Robotic surgery, telerobotic surgery, telepresence,

and telementoring
Review of early clinical results
G. H. Ballantyne
Minimally Invasive and Telerobotic Surgery Institute, Hackensack University Medical Center, 20 Prospect Avenue, Hackensack, NJ 07601, USA
Received: 12 February 2002/Accepted in nal form: 25 March 2002/Online publication: 29 July 2002
Abstract
Although laparoscopic cholecystectomy rapidly became
the standard of care for the surgical treatment of
cholelithiasis, very few other abdominal or cardiac op-
erations are currently performed using minimally inva-
sive surgical techniques. The inherent limitations of
traditional laparoscopic surgery make it dicult to
perform these operations. We, and others, have at-
tempted to use robotic technology to (a) provide a stable
camera platform, (b) replace two-dimensional with
three-dimensional (3-D) imaging, (c) simulate the uid
motions of a surgeon's wrist to overcome the motion
limitations of straight laparoscopic instruments, and (d)
oer the surgeon a comfortable, ergonomically optimal
operating position. In this article, we review the early
published clinical experience with surgical robotic and
telerobotic systems and assess their current limitations.
The voice-controlled AESOP robot replaces the cam-
eraperson and facilitates the performance of solo-sur-
geon laparoscopic operations. AESOP provides a stable
camera platform and avoids motion sickness in the op-
erative team. The telerobotic Zeus and da
1
Vinci surgical
systems permit solo surgery by a surgeon from a remote
sight. These telerobots hold the camera, replace the
surgeon's two hands with robotic instruments, and serve
in a masterslave relationship for the surgeon. Their
robotic instruments simulate the motions of the sur-
geon's wrist, facilitating dissection. Both telerobots use
3-D imaging to immerse the surgeon in a three-dimen-
sional video operating eld. These robots also provide
operating positions for the surgeon console that are er-
gonomically superior to those required by traditional
laparoscopy. The technological advances of these tele-
robots now permit telepresence surgery from remote
locations, even locations thousands of miles away. In
addition, telepresence permits the telementoring of
novice surgeons who are performing new procedures
by expert surgeons in remote locations. The studies
reviewed here indicate that robotics and telerobotics
oer potential solutions to the inherent problems of
traditional laparoscopic surgery, as well as new possi-
bilities for telesurgery and telementoring. Nonetheless,
these technologies are still in an early stage of develop-
ment, and each device entails its own set of challenges
and limitations for actual use in clinical settings.
Key words: Robots Robotic surgery Telerobotic
surgery Telesurgery Telepresence Telemen-
toring Telemedicine Laparoscopy Lapa-
roscopic surgery AESOP da Vinci Zeus
With
2
the advent of video laparoscopy, the staid surgical
suite of the 19th century entered the computer age [1].
The magnied and computer-enhanced video image
provided surgeons with superior exposure and visual-
ization of the abdomen. Yet even a decade after the
introduction of video laparoscopic colectomy, most
gastrointestinal operations are still performed using 19th
century instruments and techniques. Indeed, in the year
2000, <3% of colon resections in the United States were
done laparoscopically [2]. Why have surgeons failed to
embrace minimally invasive gastrointestinal, urological,
and cardiothoracic surgery despite the obvious advan-
tages to their patients?
Most laparoscopic gastrointestinal operations are
dicult operations to learn, master, and perform rou-
tinely. Surgeons face a long learning curve. Moreover, a
number of inherent pitfalls of laparoscopy hinder the
performance of advanced laparoscopic procedures.
These pitfalls include:
1. An unstable camera platform
2. The limited motion (degrees of freedom) of straight
laparoscopic instruments
3. Two-dimensional imaging
4. Poor ergonomics for the surgeon
Surg Endosc (2002) 16: 13891402
DOI: 10.1007/s00464-001-8283-7
Springer-Verlag New York Inc. 2002
Review article
Since the introduction of video laparoscopic cholecys-
tectomy, surgeons have speculated that computers, 3-D
imaging, and robotics could overcome these pitfalls of
laparoscopy [3, 4, 5].
In this article, we review the early published clinical
experience with surgical robotic and telerobotic systems
and assess their current limitations. We also briey
review the early experience with telepresence surgery
and telementoring. Despite the paucity of documenta-
tion in the current literature, we will also address on
the specic limitations of the currently available ro-
botic and telerobotic surgical systems. Our aim here is
to provide a perspective on the state of this emerging
eld and to chart the directions in which it should
evolve.
Denitions
Robotic surgery
The rst robots introduced into clinical practice served
as camera holders. In 1994, the FDA approved AESOP
for clinical use as a robotic camera holder; more re-
cently, it also approved a second robotic camera holder,
the Endoassist (Armstrong
2
Healthcare Ltd., United
Kingdom). Surgical robots are controlled directly by the
surgeon, who stands
2
at the side of the operating table.
Telerobotic surgery
More recently, surgical robots have evolved into tele-
robotic surgical platforms that permit surgeons to op-
erate on patients from remote locations using robotic
instruments. The surgeon and telerobot work in a
masterslave relationship. Telerobots have been speci
cally designed to overcome all four of the pitfalls of
laparoscopy. They maintain a stable camera platform,
use instruments that articulate at the end to simulate the
movements of the surgeon's hand, use three-dimensional
(3-D) imaging systems, and permit the surgeon to per-
form complex, advanced laparoscopic operations while
comfortably seated in an ergonomically correct position.
Telerobotic surgical systems have only recently achieved
limited approval for clinical use in the United States. At
the present time, telerobotic surgical systems oer a
limited selection of instruments and bulky congura-
tions that impede many specic surgical procedures.
Moreover, clinical experience, with the systems is lim-
ited. Thus, telerobotics must be regarded as an emerging
technology that is still in its infancy and in an early
phase of feasibility testing. The current generation of
telerobots is not sophisticated enough to displace pre-
vailing standard surgical practice.
Telepresence
The development of satisfactory telerobotic platforms
has kindled interest in telepresence surgery and tele-
mentoring. Telepresence projects a virtual image of the
operative eld to a remote site [6, 7]. Using the telerobot
to telecast their hand motions to the remote operating
room, surgeons perform operations without actually
seeing their patients. Telepresence enables a surgeon on
an aircraft carrier, for example, to operate on a
wounded soldier on the battleeld [8].
