Dr. Sunil Shroff
President
Medical Computer Society of India
A-113, Annanagar,
Chennai - 600102
sshroff@vsnl.com
Prof. and Head of the Department
Urology & Renal Transplantation
Sri Ramachandra Medical College
Chennai - 600116
srmc69@eth.net
Laparoscopic Telerobotic Assistant: Developments at other laboratories have also led to development of a telerobotic assistant to help with laparoscopic surgery for e.g. a laparoscopic camera positioning robot. Laparoscopic procedures using a robot assistant are available. A hydraulic hand for laparoscopic maniupulation is being developed by researchers with hand with wrist and gripper (http://robotics.eecs.berkeley.edu)
Telestartion: Telestration greatly enhances the remote surgeon's ability to control the flow of operation. In traditionally mentored procedures, the proctoring surgeon can convey part of his instructions to the primary surgeon by direct demonstration of the maneuver, pointing to a specific area of the operative field and using descriptive audio communication. The telestrator allows the mentor the ability to directly draw in the operating surgeon's visual field. This facilitates communication of the operative technique that is desired. Robotic control is necessary to control the operative view and thus the operative field being approached.
At the Intelligent Machines and Robotics Laboratory, a robotic platform for laparoscopic surgery is being developed. The platform will incorporate centimeter sized robotic manipulators with force and tactile feedback capability for high dexterity manipulation. This laparoscopic surgery platform will have a master-slave teleoperation system.
Telepresence Surgery: All the above developments in virtual reality along with concurrent developments in the field of telemedicine has opened up another area. Applications such as remote endo-urology and laparoscopic surgery using telerobotic technology have now become a reality. Better and cheaper bandwidth is likely to make this a commonly used procedure. This type of remote surgery is called Telepresence Surgery. Whereas in virtual reality the user is immersed in a computer generated world; in telepresence the user is immersed in a remote real world. The user needs to be presented with the stimuli of the remote site and to have the ability to exercise control over the remote site. Besides audio and video images the operator also requires to have the sense of touch and for this purpose special datagloves have been developed. A whole new field called Haptic rendering is developing. Haptics is the generation of touch and force feedback information. There have been very few studies done on the rendering of true touch sense (such as liquid, fur, etc.). Almost all systems to date have focused on force feedback and kinesthetic senses. These systems can provide good clues to the body regarding the touch sense, but are considered distinct from it. Many of the haptic systems thus far have been exo-skeletons that can be used for position sensing as well as providing resistance to movement or active force application. A company called Home Site System in USA has developed haptic display systems such as head mounted displays (HMDs), autostereoscopic display screens and gloves or other devices equipped with touch sensing that can be used at remote site for telepresence surgery. Applying this technology at a distance like requires perfection and synergy of many new technologies put together. Advancements and refinements with network technology in combination with 3D-video-camera with CCD unit, advancements in minaturisation of motors resulted in nano-machines and advanced Robotics, the digitising of information by computers and virtual reality has today made Telepresence surgery or Cybersurgery a reality.
CYBERSURGERY OF THE FUTURE
In the world of computer the virtual and real world are slowly merging and a new dimension is starting to slowly emerge and this dimension is the dimension of the future. The development of CT, MRI scan and PET scanners along with the power of supercomputers of tomorrow hold a fascinating future for the healthcare industry. Minimally invasive surgery is only a transition period till one day we move on to the non-invasive era of surgery. The advanced computer software programs will be able to help in creation of 3-D visualization of virtual anatomic models of patients and the full genetic code of the individual will indicate any variations in physiology with possible pathological implications and will produce an enhanced world of reality. This marriage of virtual and real world will change the way medicine is practiced. A patient on entering a surgeons office will pass through complex array of scanners. These will acquire the anatomic, physiological and biochemical parameters of the patient and when the patient sits down on a chair, linked to the computer, it will automatically create 3D Hologram image of the patient. The image like a shadow will appears next to the patient. On listening to the complaints of the patient like passing of blood in the urine with right flank pain, the surgeon will be able to rotate the holographic image and will be able to put his hand through layers of tissue and take the right kidney out and dissect it in his hand to look at the pathology. He instantly will also know the GFR of the kidney along with parameters like serum creatinine, calcium, uric acid and paratharmone levels as these will be displayed next to the holographic image when the kidney is being manipulated. This holographic image is called "the medical avatar" by Satava RM in his book called "Cybersurgey - Advanced technologies for Surgical practice".
