Robotic pyeloplasty using internet protocol and satellite network-based telesurgery.

BACKGROUND: In North America, the urological community has embraced surgical robotic technology in the performance of complex laparoscopic surgery. The performance of complex long-distance telesurgery requires further investigation prior to clinical application. METHODS: The feasibility of laparoscopic robot-assisted pyeloplasty in a porcine model was assessed using the Zeus robot and the internet protocol virtual private network (IP-VPNe) and satellite links. Eighteen pyeloplasty procedures were performed, using real-time, IP-VPNe and satellite network connection (six of each). Network and objective operative data were collected. RESULTS: Despite network delays and jitter, it was feasible to perform the pyeloplasty procedure without significant detriment in operative time or surgical results compared with real-time surgery. CONCLUSION: The completion of complex tasks such as robotic pyeloplasty is feasible using both land-line and satellite telesurgery. However, the clinical relevance of telesurgery requires further assessment.

Robotic telesurgery: a real-world comparison of ground- and satellite-based internet performance.

BACKGROUND: Telesurgery was performed with ground vs. satellite networks, and differing satellite bandwidths. METHODS: The networks were compared during internal mammary artery (LIMA) dissection in pigs (n = 8). Length of LIMA dissected and surgical quality (five-point scale) were recorded. Also, satellite bandwidth was decreased (n = 7) to determine a limit for telesurgery. RESULTS: No significant differences existed in LIMA dissection during the ground (4.3 +/- 0.5 cm) and satellite phases (5.4 +/- 1.1 cm; p > 0.05) or in quality of surgery, although latency on satellite was 10 times greater (55 vs. 600 ms). With decreasing satellite bandwidth, surgery was not possible below 3 Mb/s, and quality of surgery was significantly decreased comparing 9 Mb/s (4.38 +/- 0.66/5) to 3 Mb/s (4.10 +/- 0.80/5; p < 0.05). CONCLUSIONS: Satellite communication is a viable telesurgical modality. Satellite bandwidth should be above 5 Mb/s during telesurgery if used primarily or as back-up.

Long-distance robotic telesurgery: a feasibility study for care in remote environments.

BACKGROUND: Basic telesurgical manoeuvres were conducted with signal delays. METHODS: Eight test subjects conducted four manoeuvres. Time delays of 0-1000 ms were investigated. Time to task completion and error rate were recorded in sequential delays of 0-600 ms. Additionally, blinded random delays of 0-1000 ms were studied. RESULTS: In the sequential trials (0-600 ms), there were no significant differences in average task time compared to zero latency. The error rate remained low despite increasing time delay, and was significantly less at 500 ms (p < 0.05). In the random trials, task time was significantly greater at delays of 500, 600, 800 and 1000 ms (p < 0.05). There were no significant differences in error rates (p = 0.252). CONCLUSIONS: Operators are capable of performing surgical exercises at significant delays. Latent video feedback is difficult for telesurgery. Visual or virtual reality cues should be implemented to aid the operator in a high-cadence telesurgery environment.

[Clinical experience in thoracoscopic left internal mammary artery harvesting with voice activated robotic assistance].

Between September 1998 to February 2000, 45 consecutive patients underwent robotic-assisted, video-enhanced coronary artery bypass grafting. All IMA's were harvested using the voice-activated robotic assistant (AESOP 3000, Computer Motion Inc, Santa Barbara, CA) and the Harmonic scalpel (Ethicon Endo-Surgery, Cincinnati, OH). Left IMA's were successfully harvested in all patients. Harvested IMA's were anastomosed to LAD's under direct vision through limited left anterior thoracotomy. The IMA harvest time was 57.8 +/- 23.2 min, intraoperative graft flow was 34.3 +/- 20.5 ml/min, postoperative hospital stay was 3.9 +/- 1.5 days. The early postoperative angiogram showed that all grafts were patent. There was no mortality, no significant morbidity. The robotic assisted, video enhanced CABG provides safe and complete LIMA dissection with minimal manipulation and assures sufficient LITA length for tension free anastomosis.

Cumulative sum failure analysis of a policy change from on-pump to off-pump coronary artery bypass grafting.

