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Remote surgery (also known as telesurgery) is the ability for a doctor to perform
surgery Surgery ''cheirourgikē'' (composed of χείρ, "hand", and ἔργον, "work"), via la, chirurgiae, meaning "hand work". is a medical specialty that uses operative manual and instrumental techniques on a person to investigate or treat a pa ...
on a patient even though they are not physically in the same location. It is a form of
telepresence Telepresence refers to a set of technologies which allow a person to feel as if they were present, to give the appearance or effect of being present via telerobotics, at a place other than their true location. Telepresence requires that the use ...
. A robot surgical system generally consists of one or more arms (controlled by the surgeon), a master controller (console), and a sensory system giving feedback to the user.Intuitive Surgical. 2012. "The Da Vinci Surgical System." Intuitive Surgical. http://www.intuitivesurgical.com/products/davinci_surgical_system/. Remote surgery combines elements of
robot A robot is a machine—especially one programmable by a computer—capable of carrying out a complex series of actions automatically. A robot can be guided by an external control device, or the control may be embedded within. Robots may be ...
ics,
telecommunication Telecommunication is the transmission of information by various types of technologies over wire, radio, optical, or other electromagnetic systems. It has its origin in the desire of humans for communication over a distance greater than that ...
s such as high-speed data connections and elements of
management information system A management information system (MIS) is an information system used for decision-making, and for the coordination, control, analysis, and visualization of information in an organization. The study of the management information systems involves pe ...
s. While the field of
robotic surgery Robotic surgery are types of surgical procedures that are done using robotic systems. Robotically assisted surgery was developed to try to overcome the limitations of pre-existing minimally-invasive surgical procedures and to enhance the capabi ...
is fairly well established, most of these robots are controlled by surgeons at the location of the surgery. Remote surgery is
remote work Remote work, also called work from home (WFH), work from anywhere, telework, remote job, mobile work, and distance work is an employment arrangement in which employees do not commute to a central place of work, such as an office building, ware ...
for surgeons, where the physical distance between the surgeon and the patient is less relevant. It promises to allow the expertise of specialized surgeons to be available to patients worldwide, without the need for patients to travel beyond their local hospital.


Surgical systems

Surgical robot Robotic surgery are types of surgical procedures that are done using robotic systems. Robotically assisted surgery was developed to try to overcome the limitations of pre-existing minimally-invasive surgical procedures and to enhance the capabi ...
systems have been developed from the first functional telesurgery system-ZEUS-to the
da Vinci Surgical System The Da Vinci Surgical System is a robotic surgical system that uses a minimally invasive surgical approach. The system is manufactured by the company Intuitive Surgical. The system is used for prostatectomies, and increasingly for cardiac ...
, which is currently the only commercially available surgical robotic system. In Israel a company was established by Professor Moshe Schoham, from the faculty of Mechanical Engineering at the Technion. Used mainly for "on-site" surgery, these robots assist the surgeon visually, with better precision and less invasiveness to patients. The Da Vinci Surgical System has also been combined to form a Dual Da Vinci system which allows two surgeons to work together on a patient at the same time. The system gives the surgeons the ability to control different arms, switch command of arms at any point, and communicate through headsets during the operation.


Costs

Marketed for $975,000, the ZEUS Robot Surgical System was less expensive than the
da Vinci Surgical System The Da Vinci Surgical System is a robotic surgical system that uses a minimally invasive surgical approach. The system is manufactured by the company Intuitive Surgical. The system is used for prostatectomies, and increasingly for cardiac ...
, which cost $1 million. The cost of an operation through telesurgery is not precise but must pay for the surgical system, the surgeon, and contribute to paying for a year's worth of ATM technology which runs between $100,000-$200,000.


