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Clinical Practice

Surgery in the Information Age

Currently, surgical procedures involve direct data flows of sensation and mechanical output. As information technology progresses, surgery will change to a system of electronic data flows, with technical, ethical, and training implications.

Patrick Cregan

MJA 1999; 171: 514-516

Introduction - Electronic sensory input - Electronic mechanical output - The patient -- the data source - The surgeon - Conclusion - References - Authors' details
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Introduction Currently, a surgical procedure is a direct human-to-human process in which sensory input and mechanical output data flow directly between patient and surgeon (Box 1). Procedures are usually taught using human or animal models and the utility of the procedure and the surgeon's ability are measured predominantly by patient outcomes. However, new technologies in which computing, graphics, robotics, telecommunications and touch converge are changing all this. A surgical procedure will become a flow of electronic data: sensory input will be transmitted electronically to the surgeon, the surgeon's responses and actions will be converted to electronic data, and then translated back to mechanical intervention at the patient.


Electronic sensory input
The application of television to surgery was the basis for the revolution in laparoscopic cholecystectomy and similar advances in arthroscopic and other endoscopic surgical techniques (Box 2). With these techniques, the surgeon receives and responds to electronic data. Not only vision but other sensory input data -- force feedback sensation, touch and proprioception -- can be relayed locally or at a distance in real time.1,2 "Telesmell" is under development;3 currently about 30 smells can be rendered via an electronic interface.

Implications

  • Electronic sensory input can be manipulated. Images can be overlaid with other digital data -- a television monitor can display the patient's tumour, as imaged with spiral computed tomography (CT) or magnetic resonance imaging (MRI), superimposed on the live image to guide the surgeon (eg, Navitrack, Orthosoft Inc, Montreal4). Other data, such as history, vital signs or other physiological data, can be included in the image, or the image can be magnified, enhanced or rendered in three dimensions. The surgeon now has enhanced sensory input beyond that which is currently available in the traditional surgical scenario of the patient on the operating table.

  • Additional sensory inputs can be added to further enhance skills; for example, proximity sensing with ultrasound can drive an audio feedback similar to that used in aircraft signalling ground approach.5


Electronic mechanical output
Sensory input is only one half of the data loop in a surgical procedure. For electronic surgery the surgeon's actions must be translated reliably into electronic data which can be translated back to mechanical output.

The means for mechanical-to-electronic translation is already in use in our daily lives -- the mouse and keyboard on our computer, or controllers for video games. Surgical control interfaces have been developed: these include hand-controlled adapted instruments (eg, Virtual Laparoscopic Interface, Immersion Corporation, San Jose, California6); gloves to measure and translate hand movement to data flows (eg, CyberGlove, Virtual Technologies Inc, Palo Alto, California7); and sensors fitted to ordinary instruments (eg, the 3D tool developed at Stanford University using a miniBIRD sensing system [Ascension Technology Corporation, Burlington, Vermont]8).

Implications

  • An electronic interface allows for other methods of data input. Voice control and activation are in routine use in operating rooms with the AESOP camera-holding robots (Computer Motion Inc, Santa Barbara, California)9 and the HERMES system of controlling many functions of the operating room (Computer Motion). Other possibilities for interaction being explored include electromyographically driven devices.

Machines are good at things that humans are poor at. Machines can be immensely strong or gentle, they are perfectly still when required or can move very rapidly. Their motion can be scaled up and down and they do not become tired or bored.

Electronic-to-mechanical translation has been slower to develop, but there are now robots (AESOP)9 holding and moving laparoscopic cameras in operating rooms, approved by the US Food and Drug Administration (FDA). The first fully robotic procedure, in which all the instruments were held and moved by a robot (ZEUS, Computer Motion),9 was performed in a real life tubal reanastomosis procedure at the Cleveland Clinic in June 1998. The FDA has now given approval for a trial in humans of ZEUS for microvascular cardiac and other minimally invasive procedures, and daVinci surgical robotic systems (Intuitive Surgical Inc, Mountain View, California)10 are being assessed for use in many common surgical procedures (Box 3). French surgeons have operated on human hearts using robots to hold and use the instruments,9 and in the United States several institutions are assessing these technologies.11,12

Implications

  • A surgeon can be actively involved in mechanical movement in an operative procedure at a remote site (telesurgery). This has been performed at several places around the world, including a demonstration at the Royal Australasian College of Surgeons' Annual Scientific Congress in Sydney in 1998.

