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Telemicrosurgery: A feasibility study in a rat model
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Chirurgie de la main 27 (2008) 104–108 http://france.elsevier.com/direct/CHIMAI/
Original article
Telemicrosurgery: A feasibility study in a rat model La te´le´microchirurgie : e´tude expe´rimentale chez le rat C. Taleb a,b, E. Nectoux a, P.A. Liverneaux a,*,b a
SOS main Illkirch, CCOM, hôpitaux universitaires de Strasbourg, 10, avenue Achille-Baumann, 67403 Illkirch cedex, France b EITS, Institut européen de téléchirurgie, Strasbourg, France Received 29 December 2007; received in revised form 22 March 2008; accepted 2 April 2008
Abstract Telesurgery is frequently used in cardiac, urologic, gynaecologic or digestive surgery. Significant advances are due to this technology: reduction of the operative time, safety and precision of the surgical gesture, reduction of bleeding and more comfort for the surgeon. However, no telesurgical experiment has been reported yet in microsurgery with 10-0 nylon sutures. The aim of the present work was to assess the feasibility of vascular anastomosis by a telemicrosurgical technique. The material used for this experiment consisted of two Wistar rats, a standard set of surgical instruments and a Da Vinci S1 (Intuitive SurgicalTM) telemanipulation system. Rats were prepared in compliance with the current regulation. The rat tail was approached by cutaneous incision. The following surgical steps were carried out by telemicrosurgery: dissection, fitting of a vascular clamp, section of the artery and suture by 10-0 nylon separate stitches. Following anastomoses, patency tests were carried out and showed the suture effectiveness. The procedure lasted one hour in both cases. Physiologic tremor was abolished by the telemicrosurgical interface. In this study, the operator’s pronosupination amplitude was 3608. Optical magnification was the same as with a conventional operative microscope. The adjunction of a third articulated arm improved the ergonomics of the working space. Preliminary results are in favour of the feasibility of telemicrosurgery. The learning curve was astonishingly short. It remains to be used in human clinical practice. # 2008 Elsevier Masson SAS. All rights reserved. Résumé La téléchirurgie est utilisée couramment en chirurgie cardiaque, urologique, gynécologique ou encore digestive. Elle a apporté de notables avancées : réduction du temps opératoire, sécurité et précision du geste, diminution du saignement et confort du chirurgien. Toutefois, aucune expérience téléchirurgicale n’a été rapportée à ce jour en microchirurgie avec des sutures au fil de nylon 10/0. Le but de ce travail est d’établir la faisabilité des anastomoses vasculaires par télémicrochirurgie. Le matériel consistait en deux rats Wistar, une boîte d’instruments de chirurgie standard et un télémanipulateur Da Vinci S1 (Intuitive SurgicalTM). Les rats ont été préparés selon les règles en vigueur. Un abord de la queue des rats a été réalisé par volet cutané. Les temps suivants ont été réalisés sous télémicrochirurgie : dissection, mise en place d’un clamp vasculaire, section de l’artère, suture par des points séparés de nylon 10/0. Après les anastomoses, un test de perméabilité a permis de constater l’efficacité de la suture. La durée de la procédure était d’une heure dans les deux cas. Le tremblement physiologique était supprimé par l’interface télémicrochirurgicale. Dans cette étude, la pronosupination de l’opérateur était de 3608. Le grossissement optique était identique à celui d’un microscope opératoire conventionnel. L’adjonction d’un troisième bras articulé permettait d’améliorer l’ergonomie du poste de travail. Nos résultats préliminaires semblent montrer la faisabilité de la télémicrochirurgie. La courbe d’apprentissage était étonnamment courte. Reste à l’appliquer en clinique humaine. # 2008 Elsevier Masson SAS. All rights reserved. Keywords: Anastomosis; Artery; Hand; Microsurgery; Rat; Robot; Telesurgery; 10/0 Mots clés : Anastomose ; Artère ; Main ; Microchirurgie ; Rat ; Robot ; Téléchirurgie ; 10/0
* Corresponding author. E-mail address: [email protected] (P.A. Liverneaux). 1297-3203/$ – see front matter # 2008 Elsevier Masson SAS. All rights reserved. doi:10.1016/j.main.2008.04.001
C. Taleb et al. / Chirurgie de la main 27 (2008) 104–108
