The finest medical surgeon in Chicago can operate remotely on an injured member of an Antarctic expedition team thousands of miles away. People in developing nations and rural areas will be able to obtain surgery without leaving home. These scenarios are possible with telesurgery -- a remote procedure that combines elements of robotics and high-speed Internet connections. While telesurgery continues to emerge, some medical experts raise concerns about the safety and the legality of the technology.
Telesurgery involves the use of telecommunications to facilitate performance of an operation, regardless of the physical distance between the surgeon and the patient. Expert surgeons rely on high-speed IP communications to operate on a patient in a distant operating room (OR) using robots at the location of the surgery.
During the surgery, small incisions are made and plastic tubes are placed through these incisions. A tiny video camera and several thin operating instruments are then placed through the tubes in order to give surgeons video access to the inside of the patient. The in-body camera transmits images to a television monitor used by the surgeon. A second surgeon manages robotic instruments in the OR, and can take over if the robotic procedure has to be aborted.
Transatlantic telesurgery was first demonstrated in 2001 when surgeons in New York operated on a 68-year-old woman in Strasbourg, France, using remote-controlled robots to remove her gall bladder. Today, however, significant hurdles remain to widespread adoption of telesurgery in the U.S.
“Medical practitioners feel that network reliability and effective bandwidth provisioning still need more work,” says Chuck Doarn, executive director of the Center for Surgical Innovation at the University of Cincinnati. “We need top-notch robotic controls and reliability, and also fast-thinking neural networks.”
Signal lag is also a concern. Any delay that exceeds 200 milliseconds between the movement of the control instrument and the movement of the operating instrument creates risks for the patient, since it decreases the surgeon's control.
The network is the key to effective telesurgery, according to Peter Maag, VP of marketing at HaiVision, which provides advanced network video technology. “Latency must be reduced to a minimum to assure the kind of hand-eye coordination needed between the remote surgeon and the robotics in the operating room,” says Maag. “Network providers are aware of this and I know of at least two that offer the latest Multiprotocol Label Switching (MPLS)infrastructure, with guaranteed QOS [quality of service], reduced latency, and redundancy.”
There are the legal and regulatory issues to consider as well. Should a surgeon be able to operate on a patient in another city, or even in another country, with no way to physically intervene if something goes wrong? Whom does the patient sue when something goes wrong?Can a surgeon operate by long distance in a place where he isn't licensed?
“Canada has a federal healthcare system, so there is a single payer and all citizens should get the same quality of care,” says Dr. Moji Ghodoussi of Interface Surgical Technologies. “The U.S. does not, and there are no processes for the intervening expert surgeon to get reimbursed. Also, surgeons in the U.S. generally cannot operate on patients in another hospital or state.”Ghodoussi says it will take 10 to 15 years before telesurgery is widely adopted in the U.S., because of legal and regulatory hurdles.
On the other hand, Doarn expects to see more U.S. industry- and government-sponsored telesurgery initiatives within the next five to ten years. “For remote areas, telesurgery offers surgical expertise that otherwise could not be obtained,” says Doarn. “Medicine will continue to be driven by technology, and in many cases it will be consumers demanding freedom of choice that will drive some of the demand.”
Telesurgery can be a real advantage as you say--and you are also right on the money when it comes to the avalanche of new medical advances and technologies that physicians (and others) struggle to stay current with.
The number of medical errors, as you mentioned, is also alarming,
One technology initiative that has been going for the past ten years is the concept of a uniform electronic medical record (EMR) which would give everyone the same information on the patient's medical history, medications, surgeries, etc--and hopefully reduce the chance of error and miscommunication. The EMR is still not universally implemented.
I have a meeting with a telesurgery surgeon later this week, and will ask him about the bone setting protocol.
I also agree that the Internet itself is not always rock stable.
To date, the fallback (DR plan) for telesurgery is having another surgeon in the OR with the patient, ready to take over. Carriers provding high QoS also have redundant failover.