  • Surgical skills can be improved and new procedures may be realised; for example, beating heart coronary bypass grafts with the effectors suturing under the surgeon's control while the heart and instruments appear still to the surgeon because the view and effector instruments are electronically synchronised with the heart's movements.


The patient -- the data source
In the electronic data flow model, the patient is the main source of data, encompassing anatomy, pathology, mechanical and physiological responses to tissue handling (local and general). These data change continuously in response to the surgeon's actions. There are now a number of virtual reality (VR) simulators where training can occur using a simulated system as the "patient", with excellent graphics and the ability to change anatomy, pathology and operative problems (eg, to simulate bleeding). For example, HT Medical Inc (Gaithersburg, Maryland) produces a realistic intravenous catheterisation simulator,13 and bronchoscopy, colonoscopy, gastroscopy and arthroscopy simulators are now appearing.5,14

Implications

  • The electronic data that represent the patient can be simulated, manipulated, stored and accessed at a distance in time and space from the surgeon.

  • The need for live-patient or animal training is past; virtual surgery and VR surgical simulation have arrived.

  • Preoperative simulation may raise ethical dilemmas as well as improve technique: do we believe a simulation that says that the patient is unsuitable for operation, or try anyway in a "hopeless" case?

  • Patient privacy may be hard to guarantee when patients are reduced to "data pools".


The surgeon
Can the surgeon then be replaced in the data loop? Ultimately, the answer is "yes". However, there are technical limitations, which mean that this will happen slowly. In particular, the human ability to recognise complex patterns in real time, to develop and amend complicated strategies and to monitor the results, combined with machine limitations (insufficient computing power, lack of bandwidth to transfer the necessary data in real time and poor pattern recognition by machines), mean that surgeons will be needed at least for the foreseeable future.

Implications

  • Because the surgeon's actions are now a stream of data, they can be stored, measured, scored, reproduced and used as educational tools. One surgeon can teach procedures to many individuals simultaneously, assess their progress, and certify competence against a scale of objective measures. There is evidence that VR training using the MIST VR trainer15 or similar interface16 improves skill acquisition beyond conventional techniques. Skills decomposition studies, in which the various actions in a procedure are separated out and analysed, suggest that VR training may have a useful role in learning technique.17

  • Recertification or skills upgrading can be assessed through VR simulations.

  • New techniques can be learned remotely and rehearsed prospectively.

  • Ongoing monitoring of competence is available not only to the surgeon, but also to patients, hospital administrations, registration authorities, colleges and government.

A glimpse of the future

Dr Mary Jones wishes to perform a new technique for minimally invasive liver resection. She has studied the literature and videos, and attended a virtual workshop at the liver resection Internet site. The basic procedure was rehearsed at her surgical workstation, using a medical VR model developed by Dr Stephen Lucasberg. Her technical skills in the procedure have been assessed and accredited by the College of Surgeons' virtual certification process, and permission for the procedure was granted by the hospital's credentials committee.

A virtual simulation of the procedure, using the actual patient's MRI- and CT-derived images, indicates a 92% likelihood of success, so, after discussion with the patient, the procedure is undertaken. As this is the first time the procedure has been done in Australia, the surgery is being telementored and assisted by Dr Gates in Seattle, using a telesurgery interface so that he will be able both to assist and complete the procedure if there are problems.

The image of the patient's lesion is overlaid with data from the preoperative MRI scan, and CT scan data are available to overlay as well. After introduction of the instruments, the procedure commences. Despite the patient's respiratory excursion, and therefore movement of the liver, the working image and instruments remain still, as they are linked electronically to fiduciary points in the image.

Magnification of the image is readily available as needed, and proximity sensors fitted to the tips of the instruments will help identify and avoid damage to the inferior vena cava, which lies close behind the lesion.

As Dr Jones recently fractured her forearm while skiing, she will use electromyography to control her left-hand instruments and retinal tracking to control the picture. A voice interface controls the light and camera settings, cable position, and data display on the screen, and can call up laboratory results and other data.

The procedure was completed successfully and Dr Jones's movements were all stored, analysed, and subsequently scored. Dr Gates reviewed the scores and noted some over-shooting of the liver resector posteriorly, and recommended that Dr Jones undertake additional training in depth perception analysis before her next procedure. Her registrar will replay the procedure a number of times, being guided by haptic feedback to the instruments she is holding so as to learn the tissue "feel" and proprioception in the procedure.
Conclusion The convergence of Information Age technologies such as computing, robotics and telecommunications will radically alter the performance, teaching, recording and assessment of surgical procedures. The concept of surgery as a flow of data between surgeon and patient gives a framework for assessing these technologies and developing new techniques.

