Question 1

How can healthcare professionals in other countries help patients benefit from these interventions, given the financial constraints they face?

Dr. Rakesh Durkhure · Accepted Answer

I can answer in two parts. The logistics and financial constraints are for the Jivo team to address. What I can offer is knowledge for your own community: if you, or any surgeon you know, wants to travel to India, I can teach them surgery here. I am a good teacher, or so my students say, and I can teach laparoscopy in one month. In that way I can help produce good surgeons for your country.

Question 2

On the slide comparing bariatric procedures, the sleeve gastrectomy carries a note of recurrence at two years. What is recurring, what do you do about it, and does the anatomy change?

Dr. Rakesh Durkhure · Accepted Answer

Recurrence there means regain of weight. It results from improper counselling of the patient and from not understanding their food habits, their work and how much they walk or exercise. The stomach cannot go back to what it was, but the sleeve starts dilating. We then convert the sleeve into another procedure: the mini gastric bypass, the SASI bypass, or another option, depending on the patient's habitus.

Question 3

What are the complications of robotic thyroidectomy compared with conventional open thyroidectomy?

Dr. Rakesh Durkhure · Accepted Answer

Think of Formula One drivers: put them on a small city road and they will crash everywhere, and a city driver on an F1 track does not know how to drive it. A particular set of surgeries needs a surgeon trained for it. I trained for it and have performed robotic thyroid and neck surgery for years. What matters is the indication: if the indication is right, complications are fewer. Our limit is a thyroid nodule or lobe of no more than 6 centimetres; below that, I operate robotically or laparoscopically, and above it I advise open surgery, irrespective of cosmetic considerations. I identify the recurrent laryngeal nerve on both sides and all four parathyroid glands before removing the thyroid. If the surgeon is not well versed in robotic surgery, complications can occur: the longer the operating time, the more CO2 is absorbed through the subcutaneous tissue, which raises the patient's end-tidal CO2 during surgery.

Question 4

How can doctors train as fellows under you, and is any sponsorship or waiver of Artemis's academic fee available for the Jivo doctor network?

Dr. Rakesh Durkhure · Accepted Answer

I am a surgeon, and I can give complete training in laparoscopic surgery, in specific procedures, over one or two months. My job is to empower your hands and your mind for surgery. On fees and a possible waiver, I will discuss it with the hospital's human resources, accounts and academic departments, and the details will be passed on to you through Jivo.

Question 5

With GLP-1 drugs such as Mounjaro now approved for weight control, can these medications replace the need for bariatric surgery?

Dr. Rakesh Durkhure · Accepted Answer

Injections have to be taken every week, and they are not a permanent cure. If a patient's BMI is above 45 or 50, injections cannot bring it down to 25: a patient of 150 kg cannot become 75 kg on injections alone, and needs a more permanent, anatomical therapy. If someone wants to lose a little weight, say from 100 kg to 85 kg, or from 125 kg to 110 kg, injections alone are enough and no surgery is needed. Surgery is for patients with comorbidities such as sleep apnoea, knee joint problems, back pain or stress urinary incontinence, and for those whose weight is too high; for them, bariatric surgery is the best option. Injections are good as an initial step, and sometimes I give them for two or three months before surgery to improve the patient's condition so that the anaesthetist accepts them for surgery. I do prescribe these injections to my patients. The two go hand in hand: one cannot replace the other.

Question 6

How do you treat stress urinary incontinence robotically?

Dr. Rakesh Durkhure · Accepted Answer

In women the urethra is only about 4 centimetres long. When the internal urethral meatus, the junction of the urethra with the bladder, sags down, the muscle weakens and control at the internal meatus decreases. Our job is to lift it back up and straighten it. In a Burch suspension I place three stitches on each side of the urethra in the anterior vaginal wall, then lift and fix them to the pectineal (Cooper's) ligament, which pulls up the anterior vaginal wall and raises the internal meatus and urethra. Robotically, suturing in that very narrow space is much better than laparoscopically. The surgery is completed within an hour, with minimal intervention, and the patient goes home the next day.

Question 7

If a patient follows the lifestyle recommendations properly after sleeve gastrectomy, is there still a chance of weight regain?

Dr. Rakesh Durkhure · Accepted Answer

The risk is much lower if the patient sticks to the recommended diet, exercise and lifestyle changes, but it is not zero. Some weight regain is common in the years after a sleeve, partly because of the body's own hormonal adaptation and dilatation of the sleeve, so long-term follow-up matters.

Live Discussion with Dr. Rakesh Durkhure