Surgery Spans Miles of Ocean, Wires
A French American team has performed the first long-distance robotic surgery, with surgeons in New York City removing the gallbladder of a 68-year-old woman in Strasbourg.
Although robotic surgery is now commonplace in at least 100 hospitals around the world, the successful 45-minute operation proves the feasibility of using it over long distances, opening the possibility of operations in the space station, at the poles, on battlefields and in Third World countries.
“The barriers of space and distance have collapsed,” said Dr. Jacques Marescaux, one of the surgeons who performed the operation. Using the new technique, “any surgeon could feasibly take part in any operation anywhere in the world.”
Many researchers had questioned whether the transmission time for the long-distance signal could be kept short enough--less than about a fifth of a second--that surgeons would not be plagued by a lag in the robot’s operation that could potentially endanger the patient.
A fifth of a second may not seem like much, but it is “enough to be noticed by surgeons,” said Dr. Michel Gagner of the Mount Sinai Medical Center in New York, who also sat at the controls. “You can have bleeding during that time or an instrument touching the wrong organ.”
Using a special fiber-optic communication system owned by France Telecom and a surgical robot produced by Computer Motion Inc. of Santa Barbara, he said, the team was able to achieve a delay of only 80 milliseconds each way, meaning that the surgeon could see the results of his commands to the robot within 160 milliseconds.
That’s a “huge advance,” said Dr. Thomas Jarrett of the Johns Hopkins University Medical School, who had previously assisted remotely on a kidney operation performed in Rome.
The surgery was performed Sept. 7. The patient, whose name has not been revealed, was fully informed about the nature of the procedure beforehand and readily agreed, said Marescaux, who is at the Research Institute Against Cancers of the Digestive Tract in Strasbourg. The operation went smoothly and the woman was released 48 hours later, he said.
The details of the procedure will be published in the Sept. 27 issue of Nature and are available at https://https://www.nature.com.
The procedure takes advantage of two recent developments in medicine--laparoscopic surgery, a minimally invasive technique first used in 1988, and robotic surgery, which was first used in 1996.
In laparoscopic surgery, medical procedures are carried out by inserting thin instruments and a television camera through three small openings in the abdomen, eliminating the need to crack open the chest. The chief advantage of the procedure is the sharply reduced recovery time for the patients. There is also less bleeding and diminished pain.
Minimally invasive surgery is widely used for heart bypasses, gallbladder removal and a host of other procedures. The research institute team chose gallbladder removal, known as cholecystectomy, for its first attempt because minimally invasive surgery is now the “gold standard” for the procedure, Gagner said.
Robotic surgery is, in effect, an extension of minimally invasive techniques. But in this case, the “hands” at the end of the surgical instruments are robotic motors operated by the surgeon from a control panel.
The two major systems are made by Computer Motion and Intuitive Surgical Inc. of Mountain View. Intuitive’s Da Vinci system is approved for use in the United States and Europe. Computer Motion’s ZEUS system is approved in Europe and approval is pending in this country.
The systems have several advantages over conventional surgery. A computer program filters out the hand tremors that a surgeon can develop during a long operation. Another program scales down a surgeon’s motions, so that a 2-inch motion of his hand becomes an 0.2-inch movement inside the patient’s body. The television camera gives a 25-fold enlargement of the view, compared to the two- or three-fold increase provided by surgeon’s glasses.
And the surgeon sits during the procedure, minimizing fatigue.
The trick in performing trans-Atlantic surgery was minimizing time lag, said Tom Wyrick of France Telecom, which partially underwrote the $1-million cost of the experimental project. The system had to provide a continuous transmission of 10 megabits per second, he said, a dataflow that is comparable to that used in factory automation and other commercial processes.
The experiment used existing fiber-optic cables that now connect 45 countries, he added, and would support the operation being performed in most of them.
To test the system, the team performed a cholecystectomy six times on pigs over the last year, with the surgeons in New York each time and the pigs in France. Each test was completely successful, convincing them to go ahead with the human procedure.
The team will continue to experiment with the system and make it available to other researchers, Gagner said. “We don’t know how big a delay can be tolerated--up to which point it is acceptable to operate,” he added. “We don’t know what is the maximum distance we can use.”
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Trans-Atlantic Surgery
