Kirurginen telepoliklinikka

1. Kirurginen telepoliklinikka Kari Haukipuro, 13.02.2005

2. Telepoliklinikkatutkimus Taustaa EtäPoli vai TelePoli PC teknologia Siirtoteknologia

3. Tutkimuksen tarkoitus Korvata osa käynneistä videoneuvottelulla ja tutkia taloudellisia, toiminnallisia ja lääketieteellisiä tekijöitä Onko mahdollista ? Onko kannattavaa ? Onko laadukasta ?

4. Potilasmateriaali I Vaihe Pyhäjärven ortopediset lähetepotilaat Poliklinikalle jo ajan saaneet ortopediset kontrollipotilaat Vertailu aiempaan etäpkl-materiaalin Vuosiseuranta II Vaihe Kaikki Pyhäjärven potilaat

5. Kriteerit I vaihe: Ei sellaista laboratorio-, röntgen- tai muuta tutkimusta tai toimenpidettä, joiden vuoksi käynti sairaalan poliklinikalla olisi välttämätön II vaihe: Kaikki potilaat Tutkimustarve päätetään I kontaktissa

6. Randomisointi TelePoli (Tk ja OYS) OYS: lääkäri, hoitaja, (fysioterapeutti …) TK: potilas, lääkäri, hoitaja KirPoli (OYS) Perinteinen poliklinikkakäynti

7. M1: Toiminnot ja kustannukset Potilaan, mahdollisen saattajan ja kotiavun yms. ajankäyttö ja siihen liittyvät tekijät Vastaanotto- ja videokäynnin valmisteluvaiheen, tapahtuman ja sen jälkeisen toiminnan ja työmäärän (m.l. henkilömäärän) analysointi (toimintoperiaate) pkl:lla ja terveyskeskuksessa

8. M2: Tekniikan arviointi Videoneuvottelu Äänen ja kuvan laatu, yhteydet, häiriöt Röntgenkuvat Postitettu kuva, videovälitteinen kuva, mahdollisesti digitoitu kuva (yhteys teleradiologiaprojektiin) Muu tekniikka tai resurssi Esim. rajoittavatko tk:n muut resurssit videoneuvottelun käyttöä !!

9. M3: Tyytyväisyysarviot Mitta-asteikot ja sanalliset arviot (käyttäjä-ja potilastyytyväisyys) Arviointitasot Laitoskohtainen, henkilöryhmäkohtainen, potilaskohtainen VN:n käyttökelpoisuus koulutuksen ja ohjauksen välineenä

10. M4: Hoidon toteutuminen Koko toteutuneen hoitojakson aikavertailu Koko toteutuneen hoitojakson käyntimäärä Uusiintuneet käynnit ja tutkimukset (aiempien puutteista johtuvat) Päällekkäiset käynnit ja tutkimukset Peruuntumiset

11. M5: Dg vs. Hoito DG Lähetteessä / I konsultaatiossa / Lopuksi Tarkentuminen, muuttuminen Hoito Ensimmäinen hoitosuunnitelma Lopulta annettu hoito Kustannus-vaikuttavuusanalyysi

12. Muuttujia / poimintoja tuloksista

13. Vaikuttaakotelepoliklinikka resurssien käyttöön?

14. Resurssi ? Aika Työ Tilat Laitteet Tarvikkeet Avustukset Palvelut

15. Kenen resurssi ? Julkinen sektori Sos/Terv/Kela Potilas Työnantaja Muut palvelun tuottajat

16. Konsultaatio ? Helppo Bulk ? Vaikea Harvinainen ? Laajenna reviiriä

17. Konsultaatio ?

18. T1: Toimiiko TelePoli ?

27. T2: TelePoli ja resurssit

36. Perinteinen KirPoli

37. T3: TelePolin soveltuvuus

38. Good or very good success of tele examination in all pats Orthopaedics 97 (78%) GE- and general surgery 59 (95%) Urology 2 (11%) Vascular surgery 7 (44%) Plastic surgery 1 (11%) Hand surgery 5 (26%)

