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We examined small and long transcriptomics in skeletal muscle and serum-derived extracellular vesicles before and after a single exposure to traditional combined exercise (TRAD) and high-intensity tactical training (HITT). Across 40 young adults, we found more consistent protein-coding gene responses to TRAD, whereas HITT elicited differential expression of microRNA enriched in brain regions. Follow-up analysis revealed relationships and temporal dynamics across transcript networks, highlighting potential avenues for research into mechanisms of exercise response and adaptation.

Acute exercise elicits dynamic transcriptional changes that, when repeated, form the fundamental basis of adaptations in health, resilience, and performance. While moderate-intensity endurance training combined with conventional resistance training (traditional, TRAD) is often prescribed and recommended by public health guidance, high-intensity training combining maximal-effort intervals with intensive, limited-rest resistance training is a time-efficient alternative that may be used tactically (HITT) to seek whole body health benefits. Mechanisms of action of these distinct doses are incompletely characterized and have not been directly compared. We assessed transcriptome-wide responses in skeletal muscle and circulating extracellular vesicles (EVs) to a single exercise bout in young adults randomized to TRAD (n=21, 12M/9F, 22±3y) or HITT (n=19, 11M/8F, 22±2y). Next-generation sequencing captured small, long, and circular RNA in muscle and EVs. Analysis identified differentially expressed transcripts (|log2FC|>1, FDR≤0.05) immediately (h0, EVs only), h3, and h24 post-exercise within and between exercise doses. Additionally, all apparently responsive transcripts (FDRNEW AND NOTEWORTHYWe examined small and long transcriptomics in skeletal muscle and serum-derived extracellular vesicles before and after a single exposure to traditional combined exercise (TRAD) and high-intensity tactical training (HITT). Across 40 young adults, we found more consistent protein-coding gene responses to TRAD, whereas HITT elicited differential expression of microRNA enriched in brain regions. Follow-up analysis revealed relationships and temporal dynamics across transcript networks, highlighting potential avenues for research into mechanisms of exercise response and adaptation.

Late Triassic invertebrate and plant trace fossils are described from the Pebbly Arkose Formation of the Upper Karoo Group (Gwembe Sub-basin, Mid-Zambezi Basin), Zimbabwe. These ichnofossils appear in pedogenically modified siltstone and silty mudstone floodplain deposits and overbank fluvial channels. The ichnofossil-bearing sites show variability in their pedogenic features, maturity and preservation. Invertebrate ichnofossils are primarily recorded as horizontal, vertical and inclined burrows, sometimes branched, lined or unlined and may have an active meniscate infill. The common forms documented are Taenidium, Beaconites, Palaeophycus, Skolithos, and Planolites ispp. with some rare and more unusual morphologies (i.e., ‘Y’-shaped burrow type). Ichnofossil-bearing sites show a low-diversity but high-density of traces commonly dominated by Taenidium and Planolites ispp. The greatest diversity of invertebrate ichnofossils are within interbedded overbank sandstones in weakly pedogenically modified overbank sites. Rhizohalos and rhizoliths are common and often include carbonate infilled roots. Given the abundance and dimensions of fossilized wood and the rhizohalos and rhizoliths, the Pebbly Arkose Formation supported both large and small stature plants. Overall, the studied Pebbly Arkose Formation overbank areas are typically well-drained, calcic palaeosols subject to variable discharge, subaerial exposure, and supporting a diversity of plant and invertebrates tracemakers that lived in a semi-arid to sub-humid environment.

The Triassic–Jurassic Upper Karoo Group of the Mid-Zambezi Basin (MZB; Zimbabwe) includes a thick succession of terrestrial sediments with high palaeontological potential that has been neglected since the 1970s. Here, we review the Upper Karoo Group stratigraphy, present detailed sedimentological work and identify new vertebrate-bearing sites at several measured sections along the southern shore of Lake Kariba. These fossil-bearing sites fall within the Pebbly Arkose and Forest Sandstone formations, and are the first to be recorded from the region since the discovery ofVulcanodon karibaensisnearly 50 years ago. The unique and diverse assemblage of aquatic and terrestrial fauna reported includes phytosaurs, metoposaurid amphibians, lungfish, non-dinosaurian archosauromorphs and non-sauropod sauropodomorph dinosaurs. This improvement of Upper Karoo Group biostratigraphy is important in refining its temporal resolution, and impacts both regional and global studies. Finally, the new fossil sites demonstrate the palaeontological importance of the MZB and its role in providing a holistic understanding of early Mesozoic ecosystems in southern Gondwana.

Correlations between continental sequences within the Karoo-aged basins of southern and eastern Africa are difficult due to the dearth of shared index fossils and a lack of radioisotopic dates for key formations. Here we describe four sites along the southeastern shoreline of Lake Kariba, Zimbabwe, within the Mid-Zambezi Basin, that yield material of phytosaurs (Archosauromorpha: Phytosauria) from within the informal Tashinga Formation (Upper Karoo Group). These phytosaur remains are the first to be recovered from sub-Saharan mainland Africa, representing a major geographic range extension for this group into high southern latitudes. Furthermore, an LA-ICPMS maximum depositional age of 209.2 ± 4.5 Ma (late Norian/early Rhaetian) derived from detrital zircons provides the first absolute age estimate for any of these sites. The phytosaurs are associated with lungfish and metoposaurid amphibians, forming part of a terrestrial-aquatic dominated biota, a previously undocumented biome from the Late Triassic of southern Africa.