BACKGROUND: Use of the sequential probability cumulative sum (CUSUM) technique may be more sensitive than standard statistical analyses in detecting a cluster of surgical failures. We applied CUSUM methods to evaluate the learning curve after a policy change by a single surgeon from routine on-pump (cardiopulmonary bypass [CPB]) to off-pump coronary artery bypass grafting (OPCAB). METHODS: Fifty-five consecutive first-time coronary artery bypass patients (CPB group) were compared with the next 55 patients undergoing an attempt at routine OPCAB using the same coronary stabilizer. The goal in OPCAB patients was to obtain complete revascularization, albeit with a low threshold for conversion to CPB to maximize patient safety during the learning curve. Preoperative patient risk was calculated using previously validated models of the Cardiac Care Network of Ontario. The occurrence of operative mortality and nine predefined major complications (myocardial infarction, bleeding, stroke, renal failure, balloon pump use, mediastinitis, respiratory failure, life-threatening arrhythmia, and sepsis) was compared between the CPB and OPCAB groups using Wilcoxon, Fisher exact, and two-tailed t tests, as well as CUSUM methodology. An intention to treat analysis was performed. RESULTS: The CPB and OPCAB groups had similar predicted mortality and length of stays (2.2% +/- 2.5%, 8.1 +/- 2.5 days versus 2.4% +/- 3.5%, 8.1 +/- 2.4 days, respectively). The mean number of grafts per patient was 3.1 +/- 0.7 in the CPB group versus 3.0 +/- 0.7 in the OPCAB group (p = 0.45). Two of 55 (3.6%) CPB patients died, as opposed to 1 of 55 (1.8%) OPCAB patients (p = 0.99). Eight of 55 CPB patients (14.5%) incurred major complications, as opposed to 4 of 55 (7.3%) OPCAB patients (p = 0.36). Median hospital length of stay was 6.0 days in the CPB group versus 5.0 days in the OPCAB group (p = 0.28). On CUSUM analysis, the failure curve in CPB patients approached the upper 80% alert line after eight cases, whereas the curve in OPCAB patients reached below the lower 80% (reassurance) boundary 28 cases after the policy change, indicating superior results in the OPCAB group despite the learning curve. CONCLUSIONS: A policy change from coronary artery bypass on CPB to routinely attempting OPCAB can be accomplished safely despite the learning curve. CUSUM analysis was more sensitive than standard statistical methods in detecting a cluster of surgical failures and successes.

RAVECAB: improving outcome in off-pump minimal access surgery with robotic assistance and video enhancement.

OBJECTIVE: To determine the efficacy of using the harmonic scalpel and robotic assistance to facilitate thoracoscopic harvest of the internal thoracic artery (ITA). DESIGN: A case series. SETTING: London Health Sciences Centre, University of Western Ontario, London, Ont. PATIENTS AND METHODS: Fifteen consecutive patients requiring harvest of the ITA for coronary artery bypass grafting. INTERVENTION: Robot-assisted, video-enhanced coronary artery bypass (RAVECAB) through limited-access incisions, using the harmonic scalpel and a voice-activated robotic assistant. MAIN OUTCOME MEASURES: Ease and duration of the harvesting technique, complications of the procedure, graft flow and patency, and duration of postoperative hospitalization. RESULTS: RAVECAB facilitated thoracoscopic dissection of the ITA with the harmonic scalpel in all cases. There were no conversions to a standard approach and no reoperations for bleeding. The mean (and standard deviation) ITA harvest time was 64.1 (22.9) minutes (range from 40 to 118 minutes). Robotic voice command capture rate was greater than 95%. Mean (and SD) intraoperative graft flows were 33.1 (26.8) mL/min (range from 14 to 126 mL/min). There was 100% graft patency on postoperative angiography. There were no deaths, perioperaive myocardial infarction or arrhythmias. Mean (and SD) postoperative hospitalization was 3.3 (0.8) days. CONCLUSIONS: RAVECAB is a demanding procedure that addresses many of the disadvantages of the "conventional" minimally invasive coronary artery bypass. It allows complete pedicle dissection with minimal ITA manipulation and assures sufficient conduit length and a tension-free coronary artery anastomosis. All anastomoses were performed under direct vision through a 5- to 8-cm inferior mammary incision.

Aircraft cabin air quality: an overview [correction of overvier].

In recent years, there have been increasing complaints from cockpit crew, cabin crew, and passengers that the cabin air quality of commercial aircraft is deficient. A myriad of complaints including headache, fatigue, fever, and respiratory difficulties among many others have been registered, particularly by flight attendants on long haul routes. There is also much concern today regarding the transmission of contagious disease inflight, particularly tuberculosis. The unanswered question is whether these complaints are really due to poor cabin air quality or to other factors inherent inflight such as lowered barometric pressure, hypoxia, low humidity, circadian dysynchrony, work/rest cycles, vibration etc. This paper will review some aspects relevant to cabin air quality such as carbon dioxide (CO2), carbon monoxide (CO), ozone (O3), particulates, and microorganisms as well as the cabin ventilation system to discern if there is a possible cause and effect of illness contracted inflight. The paper will conclude with recommendations on how the issue of cabin air quality may be resolved.

