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Surgery in space: The future of robotic telesurgery
Abstract and Figures
The origins of telemedicine date back to the early 1970s, and combined with the concept of minimally invasive surgery, the idea of surgical robotics was born in the late 1980s based on the principle of providing active telepresence to surgeons. Many research projects were initiated, creating a set of instruments for endoscopic telesurgery, while visionary surgeons built networks for telesurgical patient care, demonstrated transcontinental surgery, and performed procedures in weightlessness. Long-distance telesurgery became the testbed for new medical support concepts of space missions.
This article provides a complete review of the milestone experiments in the field, and describes a feasible concept to extend telemedicine beyond Earth orbit. With a possible foundation of an extraplanetary human outpost either on the Moon or on Mars, space agencies are carefully looking for effective and affordable solutions for life-support and medical care. The major challenges of surgery in weightlessness are also discussed.
Teleoperated surgical robots have the potential to shape the future of extreme health care both in space and on Earth. Besides the apparent advantages, there are some serious challenges, primarily the difficulty of latency with teleoperation over long distances. Advanced virtualization and augmented-reality techniques should help human operators to adapt better to the special conditions. To meet safety standards and requirements in space, a three-layered architecture is recommended to provide the highest quality of telepresence technically achievable for provisional exploration missions.
Surgical robotic technology is an emerging interdisciplinary field, with a great potential impact on many areas of health care, including telemedicine. With the proposed three-layered concept-relying only on currently available technology-effective support of long-distance telesurgery and human space missions are both feasible.
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... For instance, significant bone mass loss in microgravity could increase the risk of fractures during extravehicular activities. 48 Managing surgical complications will pose major challenges due to equipment and manpower constraints, such as limited perioperative imaging capabilities and lack of both surgical equipment and on-board surgical expertise. 8 Realistically, nonoperative options should be attempted first, with surgery reserved to conditions that threaten the loss of limb or life. ...
... 66 Open surgery in weightlessness may be restricted as body fluids become hard to control in microgavity. 48 For example, in the case of a femur fracture, temporary stabilization such as long leg plastering or external fixation may be considered. Regional anesthesia should also take preference over general anesthesia in the spaceflight setting, because of their lower risks and requirement for preoperative, intraoperative, and postoperative resources. ...
INTRODUCTION:During future interplanetary space missions, a number of health conditions may arise, owing to the hostile environment of space and the myriad of stressors experienced by the crew. When managing these conditions, crews will be required to make accurate, timely clinical decisions at a high level of autonomy, as telecommunication delays and increasing distances restrict real-time support from the ground. On Earth, artificial intelligence (AI) has proven successful in healthcare, augmenting expert clinical decision-making or enhancing medical knowledge where it is lacking. Similarly, deploying AI tools in the context of a space mission could improve crew self-reliance and healthcare delivery.METHODS: We conducted a narrative review to discuss existing AI applications that could improve the prevention, recognition, evaluation, and management of the most mission-critical conditions, including psychological and mental health, acute radiation sickness, surgical emergencies, spaceflight-associated neuro-ocular syndrome, infections, and cardiovascular deconditioning.RESULTS: Some examples of the applications we identified include AI chatbots designed to prevent and mitigate psychological and mental health conditions, automated medical imaging analysis, and closed-loop systems for hemodynamic optimization. We also discuss at length gaps in current technologies, as well as the key challenges and limitations of developing and deploying AI for space medicine to inform future research and innovation. Indeed, shifts in patient cohorts, space-induced physiological changes, limited size and breadth of space biomedical datasets, and changes in disease characteristics may render the models invalid when transferred from ground settings into space.Cheung HC, De Louche C, Komorowski M. Artificial intelligence applications in space medicine. Aerosp Med Hum Perform. 2023; 94(8):610-622.
... The evolution of surgical techniques then led to the use of minimally invasive surgery (MIS, laparoscopic surgery) [32,[37][38][39] and robotic-assisted mini-invasive surgery (RAMIS) [32,[37][38][39] with the aid of telementoring or by teleoperating the surgical robot from a location on Earth in a specific NASA project known as NEEMO [40][41][42][43] that deployed the Aquarius underwater laboratory, the only undersea research station in the world, located 5.6 km off the coast in the Florida National Marine Sanctuary [40][41][42][43]. ...
