Advanced Network Opportunities for Surgical Tele-Robotics

1. Advanced Network Opportunities for Surgical Tele-Robotics Fall 2005 Internet2 Member Meeting Brett Harnett* Assistant Professor, Research Department of Surgery

2. *Contributors • Brian Miller, PhD, Intuitive Surgical • Ken Wood, BS, Senior Systems Engineer, TATRC • Barry C. Herman, MSE, Researcher, WRAMC • Jean-Marc Gosselin, Haivision Systems, Inc. • Peter Maag

3. Coming to a home near you? Courtesy: Wired Magazine

4. Having Vision In 1924, Radio News envisioned a doctor examining a remote patient via the electromagnetic spectrum.

5. A Paradigm Chasm

6. “It has become appallingly obvious that our technology has exceeded our humanity. ” ~Albert Einstein

7. Think Creatively Even if you are a doc

8. Nomenclature • Telemedicine: application of telecommunications in medical care • Telesurgery: remotely performed surgery through combined use of telecommunications and a surgical robot

9. How Stuff Will Work?

10. Operation Lindbergh Sept 7, 2001 8Mbps 155msec ATM network + Zeus TS New York - Strausbourg Laparoscopic cholecystectomy

11. The daVinci Images courtesy of Intuitive Surgical

12. Traditional vs. Robotic Diagrams courtesy of Intuitive Surgical

17. ATA Demonstration The message: “Raising The Bar: Improving Technology in the Continuum of Care”. • Key Partners • Intuitive Surgical (medical robots) • Walter Reed Army Medical Center • Johns Hopkins University • University of Cincinnati Courtesy: HaiVision

18. hai560 hai560 Network Configuration 10 Mbps 8 Mbps Public Internet Sunnyvale ISP NextWeb Denver ISP Priority Networks 1.8 Mbps 1.8 Mbps Denver - ATA Show Sunnyvale - Veterans Hospital • ATA Demo April 2005 • No VLAN • No QoS Courtesy: HaiVision

19. ATA Configuration • hai560 codec on show floor at ATA Denver • hai560 codec in Operating Room at Sunnyvale Veteran’s Hospital, CA • Local ISPS in Denver and Sunnyvale connected over public Internet Courtesy: HaiVision

20. Critical Interaction Attributes • Critical Interaction Attributes • Low latency for hand-eye coordination – typically 40ms network and less than 120ms video encoding • Best video quality – full resolution DVD quality • Resiliency to network jitter and lost packets • High reliability hardware and software – no resets, reboots, etc. Courtesy: HaiVision

22. Surgical Performance

23. Mean Times: Suturing

24. Mean Errors: Suturing

25. Real Time Internet Connections:Implications for Decision Making in Laparoscopy • Purpose: • To determine if low bandwidth Internet connection can provide adequate image quality to support remote surgical consultation • Method: • Lap CCY in Ecuador & DR remotely proctored via Internet connection • Local and remote images were screen grabbed and placed in a web-based tool • Result: • First to identify critical laparoscopic anatomy via an Internet connection • Successful proctoring of 6 lap CCY via an Internet connection • In the web-based tool, remote/local images indistinguishable • Conclusion: • Low bandwidth, Internet-based telemedicine can support intraoperative consultation in laparoscopic surgery. Broderick et al. Ann Surg 234(2): 165-71; 2001

26. Battlefield Extraction Credit: USAMRMC / TATRC

27. We must focus…

28. Telecom Issues

29. Primary Issues • Bandwidth - How much is really needed? • Scalability – To what extent? • QoS – Surgical grade network with prioritization • Inter-Networking - Peering points, tariff agreements • Standards - Ensuring interoperability and cost reduction • Security – Privacy, loitering, DoS, etc. • Military requirements – on the battlefield • NASA – Orbital and lunar, not interplanetary

30. Metrics • Performance • Latency • Jitter • Packet Loss • From Commerce Internet (CI) to CI with QoS • From CI to Cincinnati Bell LAN Advantage • From CI to Internet2 SYNCHRONOUS transfer; UDP

31. Internet2 Can Do • Virtual Reality • Telepresence • Avatars • Reverse Sensory Underload

32. Challenges • Bandwidth • Scalability • QoS • Haptics & visual fidelity • Interoperability • Risk analysis/liability • Operationally - contingency plans when…

33. When Things Go Wrong

34. In a Nutshell • Standardization efforts should continue, with emphasis on interoperability standards of network protocols and interfaces for telerobotic surgery. These would be validated/benchmarked via demonstrations, possibly between institutions that are part of an organized standards collaboratory. • The network could extend between robots, robots and other O.R. equipment, interfaces with clinical and imaging information systems, onwards to possible function on Internet2 to allow surgeons to train, collaborate and tele-mentor cases. This could eventually be used for telesurgical applications both within and outside of a given hospital.

35. Mission Critical

36. 0101010001101000011000010110111001101011001000000111100101101111011101010010000101010100011010000110000101101110011010110010000001111001011011110111010100100001 Brett Harnett Research Assistant Professor University of Cincinnati Center for Surgical Innovation brett.harnett@uc.edu (Translation: Thank you!)