This medical avatar can be then used to educate the patient. If surgery is necessary this avatar will be used to practise endo-navigation for nano-robots to be guided to the area and remotely controlled to do the necessary manipulations. The scissors will be replace by joysticks and scalpels by lasers fitted to the nano-robots. In the post-operative period fresh holographic images will indicate the improvements in the patients general condition.
What appears to be in distant future is actually at our doorstep, we must remember that as surgeons we are the torchbearers for healthcare of humanity of today and tomorrow. Technology is neither good or bad, it is neutral. We must use these technologies to our patient's advantage and to improve outcomes of the procedures in terms of no complications, it is for us to use our own humanity with humility to practice surgery like our forefathers did as both an art and science.
Telemedicine the Promises and Realities.
Telemedicine is often used as a technology showcase rather than a way to practice medicine. In pursuit of the possibilities that are visualized the limitations and fallbacks are often ignored.
For telemedicine to emerge as a viable alternative modality for delivering medical care and expertise there are a few preconditions that are to be met. Some of these are,
- Adaptation of Information technology by hospitals especially in
terms of networking and Hospital Management systems.
- Increasing awareness on IT among medical
professionals.
- Decline in the cost of telemedicine hardware to maket it more
financially viable.
- Better Internet access; possibility the advent of broadband,
which can transfer video files faster.
- Better maneuverability incase of telesurgery tools, eliminating
problems such as time lag in case of a surgeon operating from
a remote location.
- Standardization of various protocols (like DICOM in
teleradiology) and acceptance of these protocols by the
relevant equipment manufacturers.
With relevance to the specifics of the Indian scenario the major constraint is in terms of the financial viability of telemedicine initiatives. There have been several isolated initiatives from various organizations and hospitals for implementation of telemedicine projects.
The answer probably lies in pooling together resources by various facilities within a geographic locality and sharing the benefits and revenues thus created. To elaborate on this point, several hospitals within a city like Hyderabad can share a common Tele-pathology service or Teleradiology service. The benefits of such a pooled service are very obvious. Investigations can be viewed by a group of expert consultants. Such a model will reduce the initial project costs and with the patient traffic from several affiliated hospitals can achieve economy of scale and thus reduce costs of trained manpower and material costs and also provide a very efficient and optimal service to the community.
Telemedicine in principle is well suited for countries like India, Africa and South America where there is a large rural based population separated by large distances and needing access to regular medical care of quality. We in India are even more uniquely placed among these countries as we have the best of skilled manpower and computer technocrats. The telephony revolution of nineties of India has linked most of our smaller towns and villages with rest of the world. The railways also has a vast network of fibre-optics cables already laid out on many of its routes. The Space scientist of our country have placed strategic satellites of communication making a broadband network not too difficult to achieve with expenditure of minimum resources, These gateways of communications should be all used to help with the project of telemedicine and hence reduce applications costs. Even subsidies could be incorporated to facilitate telemedicine projects in our country.
It is the question of bringing together these different agencies and forums to make the revolution of telemedicine happen and to provide our humanity with the best possible medical care. If these experiments work in India over the next decade the vast population living in developing countries will be the winners and bear the fruit of our success. Telemedicine should be a used as style of practice of modern medicine rather than be exhibited vulgarly as a technological showcase. Perhaps the slogan "Health for all by 2000" which was forgotten by our politicians towards the end of last century can still be achieved by the year 2020 by making "the telemedicine revolution" happen in India.
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