Robotic surgery, telerobotic surgery, telepresence, and

Review article
Surg Endosc (2002) 16: 1389±1402
DOI: 10.1007/s00464-001-8283-7
Ó Springer-Verlag New York Inc. 2002
Robotic surgery, telerobotic surgery, telepresence,
and telementoring
Review of early clinical results
G. H. Ballantyne
Minimally Invasive and Telerobotic Surgery Institute, Hackensack University Medical Center, 20 Prospect Avenue, Hackensack, NJ 07601, USA
Received: 12 February 2002/Accepted in ®nal form: 25 March 2002/Online publication: 29 July 2002
Abstract
Although laparoscopic cholecystectomy rapidly became
the standard of care for the surgical treatment of
cholelithiasis, very few other abdominal or cardiac operations are currently performed using minimally invasive surgical techniques. The inherent limitations of
traditional laparoscopic surgery make it dicult to
perform these operations. We, and others, have attempted to use robotic technology to (a) provide a stable
camera platform, (b) replace two-dimensional with
three-dimensional (3-D) imaging, (c) simulate the ¯uid
motions of a surgeon's wrist to overcome the motion
limitations of straight laparoscopic instruments, and (d)
o€er the surgeon a comfortable, ergonomically optimal
operating position. In this article, we review the early
published clinical experience with surgical robotic and
telerobotic systems and assess their current limitations.
The voice-controlled AESOP robot replaces the cameraperson and facilitates the performance of solo-surgeon laparoscopic operations. AESOP provides a stable
camera platform and avoids motion sickness in the op1 erative team. The telerobotic Zeus and da Vinci surgical
systems permit solo surgery by a surgeon from a remote
sight. These telerobots hold the camera, replace the
surgeon's two hands with robotic instruments, and serve
in a master±slave relationship for the surgeon. Their
robotic instruments simulate the motions of the surgeon's wrist, facilitating dissection. Both telerobots use
3-D imaging to immerse the surgeon in a three-dimensional video operating ®eld. These robots also provide
operating positions for the surgeon console that are ergonomically superior to those required by traditional
laparoscopy. The technological advances of these telerobots now permit telepresence surgery from remote
locations, even locations thousands of miles away. In
addition, telepresence permits the telementoring of
novice surgeons who are performing new procedures
by expert surgeons in remote locations. The studies
reviewed here indicate that robotics and telerobotics
o€er potential solutions to the inherent problems of
traditional laparoscopic surgery, as well as new possibilities for telesurgery and telementoring. Nonetheless,
these technologies are still in an early stage of development, and each device entails its own set of challenges
and limitations for actual use in clinical settings.
Key words: Robots Ð Robotic surgery Ð Telerobotic
surgery Ð Telesurgery Ð Telepresence Ð Telementoring Ð Telemedicine Ð Laparoscopy Ð Laparoscopic surgery Ð AESOP Ð da Vinci Ð Zeus
2 With the advent of video laparoscopy, the staid surgical
suite of the 19th century entered the computer age [1].
The magni®ed and computer-enhanced video image
provided surgeons with superior exposure and visualization of the abdomen. Yet even a decade after the
introduction of video laparoscopic colectomy, most
gastrointestinal operations are still performed using 19th
century instruments and techniques. Indeed, in the year
2000, <3% of colon resections in the United States were
done laparoscopically [2]. Why have surgeons failed to
embrace minimally invasive gastrointestinal, urological,
and cardiothoracic surgery despite the obvious advantages to their patients?
Most laparoscopic gastrointestinal operations are
dicult operations to learn, master, and perform routinely. Surgeons face a long learning curve. Moreover, a
number of inherent pitfalls of laparoscopy hinder the
performance of advanced laparoscopic procedures.
These pitfalls include:
1. An unstable camera platform
2. The limited motion (degrees of freedom) of straight
laparoscopic instruments
3. Two-dimensional imaging
4. Poor ergonomics for the surgeon
1390
Since the introduction of video laparoscopic cholecystectomy, surgeons have speculated that computers, 3-D
imaging, and robotics could overcome these pitfalls of
laparoscopy [3, 4, 5].
In this article, we review the early published clinical
experience with surgical robotic and telerobotic systems
and assess their current limitations. We also brie¯y
review the early experience with telepresence surgery
and telementoring. Despite the paucity of documentation in the current literature, we will also address on
the speci®c limitations of the currently available robotic and telerobotic surgical systems. Our aim here is
to provide a perspective on the state of this emerging
®eld and to chart the directions in which it should
evolve.
De®nitions
operative ®eld to a remote site [6, 7]. Using the telerobot
to telecast their hand motions to the remote operating
room, surgeons perform operations without actually
seeing their patients. Telepresence enables a surgeon on
an aircraft carrier, for example, to operate on a
wounded soldier on the battle®eld [8].
Telementoring
Telementoring uses similar technology to create a virtual
classroom, or even a ``virtual university'' [9]. Telementoring permits an expert surgeon, who remains in his/her
own hospital, to instruct a novice in a remote location
on how to perform a new operation or use a new surgical technology. Telepresence thus provides a new
strategy for the training of surgical residents [10, 11] as
well as a new means of disseminating novel surgical
approaches around the world [12].
Robotic surgery
The ®rst robots introduced into clinical practice served
as camera holders. In 1994, the FDA approved AESOP
for clinical use as a robotic camera holder; more recently, it also approved a second robotic camera holder,
2 the Endoassist (Armstrong Healthcare Ltd., United
Kingdom). Surgical robots are controlled directly by the
2 surgeon, who stands at the side of the operating table.
Telerobotic surgery
More recently, surgical robots have evolved into telerobotic surgical platforms that permit surgeons to operate on patients from remote locations using robotic
instruments. The surgeon and telerobot work in a
master±slave relationship. Telerobots have been speci®
cally designed to overcome all four of the pitfalls of
laparoscopy. They maintain a stable camera platform,
use instruments that articulate at the end to simulate the
movements of the surgeon's hand, use three-dimensional
(3-D) imaging systems, and permit the surgeon to perform complex, advanced laparoscopic operations while
comfortably seated in an ergonomically correct position.
Telerobotic surgical systems have only recently achieved
limited approval for clinical use in the United States. At
the present time, telerobotic surgical systems o€er a
limited selection of instruments and bulky con®gurations that impede many speci®c surgical procedures.
