Full text of DOI:10.1089/109264201750539727

JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUES
Volume 11, Number 4, 2001
Mary Ann Liebert, Inc.
Technical Report
Laparoscopic Telescope with Alpha Port and Aesop to
View Open Surgical Procedures
K. MITCHELL RUSSELL, M.D., TIMOTHY J. BRODERICK, M.D.,
ERIC J. DeMARIA, M.D., SHANU N. KOTHARI, M.D.,
and RONALD C. MERRELL, M.D.
ABSTRACT
Laparoscopy has advanced surgery by allowing the surgeon to operate within a patient’s abdomi-
nal and pelvic cavity with minimal trauma and scarring. The coupling of a video camera to the la-
paroscopic telescope has had the secondary effect of allowing others to view the surgical field either
on color video monitors or by watching the video feed over the Internet at a remote location. These
advancements have allowed better teaching and mentoring of operations. Open procedures can ben-
efit from this technology as well but have suffered in the past from inadequate methods to depict
the open surgical field. We used the Alpha Port and Aesop robot to position a sterile laparoscopic
telescope near the surgical field to view open cholecystectomies performed on five pigs and to send
the video feed over the Internet to remote physicians. Viewing the video on the monitor, the sur-
geons performed the operation in a comfortable ergonomic upright position. Both the surgeons and
the remote physicians found the quality of the video to be excellent, and the remote physicians felt
comfortable learning and mentoring surgical procedures using this technique.
2
INTRODUCTION
and consultation. These advancements rely absolutely
on a small camera during laparoscopic procedures.3 Dur-
ing traditional open surgical procedures, on the other
hand, sharing the operative field has been limited. Teach-
ing during open cases has suffered as a result of the lim-
ited visibility of the surgical field by assistants or ob-
servers, the view dropping off sharply as distance
increases from the surgical field.
In the past, several attempts have been made to view
the open surgical field, including head-mounted, wall-
mounted, and overhead light-mounted cameras, as well
as cameras mounted on overhead booms that can be ex-
tended over the surgical field. This report explores the
use of the laparoscopic telescope attached to an Alpha
Port and Aesop robot (Computer Motion, Inc., Santa Bar-
APAROSCOPY HAS ADVANCED SURGERY by allowingthe
surgeon to operate within a patient’s abdominal and
L
pelvic cavity with minimal trauma and scarring.1 In ad-
dition, the coupling of advanced CCD video cameras to
the telescope permits the surgeon to share the operative
field with others. Surgical assistants, medical students,
and surgical nurses alike are afforded the view that was
once rather exclusively the surgeon’s. Thus, both surgi-
cal care and education have improved. With computer
networks availablein many operatingtheatres, the bound-
ary imposed by the very walls of the room can be tran-
scended. Surgical cases have been streamed over the In-
ternet to distant locations for the purposes of education
Medical Informatics and Technology Applications Consortium, Medical College of Virginia at Virginia Commonwealth Uni-
versity, Richmond, Virginia.
213

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RUSSELL ET AL.
bara, CA). The hypothesis was that the surgeon would
have the same optical advantage as in laparoscopy and
that the field could be shared. Using a sterile camera in
the operating field in this fashion, video from the surgi-
cal field can be viewed on a television monitor or sent
over the Internet to a remote location for proctoring or
teaching.
1
NEC Multisync MT1035
projector (NEC, Tokyo,
Japan), as well as a 29-inch PictureTel CRT monitor
model SM-72DVX2N (PictureTel Corporation, Andover,
3
MA) at a resolution of 800 600 pixels with 24-bit color
depth.
