Dr. Ajesh Raj Saksena is one of Hyderabad’s leading surgical oncologists, known for his expertise in minimally invasive and robotic cancer surgery, especially in complex gastrointestinal and esophageal cancers. Trained at premier institutions and recognised for his precision‑driven approach, he represents a new generation of Indian cancer surgeons who blend advanced technology with thoughtful, patient‑centred care. His work spans innovation, research, and high‑volume clinical practice, making him a key voice in modern oncologic surgery. In this exclusive NSH interview, Dr. Ajesh discusses evolving surgical techniques, the future of robotics, multidisciplinary care, and how precision technologies are reshaping cancer outcomes in India.
“Technology should never become surgical dogma”
1. What drew you to surgical oncology over a less high‑stakes specialty?
Surgical oncology appealed to me because it blends science, precision, and purpose in a way few fields do. Every operation has the power to alter the entire trajectory of a person’s life. You’re not just removing a tumour — you’re giving someone the chance to watch their children grow, celebrate milestones, and reclaim their future. The complexity never discouraged me; it motivated me. Cancer surgery demands continuous learning, technical excellence, and humility. No two patients are alike, and that constant challenge is what makes this specialty deeply fulfilling.
2. How does minimally invasive esophagectomy change patient outcomes compared to open surgery?
Minimally invasive esophagectomy replaces large chest and abdominal incisions with keyhole access and advanced optics. For patients, this means less pain, reduced blood loss, fewer respiratory complications, earlier mobilisation, and faster recovery. Crucially, when performed by experienced teams, it maintains the same oncological principles as open surgery — complete tumour removal and adequate lymph node dissection — while significantly reducing surgical trauma. The goal isn’t smaller scars; it’s better recovery without compromising cancer outcomes.
3. What was the learning curve like transitioning to robotic surgery?
The robot doesn’t replace surgical skill — it extends it. In the beginning, every surgeon has to retrain their instincts. You lose direct tactile feedback but gain exceptional visualisation, tremor filtration, and wristed instruments with remarkable dexterity. Confidence comes through structured training, mentorship, simulation, cadaveric practice, and a gradual progression to more complex cases. Ultimately, every critical decision remains human; the robot simply allows us to execute those decisions with greater precision.
“The robot extends skill, not replaces it”
4. Is there still a place for open surgery?
Absolutely. Technology should never become dogma. Certain operations — especially large, locally advanced tumours requiring multivisceral resections, major vascular reconstruction, or extensive cytoreductive surgery with HIPEC — may still be best performed through an open approach. The ideal operation isn’t robotic or open; it’s the one that offers the safest and most complete cancer clearance for that individual patient.
5. How has indocyanine green (ICG) angiography changed your intraoperative decision‑making?
ICG fluorescence has transformed what was once an educated judgment into objective visual information. Instead of estimating tissue perfusion based on colour or pulsation, we can directly visualise blood flow in real time. During oesophageal reconstruction, for example, it helps us select the healthiest portion of the gastric conduit before creating the anastomosis. This additional information reduces complications such as anastomotic leaks and allows more confident intraoperative decisions.
6. How do you decide between surgery first and chemotherapy or radiation first?
The decision isn’t based on the tumour alone — it’s based on the biology of the disease and the condition of the patient. We consider tumour stage, imaging, pathology, molecular characteristics, overall fitness, nutritional status, and evidence from international guidelines. Some cancers benefit from immediate surgery, while others achieve better long‑term outcomes with chemotherapy or chemoradiotherapy first. Modern cancer care is increasingly personalised. It’s no longer a one‑size‑fits‑all approach.
7. How do you balance extensive lymph node removal with patient safety?
Lymph node dissection provides accurate staging and can improve oncological clearance, but more surgery is not always better surgery. Our aim is to remove all nodes that are oncologically relevant while avoiding unnecessary morbidity. The decision depends on tumour biology, response to neoadjuvant treatment, anatomical considerations, and current evidence. The ideal cancer operation removes everything that needs to be removed — and nothing that doesn’t.
“Every complication is a lesson for progress”
8. How does delayed diagnosis affect treatment options in India?
Delayed diagnosis remains one of our biggest challenges. Early‑stage cancers have significantly higher cure rates and often require less complex surgery. Advanced disease may need multimodality treatment or, in some cases, may no longer be curable. This is why awareness, early endoscopy for persistent symptoms, screening in appropriate populations, and timely referral are just as important as advances in surgical technology.
9. Your research has documented complications during port placement. How do surgeons train themselves to avoid these mistakes?
Every complication is a lesson — not just for the surgeon involved, but for the entire surgical community. Good training isn’t only about mastering successful operations; it’s about understanding how and why complications occur. Simulation, cadaveric dissection, careful review of operative videos, mentorship, and honest audit of one’s own outcomes all contribute to safer surgery. Medicine advances because surgeons openly share both successes and complications.
10. What happens inside a multidisciplinary tumour board meeting?
A tumour board is collaborative medicine at its best. Radiologists review imaging, pathologists discuss tumour biology, medical oncologists evaluate systemic therapy, radiation oncologists assess radiotherapy options, and surgeons determine technical resectability. Every perspective is debated until a consensus plan is reached. The patient benefits from the combined expertise of an entire team rather than the opinion of a single specialist.
11. Where do you see robotic cancer surgery in India over the next decade?
Robotic surgery will become increasingly common, but technology alone isn’t enough. The real challenge is building structured training, maintaining surgical volume, ensuring quality, and developing centres of excellence that deliver consistent outcomes. As costs decrease and expertise expands, more patients across India will gain access to advanced minimally invasive cancer surgery.
12. Which emerging technology excites you the most?
The future lies in precision surgery. I’m particularly excited about artificial intelligence integration, advanced fluorescence imaging, augmented reality navigation, patient‑specific 3D planning, and next‑generation robotic platforms. The operating theatre of the future won’t just make surgery minimally invasive — it will make it more personalised, more precise, and ultimately safer. The surgeon will always remain central, but technology will increasingly help us make better decisions for every individual patient.