Moreover, clinical experience, with the systems is limited. Thus, telerobotics must be regarded as an emerging
technology that is still in its infancy and in an early
phase of feasibility testing. The current generation of
telerobots is not sophisticated enough to displace prevailing standard surgical practice.
Telepresence
The development of satisfactory telerobotic platforms
has kindled interest in telepresence surgery and telementoring. Telepresence projects a virtual image of the
Robotic replacement of the camera holder
The ®rst clinically successful robot, the Robodoc, was
introduced for use in total hip replacement [13, 14]. The
initial goal was to replace the camera holder with a
surgeon-controlled robot. In 1993 at the University of
California at Davis, Moran was the ®rst to employ a
passive electronically-regulated, pneumatically controlled camera holder [15]. Working in TuÈbingen, Germany, Buess et al. developed a prototype of a robotic
camera holder, the FIPS Endoarm [16]. This robotic
arm was remotely controlled with a ®nger ring that was
clipped to one of the surgeon's instruments. It moved
with four degrees of freedom while maintaining an invariant point of constraint motion.
A British company, Armstrong Healthcare Ltd.,
3 markets a robotic camera holder known as the ``Endoassist'' [17, 18] that has recently received FDA approval for use in the United States. Unfortunately, very
little has been published about it to date. This device
allows the surgeon to control its movements with his or
her head. A device that emits infrared rays is worn by
the surgeon. When the surgeon points the infrared
beam to the point on the video monitor that he or she
wishes to see, the robot adjusts the camera to view this
area.
From the Hotel-Dieu de Montreal Hospital, Gagner
et al. reported three laparoscopic cholecystectomies that
they performed with a prototype of a robotic surgical
assistant [19]. The robotic arm moved with six degrees of
freedom. It was controlled with a joystick by a surgeon
in a remote room who viewed the operation on a
monitor. In 1995, they updated their experience with
this device [20]. Between 1 September 1993 and 10 October 1994, they successfully accomplished eight laparoscopic cholecystectomies with cholangiography in
humans using this device. Total anesthesia time for these
operations averaged 63 min. They concluded that their
study ``represented a ®rst step toward the introduction
of robotic technology in laparoscopic surgery.''
1391
Fig. 1. AESOP, a voice-controlled robot, holds the video camera
during laparoscopic procedures. It maintains a stable camera platform
and ensures proper alignment of the video image with the horizon.
This photograph shows a surgeon performing a solo laparoscopic left
hemicolectomy with the assistance of AESOP.
AESOP
The ®rst robot approved by the FDA for clinical use in
the abdomen was automated endoscope system for optimal positioning (AESOP) (Computer Motion, Santa
4 Barbara, CA, USA) (Fig. 1). FDA approval was granted
in 1994. The acronym AESOP stands for Automated
Endoscopic System for Optimal Positioning. Computer
Motion was initially funded by a research grant from
NASA and charged with the development of a robotic
arm for the US space program. This arm was later
modi®ed to hold a laparoscope and to replace the laparoscopic camera holder. When it was ®rst introduced,
the surgeon controlled the robotic arm either manually
or remotely with a foot switch or hand control [21, 22]
but more recent generations of AESOP are voice controlled [23, 24]. The robot, which attaches to the side of
the surgical table, has a series of adapters that allow any
rigid laparoscope to be grasped.
Urologists at Johns Hopkins have demonstrated the
utility of AESOP for urological laparoscopic operations
[25]. They studied the use of AESOP as a camera holder
in 17 urological procedures, including nephrectomy,
retroperitoneal lymph node sampling, varix ligation,
pyeloplasty, Burch bladder suspension, pelvic lymph
node dissection, orchiopexy, ureterolysis, and nephropexy. When they compared these robotically assisted
operations to historical controls in which a surgical assistant held the camera, there was no increase in operating time in the robotic operations. They concluded
that it might prove cost e€ective in the future to replace
human surgical assistants with robotic assistants. In a
second study, the same group found that AESOP provided a signi®cantly steadier camera platform than the
human camera holder [26].
Surgeons in Kiel, Germany, explored the use of
AESOP in gynecological laparoscopic operations and
compared voice control of AESOP with the older foot
or hand control systems [27]. They found that the robotic arm allowed them to perform complex laparo-
scopic operations faster than when the camera was held
by a human assistant. In addition, they concluded that
the voice-controlled AESOP worked more eciently
and faster than the older systems.
AESOP facilitates solo-surgeon laparoscopic procedures in general surgery. Geis et al. used AESOP to
perform 24 solo-surgeon laparoscopic inguinal hernia
repairs, cholecystectomies, and Nissen fundoplications
[28]. All procedures were completed successfully without
the aid of a surgical assistant. Groups in Antwerp,
Belgium, and Catania, Italy, have found AESOP helpful
in performing laparoscopic adrenalectomies [29, 30].
Both groups found that the camera platform provided a
stable, constant video image that facilitated the operation. We recently documented the ability of AESOP to
facilitate solo-surgeon laparoscopic colectomy [31]. We
compared 14 robot-assisted laparoscopic colectomies
performed in 2000 with 11 laparoscopic colectomies
done the previous year. All operations were for benign
disease. We found that there was no di€erence in the
operating time between the two groups. Eleven of the 14
robot-assisted operations were done by a solo surgeon
using a three-trocar technique and without the help of
an assistant surgeon. The most common reason for
adding a fourth trocar was the need for the lysis of
adhesions from previous abdominal operations. These
two studies indicate that AESOP can adequately replace
a human camera holder for general surgery laparoscopic
procedures. Moreover, these studies found that the
surgeon can often perform laparoscopic hernia and
gastrointestinal operations on a solo basis, without the
need for a surgical assistant.
5
Surgeons in Munich, Germany, have also developed
a modi®cation of AESOP. Their SGRCCS system works
on a color tracking system [32]. They modi®ed AESOP
so that the robot automatically follows a color marker
attached to one of the laparoscopic instruments inserted
into the operative ®eld. They compared the use of
SGRCCS in 20 laparoscopic cholecystectomies with the
use of a human camera holder. The operative time was
slightly shorter with the robot: 54 min vs 60 min with the
human camera holder. There was a subjective impression on the part of the surgeon that the robot outperformed the human camera holder 70% of the time.
