We are happy to report that Vattikuti Fellow Dr. Sushil Jain Kumar, studying under the leadership of robotic surgeon S. P. Somashekhar at Manipal Hospital, has taken honors for his poster: A PROSPECTIVE STUDY OF TOTAL ROBOTIC THREE STAGE ESOPHAGECTOMY - A SINGLE INSTITUTION EXPERIENCE. He had entered his poster for consideration at UGICON2017, Ahmedabad. Here is some of what he had to say: " I am very glad to share you that I received best poster award in UGICON2017, Ahmedabad. It was an international conference and live workshop (14 - 16 April) in association with Netherland and Japan on esophagus and stomach." .

Dr. Kumar has been in his Vattikuti Fellowship at Manipal since September, 2016. He also took time to thank the Vattikuti Foundation and his Mentor Surgeon: " This is a proud moment for me and my mentor. So, on this occasion I would like to thank to Dr. Mahendra Bhandari sir, Vattikuti Foundation and my mentor Dr. Somashekhar SP who (have) given me opportunity to be a fellow of this esteemed Foundation." .

We thank Dr. Kumar for his success and kind words about Dr. Somashekhar and Dr. Bhandari. The Vattikuti Foundation offers several year-long Fellowships to deserving young surgeons working to further their careers with robotic surgery posts at some of India's leading institutions. We thank Dr. Somashekhar and his fellow mentor surgeons for guiding our Fellows with their careers. .

We were pleased to learn that one of our Vattikuti Fellows took a top award for a poster submitted at a meeting in San Diego recently. Dr. Karan Gupta has been at the Rajiv Gandhi Cancer Institute & Research Institute since last October as a Vattikuti Fellow. Dr. Surender Dabas is his Mentor Surgeon. Dr. Gupta was sponsored by the Vattikuti Foundation to attend the Annual American Head-Neck Society (AHNS) - 2017 Meet as a part of the Combined Otolaryngology Spring Meet (COSM) - 2017 at San Diego, California, USA from 26th to 30th April, 2017. There were more than 2,000 Head & Neck Oncology experts attending the annual meetings. .

Karan was able to attend with Foundation Sponsorship due to the fact that he had two Posters accepted. (This is part of the Foundation's Fellowship program- which encourages conference presentations and journal publications by our current Fellows.) The poster topics were: .

Transoral Robotic Surgery in management of supraglottic malignancies: a feasibility study at a tertiary cancer centre in India. Haemorrhage post TORS in oropharyngeal carcinoma: Incidence, risk factors and prevention..

The poster documented Dr. Gupta's research, which was to determine the technical feasibility, safety and adequacy of surgical margins for transoral robotic surgery (TORS) in supraglottic cancers. His study involved 46 H & N TORS patients who had surgical procedures with the da Vinci Surgical System. His poster was one of 733 entered in the combined conferences. (Numbers from researchposters.com website.) .

Here is what he told Vattikuti Foundation C. E. O. Dr. Mahendra Bhandari about his experience: " I wish to inform the Foundation that my posters were very well appreciated by all and the poster "Transoral Robotic Surgery in management of supraglottic malignancies: a feasibility study at a tertiary cancer centre in India." won the Poster of Distinction award at the meet." .

"All of us at the Vattikuti Foundation are very pleased with Dr. Karan Gupta's success at the combined Head and Neck conferences. What he has accomplished matches the goals we have for all of our Vattikuti Fellows. We encourage other young surgeons to strive to work as hard as he is doing. His work has been recognized internationally by his peers, what a fine achievement," says Dr. Mahendra Bhandari. .

Dr. Gupta was gracious with his praise for both his mentor and the Vattikuti Foundation for supporting him: "I specially wish to thank Dr. Bhandari Sir for giving me this golden opportunity of the Vattikuti Foundation Robotic Head-Neck Surgery Fellowship and facilitating my attendance of the conference. .

"I wish to thank my mentor Dr. Surender Dabas for all the confidence and faith and sharing his data with me. Without his guidance and help these posters and Award would not have been possible." .

We look forward to hearing more from Dr. Karan Gupta as he continues his Vattikuti Fellowship- and beyond. .