Telesurgery is not such a big jump.Even today, most surgery is done via an endoscope, with the surgeon viewing via a 6 inch LCD display.
Telesurgery just means that this one member of the team is remote.It is not clear a patient would even know his surgeon was remote.Certainly most patients today do not know the analysis of their CAT Scan or MRI was done remotely.
For surgery, lag is an issue, but the biggest problem is variable lag, or dither, which is implicit in ‘stack’ protocols like TCP/IP.This problem can be mitigated via precision clock synchronization, for example IEEE 1588; see this white paperhttp://www.applieddata.net/WP/Robotics_Platforms_Using_Intel_IXP465.pdf
Though telesurgery may useful to the people in the West, I agree with Paul that for people in developing countries, telesurgery is just another scientific fairytale!!! How many people can be able to foot the bill for telesurgery in developing countries? The other annoying aspect is the poor internet services in the developng countries and how many people can be able to assess internet.
We're all enthralld in 2001 when the first telesurgery was conducted across the atlantic and from all indications, the prospect of using computer-based technology to operate upon patients from a distance look great and pomising. The most critical challenge you mentioned was that of lag time as this will make surgery mre dangerous because the surgeon could not react quickly enough to a sudden emergency. I read from the following article that the first telesurgery was conducted on a 'special internet' and not this standard internet where data transmission times are notoriously unstable"Telesurgery
So if the standard internet is so unreliable for telesurgery, how can we ever hope the technology can become global?
Also, as Nicole mentioned those who are in dire need of the technology may not stand to gain from it. For people in developing countries, telesurgery is just another scientific fairytale!!! For the west though, the challenges will be more of a legal type than technology since more advanacements have been made to improve telesurgery:
According to a report by the Institute of Medicine[1], at least 44,000 people, and perhaps as many as 98,000 people, die in hospitals each year as a result of medical errors that could have been prevented, costing the industry up to $29B.These identifiable medical errors directly correlate to the skyrocketing costs of medical malpractice premiums within the medical community.
Worsening this already unfortunate situation, new and more effective health care treatment practices often do not quickly find their way into clinical practice, despite attention garnered in professional journals and at medical conferences. Recent studies indicate an average of 17 years is needed before new knowledge generated through research, such as randomized clinical trials, is incorporated into widespread clinical practice—and even then the application of the knowledge is very uneven.The explosion of medical knowledge during the past 20 years has made it more difficult for doctors to stay abreast of the latest diagnostic and treatment developments in their field.
All this being said, having that surgeon in the room, monitoring the procedure, acting on new information discovered during the surgery or quickly correcting mistakes when they happen is a real advantage.
[1]To Err is Human: Building a Safer Health System, Institute of Medicine, November 1999
I suspect that telesurgery will become a more availalbe treatment option after costs can be reduced (e.g., the robotics) and qualifications completed in the U.S. Regulatory and legal issues also need to be resolved.
Mary, thanks for this post. This very real idea of telesurgery is fascinating. However, it seems very, very risky to rely solely on technology to perform surgery. The fact remains that technology is never without its bugs, so to not have a doctor at the scene to step in, in the case of an emergency, seems very risky. I realize this is one of the major concerns surrounding the technology already.
On the other hand, if a person is in dire need of surgery, and the only doctor or doctors who can perform this surgery are thousands or millions of miles away -- without trying to sound insensitive -- what have they got to lose? In a life or death situation when you've no resources or doctors on hand to care for you, at least telesurgery would present the potential for survival.
In the new report launched on Internet Evolution today, The Internet and the Developing World, we touch upon telemedicine and the lack of an impact it has had in the developing world due to limited equipment and supplies, cost, and a lack of understanding of the Internet. According to our report, telemedicine efforts in Africa that do work, for example, usually involve the phone and not the Internet. So, while telesurgery and telemedicine via the Internet are potentially fantastic ideas, their potential may be lost where it's needed the most.
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