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Telemedicine- the future of surgery
Review Article Telemedicine- the future of surgery B. Challacombe MRCS(Ed) and P. Dasgupta MSc, MD, DLS, FRCS (Urol), FEBU Department of Urology, Guy’s Hospital, London, United Kingdom Correspondence to: Mr B. Challacombe, Department of Urology, Guy’s Hospital, London SE1 9RT, United Kingdom
Background Since the invention of the telephone in 1876 doctors have been able to convey medical information across long distances. The term ‘telemedicine’ derives from the Greek word ‘tele’ meaning ‘at a distance’ and the current word ‘medicine’ which itself derives from the Latin ‘mederi’ meaning ‘healing’. Although the word telemedicine has a number of definitions, it was first used in the 1970’s by Thomas Bird, who referred to a system of health care delivery where doctors could examine distant patients through the use of telecommunications technologies. It is currently taken to mean the rapid access to shared and remote medical expertise by means of telecommunications and information technologies, no matter where the patient or relevant information is located. For many years after this, telemedicine existed in its most basic form of teleconsultation, where one doctor asked the advice of another via purely audio transmission. With ever increasing technology and the introduction of video links, high-speed ISDN lines and satellite transmission, true telemedicine has evolved1. Using teleconferencing software surgeons now have the ability to telementor other surgeons from remote locations, which involves watching, advising and directing a procedure2. 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. With the introduction of sophisticated medical robots in the 1990’s and in particular the master-slave devices (Da Vinci and Zeus), the next logical step to true remote telerobotic surgery was ready to be taken. The first remote procedure on a patient occurred in September 2001 when a laparoscopic cholecystectomy took place on a patient in Strasbourg while the operating surgeon was in New York3. This procedure is now known as the Lindburgh procedure after the first trans-Atlantic flight.
Telemedicine Telemedicine as a concept has existed for many decades being regularly mentioned in science fiction books and films and an early reference is made in the novel “Five Patients” written by Michael Crichton in 19694. Within
The Journal of Surgery • Volume 1 • Issue 1 • 2003
this true account of his time spent at the Massachusetts General Hospital, he recalls how physicians at this hospital would take a history and examine patients at the medical station in Boston airport via a video link. 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 (eg MedAire) that send diagnostic information instantaneously back to ground-based doctors who subsequently give medical advice to on-board caregivers5. Similar systems are being developed for mountaineers and explorers to enable quick access to experienced medical opinions. The greatest power of telemedicine may lie in the regular use of the Internet for teleconsultation between generalists and tertiary referral centres and in the use of medical teleconferencing. As already 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 more mundane level, medical conferences, meetings and lectures are now regularly broadcast to local and remote hospital locations via teleconferencing links. This technique uses specific software, 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 almost every clinical area.
Telerobotic surgery One of the first organisations to invest significantly in the possibilities of remote surgery was the North American Space Association (NASA) who evaluated the potential of remotely operating on astronauts. Likewise, since the sixties the US has been looking at ways to remove specialist surgeons from the battlefield and employ medical robots to carry out surgery6. NASA has found laparoscopic and thoracoscopic operating both feasible and advantageous over open procedures during zero gravity experiments on pigs7. A feasibility study has even been performed on the placement of uretheral stents in reduced gravity8. The investment from
15
these two groups led to the development of the commonest surgical robots available commercially today, the Da Vinci (Intuitive), ZEUS (Computer Motion) and AESOP (Automated endoscope system for optimal positioning).
botics awaits its first clinical randomised trial. As one would expect the barriers to any randomised trial of telerobotics in the UK are immense as animal experimentation is scarce and validated models are still in development. Despite these obstacles a team at Guy’s Hospital has performed a randomised controlled trial of telerobotics between London and Johns Hopkins, Baltimore17. They used a specially adapted percutaneous kidney model into which a robotic arm introduced a Kellet needle. The robot was more accurate than the standard human introductions whether it was controlled locally or trans-Atlantically.
