EDITORIAL

01/01/2002

Code name: Lindbergh operation J Marescaux, MD, FRCS Head of Digestive Surgery Department Hôpitaux Universitaires de Strasbourg President of IRCAD/EITS Strasbourg, France

"The madman forces doors, the wise follow” Persian proverb In 1927, Charles Lindbergh flew non-stop across the Atlantic for the first time in history, aboard the “Spirit of St. Louis”. This pioneering feat took place from Paris to New York. It was in the same spirit of innovation and daring that the IRCAD/EITS (Institut de Recherche contre les Cancers de l’Appareil Digestif/European Institute of TeleSurgery) team realized the first transatlantic surgical procedure between New York and Strasbourg, appropriately dubbed the Lindbergh operation. Since 1993, the experts at IRCAD/EITS had been preparing for the impossible. The notion of long-distance surgery took shape within the EUREKA Master (minimal access surgery by telecommunication and robotics) project. It was felt that enhancing the quality, reliability and safety of the data transmission by digitizing and robotizing the surgical act could eliminate all space and time constraints. Robotization of the surgical act was first developed with the support of the Karlsruhe Research Center. This led to an effective, yet heavy, non-ergonomic system that was not suited for introduction in the operating room. Wiser for the experience, the IRCAD/EITS team geared itself towards partnership with an TM industrial company. This involved working with ZEUS , a robot comprised of three arms. Two arms manipulate the instruments in response to the movement of the surgeon’s hands. The third arm manipulates the voice-controlled endoscope. A console enables the surgeon to handle the joysticks that command the two instruments held by the robotic arms. Each articulated arm has a double security system. Signals are checked more than a thousand times per second. Manual information originating from the surgeon is analyzed by the master-slave interface and rendered safe. Demultiplication also enables the tele-effector to carry out extremely precise movements. After two years of experimental work, a laparoscopic robotic cholecystectomy was performed on a patient in September 1999. Subsequently, a prospective evaluation was conducted on 25 patients. This proved the feasibility, reproducibility and safety of the technique as well as its acceptability by the medical and paramedical teams (1). Further, computer-assisted surgery allowed some distancing between the surgeon and patient as the command console was connected to the operating table by a cable system a few meters in length. The team was only one step from the realization of a complete surgical procedure over a long distance. Data from the literature and reports by surgeons of the US army indicated limitations to the speed of data transmission and unacceptable delays between the surgeon’s commands and the visual return of the surgical act on the monitor (2). To address this problem, it was decided to use high-output fiberoptics that offered perfect transmission delay for optimal coordination of the surgical acts and high-quality video images. From September 2000, a number of procedures on porcine models were performed across local distances with the following conclusion: no delay was perceptible between the order given to perform the act, its performance and the return of control. On September 7, 2001, the IRCAD/EITS team attempted the first remote robot-assisted laparoscopic cholecystectomy, with surgeons in New York and a patient in a teaching hospital (Hôpitaux Universitaires) in Strasbourg. Signals traveled a total of 14 000 kms, with an output of 10 Mbits per second and a constant delay of 150 ms (80 ms for the transfer of data and 70 ms for the decoding of the video image). Fifty-four minutes later, the dream had become reality; a complete procedure had been performed with ease, without encountering any technical problems and without any perceptible delay in transmission (3). Such a high investment of time and capital could appear disproportionate for a surgical procedure if we were not aware of the technological and cultural transformations that may follow: - the end of the individualism typical of the surgeon: indeed, patients in any geographical location may benefit from the expertise of a well-trained surgical team; - the end of the unacceptable notion of the “learning curve”, which implies that the surgeon is trained in a new surgical technique to the detriment of the patient; - the application of such surgery in wartime when there is a lack of specialized surgeons;

EDITORIAL

01/01/2002

- the development of a new concept of humanitarian surgery where it may be proven that sophisticated technology is perhaps more cost-effective than the delegation of several missions, which may not allow for the autonomy of the teams in less developed countries; - future applications to space surgery with the implementation of the International Space Station where astronauts and space tourists will meet; - the integration of preoperative simulation and intraoperative augmented reality (4).

References: 1.

2. 3. 4.

Marescaux J, Smith MK, Fölscher D, Jamali F, Malassagne B, Leroy J. Telerobotic laparoscopic cholecystectomy: initial clinical experience with 25 patients. Ann Surg 2001;234:1-7. Satava RM. Emerging technologies for surgery in the 21st century. Arch Surg 1999;134:1197202. Marescaux J, Leroy J, Gagner M, Rubino F, Mutter D, Vix M et al. Transatlantic robot-assisted telesurgery. Nature 2001;413:379-80. Marescaux J, Clement JM, Tassetti V, Koehl C, Cotin S, Russier Y et al. Virtual reality applied to hepatic surgery simulation: the next revolution. Ann Surg 1998;228:627-34.