The atmospheric methane (CH 4 ) burden is rising sharply, but the causes are still not well understood. One factor of uncertainty is the importance of tropical CH 4 emissions into the global mix. Isotopic signatures of major sources remain poorly constrained, despite their usefulness in constraining the global methane budget. Here, a collection of new δ 13 C CH 4 signatures is presented for a range of tropical wetlands and rice fields determined from air samples collected during campaigns from 2016 to 2020. Long-term monitoring of δ 13 C CH 4 in ambient air has been conducted at the Chacaltaya observatory, Bolivia and Southern Botswana. Both long-term records are dominated by biogenic CH 4 sources, with isotopic signatures expected from wetland sources. From the longer-term Bolivian record, a seasonal isotopic shift is observed corresponding to wetland extent suggesting that there is input of relatively isotopically light CH 4 to the atmosphere during periods of reduced wetland extent. This new data expands the geographical extent and range of measurements of tropical wetland and rice δ 13 C CH 4 sources and hints at significant seasonal variation in tropical wetland δ 13 C CH 4 signatures which may be important to capture in future global and regional models. This article is part of a discussion meeting issue ‘Rising methane: is warming feeding warming? (part 2)’.

Vulcanodon karibaensis is one of the earliest-branching members of Sauropoda and a forerunner of the largest terrestrial animals ever to have lived. Its stratigraphic position has most recently been given as Toarcian (latest Early Jurassic), making it a contemporary of the northern African taxon Tazoudasaurus, but some literature suggests that it may be considerably older. This uncertainty obscures our understanding of the timing of major sauropod evolutionary events, such as the onset of the major body size increases that characterize the clade. To improve constraints on the geological age of Vulcanodon , we revisited the type locality and collected new, higher precision stratigraphic and sedimentological data. Our results show that Vulcanodon is from lower in the stratigraphy than previously documented, lying within the uppermost Forest Sandstone rather than the interbedded sandstones of the Batoka Basalt Formation. Sedimentological data suggest that the upper part of the Forest Sandstone correlates with the Clarens Formation of the main Karoo Basin, implying that Vulcanodon is likely Sinemurian–Pliensbachian in age, and potentially ∼10–15 million years (Ma) older than previously thought.

Southern Africa provides critical information on Late Triassic–Early Jurassic terrestrial tetrapod faunas. Most of the localities in this region are in South Africa and Lesotho, but preliminary work in Zimbabwe has revealed significant potential. Early Jurassic Zimbabwean localities have yielded the basal sauropodomorph Massospondylus, the early sauropod Vulcanodon and theropod material. Late Triassic localities are also known, but have yielded only fragmentary specimens thus far. In early 2017, a joint South African-Zimbabwean-UK team conducted fieldwork in the upper Karoo-aged deposits along the shores of Lake Kariba, northern Zimbabwe (Mid-Zambesi Basin). We relocated the Vulcanodon type locality on Island 126/127 and found that, contrary to previous reports suggesting a Toarcian age, the quarry was in a horizon pre-dating the onset of Drakensburg volcanism (= Batoka Basalts). It is situated instead within the earlier Lower Jurassic Forest Sandstone. This indicates that Vulcanodon is 10–15 million years older than thought previously, recalibrating several nodes within Sauropoda and indicating extensive overlap between true sauropods and 'prosauropods'. Other new vertebrate localities show that sauropodomorphs are present in the Forest Sandstone and upper Tashinga (Late Triassic) formations, but a grey mudstone facies within the Pebbly Arkose Member of the latter unit yields a more aquatic fauna, including lungfish and phytosaurs, but lacking sauropodomorphs. The phytosaur occurrence is the first in Africa south of the Sahara. Faunal and sedimentological evidence indicates that the Late Triassic and Early Jurassic sites in this region were deposited under more mesic environments than their lateral equivalents in South Africa.

Hemorrhage is the most preventable cause of posttraumatic death. Many cases are potentially anatomically salvageable, yet remain lethal without logistics or trained personnel to deliver diagnosis or resuscitative surgery in austere environments. Revolutions in technology for remote mentoring of ultrasound and surgery may enhance capabilities to utilize the skill sets of non-physicians. Thus, our research collaborative explored remote mentoring to empower non-physicians to address junctional and torso hemorrhage control in austere environments. Major studies involved using remote-telementored ultrasound (RTMUS) to identify torso and junctional exsanguination, remotely mentoring resuscitative surgery for torso hemorrhage control, understanding and mitigating physiological stress during such tasks, and the technical practicalities of conducting damage control surgery (DCS) in austere environments. Iterative projects involved randomized guiding of firefighters to identify torso (RCT) and junctional (pilot) hemorrhage using RTMUS, randomized remote mentoring of MedTechs conducting resuscitative surgery for torso exsanguination in an anatomically realistic surgical trainer ("Cut Suit") including physiological monitoring, and trained surgeons conducting a comparative randomized study for torso hemorrhage control in normal (1g) versus weightlessness (0g). This work demonstrated that firefighters could be remotely mentored to perform just-in-time torso RTMUS on a simulator. Both firefighters and mentors were confident in their abilities, the ultrasounds being 97% accurate. An ultrasound-naive firefighter in Memphis could also be remotely mentored from Hawaii to identify and subsequently tamponade an arterial junctional hemorrhage using RTMUS in a live tissue model. Thereafter, both mentored and unmentored MedTechs and trained surgeons completed resuscitative surgery for hemorrhage control on the Cut-Suit, demonstrating practicality for all involved. While remote mentoring did not decrease blood loss among MedTechs, it increased procedural confidence and decreased physiologic stress. Therefore, remote mentoring may increase the feasibility of non-physicians conducting a psychologically daunting task. Finally, DCS in weightlessness was feasible without fundamental differences from 1g. Overall, the collective evidence suggests that remote mentoring supports diagnosis, noninvasive therapy, and ultimately resuscitative surgery to potentially rescue those exsanguinating in austere environments and should be more rigorously studied.

