Inside the November/December 2002 print edition of Canadian
Feature Report: Developments in surgical systems
operating room of the future refines surgical techniques
Researchers seek to determine which procedures
are best handled by computer-assisted techniques.
London docs to create robotic solutions for surgery
CSTAR of London, Ont., has allied with aerospace
company MD Robotics to jointly create new technologies for robotic
Group aims to improve supply-chain across health system
A national organization plans to show hospitals
across the country how they can save millions of dollars annually
by improving the way they purchase and manage medical supplies.
The Chatham-Kent Health Alliance, consisting
of three hospitals in southern Ontario, is installing an IP-based
communications system that will handle all of the organizations
telephone and computer networking needs.
Canada Health Infoway Inc., the $500 million
agency for promoting the development and use of electronic records
in the healthcare system, has announced its investment strategy.
It includes information on how the organization will make investment
E-disease state management
To gain better control of long-term medical
conditions, such as menopause and diabetes, physicians, patients,
pharmaceutical companies and hospitals are all working together
with interactive, computerized solutions.
Safer insertion of lines
A U.S. government-sponsored study on patient
safety finds the use of ultrasound during the placement of central
venous catheters can greatly boost the success rate of the procedure.
PLUS news stories, analysis, and features and more.
Kingstons operating room of the future refines surgical
By Andy Shaw
A $28.1 million Ontario grant for space redevelopment
at Kingston General Hospital (KGH) has opened doors to the worlds
first fully computerized operating suite. Were using
some of the funds to build computers and tracking technology
into the walls and ceilings, so that it will be easy and convenient
to do any kind of image-guided procedure in our two new operating
rooms, says Dr. Randy Ellis, a computer scientist at Queens
University who is also appointed to KGHs surgery department.
Expected to open in early 2003, the new ORs are a joint Queens-KGH
project dubbed OR2010. Meant to set the standard for computer
assisted surgery, OR2010 has drawn both public and private sector
support, thanks to earlier successes of specialized techniques
and robotic equipment developed under Elliss leadership.
Since a casual what if...? chat in a coffee shop
with a mechanical engineering student in 1993, Dr. Ellis has
been investigating how computers can be brought to bear on orthopaedic
surgery. His work and a group of willing surgeons have made Kingston
a hotbed of computer-assisted surgery ever since.
In 1997, for example, Dr. John Rudan performed Canadas
first computer-assisted knee re-alignment at KGH, precisely removing
just a small wedge of bone instead of replacing the entire joint.
In 1998, Dr. David Pichora similarly performed the first computer-assisted
wrist surgery. Later came first-ever surgeries to remove painful,
non-cancerous bone tumours with pinpoint precision.
Now, with more than 50 computer-assisted operations to their
credit, the benefits are clear to Kingston surgeons, researchers,
and patients alike. Instead of chopping out large chunks of bone
and inserting metal plates and screws in hugely invasive and
debilitating procedures, says Dr. Ellis: We can remove
a tumour through small incisions in less than an hour. So rather
than being in a cast for six to eight weeks and undergoing six
months of rehab, the patient is discharged the same day and spends
only a week in post-operative recovery.
Typically, the surgical team first develops a 3D computer model
of the target bone or joint. Custom software then helps them
prepare a plan of attack, which they refine by doing virtual
surgery on the model. When ready, the plan is integrated with
customized surgical and optoelectrical instruments that precisely
guide surgeons through the real procedure.
Well be doing this in the new ORs primarily for orthopaedic,
cranial-facial, and neurosurgery at first. But many other kinds
can be done in the room too, says Dr. Ellis.
The computer does necessarily make every type of surgery
better, says Dr. Dr. Rudan, now an associate professor
of surgery at Queens and one of two principal investigators
along with Dr. Pichora on the OR2010 team. But that is
what we are trying to find out wheres its niche?
What can computer assisted surgery do and what cant it
Dr. Rudan says much of the OR2010 project will move from proof-of-principle
to surgerys mainstream at KGH with the opening of the new
operating rooms. Dr. Rudan expects to see a lot of minimally
invasive surgery done on arthritic knees.
