Telemedicine The Possibility and Realities

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Dr. Sunil Shroff

President
Medical Computer Society of India
A-113, Annanagar,
Chennai - 600102
sshroff@vsnl.com
Prof. and Head of the Department
Urology & Renal Transplantation
Sri Ramachandra Medical College
Chennai - 600116
srmc69@eth.net


Table.3 Tele-video-conferencing


Zero Gravity Cybersurgery for Space travel


Space travel has made us explore the possibility of delivering healthcare in remote locations. The technology required to remotely monitor cardiac and respiratory surface monitoring has been straight forward. The advances in digital radiology, imaging devices, better bandwidth for transmissions of images and high resolution computers has added to the tremendous confidence in diagnosing conditions remotely.

However, the challenges of delivering therapeutic surgical care remotely are more complex. Open surgery is ill-suited for space travel and the dangers of open surgery include wound contamination from high particulate spacecraft atmosphere and the contamination of the atmosphere of spacecraft from surgical debris, bleeding or irrigation fluid. Operating through various "surgical containment chambers" has been shown to lower the particle count at the operative site and helps to prevent atmospheric contamination in parabolic weightlessness It has been a great co-incidence that the advent of minimally invasive and laparoscopic surgery happened during the same period when space travel was being contemplated. There are advantages in performing a laparoscopy instead of an open surgical procedure in a weightless environment.. The abdominal cavity acts as its own, surgical containment chamber when laparoscopy is performed in space. It is seen that though the small bowel press against the anterior abdominal wall despite CO2 insufflations; however, the veress needle has a larger safety factor when making a puncture even in zero gravity. In experiments it was found, that laparoscopy in weightlessness was no different from when being performed in the restraints of gravity .

TELE-VIDEOCONFERENCE DEMONSTARATION OF ENDOSCOPIC PROCEDURES


In video-endoscopic procedure a surgeon looks at many bright pixels on a television monitor and sees the image of the internal anatomy that is displayed and is able to manipulate and remove tissue and organs without ever seeing them and touching them. This type of surgery is well suited for teleconference demonstration.

To demonstrate the possibility of surgical tele-conferencing through commercially available systems, a pilot project in 1995 was undertaken. A laparoscopic cholecystectomy was performed at Maastricht in Holland and was monitored in Honolulu in Hawaii. The distance of separation was sixteen thousand kilo-meters. A time delay of almost 1 second was noted in each direction. However there was a rapid adaptation to this time delay and this delay was tolerable. Since this project, many more demonstrations have taken to get a broadcast quality images and to demonstrating surgery, it is now usual to use at least three ISDN lines or use 512 Internet connectivity on a static Internet Protocol.

TELEMENTORING OR REMOTE LAPAROSCOPIC PROCEDURES


The potential of using Telemedicine to broadcast the video images has led to experiment where an expert (or mentor) has guided a trainee surgeon to undertake a laparoscopic operation. In a trail conducted at John Hopkins Hospital, Baltimore, USA Telementoring was attempted in 14 advanced and nine basic urologic laparoscopic procedures. The remote surgeon was located in a control room(>1000 feet from operating room) supervised an inexperienced surgeon. For this real time video images, two way audio communication, a robotic arm to control the video-endoscopes and a telestator. The overall mentoring success was 96% with no complications. Operative time of telementored laparoscopic procedures compared between telementored and traditionally mentored procedures were not statistically different for basic procedures but were longer for advanced cases.

Complexity of procedure
Type of procedure
Number of procedures
Basic Pelvic lymphadenectomy 5
Diagnostic laparoscopy for
nonpalpable testicle 2
Renal biopsy 1
Orchiectomy for intraabdominal testis 1
Advanced Nephrectomy 4
Pyeloplasty 3
Partial nephrectomy 2
Bladder neck suspension 3
Orchiopexy of intraabdominal testicle 1
Unilateral ureterolysis 1

In another initiative from John Hopkins (from September 1998 to July 2000) in a colloboration with surgeons from the "Tor Vergata" University in Rome, Telementored laparoscopic procedures performed by Moore et al at John Hopkins. Two different robotic devices were used for seventeen teleurology procedures on patients with urological problems in Italy. Using four ISDN lines, a PC equipped with a dedicated software to manage the telecommunication, both audio and video connection, an external video camera with a panoramic view of the operating theatre and a remote control for the electro-cautery and telestrator, the team bridged a distance of 9320 km between the Policlinico Casilino in Rome and the remote Johns Hopkins consultation site in Baltimore, Maryland. Dr. Dan Stoianovici, the director of the URobotics Lab at Johns Hopkins, presented the results of the experimental telesurgery project at the annual meeting of the American Urological Association in June 2001. The speaker explained to the audience that fourteen of the long-distance surgeries included eight cases of spermatic veins ligation, two retro-peritoneal renal biopsies, one pyleloplasty or kidney repair, and three nephrectomies for non-functioning kidneys. The three remaining procedures constituted percutaneous access to the kidney.

AESOP robotic endoscope positioner was applied for the orientation of the laparoscope. PAKY, the second robot, consisted of a passive mechanical arm, mounted on the operating table and fitted out with a radiolucent needle driver to perform the percutaneous renal access. Each procedure was carried out successfully without any post-operative complications. In seven cases however, the telesurgical connection with the remote site in Rome was suspended while the interventions were continued only from the primary site. Dr. Stoianovici also described how two of the 17 procedures were converted to open surgery. In general, the time delay for image transmission was approximately one second. The project has demonstrated that international telementoring holds a lot of potential to soften the steep educational curve which surgeons experience to learn the ropes of minimally invasive surgery.

The surgical robots augments the ability of the practising surgeon by scaling down the range of motion, providing three-dimensional vision, and eliminating hand tremor. The robotic system allows a surgeon to view and control both the console and the cart with the robotic arms which is installed next to the patient. In another demonstration on a 66 year-old male in Berlin with prostate cancer underwent radical prostatectomy using the AESOP robot from the office of Dr. Fabrizio in Virginia,USA.. Stated Dr. Fabrizio. "I was able to view the procedure as if I were in the operating room. I outlined the steps of the surgery in real time, and controlled the AESOP robot from my office in Virginia while Dr.Türk was telementored to perform the procedure in Berlin."

SURGICAL TRAINING SIMULATORS FOR ENDOSCOPIC PROCEDURE


For the past twenty five years "virtual reality" is being used to train pilots to fly where the pilot experiences a simulated life like real situation only in the virtual world of computers. A trainee endoscopic surgeon similarly today can use this technology to learn both basic and advanced skills of the minimally invasive surgery in a risk free environment at his own leisurely pace. A high degree of realism is possible in these simulations and the experience gained is reproducible when an actual situations occurs.

Multi Media Virtual reality (MMVR): Hoffman created a four dimensional education tool, the three dimension of a virtual world (3-D space) and fourth dimension of time to give a multimedia format to virtual reality. Using this format a student could fly down the urethra into the Bladder or up the ureter into the kidney and grab a stone. With this tool the surgeons can learn the intricate complexities of a endoscopic or laparoscopic procedure. The images obtained from endoscopes can be merged with high resolution digital images from a helical CT scans and MRI and individual organs can be segmented into fully interactive 3-D reconstructions on a computer monitor.

Laparoscopic Surgical Simulator : HIT Labs, USA has over the years undertaken many projects to develop a laparoscopic surgical simulator to evaluate its effectiveness as a training tool for teaching port site placement and using it to carry out simple laparoscopic maneouvres. Similar products have been developed by Immersion Corp. USA (www.vrweb.com)
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