Telementoring
Telementoring uses similar technology to create a virtual
classroom, or even a ``virtual university'' [9]. Telemen-
toring permits an expert surgeon, who remains in his/her
own hospital, to instruct a novice in a remote location
on how to perform a new operation or use a new sur-
gical technology. Telepresence thus provides a new
strategy for the training of surgical residents [10, 11] as
well as a new means of disseminating novel surgical
approaches around the world [12].
Robotic replacement of the camera holder
The rst clinically successful robot, the Robodoc, was
introduced for use in total hip replacement [13, 14]. The
initial goal was to replace the camera holder with a
surgeon-controlled robot. In 1993 at the University of
California at Davis, Moran was the rst to employ a
passive electronically-regulated, pneumatically con-
trolled camera holder [15]. Working in Tu bingen, Ger-
many, Buess et al. developed a prototype of a robotic
camera holder, the FIPS Endoarm [16]. This robotic
arm was remotely controlled with a nger ring that was
clipped to one of the surgeon's instruments. It moved
with four degrees of freedom while maintaining an in-
variant point of constraint motion.
A British company, Armstrong Healthcare Ltd.,
markets a robotic camera
3
holder known as the ``En-
doassist'' [17, 18] that has recently received FDA ap-
proval for use in the United States. Unfortunately, very
little has been published about it to date. This device
allows the surgeon to control its movements with his or
her head. A device that emits infrared rays is worn by
the surgeon. When the surgeon points the infrared
beam to the point on the video monitor that he or she
wishes to see, the robot adjusts the camera to view this
area.
From the Hotel-Dieu de Montreal Hospital, Gagner
et al. reported three laparoscopic cholecystectomies that
they performed with a prototype of a robotic surgical
assistant [19]. The robotic arm moved with six degrees of
freedom. It was controlled with a joystick by a surgeon
in a remote room who viewed the operation on a
monitor. In 1995, they updated their experience with
this device [20]. Between 1 September 1993 and 10 Oc-
tober 1994, they successfully accomplished eight lapa-
roscopic cholecystectomies with cholangiography in
humans using this device. Total anesthesia time for these
operations averaged 63 min. They concluded that their
study ``represented a rst step toward the introduction
of robotic technology in laparoscopic surgery.''
1390
AESOP
The rst robot approved by the FDA for clinical use in
the abdomen was automated endoscope system for op-
timal positioning (AESOP) (Computer Motion, Santa
Barbara, CA, USA) (Fig. 1
4
). FDA approval was granted
in 1994. The acronym AESOP stands for Automated
Endoscopic System for Optimal Positioning. Computer
Motion was initially funded by a research grant from
NASA and charged with the development of a robotic
arm for the US space program. This arm was later
modied to hold a laparoscope and to replace the la-
paroscopic camera holder. When it was rst introduced,
the surgeon controlled the robotic arm either manually
or remotely with a foot switch or hand control [21, 22]
but more recent generations of AESOP are voice con-
trolled [23, 24]. The robot, which attaches to the side of
the surgical table, has a series of adapters that allow any
rigid laparoscope to be grasped.
Urologists at Johns Hopkins have demonstrated the
utility of AESOP for urological laparoscopic operations
[25]. They studied the use of AESOP as a camera holder
in 17 urological procedures, including nephrectomy,
retroperitoneal lymph node sampling, varix ligation,
pyeloplasty, Burch bladder suspension, pelvic lymph
node dissection, orchiopexy, ureterolysis, and neph-
ropexy. When they compared these robotically assisted
operations to historical controls in which a surgical as-
sistant held the camera, there was no increase in oper-
ating time in the robotic operations. They concluded
that it might prove cost eective in the future to replace
human surgical assistants with robotic assistants. In a
second study, the same group found that AESOP pro-
vided a signicantly steadier camera platform than the
human camera holder [26].
Surgeons in Kiel, Germany, explored the use of
AESOP in gynecological laparoscopic operations and
compared voice control of AESOP with the older foot
or hand control systems [27]. They found that the ro-
botic arm allowed them to perform complex laparo-
scopic operations faster than when the camera was held
by a human assistant. In addition, they concluded that
the voice-controlled AESOP worked more eciently
and faster than the older systems.
AESOP facilitates solo-surgeon laparoscopic proce-
dures in general surgery. Geis et al. used AESOP to
perform 24 solo-surgeon laparoscopic inguinal hernia
repairs, cholecystectomies, and Nissen fundoplications
[28]. All procedures were completed successfully without
the aid of a surgical assistant. Groups in Antwerp,
Belgium, and Catania, Italy, have found AESOP helpful
in performing laparoscopic adrenalectomies [29, 30].
Both groups found that the camera platform provided a
stable, constant video image that facilitated the opera-
tion. We recently documented the ability of AESOP to
facilitate solo-surgeon laparoscopic colectomy [31]. We
compared 14 robot-assisted laparoscopic colectomies
performed in 2000 with 11 laparoscopic colectomies
done the previous year. All operations were for benign
disease. We found that there was no dierence in the
operating time between the two groups. Eleven of the 14
robot-assisted operations were done by a solo surgeon
using a three-trocar technique and without the help of
an assistant surgeon. The most common reason for
adding a fourth trocar was the need for the lysis of
adhesions from previous abdominal operations. These
two studies indicate that AESOP can adequately replace
a human camera holder for general surgery laparoscopic
procedures. Moreover, these studies found that the
surgeon can often perform laparoscopic hernia and
gastrointestinal operations on a solo basis, without the
need for a surgical assistant.
Surgeons
5
in Munich, Germany, have also developed
a modication of AESOP. Their SGRCCS system works
on a color tracking system [32]. They modied AESOP
so that the robot automatically follows a color marker
attached to one of the laparoscopic instruments inserted
into the operative eld. They compared the use of
SGRCCS in 20 laparoscopic cholecystectomies with the
use of a human camera holder. The operative time was
slightly shorter with the robot: 54 min vs 60 min with the
human camera holder. There was a subjective impres-
sion on the part of the surgeon that the robot outper-
formed the human camera holder 70% of the time.
AESOP has successfully launched the era of robot-
assisted surgery. It can reliably replace a human camera
holder, and it provides a stable camera platform that
may diminish the risk of motion sickness in the opera-
tive team. Skilled surgeons can use AESOP to perform
solo laparoscopic operations without a camera holder or
surgical assistant. In some hospitals, AESOP may oer
cost advantages by decreasing the number of hospital
employees required to assist in laparoscopic operations.
