Topic 2

Data transferring. Network technologies.

Telemedicine basics. Information resource for
Healthcare.
Part 2
Telemedicine Basics
Telemedicine Basics.............................................................................................................................1
Telemedicine ........................................................................................................................................2
Types of telemedicine ......................................................................................................................2
Teleradiology ...............................................................................................................................3
Telemedicine Systems......................................................................................................................3
Startup level Telemedicine System ..............................................................................................3
Medium level Telemedicine System ............................................................................................3
High-end level Telemedicine System ..........................................................................................3
Typical Telemedicine System Components.....................................................................................3
"T-Cart" Rollabout Telemedicine Cabinet.......................................................................................5
Portable Telemedicine Stations........................................................................................................6
"B.O.B." Big Orange Box ............................................................................................................6
DELTASS - emergency telemedicine system for critical situations............................................8
Other portable telemedicine stations............................................................................................8
Telehealth .............................................................................................................................................9
Clinical uses of telehealth technologies .....................................................................................10
Nonclinical uses of telehealth technologies ...............................................................................10
Telehealth modes............................................................................................................................10
Store-and-forward telehealth......................................................................................................10
Real-time telehealth ...................................................................................................................10
Remote monitoring.....................................................................................................................11
Benefits of telehealth......................................................................................................................11
eHealth ...............................................................................................................................................11
Definitions......................................................................................................................................11
Robotic surgery ..................................................................................................................................12
History............................................................................................................................................12
Applications ...................................................................................................................................12
Cardiac surgery ..........................................................................................................................12
Gastrointestinal surgery .............................................................................................................13
Gynecology ................................................................................................................................13
Neurosurgery..............................................................................................................................13
Orthopedics ................................................................................................................................13
Pediatrics ....................................................................................................................................13
Urology.......................................................................................................................................13
Limitations .....................................................................................................................................13
Miniature robotics ..........................................................................................................................13
Da Vinci Surgical System ..................................................................................................................14
NeuroArm...........................................................................................................................................14
History............................................................................................................................................14
ARTEMIS ..........................................................................................................................................15
The Work System...........................................................................................................................15
User Interface System ....................................................................................................................15

1
Telemedicine
Telemedicine is a rapidly developing application of clinical medicine where medical
information is transferred via telephone, the Internet or other networks for the purpose of
consulting, and sometimes remote medical procedures or examinations.
Telemedicine may be as simple as two health professionals discussing a case over the
telephone, or as complex as using satellite technology and video-conferencing equipment to
conduct a real-time consultation between medical specialists in two different countries.
Telemedicine generally refers to the use of communications and information technologies for the
delivery of clinical care.
Care at a distance (also called in absentia care), is an old practice which was often
conducted via post; there has been a long and successful history of in absentia health care, which -
thanks to modern communication technology - has metamorphosed into what we know as modern
telemedicine.
In its early manifestations, African villagers used smoke signals to warn people to stay away
from the village in case of serious disease. In the early 1900s, people living in remote areas in
Australia used two-way radios, powered by a dynamo driven by a set of bicycle pedals, to
communicate with the Royal Flying Doctor Service of Australia.
The terms e-health and telehealth are at times wrongly interchanged with telemedicine. Like
the terms "medicine" and "health care", telemedicine often refers only to the provision of clinical
services while the term telehealth can refer to clinical and non-clinical services such as medical
education, administration, and research. The term e-health is often, particularly in the UK and
Europe, used as an umbrella term that includes telehealth, electronic medical records, and other
components of health IT.