Haptics is an expensive addition to virtual reality (VR) simulators, and the added value to training has not been proven. This study evaluated the benefit of haptics in VR laparoscopic surgery training for novices.The Simbionix LapMentor II haptic VR simulator was used in the study. Randomly, 33 laparoscopic novice students were placed in one of three groups: control, haptics-trained, or nonhaptics-trained group. The control group performed nine basic laparoscopy tasks and four cholecystectomy procedural tasks one time with haptics engaged at the default setting. The haptics group was trained to proficiency in the basic tasks and then performed each of the procedural tasks one time with haptics engaged. The nonhaptics group used the same training protocol except that haptics was disengaged. The proficiency values used were previously published expert values. Each group was assessed in the performance of 10 laparoscopic cholecystectomies (alternating with and without haptics). Performance was measured via automatically collected simulator data.The three groups exhibited no differences in terms of sex, education level, hand dominance, video game experience, surgical experience, and nonsurgical simulator experience. The number of attempts required to reach proficiency did not differ between the haptics- and nonhaptics-training groups. The haptics and nonhaptics groups exhibited no difference in performance. Both training groups outperformed the control group in number of movements as well as path length of the left instrument. In addition, the nonhaptics group outperformed the control group in total time.Haptics does not improve the efficiency or effectiveness of LapMentor II VR laparoscopic surgery training. The limited benefit and the significant cost of haptics suggest that haptics should not be included routinely in VR laparoscopic surgery training.

Emergency surgery will be needed to prevent death if humans are used to explore beyond low earth's orbit. Laparoscopic surgery (LS) is envisioned as a less invasive option for space, but will induce further stresses and complicate logistical requirements. Thus, further study into the technology and physiology of LS in weightlessness is required. We recently utilized the National Research Council of Canada's Flight Research Laboratory's Falcon 20 aircraft as a terrestrial analogue space environment (TASE) for space surgery research. The Falcon 20 had never been used for this purpose nor had the involved teams collaborated previously. There were many process challenges including the lack of antecedent surgical studies on this aircraft, a requirement for multiple disciplines who were unfamiliar and geographically distant from each other, flight performance limitations with the Falcon 20, complex animal care requirements, requirements for prototypical in-flight life-support surgical suites, financial limitations, and a need to use non-flight hardened technologies. Stepwise suggested solutions to these challenges are outlined as guidelines for future investigators intending similar research. Overall, the Falcon 20 TASE, backed by the flight resources, especially the design and fabrication capabilities of the NRC-FRL, provide investigators with a versatile and responsive opportunity to pursue research into advanced medical techniques that will be needed to save lives during space exploration.

Background Multiple nations are actively pursuing manned exploration of space beyond low-earth orbit. The responsibility to improve surgical care for spaceflight is substantial. Although the use of parabolic flight as a terrestrial analogue to study surgery in weightlessness (0 g) is well described, minimal data is available to guide the appropriate delivery of anesthesia. After studying anesthetized pigs in a 0 g parabolic flight environment, our group developed a comprehensive protocol describing prolonged anesthesia in a parabolic flight analogue space surgery study (PFASSS). Novel challenges included a physically remote vivarium, prolonged (>10 h) anesthetic requirements, and the provision of veterinary operating room/intensive care unit (ICU) equivalency on-board an aircraft with physical dimensions of Methods After ethical approval, multiple ground laboratory sessions were conducted with combinations of anesthetic, pre-medication, and induction protocols on Yorkshire-cross specific pathogen-free (SPF) pigs. Several constant rate infusion (CRI) intravenous anesthetic combinations were tested. In each regimen, opioids were administered to ensure analgesia. Ventilation was supported mechanically with blended gradients of oxygen. The best performing terrestrial 1 g regime was flight tested in parabolic flight for its effectiveness in sustaining optimal and prolonged anesthesia, analgesia, and maintaining hemodynamic stability. Each flight day, a fully anesthetized, ventilated, and surgically instrumented pig was transported to the Flight Research Laboratory (FRL) in a temperature-controlled animal ambulance. A modular on-board surgical/ICU suite with appropriate anesthesia/ICU and surgical support capabilities was employed. Results The mean duration of anesthesia (per flight day) was 10.28 h over four consecutive days. A barbiturate and ketamine-based CRI anesthetic regimen supplemented with narcotic analgesia by bolus administration offered the greatest prolonged hemodynamic stability through an IV route (within multiple transport vehicles and differing gravitational environments). Standardization and pre-packaging of anesthesia, emergency pharmaceuticals, and consumables were found to facilitate the interchange of the veterinary anesthesia team members between flights. This operational process was extremely challenging. Conclusions With careful organization of caregivers, equipment and protocols, providing anesthesia and life support in weightlessness is theoretically possible. Unfortunately, human resource costs are extensive and likely overwhelming. Comprehensive algorithms for extended spaceflight must recognize these costs prior to making assumptions or attempting to provide critical care in space.

