Current Applications of Robot Assisted Remote Telepresence Surgery

In 2001, Marescaux et al. successfully utilized the Zeus TS system to perform the world's first transatlantic telerobotic surgery in which the remote surgeon, working from a

Since the inaugural surgery on February 28,2003,22 telerobotic surgeries have taken place with no major complications, no conversions to open procedures, and lengths of stay comparable to those seen in tertiary care centers.

Surgeons have been shown to have the capability to adapt to latencies of 500-700 msec but Fabrizio et al. suggest that delays beyond 700 msec lead to decreased surgical performance.

console located in New York City, performed a cholecystectomy on a patient located 3800 miles away in Strasbourg, France (17).

The procedure was completed without technical difficulties or complications in 54 minutes. Dissection of the cystic duct and artery and the dissection of the gallbladder off the liver were performed by the remote surgeons while the local operative team was responsible for exposure of structures and clip application in addition to robotic arm setup, induction of pneumoperitoneum, and trocar placement. Electrocoagulation was initiated by a local assistant upon voice command from the remote surgeon. The telecommunication link for this procedure was accomplished via a private dedicated asynchronous transfer mode. This terrestrial fiber optic network provided a bandwidth of 10 Mbps and resulted in a latency of only 155 msec. A duplicate backup line was also available in the event of disruption of the main line. However, such services are not available in many locales and are prohibitively expensive, further limiting their utility at the present point of time.

Routine Use of Robot-Assited Remote Telepresence Surgery

In February 2003, the Centre for Minimal Access Surgery in Ontario, Canada established the first remote telerobotic surgical service (18,19). This unique service links a teaching hospital (St. Joseph's Healthcare) in Hamilton with a community hospital over 400 km away, providing patients with access to advanced laparoscopic surgery in a rural community setting. The service utilizes the Zeus-TS microjoint system, which provides telepresence for the experienced laparoscopic surgeon, and three robotic arms that are placed by the local surgeon. Telecommunication is via a virtual private network, which utilizes a public telecommunication infrastructure to provide remote hospitals with secure access to urban centers. The goal of a virtual private network is to provide the same capabilities as private dedicated networks, but at a much lower cost.

Since the inaugural surgery on February 28, 2003, 22 telerobotic surgeries have taken place with no major complications, no conversions to open procedures, and lengths of stay comparable to those seen in tertiary care centers.

Procedures completed to date include fundoplications, right hemicolectomies, anterior resections, sigmoid colon resections, and inguinal hernia repairs. The system allows the local and remote surgeon to interchange roles as necessary, thus permitting the remote surgeon to either act as the primary surgeon or demonstrate plains for dissection to the local surgeon, who had received partial training in advanced laparoscopic procedures through short courses and mentoring/telementoring.

Initial experience with robot-assisted remote telepresence surgery strongly suggests that this technology has the potential to revolutionize the delivery of healthcare, especially in rural or remote areas where access to advanced laparoscopic surgical procedures is limited or nonexistent. However, there are a number of financial, technical, ethical, and medicolegal issues that will have to be resolved before remote telepresence surgery becomes widely accepted.

Technical Considerations

Initial experiences with remote telepresence surgery have raised a number of technical issues. Firstly, development of robotic platforms to support remote telepresence surgery has been slow. To date, only the Zeus robotic system permits control of the robotic arms via a telecommunication link. However, the system is no longer commercially available following the recent merger of Computer Motion Inc. with Intuitive, manufacturer of the Da Vinci robotic system. Development of new robotic platforms that are more compact, portable, and easy to set up will be critical to the widespread adoption of this technology.

Rapid, accurate, and secure transmission of large quantities of data is critical to the success and safety of telerobotic surgery, and while Internet protocol-virtual private network and asynchronous transfer mode networks are available in many areas, they are not currently available in many remote or undeveloped areas. Currently, the use of satellite technology is not feasible due to excessive time delays (often in excess of 1 sec). Although surgeons can readily adapt to latency, there is varying evidence in the literature regarding the point at which latency leads to significant difficulty or increased errors.

Surgeons have been shown to have the capability to adapt to latencies of 500-700 msec but Fabrizio et al. (20) suggest that delays beyond 700 msec lead to decreased surgical performance.

Utilizing internet protocol/virtual private network networks, latencies of less than 200 msec are typical, of which the majority (more than 80%) is due to coding and decoding algorithm compression and decompression of the video signals. Current coding and decoding algorithm devices were designed for use in applications such as videoconferencing in which image quality is of primary concern and latency is not an important issue. Development of new compression/decompression devices that are better suited to telepresence surgery could significantly reduce latency and shorten operating times.

Safety concerns surrounding telerobotic surgery are similar to those described for telementoring, because the remote surgeon is not physically present to take over in the event of a communication failure, robotic equipment failure, or operative complications. Use of a second redundant communication line provides an instantly available backup in case of a failure of the primary line. However, it is critical that the local and remote surgical teams outline in advance a plan of action and ensure that the local surgeon can successfully complete the procedure in the event of a system failure.

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