Overcoming Barriers to Wider Adoption of Mobile Telerobotic Surgery: Engineering, Clinical and Business Challenges



Advances in technology yield many benefits to our daily lives. Our ability to integrate robotics, telecommunications, information systems and surgical tools into a common platform has created new approaches in utilizing less invasive means to treat both common and more complex disease states. A significant amount of investment has been made both from government funding and private sector or commercial funding in the research and development of systems in the area of robotic surgery and the application of telesurgery; and this has led to the development of clinically-relevant distribution of surgical expertise using a surgical robot and telecommunication link. This has predominately been in support of government-funded activities. While early work by Jacques Marescaux in Operation Lindberg and the extensive research performed using Intuitive Surgical’s da Vinci, SRI’s M7 and the University of Washington’s Raven has shown tremendous promise in surgical care, there remains a variety of barriers to wider adoption of telerobotic surgery. These barriers are multidisciplinary and often interdisciplinary. Widespread application of telesurgery as a medical force multiplier depends upon resolution of these barriers, which include bandwidth, latency, quality of service (QoS), research, and reimbursement. The following summarizes how telesurgery has developed, what the challenges are and how they are being ameliorated for wider adoption.


Transmission Control Protocol Robotic Surgery Surgical Robot Defense Advance Research Project Agency Vinci Surgical System 



Much of this chapter was gleaned from a detailed report that was prepared for TATRC. This report was authored by Mr. Charles R. Doarn and Dr. Timothy J. Broderick. In addition, we acknowledge the work done by those individuals and institutions mentioned here in for their outstanding contributions to this emerging field.


  1. 1.
    Intuitive Surgical. www.intuitivesurgical.com (2009) Last accessed on 1 July 2009
  2. 2.
    WebSurg – History of Robotic Surgery. www.websurg.com/robotics/history.php (2008) Last accessed on 9 Oct 2008
  3. 3.
    MD/Consult – Classification of Surgical Robots – Townsend: Sabiston Textbook of Surgery, 18th Edn. www.mdconsult.com/das/book/body/106987206-2/0/1565/191.html (2008) Last accessed October 9, 2008
  4. 4.
    Technology Readiness Assessment Deskbook (DOD – May 2005)Google Scholar
  5. 5.
    Defense Acquisition Guidebook (DOD – July 2006)Google Scholar
  6. 6.
    DOD Directive 5000.1Google Scholar
  7. 7.
    Autonomous Military Robotics: Risk, Ethics, and Design. CalPoly report to the Office of Naval Research (ONR). Award #N00014-07-1-1152. 2009Google Scholar
  8. 8.
    Curley, K., Broderick, T., Marchessault, R., Moses, G., Taylor, R., Grundest, W., Hanly, E., Miller, B., Gallagher, A., Marohn, M.: Integrated research team final report: surgical robotics – the next steps. Telemedicine and Advanced Technology Research Center (TATRC) Report No. 04–03. United States Army Medical Research and Materiel Command, 2004Google Scholar
  9. 9.
    Doarn, C.R., Broderick, T.J.: Robotic Surgery in Flight. C-9 and Other Microgravity Simulations NASA/TM-2008-214765, pp. 12–18 (2008)Google Scholar
  10. 10.
    Doarn, C.R., Broderick, T.J.: Interim report to USAMRMC – TATRC – Grant W81XWH-07-2-0035. Advanced Center for Telemedicine and Surgical Innovation (ACTSI), 2008Google Scholar
  11. 11.
    Doarn, C.R., Broderick, T.J.: Supplemental (Final) report to USAMRMC – TATRC – Grant W81XWH-05-2-0080, High Altitude Platforms for Mobile Robotic Telesurgery, 2008Google Scholar
  12. 12.
    Doarn, C.R., Broderick, T.J.: Task report USAMRMC – TATRC – Grant W81XWH-07-2-0035. Robotic Surgery in Flight (NASA DC-9 Parabolic Flight Report), 2007Google Scholar
  13. 13.
