ROBOTS GIVE EDGE TO LONG-DISTANCE SURGERY

November 06, 2000

CHICAGO (AP) -- As Joseph Kolodzieski lay unconscious on a Baltimore hospital operating table, the doctor in charge sat more than 700 miles away, directing a remote-controlled robotic arm inside the patient's abdomen.

This is 21st century telemedicine, the latest advance in a field that doctors say someday may allow a surgeon on Earth to operate on astronauts in space.

Even the earthbound version that took place not long ago seemed out of this world.

"It's amazing," Kolodzieski said a day after undergoing the long-distance operation to treat chronic groin pain.

"I was knocked out; I didn't see any of it," he said wryly.

But a cluster of strangers did, gathering at a convention hall booth where Dr. Louis Kavoussi sat at a computer console and video screen that graphically displayed Kolodzieski's insides.

Kavoussi controlled the rate of gas injected into Kolodzieski's abdomen to create a work space inside for the minimally invasive operation, assisted by Dr. Thomas Jarrett at Johns Hopkins Bayview Medical Center in Baltimore.

With the click of a mouse, Kavoussi also directed a tiny camera attached to a slender robotic arm that probed through a small incision into the patient's abdomen. The camera allowed the operation to be witnessed live by doctors attending an American College of Surgeons meeting in Chicago.

It also allowed Kavoussi and Jarrett to view the nerve believed to be causing Kolodzieski's pain. Jarrett cut the nerve and Kavoussi, using the robotic arm, cauterized the area to stop bleeding.

The doctors spoke to each other via microphone throughout the hourlong operation.

Kavoussi, a Johns Hopkins urologist, is one of the few doctors nationwide who has done long-distance robotic surgery, which is rare and still considered experimental.

Since his first procedure about four years ago, Kavoussi has operated long-distance from Baltimore to Thailand, Singapore, Rome and Austria. In September, from the library of his Maryland home, he helped do robotic varicose vein surgery on a patient in Brazil.

Kavoussi says robots are in some ways better than human surgeons because they're "more precise and can be programmed not to slip, not to make a mistake."

They have other advantages.

"If patients wanted the guru of heart surgery to operate on them, they could," without having to travel, Kavoussi said.

Kolodzieski, who was up and walking at his Glen Burnie, Md., home a day after surgery, was thrilled to be a part of a medical milestone.

"It was great," he said. If it advances science, "I'm all for that."

Dr. W. Randolph Chitwood Jr., who has performed experimental heart valve surgery using a more sophisticated robotic system than Kavoussi's, says robots can work wonders, in the right hands.

"This is not going to take a C-grade surgeon up to a whiz-bang surgeon," he said. "We're not talking about R2-D2, C-3PO types of robots. It's an enabling technology."

Chitwood and colleagues at East Carolina University in Greenville, N.C., are using a million-dollar three-armed robot called the daVinci Surgical System, which, controlled by a computer, can grasp tissue, cut and sew stitches deep inside the body.

Though it hasn't yet been used long-distance, Chitwood and others say having a robot do the bulk of an operation is perhaps less than a decade away.

He's even consulting with NASA about potential Earth-to-space operations.

"If astronauts on a space station or on Mars have a medical emergency, how will we take care of them quickly when it takes someone six months to return to Earth? With the robotic technology, surgeons may be able to direct surgery over thousands or millions of miles by telemanipulation," Chitwood said.

Telemedicine without robots has evolved over the last decade as a way to bring state-of-the-art medicine to rural areas. It includes doctors diagnosing and monitoring patients via video screen as well as verbally directing medical procedures long-distance.

While robots add an even more hands-on dimension, the technology has limitations, says Dr. Jay Sanders, president emeritus of the American Telemedicine Association.

"We can't change the speed of light," he said. "When I'm in Chicago and push a button to move a robotic arm in Baltimore, that is literally instantaneous." But at farther distances, the robot can't respond immediately, which could pose a problem using the technology in space, Sanders said.

Kavoussi said when he operated from Baltimore to southeast Asia, the delay was only one second.

Because long-distance surgery is still experimental, Jarrett said patients have been billed only for costs associated with procedures done on-site. All the long-distance costs, including the remote surgeon's fees, have been paid for by private funding.

Among the most expensive costs are the phone bills, since several phone lines are required for the computer hookups. A three-hour surgery done in Austria in 1996, for instance, cost $3,500 in phone charges alone. Such costs have since dropped somewhat. The phone bill for the Singapore surgery two years later was under $2,000, Jarrett said.

If this type of surgery becomes more accepted, it is certainly possible patients would be billed for surgeons on and off-site, he said.

Cost-effectiveness and acceptance by the public will determine whether long-distance robotic surgery becomes commonplace. The question would then be, "Is this going to cost more than it's worth?" Jarrett said.

About the only operation that would not be compatible with this approach is emergency surgery, since long-distance surgery requires a certain amount of set-up time and pre-planning, Jarrett said.

While some might worry about entrusting their lives to a robot, Jarrett says there's no danger of robots taking over the operating room.

"Ultimately, you're going to combine the speed and accuracy of a computer with the precision of a robot and the judgment of a human," Jarrett said. "Nothing is going to replace human judgment."