Robot-assisted computer enhanced closed-chest coronary surgery: preliminary experience using a Harmonic Scalpel and ZEUS.

BACKGROUND: Successful endoscopic harvesting of arterial conduits is critical to the performance of totally endoscopic bypass grafting. Recent success with computer-enhanced robotic systems in the performance of endoscopic single vessel coronary artery bypass (ENDOCAB) has paved the way for developing techniques for multivessel ENDOCAB. The Harmonic Scalpel (Ethicon Endo-Surgery, Cincinnati, OH) has previously demonstrated versatility and efficacy in manual endoscopic internal thoracic artery (ITA) harvesting. This study was undertaken to determine the feasibility of adapting this technology to a robotic telemanipulation system and its safety and efficacy in telerobotic ITA harvesting. METHODS: The Harmonic Scalpel was adapted to the ZEUS robotic surgical system (Computer Motion, Goleta, CA) and used to harvest the ITA in 19 patients undergoing multivessel off-pump coronary artery bypass (OPCAB) surgery. With the left lung collapsed, the ITA was harvested in all patients with CO2 insufflation through three 5 mm ports in the left chest. Postoperative angiography and transthoracic Doppler studies were performed in all patients. RESULTS: There were no ITA injuries and patients tolerated insufflation without hemodynamic compromise. Side branches were controlled easily without bleeding. Average ITA harvest time was 65 +/- 21 minutes. All vessels were patent after harvesting and demonstrated no angiographic evidence of injury. CONCLUSIONS: This paper demonstrates a technique by which the Harmonic Scalpel can be readily adapted to the ZEUS robotic telemanipulation system. Using this system, ITA's can be safely harvested totally endoscopically within a reasonable time frame for patients undergoing ENDOCAB.

A comparison of robot-assisted versus manually constructed endoscopic coronary anastomosis.

BACKGROUND: New technology has enabled surgeons to attempt totally endoscopic coronary artery bypass grafting. Our purpose was to compare three different techniques of totally endoscopic anastomosis using a porcine animal model. METHODS: Porcine hearts were excised and the right coronary artery was dissected free for use as an arterial graft. The hearts were placed in a human thoracic model and an endoscopic arterial anastomosis between the free right coronary artery and the left anterior descending coronary artery was performed using one of the following: (1) two-dimensional visualization with straight endoscopic instruments (n = 8); (2) three-dimensional head-mounted visualization with curved endoscopic instruments (n = 7); or (3) three-dimensional visualization with robotic telemanipulation (n = 8). Pathologic analysis of suture placement, vessel trauma, and patency was performed. Anastomoses were graded according to quality, ease, and patency using a seven-point Likert scale (1 = excellent, 7 = very poor). RESULTS: Endoscopic anastomotic ease and quality were significantly improved when three-dimensional visualization and curved endoscopic instruments were employed. Telemanipulation enhanced the process and provided the best operative results with regard to time required to construct the anastomosis, as well as ease and quality. CONCLUSIONS: Totally endoscopic anastomosis is feasible using currently available technology. Three-dimensional visualization and robotic telemanipulation significantly facilitate anastomosis construction and will likely benefit clinical operative outcome.

Operation Homecoming: 25 years later.

Following an end to U.S. involvement in the Vietnam War in early 1973, approximately 600 Army, Navy, Air Force, and Marine personnel, the great majority aviators, were released from captivity in North and South Vietnam and Laos. Their initial medical evaluation was performed at USAF Hospital, Clark Air Base, Republic of the Philippines, between February and April 1973. The author describes the events of those memorable days.

Inflight medical kits.

Great controversy surrounds the issue of United States (US) air carrier inflight medical kits. Although there are four medications mandated by the Federal Aviation Administration (FAA) that appeared to be adequate as determined by a 1988 survey, there is now a renewed call to review the medical kit contents with an eye toward making them more robust. This has been prompted by several well publicized inflight medical events and the fact that overseas airlines have a very wide array of pharmaceuticals and supplies. Consequently, the Aerospace Medical Association (AsMA) convened a Task Force of physicians across the major specialties to put forward recommendations regarding medication, medical supplies, and automatic external defibrillators (AEDs). These deliberations were based upon a survey of AsMA physician members.