    Doarn, C.R., Broderick, T.J.: Final report to USAMRMC –TATRC – Grant W81XWH-07-2-0039, NASA Extreme Environment Mission Operation (NEEMO) 12 Robotic Telesurgery: Technology Evaluation and Performance Assessment, 2008Google Scholar
  14. 14.
    Broderick, T.J., Doarn, C.R.: Final report to USAMRMC – TATRC – Grant W81XWH-06-1-0084, Science Support – NASA Extreme Environment Mission Operation (NEEMO) 9: Evaluation of Robotic and Sensor Technology for Surgery in Extreme Environments, Oct 2006Google Scholar
  15. 15.
    Broderick, T.J., Doarn, C.R., Harnett, B.: Interim report to USAMRMC – TATRC – Grant W81XWH-05-2-0080, High Altitude Platforms for Mobile Robotic Telesurgery, 2006Google Scholar
  16. 16.
    Townsend: Sabiston Textbook of Surgery, 18th Edn. Elsevier, Saunders (2007)Google Scholar
  17. 17.
    Kumar, S., Marescaux, J.: Telesurgery. Springer, New York, NY (2007)Google Scholar
  18. 18.
    Satava, R.: CyberSurgery: Advanced Technologies for Surgical Practice Ed. Wiley-Liss, New York, NY (1998)Google Scholar
  19. 19.
    Speich, J.E., Rosen, J.: Medical Robotics. Encyclopedia of Biomaterials and Biomedical Engineering. pp. 983–993. Marcel Dekker, New York, NY (2004)Google Scholar
  20. 20.
    Moses, G.R., Doarn, C.R., Hannaford, B., Rosen, J.: Overcoming Barriers to Wider Adoption of Mobile Robotic Surgery: Engineering, Clinical and Business Challenges. National Institute for Standards and Technology. In: Performance Metrics for Intelligent Systems (PerMIS) Workshop at Gaithersburg, MD. Conference Proceedings. NIST SP 1090. pp. 293–296 (2008)Google Scholar
  21. 21.
    Moses, G.R., Doarn, C.R.: Barriers to wider adoption of mobile telerobotic surgery: engineering, clinical and business challenges. In: Westood, J.D. et al. (eds.) Medicine Meets Virtual Reality 16, Vol. 132, pp. 309–312. IOS Press, Amsterdam (2008)Google Scholar
  22. 22.
    Lum, M.J.H., Rosen, J., King, H., Friedman, D.C.W., Donlin, G., Sankaranarayanan, G., Harnett, B., Huffman, L., Doarn, C., Broderick, T.J., Hannaford, B.: Telesurgery via unmanned aerial vehicle (UAV) with a field deployable surgical robot. In: Westood, J.D. et al. (eds.) Medicine Meets Virtual Reality 15, Vol. 125, pp. 313–315. IOS Press, Amsterdam (2007)Google Scholar
  23. 23.
    Anvari, M.: Reaching the rural world through robotic surgical programs. Eur. Surg. ACA Acta Chir. Austriaca 37(5), 284–292 (2005)CrossRefGoogle Scholar
  24. 24.
    Ballantyne, G.H.: Robotic surgery, telerobotic surgery, telepresence, and telementoring – a review of early clinical results. Surg. Endosc. 16, 1389–1402 (2002)CrossRefGoogle Scholar
  25. 25.
    Bar-Cohen, Y., Mavroidis, C., Bouzit, M., Dolgin, B., Harm, D.L., Kopchok, G.E., White, R.: Virtual reality robotic telesurgery simulations using MEMICA Haptic System. Proceedings of SPIE’s 8th Annual International Symposium on Smart Structures and Materials, Newport, CA. pp. 4329–4347, 3–8 Mar 2001Google Scholar
  26. 26.
    Bennett, R. Kirstein, P.T.: Demonstrating minimally invasive therapy over the internet. Int. J. Med. Inform. 47, 101–105 (1997)CrossRefGoogle Scholar
  27. 27.
    Bolt, D., Zaidi, A. Abramson, J., Somogyi, R.: Telesurgery: advances and trends. Univ. Toronto. Med. J. 82(1), 52–54 (2004)Google Scholar
  28. 28.