These systems are already providing us with results that must be taken seriously, in particular the recent work by Menon9 from the Vattikuti Urology Institute in Detroit. He describes a large series of over 300 robotic radical retropubic prostatectomies that shows the robotic procedure to be quicker, have reduced complications and a shorter hospital stay than either the open or laparoscopic techniques while maintaining good cancer control.
Many of the fundamental problems of remote surgery concern the technology of the electronic link. Progress was slowed until systems with sufficient bandwidth, time delay and security could be established. The human operator can only compensate up to a maximum of 600m/s delay19 when performing delicate tasks. In addition the issues of significant cost and complicated ethical considerations are still to be resolved.
The claim to the first telerobotic procedure lies with an Italian group headed by Professor Rovetta who performed the first prostate biopsy in 199510. Since then several other units have performed telementored or assisted telesurgical procedures11, 12, 13, 14. The scope for regular use of remote surgery is perhaps greatest in countries with remote communities such as Australia and Canada. In 1999 a mobile operating room travelled to a remote region of Ecuador where laparoscopic cholecystectomy was successfully telementored15. This represented the first use of telemedicine outside of technically sophisticated sites and clearly illustrated the potential for true remote surgery in this situation. More recently the Lindbergh procedure and an unpublished report of a telerobotically assisted laparoscopic Nissen fundoplication between two Canadian hospitals 400km apart show the potential of remote surgery.
Future Directions Although the UK possesses relatively few remote communities, telemedicine is here to stay. In the coming years, ever-increasing numbers of UK hospital trusts will link up to carry out teleconferencing with each other, facilitating rapid diagnosis and management decisions and improving medical education. Telesurgery is likely to overcome the obstacles it faces in terms of technology and expense and become a valuable tool in the rapidly growing field of surgical robotics. Whether it is in the form of teleconsultation or telesurgery, telemedicine in general has the proven capacity to improve the provision of healthcare by bringing a wider range of services to today’s NHS.
Despite an increasing number of individual reports indicating the feasibility of different operations16, telero-
Group
Procedure
Date
Comment
Italy- Italy10
Prostate Biopsy
1995
1st remote surgery
Baltimore-Italy16
PCNL needle puncture
1998
1st successful remote percutaneous renal access
Herniorrhaphy
1999
1st military telementoring
Ecuador-Yale, USA
Laparoscopic CholecystectomyTelementored
1999
1st remote use of telementoring in a remote area
Strasbourg-New York19
Laparoscopic Cholecystectomy
2001
1st fully remote operation
Baltimore-Munich13
Laparoscopic excision renal cyst
2002
Telementoring with control of AESOP & PAKY
London-Baltimore17
Randomised control trial of PCNL
2002
1st Randomised control trial of robotics
USS Lincoln- USA9 18
Table 1: Landmarks in Telerobotic surgery18
16
The Journal of Surgery • Volume 1 • Issue 1 • 2003
Figure 1: Robotic arm in ranomised control trial
Figure 2: Computer view during remote surgery
References 1.
Dasgupta P. Robotics in Urology. BJU Int 2001; 88:300. 2. Micali S, Virgili G, Vannozzi E et al. Feasibility of telementoring between Baltimore (USA) and Rome (Italy): the first five cases. J Endourol 2000; 14: 493-6. 3. Marescaux J, Leroy J, Gagner M et al. Transatlantic robot-assisted telesurgery. Nature 2001; 413: 379-80. 4. Crichton R. Five Patients. Arrow Publishers: London 1995. 5. Garrett JS. MedAire: peace of mind in the skies—a flight nurse’s dream come true. Interview by Marlene Jezierski. J Emerg Nurs 1998; 24: 71-3. 6. Cubano M, Poulose BK, Talamini MA et al. Long distance telementoring. A novel tool for laparoscopy aboard the USS Abraham Lincoln. Surg Endosc 1999; 13: 673-8. 7. Campbell MR, Kirkpatrick AW, Billica RD et al. Endoscopic surgery in weightlessness: the investigation of basic principles for surgery in space. Surg Endosc 2001; 15: 1530 8. Jones JA, Johnston S, Campbell M, Miles B, Billica R. Endoscopic surgery and telemedicine in microgravity: developing contingency procedures for exploratory class space flight. Urology 1999; 53: 892-7 9. Menon M. Robotic radical retropubic prostatectomy. BJU Int 2003; 91: 175-6. 10. Rovetta A. and Sala R. Robotics and telerobotics applied to a prostate biopsy on a human patient. In Proceedings of the Second Symposium on Medical Robotics and Computer Assisted Surgery, Baltimore, 1995, 104. 11. Janetschek G, Bartsch G, Kavoussi LR.
