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Telesurgery Troubles?

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CELEBRATION, Fla. (Ivanhoe Newswire) - Have you ever tried to move your computer's mouse and the on-screen cursor didn't respond right away?  It can be frustrating, but it's nothing compared to what some surgeons are facing.  Researchers and doctors are trying to beat a surgical snafu that's hindering a breakthrough.

Jannett Matthews has had two robotic surgeries: one for weight loss, one to remove her gallbladder.

"It's really exciting to see how far I've come," Jannett Mathews told Ivanhoe.

Her surgeons were just feet away, but what if they were far way?

Robotic surgery has been done, "at a distance of five or 600 miles," Roger Smith, PhD, Chief Technology Officer at Florida Hospital Nicholson Center, told Ivanhoe.

But telesurgery expert Roger Smith said operating from more than 100 miles from a patient is a big challenge because of internet lag.  It causes delays between when a surgeon moves his hands, to when the robot responds.

"Above half a second you see some of them totally fall apart," Dr. Smith said.

While doctors can't speed up communication technology, they could adapt to it.

"Move and pause a second. Move and pause a second," Dr. Smith explained.

Smith is conducting studies with surgeons to help them get used to the lag.

Exercises simulate the delays.

"If the latency is very high you sometimes feel frustrated. The more exercises you do the better you get," Robotic Urology Fellow, Haidar Abdul Mushin, told Ivanhoe.

Smith said if doctors do adjust their techniques to deal with lag or if telecommunications catch up to surgical robots.

"The best surgeon in the world could be on call for the most critical cases in the world," Dr. Smith said.

A $4 million grant from department of defense is funding smith's telesurgery study.  He's still recruiting surgeons, along with performing telesurgeries across the US.  The hope is someday doctors stateside could perform surgery on wounded warriors in battlefield hospitals overseas.

RESEARCH SUMMARY

BACKGROUND:  Robotic surgery is a type of minimally invasive surgery.  Instead of operating on patients through large incisions, doctors use miniaturized surgical instruments that can fit through series of quarter-inch incisions.  When surgery is performed with the robot, the instruments are mounted on three robotic arms.  The fourth arm contains a magnified high-definition 3D camera that will guide the surgeon during the procedure.   (Source: www.robotic-surgery.med.nyu.edu)

HOW IT WORKS: The surgeon controls the instruments and camera from a location in the operating room.  The doctors can place their fingers into the master controls to operate all four arms simultaneously.  Every movement made with the master controls is replicated precisely by the robot.  The surgeon can change the scale of the robot's movements.  If the doctor selects a three-to-one scale, the tip of the robot's arm moves one inch for every three inches the surgeon's hand actually moves.  By using this technology, surgeons are able to perform a number of complex procedures.  This technology allows the patient to have fewer traumas on their bodies, minimal scarring, and faster recovery times. (Source: www.robotic-surgery.med.nyu.edu)

NEW TECHNOLOGY:  Robotic surgery is a huge breakthrough in medicine.  It was originally developed by the US Army and DARPA as a tool to enable telesurgery at a distance. Researchers are now looking for ways to perform surgery across transoceanic distances by using telecommunication technology.  An experiment at Florida Hospital Nicholson Center was carried out with the Mimic dV-Trainer (a simulator of the da Vinci robot), which was designed to insert defined levels of latency into the visual and command data streams between the operating field and a surgeon.  Participants were asked to perform four basic robotic surgical exercises.  The experiment measured the degradation of human surgical performance across a range of latency conditions.  The next phase of the research project will involve telesurgery exercises from city to city.  The DoD gave the Florida Hospital Nicholson Center a $4.2 million grant to understand how robotic surgery can be performed over long distances. (Source:www.floridahospitalnews.com

INTERVIEW

Dr. Roger Smith, PhD, Chief Technology Officer of the Florida Hospital Nicholson Center, talks about telesurgery.

Tell us what telesurgery really is?

Dr. Smith: About ten years ago the Department of Defense did research to create a robot for surgery and their intent when they created that robot to allow a surgeon in a hospital to operate on a soldier on the battlefield. So they envisioned that the surgeon would have one piece of equipment with him while another piece would be portable on the battlefield. They created a prototype system, but found that the telecommunications infrastructure around the globe couldn't support real-time connection between the surgeon and the soldier. However, several companies realized that it did support doing surgery locally in the operating room. So they bought the technology and turned it into the surgical robot that you see behind me, the da Vinci robot. It is used in a traditional operating room with the patient and the surgeon separated by ten or twenty feet. This technology provides the surgeon with much more fine control over the instruments and the ability to see the surgical field in greater detail than with traditional laparoscopic instruments. The picture that my colleague is seeing in the back there is the surgical scene in three-dimensions using stereo vision which you don't have in other kinds of surgery. We picked up that technology and are trying to enable telesurgery, not thousands of miles away, but fifty or one hundred miles away. In civilian medicine, there are hospitals that are only a dozen, fifty, or a hundred miles apart. So our research is exploring whether that's possible and the degree to which the current telecommunications infrastructure would support that. Is it possible for the equipment to connect through a high-speed internet connection, and for you to be able to do the surgery on somebody that's still in your county or maybe the next county over.

