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Japan health ministry panel OKs robotic telesurgery

Go Watanabe, bottom left, head of the Newheart Watanabe Institute in Tokyo's Suginami Ward, manipulates a da Vinci Surgical System away from a surgical bed, at top right. (Mainichi/Hiroyuki Harada)

TOKYO -- A Ministry of Health, Labor and Welfare expert panel has given the green light to remotely-controlled surgery using medical robots, opening the way for patients to get operations by highly-skilled doctors far away.

The panel approved a draft amendment to the guidelines for online medical treatment on June 28 lifting the ban on robotic telesurgery. In response, medical societies concerned will set guidelines on detailed prerequisites for the operations, aiming for practical implementation within the coming years.

Under the scheme, telesurgeries will be performed using the U.S.-made da Vinci Surgical System. The system has multiple arms equipped with endoscopes, scalpels, and other surgical necessities, and will even stitch up incisions. The robot furthermore makes very small cuts compared with standard surgical practice, in which large openings are often made in the chest, abdomen or other regions, meaning the da Vinci causes less blood loss and physical strain to the patient. However, the system does require sophisticated skills on the part of surgeons.

Currently, at least 300 da Vinci Surgical System units are employed at institutions across Japan. Fourteen types of operations using the system, including removal of stomach or lung tumors, are covered by public insurance. Doctors of the Japan Surgical Society and others had demanded the government lift the ban on using da Vinci for telesurgery, saying that current high-speed communication networks allow for stable procedures.

Under the proposed amendment, remote operations using the da Vinci system will be limited to delicate cases that can be only handled by specific doctors based far away, and in which patients are not physically strong enough to travel long distances. The proposal also requires the patient to be attended by their primary doctor so they can check the communication environment in advance and take over in case any trouble arises.

Each medical society will decide what types of ailments will be subject to robotic telesurgery and which system will be required in their guidelines.

At the Newheart Watanabe Institute in Tokyo's Suginami Ward, the da Vinci system has been in operation for over 10 years. During one recent surgery, Go Watanabe, a cardiac surgeon and the head of the institute, was seen sitting in front of the controls.

"I'm going to insert stitches," he said, as he moved controllers with his hands while staring at a 3-D image captured by an endoscopic camera. On a surgical bed three meters away lay a male patient, the da Vinci system's slender arms moving through openings in his right side.

The procedure was to repair the man's heart valves, and on a large screen above Watanabe's head could be seen two of the robot's arms, deftly wielding needles and thread to stich up incisions around the pink valves. And all this was happening in the tiny space inside the man's heart.

The procedure took just an hour and a half, and at the end of it the only exterior sign it had even happened were four small cuts on the man's right flank. There was far less bleeding than in standard open chest surgery, and there was almost no smell of blood in the operating theater.

"As there are only a few doctors who can perform heart surgery using the da Vinci system, some patients even come here from regional Japan," Watanabe said.

Da Vinci's control gear is connected to the robot with cables. If those cables are replaced with high-speed internet connections, telesurgery becomes possible.

At the institute, however, the failure of an endoscopic camera once forced doctors to switch to open chest surgery halfway through the operation.

Says Watanabe, "Even though telesurgery sounds fascinating, it is prone to trouble, requiring sophisticated skills on the part of doctors immediately attending the patients. Many challenges remain."

(Japanese original by Hiroyuki Harada, Lifestyle and Medical News Department)

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