We can replace the affected part of the joint through a
two-inch incision. We cant, of course, see the whole knee
but we can visualize it very well with our 3D reconstructions
and implant new components much more accurately than with conventional
pictures, says Dr. Rudan.
He also says such image guided techniques will make complicated
hip surgeries much less traumatic for patients. Badly mangled
wrists, a common injury for the young (skateboarders) and old
alike, will continue to be the focus of attention for Dr. Pichora
in the new ORs.
Hes been able to do some remarkable work restoring
normal joint lines in the wrist, says Dr. Rudan.
Narrowing the procedures down to those where computer assistance
has proven truly superior is the next step, says Dr. Rudan. And
theyll be chosen against a range of criteria.
First of all, the procedure has to be done at least as
well, and hopefully better than with conventional surgery. Then
it has to allow us to do more cases exactly the way we want them
done than with conventional techniques. We also have to be able
to do the procedure within the normal time allotted for it. We
cant take two or three more hours for it just because we
are using computers. It also has to be cost effective. In other
words, we cant just use these techniques for one operation
and then have a major software or hardware modification after
And for the operating room crews, they have to be comfortable
with the technology. It has to be reduced to the level of being
as simple as sliding a CD into a player. So that you dont
need a huge technical background in order to use the techniques.
Finally, it has to be possible that if the computer fails, the
surgeon can go immediately back to working conventionally. We
cant have the whole procedure dependent on the computer.
New procedures in KGHs state-of-the-art ORs will reach
places where others have not gone before into soft tissue.
Northern Digital Inc. (NDI) of Waterloo, Ontario, an OR2010 collaborator
much praised by Dr. Ellis, is developing tracking systems suitable
for laparoscopic surgery on the likes of the heart, liver, and
Were world leaders in providing localization in image
guided surgery using optical technology, says NDI president
David Crouch. Thats been very suitable for neurosurgery,
spine procedures, and orthopedics where you can get a clear line
of sight to the tool you need to track. But in soft tissue surgery,
were much more likely to be tracking internal tools such
as endoscopes and catheters that are becoming smaller and smaller.
To track those ever-smaller targets through the murky, fleshy
environment of an organ, NDI has turned to magnetic technology
that places minute sensors inside laparoscopic tools. Linked
with ultrasound imaging and moving through a magnetic field generated
by other NDI equipment, the sensors give very precise guidance,
for instance, to a surgeons biopsy needle aiming for a
dead centre sample of a liver tumour.
Backing up these new procedures in the operating rooms of the
near future will be computer-assisted record keeping. Sun Microsystems,
another praised supporter of OR2010, is already supplying its
multi-channel Jini network technology to a U.S. hospital in Virginia
where information streaming from all devices involved in an operation
can be recorded.
Theres a virtual connection to everything at work
in the OR so that blood pressure and temperature monitors, for
example, dont have to be tracked individually, explains
Greg Worth, a Sun business development manager for healthcare
world-wide based in California. The data are constantly
and automatically funnelled into one consolidated medical-legal
record of everything that occurred during the operation.
Back in Canada, other surgical researchers and developers are
also out on the leading edge. The Institute for Robotics and
Intelligent Systems (IRIS), for example, is a federal national
centre of excellence being managed by the non-profit Precarn
Inc. Under Precarn stewardship, Dr. Tim Salcudean, an electronics
engineer at the University of British Columbia in Vancouver led
a team of other university researchers from Simon Fraser, Queens
(including Randy Ellis), and McGill, as well as from the Robarts
Research Institute in London, Ontario and Western Clinical Engineering
in Vancouver. The three-year $1.47 million project, which wound
up in April this year, aimed at using technology to improve pre-surgery
diagnosis, the surgery itself, and surgical outcome assessment.
At the diagnosis end, the team tackled the problem of how surgeons
might cope better with the vast amounts of images and other data
available to them prior to pulling on the gloves.
It also went after new ways of carrying out sophisticated surgical
procedures using minimally invasive techniques in the operating
room. Finally, it grappled with how one can more systematically
determine the effectiveness of such surgeries once the patients
have gone home.
Among the upshots are a new robotic-assisted ultrasound system
suitable for carotid artery diagnoses, the new computer-aided
orthopaedic knee techniques of Dr. Ellis described above, as
well as a sensing system to measure post-operative joint performance.