... The evolution of surgical techniques then led to the use of minimally invasive surgery (MIS, laparoscopic surgery) [32,[37][38][39] and robotic-assisted mini-invasive surgery (RAMIS) [32,[37][38][39] with the aid of telementoring or by teleoperating the surgical robot from a location on Earth in a specific NASA project known as NEEMO [40][41][42][43] that deployed the Aquarius underwater laboratory, the only undersea research station in the world, located 5.6 km off the coast in the Florida National Marine Sanctuary [40][41][42][43]. ...
In the coming years, missions to the Moon and Mars shall be the new goals of space flight. The complexity of these missions due to the great distance from Earth and the unforeseen obstacles to settle on another planet have given rise to great concerns for crew health and survival. The need for advanced crew autonomy and a different approach to surgical emergency require new protocols and devices to help future crew medical officers and other crew members in a task of unprecedented difficulty. Hence, the increasing variety of schedules, devices, and protocols being developed. A serious health problem, such as an emerging surgical disease or severe trauma, can jeopardize the mission and survival of the entire crew. Many other difficulties are present in deep-space missions or settlements on other planets, such as communication and supply, also medical, delays, and shortage, and the presence of radiation. Progress in advanced technologies as well as the evolution of robotic surgery and the use of artificial intelligence are other topics of this review. In this particular area of research, even if we are still very far from an "intelligent robot", this evolution must be evaluated in the light of legislative and ethical considerations. This topic was presented at the annual meeting of the American College of Surgeons-Italy Chapter in 2021.
... A hierarchical task analysis model (HTAM) was created with the intention of following the roles and actions of surgeons, surgical assistants, and anesthesiologists using the minimum required equipment [15]. In this model, teleoperated surgical robots have the potential to shape the future of extreme health care both in Space and on Earth [16]. Accurate prediction of surgical demands during space flight missions is extremely challenging [17]. ...
Despite the location (Earth or Space), surgical simulation is a vital part of improving technical skills and ensuring patients' safety in the real procedure. The purpose of this study is to describe the Space System for Minimally Invasive Surgery (SY-MIS©) project, which started in 2016 under the supervision of the Center for Space Systems (C-SET). The process connects the best features of the following machines: Biomedik Surgeon, Space Biosurgeon, SP-LAP 1, and SP-LAP 2, which were defined using the VDI 2221 guidelines. This research uses methods based on 3 standards: i) Biomedical design: ISO 9001-13485 / FDA 21 CFR 820.30 / ASTM F1744-96(2016); ii) Aerospace human factors: HF-STD-001; iii) Mechatronics design: VDI 2206. The results depict the conceptual biomedical design of a novel training system named Surgical Engineering and Mechatronic System (SETY©), which integrates the use of 2 laparoscopic tools and 2 anthropomorphic mini-robotic arms (6 DOF). It has been validated by the Evaluation of Technical Criteria, getting a total score of 90% related to clinical assessment, machine adaptability, and robustness. The novelty of the research lies in the introduction of a new procedure that covers the simultaneous use of laparoscopic and robotic systems, named Hybrid Cyber-Physical Surgery (HYS©). In conclusion, the development of SY-MIS© promotes the use of advanced technologies to improve surgical procedures and human-machine medical cooperation for the next frontier of habitability on other planets. Doi: 10.28991/ESJ-2024-08-02-01 Full Text: PDF
... An application termed 'tele-mentoring' that involves remote surgical mentoring transmitted via audio and/or video data has been explored to improve remote surgical applications. The technology has the power to transmit specialized surgical sub-specialists remotely to locations geographically distant and/or hazardous [9,10]. Tele-mentoring has shown similar results achieved when compared to direct in-room mentoring, documenting its reliability and feasibility [2,11,12]. ...
Background
Surgical tele-mentoring leverages technology by projecting surgical expertise to improve access to care and patient outcomes. We postulate that tele-mentoring will improve surgeon satisfaction, procedural competence, the timeliness of operative intervention, surgical procedure efficiency, and key intra-operative decision-making. As a first step, we performed a pilot study utilizing a proof-of-concept tele-mentoring process during robotic-assisted surgery to determine the effects on the perceptions of all members of the surgical team.
Methods
An IRB-approved prospective feasibility study to determine the safety and efficacy of remote surgical consultation to local surgeons utilizing robotic surgery technology in the fields of general, urology, gynecology and thoracic surgery was performed. Surgical teams were provided a pre-operative face-to-face orientation. During the operation, the mentoring surgeon was located at the same institution in a separate tele-mentoring room. An evaluation was completed pre- and post-operatively by the operative team members and mentor.
