Transcontinental Robot-Assisted Remote
Telesurgery: Feasibility and Potential Applications
Jacques Marescaux, MD, Joel Leroy, MD, Francesco Rubino, MD, Michelle Smith, MD, Michel Vix, MD, Michele Simone, MD,
and Didier Mutter, MD
From the IRCAD-EITS (European Institute of Telesurgery), Louis Pasteur University, Strasbourg, France
To show the feasibility of performing surgery across transoce-
anic distances by using dedicated asynchronous transfer
mode (ATM) telecommunication technology.
Summary Background Data
Technical limitations and the issue of time delay for transmission
of digitized information across existing telecommunication lines
had been a source of concern about the feasibility of performing
a complete surgical procedure from remote distances.
To verify the feasibility and safety in humans, the authors at-
tempted remote robot-assisted laparoscopic cholecystec-
tomy on a 68-year-old woman with a history of abdominal
pain and cholelithiasis. Surgeons were in New York and the
patient in Strasbourg. Connections between the sites were
done with a high-speed terrestrial network (ATM service).
The operation was carried out successfully in 54 minutes without
difficulty or complications. Despite a round-trip distance of more
than 14,000 km, the mean time lag for transmission during the
procedure was 155 ms. The surgeons perceived the procedure
as safe and the overall system as perfectly reliable. The postop-
erative course was uneventful and the patient returned to normal
activities within 2 weeks after surgery.
Remote robot-assisted surgery appears feasible and safe.
Teletransmission of active surgical manipulations has the po-
tential to ensure availability of surgical expertise in remote lo-
cations for difficult or rare operations, and to improve surgical
Remote surgical operations require both rapid and accu-
rate transmission of information. Factors that influence sig-
nificantly the rapidity and accuracy of this information are
the time required to convert video images and gestures into
electronic signals, and the bandwidth and time lag of exist-
ing telecommunication lines.1,2Using current technology,
we recently showed the feasibility of performing remote
surgical operations in an experimental animal model.3Re-
sults of our experimental tests allowed us to perform, for the
first time, remote robot-assisted surgery on a human. Here
we present the case and postoperative course and discuss the
current limitations and the potential clinical and social im-
pact of remote telesurgery.
A 68-year-old woman with a history of recurrent abdom-
inal pain in the right hypochondrium and epigastrium un-
derwent abdominal ultrasound documenting the presence of
cholelithiasis. There was no dilatation of the common bile
duct, and laboratory findings were all in the normal range.
The patient was scheduled for laparoscopic cholecystec-
tomy. After approval was obtained from the Ethical Com-
mittee (Comite ´ Consultatif de Protection des Personnes
dans la Recherche Biomedicale d’Alsace; 19 June 2001,
01/42) and from the U.S. Food & Drug Administration, the
patient gave her informed consent to the operation.
The ZEUS system (Computer Motion, Galeta, CA) con-
sists of two physically separated subsystems named “sur-
Correspondence: Jacques Marescaux, MD, IRCAD-EITS, 1 Place de
l’Hopital, 67000 Strasbourg, France.
Accepted for publication December 5, 2001.
ANNALS OF SURGERY
Vol. 235, No. 4, 487–492
© 2002 Lippincott Williams & Wilkins, Inc.
ADVANCES IN SURGICAL TECHNIQUES
geon-side” (Fig. 1) and “patient-side” (Fig. 2). The sur-
geon’s subsystem (based in New York) has a console that
takes the surgeon’s input; the patient’s subsystem (based in
Strasbourg) includes two robotic arms that translate the
input into actual instrument manipulation, and an additional
robotic arm to control the endoscopic camera. A variety of
surgical instruments can be connected to the robotic arms,
so that the surgeon can activate graspers and so forth by
simply manipulating the handles at the remote console. Two
computers connected by the high-speed communication
channels linked the two subsystems. Camera movements
were directed from the computer in New York according to
the operating surgeon’s instructions.
Network Connections and Monitoring
Connections between New York and Strasbourg were
established through asynchronous transfer mode (ATM)
technology (France Telecom/Equant’s, Paris, France). ATM
network nodes are interconnected through a high-speed
terrestrial fiberoptic network that transports data through
virtual connections dedicated per customer. The ATM net-
work provides a high quality of service for data transport.
For instance, the probability of having no network outage is
99.99% (so-called network availability rate); the ATM net-
work provides a low transport delay and low packet loss
A virtual pathway using ATM technology was set up
between Equant’s point of presence in New York and the
operating room within IRCAD-EITS (European Institute of
Telesurgery) in Strasbourg. A bandwidth of 10 Mb/s has
been reserved through network interconnecting applications
at both sites using a network termination unit (NTU), which
provides a multiservice path to different applications.