    Broderick, T.J., Russell, K.M., Doarn, C.R., Merrell, R.C.: A novel method for visualizing the open surgical field. J. Laparoendosc. Adv. Surg. Tech. 12(4), 293–298 (2002)CrossRefGoogle Scholar
  29. 29.
    Broderick, T.J., Harnett, B.M., Doarn, C.R., Rodas, E.B., Merrell, R.C.: Real-time Internet connections: implications for surgical decision making in laparoscopy. Ann. Surg. 234(2), 165–171 (2001)CrossRefGoogle Scholar
  30. 30.
    Challacombe, B., Kavoussi, L., Patriciu, A., Stoianovici, D., Dasgupta, P.: Technology insight: telementoring and telesurgery in urology. Nat. Clin. Pract. Urol. 3, 611–617 (2006)CrossRefGoogle Scholar
  31. 31.
    Cone, S.W., Gehr, L., Hummel, R., Rafiq, A., Doarn, C.R., Merrell, R.C.: Case report of remote anesthetic monitoring using telemedicine. Anesth. Analg. 98(2), 386–388 (2004)CrossRefGoogle Scholar
  32. 32.
    Costi, R., Himpens, J., Bruyns, J., Cadiere, G.: Fundoplication: from theoretic advantages to real problems. JACS 197(3), 500–507 (2003)Google Scholar
  33. 33.
    Cregan, P.: Surgery in the information age. eMJA 171, 514–516 (1999)Google Scholar
  34. 34.
    DeBakey, M.E.: Telemedicine has now come of age. Telemed. J. 1(1), 4–5 (1995)Google Scholar
  35. 35.
    Demartines, N., Otto, U., Mutter, D., Labler, L., von Weymarn, A., Vix, M., Harder, F.: An evaluation of telemedicine in surgery. Arch. Surg. 135(7), 849–853 (2000)CrossRefGoogle Scholar
  36. 36.
    Dobrosavljevic, S., Welter, R.: TeleMEDian – telesurgery and telemedicine via satellite networks. Int. Congr. Ser. 1230(6), 1038–1043 (2001)CrossRefGoogle Scholar
  37. 37.
    Doarn, C.R., Kevin Hufford, K., Low, T., Rosen, J., Hannaford, B.: Telesurgery and robotics. Telemed. E-Health 13(4), 369–38 (2007)CrossRefGoogle Scholar
  38. 38.
    Doarn, C.R., Anvari, M., Low, T., Broderick, T.J.: Evaluation of teleoperated surgical robots in an enclosed undersea environment. Telemed. E-Health 15(4), 325–335 (2009)CrossRefGoogle Scholar
  39. 39.
    Doarn, C.R., Hufford, K., Low, T. Rosen, J., Hannaford, B.: Telesurgery and robotics: a roundtable discussion. Telemed. J. E-Health 13(4), 369–380 (2007)CrossRefGoogle Scholar
  40. 40.
    Doarn, C.R.: Telemedicine in tomorrow’s operating room: a natural fit. Semin. Laparosc. Surg. 10(3), 121–126 (2003)Google Scholar
  41. 41.
    Doarn, C.R., Fitzgerald, S., Rodas, E., Harnett, B., Praba-Egge, A., Merrell, R.C.: Telemedicine to integrate intermittent surgical services in to primary care. Telemed. J. E-Health 8(1), 131–137 (2002)CrossRefGoogle Scholar
  42. 42.
    Gandas, A., Draper, K., Chekan, E., Garcia-Oria, M., McMahon, R.L., Clary, E.M., Monnig, R. Eubanks, S.: Laparoscopy and the internet – a surgeon survey. Surg. Endosc. 15, 1044–1048 (2001)CrossRefGoogle Scholar
  43. 43.
    Graschew, G., Rakowsky, S., Balanour, P., Schlag, P.M.: Interactive telemedicine in the operating theatre of the future. J. Telemed. Telecare 6(Suppl 2), 20–24 (2000)CrossRefGoogle Scholar
  44. 44.
