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Further experiments are planned to evaluate the effect of image context and surgeon experience in performing and proctoring remote laparoscopic surgery. The ability to use smaller laparoscopes under low-bandwidth conditions will have to be evaluated. Smaller-diameter laparoscopes are important because they allow surgeons to perform operations under local anesthesia. Although we showed that the image quality provided by smaller laparoscopes is slightly worse than that provided by larger ones, the field of view of the picture also decreases with decreasing scope diameter.

The limitations of small-diameter laparoscopes could be significant enough to preclude their use over low-bandwidth connections. As mentioned earlier, telecommunications in many parts of the world, particularly underdeveloped nations, are not widely available or reliable. However, we did have some problems with authentication at the ISP, and several attempts were required for successful connect. Once the link was established, we were able to videoconference using NetMeeting, send e-mail, send images via FTP, and use network tools.

These delays typically negatively affect audio; therefore, a second line was used successfully for voice communication. In Samana, telephone service was intermittent.

Real-Time Internet Connections: Implications for Surgical Decision Making in Laparoscopy

During the second day, the phones could not make any outbound calls, although outside parties could call in. Because the Inmarsat AOR-W satellite was nearly directly overhead, the antenna was positioned on the roof of the single-story operating room without obstruction. Connection to the satellite was straightforward and reliable. Although the bandwidth for the portable satellite phone was nearly double that of a Although studies have shown that 64K bps is adequate for many telemedicine applications, increased fidelity in videoconferencing requires increased bandwidth.

As previously mentioned, it is often necessary to use a telephone to enable reliable voice communications as a result of the vagaries of the Internet and more specifically H. Dropped video frames can be tolerated during a videoconference, but dropped audio is not well tolerated. Use of inexpensive, portable, low-bandwidth videoconferencing systems will permit widespread teleproctoring of surgical procedures and diagnosis in the near future.

Similar work recently showed successful low-bandwidth transmission of ultrasound images. In the familiar TCP protocol, several communications are made from system to system to verify that data have been received properly, which allows for error-correction and ensuring the integrity of data transmitted. This is necessary because of the packet-switched nature of IP and the fact that occasionally packets of data are misrouted or lost. It would not be acceptable, for example, that a text e-mail sent over IP should simply lose or misdirect the last 50 words, so this error-correction is necessary to make IP communications effective.

In contrast, when sending video or audio data, it is not imperative that every byte be perfectly preserved: Because TCP transmits so many verifications of data, it costs a significant amount of overhead for communications to take place.

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If you remove the overhead of error-correction from the audio and video communications, additional bandwidth is available for data. This is how current videoconferencing works, using the real-time transport protocol RTP over user datagram protocol UDP. It is a far more efficient way of sending data in an IP environment, but it does so with the knowledge that some data will be lost in transmission. The likelihood of any given packet of data being lost or misdirected is no greater than under any other protocol, meaning that it is subject to the same variable circumstances of line noise, timeouts, excessive routing, and malicious packet removal.

Although most network protocols have error-correction in static data transfer, synchronous compressed video typically does not. In circumstances where the sending and receiving locations are in close proximity and connected by a broadband connection, the image quality is nearly identical.

However, when distant locations are connected by lower-band connections, the lack of error-correction will be noticed as subtle changes in image quality. Figure 4 illustrates these phenomena. In this image pair, an M4 Inmarsat satellite phone was brought into the Ecuadorian jungle to a small clinic. The pictures show the slight image degradation as a result of the latency and packet loss caused by the nearly 50,mile round trip via a geostationary satellite.

Notice the slight blurring, as well as the fact that the second hand is not visible in the remote image Fig. Microsoft NetMeeting is designed for maximum bandwidth use. It does this through a variety of techniques. For example, it transmits data in series of small packets, which minimizes spikes that are more subject to congestion. During periods of nonactivity, NetMeeting sends virtually no data except for ambient noise.

The default algorithms compress video and audio dynamically based on the bandwidth of the connection. For example, a dial-up connection is subject to much more compression than a LAN.

A more simple, precise and safe procedure

With decreasing bandwidth, video performance is most affected, whereas audio performance remains relatively constant. According to a Microsoft white paper, 10 during a videoconference NetMeeting sends a complete video frame every 15 seconds and sends only changes in the image deltas between these complete video frames. Broader-band connections process and interpret the deltas better, which results in smoother, higher-quality video.


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Use of low-bandwidth connections requires that the operator minimize camera motion. Because the deltas send changes in the image, continuous camera motion results in unreadable video. Therefore, a second full frame needs to be sent.

For the remote site to see a quality image, the camera must be held still for a full cycle plus the new frame: Holding a laparoscopic camera still for 16 seconds during surgery is a difficult skill to master. Slow movement of the laparoscope is a learned process, but it can be learned. Procedures that require minimal intermittent camera movement to perform, such as dissection of the cystic duct during a cholecystectomy, can be successfully teleproctored via low-bandwidth connections. However, procedures that mandate rapid camera and instrument movement, such as controlling significant intraoperative bleeding, cannot be teleprocotored via a low-bandwidth connection.

