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Designing a Lunar Health Maintenance Facility (HMF) for Remote Surgery: Spatial and Architectural
Considerations for Advanced Robotic Surgery in Space
Ar. Souktik Bhattacherjeea*, Dr. Amit Srivastavab
a Andy Thomas Centre for Space Resources (ATCSR), The University of Adelaide, Adelaide, 5005, South Australia,
Australia, bsouktik@gmail.com
b Andy Thomas Centre for Space Resources (ATCSR), The University of Adelaide, Adelaide, 5005, South Australia,
Australia, amit.srivastava@adelaide.edu.au
* Corresponding Author
Abstract
Crew health is an important component of any human space mission. Traditionally, health issues in space have
mostly been addressed with the help of medical kits and supplies provided onboard, along with limited paramedical
training prior to the trip, supported by telemetry. As we plan for longer-duration missions and potential human
settlement on the Moon, we need to plan the development of superior Health Maintenance Facilities (HMFs) that can
perform surgery for acute conditions such as appendicitis, perforated peptic ulcer, intestinal obstruction,
cholecystitis, pancreatitis, diverticulitis, or trauma. Latest developments in robotic surgery systems have made this
conceivable, but a full architectural solution that incorporates new technologies with capacity for further innovation
is yet to be developed. The current paper offers some initial experiments and considerations for the development of
such a Lunar HMF which incorporate robotic surgery systems. Some of the design challenges include methods for
physical restraint of patients during surgery, accessibility of instrumentation, maintenance of sterile environment,
and containment of bodily fluids. In developing the design, Hierarchical Task Analysis (HTA) was employed to
allow for various medical processes to be incorporated in the limited space of the HMF. We considered the kits
provided for Skylab (Minor Surgery Kit), Space Shuttle (Shuttle Orbiter Medical Kit), the conceptual Space Station
Freedom (Health Maintenance Facility), and the International Space Station (Advanced Life Support pack) for the
instrumentation. With a focus on the containment of bodily fluids, minimally invasive surgery (MIS) such as
laparoscopic surgery and robotic-assisted mini-invasive surgery (RAMIS) have been considered. Additionally, since
2022, developments in machine learning and artificial intelligence have also enhanced robotic surgery through visual
and haptic feedback, such as the Smart-Tissue Autonomous Robot (STAR), which has been used to perform an
anastomosis of the porcine intestine, and more recently spaceMIRA (Miniaturized In Vivo Robotic Assistant), which
performed the first remote simulated surgical procedure on 10 February 2024. These innovations are also being
factored into the design of the HMF. The results and considerations discussed in this paper will help with the
integration of emerging technologies in the design of future Lunar HMFs and provide a better standard of healthcare
for astronauts on long-term missions. The research also has implications for perioperative and remote health care for
isolated environments here on Earth.
Keywords: Space Architecture, Lunar Architecture, Space Medicine, Health Maintenance Facility, Robotic Surgery,
Long-duration Spaceflight
Nomenclature
Cfu = Colony formation units
Hz = Hertz
K = Kelvin
Lux = Unit of illuminance
Ra = General Color Rendering Index
VAC = Volts Alternating Current
W = Watts
Acronyms/Abbreviations
AISS = Aqueous Immersion Surgical System
ECG = Electrocardiogram
HTA = Hierarchical Task Analysis
ISS = International Space Station
LHMF = Lunar Health Maintenance Facility
MIS = Minimally Invasive Surgery
MIRA = Miniaturized In Vivo Robotic Assistant
NASA = National Aeronautics and Space
Administration
OR = Operating Room
1. Introduction and Background
After almost 50 years of landing on the Moon, the
Artemis Program, launched by the US National
Aeronautics and Space Administration (NASA), is
working to return humans back to the lunar surface, this
time to develop a long-term presence. With such long
duration exploration class missions, astronauts are
bound to experience medical conditions that exceed
what we have already witnessed in previous human
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spaceflights. Previous experience of medical events is
limited to motion sickness, type 1 decompression
sickness (DCS), kidney infection, cardiac irregularities,
and minor traumas, which have occurred during short
duration human spaceflights under the Apollo missions
[1]. But with the longer duration of exposure to
radiation and low gravity conditions, or extended
opportunities for trauma and injury, there will be
requirements for more complex medical intervention.
Additionally, with the challenges of communication lag
due to increased distance and not being able to rely on
emergency crew evacuation to Earth, we need to
consider the design of dedicated health maintenance
infrastructure. Such a facility has also been proposed
under Use Case (UC-18) in NASA Exploration Systems
Development Mission Directorate, Moon-to-Mars
Architecture Definition Document (NASA/TP-
20230002706) as “Remote diagnosis and treatment of
crew health during extended increments on the lunar
surface” [2]. Such a Lunar Health Maintenance Facility
(LHMF) will aim to monitor, diagnose, and treat crew
members within the lunar habitat, and provide them
with both a broader range of medications and essential
surgical support.