Limitations of AESOP
Many surgeons may not attain time savings and cost
advantages with AESOP. This robot demands specic
modications to accommodate the surgeon's operating
style. Voice control of AESOP requires constant chat-
tering by the surgeon, which other members of the team
Fig. 1. AESOP, a voice-controlled robot, holds the video camera
during laparoscopic procedures. It maintains a stable camera platform
and ensures proper alignment of the video image with the horizon.
This photograph shows a surgeon performing a solo laparoscopic left
hemicolectomy with the assistance of AESOP.
1391
may nd distracting. Moreover, voice control is slow
compared to the rapid camera movements that can be
achieved by a practiced and attentive assistant. This
drawback tends to encourage the surgeon to complete a
dissection in a single visual eld rather than jumping
back and forth among several elds. Many surgeons
may not wish to change the style of laparoscopic dis-
section that they have developed over the last decade.
Indeed, surgeons who frequently perform laparoscopic
cholecystectomies as a two-person team using a four-
trocar technique may well nd that AESOP increases
the average operating time.
Although AESOP has the potential to lower costs by
replacing a camera holder, this cost savings is not gen-
erally borne out in real operative situations. Most la-
paroscopic procedures require a surgical assistant, and
many operations (such as cholecystectomy) are per-
formed with four trocars. This method permits the as-
sistant surgeon to provide exposure with one hand while
holding the camera with the other. In teaching hospitals,
cost savings are even more unlikely. Surgical residents or
medical students, who often act as assistant surgeons
and camera holders, do not add any cost to the opera-
tion. As a result, replacing them with AESOP does
not reduce hospital costs and may even interfere with
surgical training.
Telerobotic abdominal surgery
Telerobotic surgery, or telepresence surgery, is the next
step in the evolution of robotic surgery [33]. In these
operations, the surgeon sits at a computer console. The
computer translates the movement of the surgeon's
hands into motions of the robotic instruments. The
surgical telerobot, which is positioned by the side of
the patient, holds the camera and manipulates two or
more surgical instruments. The surgeon and computer
console can be positioned at a remote site. The surgeon
acts as the ``master'' and the robot as the ``slave'' [34].
The feasibility of remote surgeon telerobotics was rst
demonstrated in 1991 [35]. The concept was that this
technology would permit a surgeon at a remote site
(such as an aircraft carrier) to operate on a distant
patient (such as a wounded soldier on the battleeld)
[36].
Several groups developed systems that were designed
to replace the surgical assistant. First-Assistant, for ex-
ample, was a nonelectronic, pneumatically controlled
robotic arm. The surgeon moved the device manually
[37]. More recent robotic systems were designed to re-
place both the surgical assistant and the camera holder.
In general, these robots were similar to camera-holding
robots but were modied to hold surgical instruments.
The surgeon controlled these robots with foot or hand
controls [38, 39]. Buess et al. have been working on a
new telerobotic system called
6
advanced robotic tele-
manipulator for minimally invasive surgery (ARTE-
MIS), but it is not yet ready for clinical trials [40, 41].
Two telerobotic systems are currently commercially
availableZeus (Computer Motion) and da Vinci (In-
tuitive Surgical, Mountain Mountain View, CA, USA).
Da Vinci
Da Vinci consists of three separate parts (Fig. 2) [42].
The surgeon sits in an ergonomically comfortable and
advantageous position at a console or work station
(Fig. 3). His/her hands t into ``masters'' that act as the
interface with the computer. The computer and (3-D)
imaging system ll the remainder of the console. A
tower holds the video electronic equipment and an in-
suator for the pneumoperitoneum. The robot has
three arms. The central arm holds the camera, and the
two outer arms hold the surgical instruments. The sur-
gical instruments articulate at a ``wrist.'' They move
with seven degrees of freedom and two degrees of axial
rotation. The robot is moved to the side of the surgical
table. It is connected to the three operative trocars and
not to the surgical table. The computer keeps track of
the 3-D location of a point near the trocar's tip, not the
tip of the surgical instruments. The telescope passes
through a 12-mm trocar and the surgical instruments
through two 8-mm trocars. In the United States, the
surgical instruments are partially reusable; they can be
used 10 times. The telerobot's computer tracks the
number of uses of each instrument and will not operate
an instrument after the 10th use.
Da Vinci oers a true 3-D imaging system that is
much like looking through eld binoculars. The tele-
scope for this system is 12 mm in diameter and contains
two separate 5-mm telescopes. Two three-chip video
cameras telecast the image to two separate CRT screens.
A synchronizer keeps the images from the two cameras
in phase. Mirrors reect the images from the CRT
screens up to the binocular viewer in the surgeon's
console. In this system, the left and right images remain
separated from telescopes to the surgeon's eyes. As in
binoculars, the right eye sees the right image and the left
eye sees the left image.
Cardiac surgery
Da Vinci was designed specically to accomplish closed-
chest coronary artery bypass grafting [43]. As a result,
Fig. 2. The da Vinci robotic surgical system consists of three parts: A
the surgeon's console, B an electronics tower holding video equipment,
and C the robotic arms. Surgeons look into the binocular viewnder,
immersing themselves in a three-dimensional projection of the opera-
tive eld. The ``masters'' into which the surgeon slides his/her ngers
translate the motions of the surgeon's hands into movements of the
robotic instruments.
1392
cardiac surgeons have accumulated substantial experi-
mental experience with da Vinci prototypes [4446]. In
1999, Carpentier et al. reported the rst successful use of
da Vinci for closed-chest coronary artery bypass grafting
[47]. Surgeons in Dresden have used da Vinci to harvest
both the left and right internal mammary arteries for
coronary artery bypass grafting in 27 patients [48]. Once
the arteries were harvested, the coronary artery bypass
was constructed through a left mini-thoracotomy. The
Leipzig group has rapidly accumulated a large clinical
experience with da Vinci for coronary artery bypass
surgery [49]. They used da Vinci in a progressive man-
ner. Initially, they used da Vinci to harvest 81 left in-
ternal mammary arteries (LIMA). They then used da
Vinci to sew 15 LIMA to left anterior descending (LAD)
coronary artery bypass grafts through a median stern-
otomy incision. Following this experience, they were
able to construct 27 LIMA
7
-to-LAD bypass grafts on an
arrested heart (Peripheral Access Technique; Heartport,
Redwood, CA, USA) with a closed chest. More recently,
they succeeded in 14 of 17 attempts to use da Vinci to
anastomose the LIMA to the LAD on a beating heart
with a closed chest. The American FDA trial of closed-
chest coronary artery bypass grafting using da Vinci has
just been initiated. Dr. Michael Argenziano of New
York Presbyterian Hospital, who is leading this multi-
institutional study, performed the rst successful pro-
cedure in January 2002.
