The last thing Madeleine Schaal did before going under anesthesia for gallbladder surgery was to say a quick bonjour to her doctors. An unremarkable gesture, except that the 68-year-old French-born homemaker was lying in an operating room in Strasbourg, France, while the surgeons watched on a video monitor 3,900 miles away in New York City. "She was waving like, 'I'm all for this' " recalls Dr. Michel Gagner, 41, chief of laparoscopic surgery at Manhattan's Mount Sinai School of Medicine, who assisted in the Sept. 7 operation by French surgeon Jacques Marescaux, 53. "She was really a sport."
And a courageous pioneer. After a doctor in Strasbourg made four incisions through which instruments could be inserted, Marescaux, using joysticks to operate a multi-armed robot in Strasbourg, separated the gallbladder duct from an artery. Then Gagner took over and removed the organ. "The quality of the image was perfect," says Gagner. "It was like working with a microscope." In 54 minutes the team had performed the first complete transatlantic remote-control surgery. The operation brings medicine to the threshold of a world in which doctors will be able to perform surgery by remote hookup on patients in distant battlefields, in isolated settlements even in space. "It's like we've stepped through a transition zone," says Virginia Commonwealth University's Dr. Ronald Merrell, a leader in the emerging field known as telemedicine. "It changes the whole landscape."
Schaal, a grandmother of four from Geispolsheim, a village near the French border with Germany, was pleased to be a part of medical history—and relieved to be rid of the abdominal pain that had begun early this year. In July she had gone to Marescaux because he had treated several of her relatives, including her husband, Armand, 70, a retired electrician who under-went hernia operation in May. "I knew he was one of the best around," says Schaal.
Her confidence could not have been better placed. "This had been my dream for three years," says Dr. Marescaux, who conceived of the project. "It was strange that it was fulfilled in one hour." The chairman of intestinal surgery at Strasbourg's Louis Pasteur University, Marescaux is also head of the European Institute of Telesurgery, where hundreds of researchers, engineers and computer specialists labor to advance the art of remote-control surgery. Since 1999, five years after he founded the institute, Marescaux has focused much of the group's energy on breaking a new barrier: Though in the past doctors in the U.S. had used robots to perform simple procedures on patients overseas, Marescaux's Operation Lindbergh—named for the first aviator to traverse the Atlantic aimed to complete an entire intercontinental gallbladder operation.
To fulfill Marescaux's vision, his team had to create a new hybrid of two commonplace procedures. Laparoscopic surgery is a minimally invasive technique in which doctors insert tiny instruments and a television camera through small holes in the patient's body. Robotic surgery, now offered at more than 100 hospitals worldwide, allows a degree of precision that the unaided hand cannot always achieve.
Working up to 14 hours a day, Marescaux secured millions of dollars in funding and oversaw the development of a new generation of technology. Last year he enlisted the help of Gagner, who had been using surgical robotic arms since 1994 for procedures ranging from gallbladder surgery to nerve reconstruction.
Before operating on humans, the team practiced by removing pigs' gallbladders in Strasbourg while sitting at a computer 243 miles away in Paris. But when the surgeons attempted their first New York City-to-Strasbourg procedure on a pig last September, the video image was so bad that they had trouble identifying organs. To get a better connection, they moved the project to an office building already equipped with advanced fiber-optic connections. There the doctors performed six remote operations on pigs this summer, with such success that the U.S. Food and Drug Administration granted permission to attempt the gallbladder procedure.
The next challenge was finding the right subject—someone with an ailing gallbladder but a healthy sense of adventure. "I thought any patient I talked to would think I was crazy," says Marescaux. Then along came Mme. Schaal, who was awed by his institute. "It was so magnificent," says Schaal. "Something like science fiction." Still, the surgeon waited until her third visit to raise the idea of a transatlantic surgery. When he explained that while he would be in New York City other surgeons would be by her side in case of a problem, she immediately agreed "She has always been very open-minded," says her husband. "I'm not surprised she wanted to do this."
Schaal had long been suspicious of technology, but she says she underwent a conversion eight years ago when her daughter-in-law gave her a food processor as a gift. Overcoming her reluctance, she used it to make Kugelhopf, a type of regional cake, and was thrilled with the results. Later, she says, the parallel with robotic surgery was easy to draw: "The machine made the moves, but a human being was in charge."
Of course, these surgeons were more than masters of machinery. Marescaux, a Strasbourg native whose parents were both physicians, was himself teaching medicine by age 32. He and wife Alice, 45, a lawyer who helps run the institute, have two grown children. "He's terribly bright and well-respected," says telemedicine expert Merrell, "and just a little ahead of his time." Gagner, son of a Montreal gynecologist and a homemaker, was a prodigy who skipped college and graduated from medical school at 22, working in hospitals from Nashville to Cleveland before arriving at Mount Sinai in 1998. He and his wife, France, 41, a lawyer, have three children.
Despite their experience and preparation, both men were nervous when the moment arrived. "I didn't sleep the night before," says Gagner. "I was thinking of all the things that might go wrong." But they relaxed once they got to work on the morning of Sept. 7, wearing street clothes instead of sterile hospital scrubs and observed by a small audience of technicians, doctors and financial backers. "I felt like we were a Formula One team," says Marescaux.
Afterward the group celebrated over champagne at a Manhattan bistro. Then Marescaux flew back to France to visit his patient, whose recovery went so well that she was home within three days. Mme. Schaal heaps praise on her doctors and their cutting-edge procedure, but it has not freed her of the aches and pains that have kept her from working in her garden. Still, she remains hopeful. "Who knows?" she says. "Maybe in the future, robots will be able to fix my arthritis as well."
• Bob Calandra in New York City and Dietlind Lerner in Strasbourg
Your Reaction