Until now healthcare in space has been largely
dependent on the on-board medical kits, supported with
limited remote diagnosis and treatment capabilities, and
the added assurance that in extreme cases crew
evacuation and return to Earth would be a valid
possibility. In 1961, the health monitoring measures for
Vostok-1 were primarily dependent on audio with
limited video capability, further supported by
biomedical telemetry, electrocardiogram (ECG), and
pneumography [3]. In the contemporary cases of
Project Mercury (1961) and Gemini (1965) ECG, blood
pressure, respiratory rate, galvanic skin resistance, and
rectal temperature were also monitored by telemetry [3].
Over the next decade, with the Apollo missions, health
monitoring was performed with Spacelabs health
monitors, biosensors and bio belt assembly on each
crew member, two-lead ECG with synchronous
phonocardiography, cardio tachometer equipment, voice
communications, and real-time television observations
[4]. On the other hand, the Mir space station (1986-
2001) had a manual and an automatic blood pressure
monitor, a 12-lead ECG, a rheoencephalograph, and
devices to measure blood and urine samples. More
recently, at the International Space Station (ISS) health
monitoring has been performed using a portable
computer, a heart rate monitor, a blood pressure/ECG
monitor, radiation hardware, toxicology hardware, and
acoustic hardware [5,6].
Beyond the monitoring equipment, treatment has
been primarily dependent on onboard medical kits. The
first four missions of Project Mercury only had an anti-
motion sickness drug, a stimulant, and a vasoconstrictor
for shock treatment, but the last Mercury flight also
carried tablets of dextroamphetamine sulphate and
antihistamine tablets placed in a suit pocket [7]. The
Gemini missions further included APCs (aspirin,
phenacetin, and caffeine), an inhibitor of gastrointestinal
motility, and other necessary drugs bringing the total to
11 drugs in the medical kit [7]. It was only with the
Apollo missions that physical injury was addressed
more substantially where the Command Module
Medical Accessory Kit included drugs like
Neomycin/polymyxin B/bacitracin cream (Neosporin),
skin cream, emollients, and bandages, etc., and was
further supplemented with the Lunar Module medical
kit, Apollo emergency medical kit, bandage kit; and
relevant telemetry [4,5,7]. With the Skylab space
station, astronauts had access to a more enhanced drug
formulary and capabilities including wound care, dental
care, minor surgery, urinary catheterization, and
microbiology assessment. Astronauts on Skylab also
received 80 hours of paramedic-level training before
launch [5]. On the other hand, the Mir space station had
medical kits which contained a cardiovascular medicine
kit, bandaging supplies, and splints; a pulse oximeter, a
portable clinical blood analyser, additional IV fluid, a
defibrillator, a cardiac drug kit, crew medical restraint
system, and even a Surgical Instrument Assembly Kit to
be used by trained physicians [5]. More recently, the
ISS has supplemented the traditional medical kits with
an ambulatory medical pack, crew contamination
protection kit, Advanced Life Support Pack, anti-
inflammatory agent kits, burns and wounds kit,
cardiovascular remedies kit, Emergency First-Aid
medical kit, and gastrointestinal and urologic remedies
kit [7,8].
Through this brief history of development of
healthcare provisions in space, we can recognise that as
space missions have increased in duration and
complexity the need for medical care has expanded to
include better health monitoring and a broader range of
available medication. While more recent missions have
included small surgical kits, one area of healthcare that
needs great attention and research is performing surgery
in space. General research in Space Medicine
recommends robotic surgery in space to account for the
slower wound healing process and immunosuppression
in the human body during space flight [9]. Robotic
surgery is understood here as a subset of Minimally
Invasive Surgery (MIS) which involves the insertion of
small surgical instruments and camera arms into the
body to carry out the surgical procedure [10]. Other
advantages of robotic surgery in space include greater
dexterity beyond that of human hands, smaller surgical
incisions, a reduced requirement for postoperative pain
medication, minimal blood loss, reduced risk of
infection, and shorter recovery time [11]. Based on this,
more research is being conducted on the potential
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advantages and challenges of robotic surgery, which are
discussed later. But one thing is clear that as we start
considering the provisions of healthcare in long duration
exploration class missions to the Moon, we will have to
provide for robotic surgery in the design of any LHMF.
Surgery in the lunar context will pose specific
challenges, and here we propose that Space Architects
can play a vital role in rethinking the spatial
organisation and other environmental considerations of
a LHMF to allow for a more effective and efficient
context for the same. This paper provides the relevant
background and discusses outcomes of a preliminary
experiment with the design of such a LHMF with
considerations for advanced robotic surgery.