1. Introduction First thumb replantation has been realized more than 40 years ago [1,2]. Since then, microsurgery has been integrated in the current practice in hand surgery, especially in traumatology. Despite obvious progress regarding instrumentation and optical magnification, no significant advance has been made in microsurgery for at least 10 years. The main limiting factor for such improvement does not pertain to the technique; it is rather related to human factors. For example, no interface permits today filtration of the physiologic tremor from the surgeon’s hand to his microsurgical instruments. In parallel, the first telesurgical intervention has been performed in 2001 [3]. It consisted in transatlantic laparoscopic cholecystectomy. At this date, the concept of telesurgery was elaborated and defined as any surgical intervention assisted from a distance by computer [4]. Telesurgery which is carried out using a telemanipulator exclusively handled by the surgeon presents two theoretical advantages: on one hand, the possibility to work from a distance and on the other hand, the improved precision of the surgical gesture. Only the second advantage is currently used in planned surgery, in numerous specialties such as cardiac, urologic, gynaecologic or digestive surgery [5–7]. No experiment of telemicrosurgery in the rat has been published to date. In such context, the aim of the present work was to study the feasibility of a new concept, the telemicrosurgery, by adapting conventional microsurgery specifications to telesurgery. It was hypothesized that the use of a telemanipulator might not only
105
improve the microsurgical gesture of the surgeon, but it might also abolish all problems related to physiologic tremor. As a demonstration, the proposed experimental paradigm is an anastomosis of the rat tail artery. 2. Material and methods Two laboratory rats, a set of standard surgical instruments and a telemanipulator were used for this experiment. The telemicrosurgical phase of the intervention was carried out using a 3-part Da Vinci S1 (Intuitive Surgical, Inc.TM) telemanipulation system that included a mobile trolley with four articulate automated arms, an imaging trolley and a console conceived to help the surgeon controlling the articulate arms of the telemanipulator (Fig. 1). Of the four articulate arms of the mobile trolley, three were fitted with surgical instruments while the fourth carried the optical equipment meant to visualize the operative area. Each of these arms had several articulations that made possible a 3-dimensional shifting of both surgical and optical instruments. The three arms dedicated to surgical material had a supplementary intracorporeal articulation with circumduction movements of 3608. The surgical instruments were dissection forceps and straight scissors. The fourth arm carried the optical equipment (Figs. 2 and 3). The imaging trolley consisted of a video column similar to that used in conventional arthroscopy, with two light sources and two cameras providing 3D vision, with a progressive enlargement, up to 20.
Fig. 1. Telemicrosurgery working space. On the right it may be seen the console that helps the operator controlling the articulate arms of the mobile trolley (on the left). The rat is positioned on the rolling table. The operator is sitting ahead of the console, his head positioned between two infrared captors on a support that makes him able to have a 3-dimensional view of the operating area seen through a binocular optical system. The operator’s hands control the movements of the mobile trolley arms by using the handles, which are connected to the surgical instruments by electronic systems transmitted by servo-motors.
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Fig. 2. Telemicrosurgical operating area. It may be seen at the bottom of the figure a vascular clamp maintaining the sectioned extremities of the rat tail artery and at the top of the figure, two telemanipulated dissection forceps surmounted by the stereovision optical system.
The telesurgeon’s console was equipped with an optical system, two telemanipulation handles and a pedal board. The optical system, called stereovision, gave a 3-dimensional view of the operative area and displayed texts and icons providing real time information on the functioning state of the system. The two handles helped distant manipulation of the four articulate arms fitted with the surgical and optical instruments; they might not handle more than two of the articulate arms simultaneously. A declutching system on the pedal board helped the operator changing the articulate arm during the course of the intervention. The pedal board allowed focal adjustment and the sharpness of the operating area; the declutching system helped keeping the surgical instruments in an optimal position on the video screen. The surgical technique differed from conventional microsurgery only by the use of telemanipulated instruments.
