Telemicrosurgery

Telemicrosurgery

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  15P. Liverneaux etal. (eds.), Telemicrosurgery, DOI 10.1007/978-2-8178-0391-3_2, © Springer-Verlag France 2013 Hippocrates (480–390 B.C.) defined surgery as the therapeutic activity practiced by the means of the “hands.” The figure of the ancient surgeon was surrounded by a kind of mysticism because they touched the inside of the sacred human body with naked hands. The early Greek surgeons reported the use of limited surgical tools to assist with surgical procedures beginning the separation of the surgeon’s hands from the patient. Halsted pioneered the use of the surgical glove in 1894 and separated the surgeon a little further form the patient. The twentieth century has seen the addition of laparoscopic surgery that moved the surgeon’s hand outside the body to reduce surgical trauma and improve patient outcomes. Despite these advances, some form of physical contact between the surgeon and patient has always remained. Surgical robotics at the turn of the twenty-first century has produced the technology to dis- rupt even the paradigm of surgeon-patient proximity. Robotics entered the operating room in 1985 with the PUMA 200 industrial robot adapted for CT-guided brain biopsy [5]. In 1988, the PROBOT was an ultra- sound-guided system used to perform prostatic resections [4]. The first commer- cially available medical robot came in 1992 with the ROBODOC (Integrated Surgical Systems, Sacramento, CA). The system was designed and approved to precisely mill the femur for hip replacements. This first generation of surgical robots was notable for performing image-guided precision tasks but was limited by the need for preoperative planning and basic computer interfaces. The evolution of surgical robots has led to a current generation of real-time tele- manipulators. The AESOP® (Automated Endoscopic System for Optimal Position, Computer Motion Inc., Goleta, CA) was the first robotic system approved for general surgery [1, 9]. In the emerging era of laparoscopy, the system was designed to assist the surgeon by taking control of the laparoscopic camera and responding to voice J. Wall, M.D. • J. Marescaux, M.D., (Hon) F.R.C.S., F.A.C.S., (Hon) J.S.E.S.(*) IRCAD, Department of General, Digestive and Endocrine Surgery, University Hospital of Strasbourg, 1 place de l’Hôpital, Strasbourg 67091, France e-mail: [email protected] 2History of Telesurgery James Wall and Jacques Marescaux
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  16 J. Walland J. Marescaux commands [8, 11, 14, 15]. The next step was to create telemanipulation machines where the robot mimics the gestures of the surgeon (Fig. 2.1). In these units, the “mas- ter” control console, from which the surgeon operates, is physically separated from the “slave” unit, composed of the robotic arms performing surgery on the patient. The development of telesurgery arose in the 1970s with the aim to replace the surgeon physical presence in situations of mass casualties in hostile environments such as war or natural catastrophes. While the foundation of telemanipulation surgi- cal systems can be traced back to the United States National Aeronautics and Space Administration (NASA), their major development was funded by DARPA (Defense Advanced Research Project Administration) as a potential military tool for remote surgical care of the injured soldier. Two main teleoperator surgical robots were developed from the research: the da Vinci® Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA) and the ZEUS® system (Computer Motion, Goleta, CA). Intuitive Surgical and Computer Motion merged in 2003, resulting in a single FDA-approved robotic platform on the market today that carries the name da Vinci® . Early systems required the surgeon to be in the same room as the patient. However, with the use of telecommunications, both telementoring and telemanipu- lation were attempted from remote locations [2, 3]. One early report from 1996 demonstrated the ability of a surgeon in the same city to successfully mentor another surgeon as well as manipulate an endoscopic camera [7]. While successful, it was felt that latency in data transmission limited telemanipulation to a distance of a few hundred kilometers [12]. Fortunately, the telecommunications industry has also seen significant improve- ments since the invention of the telephone in 1876. Modern fiber-optic global connections allow reliable high-bandwidth data transmission with delays of less than 500 ms. The combination of high-speed telecommunications and a modern telemanipulator enabled all limitations on global telesurgery to be broken by “Operation Lindberg,” the first transatlantic surgical procedure. Using advanced asynchronous transfer mode (ATM) telecommunication technology, a surgeon Fig. 2.1 The fundamental configuration of a surgical robot that enables telesurgery. The surgeon and control panel are separated from the patient and robotic arms