RESULTS
Open cholecystectomies were performed on each of
the five pigs by a surgeon and a first assistant. The Al-
MATERIALS AND METHODS
Five 30- to 40-kg Yorkshire pigs were anesthetizedand pha Port and Aesop apparatus were used with the la-
prepared for open cholecystectomy. A 10-mm flat la- paroscopic telescope for viewing during the procedure.
paroscopic telescope was fixed distally into an Alpha After establishing the surgical field, but during the chole-
Port, a rigid fixation arm that acts as the extracorporeal cystectomy dissection, the surgeon and first assistant
pivot point for the laparoscope in lieu of the traditional were asked to perform the surgery as much as possible
trocar port. This arrangement allows the telescope to re- by lookingat the video monitor (Fig. 1). During each pro-
main near the surgical field, with pivotal motion in the cedure, a handheld Richardson retractor provided suffi-
expected fashion. The telescope was attached proximally cient retraction for visibilityusing the telescope. The tele-
to an Aesop robot affixed to the operating table on the scope was adjusted an average of three to five times using
left side at the foot. The robot was controlled by the sur- the voice-operated Aesop controls to maintain adequate
geon’s voice and continuously adjusted for optimum visibility. The procedures were performed without com-
viewing by the surgeon approximately 5 cm caudally and plication. Afterward, the operators stated that they felt
7 to 10 cm above the surgical field. The telescope was comfortable performing the dissection by viewing the
attached to standard laparoscopic video equipment monitor and actually felt that they were in a more com-
(Stryker Endoscopy, Santa Clara, CA), and the images fortable ergonomic position fully upright. They com-
were displayed on a Sony 20-inch medical color video pleted a survey to qualify their experience (Table 1). The
monitor Model PVM-20M2MDU (Sony Corporation, responses indicated that not only did the surgeons feel
Tokyo, Japan). The monitor was placed at the head of the quality of the video was excellent but that they were
the table so that both the surgeon and the first assistant comfortable performing the dissection while viewing the
could view the screen during the procedure. The video monitor and that the apparatus was unobtrusive.
was also sent via S-VHS-quality cable to an Intel Team-
Three physicians viewed the procedures in a remote
station 384 videoconferencingunit (Intel, Inc., Santa Bar- conference room. A screen capture of the remote video
bara, CA). The Teamstation was connected point to point image is shown in Figure 2. The physicians viewing the
over a 10baseT local area network (LAN) to an identical operation remotely also completed a survey (Table 2).
Teamstation unit in a remote location. The connection Their responses indicated the video quality to be excel-
was established via H.323 using the H.263 FCIF/QCIF lent and that they would feel comfortable learning the
video CODEC (COder/DECoder) at approximately 400 procedure, as well as remotely mentoring the procedure
kbps bidirectionally and 15 frames per second (fps).
The surgeons performed open cholecystectomy on
each of the five pigs. The three participating surgeons all
had extensive training in laparoscopic and minimally in-
vasive surgical techniques. The mechanical skills needed
for laparoscopicsurgery are different from those required
from the video feed.
DISCUSSION
The Alpha port and Aesop robot apparatus with a la-
for open surgery,4 and the surgeons were encouraged, but paroscope constitutes a novel way to view an open sur-
not restricted, to view their actions on the video monitor gical field. In contrast to minimally invasive laparoen-
as if performing laparoscopic surgery, as opposed to doscopic surgery, which depends on a video camera for
viewing the surgical field directly. They all had corrected viewing, open surgical procedures have been difficult to
or uncorrected distance visual acuity of 20/20 and nor- view by individuals other than the surgeon and the first
mal color perception. The live video feed of the surgical or second assistant. Since the days of the early operating
field was simultaneously transmitted to three physicians theatre, where students of surgery would pack into steep
viewing in a nearby conference room. The remote physi- arrays of seats to catch a glimpse of surgical anatomy,
cians all had corrected or uncorrected distance visual acu- many attempts have been made to improve the visibility
ity of 20/20 and normal color perception. The video in of the traditional surgical operation. The simplest solu-
this conference room was projected on a screen using an tion involves the use of mirrors, an approach that has

ALPHA PORT AND AESOP FOR OPEN SURGERY
215
FIG. 1. Surgeons performing open cholecystectomy while viewing video provided by
laparoscopic telescope fixed to Alpha Port/Aesop apparatus.