Two Wistar laboratory rats were prepared in compliance with the current regulation in experimental microsurgery and anaesthesia. They had been previously anaesthetized by induction of halogen-containing anaesthetic compound and then anaesthesia was maintained by an intraperitoneal injection of combined thiopental and ketamine. After then, rats were put in dorsal decubitus on the working surface, the four limbs and tail fixed using bands of adhesive tape. The skin was cut out at the junction of the proximal and median thirds of the ventral face of the tail, using conventional surgical instruments. The detached skin was fixed on the working surface by a 4-0 nylon traction thread. The following operative steps were all carried out by telemicrosurgery. The first consisted in fascia section followed by the tail artery dissection using a dissection forceps and straight scissors; the second consisted in the installation of a double vascular clamp Biover1 (AREXTM) using two dissection forceps. The third step was the tail artery section using straight scissors and the fourth the anastomosis of this artery by four separate 10-0 nylon stitches using two dissection forceps and straight scissors. A patency test was carried out twice: the first time immediately after clamp removal and the second after one hour. 3. Results In both cases of section-anastomosis of rat tail artery, immediate and one hour delayed patency tests were positive. The total duration of the intervention was approximately one hour. No difficulty occurred while performing the anastomoses. In one rat, an anastomosis was even realized with the instruments in completely anti-physiologic retroversion position, which could not have been done with conventional instrumentation. The operator had no difficulty in realizing this procedure. The availability of three instruments allowed blocking the clamp in one position, which facilitated thread pulling with the other instruments. Physiologic tremor was abolished by the telemanipulator. The needle of the microsurgical thread has been deformed or broken each time it was seized simultaneously by the two dissection forceps. 4. Discussion
Fig. 3. Telemicrosurgical operating area. The thread crossing the lumen of the rat tail artery.
Telesurgery must not be merged with the automation of surgical gestures. Rather than robots that execute without control programmed acts, telemanipulators are surgical tools which have a specific characteristic: that of being handled from a distance under full control of the operator. In cardiac, urologic, gynaecologic or digestive surgery, telesurgery helped breaking some constraints related to conventional laparoscopy. For example, the visualization of the operative area has been improved, not only because it became 3-dimensional rather than bi-dimensional as previously [8], but also because the angle of view may be controlled by the operator himself and from a distance, without any need for external help. Besides, the operator’s gesture has been improved, both by the abolishment of physiologic tremor [9]
C. Taleb et al. / Chirurgie de la main 27 (2008) 104–108
and because instruments have been elaborated with seven degrees of liberty so as to be articulated similarly to the human wrist, with an additional advantage which is a 3608 prosupination amplitude rather than 1808 with a conventional operator. In this manner, telemanipulation allowed transcending the operator’s gesture by providing him supplementary articular sectors and a 3-dimensional view of the operative space. Indeed, it has been shown that turning bi-dimensional vision to 3-dimensional vision in association with the wide motion amplitude of the Da Vinci1 system arms were synergistic [10]. None of these two elements taken in an isolated manner could explain such gestural easiness. These undeniable technical advances make it possible today executing some very difficult microsurgical gestures without any need for patient installation tricks. For example, thumb replantation that may necessitate installing the patient in prone decubitus position, which is delicate in terms of anaesthesia, can now be realized with the patient in any position owing to the telemanipulation system. However, like others [11,12], we had some difficulties during this preliminary study of telemicrosurgery, related to the fact that the Da Vinci1 system has not been elaborated for open surgery; it was rather meant for laparoscopic surgery. The surgical instruments we used for example were conceived for vascular telesurgery and their too large size might explain some slowness in the telemanipulation of the 10-0 thread. It should be obtained from manufacturers an adaptation of the teleinstruments to microsurgery. Besides, the absence of proprioceptive retrocontrol did not permit estimating the strength of the dissection forceps’ closure. As a result, each time a needle was seized by two forceps, either torsion or needle fracture occurred. To solve this problem, it was necessary to seize the needle with only one dissection forceps. In addition, suture knotting necessitated visual control so as to compensate the absence of sensation of the traction force on soft tissues or suture threads. After few minutes of adaptation, proprioceptive retrocontrol was effectively replaced by visual retrocontrol, in accordance with other experiments reported in the literature [9]. In the future, telemicrosurgical instrumentation will have to be adapted by a refinement of the forceps and it will be necessary to standardize the vascular suture technique either by maintaining triangulation or by creating a new more rapid technique, taking into account the anti-physiologic positions tolerated by the telemicrosurgery. Nevertheless, telesurgery is carried out in current practice only in case of planned thoracic, abdominal or pelvic surgery, in order to improve surgical gesture. The distance separating the operator and the patient is still of few metres, which underexploit the potential of this technology that may be used for longer distances. For example, since the medical demography decreases today, creating a necessity for means mutualisation, it appears possible to elaborate a regional network in which the operators of a referent centre might provide real time technical help to the operators of surrounding centres for specific surgical interventions, so as to avoid useless transfers and valorise local care teams.
