Ayaz,, Ahmed

Docherty, Charles

Hasan, Obada Hussein

Hashmi, Pervaiz

Khan, Muneeba

English

eCommons@AKU

eCommons@AKUDepartment of Surgery Department of SurgeryFebruary 2019The need for simulation in surgical education indeveloping countries. The wind of change. ReviewarticleObada Hussein HasanAga Khan University, obada.husseinali@aku.eduAhmed Ayaz,Aga Khan UniversityMuneeba KhanAga Khan University, muneeba1984@hotmail.comCharles DochertyAga Khan University, charles.docherty@aku.eduPervaiz HashmiAga Khan University, pervaiz.hashmi@aku.eduFollow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_surg_surgRecommended CitationHasan, O. H., Ayaz,, A., Khan, M., Docherty, C., Hashmi, P. (2019). The need for simulation in surgical education in developingcountries. The wind of change. Review article. The Journal of the Pakistan Medical Association, 69(Supl. 1), S62-s68.Available at: https://ecommons.aku.edu/pakistan_fhs_mc_surg_surg/768Telesurgery prospects in delivering healthcare in remote areasNoman Shahzad,1 Tabish Chawla,2 Tanzeela Gala3AbstractFeasibility and safety of performing remote surgery wasfirst established by performing surgeries on pigs in laterpart of the 20th century. The first tele-robotic remotesurgical system was set up in Canada in 2003 betweentwo hospitals 400 kilometres away. The current reviewwas planned to have a look at the current state of roboticsurgery and its use in telesurgery. Literature search wasconducted for articles related to "Robotic Surgery" and"Tele-Surgery". Our search included articles published inEnglish literature, including case studies and reviewarticles. We searched Google Scholar and PubMed tosearch relevant articles. Introduction of haptic feedbacktechnology added significantly to safety robotic surgery.Tele-surgery, also called tele-robotics, combines theadvantages of robotic surgery, including magnified view,augmented reality and improved ergonomics anddexterity, and provision of surgical care in remote areasand difficult-to-reach locations like spacecrafts and ships.Challenges, like cost, availability and legislations, remainto be addressed.Keywords: Robotics, Tele-robotics, Medical education,Ethical issues, Cyber security.IntroductionConcept of distance between the surgeon and the patientcame with the advent of robotic surgery (RS). Havingbenefits of increased dexterity, accuracy and accessibilityto difficult locations such as pelvis, RS was well receivedby urologists and colorectal surgeons in particular andabdominal and thoracic surgeons in general.Combination of  rapid telecommunication andadvancements in RS led to tele-surgery (TS) as a feasibleoption.Feasibility and safety of performing RS was firstestablished by performing surgeries on pigs in the laterpart of the 20th century. Successful cholecystectomieswere performed on six pigs in Strasbourg while theoperator was in New York, a transatlantic round-tripdistance of over 14,000 kilometres. These operationsestablished that time-lag did not impact surgicalperformance and the procedure was safe, including theuse of electrocautry.1 On September 7, 2001, professorJacques Marescaux, along with his team, from theInstitute for Research into Cancer of the Digestive System(IRCAD), successfully performed first human TScholecystectomy in 54 minutes, and the operation wasnamed as the 'Lindbergh Operation'.2 The mean time-lag during the procedure was 155ms which isimperceptible to human eye.3 Dr Marescaux commentingon the operation said, "The demonstration of thefeasibility of a trans-Atlantic procedure - dubbed'Operation Lindbergh' is a richly symbolic milestone. Itlays the foundations for the globalisation of surgicalprocedures, making it possible to imagine that a surgeoncould perform an operation on a patient anywhere inthe world".4Surgeon at a distant location can have a variable levelof involvement depending upon clinical and educationalneeds. Tele-mentoring is distant supervision of surgicalprocedure with feedback given by the distant surgeonwho is watching real-time video of the procedure. Tele-stration is the form tele-mentoring in which the mentorremotely illustrates and annotates on a monitor that isvisible in the operating room. These graphical instructionsare overlaid on the real-time picture of the operativefield. This is important in RS training. Safety and feasibilityof tele-mentoring has been demonstrated via someobservational studies.5Partial involvement of proctor in operation is called tele-assist in which the mentor performs or assists part of theoperation from the distant location. Specifically designedrobots, such as The Socrates™ Tele-mentoring System,are approved by the Food and Drug Administration (FDA)in the United States for mentoring purposes.6Though RS owing to the magnified view, augmentedreality and improved ergonomics and dexterity hasrevolutionised the minimally invasive procedures andtraining, tele-robotics is still in infancy.7 The availability1General Surgery, Queen Elizabeth The Queen Mother Hospital, East KentHospitals University, NHS Foundation Trust, 3General Surgery, Royal Free HospitalNHS Foundation Trust London, UK. 2General Surgery, Aga Khan UniversityHospital Karachi Pakistan.Correspondence: Tabish Chawla. e-mail: Tabish.chawla@aku.eduS-69Vol. 69, No. 01, (Suppl. 