Robotic and Laparoscopic Surgery

Robotic and laparoscopic surgery now allow many operations that once needed a large abdominal incision to be performed through small ports. Laparoscopy works with rigid instruments and a two-dimensional camera; the da Vinci robot adds a wristed instrument tip, a magnified three-dimensional view and a seated surgeon, advantages that count most in deep, narrow spaces. For planned surgery, the patient's main gain is an earlier recovery.

Dr. Rakesh Durkhure is a general, laparoscopic, robotic and bariatric surgeon who is Head - General, MI & Bariatric Surgery (Unit IV) at Artemis Hospitals, Gurugram, India. His remit in general and bariatric surgery, as he puts it, runs the length of the digestive tract, from the oesophagus to the back passage, and it extends into the neck, the abdominal wall and the female pelvis. The organising idea of his masterclass was narrower than that remit: not the routine keyhole operations every surgeon already knows, but the procedures that have been steadily added to the minimally invasive repertoire, so that patients who once needed a large laparotomy (an open incision through the abdominal wall) no longer do.

This guide sets out how the two platforms differ, the range of operations he presented, the hospital and the principles that govern how his department treats patients who travel for surgery, and his offer to train surgeons, with links to the three deeper articles in the series.

How robotic and laparoscopic surgery differ

Both are forms of minimally invasive, or keyhole, surgery: a camera and long instruments pass into the body through small ports instead of a large incision. The difference lies in how the surgeon holds and sees the instruments. In laparoscopy the surgeon stands at the table and moves rigid instruments directly; in robotic surgery the surgeon sits at a console and moves wristed instruments through the robot.

How the da Vinci robotic system works

The da Vinci system has three components: the surgeon console, the patient cart carrying the robotic arms, and the vision cart. At the console, Dr. Durkhure sits with his eyes in the viewer, operates the instruments through two hand controllers, and controls electrocautery, the use of electrical current to cut tissue and seal bleeding vessels, with foot pedals. The arms dock to ports placed in the patient's abdomen. Dr. Durkhure described the da Vinci as the American system.

Robotic vs laparoscopic surgery: four advantages of the robot

Dr. Durkhure singled out four advantages of the robot over conventional laparoscopy.

• The wrist. A laparoscopic instrument is a rigid rod: it moves in, out and around a fixed pivot, and that is all. A robotic instrument has a wrist at its tip, which gives the surgeon seven degrees of movement, the independent directions in which the tip can move and rotate. Dr. Durkhure demonstrated this by suturing skin robotically, an unnecessary step performed only to show how the instrument can backhand a needle and twist through angles that a laparoscopic needle holder cannot reach.
• Ambidexterity. He is right-handed, yet on the robot he operates with his left hand at the same precision and angulation, which matters in deep, narrow fields where the best angle of approach belongs to the non-dominant side.
• Vision. The robot gives a three-dimensional image where laparoscopy gives a two-dimensional one, with far greater magnification. The da Vinci's 3D high-definition camera is generally described as magnifying the field up to ten times. In hernia surgery, he noted, this means seeing individual fibres, small vessels and nerves clearly enough that he encourages any surgeon contemplating such an operation to do it on the robot.
• Endurance. The surgeon operates seated. Dr. Durkhure can sustain a robotic operation for four or five hours.

When the robot is used, and when laparoscopy is enough

The robot is reserved for planned surgery, not emergencies, and the patient's main gain is an earlier recovery. Not every operation needs it: several of the procedures he showed, including a complete colectomy and a common bile duct clearance, were performed laparoscopically, and he presented the two platforms as complementary rather than competing.

Which operations can be done robotically or laparoscopically?

Dr. Durkhure structured the lecture as a journey along the digestive tract, with detours into the neck and the pelvis. The operations he presented fall into three groups.

Oesophagus, thyroid and gallbladder. He showed surgery for the tight lower oesophagus of achalasia, checked by on-table endoscopy for leaks, and robotic fundoplication for reflux, in which the upper stomach is wrapped around the lower oesophagus. He described a scarless thyroidectomy performed through the armpit and the areola, his 6-centimetre size limit for it, and the complication profile compared with open surgery. He demonstrated indocyanine green imaging, in which a fluorescent dye lights up the bile ducts, in difficult gallbladder surgery, and a laparoscopic clearance of a duct packed with stones, after which the patient eats within hours. He also described his youngest patient, whose injured oesophagus he replaced with the stomach. These are covered in robotic Heller myotomy, thyroid and gallbladder surgery.