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The high cost of telesurgical equipments may be a limiting factor to such projects, although some authors have emphasized a paradoxical cost reduction related to their utilization [13] resulting from bleeding reduction and improvement of some operative procedures. Other restricting factors may be the congestion of telesurgical systems and a certain evolution of mentalities, which might necessitate the revision of the operating rooms ergonomics. Beside these technical problems, some ethical considerations may be discussed, such as responsibility, safety and the patient-doctor relationship. Medical responsibility, for example, is a major point. Who is responsible for the gesture: the surgeon in the operative room or the operator who guides the telemanipulation at the console? This point is debated today in a telemedicine context [14]. Safety of data transmission is also another essential question. Indeed, it must be ascertained that no other operator may have control of the system from a distance. Finally, it remains difficult to estimate the impact of telesurgery on the patient–doctor relationship since this technology, by definition, suppresses any relational contact between the patient and the surgeon in a surgical procedure that can be carried out in a distant manner [8]. 5. Conclusion The preliminary results of our experiment in the rat seem to show the feasibility of a telemicrosurgical procedure for hand surgery. Among the theoretical advantages of this technique: the suppression of physiologic tremor, the simultaneous use of three instruments, the improved operator’s gesture and a very short learning curve. Application of this technique in human clinical practice is a valuable prospect. Acknowledgements Professors Jacques Marescaux and Didier Mutter, European Institute of TeleSurgery, Strasbourg, France. David Douglas and Brice Herain, Intuitive Surgical, Inc, Sunnyvale, US. References [1] Buncke JH, Schulz PW. Experimental digital amputation and reimplantation. Plast Reconstr Surg 1965;36:62–70. [2] Komatsu S, Tamai S. Successful replantation of a completely cut off thumb. Plast Reconstr Surg 1968;42:374–7. [3] Marescaux J, Leroy J, Gagner M, Rubino F, Mutter D, Vix M. Transatlantic robot-assisted telesurgery. Nature 2001;413:379–80. [4] Pande RU, Patle Y. The telecommunication revolution in the medical field: present applications and future perspective. Curr Surg 2003;6:636–40. [5] Bressler L. Place de l’assistance robotique par le système Da Vinci en chirurgie digestive et endocrinienne. Ann Chir 2006;131:299–301. [6] Zorn KC. Robotic radical prostatectomy learning curve of a fellowshiptrained laparoscopic surgeon. J Endourol 2007;21:441–7. [7] Cohn LH. Futures directions in cardiac surgery. Am Heart Hosp J 2006;4:174–8. [8] Smith A, Smith J, Jayne DG. Telerobotics: surgery for the 21st century. Surgery 2006;24:74–8.
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[9] Blavier A, Gaudissart Q, Cadière GB, Nyssen AS. Perceptual and instrumental impacts of robotic laparoscopy on surgical performance. Surg Endosc 2007;65:80–91. [10] Blavier A, Gaudissart Q, Cadière GB, Nyssen AS. Impact of 2D and 3D Vision on performance of novice subjects using Da Vinci robotic system. Acta Chir Belg 2006;106:662–4. [11] Katz R, Rosson G, Taylor J, Singh N. Robotics in microsurgery: Use of a surgical robot to perform a free flap in a pig. Microsurgery 2005;25:566–9.
[12] Van der Hulst R. Microvacular anastomosis: is there a role for robotic surgery? J Plast Reconstr Aesthet Surg 2007;60:101–2. [13] Nelson B. Comparison of length of hospital stay between radical retropubic prostatectomy and robotic assisted laparoscopic prostatectomy. J Urol 2007;177:929–31. [14] Esper C. La responsabilité en télémédecine. Bull Acad Natl Med 2006;190:357–64.