1) February 2019is poor in remote and rural areas. Major limitations arethe cost of robotic systems and the rapid wirelessconnectivity.The first tele-robotic remote surgical system was set upin Canada in 2003 between St. Joseph's Hospital inHamilton and North Bay General Hospital 400 kilometresaway using ZEUS-TS surgical system.8 The operation wasconducted using 15 Mbps of bandwidth network whichwas used for local internet services. Although the latencyusing this network was noticeable to the surgeon, it didnot affect performance. A total of 21 surgeries wereperformed without major complications.Challacombe B. et al. demonstrated that though roboticaccess to the kidney in percutaneous nephrolithotomywas slower than human insertion (56.5s vs 35s), accuracywas more (first attempt success: 88% vs 79%). Similarresults were obtained when procedures were carried outusing trans-Atlantic robot carried out via IntegratedServices for Digital Network (ISDN) lines.9 Ultrasound-guided renal biopsies have also been carried outsuccessfully using tele-robots.10Haptic Feedback TechnologyThe technology that enables transmission of tactileinformation to the tele-operator is termed 'hapticfeedback'. During operation, haptic feedback is crucialas it allows the surgeon to feel the consistency of tissueand, hence, force on the instruments is adjustedaccordingly. It is of particular importance while tyingknots and dissecting between tissue planes as too muchtension can potentially damage the tissues and too lesstension can produce suboptimal results.11,12 Early TSswere carried out relying solely on visual feedback.13 Thefirst TS prototype that implemented haptic feedbacktechnology was Telelap Alf-X, which was introduced in2015 in Italy. It successfully reduced the average time ofexperimental cholecystectomy by 60 minutes.12BenefitsBecause tele-robotic surgery operates through roboticsurgical systems, it also takes advantage of all the existingbenefits of general RS. These benefits include increaseddexterity, more natural hand-eye movement thantraditional laparoscopic surgery, filtering of hand tremors,customisable sensitivity settings, and high-quality three-dimensional (3D) visualisation with up to 10Xmagnification. In addition to benefits of RS as describedabove, operating at a distance can be beneficial in otherareas as well.Remote Areas: It promises to allow the expertise ofspecialised surgeons to be available to patientsworldwide, especially underserved areas, without theneed for patients to travel beyond their local hospital.This is particularly beneficial in situations where transferhas its own risks and time delay in transfer can becounterproductive.Military Interest: Providing expert surgical care tomobile military units can be made possible through tele-robotics. A few surgeons with expertise in specific areascan provide care to multiple units from a distant location.Naval and Space interest: Providing specialised surgicalcare to inaccessible units in space and on ships can bebrought about through utilisation of advancement intele-robotic technology.14 Feasibility studies to operatein space have already been carried out by NationalAeronautics and Space Administration (NASA). Majorlimitation remains the time latency due to longdistances.15Remote Surgical Training: Surgeons present at the siteof operation can get benefit from the expertise of theremote surgeon.16 Various degrees of interaction arepossible between remote surgeon and the surgeon onsite. In its least form, tele-mentoring can be in the formof instructions only by the proctor from the remotelocation who is watching the real-time video of theoperation being performed. On the other hand, with thehelp of distant robotic arms, TS can be eitherdemonstrated or assisted. This can potentially improvesurgical training in remote areas, ultimately improvingsurgical care.6ChallengesLatency: Time-lag between surgeon's initiation ofmovement and its actual appearance on console canarise due to delay in communication lines and/or codingand decoding of video signals. Increased latency canpotentially increase surgical inaccuracies.17,18 Ideally,latency time less than 100 msec is considered to be safeand more than 300 msec has been seen to be associatedwith technical difficulties.19 In another instance, latencyof 135-140 msec was noticed during surgery, but safetyand effectiveness was not compromised due to surgeons'adaptability.8,20 Latency of up to 200 msec is known toS-70 N. Shahzad, T.Chawla, T. GalaJ Pak Med AssocTelesurgery prospects in delivering healthcare.....be acceptable.19 Present day high-speed fibre opticcables along with dedicated asynchronous transfer mode(ATM) can achieve latency time of less than 100 msecbut availability of this network remains a challenge.Cyber Attack: As providing surgical care at a distanceis dependent upon network communication, it is proneto cyber-attack and leakage of sensitive data.21 Thoughend-to-end encryption provides security againstinformation leak, backup systems are needed in casecyber-attack during operation either completely blocksthe communication or alters command. This can bepotentially harmful.Cost: Affordability of robotic system and high-speedtelecommunication network is also a concern, especiallyfor developing nations. Though accurate assessment ofthe cost is not possible at the moment due to variablefactors according to geographic locations, new-generation robots are likely to be cheaper as more andmore companies get the license to produce them.Legal and Ethical Concerns: Regulations and licensurerequirements to practise medicine vary from country tocountry and providing surgical care across borders willrequire fulfilling geographic legal requirements. Standardoperating procedures (SOPs) are needed to be definedfor consenting of patients by surgeons operating fromremote locations.  