This research has already resulted in three spin off companies
bent on commercializing these developments.
In another IRIS project led by Vincent Hayward at McGill University,
researchers have brought haptic feedback to angiograms. In the
past, surgeons needed expensive MRI techniques to look at the
shape and size of suspect blood vessels. However, MRI snapshots
can take five minutes to appear on screen, so the challenge was
to find a cheaper, faster way for doctors to view angiograms.
The solution the team developed is software that transforms angiogram
data into 3D images. Doctors can then feel the blockages
displayed in the images using a joystick. An applied-for patent
will likely protect this new Canadian technique now dubbed skin
stretch tactile display. The team has developed four tactile
display devices aimed not only at surgical use but also for the
gaming, automotive, and computer aided design industries.
At Simon Fraser University, Professor Shahram Payandeh has turned
his mechanical engineering training to robot-assisted endoscopic
and laparoscopic work robo-surgery, in short.
A specialist in mechanical grasping and manipulating, Dr. Payandeh
is working on giving surgeons normal freedom of movement and
sense of touch at the surgical site even when working with the
long tools and endoscopes. Collaborating with other engineering
and medical researchers at the University of Victoria and the
University of British Columbia, Payandeh has developed a number
of robotic devices that place and hold surgical tools in precise
This removes the need for an assistant surgeon to do the holding
and reduces the strain on the operating surgeon who must often
assume demanding postures while manipulating various tools and
graspers. One device, for example, allows surgeons to suture
internal organs without having to hold back the skin at the same
Enabling surgeons to operate more accurately and with less stress
for both surgeon and patient alike is the common goal of Payandeh,
Ellis, Salcudean, and others who are supported by IRIS research
and development funds. The robotic technology they are producing
is quite literally cutting edge. It is also technology that has
a place to grow up. IRIS links researchers at over 40 Canadian
universities, hospitals, and research centres with over 90 private
companies with the aim of turning their developments more quickly
into marketable products.
One important piece of surgical research, however, cant
be commercialized. But it is telling about surgerys future.
In 2000, an IRIS supported survey of 1,008 British Columbia surgeons
on minimally invasive techniques and tools revealed that theres
still plenty of development work yet to be done. On average,
the surgeons performed 150 endoscopic procedures a year with
more than 73 percent of them being carried out for therapeutic
reasons. Yet more than 20 percent of the surgeons surveyed said
they had difficulties with, ...equipment inconsistency,
tools awkward to use, tools inadequate, poor image quality, limited
field of view, lack of touch feedback, and technical knowledge
of the OR staff.
As impressive as Canadian innovation in surgical technology has
been, its too soon yet to rest on our laurels.
London surgeons and Canadarm makers devise new technologies
By Jerry Zeidenberg
LONDON, ONT. CSTAR has struck an alliance
with MD Robotics, developer of the space stations Canadarm,
to collaborate in the creation of medical robotic technologies
that will leapfrog many of the applications that are available
today. The partners believe they can position Canada as a leading
producer of solutions for the fast-developing, minimally invasive
The Canadian Surgical Technologies & Advanced Robotics (CSTAR)
organization was launched in 1999 by the London Health Sciences
Centre and the Lawson Health Research Institute, also based in
London. MD Robotics is a subsidiary of MacDonald Dettwiler and
Associates. The partners plan to apply many of the advanced technologies
developed for the Canadarm and space systems to medical robotics
We can jump ahead in this area, said Dr. Reiza Rayman,
director of research and business operations for CSTAR, and a
surgeon who has scores of robotic-assisted operations to his
credit. Weve got all the right ingredients in this
partnership, including the aerospace technologies, advanced telecommunications
technologies and a great deal of experience in medical robotics.
Its now a matter of putting it all together.
Robotic surgery has taken great strides around the world in recent
years. Using computerized arms, instruments, lights and endoscopes,
the technology enables surgeons to conduct delicate operations
in patients through tiny incisions often just a few millimeters
in length. The result is less trauma to the patient and a faster
recovery. Physicians have used robotics for a variety of procedures,
from cardiac surgery to gall bladder removal.
