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GLOBALIZATION OF SURGICAL EXPERTISE WITHOUT LOSING THE HUMAN TOUCH: UTILISING THE NETWORK, OLD AND NEW Justin Collins , Prokar Dasgupta * , Roger Kirby † and Inderbir Gill ‡ – Department of Urology, St Peter ’ s Hospital, Chertsey , * Department of Urology, Guy ’ s

Hospital , † The Prostate Centre, London, UK , and ‡ Department of Urology, USC Institute of

Urology, Los Angeles, CA, USA

On September 7 th 2001, Prof. Jacques Marescaux and his team from the Institute for Research into Cancer of the Digestive System (IRCAD) successfully completed the fi rst transatlantic operation. The Lindbergh Operation was a complete telesurgical operation carried out on a patient in Strasbourg, France, with the surgeon located in New York, using high-speed ISDN fi bre-optic services and robotic surgery [ 1 ] . Speaking at the time, in 2001, Prof. Marescaux commented: ‘ The demonstration of the feasibility of a trans-Atlantic procedure, dubbed ‘ Operation Lindbergh ’ , is a richly symbolic milestone. It lays the foundations for the globalization of surgical procedures, making it possible to imagine that a surgeon could perform an operation on a patient anywhere in the world. ’

Although the benefi ts and success of minimally invasive surgery and robotic surgery are now evident, the theoretical advantages of telesurgery have yet to be realised. There are several potential reasons for this, but the most obvious is that surgery is a complex contract between the responsible clinician and their patient. A third party bridged by a faceless technology does not make for an easy union.

Remote robot-assisted surgery was initially a vision of the US Military who developed the original systems through the Defense Advanced Research Projects Agency for use on the battlefi eld [ 2 ] . Intuitive Surgical developed the Da Vinci System in 1999 with a view to cardiovascular surgery; however, robotic surgery was rapidly adopted by the urological community to perform minimally invasive surgery for prostate cancer and the potential for remote surgery, for which the technology was originally designed, was essentially set aside [ 2 ] .

Nevertheless, the potential for telesurgery to deliver surgical expertise remotely over the web, either in a teaching role or for actual surgery, is undoubtedly huge. It is also very

much in line with the current evolving philosophy of the web, the so-called Web 2.0 which is a more dynamic, interactive network. Medical blogs and ‘ wikis ’ facilitate participation and conversations across vast geographical areas. Information-pushing devices, such as RSS feeds, permit continuous instant alerting to the latest ideas in medicine [ 3 ] . Real-time video links can be a cheap and effective way for surgeons to collaborate in live surgery [ 4 ] . Social networks can be used as excellent environments to share surgical expertise and promote friendship and collaboration, as can be seen by the USC Urology Department Facebook page. Communication, access to free information, collaboration and sharing are key themes in Web 2.0. Indeed medical librarians, whose job is to archive and disseminate information, have suggested that rather than the intrinsic benefi ts of the platform itself, it is the spirit of open sharing and collaboration that is paramount [ 5 ] .

With the imminent launch of the Connect TM Network for the Da Vinci Si system there will be further impetus to realize the opportunities of a Web 2.0 approach. The Connect Network enables secure video and audio interaction between two surgeons in real time over a high speed connection. The connections are secure and also HIPAA (Health Insurance Portability and Accountability Act of 1996)-compliant in the USA. The system allows the observing party to alternate between the console view,

inside the patient, to cameras viewing the operating room. The reciprocal connection also allows the operating surgeon to see the other party in the console screen using the ‘ Tile Pro ’ technology which is a ‘ picture in the picture ’ technology ( Fig. 1 ). The observing party not only has the ability to see and communicate with the console surgeon, but also to capture images and video or even upload other video images to the console ’ s ‘ Tile-Pro ’ screen in the surgeon ’ s console.

The benefi ts to an inexperienced surgeon are clear. A s urgeon starting robotic surgery, who has done in-person case observations and perceptorships with a more experienced surgeon, may still have some questions on technique or, early in his experience, come across issues he had not previously considered. Instead of fl ying the proctoring surgeon to the hospital to discuss procedural tips and tricks, the proctoring surgeon could simply ‘ log in ’ via the internet to the surgical case and see the same real-time views as the surgeon at the console, and communicate in real time as well. This system is already available for the Da Vinci S and is currently being used in several hospitals in the USA.

Leveraging the ability for a secure internet connection with high speed connections has obvious bigger opportunities than just remote mentoring. For example, a surgeon could operate on someone in another continent or do portions of a complex

Accepted for publication 15 December 2011

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procedure as part of a specialist surgical team to improve outcomes. Technically, this is feasible, but there are technical risks, such as a failed internet or satellite connection. Whereas time delays of less than a second may not be important in conversation, Anvari showed that delays over 500 ms can negatively impact on surgeon performance during robot-assisted remote presence surgery [ 6 ] . Irrespective of their expertise, would you want your surgeon in the same room with you or across the world if something went wrong? Obviously there are moral and ethical considerations that are much bigger than just the technology component.