The first two sections of the paper focus on recent
advancements in robotic surgery to set a benchmark for
robotic surgical practice on both Earth and in space, and
further identify the basic architectural and spatial
requirements for such a setup. The next section provides
a Hierarchical Task Analysis (HTA) of the process of
performing robotic surgery to identify the various
potential workflows involved in the process and get a
better understanding of the challenges and opportunities
that can be addressed in the design of LHMFs. In the
following two sections we explain the setup of the
preliminary experiment including basic assumptions,
and then discuss the outcomes and evaluation for the
proposed design approach. The paper ends with a
reflection on the broader challenges and opportunities
for the design of LHMFs incorporating robotic surgery.
2. Robotic Surgery on Earth and in Space
In 1985, the first robotic operation was performed on
a human patient with a Programmable Universal
Machine for Assembly 200 (PUMA) in order to collect
neurosurgical biopsies [12]. This robot was further
modified for common urologic and prostate procedures,
by The Robotics Centre at Imperial College [13]. The
US medical robotic company, Circular Motions
developed the first commercial MIS robot system in
1992, and it performed its clinical application in
laparoscopic cholecystectomy in 1993. In 1999,
Intuitive Surgical Inc. announced their MIS robot called
da Vinci, which is a milestone in robotic surgery as it
was widely marketed to hospitals across the world.
Several other MIS robot systems that currently are being
used across the world include Zeus (US, 1998), PAKY-
RCM (US, 1998), ARTEMIS (Germany, 1996), and
MC2E (France, 2004) [14].
As these robotic systems for performing surgery
have developed, they have introduced many innovations
that now give robotic surgery an edge over traditional
processes. Some of these specially innovative
technologies and systems include the computer-
controlled mechanical wrist, 3-dimensional vision
systems for MIS, Robotic Telesurgical Workstation
(RTW), Natural Orifice Transluminal Endoscopic
Surgery (NOTES), and Smart Tissue Autonomous
Robots (STAR) [15,16,17,18,19,20]. In 2024, Cromwell
Hospital in the UK broke new ground in robotic surgery
by using Mixed Reality to perform spinal surgery, while
GEM Hospitals in India started using Apple Vision Pro
to perform laparoscopic surgeries [21,22]. More specific
to the context of space application, another milestone
was achieved in January 2024, when spaceMIRA,
developed by Virtual Incision and researchers at the
University of Nebraska, performed remote testing by
manipulating and cutting a simulated human tissue on
the ISS [23].
One of the key differences in considering robotic
surgery on Earth and in space, however, is the
opportunity for remote surgery using teleoperations.
Telemedicine has been widely used since the advent of
human spaceflight, and NASA has identified the use of
key information technology, along with
nanotechnologies, as the future of telemedicine in space
[24]. Following this view, teleanesthesia and telesurgery
are also a consideration and are regularly applied in
analogue space missions [25]. In 1990, KRUG Life
Science, under NASA, built the first mock-up HMF,
which had the facility to perform emergency surgery
and provide surgical critical care to the astronauts on
board [26]. Later in 2012, a human-in-the-loop (HITL)
performance study was done in a simulated lunar
analogue mission, which included a similar medical
operation workstation with a surgical table to provide
emergency and preventive medical treatment to the
crew members [27]. However, when considering the
distance to the Moon and the potential communication
lag, which can range from 5 to 14 seconds, telesurgery
is not really a viable option, and it becomes necessary
that LHMFs provide for substantial surgical capabilities
onboard [28].
3. Architectural Requirements for Robotic Surgery
As discussed in the last section, there have been
several MIS robotic systems that have been developed
in recent years, and they have different operational
requirements. However, da Vinci Surgical System by
Intuitive Surgical Inc. is by far the most successful and
widely used system on Earth. With lack of any
specialised systems available for lunar application, we
are using the da Vinci Surgical System as a basis to
determine the architectural and spatial requirements for
robotic surgery.
According to the supporting literature for the da
Vinci Surgical System, the recommended Operating
Room (OR) size to fit the robotic systems comfortably
and leave sufficient area for the movement of the
personnel is 700 to 720 square feet or 65 to 67 square
meters [29]. The da Vinci robot consists of three main
components: Vision Cart (0.93m x 0.68m x 2.23m max.
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height, 258.5 kg), Patient Cart (1.49m x 0.98m x 2.47m,
821 kg), and Surgeon’s Console (0.87m x 0.97m x
1.45m, 264 kg). Each of these components requires a
voltage of 100/230 VAC with 50/60 Hz. The room
temperature of the OR needs to be 10⁰C to 30⁰C with a
non-condensing humidity of 10% to 85%. The
atmospheric pressure should range from 523 mm of Hg
to 774 mm of Hg [30].
In the design of such an OR we are also aware that
the spatial organisation of components should be
optimized to let the surgeon view the patient and other
staff clearly [31]. Accordingly, the Surgeon’s console
should be placed away from the sterile field, away from
the traffic flow, and without direct access to the patient.