Dr. Rayman stressed that the London Health Sciences Centre is
a world leader in the application of robotics to surgery, with
an extensive base of experience and expertise to draw upon.
Indeed, the LHSC performed the worlds first robotic-assisted,
closed chest, single coronary bypass surgery on a beating heart,
in September 1999. Since then, surgeons at the hospital have
conducted more than 300 robotic procedures, including 92 heart
In February 2001, surgeons at the LHSC performed robotic-assisted
surgery using remote manipulation of a robotic arm, also known
as tele-surgery. The operation also made use of telestration,
a technique in which remote surgeons draw on monitors to assist
local surgeons with a procedure, while all of the surgeons view
the same images on the video screens.
And in March 2002, the hospital conducted the worlds first
thoracic robotic procedure an apical bullectomy.
Were a major player already when it comes to using
the technologies, and we have a number of firsts to our credit,
said Marlene Le Ber, manager of CSTAR. Now were going
to start developing and producing our own technologies.
Dr. Rayman said there are three main areas on which the partners
will concentrate, to produce solutions that improve on technologies
that are currently available.
First, they intend to enhance the visualization systems that
are presently used. These currently tend to be two-dimensional
views of the interior of the body, delivered to TV screens or
computer monitors by endoscopes. Dr. Rayman said improvements
can be made in this area.
Secondly, a good deal of work can be done in the articulation
of robotic joints, thereby giving surgeons much more dexterity
when operating the instruments. Humans have six to seven
degrees of freedom, when moving joints, said Dr. Rayman.
Medical robots need this as well.
Finally, enhancements could be made in the control systems of
the robots, enabling the movements of the robot to be more fluid
and more closely matching the intent of the surgeon. Wed
like to see the movements become much more natural, said
Once the partners devise technologies in these areas, they plan
to create a spin-off company to market the innovations worldwide.
One of our mandates is to commercialize the technologies,
if possible, said Dr. Rayman.
For its part, CSTAR has raised $17.2 million to finance a range
of activities. The organization will occupy two levels of a new,
five-floor research building at University Campus, London Health
Sciences Centre. It plans to move into the new quarters in the
early part of 2003.
CSTAR already has several research programs under way. These
Robotic-assisted interventional cardiology and cardiac
Robotic cancer therapy and thoracic surgery, including
robotic-assisted thorascopic brachytherapy for lung cancer. The
centre plans to use robotics to allow precise implantation of
radioactive seeds in lung tumours.
Telesurgery and robotic telementoring.
Robotic haptics, the development of better force
feedback systems that enable a surgeon to feel as well
as see what he or she is doing inside the patients body,
through the use of endoscopes and other instruments.
Atrial fibrillation. This project team proposes to apply
robotic surgery techniques to a procedure in which the electrical
pathways causing uncoordinated cardiac contractions are altered.
According to CSTAR, this hybrid combination will be an international
Pediatric/In Utero fetal program. Using robotic technologies,
CSTAR surgeons will be able to correct problems while the fetus
is still in the mothers womb.
For example, if there is no outflow of urine from the babys
kidneys, the surgeons can implant a temporary drain. Similarly,
if the lungs of the fetus dont expand as expected, and
fluid needs to be drained, this can again be done through precise,
Its very exciting, because it means theres
a real potential for the baby to be born perfectly normal through
the use of these techniques, said Ms. Le Ber.
CSTAR is currently seeking to raise additional funds to finance
joint projects with MD Robotics. It believes it will be successful
in this area, partly because of the federal governments
current emphasis on inventiveness through Industry Canadas
For its part, MD Robotics earlier this year established an alliance
with the University of Calgary to develop a robotic platform
for brain surgery. However, surgeons at the University of Calgary
are just launching the program, with less background in the use
of robotics than the physicians at CSTAR.
Nevertheless, CSTAR managers have been in touch with surgeons
and administrators at the University of Calgary to see if there
are ways of collaborating, including joint applications for government
And in September, the Queen Elizabeth II hospital in Halifax
announced that it had conducted a telementoring session in the
area of neurosurgery, in which brain surgeons in Halifax advised
surgeons at the Saint John Regional Hospital, in New Brunswick,
during a live operation, using Computer Motions Socrates
system for remote tele-surgery and tele-mentoring.
