Today still experimental, robotic telesurgery may be commonplace tomorrow, even in space

Chicago 05 November 2000During the recent 86th Annual Clinical Congress of the American College of Surgeons, a live robotic telesurgery session was organised between the convention hall at McCormick Place in Chicago, Illinois, and the Johns Hopkins Bayview Medical Center in Baltimore, Maryland. The male patient underwent a successful remote-controlled and computer-assisted minimally invasive operation to treat chronic groin pain. The telerobotic system which was utilised, has been developed by the Johns Hopkins School of Medicine, Applied Physics Laboratory, and ICE Communications Inc. in 1993 to serve initially as a remote surgical training system for laparoscopic procedures.

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Dr. Louis Kavoussi, a Johns Hopkins urologist, who has done a great deal of scientific research on the accuracy and use of robotic surgical arms compared to human surgical assistants during urological laparoscopic surgery, operated the computer console and video screen which graphically displayed the patient's abdomen before the congress audience at the Chicago site. At a distance of some 850 kilometers, he was assisted by his colleague, Dr. Thomas Jarrett from the Johns Hopkins Bayview Medical Center. With a simple mouse-click, Dr. Louis Kavoussi directed a tiny camera attached to a slender robotic arm as to control the rate of gas injected into the abdomen to create a work space for the minimally invasive operation.

Both Dr. Kavoussi and Dr. Jarrett were able to view the nerve which caused the chronic groin pain. Dr. Jarrett cut the nerve while Dr. Kavoussi, using the robotic arm, cauterised the area to stop bleeding. A microphone allowed the two physicians to constantly communicate with each other during the entire intervention. The telerobotic system has originally been designed to be interactive and provide co-ordinated co-operation between the remote expert and the local surgeon to assure optimal results of the operative procedure. To accomplish this, the system includes real time video display from either the laparoscope for internal body view or an externally mounted camera for overview of the operating room, and full two-way audio communication.

Telesurgical assisted surgery is bound to produce a new frontier in medicine. Dr. Kavoussi is one of the few physicians in the United States who has done long-distance robotic surgery. Since his first procedure about four years ago, Dr. Kavoussi has performed remote procedures from Baltimore to Bangkok, Thailand; Innsbruck, Austria; Rome, Italy; and Singapore. Last September, from the library of his Maryland home, he assisted in a robotic varicose vein surgery on a patient in Brazil. Dr. Kavoussi's long experience and research has demonstrated that a robotic device can more effectively manipulate and more accurately control the video endoscope than a human assistant during laparoscopic procedures.

As a result, any novel operative procedure could be performed anywhere in the world with the same standards as those at the institution in which the procedure was developed. This system is the platform for future telesurgical interventions. As robotic devices are developed for the operating room, the data features of this system will eventually allow for complete telesurgical intervention. This is 21st century telemedicine, the latest advance in a field which doctors claim someday may allow a surgeon on earth to operate on astronauts in space.

Dr. W. Randolph Chitwood, Jr., head of the cardiac team at East Carolina University in Greenville, North Carolina, already consulted with NASA about potential earth-to-space operations. His team has completed the first robotic mitral valve cardiac surgery trials with Intuitive's da Vinci Surgical System. While witnessing the telesurgical demonstration in Chicago, Dr. Chitwood stated that a robot performing the bulk of an operation is perhaps less than a decade away. Astronauts with a medical emergency in space, need months to travel back to earth. With use of telerobotic technology, surgeons may be able to direct surgery over millions of miles by telemanipulation, according to Dr. Chitwood.

One obstacle to overcome would be the time delay which has to be bridged at very long distances for the robot to respond. Parallel studies by Dr. Kavoussi have proven that the effect of time delay on physician performance may not exceed 700 ms because this would result in a significant deterioration in the remote specialist's efficacy. This data is crucial in tailoring the requirements for telecommunication between two sites based on distance, bandwidth, and cost. At present, long-distance surgery between remote sites on earth alone is still experimental. Dr. Jarrett explained that patients therefore have been billed only for costs associated with procedures done on-site. Up till now, all the long-distance costs, including the remote surgeon's fees, have been paid for by private funding.

You can read another contribution about long-distance telerobotic surgery in the VMW August 2000 article Telementoring proves ideal way of delivering advanced surgical procedures to medically underserved areas. More news on the recent accomplishment of Dr. Chitwood's team is available in this issue's article East Carolina University to test da Vinci robot in cardiac surgery trials.


Leslie Versweyveld

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