Bijoy Johnson, MBBS1, Dr. Somu
G, MBBS, MD2
1Junior Resident, Dept. of Hospital Administration,
Kasturba Medical College Manipal, Manipal University.
2Professor and Head, Dept. of Hospital
Administration, Kasturba Medical College Manipal, Manipal
University.
Address for Correspondence: Dr. Bijoy Johnson, Junior
Resident, Department of Hospital Administration, Kasturba
Medical College, Manipal, Karnataka 576104. Email:
bijoyjohnson@gmail.com.
Keywords: Robotic telesurgery, health informatics,
Virtual Private Networks
Introduction
The idea of robotic telesurgery dates back to the 1970s when
the National Aeronautics and Space Administration (NASA)
developed a project to utilize remotely controlled robots to
perform surgeries on astronauts [1]. The history of robotic
surgery begins in 1985, when Kwoh et al used a robot - Puma
200, for performing neurosurgical biopsies with greater
precision [2]. This was soon followed by the introduction of
PROBOT in 1988, a robotic system for ultrasound guided
prostatic resection [3]. A major breakthrough in the field of
robotic surgery came with the performance of the first
transatlantic telesurgical procedure (Operation Lindbergh) by
a surgeon in the United States operating on a patient in
France. Laparoscopic cholecystectomy was performed on a
68-year-old lady in Strasbourg, France by Professor Marescaux
utilising a Zeus robotic system located in New York, USA.
There were no complications during the procedure and the
patient was discharged 2 days later [4]. Since then,
telesurgery has been carried out in multiple locations around
the globe with successful outcomes.
Methods
Eligibility criteria: Literature search was
conducted to identify trials and review articles describing
the origin, implementation and latest developments in the
field of robotic telesurgery. Special focus was placed on
studying the information technology required for setting up of
a telesurgery system.
Information sources and searches: Searches were
conducted using PubMed. Additional articles were identified
from bibliographies of the articles obtained using the PubMed
search. Searches were not limited to any time period. Articles
were identified using the keywords "telesurgery" OR
"telerobotics".
Study selection: Articles retrieved were
assessed for their eligibility for inclusion in the study by
screening their titles and abstracts.
Results and discussion
A telerobotic system is composed of 'master' control console
from which the surgeon operates and a 'slave' unit which
performs surgery on the patient using robotic arms. The early
designs were limited in their scope due to basic computer
interfaces. Data transmission speed is a major obstacle in
performing long distance telesurgeries [1]. A significant
limitation in robotic telesurgery is communication latency.
Round trip latency is the time between the initiation of a
movement and the appearance of the image in the surgeon's
monitor [5]. During the first successful transatlantic robotic
telesurgery, Marescaux J et al [4] were able to minimize
latency by using a dedicated communication line provided by
France Telecom. Even though the round trip distance for data
transmission was 14000 Km, the network latency was only 155ms.
There was no significant impact on the ability to perform fine
surgical movements at this latency level. The communication
line used terrestrial fiber-optic network with asynchronous
transfer mode (ATM) technology. But dedicated ATM lines were
expensive with yearly cost ranging from $100,000 to $200,000
[4].
In addition to the high cost of ATM lines, the availability is
poor in remote and rural areas. Satellite connections (with
latency of about 500ms) and Virtual Private Networks (VPN)
with variable latency are the most commonly available
networks. Anvari et al [6] did a study to evaluate the impact
of latency of the performance of surgical tasks without
clinically important errors. Surgeons were asked to complete
surgical tasks with latencies of 0ms, 175ms, 300ms and 500ms
latencies. Order of latencies were randomized and surgeons
were blinded to the latency figures. There was significant
increase in task completion time with increasing latencies. It
was also associated with significant increase in the number of
errors [6].