As with nonproctored laparoscopic procedures, many intraoperative complications will be best addressed by conversion to an open procedure. The remote surgeons will be able to provide support of the open procedure as the telecommunication connection permits. In conclusion, low-bandwidth, Internet-based telemedicine is an exciting surgical tool that can support both diagnosis and teaching. Further clinical evaluation of these technologies is underway. Norman Stewart, and all the physicians and nursing staff involved in this project.

National Center for Biotechnology Information , U. Journal List Ann Surg v. This article has been cited by other articles in PMC. Abstract Objective To determine whether a low-bandwidth Internet connection can provide adequate image quality to support remote real-time surgical consultation. Summary Background Data Telemedicine has been used to support care at a distance through the use of expensive equipment and broadband communication links. Methods Surgeons performing a laparoscopic cholecystectomy in Ecuador or the Dominican Republic shared real-time laparoscopic images with a panel of surgeons at the parent university through a dial-up Internet account.

Results The authors showed for the first time the ability to identify critical anatomic structures in laparoscopy over a low-bandwidth connection via the Internet. Conclusions Low-bandwidth, Internet-based telemedicine is inexpensive, effective, and almost ubiquitous. Open in a separate window. The Spacebridge to Russia Project: Telemed J ; 4: Use of mobile low-bandwidth telemedical techniques for extreme telemedicine applications. J Am Coll Surg ; Transmission of live laparoscopic surgery over the Internet. Am J Surg ; A novel method of surgical instruction: World J Urol ; Use of Internet for long-term clinical follow-up.

Portable satellite telemedicine in practice. J Telemed Telecare ; 4 suppl 1: While the field of robotic surgery is fairly well established, most of these robots are controlled by surgeons at the location of the surgery. Remote surgery is essentially advanced telecommuting for surgeons, where the physical distance between the surgeon and the patient is immaterial.

It promises to allow the expertise of specialized surgeons to be available to patients worldwide, without the need for patients to travel beyond their local hospital. Surgical robot systems have been developed from the first functional telesurgery system-ZEUS-to the da Vinci Surgical System , which is currently the only commercially available surgical robotic system.

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The system gives the surgeons the ability to control different arms, switch command of arms at any point and communicate through headsets during the operation. The first true and complete remote surgery was conducted on 7 September across the Atlantic Ocean, with French surgeon Dr. It was named Operation Lindbergh. France Telecom provided the redundant fiberoptic ATM lines to minimize latency and optimize connectivity, and Computer Motion provided a modified Zeus robotic system.

The success and exposure of the procedure led the robotic team to use the same technology within Canada, this time using Bell Canada's public internet between Hamilton, Ontario and North Bay, Ontario a distance of about kilometers. A series of complex laparoscopic procedures were performed where in this case, the expert clinician would support the surgeon who was less experienced, operating on his patient. This resulted in patient receiving the best care possible while remaining in their hometown, the less experienced surgeon gaining valuable experience, and the expert surgeon providing their expertise without travel.

The robotic team's goal was to go from Lindbergh's proof of concept to a real-life solution. This was achieved with over 20 complex laparoscopic operations between Hamilton and North Bay. Cell relay technology is the method of using small fixed length packets or cells to transfer data between computers or network equipment and determines the speed at which information is transferred. This developed technology provides opportunities for more transatlantic surgeries similar to the Operation Lindbergh.

Since Operation Lindbergh, remote surgery has been conducted many times in numerous locations. Anvari, a laparoscopic surgeon in Hamilton , Canada, has conducted numerous remote surgeries on patients in North Bay , a city kilometres from Hamilton. Anvari has not had any connection problems during his procedures. Rapid development of technology has allowed remote surgery rooms to become highly specialized. With continuing advances in communication technologies, the availability of greater bandwidth and more powerful computers, the ease and cost effectiveness of deploying remote surgery units is likely to increase rapidly.

The possibility of being able to project the knowledge and the physical skill of a surgeon over long distances has many attractions. There is considerable research underway in the subject. The armed forces have an obvious interest since the combination of telepresence, teleoperation, and telerobotics can potentially save the lives of battle casualties by providing them with prompt attention in mobile operating theatres.

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Another potential advantage of having robots perform surgeries is accuracy. In , another test was conducted on the lag time involved in the robotic surgery. A Florida hospital successfully tested lag time created by the Internet for a simulated robotic surgery in Ft. Worth, Texas, more than 1, miles away from the surgeon who was at the virtual controls. The team found out that the lag time in robotic surgeries, were insignificant. Roger Smith, CTO at the Florida Hospital Nicholson Center said that the team had concluded that, telesurgery is something that is possible and generally safe for large areas within the United States.

As the techniques of expert surgeons are studied and stored in special computer systems, robots might one day be able to perform surgeries with little or no human input.

Use of the Internet and information technology for surgeons and surgical research.

Carlo Pappone, an Italian surgeon, has developed a software program that uses data collected from several surgeons and thousands of operations to perform the surgery without human intervention. The ability to carry out delicate manipulations relies greatly upon feedback. For example, it is easy to learn how much pressure is required to handle an egg.