“My experience as a Vattikuti Foundation Clinical Fellow in Robotic Urooncology at Max Institute of Cancer Care” .

The Vattikuti Foundation provides an excellent opportunity to train the novice surgeon in the field of robotic surgeries. At present 11 centres in India offer this fellowship including 6 urology centres. The application process is similar to the process of matching in USA for fellowship programs. The remarkable feature of this process is the absolute transparency in the selection of a fellow which gives full merit to the curriculum vitae of the applicant. .

I did start my Vattikuti Fellowship under the guidance of Dr. Gagan Gautam and his team in urooncology at Max Institute of Cancer Care in February 2017. This team consisted of Dr. Puneet Ahluwalia as another consultant and Mr. Surya Ojha as a dedicated robotic nurse practitioner. In addition, I worked with many more people in the team who are responsible for a successful robotic program. As mentioned earlier the selection was based on the curriculum vitae along with an interview by the mentor. The main dilemma from a fellow’s perspective is always an element of hesitation for deciding on joining this fellowship program. I was not an exception for this. For a novice who has completed his or her residency recently, it’s a difficult call to be taken especially when someone is not exposed to the robotic surgeries during the residency. It’s the enthusiasm and commitment of the mentor which gives reassurance to the candidate. There is always a very strong support on all the aspects from the Foundation on all possible grounds. Fortunately, I had both the factors to support my decision. .

As a fellow, one has to have an open mind at the start of fellowship. As you are going to enter a new challenging field in your career path, your eagerness to learn this skill is most vital. One should approach this as a clean slate; ready for the beautiful painting by the joint efforts of a fellow and a mentor. One should decide about certain goals from this fellowship right from the beginning. These can be clinical learning, surgical training, academic and research development. Finally, one has to focus on the future path in career. I have elaborated my experience from this one-year fellowship pertaining to these five aspects. .

Being a part of an exclusive urooncology unit, we had multiple referrals for the cases in urooncology which included predominantly prostate, bladder, kidney cancers and few cases of testicular and penile cancers. One can be thorough in managing these patients in every stage and in following them on long term basis by the end of the fellowship. I think that the management of prostate cancer patients is so varied due to ongoing research; one has to streamline the protocols at each individual centre considering the evidence and local patient pool characteristics. The basis of a good clinical practice revolves around the concept of a patient centric approach. Multimodality treatment concept is another factor which I did learn from the disease management group discussions which form the core of ethical practice. The most important aspect of the decision making is the basic of our medical practice i.e., primum non nocere (first do no harm). One should also understand when not to operate and when not to go for robotic approach. Another valid point which I learnt is the requirement of a thorough preoperative counselling, admitting all potential minor and major complication rates including anesthesia related complications. This avoids the adverse repercussions in the post-operative phase. .

The first and essential step of robotic surgical training is to understand the basics of the robotic instrumentation, positioning, port placement, docking and undocking of the robot. Patient safety throughout surgery including prevention of all issues related to positioning is always the priority. The core of the successful training is active independent assistance as a bedside assistant (BSA). One has to be an excellent BSA before becoming an excellent console surgeon. The main keystone of the successful robotic program is the level of coordination between console surgeon and bedside assistant. I was actively assisting the cases at the end of one month of my Vattikuti Fellowship. Care of the instruments, safe docking and undocking, proper padding of pressure points, under vision instrument insertion, guided tool exchange etc. were the points which I learnt thoroughly. Preparedness for any emergency open conversion was the most important lessons learnt by me before proceeding to console work. .

