The era of "laptop" surgery has begun.
In a medical milestone that will eventually move major surgery beyond the
operating room and into areas all around the world, French and U.S. scientists
performed a trans-oceanic operation completely by remote control.
Surgeon's Long Arms
A surgical team operating at a console in New York sent instructions to a set
of robotic arms that removed the gallbladder of a patient across the Atlantic
in Strasbourg, France.
The operating surgeons were in New York, the patient in Strasbourg, France.
Through a high-quality telecommunications circuit, the doctors in New York
guided the movements of a three-armed robot in Strasbourg-about 6,230
kilometers (3,870 miles) away-that removed the gallbladder of a 68-year-old
One of the robotic arms held a camera probe like those now used in many common
medical procedures to examine internal areas of the body and guide surgery on
internal organs-a technique known as laparoscopy. The other two arms wielded
the surgical instruments.
Other surgeons stood by in Strasbourg to make sure the operation went
smoothly. The procedure, which was done September 7, took 54 minutes. The
patient recovered without complications and went home two days later,
according to the medical team.
The researchers announced the successful results at a news conference
Wednesday in Paris. A report on the pioneering operation will be published in
the September 27 issue of Nature, but the journal posted the information early
on its Web site.
Although it will take many years before the technology is commercially
available, the researchers say it opens the way to an era of fully
interconnected medicine and surgery without borders.
"It's a gallbladder operation today, but in the future it could be any kind of
medical procedure," said team member Michael Gagner, chief of the Department
of Laparascopic Surgery at Mount Sinai Medical Center in New York.
Along with Jacques Marescaux of the University of Strasbourg and the IRCAD
European Institute of Telesurgery, Gagner was at the console in New York where
the surgeons transmitted instructions to the robot.
"As the technology evolves and becomes available, and wiring is more
widespread, it will be useful for telementoring, teaching, and performing rare
surgery that requires different expertise," Gagner added. "A smaller city
could have the help of an expert surgeon just by being connected."
As the technology becomes portable, it should also be possible to perform
complex surgery even at remote disaster sites and battlefields, when response
time is critical, and in developing countries that have few or no surgeons,
the researchers say.
"The idea of telecollaborative surgery is hugely important because of the
tremendous positive societal impact," said Yulun Wang, the founder and chief
technical officer of Computer Motion Inc. in Goleta, California.
Computer Motion developed the robotic system-called ZEUS-that was used in the
trans-Atlantic operation. FranceTelecom/Equant was also a partner in the
project, responsible for ensuring the transfer of information via a high-speed
Tool, Not "Smart" Machine
Robotics and long-distance "telesurgery" are increasingly being used to give
surgeons a helping hand in the operating room, especially for unusually
complex procedures or those that require greater dexterity. But the
trans-Atlantic surgery is the first time a robot has held the surgical
instruments and done a complete operation.
The surgical robot is not a "smart" machine, guided by artificial
intelligence, but only a tool, the researchers emphasized. "All judgments and
movements must be done by surgeons," Gagner said. "The robots were doing
exactly what we told them to do from here in New York."
Two surgeons were by the patient's side in Strasbourg to intervene if there
were complications. One had his foot on an emergency pedal, said Steven
Butner, a professor of electrical and computer engineering at the University
of California-Santa Barbara who helped Wang and others at Computer Motion
design the robotic system. "If he took his foot off the pedal, the robot would
freeze and he could take over," Butner said.
The trans-Atlantic surgery was done after nearly two years of work to refine
ZEUS, overcome technical limitations, and get approval from oversight agencies
in France and the United States to use the remote robot to operate on a human
So far the technology is allowed only for investigational use. The medical
team obtained the patient's consent and also had to acquire the go-ahead from
an ethical committee that reviewed the proposed procedure.
Gagner said a gallbladder operation was chosen as the first test procedure
because it's a "landmark" step in training doctors to perform laparascopic
surgery. "When trained in laparascopy, it's usually the first procedure
doctors do because on average it's a relatively simple operation," he said.