39. D1: TelePoli Valikoidussa materiaalissa Toimiva palvelu Täyttää potilaan toiveet hyvin

40. D2: TelePolin järjestäminen Yksinkertainen on kannattavaa Monenlaisen tiedon välittäjä

41. D3: Yksinkertainen TelePoli Ohjaa resurssien käyttöä välittömästi Pitkäaikaisvaikutukset ? Alustavasti ei eroa ad 1 vuosi Oppiminen ym? Ohjautumisen suunta myönteinen (?)

42. D4: Yksinkertainen TelePoli Ensimmäinen edunsaaja potilas Muita edunsaajia KeLa, TA, ... Lopullinen edunsaaja veronmaksaja

43. D5: Muita tekijöitä Sähköinen sairauskertomus Parantaa TelePolin tärkeintä funktiota - tiedon välittämistä Lähete – Palaute – järjestelmä Tietoverkot

44. 2 Kokemuksia muualta

45. Kokemuksia muualta 1 TM Network Map - East Carolina University ECU-Telemedicine.htm ECU-Telemedicine North Pole.htm ECU-Telemedicine - Links.htm Kiina Meksikko Malesia

46. ECU-Telemed Workstation

49. Www.pulsar.org Multimedia super Corridor - MSC "MALAYSIAN MEDICAL MATRIX"

50. Kokemuksia muualta 2 UW - Telemedicine Resources.htm UW - BioRobotics Lab - Surgical Technology.htm UW - BioRobotics Lab - Surgical Technology 2.htm UVA-Office of Telemedicine.htm UVA-Freedom Call.htm UVA-Patient Link.htm UVA-TM Partners.htm

52. U Virginia 2005

54. 3 Etäkirurgia

55. Etäkirurgia Eri muotoja on vaikea eritellä Laparoskopia Robotit Telekirurgia

56. 4 Teknisiä kehitysaskeleita

57. Master-Slave Teleoperation System Block Diagram

58. Laparoscopic telesurgical workstation

61. Berkeley Our Second Generation Robotic Telesurgical System for Laparoscopy during tests in the Experimental Surgery Lab at UC San Francisco

62. Concept - Berkeley

63. The surgical master, which has 7 degrees of freedom, is the primary interface between the surgeon and the laparoscopic surgery platform, providing force and tactile feedback. In this design, a commercial 4 DOF force-reflecting joystick

64. Mastercloseup

65. Endo-Platform will allow finer positioning control for endoscopic tools

66. Berkeley Laparoscopic Endeffector, with a 2 DOF Wrist and a Gripper

67. Berkeley end-effector, with 2 DOFwrist and gripper

68. Endoscopic ManipulatorAn endoscope is typically a 70-180 cm long flexible tube of 11mm diameter. Currently, endoscopic tools are positioned by sliding in and out, and by controlling the bending of the last 10 centimeters of the endoscope. This radius is too large for some tasks, and bending tends to displace surrounding tissue making positioning more difficult. The endo-platform, designed by Jeff Wendlandt, will allow finer positioning control for endoscopic tools. Closed-loop control of this device has been implemented; a movie of the endo-platform tracking a circle is available. 

69. Robotic hand with wrist and gripper

70. Human InterfacesPrototype glove-like device that senses the positions of the surgeon's fingers and wrist with its flex and rotation sensors. The glove provides a more natural means of control than current minimally invasive tools. It could be used as a master to drive the miniature slave robotic hand described above, if force feedback is not needed.

71. Tactile sensation is extremely important ... To provide local shape information, an array of force generators can create a pressure distribution on a finger tip, synthesizing an approximation to a true contact.