The Journal of Surgery • Volume 1 • Issue 1 • 2003
12.
13.
14.
15.
16.
17.
18. 19.
Transcontinental interactive laparoscopic telesurgery between United States and Europe. J Urol 1998; 160: 1413. Lee BR, Png DJ, Liew L et al. Laparoscopic telesurgery between the United States and Singapore. Ann Acad Med Singapore 2000; 29:665-8 Frimberger D, Kavoussi L, Stoianovici D et al. Telerobotic surgery between Baltimore and Munich Urologe A 2002; 41: 489-92. Cubano M, Poulose BK, Talamini MA et al. Long distance telementoring. A novel tool for laparoscopy aboard the USS Abraham Lincoln. Surg Endosc 1999; 13: 673-8. Rosser JC Jr, Bell RL, Harnett B, Rodas E, Murayama M, Merrell R. Use of mobile low-band width telemedical techniques for extreme telemedicine applications. J Am Coll Surg 1999; 189: 397-404 Bauer J, Lee BR, Stoianovici D et al. Remote percutaneous renal access using a new automated telesurgical robotic system. Telemed J E Health 2001; 7: 341-6. Challacombe BJ, Patriciu A, Glass J et al. A Randomised Controlled Trial of Human versus Telerobotic Access to the Kidney during Percutaneous Nephrolithotomy. Eur Urol 2003; S2: 198. Challacombe B, Kavoussi L, Dasgupta P. Trans-Oceanic Telerobotics. BJU Int 2003 In Press. Fabrizio MD, Lee BR, Chan DY et al. Effect of time delay on surgical performance during telesurgical manipulation. J Endourol 2000; 14: 133-8.
17
Background Since the invention of the telephone in 1876 doctors have been able to convey medical information across long distances. The term ‘telemedicine’ derives from the Greek word ‘tele’ meaning ‘at a distance’ and the current word ‘medicine’ which itself derives from the Latin ‘mederi’ meaning ‘healing’. Although the word telemedicine has a number of definitions, it was first used in the 1970’s by Thomas Bird, who referred to a system of health care delivery where doctors could examine distant patients through the use of telecommunications technologies. It is currently taken to mean the rapid access to shared and remote medical expertise by means of telecommunications and information technologies, no matter where the patient or relevant information is located. For many years after this, telemedicine existed in its most basic form of teleconsultation, where one doctor asked the advice of another via purely audio transmission. With ever increasing technology and the introduction of video links, high-speed ISDN lines and satellite transmission, true telemedicine has evolved1. Using teleconferencing software surgeons now have the ability to telementor other surgeons from remote locations, which involves watching, advising and directing a procedure2. 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. With the introduction of sophisticated medical robots in the 1990’s and in particular the master-slave devices (Da Vinci and Zeus), the next logical step to true remote telerobotic surgery was ready to be taken. The first remote procedure on a patient occurred in September 2001 when a laparoscopic cholecystectomy took place on a patient in Strasbourg while the operating surgeon was in New York3. This procedure is now known as the Lindburgh procedure after the first trans-Atlantic flight.
