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Telesurgery and Robotics - abstracted from original report from “Advanced Technology,” Jedediah Kaufman, MD and Mika Sinanan, PhD, MD
Technological advances in robotics and telecommunications will allow patients to have access to minimally invasive surgery by specialists who are unavailable where the patient lives.
Scenario: The surgeon performing esophageal surgery sits in her console in a building in Seattle, WA. The chief resident and another colleague arrive to observe the scheduled surgery commenced to begin. The surgeon slips behind the console in her office, glances at the monitor to see if the operation is ready to proceed. Her colleagues in Alaska are focusing robotically controlled laparoscopic cameras in preparation for the case. In Fairbanks, AK, a young woman is being prepped for surgery. The surgeon plans to perform a modified Heller esophageal myotomy, cutting the longitudinal and circular muscles of her esophageal wall while leaving the thin esophageal lining or mucosa intact. Muscle fibers of the proximal stomach are also divided, obliterating the nonrelaxing lower esophageal sphincter, the primary problem in this rare disease (achalasia).
The surgeon and patient have never met. The preoperative visits were via telemonitoring, her care directed by a surgeon and primary care provider in Alaska who do not perform advanced laparoscopic techniques. Her postop care will be performed locally at her hospital. Her surgical procedure will be broadcast to other surgeons interested in learning about this laparoscopic approach to treat achalasia. They can draw on the viewing monitor with a computer mouse, and the lines show up on the primary surgeon’s viewing screen, allowing her to answer directed anatomic questions. She can also explain the operation, approach, and any pitfalls on her monitor, with the drawing superimposed on the surgical sites to best illustrate her thoughts.
The patient will have a surgeon assisting the remote operator. The assistant will place the laparoscopic ports and retract tissue, cut, suture, and care for the patient. Should an emergency occur, the robot can be removed in about 10 seconds, and the operation converted to an open procedure.
The relationship between robotics and surgery is in its infancy. Current applications require large size and expensive equipment, advanced communications, all with significant overhead. Just as computers and the Internet use and interactive speed increased, so too will robotics and telemedicine. Sizes of the robots are decreasing, and the ability to connect surgeons is improving.
Current operations performed with robotic assistance begin by docking a large 3 or 4-armed robot to the patient. The laparoscopic instruments are placed into the patient’s abdomen via ports similar to those used for conventional laparoscopic surgery with modifications to allow interaction with the arms. The instruments and camera allow the operating surgeon to control many aspects of the operation, including camera focus, zoom, image horizon, and the multiple functions of instrument use, including electrocautery and bipolar dissection, grasping, ultrasound dissection, and cutting.
The instruments allow determination of grasp pressure, secure holding of needles/sutures. 3D images make it ever more simple, allowing depth perception and a more realistic view of abdominal or thoracic organs. Camera focus, horizon, tilt are controlled with a foot pedal (welcome to the MT world, surgeons). The torque and stress are factors on a human surgeon, but not on the machine and have no tremors (another human characteristic).
Applications include use in the military, remote locations, space travel, to name a few. Everyone involved in medical care, the surgeons, nurses, anesthesiologists, transcriptionists, and medical record-keepers will see changes as robotics become more commonplace. How this technology will change our vocabulary, descriptions, and use of tools and techniques to cure diseases is what makes robotics exciting and future endless possibilities.
The next level is interactive monitors for intraoperation surgical consultation. The remote surgeon can assist the operating surgeon via live feed, seeing the operation as it occurs, answering questions, drawing diagrams, discussing anatomy, problems, etc.
Technology promises many improvements for medical care. Although laws and ethics must often stride to keep pace, the exponential growth of these devices will continue to benefit increasing numbers of patients in the future.
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