Results
Fifteen operative cases were enrolled including seven general surgery, four urology, one gynecology and three thoracic surgery operations. Surveys were collected from 67 paired survey respondents and 15 non-paired mentor respondents. Participation in the operation had a positive effect on participant responses regarding all questions surveyed (p < 0.05) indicating value to tele-mentoring integration. Connectivity remained uninterrupted with clear delivery of audio and visual components and no perceived latency. Participant perception of leadership/administrative support was varied.
Conclusions
Surgical tele-mentoring is safe and efficacious in providing remote surgical consultation to local surgeons utilizing robotic surgery technology in a military institution. Operative teams overwhelmingly perceived this capability as beneficial with reliable audio-visual connectivity demonstrated between the main operative room and the Virtual Medical Center. Further study is needed to develop surgical tele-mentoring to improve patient care without geographic limitations during times of peace, war and pandemic outbreaks.
Background
Among the novel robotic platforms, the Hugo RAS system is the second most studied platform, next to the da Vinci system, and we aim to address our experiences in radical prostatectomy (RP) with the Hugo RAS system.
Methods
We recorded our first 12 cases of prostate cancer undergoing RP with the Hugo RAS system. The median console time was 145 min and median hospital stay was 7 days. Hedge’ g was applied to search for the cut‐off case in four parameters in surgeries.
Results
Pre‐console preparation was significantly improved after the first seven cases, and the console time was remarkably shortened after the first two cases. The intraoperative pause for trouble shooting was remarkably shortened after the first three cases.
Conclusions
We found that RP with the Hugo RAS system was feasible, and the learning curve was short as surgeons may benefit from the previous experience with the da Vinci system.
One of the most critical challenges in Robotic Eye Surgery (RES) is the applied force of the surgical instrument of the robot as it penetrates the human eye. Safe surgery requires accurate control of this force. In a teleoperated eye surgical system, there is likely to be a time delay that can affect the system control. This paper focuses on designing a predefined-time Sliding Mode Control (SMC) method to control a teleoperated robotic eye surgical system under an unknown time delay of the communication channel. The Lyapunov theory is used to prove the system stability. For the master and slave parts, manipulator robots are considered for designing and testing the controller. MATLAB software is used to simulate the controller. The simulation results show the robustness of the controller against the time delay of the communication channel.
These guidelines and capabilities identify the points of intersection between human spaceflight crews and
mission considerations such as architecture, vehicle design, technologies, operations, and science requirements. In these chapters, we will provide clear, top-level guidelines for human-related exploration studies and technology research that will address common questions and requirements. As a result, we hope that ongoing mission trade studies will consider common, standard, and practical criteria for human interfaces.
Despite the great diversity of teleoperator designs and applications, their underlying control systems have many similarities. These similarities can be exploited to enable inter-operability between heterogeneous systems. We have developed a network data specification, the Interoperable Telerobotics Protocol, that can be used for Internet based control of a wide range of teleoperators. In this work we test interoperable telerobotics on the global Internet, focusing on the telesurgery application domain. Fourteen globally dispersed telerobotic master and slave systems were connected in thirty trials in one twenty four hour period. Users performed common manipulation tasks to demonstrate effective master-slave operation. With twenty eight (93%) successful, unique connections the results show a high potential for standardizing telerobotic operation. Furthermore, new paradigms for telesurgical operation and training are presented, including a networked surgery trainer and upper-limb exoskeleton control of micro-manipulators.
We are seeing the emergence of medical applications for virtual reality (VR). These include telepresence surgery, three-dimensional (3-D) visualization of anatomy for medical education, VR surgical simulators, and virtual prototyping of surgical equipment and operating rooms. Today, approximately 90% of the knowledge a physician requires can be obtained through electronic means, such as diagnostic sensors and imaging modalities, directly seeing the patient with a video camera for medical consultation, or using electronic medical records. In addition, with telepresence, a therapy can be effected electronically, regardless of the physical location of the patient. Therefore, it makes sense to send the electronic information or manipulation, rather than sending the patient or blood samples, to obtain tests or to produce a cure. In that these applications are mediated through the computer interface, they are the embodiment of VR as the major force for change in the field of medicine. The Green Telepresence Surgery System consists of two components, the surgical workstation and the remote worksite. At the remote site are a 3-D camera system and responsive manipulators with sensory input. At the workstation are a 3-D monitor and dexterous handles with force feedback. The next generation in medical education can learn anatomy from a new perspective by "flying" inside and around the organs, using sophisticated computer systems and 3-D visualization. The VR surgical simulator is a stylized recreation of the human abdomen with several essential organs. Using this, students and surgeons can practice surgical procedures with virtual scalpels and clamps. To support these advanced technologies, the operating room and hospital of the future will first be designed and tested in virtual reality, allowing multiple iterations of equipment and surgical rooms before they are actually built. Insofar as all these technologies are based on digital information, they are the building blocks for the digital physician of the 21st century. © 1995 Informa UK Ltd All rights reserved: reproduction in whole or part not permitted.
