Imagine inserting your broken arm into a metallic, sleeve-like device, then sparks fly, machines clang and voila! You have gotten yourself a nice, fixed arm in a shiny new cast. It is more and more common to see scenes like this on display in recent sci-fi productions. These flashy Hollywood gadgets may seem far-fetched, but surgeons have been conducting robotic-assisted procedures for over thirty years.
The PUMA-560 robotic arm was introduced to the market in the early 1980s, designed to help with procedures that demanded the greatest level of precision and delicacy. After its approval for use, the first opportunity came in 1985, when surgeons successfully used PUMA-560 to complete a non-laparoscopic brain biopsy. Three years later, physicians at the Imperial College of London used PROBOT to assist with laparoscopic prostate surgeries, citing its remarkable “accuracy and lack-of-fatigue for the surgeon.”
Since these early days of robotic surgery pioneering, tens of thousands of procedures in various specialties have successfully been completed with the aid of such technology. The most famous robotic surgery apparatus was developed in 2000. Named Da Vinci, the platform commemorates the Italian polymath’s contributions to the understanding of human anatomy. The platform also marked a giant leap in accuracy, precision and ease-of-use from its counterparts of the previous generation. It was soon approved by the FDA in 2000 for general use in laparoscopic surgery and is now considered standard equipment in many modern operating rooms. Several new versions of the platform have since been released, improving upon prior feedback and adding compatibility with newer surgical methods.
In addition to their improved accuracy, precision and expanded specialty coverage, newer generations of surgical robots have broadened their repertoire to perform telesurgery. On September 7, 2001, French Surgeons based in New York City carried out a laparoscopic cholecystectomy using the Zeus surgical platform. Their patient was lying in an operating room 3800 miles away in Strasbourg, France. The surgery was a great success and was dubbed “Operation Lindbergh” by the media, comparing it to another magnificent trans-Atlantic feat accomplished over half a century ago by Charles Lindbergh, the first pilot to fly solo from America to Europe. The internet connection needed was established through a designated, high-speed route set up by France Telecom to ensure minimal latency and packet loss. Although this high level of internet bandwidth was far beyond what most hospitals could afford at the time, the surgery nevertheless demonstrated the potential of synergy between robotic surgery and telemedicine. A new era thus began.
In 2014, a team at the University of Alabama at Birmingham developed Virtual Interactive Presence (VIP), a visual system that allows surgeons collaborating on a case to see each other’s virtual hand motions within the surgical field. This application not only has significance in surgical training, but potentially allows teams from different institutions to effectively collaborate on the same operation. Another breakthrough came in 2015, when German researchers developed Telelap Alf-X, a virtual haptic feedback system that provides the surgeon with rudimentary tactile sensations during the operation. This was improved upon further in 2017, when Su et al. introduced an MRI-guided telesurgery apparatus capable of providing “varying degrees of pneumatic pressure” as cutaneous feedback to the surgeon.
For example, this technology could help surgeons remotely assess tissue integrity, so that they can choose the most appropriate tools for excision or ligation. These mechanics were subsequently paired with eye-tracking hardware that allows the surgeon more “real-time” awareness within the surgical field and prevents potential accidents by locking the surgical instruments in place when they are not in the visual field of the operator. Even more futuristic is the ongoing development of a 3D holographic visual feedback system by researchers in Beijing, China. The goal of this simulation system is to allow the surgical team to see a floating, real-to-size holographic image of the surgical field. This would allow for unprecedented attention to detail and enhance collaboration by members of various other medical institutions, who could watch online.
Perhaps one of the most beneficial applications of telesurgery is expanding coverage to rural and underserved regions. It should be noted that telemedicine access varies greatly between different U.S. states, largely due to socioeconomic disparities and discrepancies in broadband coverage. For example, compared to Mississippi, New Jersey enjoys 30% better broadband coverage and almost double the average internet speed statewide. Despite these potential impediments, some international precedents have already shown the usefulness of adapting telesurgery to better rural medical access. During the Ebola crisis, medical teams at the University of Virginia were able to remotely provide surgical support for western African nations from half a world away. This not only helped underserved patients access healthcare but also decreased the risk of exposure for the medical team. In 2019, doctors in New Delhi were able to perform percutaneous cardiac interventions (PCIs) for patients experiencing myocardial infarctions dozens of miles away in a smaller rural hospital. As the cost of telesurgery technology goes down by the year, more and more healthcare coverage could be expanded to previously inaccessible areas.
One of the major limitations impeding the use of telesurgery in many underdeveloped nations is internet connectivity. The lack of communications infrastructure in these countries cannot be realistically solved in the short term. The ideal latency (time for information to be relayed from sender to receiver over the internet) for telesurgery is under 100 milliseconds, with the threshold for major operating inaccuracies set at 300 milliseconds. Thus, without high-speed fiber optic cables as a hardware foundation, telesurgery can be extremely risky. Just think about how upset you can be while waiting for a video to slowly load on your phone. Now imagine the frustration of the surgeon who is attempting a delicate microvascular repair and is instead interrupted by the buffering of his/her live video feed, failing to see the real-time maneuvers of the surgical instruments.
However, while technology may be a limitation, it is also a potential solution. SpaceX, a private American aerospace services company, is well underway to set up its StarLink project. The ambitious operation includes establishing a constellation of 12,000 satellites around low earth orbit by 2025, supporting a global high-speed internet network with 100% of Earth’s surface coverage. As of December 2020, around 900 satellites have already been put into orbit, with regular launches scheduled to come. The completion of a global high-speed internet network would likely advance telesurgery and telemedicine to new heights. If the costs of the network are bearable, this would provide an alternative method for underdeveloped nations to connect to the world.
Connection is a major theme of the 21st century. This is even more obvious to see during these trying times of the COVID-19 pandemic, with people seeking to reach out to one another despite physical barriers. Medicine, at its core, is about people. Thus, like people, medicine will only become more and more connected and globalized. With the aid of rapidly evolving technology, telesurgery will gradually become an integral component of medicine. And here’s to hoping that more and more people of all backgrounds, cultures and origins can enjoy the highest level of care that the future of medicine can provide.