So could the Connect network take over from standard robotic training or will it subsidize or complement the current training format? Surgical teaching has traditionally been an apprenticeship and numerous studies have shown that this approach is still relevant in helping to deliver the best possible training [ 7,8 ] . Simulation training has been shown to have a role in training [ 9,10 ] and we should also remember there are additional aspects to ideal surgical training, such as working within an experienced team and understanding their philosophy and approaches. With this in mind, The Urology Foundation (TUF), with the University of Southern California Hospital in Los Angeles and Guy ’ s Hospital, have recently launched a robotic perceptorship under the mentorship of Prof. Inderbir Gill and Prof. Prokar Dasgupta. This sponsorship follows on from previously successful laparoscopic preceptorships with Dr Gill in Cleveland (2006 – 2008), wherein 12 British urologists learnt laparoscopic techniques, before returning to the UK to apply these approaches in the UK. Now, in this next phase, TUF has awarded several robotic perceptorships on a national scale to both individual robotic surgeons and robotic teams. Nationally their aim is to help further progress in robotic surgery in the UK by introducing expertise from outside the UK. By incorporating the best of robotic surgery in the UK and the USA, they have entered into the spirit of open sharing and collaboration, replicating the philosophy of the Web 2.0 network. For the successful preceptor, the aim is to experience the benefi ts of being submerged into a different environment and work in a centre of excellence, which has been shown to have a

profound effect on the surgical learning curve [ 11 ] .

The fi rst week of my perceptorship was spent at Guy ’ s Hospital where I participated in a robot-assisted radical cystectomy, with extended pelvic lymph node dissection and extra-corporeal neobladder formation. I also assisted in several robot-assisted radical prostatectomies (RARPs) and a robotic pyeloplasty. Using their new dual console I was able to sit at the console and view their techniques in three-dimensions as well as do parts of the operation and benefi t from their experience [ 12 ] . In Los Angeles I observed over 40 robotic cases in 4 weeks, experiencing innovative surgery fi rst hand, such as their zero ischaemia technique for partial nephrectomies [ 13 ] , further refi nements to RARP, and novel innovative surgery, such as bilateral renal denervation for uncontrolled essential hypertension [ 14 ] . Working in these high volume pioneering centres is a privilege that bestows insight into team working, organization and other effi ciencies that are simply not possible to fully appreciate via a two-dimensional video and audio link.

As well as the demonstration of actual surgical techniques, the ability of the teacher to convey ideas and inspire learning is paramount to the overall experience. A

good mentor is someone who likes to teach, is patient and can take on board and deal with others ’ stress. These are essential qualities, but they also need to be able to convey the reassuring sense of ‘ yes we can ’ . The best mentors have the ability to inspire innovation, giving you a drive to progress and evolve as a surgeon and as an individual.

In today ’ s age of the web, information and successful ideas are spread more readily and therefore adopted more quickly. What we choose to put on the web refl ects who we are, but what we search for refl ects who we aspire to be. Using the resources currently available over the internet will ultimately help disseminate surgical expertise. Proctorship requirements will vary for different surgeons and different patients will be in need of varying levels of expertise. With the increasing need to publish results and the natural competition that comes from market forces there are drivers in place to promote collaboration that will result in improved surgical results for our patients.

The mentors who are likely to be in greatest demand will be those who are pushing the boundaries of robotic surgery with their experience in diffi cult or complex operations or as a result of their new techniques and novel approaches [ 12,13,15 ] . If the real

FIG. 1. The Connect TM Network by Intuitive for mentorship.

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worldwide opportunities from telesurgery are realized they will literally be in demand 24 h a day.

In conclusion, if the vision of telesurgery is to be realized it will need more than a high speed network with secure connections. It will need trust and understanding of techniques and approaches between the parties involved; networking among individual surgeons is still necessary to create understanding, familiarity and confi dence in each other, resulting in a true global network of experienced surgeons, assistants and specialist teams. Working partnerships, developed over time, and ideally built on the foundations of direct exposure to each other ’ s working environment and surgical teams, will enable complex surgery to be safely delivered via telesurgery in a stepwise approach.

CONFLICT OF INTEREST

None declared. Source of funding: funding for robotic perceptorship from The Urology Foundation – registered charity.

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12 Goldstraw MA , Challacombe BJ , Patil K , Amoroso P , Dasgupta P , Kirby RS . Overcoming the challenges of robot-assisted radical prostatectomy . Prostate Cancer Prostatic Dis 2011 ; 15 : 1 – 7

13 Gill IS , Eisenberg MS , Aron M et al . ‘ Zero ischemia ’ partial nephrectomy: novel laparoscopic and robotic technique . Eur Urol 2011 ; 59 : 128 – 34

14 Krum H , Schlaich M , Whitbourn R et al . Catheter-based renal sympathetic denervation for resistant hypertension: a multicentre safety and proof-of-principle cohort study . Lancet 2009 ; 373 : 1275 – 81

15 Asimakopoulos AD , Annino F , D ’ Orazio A et al . Complete periprostatic anatomy preservation during robot-assisted laparoscopic radical prostatectomy (RALP): the new pubovesical complex-sparing technique . Eur Urol 2010 ; 58 : 407 – 17

Correspondence: Justin Collins, Department of Urology, St Peter ’ s Hospital, Chertsey Surrey, KT16 0PZ, UK. e-mail: jwcol@yahoo.co.uk