In February 2001, two surgeons in New York City used robots in the operating room in concert with Internet-based communications to successfully remove the gallbladder of a patient 3,900 miles away in Strasbourg, France. It was the first telesurgery. Using a three-armed robot, the surgeons guided two of the robotic arms to cut tiny incisions into the patient’s abdomen, while the third arm inserted  a mini-camera into her abdominal cavity for visibility of internal area that would guide the surgery.

Ten years later, Kenyan surgeons from Aga Khan University hospital performed a successful telesurgery over a dedicated 15Mbps (megabits per second) Internet connection operating a robot in the operating room. The success of the operation further built hopes that urban surgical skills could be leveraged to remote and rural areas around the world and led to the establishment of a permanent telesurgery facility.

This potential for life-saving medicine wherever you are is enormous, and is now making significant inroads into health care networks everywhere. Nevertheless, impediments to smooth operations still remain.

Communications QoS

Guaranteeing quality of service (QoS) across Internet and into a robot in the operating room, even with dedicated pipelines, is a major issue in telesurgery—as is latency of communications. One of the major concerns in the early Strasbourg telesurgery was the communications latency that was encountered when signals from the surgeon’s control board in New York City were sent to the operating room in France. The signals being transmitted also had to be translated into robotic actions that were executed during the course of surgery. While these robotic actions were being carried out in France, the surgeon in New York had to wait for incoming video signals to observe (and confirm) that what was going on in the operating room was correct. With each passing millisecond of latency, a modicum of delay-induced risk was introduced. To correct this, work was undertaken to perfect the various layers of network communications that potentially impeded the flow of telesurgery instructions and observations. Since then, what healthcare providers implementing telesurgery have concluded is that they must take network quality of service (QoS) into their own hands. This means not accepting the de facto pre-factory QoS settings that various network component providers furnish for their own pieces of equipment, and instead setting internal performance metrics that meet the requirements of a remote robotic medical procedure in an operating room being run over the Internet.

Medical procedure failovers

Medical procedures also need to be rewritten and tested for a telesurgery scenario. In early telesurgery work, a stand-by surgeon was positioned at the site of the operation, fully prepared to take over if the telesurgery communications line was somehow interrupted. To prevent this from happening on the IT side, provisions were made for failover lines so that communications could optimally be continuous and uninterrupted, even if there were a disruption to the primary communications conduit. In some cases parallel networks with immediate failover are now being run. In all cases, medical providers still rely on standby surgeons to step in with manual processes if needed.

Legal and regulatory hurdles

In the U.S., doctors (like lawyers) are certified and licensed in the states where they practice—and cannot necessarily traverse state boundaries with their medical services. The plot can become even more complicated when international boundaries must be crossed. Some states have reciprocity agreements that facilitate an event like a telesurgery with an out-state doctor, but in other cases, time-consuming licensing and certification requirements must be satisfied first.

Looking at the Future

An aging population with greater health needs is projected to create a shortage of over 130,000 doctors in the United States alone by 2024. The need for more medical care is also being felt in other parts of the world.

Meanwhile, demands for telesurgery that use robotics, along with other forms of telemedicine in rural areas, third world countries and even space will increase. Public organizations and private enterprises are coming forward with funding, at the same time that network communications are moving to 100G networks that can facilitate the level of communications QoS that telesurgery demands. All of this is welcome news—because the evolution of telesurgery into standard practice that actively teams a surgeon in one location with a robot in another will certainly be at the forefront of modern medicine.