Telemedicine Telemedicine as a concept has existed for many decades being regularly mentioned in science fiction books and films and an early reference is made in the novel “Five Patients” written by Michael Crichton in 19694. Within
The Journal of Surgery • Volume 1 • Issue 1 • 2003
this true account of his time spent at the Massachusetts General Hospital, he recalls how physicians at this hospital would take a history and examine patients at the medical station in Boston airport via a video link. 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 (eg MedAire) that send diagnostic information instantaneously back to ground-based doctors who subsequently give medical advice to on-board caregivers5. Similar systems are being developed for mountaineers and explorers to enable quick access to experienced medical opinions. The greatest power of telemedicine may lie in the regular use of the Internet for teleconsultation between generalists and tertiary referral centres and in the use of medical teleconferencing. As already 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 more mundane level, medical conferences, meetings and lectures are now regularly broadcast to local and remote hospital locations via teleconferencing links. This technique uses specific software, 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 almost every clinical area.
Telerobotic surgery One of the first organisations to invest significantly in the possibilities of remote surgery was the North American Space Association (NASA) who evaluated the potential of remotely operating on astronauts. Likewise, since the sixties the US has been looking at ways to remove specialist surgeons from the battlefield and employ medical robots to carry out surgery6. NASA has found laparoscopic and thoracoscopic operating both feasible and advantageous over open procedures during zero gravity experiments on pigs7. A feasibility study has even been performed on the placement of uretheral stents in reduced gravity8. The investment from
15
these two groups led to the development of the commonest surgical robots available commercially today, the Da Vinci (Intuitive), ZEUS (Computer Motion) and AESOP (Automated endoscope system for optimal positioning).
botics awaits its first clinical randomised trial. As one would expect the barriers to any randomised trial of telerobotics in the UK are immense as animal experimentation is scarce and validated models are still in development. Despite these obstacles a team at Guy’s Hospital has performed a randomised controlled trial of telerobotics between London and Johns Hopkins, Baltimore17. They used a specially adapted percutaneous kidney model into which a robotic arm introduced a Kellet needle. The robot was more accurate than the standard human introductions whether it was controlled locally or trans-Atlantically.
These systems are already providing us with results that must be taken seriously, in particular the recent work by Menon9 from the Vattikuti Urology Institute in Detroit. He describes a large series of over 300 robotic radical retropubic prostatectomies that shows the robotic procedure to be quicker, have reduced complications and a shorter hospital stay than either the open or laparoscopic techniques while maintaining good cancer control.
Many of the fundamental problems of remote surgery concern the technology of the electronic link. Progress was slowed until systems with sufficient bandwidth, time delay and security could be established. The human operator can only compensate up to a maximum of 600m/s delay19 when performing delicate tasks. In addition the issues of significant cost and complicated ethical considerations are still to be resolved.
The claim to the first telerobotic procedure lies with an Italian group headed by Professor Rovetta who performed the first prostate biopsy in 199510. Since then several other units have performed telementored or assisted telesurgical procedures11, 12, 13, 14. The scope for regular use of remote surgery is perhaps greatest in countries with remote communities such as Australia and Canada. In 1999 a mobile operating room travelled to a remote region of Ecuador where laparoscopic cholecystectomy was successfully telementored15. This represented the first use of telemedicine outside of technically sophisticated sites and clearly illustrated the potential for true remote surgery in this situation. More recently the Lindbergh procedure and an unpublished report of a telerobotically assisted laparoscopic Nissen fundoplication between two Canadian hospitals 400km apart show the potential of remote surgery.
Future Directions Although the UK possesses relatively few remote communities, telemedicine is here to stay. In the coming years, ever-increasing numbers of UK hospital trusts will link up to carry out teleconferencing with each other, facilitating rapid diagnosis and management decisions and improving medical education. Telesurgery is likely to overcome the obstacles it faces in terms of technology and expense and become a valuable tool in the rapidly growing field of surgical robotics. Whether it is in the form of teleconsultation or telesurgery, telemedicine in general has the proven capacity to improve the provision of healthcare by bringing a wider range of services to today’s NHS.