Chirurgie de la main 27 (2008) 104–108 http://france.elsevier.com/direct/CHIMAI/
Original article
Telemicrosurgery: A feasibility study in a rat model La te´le´microchirurgie : e´tude expe´rimentale chez le rat C. Taleb a,b, E. Nectoux a, P.A. Liverneaux a,*,b a
SOS main Illkirch, CCOM, hôpitaux universitaires de Strasbourg, 10, avenue Achille-Baumann, 67403 Illkirch cedex, France b EITS, Institut européen de téléchirurgie, Strasbourg, France Received 29 December 2007; received in revised form 22 March 2008; accepted 2 April 2008
Abstract Telesurgery is frequently used in cardiac, urologic, gynaecologic or digestive surgery. Significant advances are due to this technology: reduction of the operative time, safety and precision of the surgical gesture, reduction of bleeding and more comfort for the surgeon. However, no telesurgical experiment has been reported yet in microsurgery with 10-0 nylon sutures. The aim of the present work was to assess the feasibility of vascular anastomosis by a telemicrosurgical technique. The material used for this experiment consisted of two Wistar rats, a standard set of surgical instruments and a Da Vinci S1 (Intuitive SurgicalTM) telemanipulation system. Rats were prepared in compliance with the current regulation. The rat tail was approached by cutaneous incision. The following surgical steps were carried out by telemicrosurgery: dissection, fitting of a vascular clamp, section of the artery and suture by 10-0 nylon separate stitches. Following anastomoses, patency tests were carried out and showed the suture effectiveness. The procedure lasted one hour in both cases. Physiologic tremor was abolished by the telemicrosurgical interface. In this study, the operator’s pronosupination amplitude was 3608. Optical magnification was the same as with a conventional operative microscope. The adjunction of a third articulated arm improved the ergonomics of the working space. Preliminary results are in favour of the feasibility of telemicrosurgery. The learning curve was astonishingly short. It remains to be used in human clinical practice. # 2008 Elsevier Masson SAS. All rights reserved. Résumé La téléchirurgie est utilisée couramment en chirurgie cardiaque, urologique, gynécologique ou encore digestive. Elle a apporté de notables avancées : réduction du temps opératoire, sécurité et précision du geste, diminution du saignement et confort du chirurgien. Toutefois, aucune expérience téléchirurgicale n’a été rapportée à ce jour en microchirurgie avec des sutures au fil de nylon 10/0. Le but de ce travail est d’établir la faisabilité des anastomoses vasculaires par télémicrochirurgie. Le matériel consistait en deux rats Wistar, une boîte d’instruments de chirurgie standard et un télémanipulateur Da Vinci S1 (Intuitive SurgicalTM). Les rats ont été préparés selon les règles en vigueur. Un abord de la queue des rats a été réalisé par volet cutané. Les temps suivants ont été réalisés sous télémicrochirurgie : dissection, mise en place d’un clamp vasculaire, section de l’artère, suture par des points séparés de nylon 10/0. Après les anastomoses, un test de perméabilité a permis de constater l’efficacité de la suture. La durée de la procédure était d’une heure dans les deux cas. Le tremblement physiologique était supprimé par l’interface télémicrochirurgicale. Dans cette étude, la pronosupination de l’opérateur était de 3608. Le grossissement optique était identique à celui d’un microscope opératoire conventionnel. L’adjonction d’un troisième bras articulé permettait d’améliorer l’ergonomie du poste de travail. Nos résultats préliminaires semblent montrer la faisabilité de la télémicrochirurgie. La courbe d’apprentissage était étonnamment courte. Reste à l’appliquer en clinique humaine. # 2008 Elsevier Masson SAS. All rights reserved. Keywords: Anastomosis; Artery; Hand; Microsurgery; Rat; Robot; Telesurgery; 10/0 Mots clés : Anastomose ; Artère ; Main ; Microchirurgie ; Rat ; Robot ; Téléchirurgie ; 10/0
* Corresponding author. E-mail address: [email protected] (P.A. Liverneaux). 1297-3203/$ – see front matter # 2008 Elsevier Masson SAS. All rights reserved. doi:10.1016/j.main.2008.04.001
C. Taleb et al. / Chirurgie de la main 27 (2008) 104–108
