Thursday, September 20, 2001

In a feat billed as the first transatlantic operation, surgeons working in New York have used a remote-controlled robot to remove the gall bladder of a 68-year-old woman -- in France.

Canadian and French surgeons sat in front of a computerized control panel and a television screen at Manhattan's Mount Sinai Hospital on Sept. 7, and, for nearly an hour, manipulated robotic arms to perform surgery on a woman about 7,000 kilometres away, at the Louis Pasteur University in Strasbourg.

"It went extremely well. Over 55 minutes there were no problems, no bleeding," said Michel Gagner, 41, a pioneer of robotic surgery formerly of the University of Montreal and now head of laparoscopic surgery at Mount Sinai in New York.

The patient made a full recovery and was discharged two days later.

The success of the cross-oceanic operation suggests doctors will be able to operate on patients in isolated, medically underserviced areas, battlefronts, Third World countries, or even outerspace -- without actually being there.

As well, Dr. Gagner said, surgeons will be able to train other surgeons without standing at their sides in an operating theatre.

Many doctors had presumed that remote-controlled "telesurgery" could be performed only over distances of a few hundred kilometres.

It was thought that the visual time delay in the transmission between the giving and the execution of instructions would have the feel of a badly dubbed foreign film and ruin delicate procedures that demand precision in millimetres.

Dr. Gagner described the delay as similar to watching a TV news anchor in North America pose a question to a reporter in the Middle East, then waiting several moments for the audio feed to be received.

But with a team that included computer software specialists, scientists reduced the time delay to a manageable one-fifth of a second.
"Fractions of a second may not sound like a lot," he explained, but in surgery doctors have to see the effects of what they are doing almost immediately so they can react -- if, for example, there was sudden bleeding.

Team member Steve Butner, a computer engineering professor at the University of California at Santa Barbara, said the robotic system was split into two parts and a computer was plugged in on each side of the Atlantic. The two sides then talked to each other along a secure, fibre-optic digital telecommunications network rather than a simple telephone line.

"What they've done is really remarkable. A lot of people would have thought this was impossible," said Douglas Boyd, director of the National Centre for Advanced Surgery and Robotics at the London Health Sciences Centre.

The surgeons planned to announce their accomplishment in New York on Sept. 13, but postponed the press conference and moved it to Paris after last week's terrorist attacks in the United States. The report will be published next week in Nature.

Dr. Boyd, a cardiac surgeon who in 1999 performed the first closed-chest, beating-heart robotic surgery, likened Dr. Gagner and his Strasbourg colleague Jacques Marescaux to Orville and Wilbur Wright. "This is going to bring surgery into the 21st century," he said. "It's not going to be about blood and guts, but bits and bytes."

On the New York side, Dr. Gagner and Dr. Marescaux were able to see the patient's insides via a video feed powered by a voice-directed camera. Handheld controls, capable of moving in various directions, prompted the robotic arms of the so-called ZEUS system in Strasbourg to mimic their movements, while they watched their handiwork on the monitor.

The team chose cholecystectomy, or gallbladder removal, for the landmark operation because it is a routine, low-risk procedure that requires relatively simple instruments. They practised the procedure on a pig this summer, which Dr. Gagner described as being more difficult than operating on a human patient, because pig parts are smaller.

The trial actually drew three volunteers. In the end, the doctors chose a woman in good health to reduce the chances of any complications.

"I think the patient was excited and had a sense of this historical moment," Dr. Gagner said.

In fact, before the woman could be put to sleep, she smiled and waved into the camera, Mr. Butner said.

But the procedure was not completely hands-free. A surgeon at the bedside in Strasbourg still had to pump the patient's belly full of carbon dioxide to give doctors the room to manoeuvre and make the four initial incisions, none wider than the diameter of a pencil.

Dr. Boyd, who has also used the California-made ZEUS robotic system to repair the hearts of more than 80 patients in the past two years, said the equipment, which costs about $1-million, may be pricey, but it pays for itself.

Among the many advantages of robotic heart surgery, for example, is that the tiny mechanical parts negate the need for splitting the breastbone and opening the chest. Smaller incisions mean recovery is faster.

His patients are out of hospital in two to three days instead of a week, they suffer fewer complications, and they are able to fend for themselves.