Group aims to improve supply-chain across health system
By Jerry Zeidenberg
TORONTO A national organization, launched
this month, plans to show hospitals across the country how they
can save millions of dollars annually by improving the way they
purchase and manage medical supplies.
Called the Healthcare Supply Chain Network (HSCN), the group
was spurred into action by a recent Ontario Hospital Association
study, which found that $350 million per year could be saved
across the Canadian healthcare system through the use of better
supply-chain practices. The money could be re-invested in patient-care,
creating a windfall for cash-strapped hospitals.
Moreover, the HSCN believes it could dramatically improve patient
safety, primarily through the use of bar-coding pharmaceuticals
a practice that could ensure the right patient gets the
right drug in the correct dosage.
The time is right for an association like this because
of the increased cost pressures on hospitals, which more than
ever are looking for ways of saving money, said Sarah Friesen,
director of supply chain services at Sunnybrook and Womens
College Health Sciences Centre, in Toronto. Ms. Friesen is co-chair
of the HSCN.
Theres also a heightened awareness, lately, about
medication and patient safety issues, she added.
Ms. Friesen said the HSCN hopes to recruit 200 to 250 hospitals,
health agencies, product suppliers and other healthcare stakeholders
as members of the association in 2003.
Along with hospitals, the HSCN expects suppliers such as medical
device manufacturers, pharmaceutical corporations, blood agencies
and food companies to play an active role in the organization.
Ms. Friesens co-chair on the HSCN is Peter Goodhand, president
of Medical Devices Canada, an agency that represents a broad
range of medical device suppliers.
The new organization has its roots in a previous association,
called the Efficient Healthcare Consumer Response, which attempted
to educate supply chain managers in hospitals and corporations
about barcoding and EDI techniques, along with strategies such
as activity based costing.
Despite the enthusiasm of its members, the initiative didnt
catch on with many hospital executives.
This time round, however, Ms Friesen believes that more organizations
will rally to the cause. Were now targeting hospital
CEOs and finance chiefs, and were showing them a solid
business case on how an investment in better supply-chain management
practices will result in significant long-term savings,
What we didnt have before was the business case,
said Ms. Friesen. We can now show them how the investment
in human resources and technology will pay off. We can demonstrate,
for example, that if you install scanning technology and you
invest a certain amount, youll also save X amount of dollars
The HSCN has solutions that involve people, processes and technology.
It is also developing 10 program areas that will benefit members.
A repository of best practices. Members will have access
to a web-based repository of case studies and solutions, showing
how various hospitals solved different supply-chain problems.
The site will also link you to actual experts in these
areas, so that you can ask questions, either on-line or over
the telephone, said Ms. Friesen.
Developing a network of experts. Online or face-to-face,
the HSCN plans to establish a national network of supply-chain
experts who can help members and offer advice about implementing
new solutions and systems. The intent is to set-up a network
across Canada. Although were launching in Ontario,
we recognize that issues may be different in various parts of
the country, and we want to address this, said Ms. Friesen.
Affiliations with professional associations. There are
many related organizations that the HSCN is building links with,
to draw upon outside expertise. These organizations may include
the Canadian Association of Supply Chain and Logistics Management,
the Purchasing Managers Association of Canada, professional
health associations across the country, and others.
Development and delivery of education through programs
and seminars. The group has already started doing this. In January,
and also this summer, members will lead seminars on achieving
excellence in healthcare supply-chain management, in conjunction
with the Schulich School of Business at York University, in Toronto.
Ms. Friesen said the HSCN would like to develop other educational
programs across the country. Not everyone is able to travel
to Toronto, she said. Wed like to create programs
closer to home for people across Canada.
Development of a gap analysis tool. The group
has pretty well finished this task, and has devised a sophisticated
technique that enables hospital managers to assess the effectiveness
of their supply-chain methods without relying upon outside consultants.
The HSCN will share the gap analysis tool with members.
Facilitation of executive sponsorships. A pro-active campaign
will be launched to attain the buy-in of senior executives of
hospitals across Canada. Ms. Friesen said CEOs and finance chiefs
are seeking solutions such as those offered by the HSCN, and
that the new business-case approach being used by the organization
speaks to hospital executives in a language they understand.
