Feasibility of telesurgery in the modern era

Abstract

Telesurgery is not a foreign concept and dates to as early as the 1920s. The use of robots in medicine has had a very positive effect and improved outcomes with little to no adverse effects. Having global access to telemedicine and telesurgery during the COVID-19 pandemic and being able to provide top medical care to gravely ill and contagious patients without compromising the safety of the medical team would be a very big achievement. We explore the hurdles needed to make it a realistic goal and give recommendations to achieve it utilizing the major advancements that have occurred over the past few years in the fields of engineering, communication etc. The biggest issues needed to be addressed are of financial investment, legal concerns, and availability of high-speed uninterrupted data connections.

Introduction

Telesurgery is defined as being able to perform surgery remotely with the utilization of two robotic surgery setups in two different locations and utilizes a remote-control relationship. ¹ The first remote robotic procedure ever performed was in September 2001. The patient was in France and the surgeons in New York attempted the first remote robot-assisted laparoscopic cholecystectomy on a 68-year-old woman with a history of abdominal pain and cholelithiasis, it was called “Operation Lindbergh” ² which made the headlines as the first ever surgery being performed across two continents and the patient making a full recovery with no complications. It opened its doors to the feasibility of telesurgery and overcame significant skepticisms many professionals had about its use in human procedures. Telesurgery has mostly been used in the past for mentoring procedures, teleconsultations, and training sessions but more and more focus is being diverted to begin setup and adoption of telesurgery to perform procedures remotely. ³ It is indeed the minimally invasive nature of robotic surgery that attracts both physicians and patients in learning more about this novel procedure but also for hospital administrators and medical corporations that aim to provide top quality care and ease of access to patients with geographical imitations.

A major advantage of robotic surgery is the fact that human anatomy is unique to every individual and even the most experienced surgeons can have difficulties navigating complex procedures but through the use of precise mapping and coordination this limitation can be removed. ⁴ To improve the success of surgery, surgeons can practice using virtual reality (VR) simulators before proceeding to actual surgery. The role of DICOM (Digital Imaging and Communication in Medicine) has revolutionized medical training with low risks. 3D patient specific models can be prepared at ease for practice and reviewing anatomical details to assist with the procedure. ⁵

The earliest generation of robots to assist surgery came to being in 1985 under the name PUMA 200 industrial robot (Programmable Universal Manipulation Arm; Unimation, Stanford, California, USA) which was used for CT guided brain biopsies ⁶ Currently, the 2 US Food and Drug administration (FDA) approved robots available for performing telesurgery are Zeus® system (Computer Motion, Goleta, California, USA) and the da Vinci® Surgical System (Intuitive Surgical, Sunnyvale, California, USA). Exploring the feasibility of making these systems, and other future systems, available worldwide will not be an easy task but identifying the issues preventing it from happening and working to resolve them can be a step in the right direction.

Benefits of telesurgery

The prospect of remote surgery opens up many avenues. It gives hope to those living in rural setups with lack of availability of high-quality care7 it builds on past prospects of provision of medical care to those in military and war struck settings. ⁸ It could alleviate the burden of traveling large distances for both patients and surgeons and can be the difference between life and death when time is of the hour in critical patients. ⁹ It could l improve collaborations among medical professionals and open a new era of digital teaching and virtual training. ¹⁰ Having the opportunity to train in advanced techniques at small centers can in turn reduce the immigration of young doctors who wish to sharpen their skills and promote local training. Telesurgery training can help reduce the physician shortage and lack of skilled specialists available in remote areas as experts can perform the procedures with ease of access while the local physicians assist in setting up the procedure and learn from observation. ¹¹ One major advantage can be reducing the risk of spread of infection from various infectious diseases such ranging from typical post-operative infections related to staphylococcus to more epidemic related infections such as COVID-19 from patients to team members by having minimal to no physical contact during invasive procedures. ¹² To achieve all of these goals, there needs to be international cooperation and a unified approach involving various different organizations working towards the same goal, provision of high-quality health care.

Endovascular robots and interventions

We would like to bring special emphasis on the role of telesurgery for performing endovascular interventions remotely. Although the data are limited, it is very promising. A study conducted on the feasibility of performing robotic neurosurgery between two cities located 800 km apart took place. The robotic surgery occurred in Chapel Hill, North Carolina and the operating physician was located in Nashville, Tennessee. There were no significant differences between the procedure done locally or remotely with excellent outcomes in both cases. ¹³ This opens up a broad avenue of research focused specifically on neuro-interventions and making the feasibility of easily accessible remote neurosurgery more than just a concept.

Potential of remote robotic surgery and stroke intervention

The advent of telesurgery for stroke intervention can be a revolutionary accomplishment. Every minute after a cerebrovascular accident (CVA) occurs is valuable and the biggest difference in outcomes is the time to reach optimum care. Transport times and the lack of availability of nearby tertiary hospitals is the major issue being faced today even in the most developed nations around the world. The sparse number of Level I tertiary care centers, which are defined as those institutions which perform more than 250 stroke interventions every year and more than 50 thrombectomies per year are the most important reasons why quality of life is almost always compromised during provision of care to stroke patients. As advancements in the field of engineering and AI research continue at a rapid speed, it will not be long before ease of access to high-quality stroke care becomes a reality. This is a novel solution for improving stroke management in the form of percutaneous interventions and mechanical thrombectomies to geographically isolated areas with limited availability of experts.^14,15

Current challenges

Costs

The price of easily accessible health care is not economic with the robotic systems costing more than a $1,000,000 for the purchase of the device not including maintenance costs of up to $100,000 per year.^16,17 After comparison with standard surgical procedures, it was found that the robotic assisted procedures were less time consuming and had decreased hospital stay but this did not compensate to the overall cost of the procedure for the patient or the hospital.