"It involves removing tissue only, not reconstructing."
One of the most important issues the engineers had to address was a time lag
in the transmission of signals from the surgeon's console to the operating
room and back-a problem known as latency.
This latency, or delayed response, is critically important in remote surgery,
Butner noted, because the operating physicians are able to use only vision to
guide their movements. They lack an advantage we have in performing most
physical tasks when we rely in part on sensations to guide our
actions-applying a bolt, for example, and knowing from a sense of touch when
it's tight enough.
Any electronic signal entails some delay in transmission of the data and
conversion into a form that's readable to the recipients. The researchers had
to determine how much of a delayed response surgeons could tolerate and still
do a remote operation effectively. "We needed to minimize the time lag so the
surgeon sees the motion of the robot with minimal latency," Butner said.
Data travelling between the two locations made a round trip of more than
To determine the acceptable threshold of latency, the researchers artificially
altered the time lag of the operations between New York and Strasbourg as
surgeons used the robotic technology to remove the gallbladders of several
"From those experiments we found that surgeons had great confidence in the
procedure, the robots ran well. So we wanted to test the procedure in a human
operation," Butner said.
The time required for the transfer and video-coding of data meant that
movements executed by the operating surgeon in New York were visible to him on
his video screen 155 milliseconds later. That delay beat the estimated safe
lag time of 330 milliseconds.
Laparoscopy revolutionized the field of medicine over the past decade. It's
now widely used for many common surgical procedures, such as treating colon,
prostate, and fertility problems.
The technique is popular because it's minimally invasive, usually requiring
only a small incision through which to insert a camera scope and surgical
According to Wang, flexible fiber-optic scopes are typically used to examine
or treat ailments of organs such as the throat and colon. For thoracic and
abdominal procedures, in which body cavities are larger and surgeons have more
room to manipulate tools, the scopes are often rigid and use fixed lenses to
transmit light. A rigid scope with lenses, which is used in the ZEUS robot,
has the advantage of producing higher-resolution images than are possible with
Further improving the quality of surgical treatment today is the power and
precision of robotics.
"Robots enhance the capability of surgeons by enabling them to do procedures
more evenly and precisely," said Butner. Robots can be programmed to perform
micro-motions such as making sutures that are much smaller than those of human
surgeons and filtering out inherent human tremors for "rock-steady movement,"
he pointed out.
Moreover, automation enables surgeons to do more complicated and intricate
procedures, Gagner said. "Robots will work beautifully at different angles,
locations, and cavities where it may be difficult for human surgeons to
maneuver or work without becoming fatigued," he explained.
The trans-oceanic gallbladder operation sets the stage for the next level of
sophistication in laparoscopic surgery. "This is very much the leading edge of
minimally invasive surgery," said Butner.
Until now, long-distance surgical assistance has been limited mainly to
"telemonitoring," the researchers say. And only parts of the surgical process
have been automated.
"In the past, a remote surgeon has been able to collaborate with an on-site
surgeon, consulting with that [operating] surgeon and providing assistance
such as guiding the camera," said Wang. "But this is the first time a complete
remote telesurgical operation has been done."
Wang and his collaborators are especially hopeful that the new technology will
help raise health standards around the world and make medical expertise more
"This could be especially important in Third World countries where there are
no surgeons or very few," said Gagner. "We could have surgeons donating their
time operating in other countries."
To overcome the lack of sufficient cable connections, he suggested, it may be
possible in the future to send signals by satellite or microwave. And once the
technology is portable enough to be transported by boat or plane, nurses and
physicians in other regions of the world could be trained to position the
Said Gagner: "It will be a kind of laptop technology in the future."
--- --- --- --- ---
Useless hypotheses, etc.:
consciousness, phlogiston, philosophy, vitalism, mind, free will, qualia,
analog computing, cultural relativism, GAC, Cyc, Eliza, cryonics, individual
uniqueness, ego, human values, scientific relinquishment
We move into a better future in proportion as science displaces superstition.
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