Who would that be beneficial for? One hospital might have the technology and another might not or would it be a timing thing?

Dr. Smith: Short term hospitals all have capacity issues and timing issues. You have to schedule everything. There's a timing issue for getting all the patients ready for the surgeon and it's possible that a surgeon could service more than one hospital. So patients could be prepared in two different hospitals while the surgeon doesn't move from his cockpit. He just sits there and switches control from hospital A to hospital B to hospital C and back to A. So all day long he would operate in hospitals all around the county even though he never leaves his original office.

That sounds pretty cool.

Dr. Smith: Yeah, right now in a hospital-system like those in Orlando, it would enable us to extend the reach of our experts to all of the hospitals in county metropolitan area. Over time that's going to expand and it's going to become a situation where the doctor can reach hospitals the next county over and eventually the entire state and perhaps the entire southeast. We think that in order to do real telesurgery, you don't want to start with the most difficult case reaching all the way around the world on to a battlefield. You want to start with the cases that are most practical and doable right now and then expand out from there. You and I are used to living in a metropolitan area and going to the big hospital downtown is not such a big deal for us, but there are a lot of small rural areas around here where they're afraid to come in to the big city. They're more comfortable with their hometown hospital where they know the nurses. It would be possible for them to have a surgery in the small community hospital that they are part of being attended to by their doctors and their nurses. However, the expert surgeon, perhaps the best surgeon in the world, is actually performing the procedure for them from afar. So that's the next step in this telesurgery that we're developing.

What challenges have you run in to? How far have you gone so far?

Dr. Smith: When we present the surgeon with a case where the patient is a hundred, five hundred, or a thousand miles away there's some lag between the time that his hands move and the time that he sees that movement in his visual screen. The signal has to travel from his hands to the patient and then a video of that has to come back to him. The surgeons aren't used to that kind of lag, even though it may be as little as a quarter of a second it's enough to throw them off. When we move it up from a quarter of a second to half a second they find themselves stumbling through the operation and wrestling with the equipment because it's presenting them with a new challenge. So we need to teach the surgeons how to deal with that latency issue. It's not something that's impossible to accommodate. There are a lot of machine operators that have learned to accommodate that kind of response from their equipment. It's just that a surgeon has never had to do it. He's used to instant response when he moves his hand. So the first challenge is teaching the surgeon how to adapt to this lag that he is seeing in the instrument. Since it is being done in many other machine operator conditions we figure we can do it for the surgeons as well.

What are the best tips and tricks to help them overcome that?

Dr. Smith: The first thing the surgeon usually needs to do is just slow down a little bit. They do surgery the way people play tennis; it's very fast and it's very smooth. Their minds are seeing what is happening several steps ahead of what they're actually doing. When you put latency into that cycle it interferes with what their brain was planning and already beginning to execute. They need to learn to slow down and let the visual picture of the movement happen before they take their next move. They start moving a little more like a metronome on a piano. There is a move and a pause, move and pause. The pauses are so small that it still looks almost continuously smooth, but if you watch closely you'll see that they are stepping their way through the surgery rather than moving smoothly like a tennis player does.

So instead of doing something quickly they have to break it down?

Dr. Smith: Yeah. To some degree it's learning to do that same surgery again. It's different enough that they need some time to learn the new technique.

Do you think they should have to deal with that latency or fix the latency?

Dr. Smith: The Department of Defense has been wrestling with this telesurgery problem for ten years and the hope has always been that the telecommunications infrastructure, the AT&T's and Sprints of the world, would deliver communication lines that are so good that there is no latency between here and Paris or Moscow. In the ten years that we've been working on that problem, the solution hasn't emerged. It's gotten much better. We've gotten to a point where we're confident we can do surgery within a hundred mile radius without a noticeable latency, but it hasn't gone down to zero or far enough to be able to reach around the world.

So what is the plan for it to reach across the world and was the original objective supposed to have the surgeons help the soldiers on the battlefield?