To monitor and measure its own level of quality, the NTU
(the sender) inserted operating and maintenance (OAM)
packets within user data flow, which were extracted and
analyzed by the remote NTU (the receiver). Analyzing these
packets and comparing the number of user packets initially
sent to those actually received, we measured the number of
An identical backup line was available in case of main
line congestion. Data flow assigned to each application is
merged into the 10-Mb/s virtual path according to a specific
quality of service.
Robot motion data had a high priority and a rate guaran-
tee of 512 Kb/s within the 10-Mb/s virtual path. Video
packets were sent with a minimum guaranteed rate of 7
Mb/s, with the possibility to use more bandwidth if avail-
able within the 10-Mb/s virtual path. We have plugged a
video conferencing system and intraperitoneal phone to
NTU. Data coming from these two applications were
merged, and they received a guaranteed minimum rate of
around 3 Mb/s.
The two sites were also connected through a videocon-
ference system and a large television screen at both sites.
The operator site was set up in a nonmedical building in
Manhattan (point of presence of France Telecom). Surgeons
in New York performed the dissection of the cystic duct and
artery and the cholecystectomy, while a team in Strasbourg
Figure 1. Operator and surgeon’s robotic console in New York.
Figure 2. Robotic arms at the remote site in Strasbourg.
Marescaux and Others
Ann. Surg.●April 2002
induced the pneumoperitoneum and performed robot arm
setup, trocar placement, exposure of structures, and clip
application. In Strasbourg, the surgical team monitored the
procedure on a screen and was in constant connection
through a phone line with the colleagues in New York to
coordinate electrocoagulation. After completion of the dis-
section and introduction of a plastic bag for extraction, the
gallbladder was then removed by the surgeon bedside. The
abdomen was then exsufflated and the incisions were
closed. The operative steps were carefully monitored and
technical difficulties, complications, appropriateness of dis-
section, and operative times were recorded. After comple-
tion of the procedure, the three surgeons in the team in New
York gave a subjective evaluation of the quality of the
image and the overall safety of the procedure. Evaluation
was on a 0-to-10 scale (0 ? worst possible; 10 ? best
possible). Each surgeon was unaware of other colleagues’
Robot arm setup and trocar placement required 16 min-
utes. The laparoscopic cholecystectomy was performed in
54 minutes; this includes the time lost for switching instru-
ments at the robot arms for the different steps of the pro-
cedure (a total of 10.30 minutes). There were no complica-
tions. Coordination of electrocautery, as ordered by the
surgeon in New York, was excellent, and there was no
damage related to the use of coagulation. No bleeding
occurred. During the surgical procedures, reproduction of
image details on the video monitor at the operative site in
New York was highly accurate, resulting in perfect visual-
ization of structures. For the duration of the operation, there
were no interruptions in the transmission of surgical move-
ments or degradation of video signals. We measured a
constant time delay of 155 ms through the procedure. OAM
tools found no ATM packet lost during surgery. The sub-
jective evaluation of the quality of image by surgeons had
an average score of 9.5. The overall safety of the procedure
was intended as the combination of high-quality video im-
ages for appropriate visualization of structural and anatomic
details, ability to control surgical movements, and perfect
coordination in the use of cautery for coagulation of vessels.
All three surgeons rated as 10 the score of “perception of the
safety of the operation”; this reflects the confidence of the
surgeons and the reliability of the total system. In no in-
stances throughout the operation was there any risk to the
patient related to the teletransmission or to the use of the
The patient recovered well from anesthesia and her post-
operative course was uneventful. She was discharged from
the hospital 48 hours after the operation; during the follow-
ing week, she was monitored by daily telephone calls to rule
out postoperative complications. Two and 4 weeks after
surgery, the patient was seen in the office by the surgeons.
Her wounds were well healed, with no sign of infection. At
the time of her first visit she was already back to her routine
daily activities. Pathologic examination of the specimen
documented the presence of chronic cholecystitis and a
4-mm benign polyp in the gallbladder mucosa.
Laparoscopic surgery is performed under the guidance of
images displayed on a video monitor using specific instru-
ments through the abdominal wall. With laparoscopy, for
the first time the surgeon was separated from direct contact
with tissues and organs, allowing robotic and computer
technologies to be introduced into surgery.
