REMOTE SURGERY

Introduction
Remote surgery (also known as telesurgery) is the ability for a doctor to perform surgery on a patient even though they are not physically in the same location. It is a form of telepresence. 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. Remote surgery combines elements of robotics, cutting edge communication technology such as highspeed data connections and elements of management information systems. While the field of robotic surgery is fairly well established, most of these robots are controlled by surgeons at the location of the surgery. Remote surgery is essentially advanced telecommuting for surgeons, where the physical distance between the surgeon and the patient is immaterial. 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 systems have been developed from the first functional telesurgery system-ZEUS-to the da Vinci Surgical System, 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 Engeenering 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, 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 years worth of ATM technology which runs between $100,000-$200,000.

The Lindbergh Operation One of the earliest remote surgeries was conducted on 7 September 2001 across the Atlantic Ocean, with a surgeon (Dr. Jacques Marescaux) in New York performing a cholecystectomy on a 68-year-old female patient 6,230 km away in Strasbourg, France named Operation Lindbergh. That operation, called Project Lindbergh after Charles Lindberghs pioneering transatlantic flightfrom New York to Paris, was conducted over a dedicated fiberoptic link to ensure guaranteed connectivity and minimal lag.

Technology The speed of remote surgery is made possible through ATM technology, or Asynchronous Transfer Mode. Asynchronous Transfer Mode is a technology designed for the high-speed transfer of voice, video, and data through public and private networks using cell relay technology. Cell relay technology is the method of using small fixed length packets or cells to transfer data between computers or network equipment and determines the

speed at which information is transferred. ATM technology has a maximum speed of 10 Gbit/s (Gigabits per second). This developed technology provides opportunities for more transatlantic surgeries similar to the Operation Lindbergh. During a surgery, the robot arm can use a different angle during a laparoscopic surgery than a tool in the surgeons hand, providing easier movement. The da Vinci Surgical System, using "Endowrist" instruments, allows the surgeon seven degrees of rotation and a range of motion far greater than the human hand while filtering out the hands natural tremor.

Applications Since Operation Lindbergh, remote surgery has been conducted many times in numerous locations. To date Dr. Anvari, a laparoscopic surgeon in Hamilton, Canada, has conducted numerous remote surgeries on patients in North Bay, a city 400 kilometres from Hamilton. Even though he uses a VPN over a non-dedicated fiberoptic connection that shares bandwidth 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 Centre at Mt. Sinai Hospital in Toronto, Canada, the surgical room responds to the surgeons voice commands in order to control a variety of equipment at the surgical site, including the lighting 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 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, teleoperation, and telerobotics 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 Guys Hospital in London, England compared the success of kidney 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 stones.

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, anItalian surgeon, has developed a software program that uses data collected from several surgeons and thousands of operations to perform the surgery without human intervention.[10] 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, 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 was actually the patients body.[8][11] 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 make 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. Also, there is still the need for an anesthesiologist 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.