Possibilities and challenges of telesurgical interventions

Traditional telemedicine makes it possible to provide diagnosis, advice, monitoring and other medical services, for example, using audio-visual communication technologies, despite physical distance. Telemedicine is an important part of medical health care, especially in rural areas. Telemedicine is an important tool for the further development of care. Against this background, new areas of application for telemedicine are constantly being developed. Telemedicine also plays an important role in the digitalisation strategy for the health care sector.

An evolving branch of telemedicine is telesurgery. The concept of distance between surgeons and their patients is not new. It was first explored in the 1970s by the US National Aeronautics and Space Administration (NASA), which was interested in treating astronauts in space. Especially for missions on the International Space Station (ISS) or planned manned Mars missions, it will be essential to provide the crew with medical expertise remotely via telemedicine and telesurgery.

The development of robotic surgery as we know it today was based on the idea of telemedicine. The idea was that a trained surgeon could perform remote operations in trouble spots without having to be there in person. One example is Mobile Advanced Surgical Hospital (MASH): a system for providing care to wounded soldiers directly in a vehicle equipped with surgical robots using remote control.

Another example of the need for telemedicine and telesurgery is the case of Jerri Lin Nielsen. She was an American doctor who self-treated her newly diagnosed breast cancer while stationed at the Amundsen-Scott South Pole Station in Antarctica until she could be safely evacuated. Nielsen had conference calls with medical personnel in the United States and had to operate on herself to obtain tissue samples for analysis. A military aircraft was later sent to the pole to drop equipment and medicine for chemotherapy.^[1]

At the same time, robotic surgery allowed the surgeon to operate with greater dexterity, improved accuracy and greater access to difficult areas of the body. Significant advances in telecommunications and robotic surgery led to the idea that telerobotic surgery being considered a viable option.^[2]

This led to the development of robotic surgery, in which the surgeon is usually in the same room as the patient, rather than next to them. The requirements for true telesurgery, where the surgeon may be thousands of kilometers away, are a major challenge. There is the need to ensure that qualified surgeons are available on site in case the operation needs to be modified or technical problems arise that make further telesurgical control impossible.

The Lindbergh operation was the first complete telesurgery performed by a team of French surgeons in New York on a patient in Strasbourg. The operation was successfully performed on September 7, 2001 by Professor Jacques Marescaux and his team from Institute for Research on Cancer of the Digestive System (IRCAD). It was the first time in the history of medicine that a technical solution was able to reduce the time delay in remote transmissions that this type of procedure became possible.^[3]

Telesurgery refers to surgical procedures performed using technology, which has the potential to transform the global healthcare landscape by improving the quality of surgery, particularly in resource-limited settings and rural areas. The technology requires advanced communications and surgical robotics, allowing surgeons to perform procedures from remote or safe locations while ensuring high quality surgical outcomes and patient safety. It improves access to surgical services, reduces travel time and costs, and makes professional care available to a wider population.

A core element of telesurgery is a stable network connection with high data transfer speed. This results in a large number of different parameters that need to be adapted as much as possible to the individual operation, even to parts of a single operation. A key issue of telesurgery is the overall latency between the execution of an action at the surgeon console, the implementation of that action on the patient cart, and the visual and auditory perception of that action on the surgeon console screen. In addition to point-to-point latency, the point-to-point deviation from the average latency is also important in order to obtain a smooth image flow with no drops or lags. Image resolution also plays a crucial role. Obviously, higher image quality provides a better view for the surgeon and is important for recognising the smallest structures. In addition to image resolution, the image refresh rate also plays an important role in achieving a smooth and jerk-free surgical image.

Every network connection has a limited amount of bandwidth, and the parameters mentioned above, all compete for this bandwidth. This means that if the bandwidth remains the same, an increase in one parameter will result in a decrease in the other parameters. Depending on the operation, or even part of an operation, one parameter may be more important than another. For example, when looking for a bleeding small vein, maximum image resolution is essential, whereas when enucleating a kidney tumor, the lowest possible latency would be preferable. As the raw data is not transmitted, software-based compression of the data to be transmitted is also required. It should be noted that compression and decompression should be as lossless as possible.

In the development of telesurgical systems and their widespread use, it is therefore important to ensure that as many parameters as possible can be freely set and adapted according to the medical field, operation and stage of the operation. In addition, it is essential to create a network infrastructure that provides stable, high-bandwidth connections with a high level of resilience. Only a stable network connection guarantees operations conditions to which a surgeon can adapt, even if this means a bandwidth cap to ensure stability.

In their study, Wang et al^[4] examined the effect of network latency and bandwidth, respectively image quality, on 108 animal surgeries using the MP1000 robotic surgical system (Shenzhen Edge Medical Co., Ltd, Shenzhen, China). The surgeon was almost 3000 km away from the patient. The surgeon’s console was located at the PLA General Hospital in Beijing, and the patient cart was located at the Hainan Hospital of the PLA General Hospital in Sanya. The study used a dedicated line (China Telecom Co., Ltd, Beijing, China) with a maximum bandwidth of 60 Mbps for the robotic subsystem and a 5th generation mobile communication technology connection for teleconferencing. Performance and individual perceived task load were measured under different scenarios by adjusting network latency and image quality by bandwidth. Their study concludes that increased latency has a greater impact on the safety of telesurgery than bandwidth reduction and the associated decrease in image quality.^[4] Wang et al^[4] demonstrated and proved in their work that their telesurgery system was safe and reliable. By dynamically adjusting the image compression ratios according to the bandwidth changes, operations could be covered over a distance of 3000 km. Their study showed that a total latency of 320 ms was acceptable for telesurgery operations. They also showed that reducing the image sharpness can effectively mitigate the potential latency increase caused by reduced bandwidth, therefore provides a new method to reduce the impact of latency on telesurgery. These are promising results and the authors have to be congratulated for their innovative work as it is an important step to globally introduce telesurgery into routine medical procedures.

Although first introduced more than two decades ago, remote telerobotic surgery has still been in its infancy. Concerns about safety, cost and latency have limited the growth and adoption of remote telesurgery. Remote telerobotic surgery is a long-awaited but still nascent capability. There have been only a few reports presenting this new technology with encouraging results. Hopefully, more data of remote robotic surgery will be published soon to realise its potential, while adequately addressing existing questions of safety and feasibility.^[5]

Telesurgery is a promising surgical advancement, but it faces many challenges. Reduced latency time and improvement of haptic feedback technology are required for precise and well performed surgeries. Telecommunication networks and haptic feedback should be integrated into telesurgery to overcome these barriers. Also costs, legalization, and ethical issues still need to be discussed.^[2]

The development and widespread use of telesurgery in the future will only be possible if hospitals, hardware developers, software developers, telecommunications providers and government administration act together. Obviously, Wang and his team were very successful in creating such a multilateral consortium between academic science, the healthcare industry, the telecommunication providers, and the federal regulators. This kind of networking in order to achieve a common goal that is in the highest public interest is a marvellous feat in itself.

Conflicts of interest

None.