72. Tactile Sensing and Stimulation¨Tactile sensation is extremely important in open surgery to allow the surgeon to feel structures embedded in tissue. Important vessels and ducts are usually shrouded in connective tissue; their presence must be felt rather than seen to avoid damage. Tumors within the liver or colon must be removed without exposure that would allow the spread of cancerous cells. Teletaction allows sensing and display of tactile information to the surgeon. In teletaction, a tactile sensor array can be used to sense contact properties remotely. To provide local shape information, an array of force generators can create a pressure distribution on a finger tip, synthesizing an approximation to a true contact.

73. Human Tactile PerceptionThe limitations of human tactile perception need to be understood when designing a teletaction system. We model an ideal teletaction system simply using two elastic layers placed between the finger and an object. The tactile sensor layer transmits contact stress to a display layer. This system has no spatial sampling limits or level quantization, and allows us to study ideal information transmission, considering the effects of spatial anti-aliasing and reconstruction filters in the sensor and display respectively.

74. Close-up View of the Laparoscopic Manipulators while Tying Knots in a Laparoscopic Training Box

75. Laparoscopic Manipulator with a Roll-Pitch-Roll Wrist and a Gripper

76. Tendon Driven Multifingered Manipulator for Laparoscopy

77. MIT

82. Robot assisted micosurgery

83. Molecular and Nanomanipulation By linking the PHANToM interface with nanomanipulation devices such as Atomic Force Microscopes, researchers can actually feel and manipulate viruses or position molecules on a substrate Applications include Cellular manipulation Molecular docking

84. SensAble Technologies -Phantom Visualization data segmentation and dataset navigation Diagnosis digital palpation and virtual endoscopy Surgical Simulation surgical planning and surgical training Dexterity Enhancement touch-enabled microsurgery and touch-enabled telesurgery Rehabilitation simulated exercise environments

85. The PHANTOM haptic interface allows users to "touch" virtual objects

86. VTi: Virtual technologies CyberGlove, CyberTouch CyberGrasp, GesturePlus UpComing: CyberForce Ascension 3D Tracking Devices Polhemus 3D Tracking Devices

87. CyberGlove

88. CyberTouch

89. CyberGrasp

90. GesturePlus

91. Cyberpalm (NeatResearch)

92. darpaglove8.jpg

96. Space Center / Army The NASA Commercial Space Center at Yale University Medical Informatics & Technology Applications (MITA)

98. Merkittäviä toimijoita Yale Telemedicine Center The NASA Ames Center for Bioinformatics NASA Telemedicine Technology Gateway

99. STEPS (Sensors) In addition to the direct types of physiologic sensors mentioned, there are what can be considered indirect forms of monitoring, examples being radiology and laboratory chemistry techniques. There has been a tremendous sophistication of these ancillary assessment tools within the fields of diagnostic imaging and body fluid chemistry analysis during this recent time period but even the removal of a simple blood sample, however, should still be considered an invasive procedure.

100. STEPS (Transmittors) Transfer of the information gained from current physiologic monitors (sensors) requires an electrical interface for virtually all types of monitoring devices at this time. This process requires the monitored subject to be physically connected to the devices in some fashion, even if it consists of skin contact electrodes. Remote telemetry monitoring of cardiac function is a currently accepted modality but it has limitations in scope of functions and monitoring distance from the subject. Other forms of remote data transmission have not been developed extensively at this time. The indirect ancillary studies performed are usually processed and analyzed remote from the subject but the results can be digitized and transferred easily with the efficient speed of contemporary computers. The recent trends in the preparation of surgeons for an operative procedure with diagnostic and therapeutic radiology imaging enhancement of anatomic structures can be considered a form of data transfer and interpretation because of the computerized data manipulation that occurs after the subject has undergone the imaging procedure. Telemedicine technology and utilization is undergoing a renaissance with the current improvements in computer capability, digital data transmission and societal pressure for equitable distribution of health care services. There is not, unfortunately, a general acceptance of this communication modality in the medical community and it is still far from achieving a broad utility rate at this time, despite a demonstrated high level of comfort with the process from those institutions where telemedicine is utilized frequently. Regardless of which sensor the data is transmitted from, interpretation of the data is still performed by direct human review in virtually all situations, with the exception of a few demonstration projects utilizing neural network decision analysis or computer software-driven management of support devices (e.g. ventilators).