Robotic and computer technologies have the potential to
enhance precision and dexterity4–6and to allow perfor-
mance of surgical procedures from a remote distance.3
Robotic Enhancement of Dexterity
Enhancement of dexterity is accomplished by improving
accuracy, precision, and endurance. When working under im-
age magnification, as in laparoscopy or microsurgery, the
surgeon’s normal tremor is also magnified, increasing the in-
cidence of purposeless movements; to compensate, the sur-
geon must slow the procedure, increasing operative time. This
further increases tremor and unwanted movements.7,8Robotic
systems have computer programs that filter out hand tremors,
and the chair’s arm at the surgeon’s console adds stability and
comfort during the procedure, improving endurance. These
features and the possibility of modulating the amplitude of
surgical motions by downscaling and stabilization translate
into smooth and precise surgical maneuvers. Enhanced dexter-
ity is suitable in multiple instances. Devices that cancel phys-
iologic tremor have been used for vitroretinal microsurgery.9
Robotic systems have been used for retinal vein cannulation,
thrombosis; this involves cannulation of a 100-?m structure.10
artery bypass anastomoses in a plastic model using robotic
Although clinical trials verifying the potential advantages
of robotic over conventional surgery are not yet available, a
number of series show that using robotic devices for human
surgery is feasible and safe. Our group performed laparo-
scopic robotic cholecystectomy in 25 patients with no robot-
related complications and with operative time and patient
recovery similar to those of conventional laparoscopy.12
Cadiere et al13recently reported a series of 146 patients
undergoing robot-assisted laparoscopic surgeries, including
antireflux procedures, gastroplasties, cholecystectomies, in-
guinal hernia repair, hysterectomies, and prostatectomies.
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Transcontinental Robot-Assisted Remote Telesurgery
There were no complications related to the system, and
robotic assistance was found to be most beneficial when
microsuturing within the abdomen or in very confined
spaces. Falcone et al14reported successful robotic assis-
tance for reversal of tubal ligation using 8-0 sutures and
suggested that robotic technology may make laparoscopic
microsuturing easier. Robotic assistance has been used for
Robotic systems have also facilitated the performance of
endoscopic cardiac surgery, including coronary artery by-
pass and mitral valve repair.18–20Current efforts aim to
provide the capability to perform surgery on the beating
heart through motion compensation, which would allow the
surgeon to operate on any moving structure with the same
precision as if it was perfectly still.21
and laparoscopic radical
Remote Robot-Assisted Telesurgery
In addition to enhancing human performance, robotic
systems provides the unique ability to perform surgery in
remote locations. There are several challenges involved, but
the most important limitations have been the reliability (or
quality of service) of the telecommunication lines and the
issue of latency (the delay time from when the hand motion
is initiated by the surgeon until the remote manipulator
actually moves and the image is shown on the surgeon’s
monitor). Due to the latency factor, it was believed that the
feasible distance for remote surgery was no more than a few
hundred miles over terrestrial telecommunications;21geo-
synchronous satellite systems, which have a latency of
nearly 1.5 seconds, are considered unsuitable for perform-
ing long-distance surgery.22Our research estimated that
about 300 ms was the maximum time delay compatible with
safe performance of surgical manipulations, and we mea-
sured a mean time delay of 155 ms over transoceanic
distances3when using dedicated ATM fibers.
The case reported here, the world’s first human long-
distance operation, shows the feasibility and safety of per-
forming a complete surgical operation from a remote loca-
tion. There were no specific difficulties or complications
resulting from the use of the teletransmission of the surgical
procedure. The surgeons perceived the procedure as safe
and the robotic movements as fluid and appropriately re-
sponsive to their manipulations. These results support the
use of existing high-bandwidth, dedicated telecommunica-
tion lines for performing intercontinental surgery on hu-
mans with adequate efficacy and safety.
Technical feasibility and clinical safety, however, are not
the only issues to solve to permit implementation of tele-
surgical procedures into routine clinical practice. The use of
remote telesurgery will depend on a balance between real
benefits and limitations.
Current Limitations for Remote
There are several limitations. First, although a “back-
bone” of high-speed terrestrial ATM fibers is present in
more than 200 countries worldwide, currently most hospi-
tals are not equipped with ATM technology. This was why
we performed the surgery from an office of our partner
company of telecommunications rather than from a major
U.S. hospital, as we had planned before.
The cost of remote operations may be a reasonable con-
cern. The robotic machines cost approximately $1 million.
For our research development other significant costs in-
volved the use of telecommunication lines and human re-
sources, including several professionals, such as surgeons,
computer scientists, and engineers. Of course, the costs of
remote surgery when performed on a routine basis would
have to cover solely the cost of the robotic machine and the
teletransmission. It is difficult at present to give an exact
estimate of the cost of the telecommunication component,
because this varies depending on the distance and location
of the sites connected (i.e., transoceanic connections would
reasonably be more expensive than connections within the
same continent or country). Roughly, the cost for a 1-year
availability of ATM lines point-to-point ranges between
$100,000 and $200,000. If remote telesurgery is evaluated
solely as the expansion of existing surgical practice, it is not
certainly cost-effective. Some have suggested, however,
that if telesurgery achieves the goals of increasing access to
healthcare and improving training and efficiency with en-
hanced outcomes, it may prove less costly to healthcare
systems.23The cost of technologies is also expected to
decrease with time.
