Telemedicine in surgery

Telemedicine uses information science and telecommunications to assist in the delivery of medical care at a distance. Certainly telegraph, telephone and radio were used to transmit information including medical information for many years before the term "telemedicine" was introduced by Bird in 1971. Dr Bird used microwave transmission between the Massachusetts General Hospital and Boston Airport for videoconferencing in patient care. Videoconference or television medicine has been closely identified with telemedicine ever since (1). From a technical viewpoint the microwave television in Boston bears little resemblance to later iterations of telemedicine where digital rather than analog communications changed so much in the way we communicate. Early work with analog equipment and satellites included the work done by NASA in Armenia after the 1988 earthquake (2) and very early work with a remote Indian reservation in the United States. In Armenia, television studios in Yerevan, Houston, Fairfax, Virginia and Salt Lake City were connec-ted by satellite such that expert panels could discuss long term management of disaster victims including surgical patients. The facility of information exchange led to confident mutual management despite great differences in medical traditions, technology and 16,000 km separation. The program continued for many years and eventually evolved into an Internet program. In 1993, during an insurrection in Moscow there were many casualties near the Ostankino tower. The NASA network was activated with the satellite capability and surgical management of individual patients was conducted. However, the very high cost of satellite communications then and for that matter now made such exercises in telemedicine unlikely to ever reach practical appeal. However, the early experiences prepared surgeons for later cheaper telecommunications options.
Information management with digital technology completely changed the possibilities for not only utilizing large amounts of information but also for the transmission of those data. The gray scale and flicker of the oscilloscope gave way to neatly ordered series of positive and negative charges on microcircuits subject to Moore's Law and hurtling along fiberoptic, wireless RF, or copper wire. Telemedicine is now a multimillion dollar international business reality with its own organizations (American Telemedicine Association http://www.atmeda.org/ and The International Society for Telemedicine and eHealth http://www.isft.net) with peer reviewed journals (Telemedicine and e-Health and Journal of Telemedicine and Telecare) and some 130 service programs in the US alone. Telemedicine today largely means consultation concerning images rather than the less common videoconference. Radiology (3-5), dermatology (6-8) and pathology (9-11) are dominant. With digital images acceptable standards for compression allow transmission with very high fidelity. Within medical centers vast amounts of information including images are moved about in our hospital information systems in ways that satisfy the definition of telemedicine (12-14). However, for greater distance management care or consultation for people in corrections facilities is a standard (15). Areas of geographical isolation such as Alaska (16) and Canada (17) consistently find telemedicine including consultation to be cost effective to enhance patient access to specialty care. Telemedicine is provided as a service for airlines (18), ships (19) and is a necessity for space medicine (20-21). In the health industry found in the US telemedicine may be said to have acquired proper recognition in that many insurance companies, Medicare and Medicaid will in many circumstances pay for medical services delivered by telemedicine. Over the thirty or more years that telemedicine has existed the evidence and science of practice are reflected in the number of publications seem in Table 1 that have grown from a handful to many hundreds per year.