Types of telemedicine
Telemedicine is practiced on the basis of two concepts: real time (synchronous) and store-
and-forward (asynchronous).
Real time telemedicine could be as simple as a telephone call or as complex as robotic
surgery. It requires the presence of both parties at the same time and a communications link
between them that allows a real-time interaction to take place. Video-conferencing equipment is
one of the most common forms of technologies used in synchronous telemedicine. There are also
peripheral devices which can be attached to computers or the video-conferencing equipment which
can aid in an interactive examination. For instance, a tele-otoscope allows a remote physician to
'see' inside a patient's ear; a tele-stethoscope allows the consulting remote physician to hear the
patient's heartbeat. Medical specialties conducive to this kind of consultation include psychiatry,
family practice, internal medicine, rehabilitation, cardiology, pediatrics, obstetrics and gynecology
and neurology.
Store-and-forward telemedicine involves acquiring medical data (like medical images,
biosignals etc) and then transmitting this data to a doctor or medical specialist at a convenient time
for assessment offline. It does not require the presence of both parties at the same time.
Dermatology, radiology, and pathology are common specialties that are conducive to asynchronous
telemedicine. A properly structured Medical Record preferably in electronic form should be a
component of this transfer.
Telemedicine is most beneficial for populations living in isolated communities and remote
regions and is currently being applied in virtually all medical domains. Specialties that use
telemedicine often use a "tele-" prefix; for example, telemedicine as applied by radiologists is
called Teleradiology. Similarly telemedicine as applied by cardiologists is termed as telecardiology,
etc.
Telemedicine is also useful as a communication tool between a general practitioner and a
specialist available at a remote location.
The focus of telemedicine has mainly been consultative, meaning a general practitioner
consulting a specialist or a specialist consulting another specialist. Monitoring a patient at home
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using known devices like blood pressure monitors and transferring the information to a caregiver is
a fast growing emerging service. These remote monitoring solutions have a focus on current high
morbidity chronic diseases and are mainly deployed for the First World. In developing countries a
new way of practicing telemedicine is emerging better known as Primary Remote Diagnostic Visits
whereby a doctor uses devices to remotely examine and treat a patient. This new technology and
principle of practicing medicine holds big promises to solving major health care delivery problems
in for instance Southern Africa because Primary Remote Diagnostic Consultations not only
monitors an already diagnosed chronic disease, but has the promise to diagnosing and managing the
diseases a patient will typically visit a general practitioner for.

Teleradiology
Teleradiology is the ability to send radiographic images (x-rays) from one location to
another. For this process to be implemented, three essential components are required, an image
sending station, a transmission network, and a receiving / image review station. The most typical
implementation are two computers connected via Internet. The computer at the receiving end will
need to have a high-quality display screen that has been tested and cleared for clinical purposes.
Sometimes the receiving computer will have a printer so that images can be printed for
convenience.
The teleradiology process begins at the image sending station. The radiographic image and a
modem or other connection are required for this first step. The image is scanned and then sent via
the network connection to the receiving computer.

Telemedicine Systems

Startup level Telemedicine System

• To connect patient end data from small hospital to a Super Specialty hospital for
consultation through Videoconference.
• The diagnostic equipments will be at Patient end only.

Medium level Telemedicine System

• To connect patient end data from small hospital to a Super Specialty hospital for
consultation through Videoconference.
• The Super Specialty hospital will have only one telemedicine center for teleconferencing
and equipped with its own diagnostic equipment for referrals to other Consultants.

High-end level Telemedicine System

• Each Department of Super Specialty Hospital is interconnected through LAN for
telemedicine.
• Capture and transfer of patient data using high-speed network.
• Store the patient data of all the departments at one place and retrieve the data from
multiple locations of the network.
• Each specialist doctor can access the patient data and treat from his place.
• Super Specialty hospital provides consultancy to smaller hospitals through
Videoconferencing.

Typical Telemedicine System Components

Telemedicine system includes:
• Imaging Work-station
• Video conferencing equipment
• Digital scanner for X-ray / films and reports
• ECG machine
• Ultra Sound / Endoscopy equipment
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 • Any other diagnostic equipment for telemedicine system
• Communication Interface Modules.
• Communication network like VSAT, ISDN, PSTN, WAN and LAN

Figure 1. Typical Telemedicine System Components

An example of the PC-based Telemedicine Workstation shown on the picture (Figure 1)
and include:
Workstation with integrated videoconferencing system and medical record
allows physician to view patients live and update patient record
Computer
simultaneously. Also, Stethoscope over IP software allows sending of heart
and breath sounds to remote physician specialist
Pan/Tilt/Zoom Remote control mechanism allows physician to remotely move camera to
Camera desired shot
Document
To allow documents, x-ray images, books, etc to be shown in a video format
Camera

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Facsimile Machine For hardcopy document exchange
Medical Camera
For viewing telemedicine patient areas not accessible with regular cameras.
System
Microphone(s) For picking up audio from patient for interaction with physician.
Slitlamp Medical camera attachment that allows viewing of the surface of the eye.
Stethoscope Runs over POTS phone lines via modem.
Telephone Typically cordless for access to room.
Video Cassette Recorder - for either playback of tapes for educational
VCR
purposes or recording videoconferences
Wireless
For operation of PC
Keyboard