AESOP has successfully launched the era of robotassisted surgery. It can reliably replace a human camera
holder, and it provides a stable camera platform that
may diminish the risk of motion sickness in the operative team. Skilled surgeons can use AESOP to perform
solo laparoscopic operations without a camera holder or
surgical assistant. In some hospitals, AESOP may o€er
cost advantages by decreasing the number of hospital
employees required to assist in laparoscopic operations.
Limitations of AESOP
Many surgeons may not attain time savings and cost
advantages with AESOP. This robot demands speci®c
modi®cations to accommodate the surgeon's operating
style. Voice control of AESOP requires constant chattering by the surgeon, which other members of the team
1392
may ®nd distracting. Moreover, voice control is slow
compared to the rapid camera movements that can be
achieved by a practiced and attentive assistant. This
drawback tends to encourage the surgeon to complete a
dissection in a single visual ®eld rather than jumping
back and forth among several ®elds. Many surgeons
may not wish to change the style of laparoscopic dissection that they have developed over the last decade.
Indeed, surgeons who frequently perform laparoscopic
cholecystectomies as a two-person team using a fourtrocar technique may well ®nd that AESOP increases
the average operating time.
Although AESOP has the potential to lower costs by
replacing a camera holder, this cost savings is not generally borne out in real operative situations. Most laparoscopic procedures require a surgical assistant, and
many operations (such as cholecystectomy) are performed with four trocars. This method permits the assistant surgeon to provide exposure with one hand while
holding the camera with the other. In teaching hospitals,
cost savings are even more unlikely. Surgical residents or
medical students, who often act as assistant surgeons
and camera holders, do not add any cost to the operation. As a result, replacing them with AESOP does
not reduce hospital costs and may even interfere with
surgical training.
Telerobotic abdominal surgery
Telerobotic surgery, or telepresence surgery, is the next
step in the evolution of robotic surgery [33]. In these
operations, the surgeon sits at a computer console. The
computer translates the movement of the surgeon's
hands into motions of the robotic instruments. The
surgical telerobot, which is positioned by the side of
the patient, holds the camera and manipulates two or
more surgical instruments. The surgeon and computer
console can be positioned at a remote site. The surgeon
acts as the ``master'' and the robot as the ``slave'' [34].
The feasibility of remote surgeon telerobotics was ®rst
demonstrated in 1991 [35]. The concept was that this
technology would permit a surgeon at a remote site
(such as an aircraft carrier) to operate on a distant
patient (such as a wounded soldier on the battle®eld)
[36].
Several groups developed systems that were designed
to replace the surgical assistant. First-Assistant, for example, was a nonelectronic, pneumatically controlled
robotic arm. The surgeon moved the device manually
[37]. More recent robotic systems were designed to replace both the surgical assistant and the camera holder.
In general, these robots were similar to camera-holding
robots but were modi®ed to hold surgical instruments.
The surgeon controlled these robots with foot or hand
controls [38, 39]. Buess et al. have been working on a
6 new telerobotic system called advanced robotic telemanipulator for minimally invasive surgery (ARTEMIS), but it is not yet ready for clinical trials [40, 41].
Two telerobotic systems are currently commercially
availableÐZeus (Computer Motion) and da Vinci (Intuitive Surgical, Mountain Mountain View, CA, USA).
Fig. 2. The da Vinci robotic surgical system consists of three parts: A
the surgeon's console, B an electronics tower holding video equipment,
and C the robotic arms. Surgeons look into the binocular view®nder,
immersing themselves in a three-dimensional projection of the operative ®eld. The ``masters'' into which the surgeon slides his/her ®ngers
translate the motions of the surgeon's hands into movements of the
robotic instruments.
Da Vinci
Da Vinci consists of three separate parts (Fig. 2) [42].
The surgeon sits in an ergonomically comfortable and
advantageous position at a console or work station
(Fig. 3). His/her hands ®t into ``masters'' that act as the
interface with the computer. The computer and (3-D)
imaging system ®ll the remainder of the console. A
tower holds the video electronic equipment and an insu‚ator for the pneumoperitoneum. The robot has
three arms. The central arm holds the camera, and the
two outer arms hold the surgical instruments. The surgical instruments articulate at a ``wrist.'' They move
with seven degrees of freedom and two degrees of axial
rotation. The robot is moved to the side of the surgical
table. It is connected to the three operative trocars and
not to the surgical table. The computer keeps track of
the 3-D location of a point near the trocar's tip, not the
tip of the surgical instruments. The telescope passes
through a 12-mm trocar and the surgical instruments
through two 8-mm trocars. In the United States, the
surgical instruments are partially reusable; they can be
used 10 times. The telerobot's computer tracks the
number of uses of each instrument and will not operate
an instrument after the 10th use.
Da Vinci o€ers a true 3-D imaging system that is
much like looking through ®eld binoculars. The telescope for this system is 12 mm in diameter and contains
two separate 5-mm telescopes. Two three-chip video
cameras telecast the image to two separate CRT screens.
A synchronizer keeps the images from the two cameras
in phase. Mirrors re¯ect the images from the CRT
screens up to the binocular viewer in the surgeon's
console. In this system, the left and right images remain
separated from telescopes to the surgeon's eyes. As in
binoculars, the right eye sees the right image and the left
eye sees the left image.
Cardiac surgery
Da Vinci was designed speci®cally to accomplish closedchest coronary artery bypass grafting [43]. As a result,
1393
Fig. 3. Simulated setup of the operating room for a telerobotic laparoscopic cholecystectomy using the da Vinci telerobotic surgical system. The surgeon sits in an economically comfortable position at the
console. The bedside assistant switches instruments on the robotic
arms as required.
cardiac surgeons have accumulated substantial experimental experience with da Vinci prototypes [44±46]. In
1999, Carpentier et al. reported the ®rst successful use of
da Vinci for closed-chest coronary artery bypass grafting
[47]. Surgeons in Dresden have used da Vinci to harvest
both the left and right internal mammary arteries for
coronary artery bypass grafting in 27 patients [48]. Once
the arteries were harvested, the coronary artery bypass
was constructed through a left mini-thoracotomy. The
Leipzig group has rapidly accumulated a large clinical
experience with da Vinci for coronary artery bypass
surgery [49]. They used da Vinci in a progressive manner. Initially, they used da Vinci to harvest 81 left internal mammary arteries (LIMA). They then used da
Vinci to sew 15 LIMA to left anterior descending (LAD)
coronary artery bypass grafts through a median sternotomy incision. Following this experience, they were
7 able to construct 27 LIMA-to-LAD bypass grafts on an
arrested heart (Peripheral Access Technique; Heartport,
Redwood, CA, USA) with a closed chest. More recently,
they succeeded in 14 of 17 attempts to use da Vinci to
anastomose the LIMA to the LAD on a beating heart
with a closed chest. The American FDA trial of closedchest coronary artery bypass grafting using da Vinci has
just been initiated. Dr. Michael Argenziano of New
York Presbyterian Hospital, who is leading this multiinstitutional study, performed the ®rst successful procedure in January 2002.
