SEPARATION OF SURGEON AND PATIENT
MEHRAN ANVARI, MD
The ability to perform an operation on a patient hundreds or thousands of miles away from the surgeon was initially conceived as a means of offering emergency surgical care in extreme environments, such as a battlefield or in space. In fact, the first surgical robotic prototypes were funded by DARPA and NASA grants to meet exactly such a vision.
The first robotic-assisted remote telepresence surgery using an early prototype of the da Vinci robot developed by Stanford Research Institute was performed successfully by Drs. Rick Satava and John Bowersox in 1996 (Figure 1) [1,2]. It was, however, Prof. Jacques Marescaux and his team from IRCAD who in September 2001 performed the first clinical robot-assisted remote telepresence surgery (RARTS), a laparoscopic cholecystectomy, using a specially adapted ZEUS robot (Computer Motion, Goleta, CA) on a patient 7000 km away from the primary surgeon (Figure 2) [3]. Our team at the Centre for Minimal Access Surgery (CMAS) in Hamilton, Canada, has now performed 22 RARTS on patients 350 km away in the northern Ontario town of North Bay (Figure 3). Our ability to successfully perform complex surgical procedures ranging from laparoscopic Nissen fundoplications to laparoscopic anterior resections has demonstrated the viability of remote telesurgery in the dissemination of surgical expertise and delivery of surgical care to remote patients [4].
In October of 2004, a crew of 3 astronauts from Canada and the USA took part in NEEMO 7 (NASA Extreme Environment Mission Operation) and conducted several telesurgical experiments while living in a saturated environment in a laboratory 50 feet underwater 5 miles off the coast of Key Largo, Florida. The crew was aided by a surgical team from CMAS through Internet telecommunication and were able to successfully perform surgical procedures including cystoscopy and stone basket retrieval of a ureteric stone, repair of arteries, and laparoscopic cholecystectomy on artificial cadavers (Figure 4). The 3 astronauts were not surgeons, and one was not even a physician, yet they were able to successfully complete all the surgical tasks at a level expected of a resident in surgery using telementoring and simple telerobotic assistance.
NEEMO 7 proved that the original concept of delivering emergency surgical care in the absence of a surgeon is feasible. However, the current size and weight of the robotic platform prohibited NEEMO 7 from utilizing RARTS as a means of delivering direct emergency surgical care by a remote surgeon. For RARTS to work in an extreme environment, we need a drastic departure from the current surgical robotic platform design. Surgical robots need to become more modular, robust, easily assembled, and significantly smaller and lighter. In addition, surgical robots have to be able to perform tasks in collaboration with humans and become aware of other assistants and objects in their vicinity. Furthermore, the ability to use a variety of different telecommunication technologies available, from simple Internet to fiberoptic lines, to satellite, will make such a platform usable in all environments. A number of centers including ours are engaged in design and development of such robotic platforms, and it will not be long before programming of semi-intelligent robots will allow for RARTS in environments with long telecommunication latency (>1 second).
Future robotic evolution and development will allow remote telepresence surgery to perform a larger role in everyday surgical practice, help disseminate knowledge, provide expert surgical care at a distance, and save lives in extreme and isolated environments.
Figure 1. (A) Dr. J. Bowersox demonstrates the surgeon’s console of the Medical Forward Area Surgical Telepresence (MEDFAST) system to Alan Alda. This was a prototype robotic-assisted telesurgery system developed to provide immediate surgical support in combat conditions. (B) MEDFAST. This view, taken during field trials of the system, shows the field surgeon in the mobile unit working with the off-site surgeon who is controlling the robotic arm, to provide immediate surgical care to wounded soldiers. (C) The MEDFAST Mobile Unit. (photographs courtesy of Dr. R. Satava).
Figure 2. (A) Prof. J. Marescaux of Institut de Recherche contre les Cancers de L‘Appareil Digestif (IRCAD) performs the first transatlantic robotic assisted remote telepresence laparoscopic cholecystectomy. The surgeon’s console of the Zeus robotic platform for the “Lindbergh operation,” was located in Manhattan New York City. (B) The patient-side view of the Lindberg operation. The patient and the robotic arms were located in Strasbourg France, a distance of approximately 7000 km from Prof. Marescaux. (photographs courtesy of Prof. J. Marescaux)
Figure 3. (A) Dr. Anvari in the CMAS Robot Control Room during a telerobotic surgery. CMAS uses a Zeus TS robotic platform to work with the local surgeon in North Bay, connected via an IP-VPN network. (B) A view of the operating room in North Bay, showing the robotic arms.
Figure 4. NEEMO 7: Astronaut Robert Thirsk performing a laparoscopic cholecystectomy in the Aquarius Underwater Habitat off the coast of Florida with the aid of telementoring and telerobotic assistance from Dr. M. Anvari in Hamilton Ontario. NEEMO 7 was a joint project of CMAS, CSA, NASA, and TATRC, evaluating the use of telerobotic surgery in extreme environments.
Address reprint requests to: Mehran Anvari, MD, Centre for Minimal Access Surgery, 50 Charlton Ave, E Hamilton, Ontario, Canada, L8N 4A6. Tel: 905 522 2951, Fax: 905 521 6113, E-mail: anvari@mcmaster.ca
Mehran Anvari, MD, is a Professor of Surgery and Director of Surgical
Research at McMaster University. He is the founding Director of the
Centre for Minimal Access Surgery, the first Canadian centre dedicated
to the promotion of minimal access techniques in all surgical
specialties and was recently appointed to the newly established Chair
in Minimally Invasive Surgery and Surgical Innovation. His research
interests include the use of surgical robotics and he recently
established the world’s first telerobotic surgical service between a
tertiary institution and a distant community hospital.
References
1. Bowersox JC, Shah A, Jensen J, Hill J, Cordts PR, Green PS. Vascular applications of telepresence surgery: initial feasibility studies in swine. J Vasc Surg. 1996;23:281-287.
2. Bowersox JC. Telepresence surgery [editorial]. Br J Surg. 1996;83:433-434.
3. Marescaux J, Leroy J, Rubino F, et al. Transcontinental robot-assisted remote telesurgery: feasibility and potential applications. Ann Surg. 2002;235(4):487-492.
4. Anvari M, McKinley C, Stein H. Establishment of the world's first telerobotic remote surgical service for provision of advanced laparoscopic surgery in a rural community. Ann Surg. In press.
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