Cyber Surgery : Computers, Cameras and Robots Are Creating an Improved Operating System for Doctors : Science File / An exploration of issues and trends affecting science, medicine and the environment

Col. Richard Satava has a vision--a virtual vision--for medicine. He sees it shifting its focus from blood and guts to bits and bytes.

Satava, program manager for advanced medical technologies at the Defense Department’s Advanced Research Projects Agency, has been a driving force in bringing virtual reality to medicine, where computers create a “virtual,” or simulated environment for surgeons and other medical practitioners.

His agency has poured millions of dollars into virtual reality research projects that defense officials hope portend medicine’s future on a military battlefield.

“With virtual reality we’ll be able to put a surgeon in every foxhole,” said Satava, a U.S. Army surgeon. He envisions a time when soldiers who are wounded fighting overseas are put in mobile surgical units equipped with computers.

The computers would transmit images of the soldiers to surgeons back in the United States. The surgeons would look at the soldier through virtual reality helmets that contain a small screen displaying the image of the wound and cover the eyes to block out the real world. The doctors would use their hands to guide robotic instruments in the battlefield mobile surgical unit that operate on the soldier.

Although Satava’s vision may be years away from standard operating procedure, scientists are progressing toward virtual reality surgery. Engineers at SRI International in Palo Alto are developing a tele-operating device.

As surgeons watch a three-dimensional image of the surgery, they move instruments that are connected to a computer, which passes their movements to robotic instruments that perform the surgery. The computer provides feedback to the surgeon on force, textures and sound.

Other engineers at the Massachusetts Institute of Technology in Boston and the Jet Propulsion Laboratory in Pasadena are working on instruments that scale down surgeons’ movements to improve their dexterity to a degree that would otherwise be impossible. With these instruments, doctors hope to operate on the tiny semicircular canals of the ear, on the surface of the eye’s retina and even hover over one spot so that heart surgeons can operate on beating hearts instead of being forced to stop them, designers say.

These technological wonders may not yet be part of the community hospital setting, but increasingly some of the machinery being designed for the military is finding its way into civilian medicine. Physicians have developed three-dimensional computer graphics to simulate flying through a colon to look for cancerous polyps. During endoscopic procedures--operations that are done through small incisions in the body in which a miniature camera and surgical tools are maneuvered--surgeons are wearing 3-D glasses for a better view. And they are commanding robot surgeons to cut away tissue more accurately than human surgeons can.

Endoscopic surgery has spread dramatically. Today, in the United States, 600,000 endoscopic gallbladder operations are performed annually, and the process is being used for a host of other operations, from sinus to urinary tract surgery.

The next step is often called “augmented” reality, in which people use some parts of virtual reality technology in a real-world environment. It brings together the separate elements of medical technology--endoscopic surgery, digital imaging, electronic databases and computer networking--”and the focal point is the video monitor at a physician’s workstation,” Satava said.

Although the imaging technology used before surgery requires no approval by the U.S. Food and Drug Administration, most of the new devices used as a part of a surgical procedure are undergoing clinical trials for FDA certification.

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In this country, the number of deaths caused by colorectal cancer is second only to those caused by lung cancer. Traditionally, physicians diagnose colorectal cancer by a cumbersome and uncomfortable procedure: inserting a camera lens at the end of a flexible tube into the rectum or colon to look for polyps.

In an effort to avoid this, Dr. David Vining, a radiologist at the Bowman Gray School of Medicine at Wake Forst University in Winston-Salem, N.C., has developed what he calls a “virtual colonoscopy.” This procedure uses a computer tomography (CT) scan that takes pictures much like a video camera instead of the snapshots provided by previous technology. Then Vining translates the computer data into a 3-D image, using the same Silicon Graphics computer software that created the dinosaurs in the movie “Jurassic Park.”

Similar three-dimensional images are also being used by surgeons to plan operations. At Wayne State University Medical School, neurosurgeon Lucia Zamorano takes images of the brain from state-of-the-art magnetic resonance and computer tomography scans and uses a computer program to produce a three-dimensional image. She can then maneuver the 3-D image on the computer screen to map the shortest, least invasive surgical path to the tumor.

Zamorano is also using technology that attaches a probe to surgical instruments so that she can track their positions. While excising a tumor deep in the brain, she watches the movement of her surgical tools in a computer graphics image of the patient’s brain taken before surgery. She has used this guided imaging technology in more than 600 operations for brain tumors and epilepsy, as well as brain tissue destruction procedures for pain patients, those afflicted with Parkinson’s disease and people with serious obsessive-compulsive disorders.

Some projects have begun taking the next step: using this technology in real-time procedures.

In Boston, at Brigham and Women’s Hospital, doctors have been doing endoscopic sinus surgery with a new magnetic resonance imaging machine.

To prevent stiff necks and maintain their focus on the patient, some endoscopic sinus surgeons at UC Irvine wear a head-mounted display. They watch the inside of their patient on tiny video screens mounted inside a light headpiece, and when they need to check the positioning of their instruments, they merely glance down at their hands.

“It’s a step along the way,” endoscopic surgeon Carol MacArthur said of the technology. She’s looking forward to a head-mounted display with a three-dimensional image.Other types of three-dimensional displays are also finding their way into the operating room. Surgeons in several U.S. hospitals are using 3-D glasses approved by the FDA during endoscopic surgery to watch the picture of the operation.

Satava says: “We are in the midst of a fundamental change in the field of medicine.”