Clinical experience with da Vinci for mitral valve
repair is also building. The Leipzig group successfully
used da Vinci to repair mitral valves in 13 of 15 patients
[50]. Chitwood et al. have initiated a trial on da Vinci±
assisted repair of mitral valves at East Carolina University in Greenville, North Carolina [51]. In the United
States, the FDA has approved da Vinci for all thoracic
operations, including internal mammary artery harvesting, but not cardiac operations, such as coronary
artery bypass grafting.
Abdominal surgery
Cadiere et al. reported the ®rst successful clinical implementation of telerobotics in March of 1997 when
they performed a laparoscopic cholecystectomy using a
prototype of the da Vinci robotic surgical system [52].
Cadiere et al. also reported the successful use of this
system for telerobotic laparoscopic gastric bypass [53],
Nissen fundoplication [54, 55], and Fallopian tube reanastomosis [56]. Table 1 lists 141 published telerobotic
gastrointestinal operations accomplished with the da
Vinci robotic surgical system [31, 57±67]. The most
commonly reported operation was Nissen fundoplication (38 cases); the second most common was cholecystectomy (20 cases). Many of these cases were
presented at the annual meeting of the Society of
American Gastrointestinal Surgeons (SAGES) in April
2001. These reports indicated that telerobotic gastrointestinal surgery could be done safely.
Several studies in Table 1 examined surgical times
for telerobotic operations. Cadiere et al. compared 10 da
Vinci Nissen fundoplications with 11 laparoscopic Nissen fundoplications in a randomized trial [54, 55]. Total
surgical time for the da Vinci operations was signi®cantly longer than the standard operations: 76 min vs 52
min. Median length of stay for the da Vinci patients was
1 day. Clinical outcomes were similar for both groups.
Chapman et al. of the East Carolina University School
of Medicine reported that the total operative time for 10
da Vinci laparoscopic cholecystectomies was 60 ‹ 25
min [61]. Chapman's group average 84 min for telerobotic fundoplications [62]. At Ohio State University,
Melvin et al. averaged 178.6 min for the wide range of
foregut operations listed in Table 1 [63, 65]. None of
these reports identi®ed a learning curve for surgical
times during a surgeon's early experience with telerobotic gastrointestinal operations. In contrast, Ceconni
et al. in Grosseto, Italy found that their surgical time for
cholecystectomy improved after 20 da Vinci operations
[58]. Surgical time averaged 103.5 min for the ®rst 20
telerobotic cholecystectomies but dropped to 70.3 min
for the next 19. These time studies suggest that experienced laparoscopic surgeons rapidly gain facility with
this new technology [68].
Our initial experience suggests that telerobotic laparoscopic colectomy by a remote surgeon is feasible
and can be done safely [31]. In two of three operations, a
solo surgeon accomplished the operation. We found that
the da Vinci system could reach from the ¯exures to the
upper pelvis without much diculty. We thought that
the instruments were adequate for the task but that
speci®c bowel instruments were required to further facilitate the procedure and need to be developed by the
manufacturers.
Urologists have found important applications for
telerobotic surgery. In France, Guillonneau and Vallancien [69, 70] and Abbou et al. [71] have demonstrated the advantages of using a laparoscopic approach
for radical prostatectomy. Recently, Abbou's group in
Creteil, France, has successfully accomplished a telerobotic laparoscopic radical prostatectomy using the da
Vinci robotic surgical system [72, 73]. The articulated
instruments of da Vinci seem particularly suited for the
dicult anastomosis between the urethra and bladder.
In Paris, Guillonneau and Vallancien's group reported
®ve da Vinci radical prostatectomies [74]. The mean
1394
48 Table 1. Published telerobotic gastrointestinal operations accomplished using the da Vinci robotic surgical system
Operation
Hanische
Cecconi
Hashizume
Chapman
Cholecystectomy
Esophagectomy
Fundoplication
Heller myotomy
Gastrectomy
Splenectomy
Pancreatectomy
Collectomy
5
39
2
16
4
1
2
10
1
5
2
2
1
1
2
3
operating time, from the beginning of the dissection
until the last stitch of the anastomosis was tied, was 222
min (range, 150±381). Average blood loss for the ®ve
cases was 800 ml. The urinary catheter was left in place
for an average of 6.5 days. Four of ®ve patients were
continent for urine. These surgeons thought that the
urethral anastomosis was easier to construct with da
Vinci than when using standard laparoscopic tech8 niques. Rassweiler et al. of the Klinikum Heilbronn in
Germany also reported da Vinci radical prostatectomies
in six patients [75]. Their average operating time, including pelvic lymph node dissection, was 315 min
(range, 242±480). The urinary catheter was left in for 5
days. Three of the six patients were completely continent
for urine after 1 month. Binder et al. from Frankfurt,
Germany, reported the largest series [76]. They completed 44 of 46 attempted operations using da Vinci.
Operative time dropped from 7.5±11 h for the ®rst 20
patients to 3.5±5.5 h for the last 10 patients. These
surgeons found telerobotic radical prostatectomy feasible, but they expressed about the cost of the device and
the need for additional instruments.
So far, there have been just two published reports of
a telerobotic nephrectomy. Guillonneau et al. in Paris
reported a telerobotic nephrectomy using da Vinci in a
77-year-old woman with a nonfunctioning hydronephrotic right kidney due to ureteropelvic junction obstruction [77]. Operative time was <200 min and total
anesthesia time was 245 min. Blood loss was <100 ml.
This report con®rmed that telerobotic nephrectomy was
feasible. Vanuno and Horgan have been using da Vinci
in Chicago for laparoscopic donor nephrectomies [78].
Mean operative time for 10 donor nephrectomies was
166 min, and average hospital stay was 1.8 days. Vanuno and Horgan stated that da Vinci allowed them to
perform these operations with ``greater precision, con®dence, and comfort.''