Laparoscopic surgery has become the standard of care for many surgical diseases. Haptic (tactile) feedback (HFB) is considered an important component of laparoscopic surgery. Virtual reality simulation (VRS) is an alternative method to teach surgical skills to surgeons in training. Newer VRS trainers such as the Simbionix Lap Mentor II provide significantly improved tactile feedback. However, VRSs are expensive and adding HFB software adds an estimated cost of $30,000 to the commercial price. The HFB provided by the Lap Mentor II has not been validated by an independent party. We used the Simbionix Lap Mentor II in this study to demonstrate the effect of adding an HFB mechanism in the VRS trainer.The study was approved by the University of Cincinnati Institutional Review Board. Twenty laparoscopically novice medical students were enrolled. Each student was asked to perform three different tasks on the Lap Mentor II and repeat each one five times. The chosen tasks demanded significant amount of traction and counter traction. The first task was to pull leaking tubes enough and clip them. The second task was stretching a jelly plate enough to see its attachments to the floor and cut these attachments. In the third task, the trainee had to separate the gallbladder from its bed on the liver. The students were randomized into two groups to perform the tasks with and without HFB. We used accuracy, speed, and economy of movement as scales to compare the performance between the two groups. The participants also completed a simple questionnaire that highlighted age, sex, and experiences in videogame usage.The two groups were comparable in age, sex, and videogame playing. No differences in the accuracy, the economy, and the speed of hand movement were noticed. In fact, adding HFB to the Lap Mentor II simulator did not contribute to any improvement in the performance of the trainees. Interestingly, we found that videogame expert players tend to have faster and more economic motion in their dominant hands. However, the performance accuracy was not significantly affected.The presence of HFB has less effect than it thought to be on the performance of the novice trainees. This may suggest that better HFB is still needed. However, there may be visual compensation for the lack of haptics. Playing videogames has a positive impact on economy, and the speed of the dominant had motion without affecting its accuracy. Further research is needed to clarify the value of haptics to the expert surgeon and compare it to the new trainees.

Background Laparoscopic surgery (LS) is contemplated during long duration space flight, but it typically necessitates intraabdominal hypertension (IAH) from insufflation to create a surgical domain. Because there are spontaneous changes in abdominal wall behavior in weightlessness (0g) that have been previously suggested to increase LS visualization, we studied the comparative laparoscopic visualization between gasless (noGAS), abdominal wall retraction (AWR), and standard 15 mmHg gas insufflation (GAS) during weightlessness. Study Design In-flight LS was performed on four anesthetized pigs during weightlessness obtained through parabolic flight in a research aircraft. GAS was studied during 27 parabolas and compared with 20 parabolas using AWR-LS and 12 with noGAS. Pelvic visualization was scored in real time during flight by 2 or 3 surgeons per parabola and postflight through review of compiled digital video disk (DVD) images by 29 independent reviewers. Physical measurements of the sagittal (anterior-posterior) and transverse dimensions of anesthetized pigs were recorded during 39 parabolas. Results Despite consistent increases in the sagittal abdominal dimension in weightlessness (GAS and noGAS), on-board scored visualization in 0g was unchanged for noGAS (p=0.78) and decreased during AWR (p=0.09), compared with 1g. Although AWR was considered feasible in 1g, spontaneous visceral movements reduced the surgical domain in 0g. Neither AWR nor noGAS was believed safe. But visualization during GAS in 0g was increased over that in 1g (p Conclusions Both noGAS and AWR are impractical in weightlessness. Gas insufflation will be required. With insufflation, visualization and perceived ability to perform LS was improved by weightlessness.

The ability to support surgical care in an extreme environment is a significant issue for both military medicine and space medicine. Telemanipulation systems, those that can be remotely operated from a distant site, have been used extensively by the National Aeronautics and Space Administration (NASA) for a number of years. These systems, often called telerobots, have successfully been applied to surgical interventions. A further extension is to operate these robotic systems over data communication networks where robotic slave and master are separated by a great distance. NASA utilizes the National Oceanographic and Atmospheric Administration (NOAA) Aquarius underwater habitat as an analog environment for research and technology evaluation missions, known as NASA Extreme Environment Mission Operations (NEEMO). Three NEEMO missions have provided an opportunity to evaluate teleoperated surgical robotics by astronauts and surgeons. Three robotic systems were deployed to the habitat for evaluation during NEEMO 7, 9, and 12. These systems were linked via a telecommunications link to various sites for remote manipulation. Researchers in the habitat conducted a variety of tests to evaluate performance and applicability in extreme environments. Over three different NEEMO missions, components of the Automated Endoscopic System for Optimal Positioning (AESOP), the M7 Surgical System, and the RAVEN were deployed and evaluated. A number of factors were evaluated, including communication latency and semiautonomous functions. The M7 was modified to permit a remote surgeon the ability to insert a needle into simulated tissue with ultrasound guidance, resulting in the world's first semi-autonomous supervisory-controlled medical task. The deployment and operation of teleoperated surgical systems and semi-autonomous, supervisory-controlled tasks were successfully conducted.

Laparoscopic surgery (LS) is envisioned as an option for spaceflight, but requires intra-abdominal hypertension (IAH) to create the surgical domain. Prolonged weightlessness induces physiologic deconditioning that questions the ability of ill or injured astronauts to tolerate IAH. On earth, IAH results in marked ventilatory embarrassment. As there has been no previous study of physiologic changes related to LS in weightlessness, we studied anesthetized pigs in parabolic flight.Parabolic flight research laboratory.Five anesthetized Yorkshire pigs.Subjects were transported from an animal care facility and secured aboard an aircraft capable of generating hypergravity and weightlessness. Mechanical ventilation was performed using pressure control and positive end-expiratory pressure at 15 and 2 cm H2O, respectively; rate 12 breaths/min. Three abdominal conditions were used during LS: insufflation to produce IAH, abdominal wall retraction (AWR), and no abdominal wall manipulation (baseline). During each parabola breath by breath-tidal volumes (Vt) were recorded by a transport ventilator (HT-50 Newport Medical).Least square means (LS-means) of weight corrected Vt (milliliter per kilogram) by gravity (g) and abdominal condition were determined using a mixed effects model for repeated measures analysis. Increasing gravity (g) consistently reduced Vt (p = 0.0011) as did insufflation (p0.0001). In 1g, Vt (LS-mean 13.7, 95% confidence interval [CI]: 12.4-15.0) was relatively unaffected by AWR (LS-mean 12.8, 95% CI: 11.5-14.00), but markedly decreased by IAH (LS-mean 10.00, 95% CI: 8.9-11.1), an effect accentuated in hypergravity (LS-mean 8.1, 95% CI: 6.4-9.8). In weightlessness, Vt reduction during insufflation was near obviated (LS-mean 12.3, 95% CI: 10.6-14.1), and AWR regularly but inconsistently increased the Vt above 1g baseline (LS-mean 13.7, 95% CI: 11.7-15.8).Weightlessness protects against thoracic compliance changes that are inherent in IAH during induced pneumoperitoneum in gravity. The technique-related physiologic cost of performing LS in space deconditioned astronauts should be incorporated into design concepts for space surgery systems.