Clinical experience with da Vinci for mitral valve
repair is also building. The Leipzig group successfully
used da Vinci to repair mitral valves in 13 of 15 patients
[50]. Chitwood et al. have initiated a trial on da Vinci
assisted repair of mitral valves at East Carolina Uni-
versity in Greenville, North Carolina [51]. In the United
States, the FDA has approved da Vinci for all thoracic
operations, including internal mammary artery har-
vesting, but not cardiac operations, such as coronary
artery bypass grafting.
Abdominal surgery
Cadiere et al. reported the rst successful clinical im-
plementation of telerobotics in March of 1997 when
they performed a laparoscopic cholecystectomy using a
prototype of the da Vinci robotic surgical system [52].
Cadiere et al. also reported the successful use of this
system for telerobotic laparoscopic gastric bypass [53],
Nissen fundoplication [54, 55], and Fallopian tube re-
anastomosis [56]. Table 1 lists 141 published telerobotic
gastrointestinal operations accomplished with the da
Vinci robotic surgical system [31, 5767]. The most
commonly reported operation was Nissen fundoplica-
tion (38 cases); the second most common was chole-
cystectomy (20 cases). Many of these cases were
presented at the annual meeting of the Society of
American Gastrointestinal Surgeons (SAGES) in April
2001. These reports indicated that telerobotic gastroin-
testinal surgery could be done safely.
Several studies in Table 1 examined surgical times
for telerobotic operations. Cadiere et al. compared 10 da
Vinci Nissen fundoplications with 11 laparoscopic Nis-
sen fundoplications in a randomized trial [54, 55]. Total
surgical time for the da Vinci operations was signi-
cantly longer than the standard operations: 76 min vs 52
min. Median length of stay for the da Vinci patients was
1 day. Clinical outcomes were similar for both groups.
Chapman et al. of the East Carolina University School
of Medicine reported that the total operative time for 10
da Vinci laparoscopic cholecystectomies was 60 25
min [61]. Chapman's group average 84 min for telero-
botic fundoplications [62]. At Ohio State University,
Melvin et al. averaged 178.6 min for the wide range of
foregut operations listed in Table 1 [63, 65]. None of
these reports identied a learning curve for surgical
times during a surgeon's early experience with telero-
botic gastrointestinal operations. In contrast, Ceconni
et al. in Grosseto, Italy found that their surgical time for
cholecystectomy improved after 20 da Vinci operations
[58]. Surgical time averaged 103.5 min for the rst 20
telerobotic cholecystectomies but dropped to 70.3 min
for the next 19. These time studies suggest that experi-
enced laparoscopic surgeons rapidly gain facility with
this new technology [68].
Our initial experience suggests that telerobotic la-
paroscopic colectomy by a remote surgeon is feasible
and can be done safely [31]. In two of three operations, a
solo surgeon accomplished the operation. We found that
the da Vinci system could reach from the exures to the
upper pelvis without much diculty. We thought that
the instruments were adequate for the task but that
specic bowel instruments were required to further fa-
cilitate the procedure and need to be developed by the
manufacturers.
Urologists have found important applications for
telerobotic surgery. In France, Guillonneau and Va-
llancien [69, 70] and Abbou et al. [71] have demon-
strated the advantages of using a laparoscopic approach
for radical prostatectomy. Recently, Abbou's group in
Creteil, France, has successfully accomplished a tele-
robotic laparoscopic radical prostatectomy using the da
Vinci robotic surgical system [72, 73]. The articulated
instruments of da Vinci seem particularly suited for the
dicult anastomosis between the urethra and bladder.
In Paris, Guillonneau and Vallancien's group reported
ve da Vinci radical prostatectomies [74]. The mean
Fig. 3. Simulated setup of the operating room for a telerobotic lapa-
roscopic cholecystectomy using the da Vinci telerobotic surgical sys-
tem. The surgeon sits in an economically comfortable position at the
console. The bedside assistant switches instruments on the robotic
arms as required.
1393
operating time, from the beginning of the dissection
until the last stitch of the anastomosis was tied, was 222
min (range, 150381). Average blood loss for the ve
cases was 800 ml. The urinary catheter was left in place
for an average of 6.5 days. Four of ve patients were
continent for urine. These surgeons thought that the
urethral anastomosis was easier to construct with da
Vinci than when using standard laparoscopic tech-
niques. Rassweiler et al. of the Klinikum Heilbronn
8
in
Germany also reported da Vinci radical prostatectomies
in six patients [75]. Their average operating time, in-
cluding pelvic lymph node dissection, was 315 min
(range, 242480). The urinary catheter was left in for 5
days. Three of the six patients were completely continent
for urine after 1 month. Binder et al. from Frankfurt,
Germany, reported the largest series [76]. They com-
pleted 44 of 46 attempted operations using da Vinci.
Operative time dropped from 7.511 h for the rst 20
patients to 3.55.5 h for the last 10 patients. These
surgeons found telerobotic radical prostatectomy feasi-
ble, but they expressed about the cost of the device and
the need for additional instruments.
So far, there have been just two published reports of
a telerobotic nephrectomy. Guillonneau et al. in Paris
reported a telerobotic nephrectomy using da Vinci in a
77-year-old woman with a nonfunctioning hydroneph-
rotic right kidney due to ureteropelvic junction ob-
struction [77]. Operative time was <200 min and total
anesthesia time was 245 min. Blood loss was <100 ml.
This report conrmed that telerobotic nephrectomy was
feasible. Vanuno and Horgan have been using da Vinci
in Chicago for laparoscopic donor nephrectomies [78].
Mean operative time for 10 donor nephrectomies was
166 min, and average hospital stay was 1.8 days. Va-
nuno and Horgan stated that da Vinci allowed them to
perform these operations with ``greater precision, con-
dence, and comfort.''
Few urologists have substantial experience with la-
paroscopy, and laparoscopic radical prostatectomy is a
very dicult operation to perform [79]. As a result,
telerobotic surgery may oer specic advantages for
urologists during their initial experience with minimally
invasive approaches to this operation as well as other
urological procedures [80]. As has already occurred in
cardiac surgery, the 3-D imaging system and the artic-
ulated instruments may foster the use of minimally in-
vasive techniques in urological procedures, since few
urologist have accumulated
9
much laparoscopic experi-
ence to date.
