analysing the numbers, an even global penetration has never been reached due primarily to the high capital cost of the robotic system. Today there are over 5700 robotic systems in the world, 93% are between the United States, Europe, and Japan. This means almost 6 billion people in the world do not have easy access to this advanced medical technology, primarily due to the cost.  If you do not have access to the system then you cannot train and become better at your techniques.

Even in parts of the developed world, the availability of robotic surgery options remain in larger cities which means that in smaller cities a patient will have to travel in order to receive better surgical options.  Over 140 companies and research institutions are presently working on various robotic systems for a large spectrum of applications.  There are over 20 robotic systems that have been launched but there are only a few that are being used in a clinical setting.  In the next 3-4 years there will be an additional 10-15 companies emerging with respect to specialty specific technologies.

Tell us about the launch of MANTRA

Despite decades of successful robotic-assisted surgeries globally that have positively impacted millions of patients, access is scarce at large. The dominant current robotic system is expensive and associated with a steep learning curve, resulting in the limited availability across the world. Taking this up as a challenge and leading with a vision to offer minimally invasive robotic surgery solutions, we have launched the MANTRA surgical robotic system. It is a cost – effective, modular surgical robotic system developed to perform minimal access surgery with high precision, control & dexterity. It can be utilized for all major surgical specialties including Urology, General Surgery, Gynaecology, Thoracic, Cardiac, and Head & Neck Surgery.

Dr. Sudhir P. Srivastava, Founder, Chairman & CEO, SS Innovations

How much time did you take to take from inception to getting the product ready?

I came to India as founder and chairman of the International Centre for Robotic Surgery to be able to launch programs in the country. After having come to India in 2011 and launching programs, I realized that the cost was a major inhibiting factor for our patients to undergo surgery. The capital cost was high and  the per procedure cost was also expensive. In 2012, I decided to invest my time and money to come up with a system that would be cost-effective. Initially, my mission took me to Germany, and then in 2013, I put together a team of engineers to start looking into developing some of the ideas that were very different for a technologically different robotic systems that would also be cost-effective and have more capabilities.

It has taken us about four years or so, to come up with the latest generation of the MANTRA surgical robotic system. Recently, in our first in human clinical pilot study utilizing the MANTRA surgical robotic system, we successfully completed 18 complex abdominopelvic procedures at the Rajiv Gandhi Cancer Institute, the premier hospital for Oncology Surgery in India.

Tell us about your team, who worked on this project?

What it took really for this success in a relatively short time and with limited financial resources was the association of a clinical experience with a very talented team of  young engineers. The majority of this team is from India, while we do have international engineers along the way who have helped us. These are renowned experts in the field of robotic engineering. The SSI team has been aided by world renowned robotic surgeons and highly experienced consultants from around the world. The committed and focused efforts have resulted in an affordable multi-arm SSI Mantra Surgical Robotic System that would benefit many more patients around the world to decentralise access and excellence.

What are your plans for expansion and further development?

Our vision is to develop an affordable system that can become available to the masses.  Our goal is to be able to sell to the end-user in India at somewhere between four to five crores. This will further keep the cost of procedures as well as the maintenance contract very affordable. The hospitals can afford it and in return, more and more patients will benefit from it. Our plans for the future include making the system commercially available later in 2021 and establishing our manufacturing and assembly within India. We have raised over 300 crores or so from various resources but at this point. We will be launching our next round of funding for which our goal is to raise somewhere between 700 to 1000 crore to establish the infrastructure support systems, manufacturing and to place ourselves as a global robotic surgery company. My dream and vision are really to make the robotic system available in parts of the world where patients would otherwise not have access.  Additionally, we would hope that our system could be placed across Indian Medical Colleges so that, just as surgeons come out of their PG courses as trained laparoscopic surgeons, they could also have the opportunity to train as robotic surgeons as well.

What differentiates MANTRA from the existing Robotic system in the market?

MANTRA is unique in its ways that it is modular with an open face console. This design provides superior ergonomics for the surgeon while giving full view of hand controls, foot pedals and surgical team.  The surgeon can view the entire operating room for active guidance. Modular Robotic Arms with multiple adjustments are mounted on individual motorised carts for easy movement, positioning and docking. The design allows for total flexibility as to number of arms for specific procedures (3-5 Arms), positioning based on target anatomy and body habitus. The numbers of arms used are customisable based on types of procedures, end user requirements and budgets.
Our system will be useful in all surgical specialties, except orthopaedic at this point. Additionally, we will be including cardiac surgery as one of our focuses. Currently, no other company in the world is focused on all aspects of cardiac surgery, specifically robotic cardiac bypass procedures. The benefits in cardiac surgery are so huge in terms of having the entire complex operation done through tiny holes versus having the sternum split open, which is associated with a lot of trauma, surgical complications, and very long recovery periods.

Another major factor that we considered in this development was the cost. The current dominant system in India at the highest level sells for between 16 to 18 crores. As mentioned, our vision is to develop a system that can benefit the masses and many more hospitals, as such, our system will be available at on-third of that cost.

As a part of Make in India, what is the support you are seeking from the government?

As a part of the Make in India initiative, we would like for the government to extend a helping hand towards the robotic surgery segment by reducing the import duty on essential electronic components and other components that are not indigenously produced in India. Government support is also necessary to increase the penetration of robotic surgery technology to the tier 2 and tier 3 cities to ensure that it should be easily available to patients across the country at an affordable and subsidized rate.  Create partnerships to be able to expand healthcare to remote areas.  Robotic surgery coverage under Ayushman Bharat for half a billion people.

For robotic surgery to enter the mainstream healthcare infrastructure, the government should introduce robotic surgery at educational institutions. This will help the new generation to associate with this revolutionary technology. If fellowships are offered in robotic surgery, and post-graduate courses are started in this field, then a pool of well-trained robotic surgeons and world-class infrastructure can be developed within the country.  India truly has an opportunity to become world leaders in robotic surgery, with our large population base and desire to advance amongst the medical community,  a huge database based on the cumulative clinical experience that can be used to advance further research and development and teaching and training.    With regards to improvements in infrastructure, telesurgery can be achieved but it would require high speed bandwidth across the country in order to facilitate this novel application.

The following steps would further help to ensure penetration of robotic technology in the country:

1. Supporting the establishment of robotic surgery programs in public hospitals and putting policies in place that facilitate the adoption and access to the technology
2. Providing the required infrastructure to localize the production of surgical robots.
3. Giving preference to Indian products over foreign-made products if the quality standards are the same.
4. Promoting indigenous manufacturing of various electronic components, motors, and drives, etc.

Could you throw some light on the challenges and roadblocks you faced during this project?

Apart from the pandemic due to which the project was delayed by almost an year, the biggest hurdle that slowed us down is the dependency on foreign manufactures for importing sophisticated equipment. We are hoping that the government will take necessary steps to provide essential facilities to indigenous robotic surgery start-ups.
Apart from the above, we being a start -up faced the same set of challenges as every start up such as procurement of funds and talent, meeting the investment milestones, manufacturing delays etc., which we overcame with time, effort and consistency.