    Hall, J.C.: The internet: from basics to telesurgery. ANZ. J. Surg. 72(1), 35–39 (2002)CrossRefGoogle Scholar
  45. 45.
    Hanly, E.J., Marohn, M.R., Schenkman, N.S., Miller, B.E., Moses, G.R., Marchessault, R., Broderick, T.J.: Dynamics and organizations of telesurgery. Eur. Surg. ACA Acta Chir Austriaca 37(5), 274–278 (2005)CrossRefGoogle Scholar
  46. 46.
    Harnett, B.M., Doarn, C.R., Rosen, J., Hannaford, B., Broderick, T.J.: Evaluation of unmanned airborne vehicles and mobile robotic telesurgery in an extreme environment. Telemed. J. E-Health. 14(6), 539–544 (2008)CrossRefGoogle Scholar
  47. 47.
    Holt, D., Zaidi, A., Abramson, J., Somogyi, R.: Telesurgery: advances and trends. Univ. Toronto Med. J. 82(1), 52–54 (2004)Google Scholar
  48. 48.
    Karamanookian, H.L., Pande, R.U., Patel, Y., Freeman, A.M., Aoukar, P.S., D’Ancona, A.G.: Telerobotics, telesurgery and telementoring. Pediatr. Endosurg. Innovative. Tech. 7(4), 421–425 (2003)CrossRefGoogle Scholar
  49. 49.
    Klein, M.I., Warm, J., Riley, M., Matthews, G., Gaitonde, K., Donovan, J.F., Doarn, C.R.: Performance, stress, workload, and coping profiles in 1st year medical students’ interaction with the endoscopic/laparoscopic and robot-assisted surgical techniques. Conference Proceedings Annual Meeting of the Human Factors and Ergonomics Society (2009)Google Scholar
  50. 50.
    Latifi, R.: Editorial – telesurgery. Eur. Surg. ACA Acta Chir. Austriaca 37(5), 267–269 (2005)CrossRefGoogle Scholar
  51. 51.
    Latifi, R., Ong, C.A., Peck, K.A., Porter, J.M., Williams, M.D.: Telepresence and telemedicine in trauma and emergency care management. Eur. Surg. ACA Acta Chir. Austriaca 37(5), 293–297 (2005)CrossRefGoogle Scholar
  52. 52.
    Lee, S., Broderick, T., Haynes, J., Bagwell, C., Doarn, C., Merrell, R.: The role of low-bandwidth telemedicine in surgical prescreening. J. Pediatr. Surg. 38(9), 1181–1183 (2003)CrossRefGoogle Scholar
  53. 53.
    Lum, M.J., Rosen, J., Lendvay, T.S., Wright, A.S., Sinanan, M.N., Hannaford, B.: Telerobotic Fundamentals of laparoscopic surgery (FLS): Effects of time delay – a pilot study. Conf. Proc. IEEE Eng. Med. Bio. Sci. 2008, 5597–5600 (2008)Google Scholar
  54. 54.
    Malassagne, B., Mutter, D., Leroy, J., Smith, M., Soler, L., Marescuax, J.: Teleeducation in surgery: European institute for telesurgery experience. World J. Surg. 25(11), 1490–1494 (2001)Google Scholar
  55. 55.
    Marescaux, J., Leroy, J. Gagner, M. Rubino, F., Mutter, D., Vix, M., Butner, S.E., Smith, M.K.: Transatlantic robotic assisted remote telesurgery. Nature 413, 379–380 (2001)CrossRefGoogle Scholar
  56. 56.
    Marescaux, J., Rubino, F.: The Zeus robotic system: experimental and clinical applications. Surg. Clin. N. Am. 83, 1305–1315 (2003)CrossRefGoogle Scholar
  57. 57.
    Marescaux, J., Rubino, F.: Robotic surgery: potentials, barriers, and limitations. Eur. Surg. ACA Acta Chir. Austriaca 37(5), 279–283 (2005)CrossRefGoogle Scholar
  58. 58.