The Lindbergh Operation

The first true and complete remote surgery was conducted on 7 September 2001 across the Atlantic Ocean, with a French surgeon (Dr.
Jacques Marescaux Jacques Marescaux (born August 8, 1948) is a French doctor. He is Chairman of the digestive and endocrine surgery at the University Hospital, Strasbourg. Biography * 1948: Born in Clermont * 1971: Major in the contest for the Internat * 197 ...
) in
New York City New York, often called New York City or NYC, is the List of United States cities by population, most populous city in the United States. With a 2020 population of 8,804,190 distributed over , New York City is also the L ...
performing a
cholecystectomy Cholecystectomy is the surgical removal of the gallbladder. Cholecystectomy is a common treatment of symptomatic gallstones and other gallbladder conditions. In 2011, cholecystectomy was the eighth most common operating room procedure performed i ...
on a 68-year-old female patient 6,230 km away in
Strasbourg Strasbourg (, , ; german: Straßburg ; gsw, label= Bas Rhin Alsatian, Strossburi , gsw, label= Haut Rhin Alsatian, Strossburig ) is the prefecture and largest city of the Grand Est region of eastern France and the official seat of the ...
,
France France (), officially the French Republic ( ), is a country primarily located in Western Europe. It also comprises of Overseas France, overseas regions and territories in the Americas and the Atlantic Ocean, Atlantic, Pacific Ocean, Pac ...
. It was named Operation Lindbergh. After
Charles Lindbergh Charles Augustus Lindbergh (February 4, 1902 – August 26, 1974) was an American aviator, military officer, author, inventor, and activist. On May 20–21, 1927, Lindbergh made the first nonstop flight from New York City to Paris, a distance o ...
's pioneering
transatlantic flight A transatlantic flight is the flight of an aircraft across the Atlantic Ocean from Europe, Africa, South Asia, or the Middle East to North America, Central America, or South America, or ''vice versa''. Such flights have been made by fixed-wing air ...
from New York to Paris. France Telecom provided the redundant
fiber optic An optical fiber, or optical fibre in Commonwealth English, is a flexible, transparent fiber made by drawing glass (silica) or plastic to a diameter slightly thicker than that of a human hair. Optical fibers are used most often as a means t ...
ATM lines to minimize latency and optimize connectivity, and Computer Motion provided a modified Zeus robotic system. After clinical evaluation of the complete solution in July 2001, the human operation was successfully completed on 9/7/2001. The success and exposure of the procedure led the robotic team to use the same technology within Canada, this time using Bell Canada's public internet between Hamilton, Ontario and North Bay, Ontario (a distance of about 400 kilometers). While operation Lindbergh used the most expensive ATM fiber optics communication to ensure reliability and success of the first telesurgery, the follow on procedures in Canada used standard public internet which was provisioned with QOS using MPLS QOS-MPLS. A series of complex laparoscopic procedures were performed where in this case, the expert clinician would support the surgeon who was less experienced, operating on his patient. This resulted in patient receiving the best care possible while remaining in their hometown, the less experienced surgeon gaining valuable experience, and the expert surgeon providing their expertise without travel. The robotic team's goal was to go from Lindbergh's proof of concept to a real-life solution. This was achieved with ove
20 complex laparoscopic operations
between Hamilton and North Bay.


