"Until today, CMAS has been using telehealth to mentor surgeons located in community health settings, but now we have taken this one step further", stated Dr. Anvari. "We now can successfully use a robot from a distance, to actually assist and perform part of the surgery if necessary. The implications of this are far reaching."
"With the challenge of attracting specialised surgeons to Canada's northern communities, this technology allows us to provide necessary services close to home and family", stated Dr. McKinley. "Telerobotics procedures are the next logical step in minimal access surgery to help ensure that communities have access to needed expertise."
This event is the first in a series in collaborations between Drs. McKinley and Anvari. The series is scheduled to demonstrate the safety and feasibility of telerobotics assisted surgery to extend the reach of expert health care to Canada's remote populations.
"Based on the success of these first cases, we are investigating the next steps to take this technology to other Canadian communities including Yellowknife and Chicoutimi", stated Dr. Anvari. "Ultimately we hope to make it accessible to dozens of remote locations to create linkages that will provide both expert advice to our northern colleagues as well as expert assistance during surgery when required."
To conduct the telerobotics assisted surgery at St. Joseph's Healthcare Hamilton, Dr. Anvari used Computer Motion's ZEUS Surgical System. The ZEUS robot was connected and supported by Bell Canada's Virtual Private Network Service to the system's robotic "arms" in North Bay General Hospital's operating room.
The operation took place over Bell Canada's commercial networking service known as VPNe, or Virtual Private Network Enterprise. Regarded as one of the most advanced networks of its kind, Bell VPNe uses Cisco Multiprotocol Label Switching (MPLS) technology to enable private IP networks or VPNs to be carved out of Bell's national IP backbone infrastructure.
Bell Canada was responsible for maintaining the high level of network performance and reliability necessary for real time remote manipulation of the surgical robot. Combining the latest advances in laparoscopic surgical techniques, robotics, video compression and IP Internet working, Bell designed, built and managed all aspects of the service delivery, including the integration of all connectivity software, cabling, end-to-end network management, and engineering expertise.
Dr. Anvari's hand, wrist, and finger movements were translated from the ZEUS console, with a delay of no longer than 150 milliseconds, to control the endoscopic camera and the surgical instruments in the abdomen of the patient. At the patient's side in North Bay, Dr. McKinley, a board-certified general surgeon who routinely performs laparoscopic surgery, positioned the robotically controlled instruments and controlled the electrocautery energy source.
Bell, working with Cisco, conducted extensive testing to deliver the high levels of stability, reliability and quality of service demanded by a telerobotics assisted surgery application under various network conditions. Using 10-12 megabits per second (Mbps) of bandwidth, Bell worked to ensure that any manipulation of the remote robotic "hand" corresponded with a virtually simultaneous movement of the surgeon's hand controlling the robot.
For health networks, VPNe is a highly secure and flexible service that allows diverse communities of interest to effectively interconnect and communicate. This network provides the capacity and the service protection capabilities required to ensure the greatest level of reliability currently possible. This infrastructure dependability is achieved with physically diverse fibre routes, back-up points of presence, redundant transport and switching equipment, as well as optical and electrical protection switching capabilities, all maintained by sophisticated operational support systems.
The transport network has been designed to protect against both fibre cuts and laser failures. As a result, the VPNe network self-heals against failure within 50 milliseconds, rendering such failures transparent to even the most demanding enterprise application. The Bell VPNe network is built over an installed base of Cisco Gigabit Switching Routers (GSR) 12000 series routers, Cisco 7500 Series routers running Cisco IOS Software.
"Partnering with St. Joseph's Healthcare Hamilton on this landmark surgery demonstrates Bell Canada's expertise in reliably managing a large-scale networking project and delivering powerful applications to remote locations", stated Terry Mosey, President of Bell Ontario. "With our IP VPN solution, distance becomes irrelevant and the power of IP-based networking technologies can be leveraged to connect the most mission-critical applications, even the operating room."
The patient, who underwent the Nissen fundoplication procedure to correct chronic stomach acid reflux disease, commented that she was honoured to be part of the historic scientific milestone. "It is not every day someone gets to participate in such a landmark achievement", stated Claudette Fortier. "Not only do I feel privileged, thanks to having the procedure done laparoscopically, I feel remarkably well."
To explore telehealth capabilities, CMAS was last year awarded $1.000.000 by the Canadian Health Info-structure Partnership Programme (CHIPP). The federal government agency is mandated with promoting telehealth and Web-based electronic medical records throughout the country in efforts to combat the exodus of northern physicians. Other partners supporting CMAS include the Ontario Government, Computer Motion, Bell Canada, Stryker Canada, and Johnson & Johnson.
"Computer Motion is honoured to be working with Dr. Anvari and Dr. McKinley in this historic stride to extend the most advanced patient care possible to the entire population of Canada", stated Joseph DeVivo, President of Computer Motion. "These pioneers are the first to secure Canada's role in the use of telerobotics to provide national access to health care."
The ZEUS surgical system is designed to enable surgeons to perform advanced minimally invasive procedures by increasing the surgeon's dexterity and precision. ZEUS was granted Class IV clearance by Health Canada in October 2002 for cardiac surgery and tele-surgery applications and received United States FDA clearance for general and laparoscopic surgery in September 2002.
The major benefits of minimal access surgery to patients are less pain and surgical trauma, shorter hospital stays and faster recovery. The use of robotics has advanced the development of minimal access procedures in numerous surgical areas by increasing the precision of the surgeon's control of surgical instruments and decreasing normal human tremor and physical fatigue during surgery.
This hospital-to-hospital telerobotics assisted surgery is especially significant in light of the November "Romanow Report" on health care reform in Canada. Romanow outlined a recommendation for major support of the adoption of a national telemedicine programme to reduce the costs of reaching Canada's remote populations with specialised treatments and of surgeon and physician training. Read also the VMW October 2002 article Neurosurgeons perform robotic brain tele-surgery between Halifax and New Brunswick for more news on tele-surgery in Canada.