The Time of The Telesurgery: How to Operate Someone Thousands of Kilometres Away?

On September 7, 2001, Jacques Marescaux performed a cholecystectomy to a 68-year-old lady. It lasted 45 minutes and his prognosis was good. Nothing had distinguished him from the other 750,000 operations of this type are performed annually in the United States if it were not for the tiny detail of that was held 6.230 km away. The kilometres that separate New York (where was the surgeon) in Strasbourg (where was the patient).

Thus was born the telesurgery wanting to change the world. But sixteen years later, these tools are only used under experimental conditions or for reasons of force majeure. At least, so far. Today, something that is beginning to change: more devices, improved infrastructure, more experiences and practices. Has the time arrived for medicine distance?

An appointment with the doctor

Juan has the doctor appointment at 12 in the morning. So a few minutes earlier, he sits down at the living room television and connects to its Smart TV app. At 12 o’clock receives a call from Dr. Ramírez. The same day requested the appointment, the health center sent him im a kind of wearable that carries all its constant monitoring. The doctor Ramírez, who already has all the information of the wearable, says you how everything goes and book the appointment for surgery.

It is in a couple of days and in the Centre of health, so the surgeon is incorporated into videoconferencing and, although it will return the day of the intervention, explains the procedure. In the health center there is a computer aided surgical system. Thus, although the surgeon is in the city almost one hundred kilometres away, there will be no problem and everything will be resolved without too much problem. It will stay a few hours in observation and you can return to your home without any problem.

In a few years This will be the day of health care. Thanks to the technological evolution, medicine is returning to the homes of patients and is gaining in quality and personalization. Although it may seem like science fiction, this is a process that has been brewing many years.

Surgery and the reign of the robots

Surgical robots are more popular than ever. In 2010, 86 per cent of all eradications of prostate in United States were performed with robots; Today, they are used for multiple operations of heart, kidneys, bladder or ovaries. In Spain, the first surgical robot was installed at the Fundación Puigvert in Barcelona. Ten years later, there are more than twenty scattered throughout the Spanish geography and, in fact, the University of Cordoba and the Imibic have developed one designed and manufactured entirely in in Spain.

With more than 2000 operating surgical robots in the world, each year more than 500,000 robotic operations are performed. In fact, this type of assistants are becoming the best allies of surgeons, patients and health systems.

Robotic assistants are more popular than ever and already perform about one million operations per year

On the one hand, robotically assisted surgery allows the surgeon to make a much more accurate than the traditional job, take a less demanding than the usual physical stance, integrate real-time data and diagnostic imaging (physiological records, different cameras and perspectives, ultrasound, x-rays, etc…) and correct tics, tremors or errors in the implementation of the operative techniques. On the other hand, health systems can not only win in effectiveness and efficiency, but they can completely rethink towards models that better Generalitat field.

But without a doubt, the big winners are patients. Tools a more accurate, fast and safe intervention. In surgeries such as the prostate, these techniques have been trimmed to half the recovery time avoiding complications and reducing the pain and discomfort of patients.

Where are these robots?

In its most basic form, the telesurgery is no more complex than a videoconfrencia or the piloting of a drone. The surgeon is located at one end with a console that allows you to manipulate the robot and is connected to it via the internet. The surgeon sends instructions and the robot, in turn, sends visual information and touch (haptic) the surgeon. Obviously when we talk about something that we do do decade and a half, the technology today is something relatively trivial.

Therefore, the question is that if we have the technology, procedures and experience to carry out this type of interventions, why don’t we do them? The most obvious answer is the price. Grant Schaffner, President of ProtoStar (one of the pioneers in the development of solutions of telesurgery for astronauts), it is clear: “the technology already exists but lower costs or it will be difficult for end users to find financial resources to be able to receive these treatments”.

A Da Vinci fully operational (standard market) requires an investment of about $ 2 million. This creates a paradox: the centers that can afford to install these equipments, already have human resources capable of performing these operations. Therefore, robotic assistants end up using by its precision and speed improvements from the room of to the side. Centers that really is benificiarian of the telesurgery simply they cannot afford it. But, unfortunately, the financial is not the only problem that hinders the spread of remote surgery.

The problem of the gap

I.e., even in the event that the clinics in developing countries robotic assistants, could afford the digital infrastructure has very important problems. Last year, only a 43′ 3% of the world’s population had access to the internet: this is the true selfie of the digital world.

