he RoboConsultant: Telementoring andemote Presence in the Operating Roomuring Minimally Invasive Urologicurgeries Using a Novel Mobileobotic Interface
ahul Agarwal, Adam W. Levinson, Mohamad Allaf, Danil V. Makarov, Alex Nason,nd Li-Ming Su
BJECTIVES Remote presence is the ability of an individual to project himself from one location to another to see,hear, roam, talk, and interact just as if that individual were actually there. The objective of this studywas to evaluate the efficacy and functionality of a novel mobile robotic telementoring systemcontrolled by a portable laptop control station linked via broadband Internet connection.
ETHODS RoboConsultant (RemotePresence-7; InTouch Health, Sunnyvale, CA) was employed for thepurpose of intraoperative telementoring and consultation during five laparoscopic and endo-scopic urologic procedures. Robot functionality including navigation, zoom capability, exami-nation of external and internal endoscopic camera views, and telestration were evaluated. Therobot was controlled by a senior surgeon from various locations ranging from an adjacentoperating room to an affiliated hospital 5 miles away.
ESULTS The RoboConsultant performed without connection failure or interruption in each case, allow-ing the consulting surgeon to immerse himself and navigate within the operating room envi-ronment and provide effective communication, mentoring, telestration, and consultation.
ONCLUSIONS RoboConsultant provided clear, real-time, and effective telementoring and telestration andallowed the operator to experience remote presence in the operating room environment as asurgical consultant. The portable laptop control station and wireless connectivity allowed theconsultant to be mobile and interact with the operating room team from virtually any location.In the future, the remote presence provided by the RoboConsultant may provide useful andeffective intraoperative consultation by expert surgeons located in remote sites. UROLOGY 70:
he invention of the telephone in 1876 provided abasic means of communication over long dis-tances. The telecommunications industry has
ince advanced greatly with the perfection of radio trans-issions, wireless communications, and satellites in orbit
hat have not only made long-distance communicationighly efficient, but also facilitated communication withemote areas around the world.
The rise of telecommunications has strongly influ-nced medicine, leading to the development of an en-irely new branch of medicine known as telemedicine,
rom the James Buchanan Brady Urological Institute and the Office of Telemedicine,he Johns Hopkins Medical Institutions, Baltimore, MarylandReprint requests: Dr. Li-Ming Su, Associate Professor of Urology and Director of
aparoscopic and Robotic Surgery, Johns Hopkins Medical Institution, James Buchanan
arady Urological Institute, 600 North Wolfe Street, Phipps Building, Room 571A,altimore, MD 21287. E-mail: [email protected]
he use of telecommunications technology to provideedical services from a remote location.1 One of the first
ecorded instances of telemedicine was in 1906 wheninthoven, the father of electrocardiography, made arans-telephonic transmission of an electrocardiogramrom his laboratory to a hospital 1 mile away.2 An earlyxample of long-distance use of telemedicine was in 1967n Boston, when a medical station at Logan Internationalirport was linked to Massachusetts General Hospital in
owntown Boston using a two-way microwave audio-ideo link.3
In the decades since, teleconferencing has become theredominant form of telemedicine and it has been useduring minimally invasive procedures for telementoringnd telesurgery. One of the first cases of telesurgicalentoring was in 1996 when an endoscopic specialist at
aparoscopic procedure at a hospital 3.5 miles away.4 Thewo sites were connected via a single point-to-pointigital transmission link. The consulting surgeon success-ully guided the junior surgeon through seven laparo-copic procedures without any connection failures ornterruptions.
Similarly, between September 1998 and July 2000, 17rocedures were telementored between two sites 9230 kmpart: an operating room at the Policlinico Casilino “Torergata” University of Rome and a remote site at the
ohns Hopkins Medical Institutions in Baltimore.5 Dis-ussions between the two teams were carried out using aystem that included a dial-up Internet connection, real-ime audio-video, an external video camera with a pan-ramic view of the operating room, and a remote controlor electrocautery and telestration. Ten cases were tele-entored successfully, but in five cases the operating
oom team was unable to establish a connection with theemote site. A similar research was conducted in 2000hen a less experienced laparoscopic surgeon in Singa-ore was telementored by a senior laparoscopic surgeonocated remotely in the Johns Hopkins Medical Institu-ions in Baltimore. In this study, both cases were accom-lished successfully.6
These studies demonstrated the feasibility, safety, andffectiveness of telementoring during laparoscopic proce-ures performed anywhere in the world.4–6 However,hese studies used conventional teleconferencing tech-iques that do not allow enough direct interaction be-ween the consultant and the client (any recipient of theelementoring) because of requirements for space andquipment and dependence on skilled camera placementn the client end for detailed views of the operationhich leave the remote consultant seemingly detached
rom the operation.7,8 Although the consultant is able torovide effective guidance and advice, he is dependentn the recipient end for garnering information and can-ot himself roam about the room and investigate pointsf interest (e.g., patient positioning, x-rays, anesthesiaonitors, operative views).One breakthrough for establishing a sense of remote
resence has been the invention of the RemotePresence-7obot (RP-7; InTouch Health, Santa Barbara, Calif). Thisobot has a small footprint comparable to the size of auman being and it allows an individual to project oneself
rom one location to another to see, hear, roam, talk, andnteract in real time just as if that individual were actu-lly there. Most important, little preparation or addi-ional equipment is needed to use the RP-7 robot. Aonsultant operates the robot from a remote locationsing a joystick and a specially configured laptop com-uter to control robot movement and camera views re-pectively with minimal training.