FIG. 2. Remote video feed frame grab of open cholecystectomy as seen by remote physicians.

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RUSSELL ET AL.
TABLE 1. SURVEY OF SURGEONS PERFORMING OPERATION
Questions
Average
Range
How would you rate the overall quality of the demonstration?
How would you rate the quality of the video you viewed on the monitor?
How would you rate the quality of the color reproduction?
I felt comfortable operating while viewing the monitor video image.
I felt that I could see every structure just as well on the video monitor
as I could viewing the surgical field.
8.7
9.3
9.0
9.3
9.3
8–10
8–10
8–10
9–10
9–10
I felt comfortable operating with the telescope in place, that it was not obtrusive to the operation.
I feel that surgical education would benefit from this technology.
8.3
10.0
6–10
10
Graded Likert scale: 1 5 poor or strongly disagree;10 5 excellentor strongly agree. (N 5 3).
been used in few surgical procedures. Video cameras the open surgical field that have been used to date, a list
have advanced shared optics significantly;however, they of minimum requirements was developed, along with an
may suffer from the fact that they usually must lie be- apparatus and logistical approach that would meet these
yond the sterile field. Several vantage points for these requirements. The first requirement was to use state-of-
cameras have been explored. Cameras mounted on the the-art optics, lighting, and video equipment. A 10-mm
surgeon’s head have been useful for teaching some sur- flat laparoscopic telescope with a CCD camera and light
gical procedures, particularly in pediatric surgery, where source was chosen. This equipment has been well tested
the operative field is very small. The main problem with and proven to provide high-quality video during laparo-
head-mounted cameras is movement of the surgeon’s scopic procedures, and it is widely available. The second
head, causing the image to be jittery or to slip in relation requirement was to place the camera close to the operat-
to the surgeon’s gaze, necessitating frequent adjustment. ing field, which required the equipment to be incorpo-
Overhead light-mounted and light-handle cameras have rated into the sterile field. This arrangement permits high-
been used with good results, as they are fixed and not quality detailed close-up images, as well as allowing the
prone to jitter and can be remotely controlled.These cam- surgeons to interact and adjust the camera to optimal po-
eras have an acceptable vantage point from overhead but sitioning.
may still be rendered useless if the surgeon bends over
The third requirement was to have the telescope and
the surgical field, blocking the view of the camera. The camera apparatus fixed to avoid unnecessary motion.
perspective also may change when the overhead lights Aside from creating a better image for the surgical team
are moved and adjusted. Use of an overhead boom- to view, fixing the camera is very important when send-
mounted camera during open procedures has had con- ing the video feed digitally to a remote location using the
siderable success in our laboratory. This camera requires Internet Protocol (IP) or an ISDN connection. Modern
extra personnel to control the camera but has been found videoconferencinghardware and software, such as the In-
to be somewhat useful in teaching open surgical proce- tel Teamstation, use CODECS that maximize the quality
dures. Obviously, microsurgical procedures that employ of video transmission within a specific bandwidth. To in-
a surgical microscope can be outfitted with a beam split- crease speed of transmission and improve the smooth-
ter and a C-arm-mounted camera to obtain video footage ness of the video, the CODEC compresses the video by
that is nearly identical to what the surgeon views.
not sending redundant information about each pixel in re-
After reviewing all the various modalities for viewing lated frames.5 Every 15 seconds, a full frame (with in-
TABLE 2. SURVEY OF PHYSICIANS VIEWING OPERATION REMOTELY
Questions
Average
Range
How would you rate the overall quality of the demonstration?
How would you rate the digital video quality?
How would you rate the quality of the color reproduction?
8.7
8.0
8.6
8.0
7.6
7.6
8.3
8–9
7–9
8–9
7–9
6–10
5–10
7–9
I feel that I had a good view of the operation.
I would feel comfortable using the video to learn surgical procedures.
I would feel comfortable mentoring someone from a distance using this video feed.
I feel that surgical education would benefit from this technology.