BACKGROUND: The dawn of laparoscopic surgery and the telecommunications revolution have given birth to the field of telesurgery. METHODS: Even now, surgery is being performed over great distances to bring expert surgical care to physically isolated patients with otherwise limited healthcare access. RESULTS: As technical obstacles are eliminated in the future, telesurgery will extend the reach of military surgeons to patients at sea and on the battlefield, and astronauts will undergo procedures performed by earthbound interventionalists. Just as the Internet has revolutionized the way everyday consumers shop, eventually, telesurgery may transform surgical care, as patients may stay in their local hospitals and simply "dial up" the best telesurgeon for their specific operation. Telesurgical teams have now formed to refine technical approaches to telesurgery, study the effects of telesurgery on human task performance, and establish telesurgery networks around the world. CONCLUSIONS: While some legitimate social, political, and economic issues remain as impediments to the routine practice of telesurgery, there is now no question that telesurgery will play a role in the delivery of surgical care in the twenty-first century.

It is likely humans will venture beyond the relative safety of low earth orbit (LEO) during the next century, in space-faring journeys termed exploration class missions (ECMs). These missions will include manned missions to the Moon and, ultimately, Mars. Such a mission to Mars could entail a period of years in which space travelers would be unable to quickly return to Earth in the event of a serious surgical condition. These medical care challenges are greater than the engineering ones. Space medicine will always be limited by logistical factors such as limitations in weight, volume, power, and crew training. It will be driven by a focus on conditions that are most likely to occur, or would have the most impact on the crewmembers and mission. A human surgical event has not yet occurred in space, though injury has been ranked at the highest level of concern regarding the probable incidence versus impact and is considered a critical problem for which no reliable countermeasures exist in the National Aeronautics and Space Administration (NASA) Bioastronautics Critical Path Roadmap for long-duration, human space exploration.

Objective: It has been suggested that robotic-assisted remote telepresence surgery with a signal transmission latency of greater than 300 ms may not be possible. Methods: We evaluated the impact of four different latencies of up to 500 ms on task completion and error rate in five surgeons after completion of three different surgical tasks. Results: The surgeons were able to complete all tasks with a latency of 500 ms. However, higher latency was associated with higher error rates and task completion time (TCT). There were significant variations between surgeons and different tasks. Conclusion: Surgeons are able to complete tasks with a signal transmission latency of up to 500 ms. The clinical impact of slower TCT and increased error rates encountered at higher latency needs to be established.

Laparoscopy has advanced surgery by allowing the surgeon to operate within a patient's abdominal and pelvic cavity with minimal trauma and scarring. The coupling of a video camera to the laparoscopic telescope has had the secondary effect of allowing others to view the surgical field either on color video monitors or by watching the video feed over the Internet at a remote location. These advancements have allowed better teaching and mentoring of operations. Open procedures can benefit from this technology as well but have suffered in the past from inadequate methods to depict the open surgical field. We used the Alpha Port and Aesop robot to position a sterile laparoscopic telescope near the surgical field to view open cholecystectomies performed on five pigs and to send the video feed over the Internet to remote physicians. Viewing the video on the monitor, the surgeons performed the operation in a comfortable ergonomic upright position. Both the surgeons and the remote physicians found the quality of the video to be excellent, and the remote physicians felt comfortable learning and mentoring surgical procedures using this technique.

Telemedicine has been used to support care at a distance through the use of expensive equipment and broadband communication links. In the past, the operating room has been an isolated environment that has been relatively inaccessible for real-time consultation. Recent technological advances have permitted videoconferencing over low-bandwidth, inexpensive Internet connections. If these connections are shown to provide adequate video quality for surgical applications, low-bandwidth telemedicine will revolutionize surgical practice by enabling remote real-time surgical consultation. Many of the regions around the world that have the most need for advanced surgical mentoring can least afford it. Although expensive broadband network links such as integrated services digital network (ISDN), local area networks (LANs), and dedicated T-1 lines have provided ample throughput for acceptable video image quality in recent years, the Internet has opened new doors for inexpensive alternatives. Early work by NASA demonstrated the usefulness of the Internet for telemedicine applications. 1 Similar work was also conducted using plain old telephone system (POTS) from the jungles of Ecuador. 2 In both cases, low bandwidth proved to be very useful for telemedicine applications. Internet-2 has been shown to provide high-resolution images, 3 but Internet-2 is simply another broadband technology, which will not be broadly available in the foreseeable future in most regions of the world. By using the ordinary telephone and a dial-up account to a local or global Internet service provider (ISP), a reliable remote node network can be established easily and affordably. The Internet has been successfully shown to be a useful and effective tool in supporting telemedicine on an international scale. 4,5 Over low-bandwidth connections such as dial-up, many Internet applications such as e-mail or web browsing are completely adequate. However, transmitting video over this type of connection is more difficult because of the synchronous data transfer rate and high degrees of compression. A series of experiments were performed to determine whether the quality of video images transmitted over Internet protocol (IP) connections were adequate to support surgical applications.