References
  1. Satava RM, Jones SB. Human interface technology. In: Satava RM, editor. Cybersurgery: advanced technologies for surgical practice. In: Sackier JS, Series editor. Protocols in general surgery. New York: John Wiley & Sons, 1998; 24, 28, 30.
  2. Satava RM, Jones SB. Telepresence surgery. In: Satava RM, editor. Cybersurgery: advanced technologies for surgical practice. In: Sackier JS, Series editor. Protocols in general surgery. New York: John Wiley & Sons, 1998; 143-144.
  3. Krueger MW. Olfactory stimuli in virtual reality for medical applications. In: Medicine meets virtual reality. 7: The convergence of physical and informational technologies: options for a new era in healthcare. Proceedings of the Seventh Medicine Meets Virtual Reality Conference. 1999 Jan 20-23, San Francisco. 61.
  4. Navitrack. Orthosoft.<http://www.orthosoft.ca/navitrack.html>. Accessed 12 October 1999.
  5. Karron DB, Bucholz RD, Wegner K, Zicarelli D. Tactical audio for neurosurgical navigation: first clinical experience. In: Medicine meets virtual reality. 7: The convergence of physical and informational technologies: options for a new era in healthcare. Proceedings of the seventh Medicine Meets Virtual Reality Conference. 1999 Jan 20-23, San Francisco. 58.
  6. Immersion Corporation. <http://www.immerse.com/>. Accessed 12 October 1999.
  7. Virtual Technologies, Inc. <http://www.virtex.com/>. Accessed 12 October 1999.
  8. Ascension Technology Corporation. <http://www.ascension-tech.com/>. Accessed 12 October 1999.
  9. Computer Motion, Inc. <http://www.computermotion.com/>. Accessed 12 October 1999.
  10. Intuitive Surgical, Inc. <http://www.intusurg.com/>. Accessed 12 October 1999.
  11. Department of Surgery. Uniformed Services University of the Health Sciences.<http://surgery.usuhs.mil/>. Accessed 12 October 1999.
  12. Department of Surgery. Yale University. <http://yalesurgery.med.yale.edu/>. Accessed 6 October 1999.
  13. HT Medical Systems, Inc. <http://www.ht.com>. Accessed 12 October 1999.
  14. Englmeier K, Haubner M, Krapichler C, Reiser M. A new hybrid renderer for virtual bronchoscopy. In: Westwood JD, Hoffman HM, Robb RA, Stredney D, editors. Medicine meets virtual reality. In: studies in health technology and informatics technology. Vol. 62. Ohmsha: IOS Press, 1999; 109-115.
  15. Chaudhry A, Irvine V, Sutton C, McCloy R. Quality of human-computer interaction, learning rate, fixed and variable factors affecting performance on a laparoscopic simulator, MIST VR. In: Medicine meets virtual reality. 7: The convergence of physical and informational technologies: options for a new era in healthcare. Proceedings of the seventh Medicine Meets Virtual Reality Conference. 1999 Jan 20-23, San Francisco. 43-44.
  16. Gorman PJ, Lieser JD, Murray WB, Haluck RS, Hummel TM. Evaluation of skill acquisition using a force feedback, virtual reality based surgical trainer. In: Westwood JD, Hoffman HM, Robb RA, Stredney D, editors. Medicine meets virtual reality. In: studies in health technology and informatics technology. Vol. 62. Ohmsha: IOS Press, 1999; 121-123.
  17. Cao CGL, MacKenzie ML, Ibbotson JA, et al. Hierarchical decomposition of laparoscopic procedures. In: Medicine meets virtual reality. 7: The convergence of physical and informational technologies: options for a new era in healthcare. Proceedings of the seventh Medicine Meets Virtual Reality Conference. 1999 Jan 20-23, San Francisco. 43.

Authors' details Nepean Hospital, Penrith, NSW.
Patrick Cregan, FRACS, Surgeon, Department of Surgery.

Reprints: Dr P Cregan, PO Box 1124, Penrith, NSW 2751.
Patrick_CreganATonaustralia.com.au

©MJA 1999
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