HEALTH: At the cutting edge

A surgeon peers at an image on a screen in London and operates on a patient in Rome. Science fiction? No, says Roger Dobson. It's telesurgery - the next frontier Touch is the only diagnostic tool still missing. Synthetic skin that responds exactly like human skin has yet to be per fected
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A COMPUTER screen in a darkened room in a London hospital flickers into life. A surgeon taps the keyboard and a perfect image of the next patient is projected, like a hologram, into the empty space in front of her. She scans the pat-ient's notes,which appear to be written in the air above the image. As with a TV presenter's Autocue, the notes scroll by, controlled in this case by the movements of the doctor's eyes. Within minutes she begins the operation, cutting into the abdomen of the virtual-reality image with a special electronic scalpel. More than 1,000 miles, away in a hospital in Rome, blood flows from that first incision as robots slavishly copy her every move, but this time on the real patient.

This is telesurgery, virtual-reality medicine - the shape of things to come. Surgery and medicine are, according to futurologists like surgeon John Wickham and BT scientist Dr David Heatley, at the frontier of a brave new hi-tech world where robotic armscarry out operations and miniature cameras inside the body change direction in response to a flicker of the surgeon's eyes.

Here, too, are self-propelled surgical instruments equipped with motors less than 1mm in diameter which cruise the body cavity, driving to parts of the body that surgeons have not been able properly to reach before. Soon to be developed is synthetic skin, which will allow doctors thousands of miles from the patient to feel them as if they were in the same room.

To sceptics who see this as simply the stuff of science fiction, Dr Heatley, BT Laboratories group leader in future technology and telemedicine, says: "Simply think back two decades, when there were no personal computers or digital watches. Telemedicine is already a reality and telesurgery is only a few years away - we have the technology now."

Robotic arms are being used on patients to remove tumours and for drilling holes in bones for attaching pins and supports. Soon they will be employed in retinal surgery and the replacement of joints. Cameras which move to follow the surgeon's eyes are being developed, and self-propelled micro-instruments are at the experimental stage in the US.

"At the moment," says Dr Heatley, "the robotic arms being tested are controlled by a wire from a computer in the same room. There is no reason, though, why that wire cannot be connected to a telephone, allowing the robot to be controlled from thousands of miles away. You are using the same technology, but lengthening the wire. That would be telesurgery."

The technological advances of the last few years greatly encourage the likes of John Wickham, consultant surgeon at Guy's Hospital, who can see a future when it may be possible to operate on virtual images of patients with forceps and scissors. "By electronic transmission it may be possible for surgeons in two different cities to operate on a patient in a third city by remote control," he wrote recently in a British Medical Journal report.

The missing piece in the telesurgery jigsaw is replicating the surgeon's sense of touch. Virtual-reality technology can create a perfect image of the patient, robotic arms can be programmed to perform operations, and fibre-optic phone lines can carry thedata to control the robots, but synthetic skin that responds exactly like human skin has yet to be perfected.

Professor Peter Cochrane, head of BT Laboratories, says: "The only diagnostic technique not yet remotely available is touch. We believe, though, that by 2015 synthetic skin with all the tactile qualities of human skin will be available. One doctor will then be able to feel what another, or a robotic arm, is touching anywhere on the planet."

Scientists working for Intelligent Sys-tems Solutions in Salford have been working for some time on ways of achieving synthetic sensation. The idea is that electronic sensors would transmit the feeling of a patient's responding tissue back to the distantsurgeon through a glove full of air sacks. The sacks between the two linings of the glove would be inflated and deflated to give a sense of touch. This would be controlled by signals sent from the patient to the pneumatic equipment.

But Professor Robert Stone of Intelligent Systems Solutions says the glove may not be good enough for telesurgery. His team is working on an alternative system where the surgeon would hold a sophisticated joystick and "feel" the resistance of skin and other tissue through electromagnetic responses as the operation progressed. The virtual-reality image of the patient in front of the surgeon would also react to pressure in much the same way as a taut elastic band responds to touch.

While telesurgery may not be around in practice for another decade, telemedicine is here now. Several hundred patients have been diagnosed, and in some cases treated, by doctors in another country using images of X-rays and scans transmitted down fibre-optic telephone lines. These still images, as well as moving pictures of patients, can be converted into digital information, sent down the telephone line and reassembled at the receiving end. For the high-quality pictures needed for diagnostic purposes, the information has to be transmitted down several lines. This gives the density of detail needed to distinguish, for instance, between the different shades of grey on a foetal scan.

One of those at the sharp end of telemedicine technology is Dr Demetrios Papakostopoulos, a neurologist and neurophysiologist. While based in Bristol, he has so far examined 85 patients in Athens and is able to diagnose a wide range of conditions, including multiple sclerosis. Equipment in Athens converts images of patients' eyes into digital impulses which are then sent down the telephone line to the Bristol Eye Hospital, where they are reconstructed for his diagnosis.

"You can diagnose quite a lot by looking at the eye," Dr Papakostopoulos says, "because it is at the heart of the working nervous system. The clinic in Athens telephones me when it wants a diagnosis once every few days. This sort of technology means we can make the advanced equipment and techniques we have here available to people in Athens."

On the Isle of Wight another telemedicine trial is helping to ease the anxiety of pregnant women who have abnormal scans. A link between the island's St Mary's Hospital and the foetal care unit at Queen Charlotte's in London is being used for examining suspect scans. The 15-minute turnaround in results means mothers-to-be are saved days of worry.

In another project, patients who turn up at a minor casualty unit run by nurses in Westminster are being diagnosed by doctors in an accident and emergency unit in Belfast. And in Aberdeen, doctors have been looking at the use of camcorders on oil rigs for sending back pictures of cas-ualties to the mainland for diagnosis. Telemedicine is also being used to extend the range of primary care. In Wales, GP John Wynn Jones is using a camcorder to film his dermatology patients in Mont-gomery, Powys, and sending the pictures down a telephone line to a dermatologist nearly 100 miles away for diagnosis.

Telemedicine has been taken a step further in San Diego, California, where neurologists are using scans of a patient's brain to create a perfect virtual image of the organ. This image is projected over the patient on the operating theatre so the surgeon knows exactly where the problem is and where to make the incision without damaging actual tissue.

One of the main attractions of both telesurgery and telemedicine is that the scarce resources of specialists and expensive equipment can be shared by a much greater number of patients. Doctors will no longer be restricted by geographical boundaries; international specialists will be able to spread their skills across continents, even to battlefields, without ever leaving their own hospitals. Some enthusiasts believe teletechnology will lead to huge economies in health-service costs. Others point out that administering treatment still requires a physical presence. They say that although some teleservices may reduce costs, there will always be a demand for the personal touch.

Dr Ian Watt, senior research fellow and honorary consultant at the Centre for Health Economics at the University of York, says: "New technology helps on the diagnostic side, but you are still left with the problem of someone who needs physiotherapy or a district nurse - and that still requires personal contact."

Dr Heatley, however, is predicting that hospitals will soon have domestic robots, and in Wales Dr Wynn Jones is convinced that his telemedicine dermatology project now under way will revolutionise the delivery of many health services for people in areas like rural Powys.

"I'm very excited by it, and so are our patients," he says. "It means the patients don't have to make a round trip of about 200 miles to see a consultant and they get the results back very much faster. It is the way forward."

As Dr Wynn Jones is a medical adviser to The Archers, it may not be long before telemedicine acquires a much higher public profile. Joe Grundy's complaints about a suspected farmer's lung may one day be put to the test with a digital stethoscope examination by a specialist at the other end of a telephone in Borchester. !