This equally applies to theresponsibilities of complications arising as a result oftechnical failure of communication lines. As laws differacross the globe, a consensus is needed and global lawsare to be made which should be acceptable toparticipating countries.ConclusionTele-surgery, also called tele-robotics, combines theadvantages of robotic surgery that include magnifiedview, augmented reality and improved ergonomics anddexterity, and provision of surgical care in remote areasand difficult to reach locations like spacecraft and ships.Cost, availability and legislations to address legal andethical issues remain to be addressed.Disclaimer: None.Conflict of Interest: None.Source of Funding: None.References1. Marescaux J, Leroy J, Gagner M, Rubino F, Mutter D, Vix M, et al.Transatlantic robot-assisted telesurgery. Nature 2001;413:379-80.2. Marescaux J. [Code name: "Lindbergh operation"] Ann Chir2002;127:2-4. French3. Marescaux J, Leroy J, Rubino F, Smith M, Vix M, Simone M, et al.Transcontinental robot-assisted remote telesurgery: feasibility andpotent ia l  a ppl ica tions.  A nn S urg 2 00 2;235 :487 -92.4. Raison N, Khan MS, Challacombe B. Telemedicine in surgery: whatare the opportunities and hurdles to realising the potential? CurrUrol Rep 2015;16:43. doi: 10.1007/s11934-015-0522-x.5. Collins J, Dasgupta P, Kirby R, Gill I. Globalization of surgical expertisewithout losing the human touch: utilising the network, old andnew. BJU Int 2012;109:1129-31.6. Hung AJ, Chen J, Shah A, Gill IS. Telementoring and telesurgery forminimally invasive procedures. J Urol 2018;199:355-69.7. Diana M, Marescaux J. Robotic surgery. Br J Surg 2015;102:e15-28.doi: 10.1002/bjs.9711.8. Anvari M, McKinley C, Stein H. Establishment of the world's firsttelerobotic remote surgical service: for provision of advancedlaparoscopic surgery in a rural community. Ann Surg 2005;241:460-4.9. Challacombe B, Patriciu A, Glass J, Aron M, Jarrett T, Kim F, et al. Arandomized controlled trial of human versus robotic and teleroboticaccess to the kidney as the first step in percutaneousnephrolithotomy. Comput Aided Surg 2005;10:165-71.10. Bruyère  F, Ayoub J, Arbeille P. Use of a telerobotic arm to performultrasound guidance during renal biopsy in transplant recipients:a preliminary study. J Endourol 2011;25:231-4.11. Stark M, Benhidjeb T, Gidaro S, Morales ER. The future of telesurgery:a universal system with haptic sensation. J Turk Ger Gynecol Assoc2012;13:74-6.12. Stark M, Pomati S, D'Ambrosio A, Giraudi F, Gidaro S. A newtelesurgical platform - preliminary clinical results. Minim InvasiveTher Allied Technol 2015;24:31-6.13. Stark M, Morales ER, Gidaro S. Telesurgery is promising but stillneed proof through prospective comparative studies. J GynecolOncol 2012;23:134-135.14. Takács AR, Nagy D, Rudas I, Haidegger T. Origins of surgical robotics:from space to the operating room. Acta Polytech Hung 2016;13:13-30.15. Marescaux, J. [State of the art of surgery: robotic surgery andtelesurgery.] Cir Cir 2013;81:265-8. Spanish16. Gambadauro P, Torrejón R. The "tele" factor in surgery today andtomorrow: implications for surgical training and education. SurgToday 2013;43:115-22.17. Korte C, Nair SS, Nistor V, Low TP, Doarn CR, Schaffner G. Determiningthe threshold of time-delay for teleoperation accuracy and efficiencyin relation to telesurgery. Telemed J E Health 2014;20:1078-86.18. Xu S, Perez M, Yang K, Perrenot C, Felblinger J, Hubert J. Effect oflatency training on surgical performance in simulated robotictelesurgery procedures. Int J Med Robot 2015;11:290-5.19. Xu S, Perez M, Yang K, Perrenot C, Felblinger J, Hubert J.Determination of the latency effects on surgical performance andthe acceptable latency levels in telesurgery using the dVTrainer®simulator. Surg Endosc 2014;28:2569-76.20. Sebajang H, Trudeau P, Dougall A, Hegge S, McKinley C, Anvari M.The role of telementoring and telerobotic assistance in the provisionof laparoscopic colorectal surgery in rural areas. Surg Endosc2006;20:1389-93.21. Bonaci T, Herron J, Yusuf T, Yan J, Kohno T, Chizeck HJ. To make arobot secure: an experimental analysis of cyber security threatsagainst teleoperated surgical robots. [Internet] ArXiv.org; 2015[ c i t e d  2 0 1 8  D e c e m b e r  2 6 ]  A v a i l a b l e  f r o m :https://arxiv.org/abs/1504.04339.S-71Vol. 69, No. 01, (Suppl. 1) February 2019

The need for simulation in surgical education in developing countries. The wind of change. Review article

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The need for simulation in surgical education in developing countries. The wind of change. Review article

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