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  172 History ofTelesurgery worked from a control panel in New York, United States, to successfully perform a complete cholecystectomy on a patient in Strasbourg, France (Fig. 2.2) [6]. The routine use of telesurgical applications is still under development. In addi- tion to technical challenges, there are many medical-legal, billing, and liability issues that must be resolved to enable telesurgery across state and national boundar- ies. Progress has been made in telementoring, where specialist surgeons can mentor local surgeons through telepresence. Telementoring programs that allow rural hos- pitals access to specialists are being established worldwide (Fig. 2.3). Early reports shown that specialist surgical skills can be disseminated effectively using telemen- toring [13]. Telesurgery remains in its infancy. Significant challenges remain for the field including the cost-effectiveness, access to bandwidth, regulations, and adoption. Telesurgery in extremely remote locations is limited by the availability of advanced telecommunications. However, recently work on satellite-based telecommunications Fig. 2.2 Operation Lindberg: the first transcontinental telesurgical procedure Fig. 2.3 Surgical telementoring enables a specialist surgeon to remotely assist in complex procedures
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  18 J. Walland J. Marescaux has shown feasibility for telesurgery despite higher latency than Internet-based data transmission [10]. Another current limitation is the lack of tactile feedback that removes the key aspect of feel from the surgeon’s hands. Despite current limitations, the potential of surgical robotics and telesurgery is enormous. The ability to deliver surgical expertise to distant locations will benefit patients worldwide. Surgical robots additionally hold the promise of more than just master–slave configurations for a remote surgeon to operate in real time. One day, patient-specific models may be created from advanced imaging. Such models could allow a surgeon to remotely simulate a procedure prior to operating and determine the best surgical strategy. Ultimately, if a robot can be preoperatively trained by a remote surgeon to do the procedure, the robot may be able to autonomously perform surgery. While the future is hard to predict, one thing is for sure, the paradigm of physical contact between the surgeon and patient has been broken leading to an era where surgeons can operate from across the room, across the country, and even across continents. References 1. Allaf ME, Jackman SV, Schulam PG et al (1998) Laparoscopic visual field. Voice vs foot pedal interfaces for control of the AESOP robot. Surg Endosc 12:1415–1418 2. Cubano M, Poulose BK, Talamini MA et al (1999) Long distance telementoring. A novel tool for laparoscopy aboard the USS Abraham Lincoln. Surg Endosc 13:673–678 3. Gagner M, Begin E, Hurteau R et al (1994) Robotic interactive laparoscopic cholecystectomy. Lancet 343:596–597 4. Harris SJ, Arambula-Cosio F et al (1988) The Probot – an active robot for prostate resection. Proc Inst Mech Eng H 211:317–325 5. Kwoh YS, Hou J, Jonckheere EA et al (1988) A robot with improved absolute positioning accuracy for CT guided stereotactic brain surgery. IEEE Trans Biomed Eng 35:153–160 6. Marescaux J, Leroy J, Gagner M et al (2001) Transatlantic robot-assisted telesurgery. Nature 27:379–380 7. Moore RG, Adams JB, Partin AW et al (1996) Telementoring of laparoscopic procedures: initial clinical experience. Surg Endosc 10:107–110 8. Nebot PB, Jain Y, Haylett K et al (2003) Comparison of task performance of the camera-holder robots EndoAssist and Aesop. Surg Laparosc Endosc Percutan Tech 13:334–338 9. Omote K, Feussner H, Ungeheuer A et al (1999) Self-guided robotic camera control for lap- aroscopic surgery compared with human camera control. Am J Surg 177:321–324 10. Rayman R, Croome K, Galbraith N et al (2007) Robotic telesurgery: a real-world comparison of ground- and satellite-based internet performance. Int J Med Robot 3:111–116 11. Sackier JM, Wang Y (1994) Robotically assisted laparoscopic surgery. From concept to devel- opment. Surg Endosc 8:63–66 12. Satava RM (1999) Emerging technologies for surgery in the 21st century. Arch Surg 134:1197–1202 13. Schlachta CM, Lefebvre KL, Sorsdahl AK et al (2010) Mentoring and telementoring leads to effective incorporation of laparoscopic colon surgery. Surg Endosc 24:841–844 14. Unger SW, Unger HM, Bass RT (1994) AESOP robotic arm. Surg Endosc 8:1131 15. Wagner AA, Varkarakis IM, Link RE et al (2006) Comparison of surgical performance during laparoscopic radical prostatectomy of two robotic camera holders, EndoAssist and AESOP: a pilot study. Urology 68:70–74
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