Despite an increasing number of individual reports indicating the feasibility of different operations16, telero-
Group
Procedure
Date
Comment
Italy- Italy10
Prostate Biopsy
1995
1st remote surgery
Baltimore-Italy16
PCNL needle puncture
1998
1st successful remote percutaneous renal access
Herniorrhaphy
1999
1st military telementoring
Ecuador-Yale, USA
Laparoscopic CholecystectomyTelementored
1999
1st remote use of telementoring in a remote area
Strasbourg-New York19
Laparoscopic Cholecystectomy
2001
1st fully remote operation
Baltimore-Munich13
Laparoscopic excision renal cyst
2002
Telementoring with control of AESOP & PAKY
London-Baltimore17
Randomised control trial of PCNL
2002
1st Randomised control trial of robotics
USS Lincoln- USA9 18
Table 1: Landmarks in Telerobotic surgery18
16
The Journal of Surgery • Volume 1 • Issue 1 • 2003
Figure 1: Robotic arm in ranomised control trial
Figure 2: Computer view during remote surgery
References 1.
Dasgupta P. Robotics in Urology. BJU Int 2001; 88:300. 2. Micali S, Virgili G, Vannozzi E et al. Feasibility of telementoring between Baltimore (USA) and Rome (Italy): the first five cases. J Endourol 2000; 14: 493-6. 3. Marescaux J, Leroy J, Gagner M et al. Transatlantic robot-assisted telesurgery. Nature 2001; 413: 379-80. 4. Crichton R. Five Patients. Arrow Publishers: London 1995. 5. Garrett JS. MedAire: peace of mind in the skies—a flight nurse’s dream come true. Interview by Marlene Jezierski. J Emerg Nurs 1998; 24: 71-3. 6. Cubano M, Poulose BK, Talamini MA et al. Long distance telementoring. A novel tool for laparoscopy aboard the USS Abraham Lincoln. Surg Endosc 1999; 13: 673-8. 7. Campbell MR, Kirkpatrick AW, Billica RD et al. Endoscopic surgery in weightlessness: the investigation of basic principles for surgery in space. Surg Endosc 2001; 15: 1530 8. Jones JA, Johnston S, Campbell M, Miles B, Billica R. Endoscopic surgery and telemedicine in microgravity: developing contingency procedures for exploratory class space flight. Urology 1999; 53: 892-7 9. Menon M. Robotic radical retropubic prostatectomy. BJU Int 2003; 91: 175-6. 10. Rovetta A. and Sala R. Robotics and telerobotics applied to a prostate biopsy on a human patient. In Proceedings of the Second Symposium on Medical Robotics and Computer Assisted Surgery, Baltimore, 1995, 104. 11. Janetschek G, Bartsch G, Kavoussi LR.
The Journal of Surgery • Volume 1 • Issue 1 • 2003
12.
13.
14.
15.
16.
17.
18. 19.
Transcontinental interactive laparoscopic telesurgery between United States and Europe. J Urol 1998; 160: 1413. Lee BR, Png DJ, Liew L et al. Laparoscopic telesurgery between the United States and Singapore. Ann Acad Med Singapore 2000; 29:665-8 Frimberger D, Kavoussi L, Stoianovici D et al. Telerobotic surgery between Baltimore and Munich Urologe A 2002; 41: 489-92. Cubano M, Poulose BK, Talamini MA et al. Long distance telementoring. A novel tool for laparoscopy aboard the USS Abraham Lincoln. Surg Endosc 1999; 13: 673-8. Rosser JC Jr, Bell RL, Harnett B, Rodas E, Murayama M, Merrell R. Use of mobile low-band width telemedical techniques for extreme telemedicine applications. J Am Coll Surg 1999; 189: 397-404 Bauer J, Lee BR, Stoianovici D et al. Remote percutaneous renal access using a new automated telesurgical robotic system. Telemed J E Health 2001; 7: 341-6. Challacombe BJ, Patriciu A, Glass J et al. A Randomised Controlled Trial of Human versus Telerobotic Access to the Kidney during Percutaneous Nephrolithotomy. Eur Urol 2003; S2: 198. Challacombe B, Kavoussi L, Dasgupta P. Trans-Oceanic Telerobotics. BJU Int 2003 In Press. Fabrizio MD, Lee BR, Chan DY et al. Effect of time delay on surgical performance during telesurgical manipulation. J Endourol 2000; 14: 133-8.
17