Graded Likert scale: 1 5 poor or strongly disagree;10 5 excellentor strongly agree. (N 5 3).

ALPHA PORT AND AESOP FOR OPEN SURGERY
217
formation about every pixel in the frame) is transmitted from a stooped position over the surgical field is reduced.
as a means to refresh and maintain the image fidelity. Be- Improvements on the visualization system, including a
tween full frames, only information about pixels that suspended imaging system based on projection of the im-
change beyond a particular threshold is transmitted. age by parabolic mirrors and advanced beam-splitter
These “delta” frames stem from the temporal compres- technology, may also help visual perception and reduce
sion technique used by the CODEC.6 For example, if one fatigue.7,8 The second benefit is affording everyone in
pixel contains the same color value in two consecutive the operating room the same view as the surgeons. This
frames, no new information is sent regarding this pixel, allows operating room personnel such as assistants,
and on the receiving end, the pixel remains the same color nurses, perfusionists, anaesthesiologists,or surgical tech-
value during the second frame. In practical terms, a very nicians to keep pace with the events of the operation and
still image, with little of the overall image moving or to act preemptively and cooperativelyas the surgical pro-
changing, is necessary. With fewer pixels in the image cedure progresses. In addition, students of surgery and
actually changing, a smaller portion of the allowable nursing students can learn by watching the procedures on
bandwidth is used to transmit information about the the monitors. Furthermore, once the video stream is dig-
changing pixels, and more information can be transmit- itized with readily available teleconference equipment, it
ted to produce a higher-quality, smoother video image. can be sent to remote locations via the Internet or ISDN
If the camera is not fixed, however, pixels that would connection. Laparoscopic surgery has long taken advan-
normally remain unchanged may take on different values tage of these technical advancements in the improvement
as the picture jitters or moves, requiring more informa- of surgical education and training.9,10 The Alpha Port and
tion to be transmitted to reflect these changing values.5 Aesop apparatus have the potential to open the door to
This may result in a pixilated image or choppy video remote surgical teaching and remote surgical mentoring
stream. Fixing the telescope to an Alpha port maintains of the open surgical procedure from anywhere in the
a steady image, with minimal motion artifact. To improve world.
the quality of the video image further, a 15fps rate was
used instead of the 30 fps typical for full-motion video.
ACKNOWLEDGMENTS
When half as many new frames are sent per second, the
available bandwidth is instead employed for sending
higher-quality images for each individual frame. The
trade-off for smoother motion is negligible considering
that the camera was rigidly affixed to the table, reducing
the overall motion in the field, as mentioned in the dis-
cussion above. The remote-site physicians observing the
procedures felt that the frame rate was sufficient for men-
toring purposes.
The fourth requirement was to give the surgeon con-
trol of the camera and place ownership of the image with
the surgeon in defining the surgical field. The telescope
and camera were fixed to the Aesop robot. The robot is
voice controlled by the surgeon, allowing control of the
field of view hands free and without the assistance of
other personnel. The camera has an optimal viewing po-
sition without interfering with hands or instruments. All
movement is intentional, whether by voice command or
use of the surgical instruments.
Operators competent in laparoscopic surgery felt com-
fortable operating while viewing the procedure on the
video monitor. This offers many advantages to the oper-
ator. The images obtained are close-up, well lit, and mag-
nified. This is the equivalent of bringing the surgeon’s
eyes to within 10 cm above the surgical field, without
consideration of the surgeon’s visual acuity or refraction.
At the same time, by allowing the surgeon to operate in
a fully upright comfortable position viewing the opera-
tion from the monitors, strain and fatigue that can result
This work was supported by a grant from the United
States Surgical Corporation and the National Aeronau-
tics and Space Administration.
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Address reprint requests to:
Ronald C. Merrell, M.D.
Department of Surgery
Medical College of Virginia at
Virginia Commonwealth University
P.O. Box 980480
1101 E. Marshall Street
Richmond, VA 23298
E-mail:
Rcmerrel@hsc.vcu.edu