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Tele-Robotic Surgery for Combat Casualty Care: Proof of Feasibility
Stephen T. Bartlett1, *Francesco Bianco
1, *MAJ Christopher Dyke
4, *Gerald Gantt
1, *Ernest Lockrow
4, *Marko Rojnica
1, *Valentina Valle
1, *Dennis Fowler
2, *Kate Petty
2, *Yulun Wang
2, *Shane Farritor
3, *Piet Hinoul
3, Dmitry Oleynikov
3, *Tasha Merchant
1, Eric Elster
4, *Enrico Benedetti
1, *CAPT Matthew Bradley
41Surgery, University of Illinois Chicago, Chicago, Illinois; 2Sovato Health, Goleta, California; 3Virtual Incision, Lincoln, Nebraska; 4Uniformed Services University of the Health Sciences, Bethesda, Maryland
Objectives. Tele-robotic surgery may become a vital option as a force multiplier for combat casualty care in future conflicts, given the concern for delays in evacuation and volume of casualties. Limited research on the effects of telecommunications latency on tele-robotics has been a consistent concern in the growth of tele-robotic surgery. These experiments are designed to provide well-controlled real-world data assessing robotic surgical performance with electronically added latency simulating combat relevant, satellite-based tele-robotic communication.
Methods. A fiberoptic cable connection (Sovato) was established between two university centers 681 miles apart. Using a modified Mira® surgical robot (50 ms intrinsic latency), study surgeons at each University bi-directionally performed cholecystectomy and right colectomy dissection on cadaver subjects at the other University. To simulate the time delay expected with satellite communication, surgical performance was assessed under conditions of 0-300 ms electronically added latency. Data was collected on network performance, added latency, OR time, Global Performance (GP) as assessed by a senior surgeon, and self-reported NASA Surgery Task Load Index (TLX). Statistical Analysis: simple linear regression.
Results. The network was highly stable with NET 28-29 ms, Jitter 0.03 ms, and zero Packet Loss. Total latency (TOT) varied from 78-378 ms. There were 26 surgeries including 12 cholecystectomy (Ch) and 14 right hemi-colectomy dissections without anastomosis (Co). Co OR time unexpectedly decreased with TOT (p=0.005) but Ch did not (p=0.47). OR time was strongly associated with general surgeon experience (p=0.024) but not robotic surgeon experience (p=0.36). The TLX was strongly associated with general (p<0.001) and robotic surgeon experience (p<0.001) but not TOT (p=0.47). GP was consistently between 4 and 5 in all domains and did not correlate with TOT (p=0.41). Each surgeon showed rapid adaptation to increasing latency. One bile duct injury occurred in a poorly preserved cadaver without an error in dissection. Time to manage hemostasis in a living subject is not included in this model; our data showed satisfactory OR times. Safe robotic surgical techniques are possible with moderate practice and cognitive adaptation to increased latency.
Conclusion. Our data shows that fiberoptic cable connected latency is 78 ms. Since >95% of US hospitals have fiberoptic cable connections, tele-robotics is feasible now. Application in combat environments without fiberoptic connectivity will require low earth orbit satellite connectivity with expected additional latency of 100 ms.To date, there remains significant misunderstanding and speculation regarding the components of and tolerance for tele-robotic latency. Our data indicate a significantly greater tolerance for latency than previously reported. Development of telerobotic surgery for combat casualties is highly feasible. Funded by ONR grant N000142512034
Network and Surgeon Performance Data, Cholecystectomy, N=12 and Right Hemi-colectomy Dissection, N=14
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