Limitations of da Vinci
Da Vinci is still in its rst generation of production.
Because it was designed specically for cardiac surgery,
the engineers did not consider the requirements of ab-
dominal surgery. As a result, the use of da Vinci for
abdominal surgery presents a variety of challenges.
Instrumentation is limited. The robotic arms are bulky.
The arms are not attached to the operating room table.
Large excursion arcs of the arms lead to frequent colli-
sions. The strong robotic arms lack tensile feedback.
Use of the telerobot in standard operating rooms is
cumbersome and frustrating.
Although intuitive oers a broad range of cardiac
surgery instruments for their da Vinci telerobot, it has
released only two instruments designed specically for
gastrointestinal surgerythe Cadiere graspers and ul-
trasound scissors. Babcock-type graspers, for example,
are not available for bowel operations. The needle
holders are designed for cardiac needles but not gas-
trointestinal needles. Electrocautery scissors are not
available. Ultrasound scissors have been recently re-
leased, but they lack the handlike motions of the other
instruments.
The da Vinci system lls a large operating room, so
its use in smaller rooms is impractical. It weighs a great
deal. It is dicult to move around the room and even
more dicult to push down the hall to another operat-
ing room. Changing the setup of the operating room
from that needed for cholecystectomy to the setup
needed for fundoplication or colon resection is time
consuming and tiring. For storage outside the operating
room, a small room is required.
A mobile tower supports da Vinci's robotic arms.
The arms are not attached to the surgical table. During
complex operations such as bowel resections, the robotic
arms must be separated from the patient for each posi-
tion change. This switch adds time to complex abdom-
inal surgical procedures.
The robotic arms were engineered to meet the re-
quirements of cardiac surgery performed on patients in
a at, horizontal position. Abdominal operations re-
quire extreme positions, such as Trendelenberg and re-
verse Trendelenberg, thus forcing the extreme elevation
of one robotic arm and the extreme depression of the
other and promoting collisions of the elbows of the ro-
botic arms. For this reason, minor misplacement of the
trocars away from the ideal positions may severely im-
pede the performance of operations.
Table 1. Published telerobotic gastrointestinal operations accomplished using the da Vinci robotic surgical 48 system
Operation Hanische Cecconi Hashizume Chapman Melvin Ozawa Talimini Cadiere Ballantyne
Cholecystectomy 5 39 2 10 3
Esophagectomy 2 1
Fundoplication 1 16 1 5 10 4 5 10
Heller myotomy 4 4 1
Gastrectomy 1 2
Splenectomy 2 1
Pancreatectomy 2 1
Collectomy 3 3 3
1394
The excursion arcs and motion scaling of da Vinci's
robotic arms are designed for the delicate motions of
internal mammary artery harvest and coronary artery
bypass, but operations such as colectomy require large
excursion arcs and broad, sweeping motions of the in-
strument. The motion-scaling reduction programmed
into da Vinci makes many of these maneuvers unduly
tedious.
The current generation of da Vinci does not provide
tensile feedback. The surgeon must rely on visual clues
to estimate the tension placed on tissues by da Vinci's
powerful robotic arms. Inexperienced telerobotic sur-
geons can easily avulse tissues with the robotic arms if
they fail to heed these subtle visual clues. Similarly, the
surgeon cannot judge how tightly the instruments are
grasping the tissues. This situation can lead to the
fraying of sutures or pressure injuries to tissue. Tensile
sensors exist, and future generations of telerobots are
likely to incorporate this technology. Nonetheless, the
lack of feedback is still a problem with current systems.
The video signal from da Vinci is generally broadcast
on several slave monitors in the operating room. The
assistant surgeon, scrub nurse, and other members of
the operating room team view the operation on these
two-dimensional telecasts. Connection of the da Vinci
video image to the slave monitors is easily accomplished
in new integrated operating rooms, but it can be a wiring
challenge in older operating rooms using mobile
laparoscopy video towers. This problem is compounded
if it is necessary to switch back and forth between a
laparoscopic telescope and the da Vinci telescope during
dierent parts of the operation. As the technology de-
mands of surgery increase, the need for dedicated op-
erating rooms specically designed and wired for these
advanced technologies has also increased. As a result,
we suggest that when considering the cost of initiating a
telerobotic surgery program, an institution should in-
clude the cost of upgrading at least one operating room
to a fully integrated advanced laparoscopic surgery op-
erating room.
Zeus
Computer Motion, the manufacturer of AESOP, has
also developed the Zeus telerobot [81]. It used AESOP
as a foundation for the development of a robot capable
of telerobotic surgery. In this system, the voice-con-
trolled robot, AESOP, continues to hold the camera.
Two additional AESOP-like units have been modied to
hold surgical instruments (Fig. 4). These three units are
independently attached to the operating room table. A
computer within the surgeon's console controls the three
arms. The computer keeps track of the 3-D position of
the tip of each instrument and camera, not the position
of the trocar (as does the da Vinci computer). In earlier
models, the surgeon controlled the laparoscopic instru-
ments with handles similar to traditional laparoscopic
instruments. The computer translated movements of
these handles into identical motions of the robotic sur-
gical instruments. The most recent version of Zeus uses
a more ergonomic interface between the surgeon and
robotic instruments (Fig. 5A). These handles control
surgical instruments that articulate near their tips. The
surgeon sits in a comfortable chair in front of the video
monitor (Fig. 5B). The computer eliminates the sur-
geon's resting tremor and can be set to scale the move-
ments of the surgeon's hand over a range of 2:1 to 10:1.
In Zeus, the surgeon observes the operation with a
Storz 3-D imaging system (Karl Storz Endoscopy, Santa
Barbara, CA, USA). The robotic arm that holds the
camera is voice controlled by the surgeon. This 3-D
imaging system accelerates the frame rate of the video
system. Separate right and left video cameras visualize
the operative eld. Each broadcasts at a rate of 30
frames per second. A computer merges and accelerates
this to a broadcast rate of 60 frames per second.
This broadcast alternates frames from the left and right
video cameras. The video monitor has an active matrix
Fig. 4. The telerobot Zeus uses three robotic arms. These robotic arms
consist of a voice-controlled camera holder, AESOP, and two modied
AESOP arms that act as the surgeon's right and left hands. Each arm is
attached directly to the surgical table. Thus, permits movement of the
surgical table can be moved without separating the telerobotic arms
from the patient. Each arm is moved and attached to the table sepa-
rately.