Applications

Since Operation Lindbergh, remote surgery has been conducted many times in numerous locations. To date Dr. Anvari, a laparoscopic surgeon in
Hamilton Hamilton may refer to: People * Hamilton (name), a common British surname and occasional given name, usually of Scottish origin, including a list of persons with the surname ** The Duke of Hamilton, the premier peer of Scotland ** Lord Hamilto ...
, Canada, has conducted numerous remote surgeries on patients in North Bay, a city 400 kilometres from Hamilton. Even though he uses a
VPN A virtual private network (VPN) extends a private network across a public network and enables users to send and receive data across shared or public networks as if their computing devices were directly connected to the private network. The be ...
over a non-dedicated fiberoptic connection that shares
bandwidth Bandwidth commonly refers to: * Bandwidth (signal processing) or ''analog bandwidth'', ''frequency bandwidth'', or ''radio bandwidth'', a measure of the width of a frequency range * Bandwidth (computing), the rate of data transfer, bit rate or thr ...
with regular telecommunications data, Dr. Anvari has not had any connection problems during his procedures. Rapid development of technology has allowed remote surgery rooms to become highly specialized. At the Advanced Surgical Technology Center at Mt. Sinai Hospital in
Toronto Toronto ( ; or ) is the capital city of the Canadian province of Ontario. With a recorded population of 2,794,356 in 2021, it is the most populous city in Canada and the fourth most populous city in North America. The city is the anch ...
, Canada, the surgical room responds to the surgeon's voice commands in order to control a variety of equipment at the surgical site, including the
lighting Lighting or illumination is the deliberate use of light to achieve practical or aesthetic effects. Lighting includes the use of both artificial light sources like lamps and light fixtures, as well as natural illumination by capturing dayl ...
in the operating room, the position of the operating table and the surgical tools themselves. With continuing advances in communication technologies, the availability of greater bandwidth and more powerful computers, the ease and cost-effectiveness of deploying remote surgery units is likely to increase rapidly. The possibility of being able to project the knowledge and the physical skill of a
surgeon In modern medicine, a surgeon is a medical professional who performs surgery. Although there are different traditions in different times and places, a modern surgeon usually is also a licensed physician or received the same medical training as ...
over long distances has many attractions. There is considerable research underway in the subject. The armed forces have an obvious interest since the combination of
telepresence Telepresence refers to a set of technologies which allow a person to feel as if they were present, to give the appearance or effect of being present via telerobotics, at a place other than their true location. Telepresence requires that the use ...
,
teleoperation Teleoperation (or remote operation) indicates operation of a system or machine at a distance. It is similar in meaning to the phrase "remote control" but is usually encountered in research, academia and technology. It is most commonly associat ...
, and
telerobotics Telerobotics is the area of robotics concerned with the control of semi-autonomous robots from a distance, chiefly using television, wireless networks (like Wi-Fi, Bluetooth and the Deep Space Network) or tethered connections. It is a combinati ...
can potentially save the lives of battle casualties by providing them with prompt attention in mobile operating theatres. Another potential advantage of having robots perform surgeries is accuracy. A study conducted at Guy's Hospital in
London London is the capital and List of urban areas in the United Kingdom, largest city of England and the United Kingdom, with a population of just under 9 million. It stands on the River Thames in south-east England at the head of a estuary dow ...
,
England England is a country that is part of the United Kingdom. It shares land borders with Wales to its west and Scotland to its north. The Irish Sea lies northwest and the Celtic Sea to the southwest. It is separated from continental Europe ...
compared the success of
kidney The kidneys are two reddish-brown bean-shaped organs found in vertebrates. They are located on the left and right in the retroperitoneal space, and in adult humans are about in length. They receive blood from the paired renal arteries; blo ...
surgeries in 304 dummy patients conducted traditionally as well as remotely and found that those conducted using robots were more successful in accurately targeting
kidney stone Kidney stone disease, also known as nephrolithiasis or urolithiasis, is a crystallopathy where a solid piece of material (kidney stone) develops in the urinary tract. Kidney stones typically form in the kidney and leave the body in the urine s ...
s. In 2015, another test was conducted on the lag time involved in the robotic surgery. A Florida hospital successfully tested lag time created by the Internet for a simulated robotic surgery in Ft. Worth, Texas, more than 1,200 miles away from the surgeon who was at the virtual controls. The team found out that the lag time in robotic surgeries, were insignificant. Roger Smith, CTO at the Florida Hospital Nicholson Center said that the team had concluded that, telesurgery is something that is possible and generally safe for large areas within the United States.