Development of a skills inventory of core competencies
for supply chain professionals.
Development of a certification program. This may be done
in conjunction with other professional associations or universities.
Establishment of regional industry buying entities, and/or
increased affiliation with Group Purchasing organizations. Ms.
Friesen noted that many hospitals across Canada are still not
associated with regional or group buying organizations, and are
missing out on substantial savings. As well, she noted that purchasing
expertise can be readily shared through regional groups. There
are hospitals that are buying CTs and MRIs, she said. Its
something theyll do once, and theyll never do again.
Why not draw on the expertise of hospitals that have done it
Identification and implementation of universal standards,
such as bar codes. Ms. Friesen said perhaps the best place to
start would be with pharmaceuticals, because of the potential
benefits for patient safety.
IP-based networking solves problems for Chatham-Kent health
By Jerry Zeidenberg
The Chatham-Kent Health Alliance, a partnership
between three hospitals, will become one of the first healthcare
organizations in Canada to employ an Internet Protocol (IP) system
for its main communications infrastructure.
The CKHA is currently in the process of building a large addition
on its Public General Campus in Chatham, where St. Josephs
Campus will move in, resulting in a combined, 243-bed complex
delivering acute, chronic, rehab
and psychiatric services. The Sydenham District Campus in Wallaceburg,
Ont., with 68 beds, is also a member of the Alliance.
The new technology means that at each of the hospitals, telephones,
data communications and specialized, computerized systems
such as videoconferencing and an upcoming system for sharing
radiological images can all use the same network.
Its a substantial investment to do this, but it would
have been much more costly to set up parallel networks for all
of these applications, said Jerome Quenneville, vice president,
finance and corporate services at the CKHA.
The Chatham-Kent Health Alliance has emerged as a leader in the
use of new technologies to improve the delivery of information
to physicians and nurses, and thereby enhance the quality of
patient care. Examples include advanced projects in electronic
patient records and wireless applications.
Quenneville said the hospital is committed to this strategy of
improving its performance through the use of technologies, and
the IP-based network will provide the underlying infrastructure.
He noted that the IP network is state of the art, with a gigabit/sec-speed
backbone and bandwidth speeds of 100 megabytes/sec to the desktop.
(In most organizations, 10 megs/sec is standard, using Ethernet
The system also has failover capabilities, meaning that if by
chance the network goes down, it automatically switches over
to a backup system, enabling all telephones and computers to
Chatham-Kent has become a leader in Canada in the area
of computerized networks, commented Barry Burke, region
director, Ontario public sector, for Cisco Systems Canada, one
of the companies installing the IP-based infrastructure. Theyre
using the technology to improve productivity, their business
processes, customer relationships and above all, patient care.
Bell Canada is installing and managing the IP network technology,
which uses Ciscos Architecture for Voice, Video and Integrated
Administrative staff at the CKHA have been substantial users
of videoconferencing, to reduce the need for travel between the
sites. We dont run people up and down the highway
anymore, said Quenneville. Videoconferencing is much
However, in the past, staff members were required to meet in
a special room at each site for videoconferencing. The rooms
were equipped with videoconferencing equipment and access to
the ISDN lines that were needed.
Using the new IP network, staff will be able to stay in their
own offices and conduct desktop videoconferencing with their
colleagues. The process has been freed up, said Quenneville.
It can occur anywhere in the hospitals, we just have to
hook into any computer jack.
The technology will also make things more convenient for medical
specialists, such as psychiatrists, who have been using videoconferencing
The hospital has ambitious plans to bring various point-of-care
technologies to the patient bedside, and will be testing various
systems in the near future. The hospital has already done a good
deal of work in this area, but Quenneville said the IP network
will allow various devices, using a variety of technologies,
to all be supported.
Physicians might want to use wireless PDAs to make pharmaceutical
inquiries, access lab results and manage patient lists,
he said. Our chronic care units might want mobile phones,
and in the ICU, they might want larger tablet computers, with
headsets, to monitor their patients. All of this, with voice,
data and images, can be managed over the IP network.