The Vision Cart should be placed outside the sterile
field and could be easily accessed by the circulating
nurse to allow unrestricted camera cable and
electrocautery cord movement during surgery. The
Patient Cart should be placed in an open space to
prepare for the start-up sequence and get adequate room
for full extension of arms during draping. There should
be a clear gap between the patient cart and the operating
table to enable the movement of the Patient Cart into the
sterile field without any obstruction. During the surgery,
no one is expected to stand in the sterile operating field
or require access to the patient [29].
In addition to the components of the da Vinci robot
the surgery also requires laparoscopic instruments such
as a 12 mm x 1 Optiview Visiport for camera port, 12
mm Xcel port x 2, 6 mm port x 2, Metzenbaum scissors,
Hook cautery, Maryland dissector, needle driver, 5 mm
x 1 Hem o lok clips and its applicator, 10 mm x 1 Hem
o lok clips and its applicator, 0 and 30⁰ scopes, a Veress
needle (optional), and suction irrigation pumps.
Additional robotic implements include 8 mm robotic
trocar x 2, 5 mm robotic trocar x 3, camera adapter,
sterile camera trocar mounts and drapes, sterile drapes
for camera and instrument arms, sterile camera mount
and instrument adapter, and endowrist instruments [31].
Since there are surgical robots and imaging
equipment in the OR such as X-rays, radiation
protection materials must be used in the wall such as a
heavy lead-lined wall and vibration isolation pad.
Operators may also wear lead vests. Automatic sliding
lead stainless steel doors and lead-lined glass windows
must be used to protect users outside the OR from
radiation. The ceiling must have reinforcements for
imaging mounts, whereas the floor should be raised
with aluminium panels for electrical supplies [32].
In addition to the spatial requirements there are also
environmental and technical service requirements to be
considered. Surgical lighting in the OR must follow the
IEC 60601-2-41 surgical lighting standards. The
luminance for the surgical lights must be in the range of
40,000 to 160,000 lux, whereas the examination lighting
requirement is 1000 lux. The lighting should be uniform
to reduce glare and eye strain. The radiant heat from
surgical lights must not exceed 1000 W/m2 at the light
patch. The colour temperature should range between
3000K to 6,700K. The colour rendering index should
range from 85 to 100 Ra. The light equipment should be
easy to clean and disinfect to maintain the bacteria-free
environment of the OR. [33]. The OR must have a
laminar flow of air circulation, for which air filters are
required to supply clean air via high-efficiency
particulate air (HEPA) filters. The filtered laminar air
flows over the operative field and is extracted by an
exhaust grill. The laminar system can change the air up
to 300 times per hour, and it also lowers the
concentration of microorganisms with <10 cfu/m3,
compared to 180 cfu/m3 for conventional ventilation
systems [34].
With these basic architectural and spatial
requirements identified, we now focus on the actual
surgical procedure. For this we employ a Hierarchical
Task Analysis (HTA) to identify the various potential
workflows involved in the process and get a better
understanding of the challenges and opportunities that
need to be addressed in the design of LHMFs.
4. Hierarchical Task Analysis for Robotic Surgery
Since the purpose of a Hierarchical Task Analysis
(HTA) is to provide a structured and systematic
approach to understanding the tasks that users of the
system need to perform to achieve certain goals, we first
need to define the user base and the potential goals. In
the case of performing robotic surgery the essential user
base is the medical team which would normally include
5 members: the surgeon, the anaesthetist, a surgical
assistant, an anaesthetic assistant, and a circulating
nurse or surgical technician. This is based on the
understanding that surgical staff is trained in robotic
surgery, knowledgeable to perform surgery with da
Vinci Surgical System, and the surgical assistant is
efficient in trocar placement, draping, docking,
irrigation, retraction, changing instruments, and
performing laparoscopic surgery [30]. To prepare the
HTA we need to first understand the variety of roles and
functions the various members of the team need to play.
For instance, the anaesthesia team including the
anaesthetist and the anaesthetic assistant play a major
role in all the stages of robotic surgery. A perioperative
assessment of the cardiopulmonary system is required to
identify factors that may affect patient safety during
surgery, including airway issues, respiratory infections,
assessment of exercise tolerance, and the presence of
shortness of breath. Basic perioperative tests like
complete blood count, clotting functions, chemistry,
electrolytes, renal function, ECG, and blood typing and
screening, will also need to be done in the preoperative
assessment. Although highly unlikely in the astronaut
population, the possibility of emergency laparotomy
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with possible blood transfusion and intensive care unit
admission could be considered, with preoperative bowel
preparation and antibiotics being required for some
surgical interventions. In the intraoperative stage the
anaesthetist will be required to monitor and assess the
patient's vitals, as well as manage patient positioning,
and administration of various drugs and IV fluids.