1. Introduction First thumb replantation has been realized more than 40 years ago [1,2]. Since then, microsurgery has been integrated in the current practice in hand surgery, especially in traumatology. Despite obvious progress regarding instrumentation and optical magnification, no significant advance has been made in microsurgery for at least 10 years. The main limiting factor for such improvement does not pertain to the technique; it is rather related to human factors. For example, no interface permits today filtration of the physiologic tremor from the surgeon’s hand to his microsurgical instruments. In parallel, the first telesurgical intervention has been performed in 2001 [3]. It consisted in transatlantic laparoscopic cholecystectomy. At this date, the concept of telesurgery was elaborated and defined as any surgical intervention assisted from a distance by computer [4]. Telesurgery which is carried out using a telemanipulator exclusively handled by the surgeon presents two theoretical advantages: on one hand, the possibility to work from a distance and on the other hand, the improved precision of the surgical gesture. Only the second advantage is currently used in planned surgery, in numerous specialties such as cardiac, urologic, gynaecologic or digestive surgery [5–7]. No experiment of telemicrosurgery in the rat has been published to date. In such context, the aim of the present work was to study the feasibility of a new concept, the telemicrosurgery, by adapting conventional microsurgery specifications to telesurgery. It was hypothesized that the use of a telemanipulator might not only
105
improve the microsurgical gesture of the surgeon, but it might also abolish all problems related to physiologic tremor. As a demonstration, the proposed experimental paradigm is an anastomosis of the rat tail artery. 2. Material and methods Two laboratory rats, a set of standard surgical instruments and a telemanipulator were used for this experiment. The telemicrosurgical phase of the intervention was carried out using a 3-part Da Vinci S1 (Intuitive Surgical, Inc.TM) telemanipulation system that included a mobile trolley with four articulate automated arms, an imaging trolley and a console conceived to help the surgeon controlling the articulate arms of the telemanipulator (Fig. 1). Of the four articulate arms of the mobile trolley, three were fitted with surgical instruments while the fourth carried the optical equipment meant to visualize the operative area. Each of these arms had several articulations that made possible a 3-dimensional shifting of both surgical and optical instruments. The three arms dedicated to surgical material had a supplementary intracorporeal articulation with circumduction movements of 3608. The surgical instruments were dissection forceps and straight scissors. The fourth arm carried the optical equipment (Figs. 2 and 3). The imaging trolley consisted of a video column similar to that used in conventional arthroscopy, with two light sources and two cameras providing 3D vision, with a progressive enlargement, up to 20.
Fig. 1. Telemicrosurgery working space. On the right it may be seen the console that helps the operator controlling the articulate arms of the mobile trolley (on the left). The rat is positioned on the rolling table. The operator is sitting ahead of the console, his head positioned between two infrared captors on a support that makes him able to have a 3-dimensional view of the operating area seen through a binocular optical system. The operator’s hands control the movements of the mobile trolley arms by using the handles, which are connected to the surgical instruments by electronic systems transmitted by servo-motors.
106
C. Taleb et al. / Chirurgie de la main 27 (2008) 104–108
Fig. 2. Telemicrosurgical operating area. It may be seen at the bottom of the figure a vascular clamp maintaining the sectioned extremities of the rat tail artery and at the top of the figure, two telemanipulated dissection forceps surmounted by the stereovision optical system.
The telesurgeon’s console was equipped with an optical system, two telemanipulation handles and a pedal board. The optical system, called stereovision, gave a 3-dimensional view of the operative area and displayed texts and icons providing real time information on the functioning state of the system. The two handles helped distant manipulation of the four articulate arms fitted with the surgical and optical instruments; they might not handle more than two of the articulate arms simultaneously. A declutching system on the pedal board helped the operator changing the articulate arm during the course of the intervention. The pedal board allowed focal adjustment and the sharpness of the operating area; the declutching system helped keeping the surgical instruments in an optimal position on the video screen. The surgical technique differed from conventional microsurgery only by the use of telemanipulated instruments.
