Remote Telerobotic Surgery

It would appear from the previous discussion that most of the framework for operating on people with minimally invasive techniques could be accomplished from remote locations. The ethical, financial, and educational potential for this type of surgery is staggering. But as complex a scenario as this sounds, much basic groundwork is already being done for both research and clinical applications. The term telemedicine has become quite fashionable secondary to the world's rapid acceptance of computerized media and internet connectivity (157-165). Recall the significance of the year 1999, when computers outsold televisions in the United States. In fact, the U.S. government has been a strong supporter of pioneering efforts in the telemedicine field with research grants. The great potential for telecommunications is being realized in digital radiology practices where the radiologist can view and comment upon clinical radiographs of patients at the hospital from his/her home. Robotic surgery as we have just seen is a technology based upon computer integration of a transducer station and the robotic instrument is the end-effector. The ability to combine these essentially digital computerized modalities is both obvious and possible (166-168). The first problem for interfacing telecommunications and robotic surgery is linking for real-time interaction. Several methods are possible including regular telephone lines, fiber optic cables, microwave transmission, satellite linkages, and broadband communication (integrated services digital network, local area networks, and dedicated T-1 lines). Recently the surgical group at Virginia Commonwealth University used regular internet connections to interact with surgeons in Ecuador and the Dominican Republic to perform six laparoscopic cholecystectomies (168). These surgeons used 33.6 to 64 kbps lines to transmit voice and video.

Telementoring has already been performed for multiple surgeries as well as urologic laparoscopic cases. Dr. Kavoussi's group at John's Hopkins has gained significant recognition for these pioneering efforts. In their initial studies, the surgeon mentor was located in a control room >1000 ft from the operating room; 14 advanced and 9 basic laparoscopic procedures were performed (135). Telementoring was accomplished using real-time computer video images, two-way audio communication links, and a robotic arm to control the videoendoscope. Success was achieved in 22/23 cases without increased operative times or complications. They then extended their investigations and distances between the Johns Hopkins Bayview Medical Center and the Johns Hopkins Hospital (distance, 3.5 miles) for 27 more telementoring laparoscopic procedures utilizing public phone lines. Finally, they have extended their novel surgical instruction capabilities to the international arena with cases in Austria, Italy, and Thailand. Others have reported upon the technology necessary for successful telementoring. The U.S. Navy recently studied the feasibility of laparoscopic hernia repairs aboard the USS Abraham Lincoln while cruising the Pacific Ocean (164). Telementoring was possible from remote locations in Maryland and California. In a recent research investigation, Broderick et al. at the Virginia Commonwealth University reported that decreasing transmission bandwidth does not significantly affect laparoscopic image clarity or color fidelity as long as the laparoscopes are positioned or maintained at their optimal working distance (169).

It was only a matter of time before the da Vinci or the Zeus systems, were linked to a remote surgical effector in another place and the actual surgery was performed with the aid of an assistant. The first laparoscopic cholecystectomy done remotely was down the hall in Montreal, Canada. Kavoussi was the first to perform a surgery remotely from another hospital in the same town. Finally, a surgeon in New York City successfully removed the gallbladder of a patient in Strasbourg, France with a 155 msec time lag. The operation took one hour and 16 minutes. The robotic machines can with little doubt accomplish complex surgical interventions and function without fatigue. Because the surgeon already has given up all visual information to the technology of laparoscopic surgery, the next great step is passing the surgical dissection to the machines.

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