Finally, the anaesthetist will need to assess the
physiological state of the patient in the postoperative
context to prevent or address any complications [35].
Similarly, the surgical technician and/or circulating
nurse also play a multitude of roles. They need to
anticipate the needs of the surgeon and the patient and
ensure effective communication and process. A surgical
technician is responsible for setting up robots, holding
organs in place during procedures, handling specimens
for laboratory analysis, and ensuring efficient and safe
surgical processes. In the perioperative stage, they need
to prepare and sterilize the operating room, and gather,
sterilize, count, and arrange all the equipment required.
In the postoperative stage, they count all tools and
instruments, suture the incision, apply disinfected
dressings to the area, dispose of discarded items, and
maintain the sterile field until the patient’s surgical
wounds are closed [36,37].
In approaching the task of designing a LHMF that
accounts for robotic surgery we need to apply the
principles of Evidence Based Design (EBD) and
understand the processes and needs of the user group.
Considering the core medical team of 5 people with a
broad range of tasks, we start with developing a
Hierarchical Task Analysis (HTA) which helps break
down complex tasks into simpler sub-tasks in a
sequential manner. The sequence of tasks that takes
place during the robotic surgery is presented in a
hierarchical decomposition tree (see Fig. 1), which
provides a chronological sequence from pre-procedure
to post-procedure. In preparation of this HTA we have
considered procedural requirements for three types of
operations, namely robotic appendectomy, robotic rectal
cancer surgery, and robotic renal surgery (see Fig. 2).
The OR configuration for these procedures consists of
da Vinci robots (Vision Cart, Patient Cart, and
Surgeon’s Console), an anaesthesia cart, an instrument
Fig. 1. Hierarchical decomposition tree for robotic surgery (appendectomy) with da Vinci robot. The forward
arrows indicate a linear progression of the procedure. The optional task in the procedure is in yellow boxes.
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table, an operating table, and a surgeon's chair.
Additionally, it is stipulated that the Vision cart can be
easily rolled and placed around the operating table as
needed, but it can also be mounted on a boom arm, and
additional monitors can be placed with the arm, as per
requirement. Additional equipment like ultrasound, C-
arm, various energy devices, laser, etc, can also be
placed in the OR, depending on the required procedure
[37].
It is clear from the HTA process that the spatial
configuration of the OR depends on the surgical
procedure that the medical team would perform. So,
before we can continue with the spatial experiments, we
first need to explicitly state the assumptions under
which the design exercise was conducted and the
evaluative framework employed to assess its efficacy.
5. Assumptions and Frameworks for LHMF Design
The tasks performed by the medical team in robotic
surgery can be broadly divided into two categories:
Operative and Non-Operative. Operative tasks are
performed by the surgeon, and surgical assistant, while
non-operative tasks are performed by the anaesthetist
and circulating nurse or surgical technician. Since the
communication delay for Earth-Moon communication
can be 5 to 14 seconds, while the recommended delay
for telesurgery is 100 milliseconds, operative tasks
cannot be performed remotely, and the surgeons are
required on board [25,38]. We assume the need for two
surgeons on board, who will take the role of the surgeon
and surgical assistant respectively. Additionally, the
surgical assistant will need to be aware of the non-
operative procedures that are required for the surgery.
In the case of anaesthesia, tele-anaesthesia could be
implemented in LHMF with a combination of
telemedicine and wearable healthcare technologies for
perioperative and postoperative assessments [39].
Therefore, anaesthetists from Earth could monitor vitals
and provide feedback to the surgical team on board via
telecommunications. The tele-anaesthesia could further
be implemented with the utilization of augmented
reality (AR) for assistance and monitoring; and artificial
intelligence (AI) for optimization of workplace,
integration of systems, and improving logistics [38,40].
Therefore, the other crew members on board should be
trained to perform the non-operative tasks of circulating
nurse or surgical technician. Accordingly, we can
assume that the medical team in the LHMF will be
constituted of 3-4 members.
In developing our spatial experiments, we are also
making several assumptions about the potential
instrumentation that will be required and available for
carrying out robotic surgery in the lunar context. We are
working with the da Vinci Surgical System, including
the spatial requirements of the Vision Cart, Patient Cart,
and Surgeon’s Console, as discussed in Section 3.