101. STEPS (Effectors) Significant progress from the DOD, DARPA and the recent revolution with minimally invasive surgery (e.g. laparoscopy) has precipitated further research efforts from a variety of institutions to develop remote non-contact forms of interventions, including the utilization of robotics and teleprescence surgery. There have also been some recent developments of automated effector devices that require only intermittent human direction. These are relatively simple devices but their utility is effective despite the invasive nature of the components. Examples of NASA's earlier contributions are the automated drug delivery systems for people requiring chronic delivery of medications (e.g. insulin) and the automated implantable cardiac defibrillation (AICD) devices for people with chronic, recurring cardiac rhythm disturbances.

102. STEPS (Process Simulators) Applications already available for improving the educational process and consolidation of knowledge or skills computerized surgical simulators with 3-D imaging and photorealism hologram development for modeling of anatomy and surgical fields 3-D functional magnetic resonance imaging (MRI) and overlay for mapping out anatomical defects and cognitive function in advance of neurosurgery procedures and interventional informatics

105. 5 Muita välineitä MedTech Exhibit Beyond the Cutting Edge LSTAT.htm

106. LSTAT

107. Smart T-shirt

108. Eräitä kehitysvaiheita Remote Sound (telephone) about 1900 Remote Image (television) about 1950 Remote Touch / Texture (teletaction) 199? Remote Smell (teleolfaction) 199?

109. 6 Robotit - nykytilanne

110. Robotic surgery update Surg Endosc 2004_18_8 Laparoskopian rajoitteet

111. Integrated Surgical Systems, Sacramento CA, USA RoboDoc Femur drilling accuracy from 75% to 96%

112. Computer Motion, Goleta, CA AESOP Automated Endoscopic System for Optimal Positioning HERMES a host of tools that when incorporated into an operative suite can recognize a surgeon’s voice and follow commands to adjust the operative table and lights, contact another physician, or access knowledge-containing databases

113. Computer Motion, Goleta, CA ZEUS Robotic Surgical System Five degrees of freedom: in-and-out motion, rotation of the shaft, and pitch and yaw at the port site AESOP camera control system Three-dimensional image while viewing the monitor with special glasses. The ability to view the rest of the operating room from his peripheral vision

114. Zeus room setup with robotic arms and surgeon in the background

115. Zeus robotic console

116. Intuitive Surgical, Sunny Valley CA DA VINCI Robotic Surgical System Six degrees of freedom together with grip (seven total) In-and-out motion, rotation of the shaft, pitch (up–down), and yaw (left–right) at the instrument’s tip (EndoWrist), in addition to pitch and yaw at the port site. These seven degrees translate open surgical maneuvers to the tip of the robotic instrument intuitively. In addition, IS is working a fourth arm, which the surgeon may use as his own assistant without affecting the movements of his two operative hands

117. Intuitive Surgical, Sunny Valley CA DA VINCI Robotic Surgical System Forehead placed on a console that has two independent monitors serving as eyepieces Sensation of being immersed in the operative field The range of robotic cases: from the simplest cholecystectomy to the most complex mitral valve repair FDA is expected to approve da Vinci for mitral valve repair in 10.2004, with approval for atrial septal defect and coronary artery bypass graft soon to follow.