The objective of this paper is to determine the effect of varying transmission bandwidth on image quality in laparoscopic surgery. Surgeons located in remote operating rooms connected through a telemedicine link must be able to transmit medical images for interaction. Image clarity and color fidelity are of critical importance in telementoring laparoscopic procedures. The clarity of laparoscopic images was measured by assessing visual acuity using a video image of a Snellen eye chart obtained with standard diameter laparoscopes (2, 5, and 10 mm). The clarity of the local image was then compared to that of remote images transmitted using various bandwidths and connection protocols [33.6 Kbps POTS (IP), 128 Kbps ISDN, 384 Kbps ISDN, 10 Mbps LAN (IP)]. The laparoscopes were subsequently used to view standard color placards. These color images were sent via similar transmission bandwidths and connection protocols. The local and remote images of the color placards were compared to determine the effect of the transmission protocols on color fidelity. Use of laparoscopes of different diameter does not significantly affect image clarity or color fidelity as long as the laparoscopes are positioned at their optimal working distance. Decreasing transmission bandwidth does not significantly affect image clarity or color fidelity when sufficient time is allowed for the algorithms to redraw the remote image. Remote telementoring of laparoscopic procedures is feasible. However, low bandwidth connections require slow and/or temporarily stopped camera movements for the quality of the remote video image to approximate that of the local video image.

Eight patients underwent laparoscopic Roux-en-Y gastric bypass from May 1998 to September 1998 in which a hand-assist technique was used. The operation consisted of a 7.5-cm periumbilical midline incision along with three trocars placed in the upper abdomen. The operative times ranged from 2.25 to 4.5 h. The average preoperative body mass index was 44 kg/m.2 Three-month postoperative follow-up revealed an average weight loss of 59 lb. Cosmetic results to date have been excellent even when compared with those of a total laparoscopic operation. The hand-assist technique allows the surgeon to have more control over the most difficult part of the case, which is manipulation of the small bowel in a morbidly obese abdomen.

A 24-year-old female patient who had suffered from recurrent bouts of acute pancreatitis for over 3 years was found on endoscopic retrograde cholangiopancreatography to have an aberrant pancreatic duct that terminated in a cyst. An aberrant lobe of pancreas had been discovered at exploratory laparotomy 3 years previously and was left untreated. Excision of the aberrant lobe of pancreas and accompanying gastric duplication cyst was curative. This case illustrates the importance of obtaining endoscopic retrograde cholangiopancreatography in all young individuals with recurrent pancreatitis to detect this rare, but curable, cause of pancreatitis.

OBJECTIVES Robotic telesurgery has been demonstrated over long distances and offers theoretical benefits to urologic training and the care of patients in remote regions. The multiple arms and three-dimensional vision of the da Vinci robotic system provide a platform conducive to long-distance telementoring and telesurgery. Whereas prior telesurgical efforts have used dedicated lines for information transmission, the public Internet offers a less expensive alternative. It was the intent of this study to test the validity of using the da Vinci system in urologic telesurgery, and to conduct telerobotic nephrectomies using the public Internet. METHODS We performed four right nephrectomies in porcine models using the da Vinci robotic system. Telementoring and telesurgical approaches were used, with resident surgeons operating a console adjacent to the swine, while attending surgeons simultaneously operated a second console at distances of 1300 and 2400 miles from the operating room. RESULTS All four procedures and both telementoring and telesurgical models were successful. Round-trip delays from 450 to 900 ms were demonstrated. Blood loss was minimal, and there were no intraoperative complications. CONCLUSIONS This study represents the first use of the da Vinci Surgical System in urologic telesurgery and the first successful telesurgical nephrectomy in an animal model.

This article explores the potential benefits and defined risks associated with prophylactic surgical procedures for astronauts before extended-duration space flight. This includes, but is not limited to, appendectomy and cholecystesctomy. Furthermore, discussion of treatment during space flight, potential impact of an acute illness on a defined mission and the ethical issues surrounding this concept are debated in detail.

Buddy treatment, first responder combat casualty care, and patient evacuation under hostile fire have compounded combat losses throughout history. Force protection of military first responders is complicated by current international and coalition troop deployments for peacekeeping operations, counter terrorism, and humanitarian assistance missions that involve highly visible, politically sensitive, low intensity combat in urban terrain. The United States Department of Defense (DoD) has significantly invested in autonomous vehicles, and other robots to support its Future Force. The US Army Telemedicine and Advanced Technology Research Center (TATRC) has leveraged this DoD investment with augmented funding to broadly focus on implementing technology in each phase of combat casualty care. This ranges from casualty extraction, physiologic real-time monitoring, and life saving interventions during the “golden hour” while greatly reducing the risk to first responders.

Introduction: Cutaneous wounds, either from injuries or as a result of surgical incisions, are a likely possibility that future space medicine specialists will need to address. While there has been some prior study of manual suturing in microgravity (0 G), there has been no study of manual suturing in reduced gravity consistent with that of the Moon. Methods: Six separate operators with varying degrees of surgical experience (four trained surgeons, and two non-surgeons) attempted to manually suture wound phantoms during the reduced gravity phases of parabolic flight simulating either 0 G or lunar gravity (0.16 G). Each operator subjectively evaluated the difficulty and relative speed in performing the same task in different environments, serving as their own internal control. There were 20-s periods of 1 G that were carefully timed for each surgeon to compare to the approximately 20 s available for each parabola of either 0 G or 0.16 G. Results: Six periods of 1 G were used as controls to perform manual suturing of the phantoms. There were 51 parabolas of 0 G and 67 parabolas of 0.16 G performed by the six operators. As judged subjectively by the operators themselves and by group inspection of the sutured phantoms, there was no qualitative difference in the adequacy of wound closure as judged by suture placement accuracy and wound coaptation. There was consensus, though, that suturing in microgravity was significantly slower, as has been noted in more complex surgical studies. Discussion: The technical aspects of wound management during exploration-class missions in prolonged microgravity or lunar missions with reduced gravity (0.16 G) will likely not present challenges beyond those faced in addressing the tremendous logistical and training obstacles to providing experienced and equipped surgeons on-board such a mission.