Safety

Although telesurgery may be very beneficial, there is always an associated surgical risk with very real safety concerns for the patients and lack of availability of specialists in case of an emergency. Robotic surgeries are much more complex than those done manually, hence the operating surgeon should be thoroughly experienced and skilled in robotic surgery as lack of practice can open the door for malfunctions and complications ¹⁸ they may also require additional instruments and hence carry a significantly higher risk if done incorrectly. ¹⁹

Training

This poses another dilemma regarding the appropriate training of robotic surgeons as there are limited official training institutions available for telesurgery or robotic surgery, no stringent guidelines on the number of years or procedures required to attain qualifications which is a point of worry for the patients upon whom the surgeries are going to be performed. ²⁰

Support personnel

All interventions require a team approach. Nurses, technical staff, engineers/etc. have to be trained on the devices. If a site is extremely low volume, then it would be difficult or impossible to have sufficiently experienced personnel helping support a robotic case. It is not all about the surgeon but the entire team that works together to achieve success. ²¹

Network connections

Another major problem in providing access to telesurgery is the requirement of a high-speed uninterrupted data connection and private internet network. Although modern advancements have made access to high-speed internet a thing of the past, it comes with a significant cost and latency problems can lead to increased inaccuracies as shown by trial and error. ²² Many physicians concluded that surgical performance decreased as latency periods increased exponentially, latencies <300 ms were considered to be a safe time lag but anything above would make proceedings difficult to accomplish efficiently. Setting up a high-speed network might be difficult in mountainous areas where telecommunications networks cannot be established or signal transmission may be slow.

Legal and ethical concerns

After surpassing the initial hurdles of cost of machinery and setting up data transmission, the major issue left behind is that of legal implications and ethical concerns. In case of a poor outcome, the hospitals, surgeons, and even the medical device companies are liable to be sued for damages. It is to be noted that the laws and protocols followed in one country might not be the same as the ones followed in another. With international involvement and aims of providing global care, there is a major concern of legal culpability amongst hospital administrators and physicians when it comes to patient confidentiality, consent, and data security. ²³ If well-known hospital systems or health care corporations are going to be making unions with national and international hospitals that do not follow the same regulations and quality check points, it raises a concern for the standard of care being provided. ¹

Potential solutions to hurdles

Costs

With the prospects of robotic surgery becoming a topic of interest across the world, it is feasible to say we are not far from making it a reality. With the increasing demand for setting up a telesurgery practice, it might be in the best interest of medical device companies to provide setups with a low installment cost or a personalized payment plan for securing the devices. Division of costs among the hospital systems involved can definitely alleviate the burden and share the responsibility. The role of international collaboration and mutual funding through both government and private corporations can help eliminate the problem. Furthermore, once a robotic telesurgery system is set up, it opens up the broad avenue of hundreds if not thousands of surgical procedures which can be performed that will bring in both media attention and funding for procedural costs. ²⁴

Network connections

One such prime example is of the telesurgery service setup in Ontario, Canada ²⁵ where two surgeons perform successful surgical procedures between two separate cities in the province of Ontario more than 400 km apart on a daily basis. This was made possible by setting up a virtual private network (VPN) and Asynchronous transfer mode (ATM) telecommunication which prioritized the transmission of data during the procedure above all other traffic. ATM utilizes a high-speed network that transports data using a fiberoptic network and provides the highest quality of service between two data points. With speeds of 15 mbps, the ATM system provides low transport delays and high-quality outcomes as was used in the first transcontinental telesurgery performed. ² As technology advances, the role of fifth generation wireless system has made performing telesurgery more feasible and cost effective as local telecommunication companies are able to provide high-speed data services across vast distances. This was tried and tested in a telerobotic spine surgery procedure done in China using local 5G network services with a high success rate of 92% with no intraoperative adverse event. ²⁶ To further increase the success of surgery and make it as real as possible for the surgeon, the role of haptic feedback has been brought to existence using 5G data network and has shown to improve dexterity, increase precision which leads to higher success rates when compared to conventional surgery.^{27, 28}

Training and safety

Surgeons, nurses, and technical support staff who are going to be performing such procedures must have undergone training under direct supervision, have completed the required number of hours and hold a robotic surgery qualification from institutions that have fulfilled the requirements.^{29, 30} Safe protocols must be developed for every type of procedure that is going to be performed, all staff members must be prepared for all types of emergency situations. Local emergency surgeons and nurse personnel should be present at all times to oversee such procedures in rural setups where such services plan to be set up.

Legal and ethical concerns

The last issue left to legitimize telesurgery is a legally binding contract providing the highest standard of care. When such a service is to be setup both nationally or internationally, it is imperative that it meet all ethical and legal criteria. The hospitals and clinical setups to be involved should draw up a framework which includes equal responsibility, shared decision making, and prioritizing patient confidentiality. A complete consent form should be signed from the patients informing them of the procedure and all its details. The clinical setup should have an insurance company set up specifically for covering the costs of the procedure and if the need arises, complications both intra and post-operative. ³¹ Regardless of cross-border care and lack of direct patient contact the standard of medical ethics which includes informed consent, confidentiality, answering all patient questions, recording, and storage of patient data should be the same as if they were in a standard setup. ³²

Conclusions

Telemedicine and Telesurgery is the future of universal healthcare which has vast potential to overcome the barriers in providing the highest quality of care to patients in rural and distant setups. We hope that these recommendations can become the guidelines for establishing a successful telesurgery practice and provide the framework for making it a realistic goal.

ORCID iD

Muhammad Hammad Malik https://orcid.org/0000-0003-3929-7916