Another primary consideration for the spatial layout is
the accessibility of instruments, and a compact stowage
system for instruments is not readily available. So, we
have proposed a rack for tools and medicines with an
attachable instrument table (see Fig. 3). We considered
the kits provided for Skylab (Minor Surgery Kit), Space
Shuttle (Shuttle Orbiter Medical Kit), the conceptual
Space Station Freedom (Health Maintenance Facility),
and the International Space Station (Advanced Life
Support pack) for the instrumentation. Additionally, due
to lower gravity conditions, containment of bodily fluids
is an important consideration [8]. With a focus on the
containment of bodily fluids, minimally invasive
surgery (MIS) such as laparoscopic surgery and robotic-
assisted mini-invasive surgery (RAMIS) have been
considered. We have also proposed a human-size
Aqueous Immersion Surgical System (AISS) to
maintain the sterile environment. The AISS is an
optically clear enclosure, which prevents contamination
of the environment with bodily fluids and tissue debris,
reduces blood loss, and maintains visualization of the
operative field during the surgery [41]. The proposed
AISS would include space for human intervention in
surgery, inserting the arms of da Vinci’s patient’s cart,
Fig. 2. Spatial configuration of OR for robotic appendectomy (A), robotic rectal cancer surgery (B), and robotic
renal surgery (C).
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and attaching an anaesthetic mask with other necessary
attachments (see Fig. 3). This AISS could be connected
to the operating table during the surgery.
Based on these assumptions, and general standards
for ergonomics and spatial organisation, we proposed a
series of experimental layouts for the OR in a LHMF,
which are discussed in the next section. As a primary
concern of this research, and to keep the discussion
within the limited scope of this conference paper, the
following section will only focus on the process of
optimising the sightlines and circulation. As discussed
before, the surgical staff need to have a clear view of
patient and equipment during the entire duration of the
surgical procedure, and this is one of the primary
concerns of this research. [31] To achieve this aim, we
developed an evaluative framework and further assessed
the various proposed layout by quantifying the visibility
of the equipment from the surgeon's and assistant
surgeon's point of view. The evaluative framework and
the outcomes are presented in further detail.
6. Optimising Spatial Layouts for OR in LHMF
For the purpose of this experiment, eight different
layouts for Operating Rooms (OR) with robotic surgery
Fig. 3. Rack of tools and medicines (left), and human-size Aqueous Immersion Surgical System (AISS) (right).
Fig. 4. Layout of LHMF with robotic surgical capabilities.
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facility were proposed (see Fig. 4). The main variation
deals with the placement of the three component parts
of the da Vinci Surgical System and the proposed
equipment rack. For the layouts 1A, 1B, 1C, and 1D, the
equipment rack was located parallel to the operation
table, while for layouts 2A, 2B, 2C, and 2D, the
equipment rack was placed perpendicular to the
operation table. The latter set of four tend to provide
some additional area, which could be used to
incorporate a second operation table if required.
Alternatively, this extra space could be utilized for other
medical and surgical procedures that do not use the
surgical robots. Of the two sets, the variations A and B,
i.e., 1A, 1B, 2A, and 2B, have included the Surgeon's
Console in parallel to the operation table, while the
variations C and D, i.e., 1C, 1D, 2C, and 2D, have the
Surgeon's Console placed perpendicular to the operation
table. Finally, the variations A and C in both sets, i.e.
1A, 1C, 2A, and 2C, have the Surgeon's Console located
near the door, while the variations B and D, i.e. 1B, 1D,
2B, and 2D, have the Surgeon's Console located near
the operation table.
For the evaluation of these proposed layouts and
optimisation of the sightlines and circulation, the
surgeon’s and assistant surgeon’s point of view was
considered, and a set of diagrams were developed
mapping the visible areas of the OR (see Fig. 5). In
addition to this a system was developed to quantify the
level of visibility, creating further distinction between
the patient, the medical crew, and the equipment. By
applying a weighting to each component based on their
priority and relationship as explored in the Hierarchical
Task Analysis (HTA), a comparative table was
developed (see Table 1). Based on the mapping of
visible areas and the highest score achieved through this
table, the most effective spatial configuration for the OR
in a LHMF can be determined. A more detailed
explanation of the evaluative system and outcomes is
discussed below.
The scores in the table reflect the amount of
visibility of each instrument to the users, where the
maximum score for each relation is 100. This means
that no visibility or an oblique view is scored 0, while a
direct view is scored 100, and any score in-between is
based on the percentage of area of the instrument that is
Fig. 5. Visibility of surgeon from surgeon’s console (left), visibility of surgeon from assistant surgeon’s chair
beside the rack (right).
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Copyright 2024 by University of Adelaide. Published by the IAF, with permission and released to the IAF to publish in all forms.
IAC-24- E5.1.5.x87817 Page 9 of 13
visible. Furthermore, these scores are multiplied by a
factor to capture the priority and relationship as
demonstrated in the HTA. For instance, the operating
table requires the maximum visibility of all components,
thus the score for this relation (S2) is increased by 100%
or multiplied by the factor of 2 (WS2 = 2). The order of
priority from the perspective of the surgeon can be
further captured by a diminishing multiplication factor,
namely, assistant surgeon (WS5=1.75), instrument table
(WS4=1.5), patient’s cart (WS1=1.25), and anaesthesia
cart (WS3=1). Similarly, the order of priority from the
perspective of the assistant surgeon can be captured for,
Operation Table (WAS2=2), Surgeon (WAS5=1.75),
Anaesthesia Cart (WAS3=1.5), Instrument Table
(WAS4=1.25), and Patient’s Cart (WAS1=1). Based on
this, the visibility scores for each relation are multiplied
by their respective priority scores, and the weighted
visibility score is added up to get the weighted total.