Two Wistar laboratory rats were prepared in compliance with the current regulation in experimental microsurgery and anaesthesia. They had been previously anaesthetized by induction of halogen-containing anaesthetic compound and then anaesthesia was maintained by an intraperitoneal injection of combined thiopental and ketamine. After then, rats were put in dorsal decubitus on the working surface, the four limbs and tail fixed using bands of adhesive tape. The skin was cut out at the junction of the proximal and median thirds of the ventral face of the tail, using conventional surgical instruments. The detached skin was fixed on the working surface by a 4-0 nylon traction thread. The following operative steps were all carried out by telemicrosurgery. The first consisted in fascia section followed by the tail artery dissection using a dissection forceps and straight scissors; the second consisted in the installation of a double vascular clamp Biover1 (AREXTM) using two dissection forceps. The third step was the tail artery section using straight scissors and the fourth the anastomosis of this artery by four separate 10-0 nylon stitches using two dissection forceps and straight scissors. A patency test was carried out twice: the first time immediately after clamp removal and the second after one hour. 3. Results In both cases of section-anastomosis of rat tail artery, immediate and one hour delayed patency tests were positive. The total duration of the intervention was approximately one hour. No difficulty occurred while performing the anastomoses. In one rat, an anastomosis was even realized with the instruments in completely anti-physiologic retroversion position, which could not have been done with conventional instrumentation. The operator had no difficulty in realizing this procedure. The availability of three instruments allowed blocking the clamp in one position, which facilitated thread pulling with the other instruments. Physiologic tremor was abolished by the telemanipulator. The needle of the microsurgical thread has been deformed or broken each time it was seized simultaneously by the two dissection forceps. 4. Discussion
Fig. 3. Telemicrosurgical operating area. The thread crossing the lumen of the rat tail artery.
Telesurgery must not be merged with the automation of surgical gestures. Rather than robots that execute without control programmed acts, telemanipulators are surgical tools which have a specific characteristic: that of being handled from a distance under full control of the operator. In cardiac, urologic, gynaecologic or digestive surgery, telesurgery helped breaking some constraints related to conventional laparoscopy. For example, the visualization of the operative area has been improved, not only because it became 3-dimensional rather than bi-dimensional as previously [8], but also because the angle of view may be controlled by the operator himself and from a distance, without any need for external help. Besides, the operator’s gesture has been improved, both by the abolishment of physiologic tremor [9]
C. Taleb et al. / Chirurgie de la main 27 (2008) 104–108
and because instruments have been elaborated with seven degrees of liberty so as to be articulated similarly to the human wrist, with an additional advantage which is a 3608 prosupination amplitude rather than 1808 with a conventional operator. In this manner, telemanipulation allowed transcending the operator’s gesture by providing him supplementary articular sectors and a 3-dimensional view of the operative space. Indeed, it has been shown that turning bi-dimensional vision to 3-dimensional vision in association with the wide motion amplitude of the Da Vinci1 system arms were synergistic [10]. None of these two elements taken in an isolated manner could explain such gestural easiness. These undeniable technical advances make it possible today executing some very difficult microsurgical gestures without any need for patient installation tricks. For example, thumb replantation that may necessitate installing the patient in prone decubitus position, which is delicate in terms of anaesthesia, can now be realized with the patient in any position owing to the telemanipulation system. However, like others [11,12], we had some difficulties during this preliminary study of telemicrosurgery, related to the fact that the Da Vinci1 system has not been elaborated for open surgery; it was rather meant for laparoscopic surgery. The surgical instruments we used for example were conceived for vascular telesurgery and their too large size might explain some slowness in the telemanipulation of the 10-0 thread. It should be obtained from manufacturers an adaptation of the teleinstruments to microsurgery. Besides, the absence of proprioceptive retrocontrol did not permit estimating the strength of the dissection forceps’ closure. As a result, each time a needle was seized by two forceps, either torsion or needle fracture occurred. To solve this problem, it was necessary to seize the needle with only one dissection forceps. In addition, suture knotting necessitated visual control so as to compensate the absence of sensation of the traction force on soft tissues or suture threads. After few minutes of adaptation, proprioceptive retrocontrol was effectively replaced by visual retrocontrol, in accordance with other experiments reported in the literature [9]. In the future, telemicrosurgical instrumentation will have to be adapted by a refinement of the forceps and it will be necessary to standardize the vascular suture technique either by maintaining triangulation or by creating a new more rapid technique, taking into account the anti-physiologic positions tolerated by the telemicrosurgery. Nevertheless, telesurgery is carried out in current practice only in case of planned thoracic, abdominal or pelvic surgery, in order to improve surgical gesture. The distance separating the operator and the patient is still of few metres, which underexploit the potential of this technology that may be used for longer distances. For example, since the medical demography decreases today, creating a necessity for means mutualisation, it appears possible to elaborate a regional network in which the operators of a referent centre might provide real time technical help to the operators of surrounding centres for specific surgical interventions, so as to avoid useless transfers and valorise local care teams.
