Tuesday, July 8, 2014

Surgery in space: I foresee problems.

The astronauts are halfway to Mars when suddenly one of them develops abdominal pain and requires surgery. What will they do?

According to NASA, a miniature robot capable of assisting in surgery has been developed, tested in pigs, and is soon to be trialed in a weightless environment. The robot, which weighs less than 1 pound, can be inserted into the abdomen via the umbilicus and controlled remotely.

The press release from NASA said types of operations that the robot would be capable of performing were "emergency appendectomies, emergency cholecystectomies, emergency perforation of gastric ulcers [sic], and intra-abdominal bleeding due to trauma." NASA meant to say "repair of perforated gastric ulcers." Not surprisingly, many science reporters for media outlets, for example, SFGate and WiredUK, did not notice the error. New Scientist also missed it, but at least published a later correction.

However, even the famous da Vinci robot is incapable of performing surgery on its own.

The original idea was that a surgeon on the ground would direct the robot's movements, but that will not be possible for two reasons. In deep space, the time lag between the earthbound surgeon's actions and the robot's response would be too long, and a recent article about remote-controlled drone crashes highlighted the problems that can occur when links are lost or computers malfunction.

The plan is to train the astronauts to perform minimally invasive robotic surgery on each other. What could go wrong?

A lot.

If they are only going to train on simulators and then have to do real surgery in space, they will be completely lost, robot or not. I know of no simulator that can re-create the degree of inflammation accompanying some cases of acute appendicitis or cholecystitis. My experience in performing and supervising thousands of these procedures is that at times, these organs are so adherent to the omentum and other structures that dissection is very difficult.

What happens if a cholecystectomy has to be converted to an open procedure, which occurs in 10% or more of acute cases?

Good luck dealing with intra-abdominal bleeding from trauma using a miniature robot. Have you noticed that blood is not transparent? And how would an astronaut controlling a robot manage a ruptured spleen?

If the plan is for them to practice on humans, who are the subjects going to be? Would you want to have your appendix removed by someone who isn't even a physician, let alone a surgeon?

Assuming they can be adequately trained, which I seriously doubt, how are they going to maintain their skills? A recent paper claims that cardiac surgeons' skills deteriorate if they spend even one day outside of the operating room. [Update on 8/13/14: Here's a link to my post about that paper.]

There is another issue. Because carbon dioxide must be pumped into the abdomen in order to create a space for visualization of the organs, minimally invasive abdominal surgery requires general anesthesia.

The astronauts would have to be able to intubate the trachea of their colleague, induce and maintain deep anesthesia, and of course, successfully awaken the patient.

Is every space vehicle going to have a fully equipped operating room?

I never thought about this before, but one of the biggest barriers to space travel may be medical care—specifically surgery.

Anyway, the colonization of Mars is on the horizon. Crews of 4 are scheduled to depart every 2 years starting in 2024.

Maybe only surgeons and anesthesiologists should be astronauts. Don't forget there should be two of each in case one of them needs surgery.

PS: I know appendicitis can be treated with antibiotics. Don't go there.


Josh said...

I agree - horrible idea. Am I making this up or didn't they do appendectomies on early astronauts? I would be pretty quick and easy to just take out the appendix and gallbladder of these guys before they leave.

Skeptical Scalpel said...

Josh, I'm not sure about the early astronauts. Taking out the appendix and probably the gallbladder wouldn't be too difficult. I was going to mention that option in the post, but it was already too long. The problem would be if an astronaut had a perforated ulcer or other sudden catastrophe.

Anonymous said...

If this space laparoscopy were attempted, I wonder how much of a problem fluids and debris floating inside the abdominal cavity would pose. It could interfere with the procedure and even create unforeseen complications.

I guess I'll postpone my Mars trip until they have nice big comfy space stations.

Skeptical Scalpel said...

Good question. As I mentioned, they will be testing the mini robot in zero gravity. It will be interesting to see if you are right.

Anonymous said...

I'm sure that the medical examinations these astronauts go through are highly rigorous, with only highly selected individuals eventually embarking on the trip. Additionally, for longer space flights: prophylactic single port lap appendicectomy + cholecystectomy may be a requirement. H. Pylori may be actively sought for and cleared prior to travel.

The rest of us will just go when spaceships are large enough to have an OR and artificial gravity. :-)

DD said...

Hi SS, speaking of space surgery- If you saw the movie Prometheus (I think from 2012) it shows a female astronaut having abdominal surgery (spoiler, to remove an alien growing inside her) via a machine she programs and then gets inside of (here is the You Tube link: http://www.youtube.com/watch?v=LW4PH2ibdh4) Unrealistic on so many levels.

Skeptical Scalpel said...

DD, thanks for the link. I'm a big fan of early ambulatory, but that was a bit much. And no anesthesia. Also, they used staples for the skin, but what about the fascia? A study just came out that said sutures were better than staples for C sections, another type of transverse incision. Also, the study may be flawed because the obstetricians may have taken the staples out too soon.