Bariatric and metabolic surgery. He compared the gastric balloon, sleeve gastrectomy, mini gastric bypass, SASI bypass and Roux-en-Y gastric bypass, and set out his selection criteria, his multidisciplinary team, his one-day stay, his approach to weight regain after a sleeve, and his view that GLP-1 injections and surgery complement rather than replace each other. These are covered in sleeve gastrectomy vs mini gastric bypass, revision and GLP-1s.

Hernia, colorectal and pelvic floor surgery. He showed robotic hernia repair, laparoscopic removal of the entire colon through three working ports, ileal pouch surgery for ulcerative colitis, robotic rectopexy for prolapse, fistula and haemorrhoid surgery, single-port surgery, and the gynaecological and urogynaecological operations he performs alongside gynaecologists, including Burch colposuspension for stress urinary incontinence. These are covered in robotic hernia repair, colorectal and pelvic floor surgery.

Artemis Hospitals: the institution behind the surgery

Artemis is a 750-bed hospital with five intensive care units and 23 operating theatres. It performs heart, lung, kidney and liver transplants, runs a full oncology department with radiation machines and PET-CT, and operates two kinds of surgical robot: an orthopaedic robot and two da Vinci systems for general surgery, shared by general surgeons, urologists, gynaecologists and surgical oncologists.

For a surgeon whose patients often cross an ocean to reach him, the institutional depth matters as much as the robot. A complex abdominal operation in a patient with cardiac, endocrine or renal comorbidity is safer in a hospital where every one of those specialties sits under the same roof. The hospital is close to the airport, to shopping centres and to the metro, and is surrounded by guest houses where families can stay, which Dr. Durkhure sees as part of ensuring a patient does not feel isolated during a long stay away from home.

How the department cares for international patients

Dr. Durkhure's department works to a written set of principles, designed mainly with international patients in mind, and he requires his juniors and colleagues to work through them before any patient reaches them.

Dedicated, unhurried consultation. A patient who has travelled across an ocean needs time that is not bound to a 10 or 15-minute slot, with a doctor who is not picking up the phone or discussing personal matters. His formulation is that less communication always produces more confusion, so communication has to rise for confusion to fall. Where the patient does not speak English, an interpreter is arranged through Jivo Healthcare.

Two meetings before surgery. He recommends at least two consultations. The first discussion inevitably raises questions in the patient's mind; the patient goes away, returns with them, and the team answers every one before proceeding.

Pen and paper, not stock images. His team explains each operation with hand-drawn, coloured diagrams rather than images from Google or AI tools. They write down the expected results and the possible good and bad outcomes, and hand that paper to the patient, so that at discharge, or before flying home, the patient holds a document that records exactly what the doctor said.

The box approach. Every step, from consent to clinical examination to the operation itself, is classified and followed in sequence, A to Z, according to the plan agreed with the patient.

Innovation without experiment. The department innovates, but does not experiment with new operations on patients: it selects procedures that are the gold standard.

No false promises. Complications are explained. If the success rate is 98 percent, the patient is told 98, and told what makes up the remaining 2 or 3 percent.

Video and implants on the record. Dr. Durkhure records his operations and gives the patient clips at discharge, so that the referring doctor back home receives not just a discharge summary but footage of exactly what was done inside, and which implant was used. His department uses implants only from established German or American companies approved by the US FDA, and for hernia repair he uses only American mesh, without offering patients alternatives.

Follow-up. He keeps regular contact with his patients after they return home. Among those he showed were bariatric patients from New Zealand, Kenya, Australia, England and Afghanistan, shown with their BMI (body mass index) substantially reduced.

Robotic and laparoscopic surgery training for surgeons

Dr. Durkhure teaches laparoscopic surgery and is a proctor for robotic surgery, a senior surgeon who supervises new robotic surgeons through their early cases. Producing more surgeons is the second goal on his list, alongside treating patients. He offered to train any surgeon who travels to Artemis, saying he can teach laparoscopy in a month, or within one to two months for complete training in specific procedures. His stated aim is to strengthen the trainee's hands and judgement for surgery. In the live discussion after the masterclass, questions about a fee waiver for doctors in the Jivo Doctor Network he referred to the hospital's human resources, accounts and academic departments.

He also offered to travel. Where a group of surgeons in another country has suitable cases, he can spend two, three or four days on site, teaching them in their own setting. For doctors in countries where these operations are not yet routine, that may prove the more durable contribution: the skills stay where the patients are.