The console work started after this, at about 2 months from the start of my fellowship. Console training is a stepwise process starting from basic non critical steps followed by more critical steps of the procedure. Pertaining to robotic prostatectomy, training starts from the step of bladder drop, followed by posterior dissections, then lymphadenectomy. The day you perform your first bladder drop; you actually understand the gravity of a console surgeon’s skill. Advancing further it involves bladder neck dissections, control of dorsal venous complex, lateral pedicle dissections to anastomoses in sequential manner. Nerve sparing and apical dissection are the most critical steps which should be focused upon at the end. Before advancing to the next step, the factor which is most essential is the confidence of a fellow in performing the previous step. In my focused training of robotic prostatectomy, I have performed each and every step for several numbers of times. Apart from prostatectomy, as a fellow you get to perform certain steps of robotic surgeries of the kidney in the form of mobilization of colon, lifting of ureterogonadal packet, hilar dissection, tumor excision for partial nephrectomy etc. This gives a comprehensive hands-on experience of the lower tract as well as the upper tract to a fellow. The learning at this stage also depends upon observing and actively assisting certain complex cases like cystectomies and atypical cases like retroperitoneal lymph node dissections, video endoscopic inguinal lymph node dissections, total pelvic exenteration etc. I received this hands-on training in about 73 cases during my one year of fellowship. In total I did spend about 4470 minutes on the robotic console amounting to approximately one hour per case. During all these sessions of console work, patient safety is not compromised. All the steps are mentored by expert BSA and the mentor. In total, I had an exposure of 137 cases, which included all types of robotic surgeries in urooncology. It’s a very good habit to maintain all the data in your log including all steps of assistance and console work which would include the precise timings. It is most essential to store your videos and analyses them periodically. If you encounter a complication, it is essential to analyze the video and identify the reason for the complication so as to avoid it in future. I encountered one minor complication in the form of partial diathermy injury to obturator nerve. Fortunately, the patient did not have any sequelae, but I did analyze the video and learnt from the mistake. The Vattikuti Foundation website gives you an opportunity to see excellent videos in your field which would make one’s learning more focused. Another important aspect which I learnt was the importance of the team work. You should learn from each and every member of the team. The level of coordination between each and every team member is utmost vital. .

On the academic front this fellowship is an excellent opportunity to present data and videos on all possible platforms including international conferences. It’s an excellent opportunity to add some feathers in your cap by getting awards in different conferences. I presented about 18 abstracts in different conferences. I also presented papers during the European Association of Urology (EAU) annual conference in 2018 and EAU Robotic Urology Section conference 2017. Totally I was honored with five awards for different topics, including one national award (Dr. Sitharaman memorial prize) for the essay which I wrote on the topic ‘The Future of Urological Research in India’. I also won a national award for my video on robotic intracorporeal conduit in RUFCON (Robotic Urology Forum of India Conference) 2017. My poster on evaluation of outcomes of continuation of low dose aspirin in robotic prostatectomy was awarded as the best poster for RUFCON 2018. It was a proud moment for me to receive the Vattikuti Foundation’s prestigious award ‘Late Shri Krishnaswamy Subramaniam Memorial Award’ for the video on robotic retroperitoneal lymph node dissection during VIII Robotic Surgeons Council of India meet. These presentations help to make the Vattikuti Fellow confident in presenting and delivering their academic work to the fullest. .

One of the examples of this was that I was actively involved in writing guidelines for Urological Society of India on certain topics of urological cancers. This was a different learning experience for me, gathering the knowledge on those topics with specific focus on the published Indian literature. My academic growth also involved writing manuscripts, reviews and book chapters. I wrote two book chapters which included updates on non-muscle invasive bladder cancer and another chapter on the basics of robotics, instrumentation, port placement and docking. I also had two projects approved by the hospital ethics committee. One of my projects was a randomized controlled trial on outcomes of pre division and post division suturing of the dorsal venous complex during Robot Assisted Radical Prostatectomy. The team has completed the patient enrollment (n=64) and active follow up is being done at present. Another topic was a pilot study of enhanced recovery after surgery (ERAS) protocol for robot assisted radical cystectomy with intracorporeal conduit. At present I have six manuscripts from my Fellowship work, under evaluation at different stages with international peer reviewed journals. .

The Vattikuti Collective Quality Initiative (VCQI) database is the authentic database maintained by the individual centres on a common forum. Fellows are always encouraged by the Foundation for utilising this database for writing manuscripts. In this fellowship, you can always visit different centres across the globe to learn different skills and practice patterns. The Vattikuti Foundation provides excellent support for all these activities. I had an opportunity to visit two internationally known centers of robotic surgery, one at the beginning of my console training and another at the end of my tenure. I went to observe Dr. Ashutosh Tewari at Mount Sinai Hospital, New York for a week during my initial days. In the end of my Vattikuti Fellowship, I had a clinical attachment at Lister Hospital, UK with Dr. Nikhil Vasdev, Dr. Jim Adshead and Dr. Tim Lane for a week. These opportunities helped me to decide about focus of interest and guided me for different research ideas. I believe that the Fellows should have some targets in an observer-ship and should analyse those at the time of completion. It’s a good habit for one to have a self-assessment file at the end of a clinical attachment which would mention all the new things which one has learnt from that place. .