Fig. 5. The surgeon's console for Zeus is divided into two parts. A The
video monitor projects a three-dimensional image that can be viewed
through glasses mounted with polarizing lters. The balllike hand in-
terface translates the motions of the surgeon's hands into motions of
the robotic instruments. B The surgeon sits comfortably in a chair at
Zeus's console. The three Zeus robotic arms are visible in the back-
ground.
1395
covering its surface. The matrix alternates between a
clockwise and counterclockwise polarizing lter. The
clockwise lter synchronizes with the right video frame,
and the counterclockwise one matches the left video
image. The surgeon wears glasses that have a clockwise
polarizing lter as the right lens and a counterclockwise
polarizing lter as the left lens. These glasses permit the
left eye to see only the video image from the left camera
while the right eye sees the video image from the right
camera. This causes a 3-D image to be projected from
the video monitor.
Cardiac surgery
Zeus, like da Vinci, was developed specically to do
cardiac operations. Most of the clinical reports on Zeus
have focused on this area. The most advanced area of
telerobotic surgery for Zeus is internal mammary artery
harvest and coronary artery bypass grafting. Boyd et al.
in London, Ontario, demonstrated the eective and safe
use of Zeus for harvesting internal mammary arteries
[82, 83]. The left internal mammary arteries were suc-
cessfully harvested with Zeus in 19 patients. A closed-
chest, three-trocar technique was used. All 19 operations
were completed successfully and had excellent clinical
outcomes. A number of early publications documented
the feasibility of performing coronary artery bypass
surgery with Zeus in both live animal models [84, 85]
and cadavers [86, 87]. Clinical cases soon followed.
Surgeons in Munich have championed the use of
Zeus for coronary artery bypass grafting. In 1999, Rei-
chenspurner et al. reported the rst successful clinical
use of Zeus for coronary artery bypass grafting [88]. In
two patients, surgeons harvested the left internal mam-
mary artery using endoscopic techniques and then su-
tured the internal mammary artery to the left anterior
descending artery anastomosis through three thoracic
trocars. The heart was arrested using an endovascular
cardiopulmonary bypass system (Port Access; Heart-
port). Both patients recovered uneventfully. Later that
year, the Munich group used Zeus to successfully per-
form closed-chest, o-pump coronary artery bypass
grafting (left internal mammary artery to left anterior
descending coronary artery) in three patients [89]. By
2000, the same group had performed coronary artery
bypass grafting on beating hearts in 10 patients with
Zeus. The anastomoses were technically satisfactory by
angiography in all 10 patients [90]. Total operative time
ranged from 4 to 8 h (median, 5.5). The Zeus-assisted
anastomoses required 1450 min (median, 25). Boyd's
group in London, Ontario is the only group in North
America that has reported closed-chest, o-pump cor-
onary artery bypass grafting with Zeus [91]. These pa-
pers have paved the way for other groups and
documented the clinical possibility of closed-chest, o-
pump coronary artery bypass grafting using Zeus.
Two groups in the United States have used Zeus for
coronary artery bypass grafting as part of FDA trials.
Surgeons at Hershey Medical Center in Pennsylvania
harvested left internal mammary arteries through open
chests with the patients on standard bypass [92]. Three
subxiphoid trocars were then inserted. Zeus was used to
sew the left internal mammary arteries to the left ante-
rior descending arteries. Other bypass grafts were sewn
by traditional techniques. Eight of the 10 anastomoses
were satisfactory, but the other two required revision.
All 10 patients recovered uneventfully. All grafts were
open by angiography 6 weeks after the operation.
Surgeons at Washington University in St. Louis,
Missouri, reported 1-year follow-up on patients who
had undergone Zeus-assisted operations. These surgeons
used Zeus through three 5-mm trocars. The heart was
arrested and on bypass. Left internal mammary artery
to left anterior descending artery anastomoses were
constructed using Zeus in 19 patients. Other bypass
grafts were constructed without Zeus. All grafts were
patent on postoperative angiographies. At an average
follow-up of 1 year, all patients were functioning at a
New York Heart Association class I [93]. FDA trials are
ongoing in this area, and additional reports are expected
in the near future.
Zeus will be used for a variety of cardiac procedures
in the future. Luison and Boyd, for example, reported a
pericardiectomy accomplished with a 3-D imaging sys-
tem [94]. This report served to focus attention on the
advantages of 3-D imaging systems in complex ana-
tomical environments. Similarly, Grossi et al. have used
Zeus at New York University for mitral valve surgery
[95]. These areas of development look especially prom-
ising.
Abdominal surgery
The FDA only recently (October 2001) granted Zeus
limited clinical approval for abdominal operations in the
United States. Consequently, much of the work to date
with Zeus has been done in animal models. Goh's group
in Singapore, for example, used Zeus to perform
cholecystectomies in seven pigs [96]. Their mean opera-
tive time was 46 min (range, 3062). They found that,
with practice, their setup time dropped from 30 to 14
min.
Hollands et al. at Louisiana State University (LSU)
have explored the utility of Zeus for pediatric proce-
dures and, in particular, the advantages of telerobotic
suturing over standard laparoscopic suturing tech-
niques. The LSU group found that they could construct
porcine enteroenterostomies faster with Zeus than with
standard laparoscopic techniques [97]. The telerobotic
operations averaged 14 min less than the laparoscopic
operations, including setup time for the robot. The
group also compared the repair of a choledochotomy in
pigs using standard laparoscopic techniques with the
same procedures using Zeus [98]. The Zeus repair re-
quired 7090 min more than the laparoscopic technique,
but there were signicantly fewer complications (four vs
nine) in the Zeus group. These studies suggest that
gastrointestinal suturing with Zeus may oer advanta-
ges over traditional laparoscopic techniques.
Using experimental models, the Cleveland Clinic
has explored the applications for Zeus in gynecology
and urology. Margossian et al. demonstrated that
1396
uterine horn anastomoses in six pigs sutured using
Zeus were all patent 4 weeks after surgery [99]. This
study highlighted the potential role of telerobotics for
microsurgical suturing. Margossian and Falcone also
used Zeus to perform ve adnexal operations and ve
hysterectomies in pigs [100]. The mean length of sur-
gery was 170 min for the adnexal operations and 200
min for the hysterectomies. All 10 operations were
done telerobotically.