Skeptical Scalpel said...

Anon, sorry that I missed your comment for a few days. Why single-port surgery? Do you want the astronauts to develop incisional hernias? Who would fix them in space? :-)

RuggerMD said...

When I was in fellowship, I met a resident who change to aerospace medicine and was down in Houston trying to become an astronaut.
We had the exact discussion as you stated above SS.
I said you would have to have a surgeon on board.
He told me that at that time NASA was contemplating having an ER physician as part of the crew and that doc would learn surgical procedures...which is still a horrible idea.
Not sure if this is true as well, but he told me that blood would pool and coalesce into a ball, much like water does in zero gravity.
For any amount of long time in space, you almost have to have a surgeon, and I would say one with critical care and acute care surgery training. We still can operate in the ICU without an anesthesiologist.
If they need me, I'm ready to go.

Libby said...

I'll take a pass on a robot being put inside me. With my luck it would get stuck somewhere or malfunction. Oh happy happy joy joy. What if, like in real life, the case isn't as straight forward as believed? "Beam me down Scotty"!
I do however like the typo, having a robot doing the perferating, not sure where to go with this, but I do like a good typo.

Anonymous said...

I'm an OR nurse and would looove to be part a surgical team to do surgery in space... SIGN ME UP!!

Skeptical Scalpel said...

Rugger, I agree that an ED doc is not the answer although it certainly better than trying to teach a pilot how to operate.

Libby, I'm with you. If the robot malfunctions, good luck.

Anon, I guess we will need 2 OR nurses too.

Anonymous said...

What NASA never wants to discuss publicly is the scenario: If X happens then you die. They also don't like to discuss the plans for storage/disposal of a body. Thus they tend to publicly take a hardware approach to everything. Appendectomy? Robot surgery. Mysterious illness. Flyable imaging. etc.

Skeptical Scalpel said...

Anon, thanks for the comments. I hadn't thought of it but you may be right. It's hard to believe that NASA scientists haven't considered some of the points I raised. Maybe they think it's better to delude the general public by creating this fantasy of astronauts operating on each other.

T. said...

NASA is well aware of the numerous problems arising with space surgery, yet it focuses on RnD that _may_ enable one day the handling of surgical issues on board of a space craft. See our previous reports: http://surgrob.blogspot.hu/2009/04/robotic-surgery-in-space-iii.html
If you consider the conditions on the International Space Station e.g., latency is not an issue. Microgravity is, so closed-compatment surgical boxes are also in consideration: http://surgrob.blogspot.hu/2012/09/space-surgery-possible-with-zero.html
Further, simulators are getting a LOT better these days (http://surgrob.blogspot.hu/2014/06/cis-news.html), and numerous studies have shown that 100% realistic representation of the organs is not necessary for effective skill maintenance (although, initial training depends a lot on it.)
So do not expect today's prototypes to provide complete solutions, yet these developments should lead to proper tool in 8-10 years.

Skeptical Scalpel said...

T, thanks for the links. Very interesting and worth reading. What about anesthesia, recovery, supplies, etc?

T. said...

Hi there,
Robotic anesthesia is on the way: first links here http://surgrob.blogspot.hu/2010/10/cis-news.html
Rehabilitation robotics is also emerging: http://www.ieee-ras.org/rehabilitation-robotics
The idea there could be to have a universal mechatronic system that can be used for various purposes. (The U.Nebraska approach is different.)
Supplies is a great problem, for sure! As it was cited before, "the medical equipment for a Mars mission is estimated to weight 500 kg, filling up 4 m3."
But I have to admit, we can not imagine a human mission without a trained medical assistant on board, but you simply cannot have anyone trained as an astronaut, engineer, scientist AND physician. That is why I have long been an advocate of robotics space exploration missions.

Skeptical Scalpel said...

T, thanks again for the links.

Of course there is no mention of what might happen if the robotic surgeon or anesthesiologist breaks or malfunctions, accidental laceration of an organ occurs, or who would treat a complication.

It will be interesting to see how all of this turns out.

T. said...

I believe it leads to the same scenario when the human surgeon gets injured: you have to provide a backup option, then backup for a backup, etc. until the probability of system failure is low enough...NASA is good with this!

Skeptical Scalpel said...

T, I don't follow your reasoning. What is the first backup for your "trained medical assistant" in space?

T. said...

I believe all crew members receive a basic medical training on ground. Then there is telementoring/teleproctoring to guide them through the emergency procedure. It is not an ideal solution, sure, but there are all these rule of procedures for emergencies (reading out loud and following hundreds of bullet points...)

Skeptical Scalpel said...

T, thanks. Your comment made me wonder if the astronauts have to do a time out before they operate on each other.

T. said...

I believe so. They would need to bootstrap all the required knowledge. No question, I'd NOT like to be the one that is being operated... That is why the concept of remote telesurgery was so much favored by NASA. As long as the technology makes it feasible.

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