|Year : 2005 | Volume
| Issue : 2 | Page : 89-92
Prokar Dasgupta, Ben J Challacombe
Department of Urology, Guy's Hospital, London, United Kingdom
Department of Urology, Guy's Hospital,St. Thomas' Street,London SE1 9RT
Source of Support: None, Conflict of Interest: None
| Abstract|| |
With continued advances in medical robotic technology and global telecommunications, the concept of remote telerobotic surgery continues to develop. The ultimate goal of an experienced specialist operating remotely using a robot controlled by high-speed audiovisual connections has been shown to be feasible but is limited by local resources and a lack of evidence from randomised controlled trials. This article looks at the development of this exciting field and its impact on modern urology.
Keywords: Telementoring; Telerobotics; Telesurgery
|How to cite this article:|
Dasgupta P, Challacombe BJ. Telerobotic surgery. Indian J Urol 2005;21:89-92
Since the end of the industrial revolution in the late nineteenth century, it has been possible to relay medical information and advice to doctors or patients in distant places. The word telerobotics is derived from the Greek, ' tele ' meaning 'at a distance ' and the Czech ' robota ' meaning 'worker' and this term represents the culmination of a series of developments in medical communication since medieval times. Telemedicine as a concept has existed for many decades being regularly outlined in science fiction literature and cinema with an early reference being made in the novel 'Five Patients' written by Michael Crichton in 1969. Within this true account of his time spent at the Massachusetts General Hospital, he recalls how physicians at this hospital would took histories and even examined patients at the local medical station in Boston airport several miles away via a video link.
The greatest power of telemedicine itself may lie in the regular use of the Internet or teleconferencing applications for teleconsultation between generalists and tertiary referral centres. As already clearly shown in the US, both emergency and chronic pathologies can be assessed, discussed and followed up without the remote physician having to move to the patient. Areas particularly suitable for this kind of telemedicine include dermatology and radiology where visual images provide the vital diagnostic clues.
At a less sophisticated level, medical meetings, conferences and lectures are now routinely broadcast to local and remote hospital locations via teleconferencing links. This technique uses cameras that can be controlled remotely and microphones to relay sound and vision in almost real time. Some hospitals are developing local area network (LAN) systems that will allow audiovisual links to be made from every clinical area including theatres, clinics and department offices to facilitate remote links.
Perhaps the greatest regular user of telemedicine today is the aviation industry where the majority of commercial airliners now routinely carry global emergency telemedicine equipment. This includes remote vital sign monitors (e.g. MedAire‘, Hampshire, UK) that send diagnostic information instantaneously back to ground-based doctors who subsequently give medical advice to on-board caregivers.
During the 1990s the development and application of minimally invasive surgical technology, particularly laparoscopy, revolutionised surgery and opened the way for remote operating once a mechanical way of controlling the instruments had been developed. This appeared in the form of robots modified for medical use. Robots have been used in surgical practice since the 1980s when they were introduced to assist with orthopaedic and neurosurgical procedures.
Development of robotics
Robotic systems in urology were initially developed at Guy's Hospital, London, in the early 1990s using a robotic frame to assist in transurethral resection of the prostate. Currently there are a number of medical robots in existence with proven ability to carry out sophisticated surgical tasks. The most developed of these are the master-slaver devices such as the Da Vinci‘ (Intuitive), and ZEUS‘ (Computer Motion) systems. These robots have been used to perform a number of urological procedures such as radical prostatectomy, pyeloplasty and nephrectomy in addition to widespread worldwide use by paediatric urologists and cardiac surgeons. For those in doubt as to the advantages of robotic surgery one only has to look at the recent work by Menon from the Vattikuti Urology institute in Detroit. He describes a large series of over 300 robotic radical retropubic prostatectomies that clearly shows the robotic procedure to be not only quicker but also to have reduced complications and a shorter hospital stay than either the open or laparoscopic techniques while maintaining good cancer control.
Robotic surgery is certainly here to stay and with the expansion in global telecommunications, it is now possible to transmit and receive precise signals with minimal delay using exceptional audiovisual links, albeit at high connection cost. This has opened the door to genuinely remote operating [Figure - 1]. This was a concept originally developed by NASA in the seventies to run in conjunction with the space programme. NASA has found laparoscopic and thoracoscopic operating both feasible and advantageous over open procedures during zero gravity experiments on pigs. A feasibility study has even been performed on the placement of ureteral stents in reduced gravity. The initial technological advances of the American space programme led to the development of the Da Vinci‘ robot now in common use. The concept has also been looked at by the military that envisages a situation where senior surgeons could operate remotely on casualties without ever having to enter the combat zone. Despite significant interest only relatively few attempts have been made at remote robotic surgery, possibly due to concerns over the medico-legal issues that arise from remote surgery.
