Transatlantic surgery first for Canadian surgeon

In theory, Dr, Michel Gagner could perform gallbladder surgery in France while sitting in a recliner in New York, but it may take a while for him to become that relaxed.

Gagner, the head of laparoscopic surgery at Mount Sinai Hospital in New York, became the first doctor to perform transatlantic robotic surgery last month, using a robot called the Zeus to operate on the gallbladder of 68-year old France resident. The surgery was successful and very different from his first experience with a robotic arm more than five years ago – calling the device a “crude model,” he sat in an office chair while manipulating the controls which resembled bicycle handles.

“It worked, but it needed a lot of work,” he said.

Using pigs to practice surgical techniques, doctors worked with engineers to hone the technology that would eventually have special applications with microsurgery, where millimetric scale operations like tube reconstruction and coronary bypass require more than the steadiest hand can promise. Gagner, however, had an even loftier goal. He wanted to perform surgery remotely.

“We needed to be able to transfer it into a telephone line,” he said. “You need a special line that is dedicated to this so there is no downtime or accidents or cut off signals during the procedure. It is very expensive to transfer this signal.”

At first, the image quality was “terrible” and the delay was “unacceptable,” Gagner said.

“We were looking at a delay about half a second, and it was just too much,” he said. “The image was in kilobytes per second and the quality of image wasn’t high enough to compensate for the delay. At the end of July 2001, we solved all the problems and the experiments went very well.”

Gagner said the public hasn’t really measured the impact of this technology yet, explaining that it could benefit not only the educational sector of medicine, but patients in the most remote areas, in – and out – of the world.

“The surgery in third-world countries is also possible, where we could have mobile units in trucks or boats,” he said. “Think of surgery in space.”

Before that, Gagner knows he will have to explore the legal issues and regulations surrounding this, along with the logistics of this kind of surgery.

“Do we still have to do this from a surgery room, or can we do it from any room with the technology,” he said. “I don’t think this is going to be established in every hospital in a year. It is going to take some time for the network to be built and it going to take time for these robots to become compact and affordable and easy to use.”

While Gagner and his patient will be remembered for the operation, not even the promise of being famous would make Kandis Pryma undergo transatlantic gallbladder surgery.

Pryma, a social worker from Saskatoon, had gallbladder surgery just a few weeks ago and while she said she only met with her surgeon for a few minutes before she was operated on, those moments were important to her. What’s more, she is not fond of the idea of her doctor being thousands of miles away.

“I think someone would have to do a lot of explaining to me if my surgeon wasn’t even going to be in the room and tell me what was going to happen,” she said, adding that she would be especially worried if something unexpected came up during the surgery. “What it they find a tumour or something like that and then what? Can he just continue on doing all of that over the Internet too? There are things that could go wrong and it’s scary because you are completely out, you are totally unaware of what is happening.”

As luck would have it for Pryma, it doesn’t look she will have to make that decision anytime soon. The technology, along with not being fully developed, is expensive and bogged down with several legal snarls, said Dr. Lloyd Smith, the director of minimally invasive surgery at the University Health Network in Toronto.

“Equipment all fails at some point; let’s be realistic,” he said. “The solution will depend on the ultimate uses of this (that) are felt to be appropriate.”

He continued that, for now, this is a very interesting example of what robotics can do, but “it may be a bit more show than it is actually something that is going to affect most of us.” That’s because patients can still travel to surgeons for most operations and places that would really need remote surgery don’t usually have the money or the infrastructure to support it.

“It’s not like, ‘Ah, we have finally found something that is going to solve this problem,'” he said. “One of the things they talked about in other newspapers was that it would allow a surgeon in New York to operate on someone in the third world. Well, tell me where in the third world is (someone) going to get a $1 million robot.”

Lisa Abe, a partner at legal firm Blake, Cassels and Gradon, agrees that there is a long way to go before this sort of medicine becomes common.

“From a liability point of view, given that they are using this really new technology with this new hardware and software and fibreoptic and telecommunications lines which they have never been able to use before with that kind of speed, there is a big concern from a medical malpractice point of view,” she said. “This is not like your traditional (surgery) using the knife. If there is a problem with the technology or a problem with the connection, the doctor could make a mistake and the person at the other end could be injured.”