"T-Cart" Rollabout Telemedicine Cabinet

Requests for smaller and lighter telemedicine systems has led to the creation of a roll-around
patient cabinet. When fully equipped, the cabinet is a full telemedicine system, with medical
instrumentation and a versatile configuration to allow the system to be used in a number of
environments with different pieces of equipment. Features:
The overall cabinet is aluminum construction with stainless-steel accessories.
The bottom cabinet features dual-locking doors on the front. Opening the cabinets reveals a
lower shelf for a PC/CODEC combination as well as UPS and a medically approved isolation
transformer. An upper shelf is provided for a VCR and a subwoofer/amplifier combination for the
audio. Full venting along the entire bottom cabinet is provided for proper cooling of electronic
components. The rear section of the bottom cabinet is covered by a locking door that comes off
allowing full access to the rear of all electronics in the cabinet. There is also a cable wrap stanchion
for the electrical cable and network wires.
Above the bottom cabinet is a pullout drawer for the keyboard and microphone storage. The
unit front folds down allowing access to the keyboard. This drawer is lockable as well.
Above the keyboard drawer is a stainless steel shelf that has a triple articulating arm with
the LCD monitor and camera mounted on it. This allows the monitor/camera combination to be
swung out, up, down, tilted left or right, up or down for maximum viewing by both the local patient
and the far-end consultant.
On the left hand side of the cabinet, above the stainless steel shelf, is a small patch-panel
allowing auxiliary video, audio and data connections to be easily accessed.
The top cabinet features two shelves and a single lockable cabinet door located on the right
side of the unit. Medical instrumentation may be placed on these shelves for easy access. Wiring
access holes are present for running audio, video, and power.
The left side of the top has two stainless steel handles for steering the unit as it is being
rolled around.

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 Figure 2. "T-Cart" Rollabout Telemedicine Cabinet

Portable Telemedicine Stations

"B.O.B." Big Orange Box

BOB is based on the idea that in order to put telemedicine in certain remote environments, a
heavy-duty system was necessary. Something in a strong box, cushioned, with all medical
instrumentation ready-to-go without having to have an engineer present to operate it.
BOB is an acronym for Big Orange Box. The box is a heavy-duty container for containing
the electronics associated with a telemedicine system. A look inside reveals a fully shock-mounted
EIA Rack configuration for holding the electronics (Figure 9, Figure 10).
Bob is available with the following equipment:
• Monitor/Keyboard Assembly
• Computer
6
 • VideoConferencing system with ISDN/IP networking
• Pan/Tilt/Zoom Camera
• Stethoscope
• Medical Camera
BOB is a fully integrated system. Open up the case, pull out the instruments, plug into a
network and plug in the power and you are ready to contact UTMB with any medical problems for
remote diagnosis and treatment.

Figure 3. "B.O.B." front side

Figure 4. "B.O.B." rear side

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DELTASS - emergency telemedicine system for critical situations
DELTASS (Figure 5) is designed to improve the efficiency of the management of rescue,
first aid and emergency operations in Disaster Telemedicine contexts such as earthquakes or
explosions.
In such situations, the existing terrestrial infrastructures could be damaged. Remote medical
expertise and fast deployment of the management of the logistic and medical means are also
required. Satellite systems can effectively complement partly destroyed terrestrial infrastructures to
meet the requirements of emergency healthcare services.
Using satellite networks the DELTASS system enables the mobile users such as paramedics
to co-ordinate their activities and to generate and transmit localization and medical data directly
from the disaster fields to a co-ordination centre using specially adapted equipment.

Figure 5. DELTASS - emergency telemedicine system for critical situations

Other portable telemedicine stations

Telemedicine Portable Station equipment is designed to monitor key medical data: ECG,
blood pressure (measured on the wrist - radial artery), pulse oxymetry (02 saturation of blood
measured on the finger). Data are recorded on the computer and transmitted to the remote clinic to
get a second medical advice (Figure 7, Figure 8).

8
 Figure 6. Use of the electronic stethoscope and of the wrist-worn automatic blood pressure
recorder

Figure 7. Installation of the equipment of the Telemedicine Portable Station on patient

Telehealth
Telehealth is the delivery of health-related services and information via
telecommunications technologies. Telehealth delivery could be as simple as two health
9
professionals discussing a case over the telephone, or as sophisticated as using videoconferencing
to between providers at facilities in two countries, or even as complex as robotic technology.
Telehealth is an expansion of telemedicine, and unlike telemedicine (which more narrowly
focuses on the curative aspect) it encompasses preventive, promotive and curative aspects.
Originally used to describe administrative or educational functions related to telemedicine, today
telehealth stresses a myriad of technology solutions. For example, physicians use email to
communicate with patients, order drug prescriptions and provide other health services.

