The concept of remote surgery has been around since at least the 1970s when scientists at NASA first started to tackle the issue of performing operations on injured or sick astronauts in space.
Since then, the experimental use of robots to carry out surgery at a distance has entered the mainstream. Canadian surgeon Mehran Anvari, who has worked with NASA performing remote robotic surgery at its NEEMO deep sea test lab, also regularly operates on patients at distances of up to 400km.
Supervisory-controlled robotic surgical systems, which perform procedures based on instructions given via a computer terminal, can be ‘unmanned’, or controlled remotely by a surgeon not in theatre. The most famous such system, the Da Vinci laparoscopic robot, has been used in 1.5 million operations.
Now, with the advent of augmented reality (AR) based applications like Proximie, remote surgery is taking place without robots, too. AR-assisted telesurgery involves two surgeons or surgical teams using devices like iPads or laptops to collaborate on a procedure over distance, allowing a specialist to guide a colleague through an operation even if they cannot be physically present.
Remote surgery offers numerous benefits to healthcare services. Through remote digital networks, available human capital – the number of qualified surgeons – can reach further and be utilised more efficiently. Less travelling for surgeons and patients to a particular location at the same time means lower costs.
Without the lag caused by the logistics of travel, waiting times can be reduced and service levels improved. The ability to reach patients more quickly, and in their current location, will improve outcomes and bring services to harder-to-reach places.
But are patients entirely comfortable with the idea of going under the knife when the person ostensibly in charge is not in the same room, and possibly many miles away? Is it entirely safe, and what about issues of patient confidentiality, trust and privacy? And what exactly are the benefits to the patient, anyway?
How telesurgery benefits patients
The ultimate aim of remote surgery is to be able to operate on patients at a considerable distance. One of the first demonstrations of this came in 2001, when a team led by the European Institute of Telesurgery in Strasbourg carried the world’s first trans-atlantic operation. Controlling a robotic laparoscopy system, a surgeon in New York was able to successfully remove the gall bladder of a patient in France almost 9,000 miles away.
The main benefit remote surgery offers to patients is improved access. Healthcare services around the world have been battling a shortage of surgeons for years as the number of new entrants coming into the profession through training programmes has failed to keep pace with rising demand.
Medicine has always been a face-to-face undertaking. Patients visit their GP in person for consultation; surgery is carried out by team of surgeons working directly on the patient in the operating theatre.
Not having enough surgeons to meet demand for procedures therefore creates barriers to access. Waiting times increase as patients effectively queue for an available surgeon. Location also becomes important. Most surgeons operate out of a particular hospital, so to undergo a specialist procedure, patients routinely have to travel to where an expert is based.
All of this raises the costs of surgery and makes access more complex and difficult for everyone.
Remote surgery removes one of these barriers – location. Instead of having to travel to undergo surgery with a particular specialist, patient and surgeon can remain where they are, as demonstrated by the Strasbourg trans-atlantic operation. The time and cost created by the need to travel is removed, so waiting lists can be dealt with more swiftly and efficiently.
The drawback with robot-assisted remote surgery is expense. Some systems cost up to $1m to purchase, and $100,000 a year to run, which creates its own barriers. By contrast, AR-assisted remote surgery is extremely cheap and cost-effective to run. With Proximie, all you need is a pair of laptops or tablets, and a subscription to the service.
One final benefit to patients that remote surgery brings is choice. Being able to provide patient choice is now widely viewed as a measure of quality of service. In the UK’s National Health Service (NHS), offering patients choice in where they receive treatment, what doctors they see and so on is now formal policy.
Remote surgery fits well with the choice agenda. Without the limitations of travel and the pressure on beds created when services are concentrated in one location, patients can in theory choose whichever surgeon they like from around the world to perform their operation. Specialist expertise becomes more accessible, so patients with rare or complex conditions are more likely to be able to get the treatment they need.
Because of its lower costs and ease of deployment, AR-assisted remote surgery is much better placed to extend patient choice in surgery than robotics.
What are the drawbacks?
The primary concern raised about telesurgery is patient safety. Robotic surgery is largely recognised to not only be safe, but to offer certain advantages over a person carrying out surgery. Robots can be more accurate and precise, they don’t tire in long operations, and because they can work more efficiently, they allow for shorter anaesthesia, less blood loss and quicker recovery times.
These benefits, however, are not universally accepted when a surgical robot is being controlled remotely. Robots are only as precise as the input from the surgeon controlling them. Surgical procedures are ‘live’ processes, things change and things do go wrong. If a surgeon makes an error with a data he or she inputs from thousands of miles away, how effectively can they remedy it?
There is also the challenge of latency, or the lag that occurs in the transmission of data over a network. Robot-assisted remote surgery has had to battle the time delay between an instruction being sent and the robot receiving and acting on it, and also the lag in pictures being sent back to the surgeon. These delays are measured in milliseconds, but again raise concerns over reacting to errors or unforeseen events.
Rather than aiming to automate aspects of surgery, AR remote-assisted surgery seeks to widen the scope of who can be involved in planning and delivering a particular procedure.
As the specialist that manages a surgical team often stands in an advisory or guiding role, it does not make much material difference if they are stood in theatre or relaying information and instruction through an augmented video stream. The full team responsible for patient safety is still in situ, and there are trained surgeons carrying out the procedure who can react as required.
Other questions patients will justifiably ask about remote surgery centre on confidentiality and privacy. Telemedicine relies on collecting large volumes of personal patient data and making it available over digital networks. With telesurgery, live images of intimate procedures are broadcast over large distances.
Patients would be right to question who can access this data, who is viewing the video feed, and how secure the system is from hackers and snoopers. The healthcare sector has had to move fast in responding to these concerns as digital technology has increasingly taken centre stage, and in most cases has been obliged to do so through regulation.
The US Health Insurance Portability and Accountability Act (HIPAA) set the global standard for defining the duties placed on healthcare providers for protecting private patient data stored and distributed electronically. In Europe, the new General Data Protection Regulation (GDPR) coming into force across the EU will introduce even stricter controls on the management of private data, which healthcare providers will have to meet or face stiff fines.
As the GDPR will claim jurisdiction over any digital transactions involving EU citizens, even if parties involved are outside its borders, we can expect its requirements to become the new standard in data protection and digital security.
Patients can be assured, then, that their privacy will be protected in remote surgery, and across all telemedicine services, by tight regulation. The argument over whether patients feel comfortable consulting a doctor over in iPad or being operated on with a consultant overseeing procedures from thousands of miles away is more complex. These mark considerable changes in how healthcare is delivered, and like all innovations will take time to be universally accepted. But the benefits are clear and the argument is there to be won.