The Tribune, Chandigarh, India

Robotic heart surgery
Nintendo medicine in operation
By Dr Harinder Singh Bedi

THE cardiac surgeon (in a party suit) sits down at a large grey console. Peering into a binocular-like viewer, he adjusts the 3-D picture, grabs two joysticks and calmly proceeds to perform a complex triple bypass on a patient who is thousands of miles away in another continent. The patient wakes up one hour later with only three 5mm keyhole incisions in the side of his chest. He has a hearty meal and is discharged two days later. Space-age-science-fiction imagination? Not really, for robotic cardiac surgery, blended with virtual reality, is already with us in the last year of the fading millennium.

Traditional and minimally invasive endoscopic surgery has been with us for quite some time now. It was realised that the need for big incisions was due to the fact that the surgeon had to insert his hands into the operative field. This was circumvented to some extent by the advent of special and long instruments which were inserted via small holes or "ports" in the patient's body.

The surgeon would manipulate these instruments to perform surgery. However, the biggest limitation of conventional endoscopic instruments was the limited number of degrees of freedom (DoF) at the tip of the long instrument. In addition, operator tremors and the lack of motion scaling rendered delicate endoscopic bypass surgery impossible. It was like using a one-foot long pen to sign your name.

In order to overcome these limitations computer-enhanced instrumentation systems have been developed.

These are basically spin-offs of the space-age NASA technology (where astronauts are able to remote-control fine instruments to manipulate equipment in outer space) and of the Pentagon Research and Development Wing which aims at putting MASH-style surgeons out of the battlefield and let them operate on injured armymen at the frontline without physically being there.

These have allowed a quantum leap in minimally invasive surgery and are one of the biggest revolutions in cardiac surgery in which robots are becoming the surgeon's hands. Highly advanced computer systems seamlessly translate the surgeon's natural hand movements into corresponding micro-movements of the robot placed inside the patient.

The incision on the patient's chest will be totally unlike that in the over one million patients per year worldwide who undergo bypass surgery. Normally, in a multivessel bypass surgery (the commonest type — the others much less common being single and double vessel bypass), the surgeon approaches the heart by a long midline cut in the sternum or the breastbone. In robotic multivessel bypass surgery there are only three tiny "keyholes" in the left side of the chest. Through these pass in delicate computerised hardware — a light source, a camera and the "robot". The robot basically comprises two "hands" which have tiny metal fingers with rotating wrists which hold various microsurgical tools such as needles and scalpels. The new robotic wrist has seven DoF including tool function, i.e., the grip available at the tip of the instrument.

The camera (three-chip CCD) projects a magnified view (up to 10 times) of the operative field on a video screen and also on to two videoscopes in front of the surgeon's eyes. Because of improvements in technology, the surgeon has an actual 3-D high resolution view as opposed to a 2-D view which was available till now. The surgeon sits at a console which is some distance away from the patient (it could be in another room or even in another country altogether!).

The advantage of the remote master control is that all ground noise and information unrelated to the surgery are filtered out and the surgeon can fully concentrate on the technical details of the delicate surgery.

The surgeon has control on the robot via two joysticks (as in a computer Nintendo game) which have 40 sensors along the joints to register the movements he makes at the console. These sensors duplicate his hand movements and convey the same movement to the robot which is inside the patient's body. All motions are translated to the end of the instrument by electronic actuators using a matrix transform based on Cartesian coordinates. The computer (of the size of a PC) recalculates the surgeon's positions 1300 times a second. It also filters out the inevitable fine tremors which affect even the best surgeons and convey only exact and precise commands to the robot. By intelligent software, the illusion is created that the robotic instrument tips are in direct contact with the master handles at the console.

There are at present two systems available — the da Vinci (intuitive surgical) and Zeus (computer motion). The Zeus system has a voice recognition system called AESOP (Automated Endoscopic System for Optimal Positioning) by which the surgeon can 'tell' the light and the camera where to go inside the patient's body. This system, besides being very precise and steady, does away with the need for one assistant. With it, a totally endoscopic coronary artery bypass (TECAB) has already been performed in Dresden, Germany. The technology is thus no longer science fiction.

Over 500 operations have already been performed in Europe and the USA. The system is equally adept at treating valve disorders (repair and replacement of defective heart valves) and repairing congenital heart defects (a hole in the heart etc). The author has had extensive training in the use of the robot in Hamburg, Germany. Punjab may well be the first place in Asia to perform the first totally endoscopic heart surgery soon.

The advantages of the system are manifold:

There is a significant reduction in tissue trauma so that a patient will need very little or no blood for major bypass surgery (normally upto six units of blood are required).

Much lesser pain with the resultant faster recovery.

The patient will be able to wake up soon after surgery, have a normal meal and go home two days later (normally it takes 6 to 10 days before the patient can be discharged).

Pleasing cosmetic result as there are only three tiny keyhole scars in the side of the chest. This has obvious advantages especially for young female patients.

A shorter stay translates into lesser cost to the health provider.

With further developments, major surgery may well become an outpatient procedure leading to a greater number of patients being treated for what is basically a potentially fatal condition.