Written by renowned experts from Australia, Canada, the United States, Asia, and Europe, Telesurgery explains technical issues, digital information processing, and provides collective experiences from practitioners in different parts of the world who perform a wide range of telesurgery applications. This includes transatlantic telesurgery and telesurgery for urology, brachytherapy, Heller myotomy, etc. There are numerous graphics and clinical photographs throughout, which illustrate and illuminate the text well, providing high-quality visual reference material. Telesurgery lays the foundation for the globalization of surgical procedures, making possible the ability of a surgeon located in one part of the world to operate on a patient located in another.
Although no surgical procedures have been performed on humans during space flight, the risk of a problem arising that requires surgical intervention is nonetheless real. From a timeweighted standpoint, until the advent of long-duration missions in the U.S. Skylab program and the Russian Salyut and Mir programs, the probability of an in-flight problem arising that would require a surgical solution was small; thus clinical experience and expertise in performing surgery on humans in microgravity remained quite limited. The lack of on-site surgical expertise was keenly felt when Russian space program officials were faced with the possible medical evacuation of a Salyut 7 cosmonaut who was experiencing abdominal pain thought to be due to appendicitis. Although that episode turned out to have been caused by probable ureterolithiasis rather than appendicitis—the cosmonaut recovered and did not require an early return to Earth—this experience nonetheless underscored a pressing need in space flight.
A national survey study of state-of-the-art technology, major civil sector user needs and recommendations for Federal initiatives in the field of teleoperators, robotics and remote systems is reviewed. Impending developments in the application of telemation to remote emergency medical care and to remote mining operations are speculated upon.
Microsurgeons use a microscope with 20 to 30 times magnification to help them visualize the microscopic field they work with. However, they still use their hands to hold instruments that manipulate tissue with feature sizes from fifty to a few hundred microns. A microsurgical manipulator that can scale down the surgeon's hand motions to the microscopic field would allow the average surgeon to perform at the level of the best surgeons and allow the most skillful surgeons to perform at unprecedented levels of dexterity. Development of practical systems for assisting microsurgeons in this way is a growing field of research. Microtelerobotic workstations systems that have been developed for biomedical applications.The work reported here is the result of collaboration between researchers at the Jet Propulsion Laboratory (JPL) and Steve Charles, a vitreo-retinal surgeon. The Robot-Assisted Microsurgery (RAMS) telerobotic workstation developed at JPL is a prototype of a system that will be completely under the manual control of a surgeon. It is unique in its combination of compact size, light weight, and high precision. The system, has a slave robot that holds surgical instruments. The surgeon commands motions for the instrument by moving the handle on a master device in the desired trajectories. The trajectories are measured, filtered, and scaled down then used to drive the slave robot.We present the details of this telerobotic system by first giving an overview of the subsystems and their interactions and then presenting details. The chapter concludes with a description of a recent demonstration of a simulated microsurgery procedure performed at JPL.
Background: As general surgeons perform a growing number of laparoscopic operations in increasingly specialized environments, the ability to obtain expert advice during procedures becomes more important. Technological advances in video and computer communications are enabling surgeons to procure expertise quickly and efficiently. In this article, we present laparoscopic procedures completed through an intercontinental telementoring system and the first telementored laparoscopic procedures performed aboard a naval vessel.
Methods: Video, voice, and data streams were linked between the USS Abraham Lincoln Aircraft Carrier Battlegroup cruising the Pacific Ocean and locations in Maryland and California, creating the Battlegroup Telemedicine (BGTM) system. Three modes of BGTM communication were used: intraship, ship to ship, and ship to shore.
Results: Five laparoscopic inguinal hernia repairs were completed aboard the Lincoln under telementoring guidance from land-based surgeons thousands of miles away. In addition, the BGTM system proved invaluable in obtaining timely expertise on a wide variety of surgical and medical problems that would otherwise have required a shore visit.
Conclusions: Successful intercontinental laparoscopic telementoring aboard a naval vessel was accomplished using ``off-the-shelf'' components. In many instances, the high risk and cost of transporting patients to land-based facilities was averted because of the BGTM system. Also, the relationship between the on-site and telementoring surgeon was critical to the success of this experiment. Long-distance telementoring is an invaluable tool in providing instantly available expertise during laparoscopic procedures.