When we use a robotic Assistant in the same hospital, we have cables that connect directly with the robot with the console and, for that reason, the gaps are invaluable. When we use internet to communicate the two devices, the thing changes and the accuracy may be compromised and the speed of movements as well as the feedback may be compromised. Blake Hannaford, one of the creators of system surgical open-source RAVEN explains that only streaming video requires a bandwidth of less than 2 megabits per second. When we do not have that wide, it appears the problem of the gap.

In fact, until last year We didn’t know until this point was a problem. A team from the University of Minneapolis carried out some research to know until that point the gap was problematic. They selected 20 surgeons with different levels of expertise and asked that they execute different tasks with bots. In tasks, the researchers introduced random gaps of between 100 and 1000 milliseconds. The findings show that the problems begin to be important from gaps of 250 milliseconds. But perhaps the most worrying conclusion is that the problems of desafase affect equally skilled surgeons that inexperienced surgeons. I mean, Neither the experience nor the expertise to correct gap problems.

Connection and bandwidth problems are one of the major problems of surgery in remote

On the other hand, as explains Roger Smith, researcher in robotic surgery at the Nicholson Center of Florida, these delays are not caused by distance. Or not necessarily. We have to be clear that infrastructures present a series of “glass ceiling” that slow flows of information among surgical devices. “We will find cases in which it is possible to perform an operation to 2000 miles away but not 2,” says Smith. We have of find ways to identify and overcome those barriers.

Security, a pending issue

While engineers and surgeons are aware of the problem of the gap, there is another almost forgotten issue: the security of communications. “To separate the robot surgeon, opens the possibility of infringing their systems”explained Howard Chizeck Professor of electrical engineering at the University of Washington,”on the other hand, has been a traditionally forgotten subject””.

To study the vulnerability of the robotic assistants, Chizeck and his team decided by the classical method: find all the ways to break the security of the Raven. In the study, they tried to interfere with communications between the console and the robot while the operator performed tasks such as moving toy cubes. Not only they managed to intervene These submissions, but that in the majority of cases the surgeon did not even notice of that system was not behaving as it should.

However, it must bear in mind that, in reality, not has been given much attention to this issue: devices not encrypt the information in any way and they do not have identification systems sophisticated as the so-called surgical signature (using the particular patterns of each surgeon to identify it).

Being sincere, the problem is that manufacturers do not have any real pressure to address the issue of security. Finally and after, and perhaps by the low use of these devices, so far there have been no security problems. But it seems reasonable that we have to wait for these problems to occur. “Ideally, [the digital security] starts in the design phase of the product, at the beginning of conceptualization. But is not the case,”explains Stephen Wu, lawyer of the Silicon Valley Law Group.

Little by little, teams of engineers are becoming aware of the matter. In this sense, it is working on the use of artificial intelligence to develop ‘autopilots’ that provide vital support in the event that the security is compromised.

When the robotic assistants to become smart

However, There are reasons to be optimistic. Internet has become a market so huge that every time there are more efforts to ensure that ‘the map is the territory’; in other words, to ensure that each and every one of the world’s inhabitants have access to internet. That’s going to do that in not entirely unexpected way, the technical problems and the ‘glass ceiling’ will be reduced.

In addition, the field of surgical robotics has caught the attention of large technological. For example, Verily, a division of Alphabet (Google), launched at the end of the year its own surgical robot development project. These movements suggest that the costs are going to suffer a radical drop.

The main technology that competes against surgery in remote are autonomous robots. Systems that we already have prototypes, but which are very far from being useful

As optimistic as we can be, that if does not extend the telesurgery won’t be by his failure, but by the success of ‘its technological competence’. The main competitor facing the telesurgery is the development of autonomous surgical robots guided by complex systems of artificial intelligence. A couple of days, here at Engadget we talked about how this type of device have evolved and the latest developments.

One of the most important human companies in the next century, as the colonization of space, depend on our ability to dispense with land in providing medical services. Protostar has spent years working on these issues and plan to using an autonomous robot to implant a profound hearing aid in a cadaver over this summer.

There is much more, that is clear. But according to the experts, it would be not unreasonable that in a period of 10 or 20 years see robots autonomously performing biopsies, prostatectomies u operating appendicitis. Don’t tell me that it is not something amazing.