I think the learning is an ongoing process and one has to develop the skills for a basic foundation. This Vattikuti Fellowship gives young surgeons not unlike me, a solid base on which to build own surgical pyramid. Fellows joining this program are in a phase of unconscious incompetence in the beginning, which means they are not in a position to understand the level of incompetence. Once they start acquiring the skill, they know exactly what they are lacking, which is a phase of conscious incompetence. In my opinion this learning curve has a steep up slope after this phase in which they gradually progress to the stage when they will consciously put efforts into reaching the level of competence which is called conscious competence. The aim of a fellow during the training should always be to start going on this path towards conscious competence. The ideal mentor always keeps on showing his or her fellows the correct path forever. .

Progress is impossible without analyzing the potential aspects for improvement. There are some minor points in my opinion which the Vattikuti Foundation and Mentor Surgeons could focus upon in addition to the current level of excellence. The Foundation can consider organizing the sessions for all the fellows, along with their respective mentors as joint meetings for discussion on the progress on academic and surgical fronts across all the centres. Fellows should explore options of E-learning which would include recent advances in the field, recent published trials etc. The videos of steps performed by the Vattikuti Fellows can be analyzed across all centres by different mentors. This would enhance the learning pattern leading to rapid skill development. Multi-institutional prospective studies can be considered across all these centres. Periodic appraisals, maybe every three months which would potentially assess developments in clinical, surgical and academic fronts would be a trigger for the betterment to all Fellows. .

To conclude, the Vattikuti Robotic Fellowship program is an excellent ground for structured training for rapid skill and academic development for a novice surgeon. The most important aspect for the success of the program is the firm commitment from the mentor and the mentee. If prospective Vattikuti Fellows have the beginner’s mind which would always be ready to learn without any preconceptions, I believe that they would end up with a boundless learning experience in this Vattikuti Fellowship, like I experienced during my tenure. .

I sincerely would like to thank each and every member of Vattikuti Foundation, my mentor Dr. Gagan Gautam and the Urooncology Team at Max Hospital for making me a better person. I would cherish this excellent learning experience forever in my life. It is an honor to be the first individual Fellow of this Vattikuti Fellowship program with Dr. Gagan Gautam at Max Institute of Cancer Care. .

Dr. Ashwin Sunil Tamhankar (MCh, DNB Urology)
Vattikuti Clinical Fellowship in Robotic Urooncology

(All images provided by Dr. Tamhankar).
By: Dr. Ashwin Tamhankar

Though we are a little late publishing this, we want to share the news about our former Vattikuti Fellow Dr. Santosh Waigankar. He was a Fellow with Dr. T. B. Yuvaraja at Kokilaben Dhirubhai Ambani Hospital, completing his term in October, 2016. He let us know last March that he had received recognition from ERUS 2017 for his poster abstract entitled: “Pentafecta outcomes of robotic partial nephrectomy for T1b renal masses: Single institute-single surgeon retrospective analysis”. This was awarded 2nd prize at the Junior ERUS-YAU meeting held on 25 September 2017, Bruges, Belgium. He received the prize from Dr. Geert De Naeyer, OLV Hospital Department of Urology.

Dr. Waigankar also has received his Intuitive Surgical certification as a robotic Surgeon trained on the da Vinci Si, Xi and X Surgical Systems. This is a significant accomplishment- and an important component of the Vattikuti Fellowship Program. We congratulate Dr. Waigankar for both of these honors, and wish him continues success in his career. We also thank Dr. Yuvaraja for his dedication to the Vattikuti Fellowship Program. .

UPDATE: We just learned that Dr. Waigankar has been awarded the scholarship from the SIU (Société Internationale d'Urologie) to attend the 38th Congress of the Société Internationale d'Urologie to be held from October 4 – 7 at Seoul, South Korea. Two of his abstracts have been accepted for the SIU Congress as well. We wish to congratulate him again on achieving this honor.