Few urologists have substantial experience with laparoscopy, and laparoscopic radical prostatectomy is a
very dicult operation to perform [79]. As a result,
telerobotic surgery may o€er speci®c advantages for
urologists during their initial experience with minimally
invasive approaches to this operation as well as other
urological procedures [80]. As has already occurred in
cardiac surgery, the 3-D imaging system and the articulated instruments may foster the use of minimally invasive techniques in urological procedures, since few
9 urologist have accumulated much laparoscopic experience to date.
Melvin
1
10
4
Ozawa
Talimini
Cadiere
Ballantyne
3
4
1
1
5
3
10
3
Limitations of da Vinci
Da Vinci is still in its ®rst generation of production.
Because it was designed speci®cally for cardiac surgery,
the engineers did not consider the requirements of abdominal surgery. As a result, the use of da Vinci for
abdominal surgery presents a variety of challenges.
Instrumentation is limited. The robotic arms are bulky.
The arms are not attached to the operating room table.
Large excursion arcs of the arms lead to frequent collisions. The strong robotic arms lack tensile feedback.
Use of the telerobot in standard operating rooms is
cumbersome and frustrating.
Although intuitive o€ers a broad range of cardiac
surgery instruments for their da Vinci telerobot, it has
released only two instruments designed speci®cally for
gastrointestinal surgeryÐthe Cadiere graspers and ultrasound scissors. Babcock-type graspers, for example,
are not available for bowel operations. The needle
holders are designed for cardiac needles but not gastrointestinal needles. Electrocautery scissors are not
available. Ultrasound scissors have been recently released, but they lack the handlike motions of the other
instruments.
The da Vinci system ®lls a large operating room, so
its use in smaller rooms is impractical. It weighs a great
deal. It is dicult to move around the room and even
more dicult to push down the hall to another operating room. Changing the setup of the operating room
from that needed for cholecystectomy to the setup
needed for fundoplication or colon resection is time
consuming and tiring. For storage outside the operating
room, a small room is required.
A mobile tower supports da Vinci's robotic arms.
The arms are not attached to the surgical table. During
complex operations such as bowel resections, the robotic
arms must be separated from the patient for each position change. This switch adds time to complex abdominal surgical procedures.
The robotic arms were engineered to meet the requirements of cardiac surgery performed on patients in
a ¯at, horizontal position. Abdominal operations require extreme positions, such as Trendelenberg and reverse Trendelenberg, thus forcing the extreme elevation
of one robotic arm and the extreme depression of the
other and promoting collisions of the elbows of the robotic arms. For this reason, minor misplacement of the
trocars away from the ideal positions may severely impede the performance of operations.
1395
Fig. 5. The surgeon's console for Zeus is divided into two parts. A The
video monitor projects a three-dimensional image that can be viewed
through glasses mounted with polarizing ®lters. The balllike hand interface translates the motions of the surgeon's hands into motions of
the robotic instruments. B The surgeon sits comfortably in a chair at
Zeus's console. The three Zeus robotic arms are visible in the background.
Fig. 4. The telerobot Zeus uses three robotic arms. These robotic arms
consist of a voice-controlled camera holder, AESOP, and two modi®ed
AESOP arms that act as the surgeon's right and left hands. Each arm is
attached directly to the surgical table. Thus, permits movement of the
surgical table can be moved without separating the telerobotic arms
from the patient. Each arm is moved and attached to the table separately.
The excursion arcs and motion scaling of da Vinci's
robotic arms are designed for the delicate motions of
internal mammary artery harvest and coronary artery
bypass, but operations such as colectomy require large
excursion arcs and broad, sweeping motions of the instrument. The motion-scaling reduction programmed
into da Vinci makes many of these maneuvers unduly
tedious.
The current generation of da Vinci does not provide
tensile feedback. The surgeon must rely on visual clues
to estimate the tension placed on tissues by da Vinci's
powerful robotic arms. Inexperienced telerobotic surgeons can easily avulse tissues with the robotic arms if
they fail to heed these subtle visual clues. Similarly, the
surgeon cannot judge how tightly the instruments are
grasping the tissues. This situation can lead to the
fraying of sutures or pressure injuries to tissue. Tensile
sensors exist, and future generations of telerobots are
likely to incorporate this technology. Nonetheless, the
lack of feedback is still a problem with current systems.
The video signal from da Vinci is generally broadcast
on several slave monitors in the operating room. The
assistant surgeon, scrub nurse, and other members of
the operating room team view the operation on these
two-dimensional telecasts. Connection of the da Vinci
video image to the slave monitors is easily accomplished
in new integrated operating rooms, but it can be a wiring
challenge in older operating rooms using mobile
laparoscopy video towers. This problem is compounded
if it is necessary to switch back and forth between a
laparoscopic telescope and the da Vinci telescope during
di€erent parts of the operation. As the technology demands of surgery increase, the need for dedicated operating rooms speci®cally designed and wired for these
advanced technologies has also increased. As a result,
we suggest that when considering the cost of initiating a
telerobotic surgery program, an institution should in-
clude the cost of upgrading at least one operating room
to a fully integrated advanced laparoscopic surgery operating room.
Zeus
Computer Motion, the manufacturer of AESOP, has
also developed the Zeus telerobot [81]. It used AESOP
as a foundation for the development of a robot capable
of telerobotic surgery. In this system, the voice-controlled robot, AESOP, continues to hold the camera.
Two additional AESOP-like units have been modi®ed to
hold surgical instruments (Fig. 4). These three units are
independently attached to the operating room table. A
computer within the surgeon's console controls the three
arms. The computer keeps track of the 3-D position of
the tip of each instrument and camera, not the position
of the trocar (as does the da Vinci computer). In earlier
models, the surgeon controlled the laparoscopic instruments with handles similar to traditional laparoscopic
instruments. The computer translated movements of
these handles into identical motions of the robotic surgical instruments. The most recent version of Zeus uses
a more ergonomic interface between the surgeon and
robotic instruments (Fig. 5A). These handles control
surgical instruments that articulate near their tips. The
surgeon sits in a comfortable chair in front of the video
monitor (Fig. 5B). The computer eliminates the surgeon's resting tremor and can be set to scale the movements of the surgeon's hand over a range of 2:1 to 10:1.
