Market Situation and Prospects

Today, on-line transmission of animated colour video images of surgical quality is a rarity and only used in the congress environment or in experimental surroundings due to its costs and the technological know-how implied, knowledge acquired and detained by the teams which are interested in this matter.

On the other hand, the congress feedback indicates this quite clearly, many laparoscopic surgery teams would like to use and manage the video images, inescapable medium of their craft, just as they use phone and fax today.

There is ongoing European research in the telesurgical domain, but it must be stressed that this R&D is still not very developed: this R&D must be seen as an evolution from the research undertaken in Pathology and Radiology image transmission. These two medical specialities work on still pictures: their transmission protocols call for less complicated equipment and can be implemented over standard ISDN links.

Furthermore, transmission of surgical images initiated in open surgery procedures should be made possible as well, as open surgery will continue to make up a non negligible part of all surgical procedures. This will imply use of additional video equipment which, as we have seen above, is an integrated part of the obligatory equipment in laparoscopic surgery.

If one analyses the European health market as it is today, it appears that the EU has over 52000 surgeons specialised in digestive surgery (see chart below, with relevant numbers for laparoscopy). These surgeons work in over 7000 hospitals and clinics, each of these equiped with at least 3 operating rooms. It can thus be estimated that the proposed services could have a field of dissemination of 21000 OR.

A conservative estimate should put these numbers into perspective, but from the echo obtained during professional contacts these last years, it appears that the interest is very high, not only for the connections between University Hospitals, but mainly for the in fact highly needed expert advice, from University, asked for by peripheral hospitals in the vicinity. This vicinity has been defined at about 100 to 150 kilometers in densily populated areas, but could be much higher in less populated regions, of the KU, of Eastern Europe or even the Third World as will be developed further later in this paper.

Country Hospitals and clinics with at least OR Mean of surgical beds Number of surgeons (general) Number of surgeons (urology) Number of surgeons (gynaecology) Population in millions
FR 1588 145752 4431 903 1082 56.5
DE 1616 282600 5510 640 1940 62.0
IT 1972 83657 7300 2466 1490 57.5
ES 552 36195 2917 1394 4746 39.0
UK 684 80313 1500 300 2000 57.0
Scand 329 26546 4289 528 2817 22.8
Benelux* 254 25056 2542 522 1864 25.4
Total 6945 680119 28489 6753 15939 320.2

TOTAL surgeons: 51181
* without Luxemburg
(source: health care industry)

The prospects of development in the area of telesurgery are very high:

Initial Training - Accreditation

The short term evolution of initial training in laparoscopic surgery in Europe is towards an accreditation procedure for this designated field inside the surgical speciality. This evolution is on one side essential by its aspects of health care and cost containment but on the other side also looked for by the medical doctors as it will give them university sanctioning of their in-depth training. This accreditation is well under way in some European countries (e.g. United Kingdom), will be implemented in some others in the next two to three years (e.g. France, Belgium, Switzerland, Italy, Spain), and is under discussion in some others (e.g. Germany).

Permanet Education - Capacitation

Where permanent education is concerned, many orientations are under consideration today. No distinctive decision has yet been reached between the advocates of the permanent training on the work-site of the trainee and those advocating training outside this environment in specifically designed locations across Europe. The same applies to the subject of frequency of this training or its mandatory aspect: no decision yet.

In both cases, these "trainees" will need teaching personnel originated in university and hospital to effectuate this permanent education. However, one needs to fully understand a University Hospital surgeon's activities, involving patient care, medical student teaching and surgical resident training, to appreciate the time consuming effect of travels to perform permanent education.

A system allowing for teletraining would in these surroundings be extremely beneficial to patient and surgeon alike. At the same time, it must be underlined, especially in the surgical speciality, that it cannot be envisaged to create a body of npermanent education" trainers, as these will soon loose all their credibility as this kind of activity will clearly distanciate them from patient care. The best possible compromise still resides in the conception of a system authorising spread of surgical knowledge and know-how without weakening surgical patient care.

In short, the system should endorse "transportation of digital images and not of surgeons". On-line and off-line surgical advice When surgeons analyse their Operating Room (OR) activities and the procedures they perform, they often encounter what should be named "the perceived needfor exterrzal advice and potential endorsement". This is today taken care of by simple phone call and vocal description of the case and the on-going procedure. There is no other interactivity than voice. The caller cannot show his operating view, the called expert has no ability to comment this animated picture, either with word or with pointer.

The fact is that laparoscopic surgery is in essence a close-up inner view of the body and the organ that is operated on; the picture used to visualise this can by today's technologies be broadcasted outside me OR without diff'culties. This capacity is not really taken into account by surgeons, underlining the point that progression in the surgeon's mind has as yet to be achieved. Once accustomed to this presentation of the ongoing case for expert advice, the surgeon will make this a standardised approach of diff'cult or exceptional cases, optimising the care he gives his patients.

This concept has already been validated in its pre-experimental stage in the training centre of the KITS, the European Institute of Telesurgery in Strasbourg, France, where laparoscopic images of on-going procedures undertaken by surgical trainees can be shown to the expert for advice and comment, even notation in view of accreditation. This happens in a 16 tables OR, where 15 "trainee" operating tables report to one expert operating table, the role of which is to show the step by step procedure and to verify its correct implementation on the trainee tables, all by video transmission.

1998, © TESUS, All rights reserved.

Universitätsrechenzentrum Basel / Dieter Glatz