    Newlin, M.E., Mikami, D.J., Melvin, S.W.: Initial experience with the four-arm computer-enhanced telesurgery device in foregut surgery. JLAST 14(3), 121–124 (2004)Google Scholar
  59. 59.
    Melvin, W.S., Needleman, B.J., Krause, K.R., Schneider, C., Wolf, R.K., Michler, R.E., Ellison, E.L.: Computer-enhanced robotic telesurgery initial experience in foregut surgery. Surg. Endosc. 16, 1790–1792 (2002)CrossRefGoogle Scholar
  60. 60.
    Merrell, R.C., Doarn, C.R.: Meeting summary: a department of defense agenda for development of the surgical suite of tomorrow – implications for telemedicine. Telemed. J. E-Health 9(3), 297–301 (2003)CrossRefGoogle Scholar
  61. 61.
    Merrell, R.C.: Telemedicine in surgery. Eur. Surg. ACA Acta Chir. Austriaca 37(5), 270–273 (2005)CrossRefGoogle Scholar
  62. 62.
    Mohamed, A., Rafiq, A., Panait, L., Lavrentyev, V., Doarn, C.R., Merrell, R.C.: Skill performance in open videoscopic surgery. J. Surg. Endosc. 20(8), 1281–1285 (2006)CrossRefGoogle Scholar
  63. 63.
    Moeller, M.G., Santiago, L.A., Karamichalis, J., Mammen, J.M.V.: New ways of practicing surgery: alternatives and challenges. Bull. Am. Coll. Surg. 92(7), 51–58 (2007)Google Scholar
  64. 64.
    Organ, C.H.: The impact of technology on surgery. Arch. Surg. 134, 1175–1177 (1999)CrossRefGoogle Scholar
  65. 65.
    Panait, L., Rafiq, A., Mohamed, A., Doarn, C.R., Merrell, R.C.: Surgical skill facilitation in videoscopic open surgery. J. Laparoendosc. Adv. Surg. Tech. 13(6), 387–395 (2003)CrossRefGoogle Scholar
  66. 66.
    Panait, L., Doarn, C.R., Merrell, R.C.: Applications of robotics in surgery. Chirurgia (Bucur) 97(6), 549–555 (2002)Google Scholar
  67. 67.
    Pande, R.U., Patel, Y., Powers, C.J., D’ancona, G., Karamanoukian, H.L.: The telecommunication revolution in the medical field: present applications and future perspective. Curr. Surg. 60(6), 636–640 (2003)CrossRefGoogle Scholar
  68. 68.
    Paul, D.L., Pearlson, K.E., McDaniel, R.R.: Assessing technological barriers to telemedicine: technology-management implications. IEEE Trans. Eng. Manage. 46(3), 279–288 (1999)CrossRefGoogle Scholar
  69. 69.
    Paulos, E., Canny, J.: Delivering real reality to the world wide web via telerobotics. Proceedings of the 1996 IEEE International Conference on Robotics and Automation, 1694–1699 (1996)Google Scholar
  70. 70.
    Rafiq, A., Moore, J.A., Zhao, X., Doarn, C.R., Merrell, R.C.: Digital video capture and synchronous consultation in open surgery. Ann. Surg. 239(4), 567–573 (2004)CrossRefGoogle Scholar
  71. 71.
    Rafiq, A.R., Moore, J.A., Doarn, C.R., Merrell, R.C.: Asynchronous confirmation of anatomical landmarks by optical capture in open surgery. Arch. Surg. 138(7), 792–795 (2003)CrossRefGoogle Scholar
  72. 72.
    Rainer, W.G.: Invited critique: Rural Surgery. Arch. Surg. 135(2), 124 (2000)CrossRefMathSciNetGoogle Scholar
  73. 73.
    Riva, G., Gamberini, L.: Virtual reality in telemedicine. Telemed. E Health 6(3), 327–340 (2000)CrossRefGoogle Scholar
  74. 74.