In Zeus, the surgeon observes the operation with a
Storz 3-D imaging system (Karl Storz Endoscopy, Santa
Barbara, CA, USA). The robotic arm that holds the
camera is voice controlled by the surgeon. This 3-D
imaging system accelerates the frame rate of the video
system. Separate right and left video cameras visualize
the operative ®eld. Each broadcasts at a rate of 30
frames per second. A computer merges and accelerates
this to a broadcast rate of 60 frames per second.
This broadcast alternates frames from the left and right
video cameras. The video monitor has an active matrix
1396
covering its surface. The matrix alternates between a
clockwise and counterclockwise polarizing ®lter. The
clockwise ®lter synchronizes with the right video frame,
and the counterclockwise one matches the left video
image. The surgeon wears glasses that have a clockwise
polarizing ®lter as the right lens and a counterclockwise
polarizing ®lter as the left lens. These glasses permit the
left eye to see only the video image from the left camera
while the right eye sees the video image from the right
camera. This causes a 3-D image to be projected from
the video monitor.
Cardiac surgery
Zeus, like da Vinci, was developed speci®cally to do
cardiac operations. Most of the clinical reports on Zeus
have focused on this area. The most advanced area of
telerobotic surgery for Zeus is internal mammary artery
harvest and coronary artery bypass grafting. Boyd et al.
in London, Ontario, demonstrated the e€ective and safe
use of Zeus for harvesting internal mammary arteries
[82, 83]. The left internal mammary arteries were successfully harvested with Zeus in 19 patients. A closedchest, three-trocar technique was used. All 19 operations
were completed successfully and had excellent clinical
outcomes. A number of early publications documented
the feasibility of performing coronary artery bypass
surgery with Zeus in both live animal models [84, 85]
and cadavers [86, 87]. Clinical cases soon followed.
Surgeons in Munich have championed the use of
Zeus for coronary artery bypass grafting. In 1999, Reichenspurner et al. reported the ®rst successful clinical
use of Zeus for coronary artery bypass grafting [88]. In
two patients, surgeons harvested the left internal mammary artery using endoscopic techniques and then sutured the internal mammary artery to the left anterior
descending artery anastomosis through three thoracic
trocars. The heart was arrested using an endovascular
cardiopulmonary bypass system (Port Access; Heartport). Both patients recovered uneventfully. Later that
year, the Munich group used Zeus to successfully perform closed-chest, o€-pump coronary artery bypass
grafting (left internal mammary artery to left anterior
descending coronary artery) in three patients [89]. By
2000, the same group had performed coronary artery
bypass grafting on beating hearts in 10 patients with
Zeus. The anastomoses were technically satisfactory by
angiography in all 10 patients [90]. Total operative time
ranged from 4 to 8 h (median, 5.5). The Zeus-assisted
anastomoses required 14±50 min (median, 25). Boyd's
group in London, Ontario is the only group in North
America that has reported closed-chest, o€-pump coronary artery bypass grafting with Zeus [91]. These papers have paved the way for other groups and
documented the clinical possibility of closed-chest, o€pump coronary artery bypass grafting using Zeus.
Two groups in the United States have used Zeus for
coronary artery bypass grafting as part of FDA trials.
Surgeons at Hershey Medical Center in Pennsylvania
harvested left internal mammary arteries through open
chests with the patients on standard bypass [92]. Three
subxiphoid trocars were then inserted. Zeus was used to
sew the left internal mammary arteries to the left anterior descending arteries. Other bypass grafts were sewn
by traditional techniques. Eight of the 10 anastomoses
were satisfactory, but the other two required revision.
All 10 patients recovered uneventfully. All grafts were
open by angiography 6 weeks after the operation.
Surgeons at Washington University in St. Louis,
Missouri, reported 1-year follow-up on patients who
had undergone Zeus-assisted operations. These surgeons
used Zeus through three 5-mm trocars. The heart was
arrested and on bypass. Left internal mammary artery
to left anterior descending artery anastomoses were
constructed using Zeus in 19 patients. Other bypass
grafts were constructed without Zeus. All grafts were
patent on postoperative angiographies. At an average
follow-up of 1 year, all patients were functioning at a
New York Heart Association class I [93]. FDA trials are
ongoing in this area, and additional reports are expected
in the near future.
Zeus will be used for a variety of cardiac procedures
in the future. Luison and Boyd, for example, reported a
pericardiectomy accomplished with a 3-D imaging system [94]. This report served to focus attention on the
advantages of 3-D imaging systems in complex anatomical environments. Similarly, Grossi et al. have used
Zeus at New York University for mitral valve surgery
[95]. These areas of development look especially promising.
Abdominal surgery
The FDA only recently (October 2001) granted Zeus
limited clinical approval for abdominal operations in the
United States. Consequently, much of the work to date
with Zeus has been done in animal models. Goh's group
in Singapore, for example, used Zeus to perform
cholecystectomies in seven pigs [96]. Their mean operative time was 46 min (range, 30±62). They found that,
with practice, their setup time dropped from 30 to 14
min.
Hollands et al. at Louisiana State University (LSU)
have explored the utility of Zeus for pediatric procedures and, in particular, the advantages of telerobotic
suturing over standard laparoscopic suturing techniques. The LSU group found that they could construct
porcine enteroenterostomies faster with Zeus than with
standard laparoscopic techniques [97]. The telerobotic
operations averaged 14 min less than the laparoscopic
operations, including setup time for the robot. The
group also compared the repair of a choledochotomy in
pigs using standard laparoscopic techniques with the
same procedures using Zeus [98]. The Zeus repair required 70±90 min more than the laparoscopic technique,
but there were signi®cantly fewer complications (four vs
nine) in the Zeus group. These studies suggest that
gastrointestinal suturing with Zeus may o€er advantages over traditional laparoscopic techniques.
