In telesurgery, the actions of the robot are not predetermined, but controlled by the operating surgeon in real time through an interface.

Telesurgery involves a surgeon performing surgery from a remote location, be it a far away place or across the room.

eStryker Endoscopy, San Jose, CA.

Because the surgeon is separated from the patient by distance, a robot, local to the patient, becomes the surgeon's hands, while an intricate interface helps the surgeon connect and communicate with the patient. Telesurgery is a part of robotic surgery because the robot is the one actually performing the surgery.

In telesurgery, the surgeon relies completely on the sensor data, which is transmitted by the robot at the remote location. The sensor data, therefore, must be very accurately transmitted.

Various schemes are used for this purpose. Fiducials are reference features, located on both the computer-based model and the anatomic object, and are used as a means of aligning the virtual image with the actual position of both the robot and the patient. In addition to that, infrared transmitters and receivers are used, as they offer very fast and very accurate registration.

Human-computer interface is one of the most complicated aspects of telesurgery. It has to be simple, intuitive, and efficient.

The virtual reality glove is one potential approach. The glove uses flex-controlled potentiometers or optical fibers, which can sense the position of the surgeon's hands with satisfactory speed and precision. This data is then transmitted to the robot, which follows the hand movement.

Telesurgery offers the advantages of minimally invasive surgery. In traditional surgery, hand size is a limiting factor when it comes to performing delicate movements or operating in hard-to-reach places. The robot can overcome this limitation because it can be as small as desired and can enter through a small opening and access any part of the body without the need for big incisions.

Additional potential benefits associated with telesurgery are:

Reduced costs related to patients and specialist traveling.

■ Remote treatment of patients by national and international specialists.

■ Surgeon skills enhanced by a robotic interface.

■ Robotic arms and controllers operating at an accuracy of approximately ±5pm, computed with ±50 pm for the best microsurgeons (41).

■ Motion scaling and tremor filtering allowing tasks impossible to perform otherwise.

In spite of these potential advantages, there are several concerns about telesurgery. The initial financial investment in acquiring a telesurgical system is considerable. Moreover, there are also medicolegal concerns regarding liability. Due to the fact that telesurgery would involve a number of specialists, hospitals, and countries, jurisdiction conflicts may occur (42). However, the major concern about telesurgery relates to its safety. Current robotic surgical systems have a variety of built-in safely features such as manual override (43) and "safety freeze" (16). However, problems such as loss of communication between the surgeon and the operating room or failure of the telesur-gical system may occur and require someone on site to take charge.

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