Current telesurgical robotic systems are designed to be used exclusively in stationary environments. The ability of a robotic master and slave system to monitor and correct for acceleration induced movement errors would enable conduct of delicate medical procedures onboard moving vehicles. Such operations, without compensation, would be complicated by unintended movement of the surgeonpsilas hands and master controls, causing potentially dangerous response of the surgical robot manipulators. In caring for astronauts on long haul interplanetary missions, it is essential to compensate for alterations in gravitational acceleration when delivering telesurgical or autonomous robotic therapy in the microgravity of space or on non-terrestrial planetary surfaces. This paper introduces new work focused on compensating for unintended master and slave manipulator motion resulting from accelerations of the environment within which they are operated. Experimental results from vehicular operation show how induced motion can be reduced by introduction of dynamic electronic balancing of the master manipulator device and the addition of variable damping proportional to vehicle acceleration. A surgical master console and robot were operated in the micro-gravity and variable gravity of the NASA C-9 airborne parabolic laboratory. Robot kinematics data and surveys of surgeon and astronaut users show that compensating for different gravitational conditions improves usability of the system. Further experiments using an elevator as a motion platform demonstrate the effectiveness of acceleration compensation.

As unmanned extraction vehicles become a reality in the military theater, opportunities to augment medical operations with telesurgical robotics become more plausible. This project demonstrated an experimental surgical robot using an unmanned airborne vehicle (UAV) as a network topology. Because battlefield operations are dynamic and geographically challenging, the installation of wireless networks is not a feasible option at this point. However, to utilize telesurgical robotics to assist in the urgent medical care of wounded soldiers, a robust, high bandwidth, low latency network is requisite. For the first time, a mobile surgical robotic system was deployed to an austere environment and surgeons were able to remotely operate the systems wirelessly using a UAV. Two University of Cincinnati surgeons were able to remotely drive the University of Washington's RAVEN robot's end effectors. The network topology demonstrated a highly portable, quickly deployable, bandwidth-sufficient and low latency wireless network required for battlefield use.

The University of Cincinnati partnered with SRI and the University of Washington (UW) to develop and validate robotic technology that enables telesurgical and autonomous robotic therapeutics. This surgical robotics research was conducted in part in the National Undersea Research Center (NURC) Aquarius Habitat during the NASA Extreme Environment Mission Operations (NEEMO) 12. Two robotic systems, SRI s M7 and the UW s RAVEN, were modified with updated hardware/software and were deployed to the habitat for evaluation. This research represents an important step in the evolution of surgical robotics from telesurgery to distributed autonomous therapeutics that includes remote supervisory-controlled, semiautonomous robotic function. This research marked the first time ever that a surgeon, remotely located from the robotic system and simulated tissue, was able to insert a needle into a blood vessel using ultrasound-image guidance. More importantly, the robotic system was able to autonomously insert a needle into a simulated blood vessel. Further distributed autonomous therapeutics research is indicated to help save the lives and limbs of our injured warfighters.

“Robotic surgery” originated as an imprecise term, but it has been widely used by both the medical and lay press and is now generally accepted by the medical community. The term refers to surgical technology that places a computer-assisted electromechanical device in the path between the surgeon and the patient. A more scientifically accurate term for current devices would be “remote telepresence manipulators” because available technology does not generally function without the explicit and direct control of a human operator. For the purposes of the document, we define robotic surgery as a surgical procedure or technology that adds a computer technology–enhanced device to the interaction between a surgeon and a patient during a surgical operation and assumes some degree of control heretofore completely reserved for the surgeon. For example, in laparoscopic surgery, the surgeon directly controls and manipulates tissue, albeit at some distance from the patient and through a fulcrum point in the abdominal wall. This differs from the use of current robotic devices, whereby the surgeon sits at a console, typically in the operating room but outside the sterile field, directing and controlling the movements of one or more robotic arms. Although the surgeon still maintains control over the operation, the control is indirect and effected from an increased distance. This definition of robotic surgery encompasses micromanipulators, remotely controlled endoscopes, and console-manipulator devices. The key elements are enhancements of the surgeon’s abilities—be they vision, tissue manipulation, or tissue sensing—and alteration of the traditional direct local contact between surgeon and patient.

International audience; Robotic assisted surgery generates the possibility of remote operation between surgeon and patient. We need better understanding of the engineering issues involved in operating a surgical robot in remote locations and through novel communication links between surgeon and surgery site. This paper describes two recent experiments in which we tested the RAVEN, a new prototype surgical robot manipulation system, in field and laboratory conditions. In the first experiment, the RAVEN was deployed in a pasture and ran on generator power. Telecommunication with the surgical control station was provided by a novel airborne radio link sup- ported by an unmanned aerial vehicle. In the second experiment, the RAVEN was teleoperated via Internet between Imperial College in London and the BioRobotics Lab at the University of Washington in Seattle. Data are reported on surgeon com- pletion times for basic tasks and on network latency experience. The results are a small step towards teleoperated surgical robots which can be rapidly deployed in emergency situations in the field

This document serves as an interim report for the HAPsMRT. A prototype surgical robot from the University of Washington was deployed in an extreme environment near Simi Valley, CA. The robot controller (master) and robot (slave) were separated by approximately 100 feet. These were connected wirelessly using AeroVironment s Unmanned Airborne Vehicle (UAV). Using this system, University of Cincinnati surgeons were able to manipulate the end effectors. This demonstrated that a surgical robot could be deployed in an extreme environment and controlled by a surgeon who was remotely located from the robot using a wireless communication system (UAV) normally used for military operations.

