Telesurgery
Telesurgery
Definition
Telesurgery, also called remote surgery, is performed by a surgeon at a site removed from the patient. Surgical tasks are directly performed by a robotic system controlled by the surgeon at the remote site. The word telesurgery is derived from the Greek words tele, meaning “far off,” and cheirourgia, meaning “working by hand.”
Description
In the early 2000s, several projects investigating the possibility and practicality of telesurgery were successful in performing complete surgical procedures on human patients from remote locations.
Preceding technologies
Telesurgery became a possibility with the advent of laparoscopic surgery in the late 1980s. Laparoscopy (also called minimally invasive surgery) is a surgical procedure in which a laparoscope (a thin, lighted tube) and other instruments are inserted into the abdomen through small incisions. The internal operating field may then be visualized on a video monitor connected to the scope. In certain cases, the technique may be used in place of more invasive surgical procedures that require more extensive incisions and longer recovery times.
Computer-assisted surgery premiered in the mid-1990s; it was the next step toward the goal of remote surgery. The ZEUS Surgical System, developed in 1995 by Computer Motion, Inc., was approved by the Federal Drug Administration (FDA) in 2002 for use in general and laparoscopic surgeries with the patient and surgeon in the same room. ZEUS comprises three table-mounted robotic arms—one holding the AESOP endoscope positioner, which provides a view of the internal operating field, the others holding surgical instruments. The robotic arms are controlled by the surgeon, who sits at a console several meters away. Visualization of the operating field is controlled by voice activation, while the robotic arms are controlled by movements of the surgeon’s hands and wrists.
Computer-assisted surgery, which is generally called telerobotic surgery as of 2007, has a number of advantages over traditional laparoscopic surgery. The computer interface provides a method for filtering out the normal hand tremors of the surgeon. Two- and three-dimensional visualization of the operating field is possible. The surgeon can perform a maneuver on the console, review it to be sure of its safety and efficacy, then instruct the remote device to perform the task. The surgeon is also seated in an ergonomic position with arms supported by arm rests for the duration of the operation. One limitation on telerobotic surgery as of the early 2000s is the cost of the robots; the Da Vinci surgical robot, a new model with four arms, costs $2.2 million.
Operation Lindbergh
While the concept of telesurgery seems like a logical technological progression, there is a major constraint that could lead to disastrous results during surgery, namely time delay. In the case of computer-assisted surgery, the computer console and remote surgical device are directly connected by several feet (meters) of cable; there is therefore virtually no delay in the transmission of data from the console to the surgical device back to the console. The surgeon views his or her movements on the computer interface as they are happening. If the surgical system were removed to a more distant site, however, it would introduce a time delay. Visualization of the operating field could be milliseconds or even seconds behind the real-time manipulations of the surgeon. Studies showed that a delay of more than 150-200 milliseconds would be dangerous; satellite transmission, for example, would introduce a delay of more than 600 milliseconds.
In order to make telesurgery a reality, expert surgeons would need to work with the telecommunication industry to develop secure, reliable, high-speed transmission of data over large distances with imperceptible delays. In January 2000, such a project, labeled Operation Lindbergh, began under the direction of Dr. Jacques Marescaux, director of the European Institute of Telesurgery; Moji Ghodoussi, project manager at Computer Motions, Inc.; and communication experts from France Telecom. Testing began on a prototype remote system (a modified version of the ZEUS Surgical System called ZEUS TS) in September 2000, with data being relayed between Paris and Strasbourg, France—a distance of approximately 625 mi (1,000 km). Once an acceptable length of time delay was established, trials began in July 2001 between NewYork City and Strasbourg.
On September 7, 2001, Operation Lindbergh culminated in the first complete remote surgery on a human patient (a 68-year-old female), performed over a distance of 4,300 mi (7,000 km). The patient and surgical system were located in an operating room in Strasbourg, while the surgeon and remote console were situated in a high-rise building in downtown NewYork. A team of surgeons remained at the patient’s side to step in if need arose. The procedure performed was a laparoscopic cholecystectomy (gall bladder removal), considered the standard of care in minimally invasive surgery. The established time delay during the surgery was 135 ms remarkable considering that the data traveled a distance of more than 8,600 mi (14,000 km) from the surgeon’s console to the surgical system and back to the console. The patient left the hospital within 48 hours—a typical stay following laparoscopic cholecystectomy—and had an uneventful recovery.