So, the total score may be calculated with the
formula → S1 + S2 + S3 + S4 + S5 + AS1 + AS2 +
AS3 + AS4 + AS5,
And the weighted total score may be calculated with
the formula → (WS1*S1) + (WS2*S2) + (WS3*S3) +
(WS4*S4) + (WS5*S5) + (WAS1*AS1) + (WAS2*AS2) +
(WAS3*AS3) + (WAS4*AS4) + (WAS5*AS5),
where W (relation code) is determined on the priority for
each relation as determined by the Hierarchical Task
Analysis (HTA).
From the mapping in Fig. 5 and the overall scores
obtained in Table 1, it could be argued that the Layout
1C offers the most efficient configuration to perform
robotic surgery in the lunar context. We can make
further relevant observations based on other constraints.
For instance, within the second set, where the
equipment rack is placed perpendicular to the operation
table, Layout 2C obtains the highest score. Or, if space
is constrained, we might argue that the first set of
configurations, with the equipment rack located parallel
to the operation table, (layouts 1A, 1B, 1C, and 1D), are
more compact with an area of 31.113 square meters,
compared to an area of 38.637 square meters for the
second set. Further such experiments with changing
constraints can provide us with a clearer idea on how we
can optimise the design for ORs in LHMFs.
7. Challenges of Robotic Surgery in Lunar Context
In outlining the Hierarchical Task Analysis (HTA)
and the process developed for optimisation of sightlines
and circulation in the design of an OR for robotic
surgery, this paper has tried to share some initial
thoughts and considerations in the design of LHMFs.
This is, however, a much broader topic of research and
there are several other considerations that need to be
explored. What has become clear through the process of
this initial analysis and experimentation is that the
design of LHMFs cannot simply be considered the
domain of Space Medicine and various other disciplines
including Space Architecture, Bio-Medical Product
Design, and Information and Communication
Technology will have to play an integral role in the
development of such faculties. Solely focusing on the
task of robotic surgery in the lunar context, the HTA
and the related literature already reveals a range of
issues and challenges that need further consideration. In
the challenges listed below we have tried to identify
aspects where Space Architects could be valuable allies
in the process.
a) Ergonomic challenges: Surgical instruments are
currently designed based on the ergonomic
requirements of the doctors that use them on Earth.
Therefore, the surgical instruments will need to be
redesigned with the consideration of any
physiological and sensory changes affected by the
Table 1. Table for the amount of visibility from the user to the equipment in OR for each layout (* represents
minimal visibility of an instrument through oblique view)
Surgeon’s view
Assistant Surgeon’s View
Total
Score
Weighted
Total
Score
S1
S2
S3
S4
S5
AS1
AS2
AS3
AS4
AS5
Layout
WS1
WS2
WS3
WS4
WS5
WAS1
WAS2
WAS3
WAS4
WAS5
Out of
1000
Out of 1500
1A
100
90
0
0
0
40
100
0
100
0
430
670
1B
100
100
0*
0
0
100
100
100
100
0
600
900
1C
95
100
100
80
100
40
100
0
100
100
815
1253.75
1D
0
30
0
80
100
100
100
100
100
100
710
1105
2A
100
90
0
0
0
100
100
0*
100
0
490
730
2B
100
100
0*
0
0
100
100
100
100
0
600
900
2C
0
30
100
100
100
100
100
0*
100
100
730
1085
2D
0
0
0
100
100
100
100
100
100
100
700
1075
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Copyright 2024 by University of Adelaide. Published by the IAF, with permission and released to the IAF to publish in all forms.
IAC-24- E5.1.5.x87817 Page 10 of 13
lunar environment. This sort of product design
process could also extend to devices utilising mixed
reality for robotic surgery, in order to reduce
fatigue and enhance performance. Expanding to
larger scale ergonomics, the physical and visual
accessibility of instruments will need to be
considered, and an appropriate human-machine
interface will need to be developed for the reduced
gravity environment. Here, space architects could
work with product designers to provide for
appropriate ergonomics.
b) Logistical challenges: The design and construction
of an LHMF will be highly dependent on mission
requirements and related payload capacities and
costs. Therefore, there is a need to reduce the
overall mass, volume, and power consumption of
relevant equipment, so that launch and operational
costs are minimised. While some of this will
require redesign of equipment, space architects
could also help perform task analysis to identify the
appropriate equipment and incorporate them into a
compact stowage system.