118. da Vinci room setup

119. da Vinci robotic console

120. Number of da Vinci systemsplaced versus time

121. N of surgical cases performed on the da Vinci system vs time

122. da Vinci and Zeus compared Degrees of freedom: dV 7 / Z 3 3D rendering: dV + / Z + Camera control: dV Manual / Z Voice Motion scaling: dV + / Z + Tremor filtering: dV + / Z + Haptic: dV - / Z – Some degree of sensation: dV + / Z + Current FDA approval dV: All MIS indications except cardiac Z: Assistance in laparoscopic indications

123. da Vinci and Zeus compared The operative times and learning curve were significantly shorten with the da Vinci system. Additionally, the movements appeared to be inherently more intuitive. Movement with the Zeus system was more like conventional laparoscopic techniques than with the traditional open approach. However, individual preference, surgical application, and availability of the device still play a large role in system selection at various institutions.

124. Academic Robotics Group East Carolina University, Johns Hopkins University, Ohio State University University of Illinois at Chicago da Vinci system vs. laparoscopy Experience involving 211 robotically assisted surgical procedures

125. Academic Robotics Group The average times for all the cases operative time 188 ± 83 min (range, 45–387) surgical time 143 ± 63 min (range, 35–462) robotic time 90 ± 47 min (range, 12–235) Median length of stay was 1 day (range, 0–37) Conclusions the operative outcomes compared favorably with those for conventional laparoscopic procedures da Vinci system was both safe and effective.

126. Academic Robotics Group For basic procedures, no difference was found for length of hospital stay, but operative time was significantly longer (132 vs 91 min). For advanced procedures, the length of hospital stay (2.6 vs 5.6 days) and the operation time (216 vs 225 min) were shorter for robotic cases

127. Telesurgery: Early experience Separation of the surgeon from the operative field 2001: a monumental case / After completing a pilot study of 25 telerobotic laparoscopic cholecystectomies, a group of surgeons undertook the first transcontinental operation Nonhospital setting in New York, Drs. Gagner and Marascaux Zeus system to remove a gallbladder from a patient with symptomatic cholelithiasis in Strasburg, France Operation proceeded without difficulty, and the patient was discharged within 48 h after the operation One of the main difficulties of operating in this manner is the latency experienced in movement and video images over such long distances Overcome by using asynchronous transfer mode telecommunication (ATM) The latency over the 14,000-km distance was 155 ms (safe 300 ms) The cost of an ATM line $100,000 to $200,000 U.S. dollars per year

128. Doctors Perform Successful Transatlantic Telesurgery  By Steve Gold, NewsbytesSTRASBOURG, FRANCE,19 Sep 2001, 9:59 AM CST A major test of remote surgical robotics took place earlier this month, allowing a group of surgeons in New York to operate on a patient located in France. Researchers with the Institute for Research into Cancer of the Digestive System (IRCAD) say that the operation was carried out on patient in Strasbourg, France, using minimally invasive, or "keyhole" surgery.  "The operation, which took place on Sept. 7, was a great success. There were no problems, and the patient has now made a full recovery," Caroline Reiller, a spokesperson for IRCAD, told Newsbytes this morning,

130. Robots in medicine

131. Telesurgery With advances in information technology advances in communication speed more cost-effective transmission of data signals telesurgical applications may one day allow affordable remote surgical intervention Applications such as terrestrial to space intervention have been considered, and NASA is even considering the application of this technology for a proposed mission to Mars in 2016 In the near future operate on battlefield patients or patients for whom intimate contact poses a risk to either surgeon or patient someday access to highly trained robotic specialists in remote areas of the world train surgeons who may not have access to highly specialized training Both international and local boundaries are broken, and the question of how to regulate surgeons will become more critical

132. Robotic and telesurgery Robotic surgery has arrived and is growing exponentially. Surgeons throughout many different subspecialties and from many nations are working to define which surgical pathology will benefit most from this new technology. Robotic systems have been proved safe and effective by many academic centers, and the technology begins its journey into the hands of the eagerly awaiting public.

133. Business As of June 2003, Intuitive Surgical and Computer Motion have merged and will be basing further development on the da Vinci platform.

134. Langaton sairaala

135. Wireless Hospital 041028 TiedTil.ppt

136. 7 Käsitteet Telemedicine Glossary.htm Telemedicine Glossary