Unassisted robotic surgery

As the techniques of expert surgeons are studied and stored in special computer systems, robots might one day be able to perform surgeries with little or no human input. Carlo Pappone, an
Italian Italian(s) may refer to: * Anything of, from, or related to the people of Italy over the centuries ** Italians, an ethnic group or simply a citizen of the Italian Republic or Italian Kingdom ** Italian language, a Romance language *** Regional Ita ...
surgeon, has developed a software program that uses data collected from several surgeons and thousands of operations to perform the surgery without human intervention. This could one day make expensive, complicated surgeries much more widely available, even to patients in regions which have traditionally lacked proper medical facilities.


Force-feedback and time delay

The ability to carry out delicate manipulations relies greatly upon feedback. For example, it is easy to learn how much pressure is required to handle an egg. In robotic surgery, surgeons need to be able to perceive the amount of force being applied without directly touching the surgical tools. Systems known as force-feedback, or
haptic technology Haptic technology (also kinaesthetic communication or 3D touch) is technology that can create an experience of touch by applying forces, vibrations, or motions to the user. These technologies can be used to create virtual objects in a computer ...
, have been developed to simulate this. Haptics is the science of touch. Any type of Haptic feedback provides a responsive force in opposition to the touch of the hand. Haptic technology in telesurgery, making a virtual image of a patient or incision, would allow a surgeon to see what they are working on as well as feel it. This technology is designed to give a surgeon the ability to feel tendons and muscles as if it were actually the patient's body. However these systems are very sensitive to time-delays such as those present in the networks used in remote surgery.


Depth perception

Being able to gauge the depth of an incision is crucial. Humans'
binocular vision In biology, binocular vision is a type of vision in which an animal has two eyes capable of facing the same direction to perceive a single three-dimensional image of its surroundings. Binocular vision does not typically refer to vision where an ...
makes this easy in a three-dimensional environment. However, this can be much more difficult when the view is presented on a flat computer screen.


Possible uses

One possible use of remote surgery is the Trauma-Pod project conceived by the US military under the Defense Advanced Research Agency. This system is intended to aid wounded soldiers in the battlefield by making use of the skills of remotely located medical personnel. Another future possibility could be the use of remote surgery during long space exploration missions.


Limitations

For now, remote surgery is not a widespread technology in part because it does not have sponsorship by the governments. Before its acceptance on a broader scale, many issues will need to be resolved. For example, established clinical protocols, training, and global compatibility of equipment must be developed. Another technological limitation is the risk of interference with the communications (hacking).Researchers hijack teleoperated surgical robot: Remote surgery hacking threats, Computerworld, 27 April 2015 https://www.computerworld.com/article/2914741/researchers-hijack-teleoperated-surgical-robot-remote-surgery-hacking-threats.html. Also, there is still the need for an
anesthesiologist Anesthesiology, anaesthesiology, or anaesthesia is the medical specialty concerned with the total perioperative care of patients before, during and after surgery. It encompasses anesthesia, intensive care medicine, critical emergency medicin ...
and a backup surgeon to be present in case there is a disruption of communications or a malfunction in the robot. Nevertheless, Operation Lindbergh proved that the technology exists today to enable delivery of expert care to remote areas of the globe.


See also

*
Waldo (short story) "Waldo" (1942) is a short story by American writer Robert A. Heinlein, originally published in ''Astounding Magazine'' in August 1942 under the pseudonym Anson MacDonald. It is available in the 1950 book '' Waldo & Magic, Inc.'' (as well as othe ...
by
Robert A. Heinlein Robert Anson Heinlein (; July 7, 1907 – May 8, 1988) was an American science fiction author, aeronautical engineer, and naval officer. Sometimes called the "dean of science fiction writers", he was among the first to emphasize scientific accu ...
.


References


External links


BBC News SCI/TECH -- First transatlantic surgery
{{Telemedicine navbox Surgical procedures and techniques French inventions Computer-assisted surgery Telemedicine Videotelephony Telepresence