The combination is thus a win for the patients, surgeons, institutions, healthcare-providers, society and the State. The system goes along with sound conventional surgical procedures and basically acts as a translator of standard open-heart surgery techniques into endosurgery techniques. While still in its pioneering stage, the system is likely to change the way we would treat heart patients in the coming decade.

Dr Bedi is the Chairman of the Department of Cardiac Surgery, Tagore Heart Care, Jalandhar.

Right way to treat senior citizens
By Dr M.L. Kataria

GURU Nanak Dev gave the eternal message of universal brotherhood, love and peace to mankind. This message was put in actual practice to celebrate the 532nd birth anniversary of the Guru on November 11 in a unique manner.

The Senior Citizens' Health-Care Centre, the only one of its kind in our region, functioning at Lajpat Rai Bhavan, Chandigarh, for over 10 years, offered a humble Gurpurb gift of brotherhood, love and good health to the residents of Mohali on this auspicious day last week.

This bouquet of best wishes, worth a few lakhs of rupees, consists of an x-ray plant, a well-equipped laboratory for a full range of investigations, the latest model of an ECG machine and a well-stocked dispensary.

The Health-Care Centre has been established at the imposing Gurdwara Kalgidhar Sahib in Phase IV SAS Nagar. The dynamic management of the holy shrine worked hard to construct and provide excellent accommodation for this centre in record time.

The Kalgidhar Health-Care Centre was inaugurated by the veteran of many wars, the hero of Bangladesh, Major-General J.S. Bhullar PVSM amidst the chanting of the holy Gurbani, in the presence of thousands of people the devoted "sangat" from all walks of life. The environment reverberated with endless "Bole So Nihal, Sat Sri Akal"! The faithful gathered under a life-size portrait of Guru Nanak felt as if the Baba himself was blessing them and their Health-Care Centre!

General Bhullar (who has also donated Rs 20,000 for the centre), in his inaugural address said: "This centre is a symbol of our traditional culture of love and service to humanity".

The doyen of the elite bureaucracy of India, Mr P.H. Vaishnava (a former Chief Secretary of Punjab), blessed the centre and said: "Serving the ailing humanity is a supreme service. Chandigarh's gift of health care to Punjab on this auspicious day should be emulated by all."

Mr Onkar Chand, Secretary, Servants of the People Society, Chandigarh, praised the management of the Kalgidhar Gurdwara for its foresight and commitment to the service of the sick. He congratulated the Senior Citizens Health-Care Centre, Chandigarh, for their thoughtful gesture to spread Guru Nanak's message of global harmony.

Colonel Harsharan Singh, President of the Rashtriya Raksha Dal, said "This centre will be a boon for the exservicemen and their families living in and around Mohali."

Bibi Manmohan Kaur, a prominent citizen of the town and a municipal councillor functioning for the second term, was full of praise for the centre and compared it to an oasis of selfless and free service in the midst of a desert of medical commercialism.

The same team which operates the Senior Citizens' Centre at Lajpat Rai Bhavan, Chandigarh, is operating the centre.

The Kalgidhar Health-Care Centre caters to all the citizens of Mohali and the villages and slums around it. The services, including consultancy, laboratories, x-ray, ECG and dispensary, are free! It will be funded by Baba Nanak! The beneficiaries will see a divine dispensation in the years to come.

Dr (Brig) M.L. Kataria, an honorary consultant and a winner of the coveted Dr B.C. Roy National Award for Professional Excellence in Socio-Medical Relief to Humanity, is operating the Kalgidhar Health-Care Centre at Mohali. He also looks after 12 health-care centres in Chandigarh, Panchkula, nearby villages and slums.

Hidden food allergens: a quick look
By Dr Shakuntala Lavasa

FOOD allergies affect 2 per cent of the population and 5 per cent of the children. Food, as an allergen, has been mentioned by Hippocrates who said: "One man's meat is another man's poison."

Some relatively knew knowledge has come about modern food stuff where certain additives are most likely to cause asthma and other allergies in sensitive people.

Metabisulfite, added to preserve food in salads, wine, beer, fruit juices, dry fruits, shrimp, processed potatoes and sauce, is one such agent. Exposure to sulfites particularly in the setting of restaurant salad bars has been incriminated in many severe and even fatal asthma.

Green leafy vegetables become particularly dangerous because of the loose binding of the sulfite and added citric acid. Sulfur dioxide is a known susceptible incriminant by which asthmatics are particularly affected and levels produced from food and beverages can easily cause attacks in susceptible people.

Besides food, there is another source of sulfite exposure through medication. Sulfites are used to prevent the oxidation of nebulising solutions. The amount is sufficient to cause the paradoxical worsening of asthma and should be avoided by sensitive individuals.

Monosodium glutamate (agenomoto) in Chinese Food may cause wheezing and "Chinese Food Syndrome". Tartazine, added to colour food, drinks and medicines can cause asthma attacks in tartazine-sensitive people and also in aspirin sensitive persons.

The list is extensive and there are a lot of unlisted indigenous colours and preservatives put in cheap sweets, toffees, squashes etc., resulting in severe reactions. It is a good idea for everyone to eat freshly prepared food—more so for people with allergies and asthma!