The first telerobotic remote surgical system was setup in
Canada by Anvari et al [7]. It was established in 2003 between
St. Joseph's Hospital in Hamilton and North Bay General
Hospital 400 km away. Surgeons operated the Zeus-TS surgical
system in North Bay from a console in Hamilton. Unlike the
expensive ATM network used by Marescaux J et al [4], a
commercially available IP-VPN (Internet Protocol-Virtual
Private Network) with 15 Mbps of bandwidth was used here. This
was the same system used for local internet services. The
service included an active line and a redundant backup line to
be used in case of failure of the active line. Telesurgery
data transmission was given the highest priority in the
network, thus ensuring the most rapid data rate possible. The
overall latency was 135-140 ms. Of this, 14 ms was due to
delay in the network and the rest was due to delay in
compression and decompression of video signals. Although the
latency was noticeable to the surgeon, he was able to adapt to
it easily. A total of 21 surgeries were performed and there
were no major complications [7].
Of the seven clinical trials identified during literature
search, only one involved the use of remote telesurgical
procedures. Another study evaluated the use of remote
ultrasound guidance using robotic arms. Other studies were not
found to be relevant and were excluded from the study.
Challacombe B et al [8] compared human versus robotic and
telerobotic access to the kidney in percutaneous
nephrolithotomy. They used a validated kidney model for
comparing human and robotic modes. Although they found robotic
insertion to be slower than human insertion (56.5s vs 35s),
robotic mode was found to be more accurate (first attempt
success 88% vs 79%). Trans-Atlantic robotic procedures done
via Integrated Services for Digital Network (ISDN) lines also
produced comparable results [8].
Bruyere F et al [9] studied the use of telerobotic arms to
perform ultrasound guidance during renal biopsy in transplant
recipients. They demonstrated the feasibility of tele-operated
ultrasound-guided renal biopsies. But the time required was
significantly increased compared to conventional technique.
There were no post-biopsy complications [9].
Possibly, the ultimate application of robotic telesurgery is
the one proposed by NASA in the 1970s - telesurgery in space.
The challenges faced in the implementation of such a system
include: performing surgery in reduced gravity conditions,
portable equipment and most importantly, the latency in long
range data transmission. The feasibility of using robotic
surgery in zero gravity has already been demonstrated. In
September 2007, NASA successfully tested M7, a light and
portable robotic device developed by Stanford Research
International. Parabolic flights were used to simulate zero
gravity. Telesurgical procedures in space controlled from
earth will be limited by light speed data transmission. For
Earth-Moon distance, this will translate into a delay of about
1 second, which will only be suitable for basic telesurgical
procedures [1].
Conclusion
Information technology has the potential to revolutionize the
field of surgery. Patients in remote areas can have access to
the latest surgical procedures through robotic telesurgery.
The benefits of telesurgery extends beyond geographic
barriers. Telementoring programs will allow training of
surgeons in performing complex procedures. It also opens
avenues for international surgical collaboration. Development
of faster computer networks will allow reduction in data
transfer latency and allow surgeries to be performed over
longer distances. But more clinical trials should be carried
out to compare the outcome of telesurgery with conventional
modalities. Even though high cost of implementing and running
a telesurgery system was initially a deterrent, decrease in
cost of components and services are paving the way for wider
implementation.
References
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and telesurgery. Cir Cir, 2013;81, 247-250.
2. Kwoh YS, Hou J, Jonckheere EA, et al. A robot with improved
absolute positioning accuracy for CT guided stereotactic brain
surgery. IEEE Trans Biomed Eng. 1988;35:153-161.
3. Harris SJ, Arambula-Cosio F, Mei Q, Hibberd RD, Davies BL,
Wickham JE et al. The Probot--an active robot for prostate
resection. Proc Inst Mech Eng H. 1997;211:317-25.
4. Marescaux J, Leroy J, Rubino F, Smith M, Vix M, Simone M,
Mutter D. Transcontinental Robot-Assisted Remote Telesurgery:
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8. Challacombe B, Patriciu A, Glass J, et al. A randomized
controlled trial of human versus robotic and telerobotic
access to the kidney as the first step in percutaneous
nephrolithotomy. Comput Aided Surg. 2005;10:165-171.
9. Bruyere F, Ayoub J, Arbeille P. Use of a telerobotic arm to
perform ultrasound guidance during renal biopsy in transplant
recipients: a preliminary study. J Endourol. 2011
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