Gill et al. have used Zeus in experimental studies at
the Cleveland Clinic for pyeloplasty, nephrectomy, and
adrenalectomy [101]
10
. Using a swine model, they sutured
four pyeloplasties laparoscopically and six pyeloplasties
telerobotically. The telerobotic anastomoses averaged a
total of 115 min vs 94 min for the laparoscopic ones.
Five of six of the Zeus and three of four of the laparo-
scopic pyeloplasties were immediately watertight. The
same group also compared telerobotic nephrectomy and
adrenalectomy with laparoscopic operations [101].
Again, the telerobotic operation required signicantly
more time, but similar dissections were accomplished in
both groups. The Cleveland Clinic surgeons thought
that telerobotics oered distinct advantages when su-
turing was required and that telerobotic dissection
achieved results similar to laparoscopic techniques.
Several groups have assessed Zeus as a means for
instructing medical students, surgical residents, and
surgeons in the techniques of advanced laparoscopic
surgery [102104]. These studies found that telerobotics
conferred little advantage on the performance of simple
tasks, such as picking up and dropping beads into a
receptacle. However, complex tasks, such as suturing or
suture tying, were accomplished with greater speed and
precision when performed telerobotically, regardless of
the individual's prior level of training. These studies
suggested that telerobotic surgical systems could facili-
tate the learning and performance of complex laparo-
scopic operations.
Two recent reports attest to the clinical utility of
Zeus in gynecology and urology. In 1999, Falcone et al.
reported the use of Zeus at the Cleveland Clinic in a
tubal reanastomosis [105]. They updated their experi-
ence in 2000 with an additional 10 patients. The tubal
reanastomosis was accomplished in each patient with
four sutures of 8-0 polygalactin sutures. Postoperative
hysterosalpingograms 6 weeks after surgery demon-
strated patency in 17 of the 19 tubes. Guillonneau and
Vallancien have used Zeus for pelvic lymph node dis-
sections in patients with prostate cancer [106]. The av-
erage operating time for 10 telerobotic lymph node
dissections was 125 minsignicantly longer than the
average of 60 min required for the standard laparo-
scopic operations. These two studies concluded that
this technology warrants further study in these clinical
arenas.
Marescaux et al. of the European Institute
11
for
Telesurgery (Strasbourg, France) recently reported the
largest clinical trial with Zeus in abdominal surgery
[107]. Twenty-ve selected patients underwent Zeus-
assisted laparoscopic cholecystectomies. One operation
was converted from a telerobotic procedure to a stan-
dard laparoscopic cholecystectomy. The median time
needed to set up and take down the Zeus robot was 18
min. Median time of dissection using Zeus was 25 min,
and the median overall operative time was 108 min. The
only complication among the 25 patients was a possible
pulmonary embolism
12
, but no embolist was found on CT
scan. The average length of postoperative stay was 3
days, which was similar to that for standard laparo-
scopic cholecystectomy in France. These surgeons em-
phasized the potential advantages of a digitized format
for information transfer and the visualization by the
surgeon
13
of remote surgery over long distances.
Limitations of Zeus
Zeus evolved from AESOP and has already passed
through four generations of development. Nevertheless,
surgeons still face a number of obstacles before this
telerobot can be used on a routine clinical basis. Zeus
has many of the same diculties as da Vinci. Mis-
placement of the trocars leads to collisions conicts
between the robotic arms. Zeus's various components
ll a large operating room and hopelessly clutter small
ones. Zeus does not yet oer tensile feedback. More-
over, feeding Zeus's video output into traditional mobile
video towers is often a challenge. Like da Vinci, this
telerobot is also much better suited for use in a modern,
fully integrated operating room. In addition, Zeus pre-
sents some unique challenges.
Zeus's 3-D imaging system requires the use of spe-
cic glasses. These glasses allow each eye to see only one
of the two alternating video signals. The right eye sees
only the right video image and the left eye only the right.
The image is blurred when the glasses are not worn.
Some surgeons dislike wearing these glasses. The ick-
ering of the alternating images on the same video screen
gives some individuals motion sickness. As a result,
some surgeons prefer a standard two-dimensional image
when using Zeus.
Computer Motion introduced in 2001 Zeus surgical
instruments with handlike motions. These instruments
provide motion with six degrees of freedom. Although
this technology seems promising, little clinical experi-
ence is available as yet.
At present, however, the greatest obstacle to the
clinical use of Zeus is its limited FDA approval. Zeus is
currently approved by the FDA for use as a surgical
assistant but not on an operating surgeon. This limita-
tion continues to impede the acquisition of clinical ex-
perience in the United States, since clinical use of Zeus is
conned to FDA-approved trials. Fortunately, Com-
puter Motion has completed trials with Zeus for chole-
cystectomy and Nissen fundoplication, and full FDA
approval for abdominal surgery is expected in the near
future.
Telepresence surgery
Telerobotics was rst developed with grants from the
US Department of Defense to allow surgeons at remote
locations to operate on wounded soldiers on the bat-
1397
tleeld [108]. Ninety percent of all combat deaths occur
before the soldier reaches a medical facility; few soldiers
die after reaching military hospitals [109, 110]. There-
fore, the aim was to allow surgeons to immediately treat
life-threatening injuriessuch as hemorrhaging from
major vesselsthat might kill soldiers before they could
be evacuated to military hospitals [111]. In this scenario,
the wounded soldier is placed in a telepresence surgery
vehicle. Three-dimensional imaging systems project the
image of the wounded soldier back to the surgeon on an
aircraft carrier or at another remote site. This virtual
environment allows the surgeon to perform the life-
saving operation.
Experimental studies have proven the validity of this
approach. In 1998, Bowersox et al. used a prototype of a
telerobotic surgical system to close gastrotomies and
enterotomies, excise gallbladders, and repair liver lac-
erations in swine [112]. Recently, telepresence surgery
was achieved with the surgeon separated from his pa-
tient by 3800 miles [113]. Sitting at a Zeus console in
New York City, Marescaux performed a telerobotic
cholecystectomy on a patient in Strasbourg, France
[114, 115]. The surgeon's console was connected directly
to Zeus's robotic arms by a transatlantic beroptic
cable. This direct connection minimized the time lag
between motions of the surgeon's hands, movements of
the robotic instruments, and the returned video image.
The use of satellites to transmit the digital signals
introduces too great a distance and signicantly delays
the round trip of these electronic signals.