Limitations that still need to be overcome in order to make telesurgery more widely available include the establishment of international compatibility of equipment and training to overcome linguistic difficulties. Another concern is the need for a backup human surgeon at the remote location in case the robot malfunctions or there is an interruption in telecommunications.
Applications
Operation Lindbergh has paved the way for wide-ranging applications of telesurgery technology. On February 28, 2003, the first hospital-to-hospital telerobotic-assisted surgery took place in Ontario, Canada, over a distance of 250 mi (400 km). Two surgeons worked together to perform a Nissen fundoplication (surgery to treat chronic acid reflux), with one situated at the patient’s side and the other controlling a robotic surgical system from a remote hospital site. Such a scenario may eventually allow surgeons in rural areas to receive expert assistance during minimally invasive procedures. Since the first telesurgery in Canada, Dr. Mehran Anvari, the founder of the Centre for Minimal Access Surgery (CMAS) in Ontario, has performed a number of remote surgeries between St. Joseph’s Hospital in Hamilton, Ontario, and a community hospital in North Bay, about 250 miles from Hamilton. Dr. Anvari uses a virtual private network (VPN) over a non-dedicated fiber-optic connection that shares bandwidth with regular telecommunications data.
Other applications of telesurgery include:
- Training new surgeons. CMAS has developed a program in advanced minimal access surgery for Canadian surgeons, which combines lectures, laboratory sessions, and live surgery. As of 2007, about 160 surgeons have completed the program.
- Assisting and training surgeons in developing countries.
- Treating injured soldiers on or near the battlefield.
- The expanded use of telerobotic surgery. Telerobotic surgery offers the advantages of allowing surgery to be performed during an epidemic (such as the SARS outbreak of 2002–2003) without having to bring patients from remote and uninfected communities into cities affected by the epidemic.
- Performing surgical procedures in space or underwater. CMAS joined forces in 2006 with the National Aeronautics and Space Administration (NASA), the U.S. Army Telemedicine and Advanced Technology Research Center (TATRC), and the National Space Biomedical Research Institute (NSBRI) to work on NASA’s Extreme Environment Mission Operation 9, or NEEMO 9. Dr. Anvari at CMAS tested remote surgery with a next-generation surgical robot and a patient simulator in the Aquarius Undersea Habitat, an underwater laboratory operated by the National Undersea Research Center at the University of North Carolina at Wilmington (UNCW) for the National Oceanic and Atmospheric Administration (NOAA). The laboratory is located on the ocean floor off Key Largo in the Florida Keys, 70 feet beneath the surface. The mission lasted 18 days. A two-second time delay was built into the telecommunications system to simulate the time delay that would be present in a manned lunar exploration mission.
- Collaborating and mentoring during surgery by surgeons around the globe. Telementoring has been used in Canada since 2004 with financial assistance from a government partnership program. Telementoring involves an experienced surgeon in an advanced treatment facility in a major city using a two-way telecommunications link to guide the remote surgeon during an operation.
Resources
BOOKS
Telesurgery, 1st ed. New York: Springer, 2007.
PERIODICALS
Birch, D. W., C. Sample, and R. Gupta. “The Impact of a Comprehensive Course in Advanced Minimal Access Surgery on Surgeon Practice.” Canadian Journal of Surgery 50 (February 2007): 9–12.
Gondziola, Jason. “Telerobotic Surgery: Harnessing the Many-Armed Beast.” National Review of Medicine 1 (September 23, 2004). Available online at http://www.nationalreviewofmedicine.com/issue/2004/09_23/feature05_17.html [cited January 7, 2008, accessed April 8, 2008].
Marescaux, J., et al. “Transatlantic Robotic Assisted Remote Telesurgery.” Nature 413, no. 6854 (September 27, 2001): 379–80.
ORGANIZATIONS
Centre for Minimal Access Surgery (CMAS). 50 Charlton Avenue E., Hamilton, Ontario L8N 4A6 Canada. (905) 522-1155 x 5144. http://www.cmas.ca/ (accessed April 8, 2008).