Clinical uses of telehealth technologies

• Transmission of medical images for diagnosis (often referred to as store and forward
telehealth)
• Groups or individuals exchanging health services or education live via videoconference
(real-time telehealth)
• Transmission of medical data for diagnosis or disease management (sometimes referred
to as remote monitoring)
• Advice on prevention of diseases and promotion of good health by patient monitoring
and followup.
• Health advice by telephone in emergent cases(referred to as teletriage)

Nonclinical uses of telehealth technologies

• Distance education including continuing medical education, grand rounds, and patient
education
• Administrative uses including meetings among telehealth networks, supervision, and
presentations
• Research
• Online information and health data management
• heathcare system integration
• asset identification, listing, and patient to asset matching, and movement
• overall healtcare system management
• patient movement and remote admission

Telehealth modes

Store-and-forward telehealth
In store-and-forward telehealth, digital images, video, audio and clinical data are captured
and "stored" on the client computer; then at a convenient time transmitted securely ("forwarded") to
a clinic at another location where they are studied by relevant specialists. The opinion of the
specialist is then transmitted back. Based on the requirements of the participating healthcare
entities, this roundtrip could take between 2 to 48 hours. In many store-and-forward specialties,
such as teleradiology, an immediate response is not critical. Dermatology, radiology and pathology
are common specialties that are conducive to store-and-forward technologies.

Real-time telehealth
In real-time telehealth, a telecommunications link allows instantaneous interaction. Video-
conferencing equipment is one of the most common forms of synchronous telemedicine. Peripheral
devices can also be attached to computers or the video-conferencing equipment which can aid in an
interactive examination. With the availability of better and cheaper communication channels, direct
two-way audio and video streaming between centers through computers is leading to lower costs.
Examples of real-time clinical telehealth include"
• Telemental health -- the use of videoconferencing technology to connect a psychiatrist
with a mental health client
• Telerehabilitation
10
 • Telecardiology
• Teleneurology
• Telenursing
• Teleradiology

Remote monitoring
In remote monitoring, sensors are used to capture and transmit biometric data. For example,
a tele-eeg device monitors the electrical activity of a patients brain and then transmits that data to a
specialist. This could be done in either real time or the data could be stored and then forwarded.
Examples of remote monitoring include:
• Home-based nocturnal dialysis
• Cardiac and multi-parameter monitoring of remote ICUs
• Home telehealth
• Disease management

Benefits of telehealth
Telehealth benefits patients in countries where traditional delivery of health services are
affected by distance and lack of local specialist clinicians to deliver services. The rate of adoption
of telehealth services in any jurisdiction is frequently influenced by factors such as the adequacy
and cost of existing conventional health services in meeting patient needs; the policies of
governments and/or insurers with respect to coverage and payment for telehealth services; and
medical licensing requirements that may inhibit or deter the provision of telehealth second opinions
or primary consultations by physicians.

eHealth
eHealth (also written e-health) is a relatively recent term for healthcare practice which is
supported by electronic processes and communication. The term is inconsistently used: some would
argue it is interchangeable with health care informatics, while others use it in the narrower sense of
healthcare practice using the Internet. The term can encompass a range of services that are at the
edge of medicine/healthcare and information technology:
• Electronic Medical Records: enable easy communication of patient data between
different healthcare professionals (GPs, specialists, care team, pharmacy)
• Telemedicine: includes all types of physical and psychological measurements that do
not require a patient to travel to a specialist. When this service works, patients need to
travel less to a specialist or conversely the specialist has a larger catchment area.
• Evidence Based Medicine: entails a system that provides information on appropriate
treatment under certain patient conditions. A healthcare professional can look up
whether his/her diagnosis is in line with scientific research. The advantage is that the
data can be kept up-to-date.
• Consumer Health Informatics (or citizen-oriented information provision): both healthy
individuals and patients want to be informed on medical topics.
• Health knowledge management (or specialist-oriented information provision): e.g. in
an overview of latest medical journals, best practice guidelines or epidemiological
tracking.
• Virtual healthcare teams: consist of healthcare professionals who collaborate and share
information on patients through digital equipment (for transmural care).
• Medical research uses eHealth Grids that provide powerful computing and data
management capabilities to handle large amounts of heterogenous data.

