With robotics, space is the limit for outpatient surgery in the future
Should you invest now or wait? Experts weigh in
Remote robot surgery on wounded soldiers on battlefields? Out-patient surgery on astronauts in space? These are the scenarios being batted about in the aftermath of a recent collaboration that allowed surgeons in New York City to use a robotic system to perform successful gallbladder removal on a woman 4,000 miles away in France. Recent technological advances allowed the procedure to be performed with virtually no lag time (an average delay of 150 milliseconds).
Such procedures could open the door for surgeons and their facilities to have unlimited geographic access to patients. Also, robotic devices are likely to contribute to the trend of inpatient procedures moving to the outpatient setting, predicts Mark A. Talamini, MD, associate professor of surgery and director of minimally invasive surgery at Johns Hopkins University School of Medicine in Baltimore. "Other exciting technologies, such as computer-based home monitoring of recovering patients, are also likely to continue the trend," he says.
The technological advances of recent years will impact how surgeons learn procedures, predicts Yulun Wang, PhD, chief technical officer at Computer Motion in Santa Barbara, CA. Computer Motion develops, manufactures, and markets computer and robotic surgical systems for the operating room and created the digital robot required for the New York City/France collaborative surgery. "Surgeons can teach surgeons techniques much more efficiently and faster than before," Wang says.
Perhaps the most potent near application will be in long-distance surgical consultation, Talamini predicts. "For example, say a surgeon in a remote area runs into a difficult part of an operation and needs some help, but there is no one around," he says. "[He or she] could potentially hook up’ with an expert at Hopkins, who could use telesurgery to assist."
What’s the limit?
Previously, telemedicine experts believed they were limited to performing procedures within 300 miles, says Richard Satava, MD, professor of surgery at Yale University in New Haven, CT. "The fact that they could do surgery over 4,000 miles across an ocean indicates that the original estimates were not accurate," Satava says.
There are technical issues left to be resolved, but theoretically, a facility with high bandwidth access to the Internet and robotics could contact any surgeons within 5,000 miles with those same components and perform surgery, he says. "What they showed is that the limitations are not at 200 miles, but thousands of miles," Satava says. "It’s not theoretical; it can actually happen." One technical issue that is unresolved is access to high bandwidth, he says. Currently, access is available in some places in the United States, Europe, and Asia, he says.
The first question to resolve is whether such remote surgery is desirable, Talamini says. He asks, "Does anyone really want [the] surgeon to be anywhere other than next to [him or her] when an operation is taking place?" There are scenarios where this may be of great benefit, Talamini acknowledges. For example, in the military, surgeons could multiply their effectiveness by operating in multiple geographic locations from one spot, or in space, where a surgeon is unlikely to be available, he says.
The expense of the technology is dramatic, however, Satava points out. "At the moment, it costs about a million dollars," he says. "But we know that as this becomes more and more used in day-to-day practice, that kind of price will go down significantly." Whether the public is willing to pay the cost of these technological improvements remains uncertain, Talamini says. "Certainly the insurance companies and HMOs, and the government do not [want to pay]," he says. "New technology is seen as an unnecessary expense, not an advantage."
Expect a three- to five-year wait before such hurdles are overcome and the "typical" hospital has the technology to permit remote surgeries, Talamini predicts. And there are regulatory hurdles. Parts of the system used in the remote gallbladder surgery have been approved by the Food and Drug Administration for use in a nonremote scenario, but the entire system hasn’t been approved for commercial release, according to the Chicago-based American Hospital Association.
Legal hurdles also exist, Talamini points out. "If the connection causes a surgical problem, who will be liable? The phone company?" he asks. "Can this occur across state lines if the helping’ surgeon does not have a license in that state?" Outpatient surgery providers should be looking toward being wired to the outside world with broadband connections for data transfer and teleconsultation/surgery, Talamini advises.
Also, managers should broaden their reading, Satava suggests. "Read magazines such as Science or Nature that publish these technologies in other fields," he advises. The New York City/France collaborative procedure was covered in the Sept. 27 issue of Nature. (See "Sources and resources," below, for ordering information.) Attend conferences for robotics and image-guided surgery, Satava suggests. (See "Sources and resources.") "The more we know about all of these advances, the easier it will be to take advantage of them," Talamini says.
Sources and resources
For more information on technological advances, contact:
• Richard Satava, MD, Professor of Surgery, Yale University, New Haven, CT. Telephone: (203) 764-9069. E-mail: [email protected].
• Mark A. Talamini, MD, Associate Professor of Surgery, Director of Minimally Invasive Surgery, Johns Hopkins University School of Medicine, Baltimore. E-mail: [email protected].
• Yulun Wang, PhD, Chief Technical Officer, Computer Motion, Santa Barbara, CA. E-mail: [email protected].
For information on the annual Medicine Meets Virtual Reality Conference, contact: Aligned Management Associates, 1835 S. Centre City Parkway, PMB No. 513, Escondido, CA 92025. Telephone: (760) 839-1200. Fax: (760) 839-1250. E-mail: [email protected]. Web: www.nextmed.com.
For information on subscribing to Nature, contact: Nature America, P.O. Box 5055, Brentwood, TN 37024-5055. Telephone: (800) 524-0384. Outside the United States: (615) 377-3322. Fax: (615) 377-0525. E-mail: [email protected]. Web: www.nature.com.
For information on subscribing to Science, contact: Membership Department, American Association for the Advancement of Science, 1200 New York Ave. N.W., Washington, DC 20005. Telephone: (202) 326-6417. Fax: (202) 842-1065. E-mail: [email protected]. Web: www.sciencemag.org.
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