Computer Motion, Inc. 130-B Cremona Dr., Goleta, CA 93117.(805)968-9600.
European Institute of TeleSurgery (EITS). Hôpitaux Universitaires 1, place de l’Hôpital 67091 Strasbourg Cedex, France. +33 (0)3 88 11 90 00. http://www.eits.fr/homepage.php (accessed April 8, 2008)
OTHER
Canada Health Infrastructure Partnership Program (CHIPP). Project: Centre for Minimal Access Surgery, 2005. http://www.hc-sc.gc.ca/hcs-sss/pubs/chipp-ppics/2004-surg-support-network/synopsis/index_e.html [cited January 7, 2008, accessed April 8, 2008].
Ghodoussi, Moji. http://isandtcolloq.gsfc.nasa.gov/spring2002/speakers/ghodoussi.html (accessed April 8, 2008).
Intuitive Surgery, Mountain View, CA. Da Vinci Telerobotic Surgical System.http://www.teleroboticsurgeons.com/davinci.htm [cited January 7, 2008, accessed April 8, 2008].
Kay, Sharon. “Remote Surgery.”Light Speed Special Report.http://www.pbs.org/wnet/innovation/episode7_essayl.html [cited January 7, 2008, accessed April 8, 2008].
Malik, Tariq. “NASA’s NEEMO 9: Remote Surgery and Mock Moonwalks on the Sea Floor.”SPACE.com, April 19, 2006 [cited January 7, 2008]. http://www.space.com/businesstechnology/060419_neemo9_techwed.html (accessed April 8, 2008).
NEEMO 9/Centre for Minimal Access Surgery.http://www.cmas.ca/neemo9/NEEM09-CentreforMinimalAccessSurgery.htm [cited January 7, 2008, accessed April 8, 2008].
Stephanie Dionne Sherk
Rebecca Frey, PhD
Telesurgery
Telesurgery
Definition
Telesurgery, also called remote surgery, is performed by a surgeon at a site removed from the patient. Surgical tasks are directly performed by a robotic system controlled by the surgeon at the remote site. The word "telesurgery" is derived from the Greek words tele, meaning "far off," and cheirourgia, meaning "working by hand."
Description
In the early 2000s, several projects investigating the possibility and practicality of telesurgery were successful in performing complete surgical procedures on human patients from remote locations.
Preceding technologies
Telesurgery became a possibility with the advent of laparoscopic surgery in the late 1980s. Laparoscopy (also called minimally invasive surgery) is a surgical procedure in which a laparoscope (a thin lighted tube) and other instruments are inserted into the abdomen through small incisions. The internal operating field may then be visualized on a video monitor connected to the scope. In certain cases, the technique may be used in place of more invasive surgical procedures that require more extensive incisions and longer recovery times.
Computer-assisted surgery premiered in the mid-1990s; it was the next step toward the goal of remote surgery. The ZEUS Surgical System, developed in 1995 by Computer Motion, Inc., was approved by the Federal Drug Administration (FDA) in 2002 for use in general and laparoscopic surgeries with the patient and surgeon in the same room. ZEUS comprises three table-mounted robotic arms—one holding the AESOP endoscope positioner, which provides a view of the internal operating field, the others holding surgical instruments . The robotic arms are controlled by the surgeon, who sits at a console several meters away. Visualization of the operating field is controlled by voice activation, while the robotic arms are controlled by movements of the surgeon's hands and wrists.
Computer-assisted surgery has a number of advantages over traditional laparoscopic surgery. The computer interface provides a method for filtering out the normal hand tremors of the surgeon. Two- and three-dimensional visualization of the operating field is possible. The surgeon can perform a maneuver on the console, review it to be sure of its safety and efficacy, then instruct the remote device to perform the task. The surgeon is also seated in an ergonomic position with arms supported by arm rests for the duration of the operation.