Definitions

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 A seminal 2001 definition published in the article What is e-health? J Med Internet Res
2001;3(2):e20, by eHealth researcher Gunther Eysenbach is among the most frequently cited and
reads:
e-health is an emerging field in the intersection of medical informatics, public health and
business, referring to health services and information delivered or enhanced through the
Internet and related technologies. In a broader sense, the term characterizes not only a technical
development, but also a state-of-mind, a way of thinking, an attitude, and a commitment for
networked, global thinking, to improve health care locally, regionally, and worldwide by using
information and communication technology.
EU ICTs for Health: eHealth describes the application of information and
communications technologies across the whole range of functions that affect the health sector,
from the doctor to the hospital manager, via nurses, data processing specialists, social security
administrators and - of course - the patients.

Robotic surgery
Robotic surgery is the use of robots in performing surgery. Three major advances aided by
surgical robots have been remote surgery, minimally invasive surgery and unmanned surgery.
Major potential advantages of robotic surgery are precision and miniaturization. Further advantages
are articulation beyond normal manipulation and three-dimensional magnification.

History
In 1985 a robot, the PUMA 560, was used to place a needle for a brain biopsy using CT
guidance. In 1988, the PROBOT, developed at Imperial College London, was used to perform
prostatic surgery. The ROBODOC from Integrated Surgical Systems was introduced in 1992 to mill
out precise fittings in the femur for hip replacement. Further development of robotic systems was
carried out by Intuitive Surgical with the introduction of the da Vinci Surgical System and
Computer Motion with the AESOP and the ZEUS robotic surgical system.
The da Vinci Surgical System is comprised of three components: a surgeon’s console, a
patient-side robotic cart with 2 arms manipulated by the surgeon, and a high-definition 3D vision
system in connection with a camera introduced into the body by a voice-controlled third arm on the
robotic cart. Articulating surgical instruments are mounted on the robotic arms which are
introduced into the body through cannulas. The surgeon’s hand movements are scaled and filtered
to eliminate hand tremor then translated into micro-movements of the proprietary instruments. The
da Vinci System is FDA cleared for a variety of surgical procedures including surgery for prostate
cancer, hysterectomy and mitral valve repair and used in more than 800 hospitals in the Americas
and Europe. The da Vinci System was used in 48,000 procedures in 2006 and sells for about $1.2
million.
• In 1997 a reconnection of the fallopian tubes operation was performed successfully in
Cleavland using ZEUS.
• In May 1998, Dr. Friedrich-Wilhelm Mohr using the Da Vinci surgical robot performed
the first robotically assisted heart bypass at the Leipzig Heart Centre in Germany.
• In October 1999 the world's first surgical robotics beating heart coronary artery bypass
graft (CABG) was performed in Canada using the ZEUS surgical robot.
• In 2001, Prof. Marescaux used the Zeus robot to perform a cholecystectomy on a pig in
Strasbourg, France while in New York.
• The first unmanned robotic surgery took place in May 2006 in Italy.

Applications

Cardiac surgery

12
 Endoscopic coronary artery bypass (TECAB) surgery and mitral valve replacement have
been performed. Totally closed chest, endoscopic mitral valve surgeries are being performed now
with the robot.

Gastrointestinal surgery
Multiple types of procedures have been performed with either the Zeus or da Vinci robot
systems, including bariatric surgery.

Gynecology
Reproductive surgery and ablative surgery including hysterectomy have been performed.

Neurosurgery
Several systems for stereotactic intervention are currently on the market. MD Robotic's
NeuroArm is the world’s first MRI-compatible surgical robot.

Orthopedics
The ROBODOC system was released in 1992 by the Integrated Surgical Systems, Inc.

Pediatrics
Surgical robotics has been used in many types of pediatric surgical procedures including:
tracheoesophageal fistula repair, cholecystectomy, nissen fundoplication, morgagni hernia repair,
kasai portoenterostomy, congenital diaphragmatic hernia repair, and others. On January 17, 2002,
surgeons at Children's Hospital of Michigan in Detroit performed the nation's first advanced
computer-assisted robot-enhanced surgical procedure at a children's hospital.

Urology
The da Vinci robot is commonly used to remove the prostate gland for cancer, repair
obstructed kidneys, repair bladder abnormalities and removed diseased kidneys.