The lack of face-to-face contact between the patient and
the surgeon is another important aspect of telesurgery that
might be an issue in malpractice actions. Because telesur-
gery may involve more than one state or country, conflicts
of jurisdictions may also arise. Other legal issues also need
to be addressed, such as whether the surgeon should or not
be liable for errors related to delays in transmission or
equipment failure or whether a special consent should be
obtained, and who is the person responsible for it. In our
opinion, the telemedicine community should set up an ad
hoc international committee to address these and other legal
issues to provide clear and internationally valid rules to
regulate the practice of telesurgery.
The technical issue of performing surgeries on a ship in
the ocean or in space stations has not yet been solved
because they are currently reachable only through satellite
transmission, which at present has an estimated latency
incompatible with safe surgical operations.22Low earth
orbit satellites might overcome this technical limitation.
Applications of Remote Surgery
Benefits of remote robot-assisted surgery are multiple.
Geographic constraints will no longer determine the type of
Marescaux and Others
Ann. Surg.●April 2002
treatment the patient receives because of lack of surgical
expertise. Ideally, any patient can receive the form of treat-
ment more appropriate for his or her condition or more
advantageous, such as new minimally invasive techniques.
This may have an even more profound impact on develop-
ing countries, where healthcare is often provided by volun-
teers who do not necessarily have expertise in all fields of
medicine and surgery.
Emergency operations in small rural hospitals are some-
times challenging for young surgeons on call. The avail-
ability of a network connecting the hospital to a major
center would allow expert surgeons to assist or carry out the
procedure themselves. The availability of expert surgeons
might very well help in remote areas where military or
scientific missions are being performed or in remote islands,
especially in the case of emergency operations.
In addition to all these potential advantages for the pa-
tient, active intervention from remote locations opens new
avenues for surgical education. The objective of performing
remote procedures is not in fact to replace surgeons. It can
improve surgery through teaching and mentoring to reduce
the learning curve of surgeons for new procedures. Various
degrees of interaction between the expert and the surgeon at
the bedside are possible. Assistance of an expert may range
from complete performance of the procedure to help just
with exposure of anatomic structures to facilitate the work
of the surgeons at the bedside. It has been estimated that
44,000 to 98,000 deaths annually occur due to errors in
hospital care, and that as many as 54% of surgical errors
could be prevented.24We believe that by enabling the direct
intervention of an expert, remote telesurgery will likely
reduce the errors that are caused by lack of experience or
related to the early phase of the learning curve of new
procedures. As a result of this potential impact on training
and education, telesurgery might eventually improve the
standard of surgical care throughout the world.
However, cautions and strict controls and standards must
be put in place before telerobotic surgery becomes common.
Teleperformance of a surgical operation requires the expert
surgeon to be familiar with robotic devices. Simple exper-
tise in a particular procedure or disease would not be suf-
ficient to provide active support. At present, there are not
enough surgeons specifically trained in robotic surgery and
remote performance to contribute to the implementation of
telesurgery. Admittedly, until such a workforce is available,
telesurgery will not likely be capable of reducing errors and
related costs on a large scale, not enough at least to become
There is no doubt that remote telesurgery depends on
robotic assistance and information technologies and there-
fore will benefit from the future development of robotic
technologies and implementation of virtual reality and sim-
ulation in surgical practice. Rehearsal of surgical procedures
might be optimized as a stored data set of movements, with
false moves eliminated and the perfect surgical procedure
delivered by computer-driven and computer-enhanced ro-
The enhancement of human dexterity resulting from the
use of a robot and performance of high-precision tasks from
a distance may have other advantages that extend beyond
surgery. Indeed, this achievement symbolizes and realizes
an important technological revolution. Whether up-to-date,
telecommunication technologies have allowed the sharing
of information, voice, and images, here we show for the first
time that complex gestures can be performed with high
precision and in real time over long distances. Applications
of teleperformance of precise tasks might be multiple and
might well apply to distant manipulations of hazardous
materials such as nuclear or biologic devices.
Remote robot-assisted telesurgery is feasible and safe
using a designated ATM telecommunication line. The pos-
sibility of performing complex manipulations from remote
locations allows an expert surgeon to teach or proctor the
performance of an advanced or new technique by real-time
intervention and actually eliminates geographic constraints
for obtaining high surgical expertise where this is required.
The authors thank Mrs. Heather Smith for her fundamental work in the
realization of this project. We also acknowledge the support of France
Telecom (Paris, France) and Computer Motion, Inc. (Goleta, CA). A
special thanks to Cristophe Rabadan (FT) and Moji Ghodoussi (CM) for
their expertise and assistance and to Herve Maisonneuve for his help in
editing the manuscript.
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