Operation Lindbergh
While the concept of telesurgery seems like a logical technological progression—if a surgeon can perform a procedure from several meters away, why not from several thousand meters?—there is a major constraint that could lead to disastrous results during surgery, namely time delay. In the case of computer-assisted surgery, the computer console and remote surgical device are directly connected by several meters of cable; there is therefore virtually no delay in the transmission of data from the console to the surgical device back to the console. The surgeon therefore views his or her movements on the computer interface as they are happening. If the surgical system were removed to a more distant site, however, it would introduce a time delay. Visualization of the operating field could be milliseconds or even seconds behind the real-time manipulations of the surgeon. Studies showed that a delay of more than 150–200 milliseconds would be dangerous; satellite transmission, for example, would introduce a delay of more than 600 milliseconds.
In order to make telesurgery a reality, expert surgeons would need to work with the telecommunication industry to develop secure, reliable, high-speed transmission of data over large distances with imperceptible delays. In January 2000, such a project, labeled "Operation Lindbergh," began under the direction of Dr. Jacques Marescaux, director of the European Institute of Telesurgery; Moji Ghodoussi, project manager at Computer Motions, Inc.; and communication experts from France Télécom. Testing began on a prototype remote system (a modified version of the ZEUS Surgical System called ZEUS TS) in September 2000, with data being relayed between Paris and Strasbourg, France—a distance of approximately 625 mi (1000 km). Once an acceptable length of time delay was established, trials began in July 2001 between New York City and Strasbourg.
On September 7, 2001, Operation Lindbergh culminated in the first complete remote surgery on a human patient (a 68-year-old female), performed over a distance of 4300 mi (7000 km). The patient and surgical system were located in an operating room in Strasbourg, while the surgeon and remote console were situated in a high-rise building in downtown New York. A team of surgeons remained at the patient's side to step in if need arose. The procedure performed was a laparoscopic cholecystectomy (gall bladder removal), considered the standard of care in minimally invasive surgery. The established time delay during the surgery was 135 ms—remarkable considering that the data traveled a distance of more than 8600 mi (14,000 km) from the surgeon's console to the surgical system and back to the console. The patient left the hospital within 48 hours—a typical stay following laparoscopic cholecystectomy—and had an uneventful recovery.
Applications
Operation Lindbergh has paved the way for wide-ranging applications of telesurgery technology. On February 28, 2003, the first hospital-to-hospital teleroboticassisted surgery took place in Ontario, Canada, over a distance of 250 mi (400 km). Two surgeons worked together to perform a Nissen fundoplication (surgery to treat chronic acid reflux), with one situated at the patient's side and the other controlling a robotic surgical system from a remote hospital site. Such a scenario may eventually allow surgeons in rural areas to receive expert assistance during minimally invasive procedures.
Other potential applications of telesurgery include:
- training new surgeons
- assisting and training surgeons in developing countries
- treating injured soldiers on or near the battlefield
- performing surgical procedures in space
- collaborating and mentoring during surgery by surgeons around the globe
Resources
periodicals
Marescaux, J., et al. "Transatlantic Robotic Assisted Remote Telesurgery." Nature 413, no. 6854 (September 27, 2001): 379-80.
organizations
Computer Motion, Inc. 130-B Cremona Dr., Goleta, CA 93117. (805) 968-9600. <www.computermotion.com>.
European Institute of Telesurgery. 1, Place de l'Hôpital, F 67091 STRASBOURG Cedex. +33(0)388119000. <www.eits.org>.
other
Ghodoussi, Moji. "Project Lindbergh: World's First Transatlantic Telesurgery." Computer Motion, Inc., 2002 [cited April 13, 2003]. <www.computermotion.com/about/newsroom/features/projectlindbergh>.
"Operation Lindbergh: First Transatlantic Robot-Assisted Operation." WebSurg, 2003 [cited April 13, 2003]. <www.websurg.com/lindbergh>.
Rola, Monika. "Telerobotics Bridges Rural Health Care Divide." itbusiness.ca, March 4, 2003 [cited April 13, 2003]. <www.itbusiness.ca/index.asp?theaction=61&lid=1&sid=51570>.
"ZEUS Surgical System." Computer Motion, Inc., 2002 [cited April 13, 2003]. <www.computermotion.com/productsandsolutions/products/zeus>.
Stephanie Dionne Sherk