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The high cost of telesurgical equipments may be a limiting factor to such projects, although some authors have emphasized a paradoxical cost reduction related to their utilization [13] resulting from bleeding reduction and improvement of some operative procedures. Other restricting factors may be the congestion of telesurgical systems and a certain evolution of mentalities, which might necessitate the revision of the operating rooms ergonomics. Beside these technical problems, some ethical considerations may be discussed, such as responsibility, safety and the patient-doctor relationship. Medical responsibility, for example, is a major point. Who is responsible for the gesture: the surgeon in the operative room or the operator who guides the telemanipulation at the console? This point is debated today in a telemedicine context [14]. Safety of data transmission is also another essential question. Indeed, it must be ascertained that no other operator may have control of the system from a distance. Finally, it remains difficult to estimate the impact of telesurgery on the patient–doctor relationship since this technology, by definition, suppresses any relational contact between the patient and the surgeon in a surgical procedure that can be carried out in a distant manner [8]. 5. Conclusion The preliminary results of our experiment in the rat seem to show the feasibility of a telemicrosurgical procedure for hand surgery. Among the theoretical advantages of this technique: the suppression of physiologic tremor, the simultaneous use of three instruments, the improved operator’s gesture and a very short learning curve. Application of this technique in human clinical practice is a valuable prospect. Acknowledgements Professors Jacques Marescaux and Didier Mutter, European Institute of TeleSurgery, Strasbourg, France. David Douglas and Brice Herain, Intuitive Surgical, Inc, Sunnyvale, US. References [1] Buncke JH, Schulz PW. Experimental digital amputation and reimplantation. Plast Reconstr Surg 1965;36:62–70. [2] Komatsu S, Tamai S. Successful replantation of a completely cut off thumb. Plast Reconstr Surg 1968;42:374–7. [3] Marescaux J, Leroy J, Gagner M, Rubino F, Mutter D, Vix M. Transatlantic robot-assisted telesurgery. Nature 2001;413:379–80. [4] Pande RU, Patle Y. The telecommunication revolution in the medical field: present applications and future perspective. Curr Surg 2003;6:636–40. [5] Bressler L. Place de l’assistance robotique par le système Da Vinci en chirurgie digestive et endocrinienne. Ann Chir 2006;131:299–301. [6] Zorn KC. Robotic radical prostatectomy learning curve of a fellowshiptrained laparoscopic surgeon. J Endourol 2007;21:441–7. [7] Cohn LH. Futures directions in cardiac surgery. Am Heart Hosp J 2006;4:174–8. [8] Smith A, Smith J, Jayne DG. Telerobotics: surgery for the 21st century. Surgery 2006;24:74–8.
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[9] Blavier A, Gaudissart Q, Cadière GB, Nyssen AS. Perceptual and instrumental impacts of robotic laparoscopy on surgical performance. Surg Endosc 2007;65:80–91. [10] Blavier A, Gaudissart Q, Cadière GB, Nyssen AS. Impact of 2D and 3D Vision on performance of novice subjects using Da Vinci robotic system. Acta Chir Belg 2006;106:662–4. [11] Katz R, Rosson G, Taylor J, Singh N. Robotics in microsurgery: Use of a surgical robot to perform a free flap in a pig. Microsurgery 2005;25:566–9.
[12] Van der Hulst R. Microvacular anastomosis: is there a role for robotic surgery? J Plast Reconstr Aesthet Surg 2007;60:101–2. [13] Nelson B. Comparison of length of hospital stay between radical retropubic prostatectomy and robotic assisted laparoscopic prostatectomy. J Urol 2007;177:929–31. [14] Esper C. La responsabilité en télémédecine. Bull Acad Natl Med 2006;190:357–64.