c) Crew configuration challenges: Considering the
communication lag between the Earth and the
Moon, robotic surgery in space will need qualified
surgeons and support staff onboard. This means
that appropriate training and qualifications will
need to be organised to allow crew members to
perform the required roles during robotic surgery in
the LHMF. While space architects cannot directly
contribute to this process, the design of LHMFs
could further account for training of medical
personnel and even serve as a research facility for
promoting advances in space medicine and space
surgery. Additionally, the shifting number and roles
of the crew members will affect the spatial
configuration of the LHMF.
d) Surgical challenges: Performing robotic surgery in
the lunar context raises specific challenges for the
surgeon itself, where loss of direct tactile feedback
of the tissues during surgery, loss of depth
perception due to indirect visual input, loss of
peripheral vision caused by the limited viewing
spectrum of the camera, the difficulty of converting
from laparoscopic to open surgery, and possible
human error along with mechanical failures of the
robotic systems, can lead to a steep and specialised
learning curve [42,43,44]. Space architects could
assist by helping develop better workflow, but also
create virtual environments with great spatial
fidelity to allow for training and experimentation.
e) Infrastructural challenges: As we have already
established, robotic surgery in the lunar context has
a range of spatial and environmental requirements
that can be best addressed by a Space Architect.
This paper has already shared some approaches to
optimising sightlines and circulation for better
workflow. Additional considerations of lighting and
ventilation need further research. Additionally,
material and textural qualities of the habitat itself
will need to be considered in further detail to
account for better healthcare before, during and
after surgical procedures.
8. Conclusion
Over the coming decades, as we plan and carry out
long duration exploration class missions to the Moon
and beyond, we will encounter medical conditions that
exceed what we have already witnessed in previous
human spaceflights. To provide for crew health on such
missions to the lunar surface we will need to develop a
Lunar Health Maintenance Facility (LHMF) with
surgical capabilities to perform minor and major
operations. Robotic surgery is proposed as the preferred
method for surgical intervention as it has optimal patient
outcomes due to smaller surgical incisions, a reduced
requirement for postoperative pain medication, minimal
blood loss, reduced risk of infection, and shorter
recovery time. Accordingly, the design of a LHMF will
need to provide for an Operating Room (OR) that is
suited for robotic surgery in the lunar context. While
there are a range of ergonomic, logistical, and
infrastructural challenges relating to robotic surgery on
the Moon, space architects can play an important role in
integrating these specialist requirements of surgical
processes with the spatial and environmental
considerations to develop effective OR modules.
In this paper, we have discussed some initial
processes and experiments that Space Architects can use
to understand the requirements and start developing an
approach to the design of LHMFs. The Hierarchical
Task Analysis (HTA) is a valuable process that helps
architects understand the workflow and circulation
requirements of the different medical crew members
during various surgical procedures. The HTA discussed
in this paper also outlines other challenges relating to
design and accessibility of equipment racks which needs
further work. Using the HTA, designers can begin to
outline the priorities and relationships between the
various crew members and the equipment, and we have
proposed eight initial layouts. The paper then focuses on
how certain aspects of the design and workflow can be
optimised by creating an analytical system, and further
proposes a system for quantification and measurement
of visual access and circulation. Such an approach helps
us optimise sightlines and circulation paths, but also
allow for other valuable decisions where certain
configuration or spatial constraints must be considered.
While the issues discussed in this paper provide
valuable insight into the architect’s process and
considerations for the design of an OR for robotic
surgery, further research is required to create a proper
75th International Astronautical Congress (IAC), Milan, Italy, 14-18 October 2024.
Copyright 2024 by University of Adelaide. Published by the IAF, with permission and released to the IAF to publish in all forms.
IAC-24- E5.1.5.x87817 Page 11 of 13
multi-disciplinary approach to design of LHMFs. These
facilities will vary based on the type and duration of the
mission, and the physiological and sensory effects of the
lunar environment will also need to be incorporated into
the design of the relevant equipment. Space architecture
can work in collaboration with space medicine, as well
as bio-medical product design and information and
communication technology specialists to develop better
equipment as well as techniques for lunar healthcare.
While this paper has looked at the da Vinci Surgical
System, other systems like spaceMIRA could also be
considered for future research. Other technologies like
the proposed Aqueous Immersion Surgical System
(AISS) can also be further developed, to help elevate the
overall Technology Readiness Level (TRL). Finally,
new design techniques including extended reality (XR)
methods need to be incorporated into both the design
and implementation phases of LHMFs. It is only such a
cross-disciplinary approach that could lead to the design
of an efficient and effective LHMF, and lay the
foundations for better healthcare in long-duration
exploration class missions. Such an approach will also
have valuable implications for perioperative and remote
health care for isolated environments here on Earth.
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