Word came to us recently from Vattikuti Fellow Ashwin Tamhankar, who served his Fellowship at the Max Institute of Cancer Care under Dr. Gagan Gautam, that he has earned his Certificate of da Vinci System Training from Intuitive Surgical, manufacturer of the da Vinci robot. Tamhankar's one-year Vattikuti Fellowship in Robotic Uro-Oncology was completed February 14th, 2018. He has remained working at Max since. Here is what he had to tell Vattikuti Foundation CEO Dr. Mahendra Bhandari via email: .

"It's a proud privilege to be a member of Vattikuti Family. I am happy to inform that I got the final console certification from Intuitive surgical today. .

Thank you for this wonderful training opportunity with Dr Gagan Gautam.

I would like to thank Dr. Gagan Gautam for being there as a strong support for me always. As (I) presented in RSC (Robotic Surgeons Council of India), I had an excellent time in my fellowship. .

I would like to thank each and every member of Vattikuti Foundation for the extended support on all possible grounds. Efforts put in by everyone for me especially Dave, Rekha, Madhavi, Rich, Shannon are exceptional. Ashwin Tamhankar" .

We also heard from Dr. Gagan Gautam, his Fellowship Director: .

"Congratulations,Ashwin!
I am sure you will do extremely well in this field in the future as well. Proud of you! .

Intuitive Surgical certification is not an easy task. It requires hours of online study from the da Vinci Surgical Community website. This is followed by simulator training, plus hours of work as a bedside assistant during robotic surgery, which is then followed by even more hours of work as the console surgeon for a specified minimum number of hours. This all must be completed under the guidance of an experienced mentor surgeon like Dr. Gagan Gautam.* All of us at the Vattikuti Foundation are very pleased with this news, because it successfully represents one of the major initiatives established by the Raj and Padma Vattikuti and Dr. Mahendra Bhandari for the Foundation. We extend our congratulations to Dr. Tamkankar, with thanks for a job well done! We also want to express our gratitude to Dr. Gagan Gautam for his role in training our Vattikuti Fellows- a commitment that is continuing even today! .

*For complete details, consult Intuitive Surgical, this is just an outline of what is required.

The Vattikuti Foundation, in cooperation with Dr. Khurshid Guru and the ATLAS Program at the Roswell Park Comprehensive Cancer Center in Buffalo, New York have had a number of Vattikuti Fellows obtain expert training in Robotic Surgery. Dr. Amit Tuli just completed his 2-week intensive training program there and sent us this report: .

I am highly thankful to Dr. Mahendra Bhandari (CEO of the Vattikuti Foundation) for having chosen me for this International Fellowship. It was a great honor for me to attend Roswell Park Comprehensive Cancer Center, a highly prestigious Institute in the heart of Buffalo City, New York. I am thankful to Dr. Khurshid Guru, Director, ATLAS Program and his team for having taken good care of me. .

I have learnt a lot from this Fellowship. I had the opportunity to visit the operating room and watch surgeries like robotic radical prostatectomy and robotic radical cystectomy, done by eminent surgeons like Dr. Khurshid Guru, Dr. Lee and Dr. Kaufman. .

I am also thankful to the ATLAS team, especially Dr. Ahmed EL Sayed and Jenna Bizovi, who took me through a very well-structured training in robotic skills. The training at Roswell Park Cancer Center is very well organized. It goes through a series of initial robotic exercises on simulator to inanimate models, followed by training on animal tissue and then to a porcine model. I am also thankful to the whole team, who took so much pain for porcine model exercise. .

I enjoyed my trip to Buffalo, as it is a beautiful city, famous for Niagara Falls. I enjoyed the food, weather and hospitality provided to me by the people of Buffalo. .

- We thank Dr. Tuli for his kind report- his experience is why the Vattikuti Fellowship program exists! We also thank Dr Khurshid Guru and his team at Roswell Park Comprehensive Cancer Center ATLAS Program. Without their generosity and dedication, this Fellowship could not exist.

By: Dr. Amit Tuli (edited by Dave Meinhard)