Using experimental models, the Cleveland Clinic
has explored the applications for Zeus in gynecology
and urology. Margossian et al. demonstrated that
1397
uterine horn anastomoses in six pigs sutured using
needed to set up and take down the Zeus robot was 18
Zeus were all patent 4 weeks after surgery [99]. This
min. Median time of dissection using Zeus was 25 min,
study highlighted the potential role of telerobotics for
and the median overall operative time was 108 min. The
microsurgical suturing. Margossian and Falcone also
only complication among the 25 patients was a possible
used Zeus to perform ®ve adnexal operations and ®ve 12 pulmonary embolism, but no embolist was found on CT
hysterectomies in pigs [100]. The mean length of surscan. The average length of postoperative stay was 3
gery was 170 min for the adnexal operations and 200
days, which was similar to that for standard laparomin for the hysterectomies. All 10 operations were
scopic cholecystectomy in France. These surgeons emdone telerobotically.
phasized the potential advantages of a digitized format
Gill et al. have used Zeus in experimental studies at
for information transfer and the visualization by the
the Cleveland Clinic for pyeloplasty, nephrectomy, and 13 surgeon of remote surgery over long distances.
10 adrenalectomy [101]. Using a swine model, they sutured
four pyeloplasties laparoscopically and six pyeloplasties
Limitations of Zeus
telerobotically. The telerobotic anastomoses averaged a
total of 115 min vs 94 min for the laparoscopic ones.
Zeus evolved from AESOP and has already passed
Five of six of the Zeus and three of four of the laparothrough four generations of development. Nevertheless,
scopic pyeloplasties were immediately watertight. The
surgeons still face a number of obstacles before this
same group also compared telerobotic nephrectomy and
telerobot can be used on a routine clinical basis. Zeus
adrenalectomy with laparoscopic operations [101].
has many of the same diculties as da Vinci. MisAgain, the telerobotic operation required signi®cantly
placement of the trocars leads to collisions con¯icts
more time, but similar dissections were accomplished in
between the robotic arms. Zeus's various components
both groups. The Cleveland Clinic surgeons thought
®ll a large operating room and hopelessly clutter small
that telerobotics o€ered distinct advantages when suones. Zeus does not yet o€er tensile feedback. Moreturing was required and that telerobotic dissection
over, feeding Zeus's video output into traditional mobile
achieved results similar to laparoscopic techniques.
video towers is often a challenge. Like da Vinci, this
Several groups have assessed Zeus as a means for
telerobot is also much better suited for use in a modern,
instructing medical students, surgical residents, and
fully integrated operating room. In addition, Zeus presurgeons in the techniques of advanced laparoscopic
sents some unique challenges.
surgery [102±104]. These studies found that telerobotics
Zeus's 3-D imaging system requires the use of speconferred little advantage on the performance of simple
ci®c
glasses. These glasses allow each eye to see only one
tasks, such as picking up and dropping beads into a
of the two alternating video signals. The right eye sees
receptacle. However, complex tasks, such as suturing or
only the right video image and the left eye only the right.
suture tying, were accomplished with greater speed and
The image is blurred when the glasses are not worn.
precision when performed telerobotically, regardless of
Some surgeons dislike wearing these glasses. The ¯ickthe individual's prior level of training. These studies
ering of the alternating images on the same video screen
suggested that telerobotic surgical systems could faciligives some individuals motion sickness. As a result,
tate the learning and performance of complex laparosome surgeons prefer a standard two-dimensional image
scopic operations.
when using Zeus.
Two recent reports attest to the clinical utility of
Computer Motion introduced in 2001 Zeus surgical
Zeus in gynecology and urology. In 1999, Falcone et al.
instruments with handlike motions. These instruments
reported the use of Zeus at the Cleveland Clinic in a
provide motion with six degrees of freedom. Although
tubal reanastomosis [105]. They updated their experithis technology seems promising, little clinical experience in 2000 with an additional 10 patients. The tubal
ence is available as yet.
reanastomosis was accomplished in each patient with
At present, however, the greatest obstacle to the
four sutures of 8-0 polygalactin sutures. Postoperative
clinical
use of Zeus is its limited FDA approval. Zeus is
hysterosalpingograms 6 weeks after surgery demoncurrently
approved by the FDA for use as a surgical
strated patency in 17 of the 19 tubes. Guillonneau and
assistant but not on an operating surgeon. This limitaVallancien have used Zeus for pelvic lymph node distion continues to impede the acquisition of clinical exsections in patients with prostate cancer [106]. The avperience in the United States, since clinical use of Zeus is
erage operating time for 10 telerobotic lymph node
con®ned to FDA-approved trials. Fortunately, Comdissections was 125 minÐsigni®cantly longer than the
puter Motion has completed trials with Zeus for choleaverage of 60 min required for the standard laparocystectomy and Nissen fundoplication, and full FDA
scopic operations. These two studies concluded that
approval for abdominal surgery is expected in the near
this technology warrants further study in these clinical
future.
arenas.
11
Marescaux et al. of the European Institute for
Telesurgery (Strasbourg, France) recently reported the
Telepresence surgery
largest clinical trial with Zeus in abdominal surgery
[107]. Twenty-®ve selected patients underwent Zeusassisted laparoscopic cholecystectomies. One operation
Telerobotics was ®rst developed with grants from the
US Department of Defense to allow surgeons at remote
was converted from a telerobotic procedure to a standard laparoscopic cholecystectomy. The median time
locations to operate on wounded soldiers on the bat-
1398
tle®eld [108]. Ninety percent of all combat deaths occur
1. The novice surgeon should pass a formal course that
before the soldier reaches a medical facility; few soldiers
includes didactic sessions and animal experience with
die after reaching military hospitals [109, 110]. Therethe procedure.
fore, the aim was to allow surgeons to immediately treat
2. The surgeon should observe an expert surgeon perlife-threatening injuriesÐsuch as hemorrhaging from
forming the operation.
major vesselsÐthat might kill soldiers before they could
3. The surgeon should act as a ®rst assistant to an expert
be evacuated to military hospitals [111]. In this scenario,
surgeon for the procedure or be preceptored by an
the wounded soldier is placed in a telepresence surgery
expert surgeon during his/her early clinical experivehicle. Three-dimensional imaging systems project the
ence.
image of the wounded soldier back to the surgeon on an
4. A proctor should monitor the surgeon during the
aircraft carrier or at another remote site. This virtual
surgeon's initial independent experience with the
environment allows the surgeon to perform the lifeprocedure.
saving operation.