    Rodas, E.B., Latifi, R., Cone, S., Broderick, T.J., Doarn, C.R., Merrell, R.C.: Telesurgical presence and consultation for open surgery. Arch. Surg. 137(12), 1360–1363 (2002)CrossRefGoogle Scholar
  75. 75.
    Rosser, J.C. Jr, Young, S.M., Klonsky, J.: Telementoring: an application whose time has come. Surg. Endosc. 21(8), 1458–1463 (2007)CrossRefGoogle Scholar
  76. 76.
    Rosser, J.C. Jr, Herman, B., Giammaria, L.E.: Telementoring. Semin. Laparosc. Surg. 10(4), 209–217.(2003)Google Scholar
  77. 77.
    Rosser, J.C.J.R., Gabriel, N., Herman, B., Murayama, M.: Telementoring and teleproctoring. World. J. Surg. 25(11), 1438–1448 (2001)CrossRefGoogle Scholar
  78. 78.
    Rovetta, A., Sala, R., Wen, X., Togno, A.: Remote control in telerobotic surgery. IEEE Trans. Syst. Man. Cybern. A Syst. Hum. 26(4), 438–444 (1996)CrossRefGoogle Scholar
  79. 79.
    Satava, R.M.: Emerging technologies for surgery in the 21st Century. Arch. Surg. 134, 1197–1202 (1999)CrossRefGoogle Scholar
  80. 80.
    Satava, R.: Surgical robotics: the early chronicles: a personal historical perspective. Surg. Laparosc. Endosc. Percutan. Tech. 12(1), 6–16 (2002)CrossRefGoogle Scholar
  81. 81.
    Satava, R.M.: Disruptive visions: a robot is not a machine. Surg. Endosc. 18, 617–620 (2004)CrossRefGoogle Scholar
  82. 82.
    Satava, R.M.: Telesurgery, robotics, and the future of telemedicine. Eur. Surg. ACA Acta Chir. Austriaca 37(5), 304–307 (2005)CrossRefGoogle Scholar
  83. 83.
    Schlag, P.M., Moesta, T., Rakovsky, S., Graschew, G.: Telemedicine – the new must for surgery. Arch. Surg. 134, 1216–1221 (1999)CrossRefGoogle Scholar
  84. 84.
    Seymour, N.E.: Virtual reality in general surgical training. Eur. Surg. ACA Acta Chir. Austriaca 37(5), 298–303 (2005)CrossRefGoogle Scholar
  85. 85.
    Smithwick, M.: Network options for wide-area telesurgery. J. Telemed. Telecare 1(3): 131–138 (1995)Google Scholar
  86. 86.
    Sterbis, J.R., Hanly, R.J., Herman, B.C., Marohn, M.R., Broderick, T.J., Shih, S.P., Harnett, B., Doarn, C.R., Schenkman, N.S.: Transcontinental telesurgical nephrectomy using the da Vinci robot in a porcine model. Urology 71(5), 971–973 (2008)CrossRefGoogle Scholar
  87. 87.
    Taylor, R.H., Stoianovici, D.: Medical robotics in computer-assisted surgery. IEEE Trans. Robot. Autom. 19(5), 765–781 (2003)CrossRefGoogle Scholar
  88. 88.
    Gourley, S.: Long distance operators: Robotic and telecommunications take the surgeons skills anywhere in the world. Popular Mechanics Sep. 64–67 (1995)Google Scholar
  89. 89.
    van Wynsberghe, A., Gastmans, C.: Telesurgery; an ethical appraisal. J. Med. Ethics 34, e22 (2008)Google Scholar
  90. 90.
    Varkarakis, I., Rais-Bahrami, S., Kavoussi, L., Stoianovici, D.: Robotic surgery and telesurgery in urology. Urology65(5), 840–46 (2005)CrossRefGoogle Scholar
  91. 91.
    Whitten, P., Mair, F.: Telesurgery vs telemedicine in surgery – an overview. Surg. Technol. Int. 12, 68–72 (2004)Google Scholar

Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  1. 1.Departments of Surgery and Biomedical EngineeringUniversity of CincinnatiCincinnatiUSA

Personalised recommendations