Table 1

Surgery had been a part of telemedicine in its own way from the beginning and perhaps before the term "telemedicine" was coined. Surgery involves the highly visual surgical field and surgeons have applied video technology regularly to share their work with others. The video library using analog technology was long a standard. The first broadcast of an operation was by Dr Michael DeBakey from Houston to a group in Switzerland in 1963 (22). T1 or even ISDN with video equipment can transmit live surgical procedures relatively inexpensively using systems such as Polycom or the telemedicine called Socrates with the products Hermes and Aesop for voice and robotic control of the camera (23, 24). When Internet is utilized the cost can be negligible and most medical centers have the ability to enter the Internet by broad band from their internal information system. Surgical departments may make their educational conferences available by archiving and distribution on demand using video streaming on the Internet. Webcast is rising in popularity for real time interaction and programs can be found almost every day from some distinguished surgical program in the world. For webcasts the Internet accessed by broad band thorough the institutional Ethernet, ISDN with Internet Protocol connecting excellent and inexpensive cameras to the viewing community. The digital cameras are of excellent quality and cost less than a thousand dollars. Compression with H.323 can deliver with streaming 15 frames per second with excellent voice at only 128 kbps, the bandwidth of a single ISDN line. Distance learning with telemedicine is highly developed in surgery. Professor Marescaux at IRCAD in Strasbourg led the way with standard closed circuit programming in Europe starting 10 years ago (25). However, Internet seems to be the growing favorite since its first availability in 1995.
Consultation is the most obvious application for telemedicine over the Internet. Early Internet consultation was done in Russia by NASA partners. Surgeons were early and avidly creative users of the Internet where the cost was usually very low and the fidelity solely determined by the actual bandwidth of the connection. If the access to the Internet was sufficient or the application planned by the surgeon was tailored to the actual bandwidth fidelity was not in doubt. Telemedicine consultation with phone or dial modem was codified in the late 1990's and review of surgical patients by a volunteer surgical group from the Amazon using store and forward or asynchronous format was reported (26). Intraoperative consultation using freeze frame transmission was done in the Dominican Republic and Kenya by dial up modem in the late 1990's as well (27-29). Internet, H.323 compression, IP software, and stabilized digital cameras made acceptable videoconferencing from the OR possible with acceptable and interpretable results at 56 kbps. This has allowed integration of primary care and surgical programs with excellent benefits. Use of telemedicine to teach surgical skills has been extensively evaluated and validated. One example is the teaching of laparoscopic skills in virtual environments at the Fundeni Institute in Bucharest. (30)
It is useful to clarify a number of terms with regard to telemedicine in the service of surgical patients. Certainly telesurgery could be used to describe any application of telemedicine in surgery just as that construction is applied to teleophthalmology, teledermatology, etc. Telesurgery is probably best understood as the use of robots such as the Zeus or DaVinci to realize the moves of a surgeon's hands at very great distance from a master robot interface to the slave unit at the site of the patient. This use was so dramatically validated by Marescaux in 2001 when he and colleagues removed the gallbladder from his patient in Strasbourg with the Zeus robot which he controlled from New York. The background work for this momentous feat was critical and permitted a lag of only 155 msecs but required massive allocation of fiberoptic cable for bandwidth. Subsequent applications of robotics have been notable in a long list of surgical procedures including cardiac, obesity surgery and prosthetic procedures (31-36). A program in Canada headed by Dr Mehran Anvari is probably the best example of the successful application of robotic telesurgery to remote populations (37). Currently, the cost of surgical robots and the requirements for extra-ordinary bandwidth to maintain fidelity and avoid lag time make the wide application of telesurgery unlikely. However, as with other aspects of telemedicine, the steady reduction in the size and cost of advanced medical instruments coupled with the drastic reduction in the cost of telecommunications should encourage surgeons to be creative and visionary as always in the study and application of this new approach to surgical care.
If the performance of the procedure by the primary surgeon is called telesurgery some other terms should be clarified that sometimes are also called telesurgery. If the assistant surgeon is at another location is utilizing only voice or some image interaction but not instrument a mentor relationship exists if the distant surgeon previously taught the primary surgeon to perform the procedure at hand. This should be termed telementoring. If the surgeon is being observed by a distant surgeon to assess competence in the early adoption of a new procedure the distant surgeon is a proctor and the proper term is teleproctoring. If the distant surgeon has been invited to share the surgical field by telemedicine for the purpose of consultation the term should be teleconsulting. In telementoring, teleproctoring and teleconsulting the interaction of the distant surgeon is limited to voice, and perhaps marking on the shared surgical monitor with an arrow or telestrator. If the distant surgeon is moving the camera or has a robotic arm to engage the surgical field as an assistant the distant surgeon is projecting a presence more than cognitive into the care of the patient and the term for this form of telemedicine in surgery is telepresence.
Telemedicine has more to offer the surgical community and its patience than the terms defined above. For preoperative consultation, postoperative consultation, information management and education the best term is simply telemedicine in surgery, an all-inclusive description of the use of information science and telecommunications to support the delivery of surgical knowledge and service. If in fact the surgeon is using a robot such as the InHealth product to make rounds and interact with patients that modality is probably still best termed telemedicine in surgery since we should reserve the term telesurgery to the actual performance of the operation by a robotic mediation.
Telemedicine pioneers have included surgeons from the very earliest days. The generous use of telecommunications and information science in surgery allows virtual collaboration and a pervasive opening of the traditional operating room, a place that could be terrifyingly isolated for the surgeon in trouble or a place slow to change in the agonizing pace of diffusion of new surgical techniques that required long travel, observation, and directly observed practice to assure safety and competence in the surgeon taking on a new skill. The operating room looks to a future enriched by collaboration, imported information, exported information and generously shared with colleagues, teachers and trainees (38-40). This operating room of the future will surely come about since surgeons are inevitably attracted to new technology and the best in science and clinical skill in the interest of improvement and patient care.

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