The RP-7 robot has been used experimentally for tel-rounding, which has been linked to increased patientatisfaction in postoperative care.9,10 A survey of patients
n the intensive care unit revealed that telerounding with j
ROLOGY 70 (5), 2007
he RP-7 robot increased examination thoroughness,trengthened the continuity of contact between patientnd physician11 and provided opportunity for more fre-uent face-to-face discussions, and improved the coordi-ation of postoperative care.8 The RP-7 allows the phy-ician to do almost everything that he would have donen an actual bedside visit including looking at all chartingnformation, test results, scans, and x-rays.
The robot has also been used for teleproctoring ofedical students during an anatomy class cadaver dissec-
ion.7 The robot is operated by a senior surgeon in aemote location to monitor students’ dissections and ad-ise them as needed. The most compelling aspect ofeleproctoring has been the sense of physical presence ofhe proctor in the operating room.7 The robot’s humanootprint and ability to move around and interact in auman way through face-to-face audio-visual communi-ation establishes remote presence of the proctoring phy-ician and provides students with efficient, timely advice.
In the current study, we examine the impact andeasibility of telementoring using the RP-7 robot inive, minimally invasive urologic surgeries. In addition,e evaluate the potential of remote presence in theperating room and the efficacy of the InTouch RP-7obot as an intraoperative consultant—thus, the nick-ame “RoboConsultant.”
ATERIAL AND METHODS
he RP-7 Robothe RP-7 is a sophisticated remote presence robotic system thatan be controlled by a portable laptop control station linked viaroadband Internet connection. Its dimensions are 165 cm ineight and 63 � 76 cm at its base, comparable to the size of auman (Fig. 1A).The head of the robot is fitted with two advanced digital
ameras, an audio microphone, and amplification circuitry al-owing for real-time, two-way audio-video communication (Fig.B). In addition, the robot head is moveable, allowing it to pan,oom, and tilt, thus replicating similar motions to a human andllowing for more flexibility to see, evaluate, and investigate.eal-time video allows for detailed viewing and image capturef items of interest as well as telestration. The power supply inhe form of a rechargeable battery is estimated to last betweenand 6 hours.The control station consists of a laptop computer, a headset
ith earphones and a microphone, and a joystick control (Fig. 2).he control station is linked to the robot via broadband Inter-et connection (either wireless or a wired ethernet connec-ion), allowing the consultant to be mobile and link to theobot from virtually any location including the office, operatingoom, patient ward, clinic, or even from home. The laptopomputer has a built-in camera that allows the receiver to viewhe consultant on the robot screen.
The RP-7 is equipped along the perimeter of its waist andase with advanced infrared sensors that detect when the robots nearing an object, thus preventing unwanted collisions. Theobot is controlled by a joystick, allowing for rotation as well asorward, backward, and strafe movements. The buttons atop the
oystick toggle between control of the robot’s base and rota-
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ional and tilt movements of the robot head. The zoom featuref the robot camera is easily controlled by pointing to an areaf interest using touchpad controls on the laptop and dragginghe cursor to expand the view, a feature that allows the con-ultant to interrogate areas of interest such as x-ray films inreater detail (Video Clip 1). A video input jack located alonghe back of the robot allows for connection of any video sourceuch as an endoscopic camera or fluoroscopy, thus allowing theonsultant to view directly the images seen by the recipienturgical team. In addition, using the image capture feature, theonsultant can capture still images and telestrate items of im-ortance directly back to the recipient on the robot screen. Theotal cost of RP-7 is approximately $150,000.
he RoboConsultant Studyn this pilot study, we investigated the utility of the RoboConsultantor telementoring in the operating room. To determine the func-ionality of the robotic interface at different distances and sites,he robot was operated from a remote location by a seniorurgeon during endoscopic and laparoscopic urological proce-ures in an adjacent room, an adjacent building, and a hospital
miles away. The senior surgeon was mentoring a juniorttending in each case.
The operating team evaluated the subjective effectiveness ofhe telementoring and telestration experience. The criteria for
igure 1. (A) Front view of the RP-7 robot demonstratingey components such as speaker, collision avoidanceensors around waist and base, and (B) view of the robotead including the screen, one camera for general pur-oses such as driving and another camera for zooming,nd a microphone.
valuation included the impact of the presence of the robot in a
72
he operating room and the efficacy and ease of communicationith the consulting surgeon. The consultant evaluated the easef using the control station, the overall handling of the robot,nd any interface connection failures. Both teams also evalu-ted overall robot functionality, including navigation, zoomapability, examination of external and internal endoscopicamera views, and telestration.