Experimental studies have proven the validity of this
Unfortunately, preceptoring and proctoring proapproach. In 1998, Bowersox et al. used a prototype of a 18 grams have always been dicult to implement. For one
telerobotic surgical system to close gastrotomies and
thing, they often represent an inecient use of the
enterotomies, excise gallbladders, and repair liver lacexpert surgeon's time. Additionally, no mechanism has
erations in swine [112]. Recently, telepresence surgery
been developed to pay for these services. It is thus
was achieved with the surgeon separated from his padicult for expert surgeons to justify the requisite time
tient by 3800 miles [113]. Sitting at a Zeus console in
expenditure. Telepresence resolves many of these isNew York City, Marescaux performed a telerobotic
sues. The expert surgeon can remain in his/her oce or
cholecystectomy on a patient in Strasbourg, France
hospital and telementor the novice surgeon at remote
[114, 115]. The surgeon's console was connected directly
sites.
to Zeus's robotic arms by a transatlantic ®beroptic
The introduction of relatively inexpensive means of
cable. This direct connection minimized the time lag
teleconferencing in the 1990s spurred interest in telebetween motions of the surgeon's hands, movements of
mentoring. Surgeons at Cedars-Sinai in Los Angeles
the robotic instruments, and the returned video image.
determined the maximum degree of video compression
The use of satellites to transmit the digital signals
that still allowed acceptable remote proctoring of lapaintroduces too great a distance and signi®cantly delays
roscopic operations. They found that a standard 1.5 mb/
the round trip of these electronic signals.
sec telecommunications data line provided an adequate
Telepresence surgery o€ers a technological solution
telesurgical image [121]. In 1997, Rosser telementored
to surgical manpower shortages in remote and underlaparoscopic colectomies performed by inexperienced
served areas. Moreover, it o€ers a means of improving
surgeons from across campus [122]. The operating suroutcomes for infrequently performed and technically
geon was coached from a mobile command center
demanding operations. One can envision a future in
parked outside the hospital. In the next phase, Rosser
which an expert surgeon performs operations such as
telementored laparoscopic Nissen fundoplications at
adrenalectomy or Heller myotomy for an entire region
another hospital 5 miles away. In 1998, Johns Hopkins
from a central location, such as the state university.
instituted a telementoring program between Johns
Similarly, mobile vehicles carrying the telerobot could
Hopkins Bayview Medical Center and Johns Hopkins
migrate across third-world areas, allowing an expert
Hospital, which are 3.5 miles apart [123]. The surgeons
surgeon to remain at the university while eciently
at Johns Hopkins then succeeded in telementoring a
performing the sophisticated operations needed in poor
laparoscopic adrenalectomy in Innsbruck, Austria;
communities. Nonetheless, ethical and legal paradoxes
a laparoscopic varicocelectomy in Bangkok, Thailand; a
raised by telepresence surgery have already been idenlaparoscopic radical nephrectomy in Singapore [124,
ti®ed. For one thing, the impact of state and interna125]; and ®ve urological procedures, including a lapational borders on medical licensing remains ill de®ned
roscopic radical nephrectomy, in Rome, Italy [126].
[117]. For another, remote telepresence surgery certainly
Newer technology permitted this telementoring to occur
interferes with traditional clinician±patient relationships
over three ISDN lines at 384 kbps. The time lag of the
[116]. It will be necessary to balance the advantages of
video image was 1 sec.
delivering sophisticated surgical care to remote areas
Other groups have also explored the utility of this
against the importance of direct surgeon-to-patient
approach. In 1997, Osaka University in Japan estabcontact.
lished a tele-education and telementoring network that
linked ®ve remote hospitals with the university [127].
This network served to tele-educate young surgeons and
to telementor surgeon during advanced laparoscopic
Telementoring
procedures. The US Navy demonstrated another interesting use of telementoring. Video and computer comThe introduction of laparoscopic cholecystectomy in the
munications technology were used to establish a
late 1980s led to new guidelines for the training of surBattlegroup Telemedicine system [128]. Land-based
geons already in practice in the performance of new
surgeons telementored the performance of ®ve laparooperation [118±120]. These guidelines generally include
scopic inguinal hernia repairs on the aircraft carrier USS
the following recommendations:
Abraham Lincoln. The telemedicine system was also used
1399
to obtain surgical consultations with other surgical
specialists.
Telementoring may have a future role in teaching
laparoscopic surgery to surgical residents. The University of Hawaii tested the ability of a surgeon to
telementor residents performing laparoscopic cholecys17 tectomy [129]. The operating times of six operations
performed with and six operations without a scrubbed
attending surgeon in the operating room were similar.
All operations were telementored from a remote site.
18 In Chorey, United Kingdom, attending surgeons telementored higher surgical trainees from a remote
room. The trainees independently performed laparoscopic cholecystectomies in a total of 34 patients. The
trainees could seek advice from the telementor, and the
telementor could o€er advice or intervene during the
operation. The trainees completed 33 of the 34 operations. These studies indicated that telementoring is a
safe and e€ective teaching technique and may represent
a satisfactory means of assessing when trainees are
adequately trained to perform independent and unsupervised operations.
In Europe, there is growing interest in the idea of
linking the resources of several universities to provide
teleconsulting and telesurgical resources to other surgeons [130±132]. Marescaux et al. have envisioned a future in which a ``virtual university'' will provide
teleeducation, teletraining, telementoring, teleproctoring, and teleaccreditation for surgeons who wish to learn
new procedures and technologies or to update themselves
21 on recent developments. In addition, the virtual university on the internet would allow the experience of expert
19 surgeons to be applied throughout the served area via
telepresence surgery [133].
Rosser et al. of the Yale University School of
Medicine demonstrated how telementoring from a
virtual university could bene®t third-world areas.
Rosser telementored surgeons performing laparoscopic
cholecystectomies in Ecuador [134]. A mobile operating
room was equipped with telecommunications equipment that permitted him to supervise surgeons in Ecuador from his oce in New Haven, Connecticut. This
study suggests that telecommunications can provide
new avenues for surgeons around the world to gain
training from expert surgeons in a cost-e€ective manner.
The FDA approved the ®rst robotic telemedicine
device in October 2001 [135]. Computer Motion, CA
manufactures Socrates, which is a robotic telecollaboration device. Socrates is designed to facilitate telementoring. The telementor uses Socrates from a remote
site to connect with an operating room and share audio
and video signals. The telementor uses Socrates' telestrator to annotate anatomy or surgical instructions.
20 The telementor can also control the movements of the
camera and other electronic equipment in the operating
room via a voice-controlled system. New technologies
such as Socrates will make the virtual university
available to many users in the immediate future and
help to ®rmly establish telerobotics, telepresence,
and telementoring into the landscape of 21st century
surgery.
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