The objective of the study was to assess if performance of basic laparoscopic skills on a virtual reality (VR) simulator is impaired in microgravity relative to normal gravitational influences.Fourteen subjects with various educational backgrounds underwent basic laparoscopy skill training for five consecutive days on the ground before flying aboard NASA's KC-135 zero-gravity laboratory. The participants performed basic laparoscopic exercises (clip applying, grasping, cutting, and suturing) on a VR laparoscopy simulator, both on the ground and during 25-s microgravity windows in parabolic flight. Skill levels after ground training were compared with skill levels in performing the same tasks in microgravity. Blinded reviewers measured the number of tasks successfully completed, tissue damage number, left and right hand path lengths during task execution, and percentage of task attempts that resulted in successful completion.A significant increase in tissue injury (t test, P0.05) and task erosion were seen in clip applying, cutting, and grasping in microgravity (45%, 20% and 57% decrease in task attempts that resulted in a successful completion, respectively). However, there was no significant difference in the left and right hand path lengths, and the total number of tasks successfully completed on the ground versus in microgravity, for any of the four laparoscopic exercises (t test, P0.05).This study demonstrates decreased efficiency and increased injury to the simulated tissues in performing laparoscopic skills during microgravity as compared to performing these skills in standard gravitational influence. Additional experiments are indicated to further develop and validate VR microgravity surgical simulation.

Investigators have looked at the effect of night call on surgical residents but not at learning of laparoscopic skills. The Minimally Invasive Surgical Trainer-Virtual Reality (MIST-VR) tests 6 tasks similar to a laparoscopic cholecystectomy. We hypothesized that night call would impair laparoscopic performance and that skills would not improve but rather deteriorate after night call. Seventeen volunteers were tested before and after night call. Data collected included economy of movement, time, and number of errors for each hand/foot. A paired Student t test was used for statistical analysis. On the first 2 tasks, there was an improvement in all parameters post-call, with significance reached in 5 of 18 parameters (P

The technology explosion of the last 20 years has changed the face of surgery dramatically. For example, application of video technology in minimally invasive surgery (MIS) has revolutionized care with proven benefits to the patient that include reduced morbidity, decreased hospital stay, and earlier detection of pathology. There exists additional opportunity to improve surgery through technology over the next decade. Surgeons can and should exploit technologies that we routinely use in our everyday life. Industry and government have invested billions of dollars and decades of effort in technologies such as computers and robotics that can be readily applied to improve surgical practice. As the annual meeting of the Association for Academic Surgeons was held in Houston, exploitation of National Aeronautics and Space Administration (NASA) related technology was explored during this presentation. Effective application of advanced technology in surgery should address fundamental issues of cost, access, and quality of care. From the standpoint of cost, economists predict that nearly 18% of the Gross Domestic Product (GDP) will be spent on healthcare in 2005 ($1.1 trillion). Despite staggering healthcare expenditures, geographic and socioeconomic disparities in health care delivery persist such that many Americans lack access to quality care. The recent reports by the Institute of Medicine (IOM), To Err is Human and Crossing the Quality Chasm, Patient Safety describe fundamental issues in quality that threaten and kill patients. The lack of quality is disturbing: medical errors cause up to 98,000 unnecessary deaths per year in the United States [1]. The magnitude of the problem is alarming— more people in our nation die from medical errors each

Previous simulation and porcine experiments aboard the reduced gravity program KC-135 turbojet have demonstrated that microgravity surgery is feasible. Ideally, surgical care in spaceflight will incorporate recent advances in care while remaining easy enough for a crew medical officer (CMO) lacking surgical proficiency or extensive surgical experience to perform. As a minimally invasive surgical technique, hand-assisted laparoscopic surgery (HALS) benefits the patient via smaller incisions, less pain, and faster recovery than traditional open surgery. HALS also helps less experienced laparoscopic surgeons perform laparoscopic surgery.An inexpensive inanimate surgical simulator was constructed to evaluate the usefulness of HALS in microgravity. This simulator was utilized during brief periods of microgravity provided by parabolic flight on the KC-135. The simulator was successfully used by both a physician-astronaut and an experienced laparoscopic surgeon. Task completion included simulated surgery with exploration of the intestines and ligation of the appendix.Simulated HALS was successfully performed in microgravity. HALS effectively contained operative equipment and small amounts of introduced fluids within the simulated abdominal cavity. Astronaut and surgeon experience suggest that HALS could facilitate minimally invasive surgery (MIS) in microgravity.HALS holds promise as a surgical approach in microgravity, particularly as space travel extends beyond low earth orbit. HALS provides the benefits of MIS, facilitates MIS surgery by less surgically proficient or experienced CMOs, and contains equipment and fluid within the operative field. Simulation provides an easy, cost-effective platform to evaluate medical technology for space flight as well as a method to train CMOs on-orbit.

During spaceflight crew health is paramount in the success of flight missions. The delivery of healthcare during flight requires crew readiness for medical and surgical response.There were 20 participants who were evaluated for accurate performance of 4 basic laparoscopic surgical skills (clip applying, cutting, grasping, and suturing) during parabolic weightlessness using an inanimate workstation aboard the NASA KC-135 aircraft.Data indicate that motor skill performance decreased within the parabolic microgravity flight environment. Performance in parabolic microgravity flight included futile effort with an increase in number of tasks attempted and a decrease in tasks completed successfully.There is a decreased frequency of accurate task completion in parabolic microgravity flight, but it is not an obstacle to implementation of effective training for providing in-flight medical care. The data reveal that individuals perform basic laparoscopic surgical simulation with greater effort in microgravity following simulation training.