ESULTShe RoboConsultant was easy to operate and performedithout connection failure or interruption in each case.he consulting surgeon successfully immersed himselfithin the operating room and provided effective com-unication, mentoring, telestration, and consultation tojunior attending. The following two cases will highlight
he utility and efficacy of RP-7 in the operating roometting.
The first case was of a laparoscopic radical nephrec-omy for tumor in a morbidly obese patient. This caseighlighted the mobility of the robot in the operatingoom, effective two-way, real-time, audio-visual commu-ication between the consultant and the operating roomeam (Video Clips 2, 3), and the ability of the robot tovaluate external monitor and internal camera views inhe operating room (Video Clips 4, 5).
The second case was of a laparoscopic partial cystec-omy for a urachal mass. This case highlighted the robot’s
Joystick
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igure 2. The laptop control station including a built-in cam-ra, headphones, and a joystick to control robot movement.
bility to evaluate external trocar positioning (Video
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lip 6), image capture and telestration, and picture-in-icture projection format (Video Clips 7, 8).
The operations were not disrupted in any way owing tohe presence of the robot. The small footprint of theobot allowed for easy maneuvering inside the operatingoom. The high-magnification capabilities of the built-inameras captured clear, detailed images of the operationnd the robot was easily linked to the internal cameraiews via a video input jack, allowing the consultant toiew the same images as the operating team.
OMMENTn our experience, the RP-7 RoboConsultant provideslear, real-time telementoring and telestration by sub-ersing the consultant into the operating room environ-ent. The greatest advantages of the RoboConsultant
ver conventional teleconferencing techniques are itsmall footprint and human-like dimensions, maneuver-bility, versatility, and ease of use, all of which give it aeeling of just another human being in the operatingoom. The RP-7 can be moved promptly from one roomo another depending on where it is needed. The mobile,uilt-in camera acts as the eyes of the consultant and theuilt-in audio capabilities function as the consultant’soice. The real-time images of the operating room andhe image of the consultant on the robot screen provideirect face-to-face communication between the recipienturgeon and the remote consultant. Most important, nodditional staff support is needed to use the RP-7, excepto open a door or plug in after a procedure.
In addition to enhancing a sense of remote presence,he RoboConsultant’s ability to capture and telestratemages makes consultations more detailed, informative,nd educational. The consultant can magnify certainortions of an image and telestrate them back on theobot screen and explain to the recipient any significancer feature of that image. During live surgery this featurellows for improved planning of an operation and appro-riate course correction by the consultant during techni-ally difficult steps. An additional advantage of theoboConsultant with endoscopic procedures is its ability
o link to the internal camera views. With this feature,he consultant can view the precise images as the recip-ent surgeon and provide more informed and comprehen-ive consultations.
The RoboConsultant can potentially be used to pro-ide mentoring and consultation worldwide. Because itan be used for telementoring in the operating room fromny remote location that has broadband Internet capa-ilities, the location can be an adjacent room, an adja-ent building, or even in medical centers hundreds tohousands of miles away. Although broadband wirelessonnections are not without fault, we experienced noignal drops during our study.
The RoboConsultant is particularly beneficial in time-ensitive situations such as problems during an operation
hat require immediate consultation from an expert.10 In
ROLOGY 70 (5), 2007
uch cases, instead of waiting for a consulting surgeon toome to the operating room, the consultant can connecto the RoboConsultant using the laptop control stationrom his or her current location and provide promptdvice. Already the RP-7 has been effectively used in theetting of intensive care units and emergency rooms.9,10
The RoboConsultant has the potential to bring med-cal services to developing countries that lack medicalxpertise or experience. An expert surgeon can mentor oremonstrate to another surgeon in an underdevelopedountry who has limited experience with a certain diseaser surgical procedure. In some cases, the resources andechnology may be available in the host country but thehysicians are not experienced enough and require moreraining or guidance. The RoboConsultant may helphorten the learning curve for novice surgeons7 and re-uce the number of patients who would have to travelbroad to seek expert care.
A major shortcoming of this study is the lack of quan-itative assessment to evaluate the robot’s efficacy. Ourrimary goal was to test the feasibility of using the RP-7eleconferencing robot in the operating room setting.urther multi-institutional studies and consideration ofedico-legal issues are certainly required to assess RP-7’s
tility and role.Although the Roboconsultant proved effective in our
ilot study, the RP-7 in its current form is only a meansf expanding heath care delivery, but by no means canompletely replace the presence of a human being. Thiss especially evident by the lack of ability to examine aatient physically or participate in surgery. However,elesurgical interventions have already been demon-trated and haptic feedback technology can likely bencorporated into this robotic interface in the future.
ONCLUSIONhe RP-7 RoboConsultant provided clear, real-time tele-entoring and telestration and allowed the consultant to
xperience remote presence in the operating room envi-onment as a surgical consultant. The portable laptopontrol station and wireless connectivity allowed theonsultant to be mobile, interacting with the operatingoom team remotely from virtually any location withroadband connectivity. In the future, the remote pres-nce provided by the RoboConsultant may provide usefulnd effective intraoperative consultation by expert sur-eons located in remote sites.
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Video Clips cited in this article can be foundon the internet at: http://www.goldjournal.net