Dr. Smith: When communicating around the world almost every other application doesn't require instantaneous response. When a drone has a camera pointed at the battlefield and is streaming that video back to a command center, the fact that the command center actually receives that video two seconds after it is shot is no big deal. It doesn't change how fast they make a decision. It doesn't change the outcome of the battle. So they're not interested in that the kind of network performance that is necessary for robotic surgery. When you watch a streaming video from Netflix, the video may actually leave a Netflix server five or ten seconds before it arrives at your home. However, that usually does not change your viewing experience. There's not a two way interaction going on there. There are very few applications where instantaneous response and that two way communication are necessary. Most of the world is very happy with the telecommunication networks that they have now. There's not a big push, at least financially, for the communications companies to improve that to a point where we could do two-way surgery around the world. So I don't see that happening right away. I see us being able to take advantage of a really good communication infrastructure that exists in cities and between big facilities like hospitals and being able to do successful telesurgery in those environments pretty soon. As far as extending it to the entire world, I think it will be awhile before somebody spends the money to deliver that to capability.

If it does happen, how could it change surgical care?

Dr. Smith: If this were possible, the best surgeon in the world could be on call for the most critical cases in the world. Right now, especially if it's accident related or if it's a critical event in your life, you can't count on the fact that the event happens within driving distance of the best surgeon to treat you. Over time we could build up a network that connects the best surgeons in the world to many of these robotic devices. You could be rushed a station with this connection and the best surgeons in the world could be plugged in and ready to treat you. So it's going to allow us to extend skills to where we need them the most. Right now you get care from very good doctors, but randomly the ones who are available near you when you really need them.

So have you tried anything on humans yet?

Dr. Smith: We have not done any human surgery. There are surgeons in Canada that have done remote human surgery. Simple things like removing a gallbladder. Their motivation is very similar to what I described earlier, in that the patients live in very rural areas and are hesitant to come in to the big city. There has also been one famous experiment in which a surgeon in New York removed the gallbladder from a woman in France.

They go that far?

Dr. Smith: Yes. This was a special planned situation in which they purchased some of the best dedicated network bandwith in the world to demonstrate that it could be done.

So what is your ultimate goal, how long do you think before you reach it?

Dr. Smith: Our ultimate goal, because we're working as part of a big community hospital system, is to allow the best surgeons that we have to perform surgery in all of our hospitals. So you could go in to a hospital that's downtown, that's on the north side of town perhaps in Daytona Beach or maybe over in Tampa, and get treatment from the best surgeon that this network could reach.

How many years until we see that around the country and around the world?

Dr. Smith: Our research here is targeted at finding out what the technology will support. Once we know what's possible with the technology, you're in a situation where you can deploy it but there are still a lot of regulations that control this. So there's a lot of work to be done legally on whether this can be employed, whether the insurance companies will support it, and whether patients will accept it. There's a lot more work that's non-technical than there is technical. The technical work will be done in a year or two, but the nontechnical work could go on for two, three years, or ten years. You just don't know how long that's going to take.

And your research is basically bringing in doctors from around the country and testing them out on the equipment?

Dr. Smith: In doing this research we want to tap in to a wide range of doctors. Some are world-renowned experts and some are brand new to robotic surgery. To accommodate, we take our equipment to leading robotic surgery conferences and get those surgeons to participate. We've collected data from just over one hundred different surgeons from all around the country and a couple of them from India and South America.

And what have you found?

Dr. Smith: What we've found is that if the latency is less than one quarter of a second most of the surgeons can perform the surgery without a hiccup. They're very smooth; they may not even notice the latency because it's so small, but between one quarter of a second and one half of a second they have to adjust; they have to change their techniques but they're usually successful. Above a half a second you see some of them totally fall apart. They can't perform successfully. You can see them failing and stumbling over and over again. Curiously enough there are a few even at those extreme levels who sail through and do a fantastic job on the experiment. We haven't dug in to what makes surgeon A very successful in this harsh environment and surgeon B fall apart.

Do they get frustrated?

Sr. Smith: Yes. You see them doing what they believe should work, should be successful, and becoming frustrated because it doesn't. After they do it the same way a couple of times, they start regulating themselves and adjusting their behavior to try and accommodate for the problem that they encountered.

How many more doctors do you think you'll put through the study?

Dr. Smith: Our goal is to put between one hundred and two hundred doctors through the study. We keep moving the equipment to the locations of these robotic surgery conferences where we can get more and more of them. Here at the Nicholson Center we teach about a dozen robotic surgeons every couple of days. So when possible we grab them and get them to participate in the experiment as well.

So how long do you think it will take to get the rest of the group?

Dr. Smith: I think six months.

FOR MORE INFORMATION, PLEASE CONTACT:

Jennifer Roberts
Media Relations Manager
Florida Hospital Nicholson Center
407-303-8221
jennifer.n.roberts@flhosp.org

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