Telepresence surgery oers a technological solution
to surgical manpower shortages in remote and under-
served areas. Moreover, it oers a means of improving
outcomes for infrequently performed and technically
demanding operations. One can envision a future in
which an expert surgeon performs operations such as
adrenalectomy or Heller myotomy for an entire region
from a central location, such as the state university.
Similarly, mobile vehicles carrying the telerobot could
migrate across third-world areas, allowing an expert
surgeon to remain at the university while eciently
performing the sophisticated operations needed in poor
communities. Nonetheless, ethical and legal paradoxes
raised by telepresence surgery have already been iden-
tied. For one thing, the impact of state and interna-
tional borders on medical licensing remains ill dened
[117]. For another, remote telepresence surgery certainly
interferes with traditional clinicianpatient relationships
[116]. It will be necessary to balance the advantages of
delivering sophisticated surgical care to remote areas
against the importance of direct surgeon-to-patient
contact.
Telementoring
The introduction of laparoscopic cholecystectomy in the
late 1980s led to new guidelines for the training of sur-
geons already in practice in the performance of new
operation [118120]. These guidelines generally include
the following recommendations:
1. The novice surgeon should pass a formal course that
includes didactic sessions and animal experience with
the procedure.
2. The surgeon should observe an expert surgeon per-
forming the operation.
3. The surgeon should act as a rst assistant to an expert
surgeon for the procedure or be preceptored by an
expert surgeon during his/her early clinical experi-
ence.
4. A proctor should monitor the surgeon during the
surgeon's initial independent experience with the
procedure.
Unfortunately, preceptoring and proctoring pro-
grams have always been dicult to implement. For
18
one
thing, they often represent an inecient use of the
expert surgeon's time. Additionally, no mechanism has
been developed to pay for these services. It is thus
dicult for expert surgeons to justify the requisite time
expenditure. Telepresence resolves many of these is-
sues. The expert surgeon can remain in his/her oce or
hospital and telementor the novice surgeon at remote
sites.
The introduction of relatively inexpensive means of
teleconferencing in the 1990s spurred interest in tele-
mentoring. Surgeons at Cedars-Sinai in Los Angeles
determined the maximum degree of video compression
that still allowed acceptable remote proctoring of lapa-
roscopic operations. They found that a standard 1.5 mb/
sec telecommunications data line provided an adequate
telesurgical image [121]. In 1997, Rosser telementored
laparoscopic colectomies performed by inexperienced
surgeons from across campus [122]. The operating sur-
geon was coached from a mobile command center
parked outside the hospital. In the next phase, Rosser
telementored laparoscopic Nissen fundoplications at
another hospital 5 miles away. In 1998, Johns Hopkins
instituted a telementoring program between Johns
Hopkins Bayview Medical Center and Johns Hopkins
Hospital, which are 3.5 miles apart [123]. The surgeons
at Johns Hopkins then succeeded in telementoring a
laparoscopic adrenalectomy in Innsbruck, Austria;
a laparoscopic varicocelectomy in Bangkok, Thailand; a
laparoscopic radical nephrectomy in Singapore [124,
125]; and ve urological procedures, including a lapa-
roscopic radical nephrectomy, in Rome, Italy [126].
Newer technology permitted this telementoring to occur
over three ISDN lines at 384 kbps. The time lag of the
video image was 1 sec.
Other groups have also explored the utility of this
approach. In 1997, Osaka University in Japan estab-
lished a tele-education and telementoring network that
linked ve remote hospitals with the university [127].
This network served to tele-educate young surgeons and
to telementor surgeon during advanced laparoscopic
procedures. The US Navy demonstrated another inter-
esting use of telementoring. Video and computer com-
munications technology were used to establish a
Battlegroup Telemedicine system [128]. Land-based
surgeons telementored the performance of ve laparo-
scopic inguinal hernia repairs on the aircraft carrier USS
Abraham Lincoln. The telemedicine system was also used
1398
to obtain surgical consultations with other surgical
specialists.
Telementoring may have a future role in teaching
laparoscopic surgery to surgical residents. The Uni-
versity of Hawaii tested the ability of a surgeon to
telementor residents performing laparoscopic cholecys-
tectomy [129]. The
17
operating times of six operations
performed with and six operations without a scrubbed
attending surgeon in the operating room were similar.
All operations were telementored from a remote site.
In Chorey
18
, United Kingdom, attending surgeons te-
lementored higher surgical trainees from a remote
room. The trainees independently performed laparo-
scopic cholecystectomies in a total of 34 patients. The
trainees could seek advice from the telementor, and the
telementor could oer advice or intervene during the
operation. The trainees completed 33 of the 34 opera-
tions. These studies indicated that telementoring is a
safe and eective teaching technique and may represent
a satisfactory means of assessing when trainees are
adequately trained to perform independent and unsu-
pervised operations.
In Europe, there is growing interest in the idea of
linking the resources of several universities to provide
teleconsulting and telesurgical resources to other sur-
geons [130132]. Marescaux et al. have envisioned a fu-
ture in which a ``virtual university'' will provide
teleeducation, teletraining, telementoring, teleproctor-
ing, and teleaccreditation for surgeons who wish to learn
newprocedures and technologies or to update themselves
on recent developments. In addition, the virtual
21
univer-
sity on the internet would allow the experience of expert
surgeons to be
19
applied throughout the served area via
telepresence surgery [133].
Rosser et al. of the Yale University School of
Medicine demonstrated how telementoring from a
virtual university could benet third-world areas.
Rosser telementored surgeons performing laparoscopic
cholecystectomies in Ecuador [134]. A mobile operating
room was equipped with telecommunications equip-
ment that permitted him to supervise surgeons in Ec-
uador from his oce in New Haven, Connecticut. This
study suggests that telecommunications can provide
new avenues for surgeons around the world to gain
training from expert surgeons in a cost-eective man-
ner.
The FDA approved the rst robotic telemedicine
device in October 2001 [135]. Computer Motion, CA
manufactures Socrates, which is a robotic telecollabo-
ration device. Socrates is designed to facilitate tele-
mentoring. The telementor uses Socrates from a remote
site to connect with an operating room and share audio
and video signals. The telementor uses Socrates' tele-
strator to annotate anatomy or surgical instructions.
The
20
telementor can also control the movements of the
camera and other electronic equipment in the operating
room via a voice-controlled system. New technologies
such as Socrates will make the virtual university
available to many users in the immediate future and
help to rmly establish telerobotics, telepresence,
and telementoring into the landscape of 21st century
surgery.
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