Limitations
Current equipment is expensive to obtain, maintain and operate. If one of the older model
non-autonomous robots is being used, surgeons and staff need special training. Data collection of
procedures and their outcomes remains limited.

Miniature robotics
As scientists seek to improve the versatility and utility of robotics in surgery, some are
attempting to miniaturize the robots. For example, the University of Nebraska Medical Center has
led a multi-campus effort to provide collaborative research on mini-robotics among surgeons,
engineers and computer scientists.

13
Da Vinci Surgical System

Figure 8. Patient-side cart of the da Vinci surgical system

The da Vinci surgical system (Figure 8) made by Intuitive Surgical is a robotic surgical
system. It is most commonly used for prostatectomies and cardiac valve replacement operations, but
can be used for any abdominal or thoracic operation. It has three robotic arms, two of them are for
holding objects and the other for a camera. Instead of a robotic scappel, the end of the arm heats up
when it is grabbing "something variable" and the surgeron twists a control, making that "something
variable" become weak, then the arm moves to apply pressure on "something variable" making it
break.

NeuroArm
NeuroArm, the world’s first MRI-compatible surgical robot, was engineered using plastics,
titanium and other non-magnetic materials. NeuroArm is a tool that aims to revolutionize
neurosurgery and other branches of operative medicine by reducing the constraints of the human
hand while maintaining the tactile feedback important to the surgeons. The machine uses something
called "motion scaling" which allows the surgeon to be precise within 0.01 mm (compare to 2mm
by neurosurgeons with years of experience). With NeuroArm, experience neurosurgeons can join
together vessels that are much smaller.
When performing surgery, NeuroArm will be used in conjunction with the iMotion 1.5
Tesla Magnet. The iMotion magnet will move to the patient, "gliding in and out of place as needed,
without affecting surgical, anesthetic, and nursing management."
"Tests will be conducted on mannequins, cadavers and tissues to prove to Health Canada
and the U.S. Food and Drug Administration that it is safe for people. Officials hope neuroArm will
be used to treat its first patient this summer [2007]."

History
The $27-million NeuroArm project began in 2001 when the namesakes of the Seaman
Family MR Research Centre, Calgary philanthropists and brothers Doc, B.J. and Don Seaman
provided $2 million to begin planning neuroArm.

14
 NeuroArm is the creation of neurosurgeon Dr. Garnette Sutherland and his team. Dr.
Sutherland has spent six years leading a team of Canadian scientists, in cooperation with
MacDonald Dettwiler and Associates's MD Robotics division to design and build a machine “that
represents a milestone in medical technology.”
NeuroArm was unveiled on April 17, 2007 in Calgary.

ARTEMIS
The Work System
The work system of ARTEMIS is situated at the operating table and consists of
• the instrument guidance system (IGS) TISKA with integrated changeable instrument
• the endoscope guidance system (EGS) ROBOXwith 3D Video endoscope
IGS and EGS are telemanipulator systems, which can be controlled by the surgeon from the
input units within the user interface. In order to guarantee the incision point as an invariant point,
the systems are mechanically guided for safety reasons.
Since the IGS and the EGS communicate via the control system, instrument tracking is
possible as an option for EGS movement: the endoscope follows the instrument in such a way that
the instrument tip remains in the middle of the picture.
The figure (Figure 9) shows an artificial body (Pelvitrainer) with two IGSs TISKA and in
the middle the EGS ROBOX.

Figure 9. The ARTEMIS Work System

User Interface System

The user interface of ARTEMIS is an integrated MIS work place (MIS = minimally
invasive surgery), allowing the surgeon to handle the different instruments and units in an
ergonomical good position and to follow the surgery on video screens.
The different components currently are:
• Handling units for the instruments (Master):
o HIT-Master II: an input unit with a kinematic similar to the work unit TISKA;
o TeST: an input unit with weigth compensation, prepared for force reflection.
• Visual Information:
o 3D-Video picture of the surgical area (picture of the endoscope);
o Graphical user interface for system initialisation and control; Graphical simulation
(monitoring) with KISMET.
• Other input units:
o Voice input, eg. for endoscope guidance;
o Pedale, eg. for endoscope guidance or as substitute for a mouse;
o Mouse;
15
 o Keyboard.
The picture (Figure 10) shows the ARTEMIS user interface system with two identical HIT-
Master-II, and three video screens for the graphical user interface, the 3D video endoscope picture
and the simulation.

Figure 10. ARTEMIS User Interface System

16