Telerobotic surgery in urology
The claim to the first ever telerobotic surgery is held by an Italian group led by Professor Rovetta of Milan [Table - 1], which has a number of published experiments investigating the possible applications of telerobotics and which in 1995 performed a prostate biopsy on a patient 5 km away.
One of the few telesurgery projects that have been completed involves the team at the Brady Urological Institute, who have designed and developed a robot capable of performing a remote percutaneous renal needle puncture. The percutaneous access robot ( PAKY-RCM ) was initially developed in 1996 and was superseded by the production of the Tracker last year. This can be mounted on the operating table. It has six degrees of motion and can be used with fluoroscopy or CT guidance to improve the accuracy of needle placement. This could provide a precise and reliable method of routinely performing the preliminary step in percutaneous nephrolithotomy or tissue biopsy and can be controlled remotely.
Using teleconferencing software surgeons now have the ability to telementor other surgeons from remote locations, which involves watching, advising and directing a procedure. This technique may involve more than just observing, as mentors can indicate specific areas to the operating surgeons by digitally drawing on the remote monitors with the resulting image seen locally. Indeed it is even possible to manipulate a laparoscopic camera and control diathermy at the distant site, thus truly making the remote operator part of the procedure. The Baltimore group has telementored several procedures in Austria, Singapore and Germany including laparoscopic adrenalectomy, radical nephrectomy, varicocelectomy and renal cyst ablation.
In some procedures there has been telerobotic control of the AESOP‘ (Automated endoscope system for optimal positioning, Computer Motion) or PAKY robotic arms via ISDN lines. The PAKY can be combined with a smart needle (modified from a percutaneous access needle) to measure bio-impedance and confirm percutaneous access at a distant site. Regular clinical use of the PAKY arm is also well underway with a series of 23 patients undergoing robotic PCNL being compared to patients undergoing conventional manual PCNL. Robotic insertions compared favourably when time to access, number of attempts and estimated blood loss were looked at.  This system has also successfully performed a single remote percutaneous renal access on a patient in Rome while being controlled from Maryland, USA. Within the last year the first randomised controlled trial of trans-Atlantic telerobotics has been performed between Guy's and Johns Hopkins Hospitals with robotic needle punctures during PCNL into a kidney model controlled remotely. The robot took longer to perform the procedure but was significantly more accurate than a human. There was no difference between trans-Atlantic and local needle insertions with regards to either time or accuracy.
Telerobotic surgery in other surgical fields
In perhaps the most ambitious study a mobile operating room travelled to a remote region of Ecuador where laparoscopic cholecystectomy was successfully telementored. This represents the first use of telemedicine outside of technically sophisticated sites and illustrates the potential for true remote surgery in regions with remote communities.
The dream of having a surgeon in one country performing an operation in another via a computer assisted link became reality in September 2001 when Professor Jacques Marescaux in New York performed a laparoscopic cholecystectomy on a French patient in Strasbourg, the trans-Atlantic connection being provided by French Telecom (Lindbergh Operation). The operation lasted 45 min and the patient had no post-operative complications.
The current technique uses telecontrol by a combination of ISDN and Internet modalities as demonstrated by the Italian group in 1997. The vital ingredient to successful telerobotic surgery lies in the speed of transfer of information from operator to robot. Time delay can significantly affect surgical performance; however if the lag time is < 700 ms an operator is able to learn to compensate. In the Lindbergh operation the transmission delay was reduced to 150 ms over the 8000-mile distance thus greatly facilitating operator movements.
The New York-Strasbourg procedure may mark the start of an entire revolution in minimally invasive surgery by allowing global access to highly specialised surgeons.
In March 2003 in an as yet unpublished press release, a team of general surgeons in Canada performed elements of a laparoscopic Nissen's fundoplication from a distance of 400 km using a ZEUS‘ robot with a time delay of 150 ms. Canada is an ideal country to develop telerobotic surgery as it has a number of remote northern communities with limited access to specialist healthcare. Still to be resolved in all these experimental procedures are the ethical, legal and social issues surrounding telerobotic surgery. It is of course vital to have a trained surgical team present locally who have the necessary skills and experience to complete any attempted telesurgical procedure in the event of equipment failure or loss of connection. Telecommunication links must be secure, quick and reliable, with a large enough bandwidth to ensure visual and audio quality. It is feasible to obtain consent remotely using the same high-speed connection but this has not been implemented to date. With increasing technological support, the cost of communicating via high speed ISDN lines or other modalities will continue to fall making remote surgery more financially viable, however, at present connection costs remain significant.
The eventual goal is to have the world's best surgeons performing specialist procedures remotely using robotic control wherever they or the patient are geographically located. Telerobotic surgery is particularly suited to countries with a high technological and medical expertise that possess a number of remote communities who could potentially benefit from this technique. Although all the technological components are in place a number of medico-legal issues remain. It remains to be seen whether true remote surgery will have a consistent role in future civilian life but it deserves serious consideration as it is certainly an exciting prospect with huge potential.
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[Figure - 1]
[Table - 1]