September 5, 2024
JAKARTA – Indonesia became the first Southeast Asian country to successfully perform telerobotic surgery on humans, following a showcase on Aug. 30 of a live remote operation for kidney treatment between Jakarta and Bali.
Urological surgeon Ponco Birowo performed the procedure to remove a cyst on the patient’s right kidney using a robotic controller at Prof. Dr. IGNG Ngoerah General Hospital in Denpasar, Bali. He was assisted by urologic oncologist Agus Rizal Ardy Hariandy Hamid.
The patient, a 71-year-old man, was in an operating theater of Cipto Mangunkusumo Central General Hospital (RSCM) in Jakarta; nearly 1,200 kilometers away from Bali. Urologic oncologist Chaidir A. Mochtar and other surgical doctors and nurses helped with the procedure in Jakarta.
The surgery used equipment made by Edge Medical Robotics from China.
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The procedure aimed to assess the latency time and general work of the remote configurations, including wireless internet bandwidth and network jitter, for the feasibility and safety of robot-assisted remote surgery in the future.
The operation was shown through two screens installed at the RSCM Kencana pavilion, from where doctors, medical experts and journalists watched the overall procedure.
After two hours of watching the screen, lead surgeon Ponco announced, “[The surgery] is done!”, followed by applause from spectators.
Health Minister Budi Gunadi Sadikin, who was among the spectators, entered the RSCM surgery theater to talk with surgeons in Jakarta and Bali. He asked whether the surgeons felt any delay when operating on the patient.
“Not at all. It’s fine. I feel like I did it with my own hands,” Ponco told the minister.
During a press briefing after the procedure, Budi called the surgery a “breakthrough” moment. “This achievement is a critical stepping stone for Indonesia to become the center of global innovation in health care.”
Before the operation, remote surgeons in Jakarta, Singapore and Thailand had performed such practices before, but none were on humans. The Thailand one in 2008, a joint operation with Japan, was performed on a pig. Meanwhile, a gastrectomy in Singapore in 2023, also with Japan, was performed on a mannequin.
Patient safety was among top priority, said Ponco, with the surgery team inspecting the telerobotic system in China to make sure of its reliability. They also practiced on models for performing incisions and stitches before the one deemed trained enough was selected for the surgical team.
“Medical staff obtain informed consent from both the patient and his family for the surgery to be conducted remotely and to be broadcast live,” Ponco said.
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Two key components of the surgery, the surgeon console in Bali, and the robotic arm in Jakarta, were connected by high-speed internet connection through fiber optic cables. The connection must have a bandwidth of more than 50 megabits per second (mbps), with latency time below 150 milliseconds (ms) and network jitter cannot exceed 10 ms.
The 5G network used during the procedure on Friday, provided by state-owned telecommunication operator Telkomsel, had the bandwidth of 605 mbps, with the latency time of around 15 ms and jitter relatively unnoticeable at 3 ms.
Despite the network stability testing having been done since June, surgeons stood by in the theater in Jakarta to take over the procedure manually should the network fail or be met with delays.
Thanks to the robotic technology supported by high-speed networks, a surgeon can treat patients from a distance with high precision.
The robotic surgery itself had been used by urologic surgeons to perform radical prostatectomy operations to treat prostate cancer as well as other surgeries, according to Agus, who heads the Indonesian Medical Robotic Association (Robomedisia).
However, only two hospitals in Indonesia have the robotic surgery facilities and no medical facilities in the country have the telerobotic system yet.
“We’re hoping that in the future, robotic and telerobotic operations can be implemented in more hospitals by following the development of robotic systems from various countries, such as the United States, China, India, Japan and South Korea,” Agus said.
The telerobotic surgery may help the even distribution of healthcare services in the country, as it may surpass geographical and socio-economic barriers, said Indonesia Urological Association (InaUA) chair Ferry Safriadi. He cited the association’s data that Indonesia only has 701 urologists and 132 subspecialists, mostly concentrated in big cities across Java.
“Some remote areas don’t have a urologist at all, while in fact, many patients live in remote areas,” Ferry said, adding that the technology would help patients get treated with little to no travel.
Innovations in urologic treatment are deemed pressing for Indonesia, as the country recorded high figures on urologic diseases and deaths in recent years.
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Global Cancer Statistics data show prostate cancer is the fifth most common cancer in men in Indonesia, with 13,563 new cases recorded in 2020. In the same year, nearly 2,400 new cases of kidney cancer were recorded in Indonesia, with 1,358 patients having died, according to the Health Ministry’s Basic Health Survey (Riskesdas).
Telerobotic surgery will be among topics discussed in the 2024 Urological Association of Asia (UAA) Congress, with the theme of “Integrating Urological Frontiers: Transformative Innovation Meets Global Collaboration” in Nusa Dua, Bali, from Thursday to Sunday.