Surgery in Space:The Next Frontier

Geoffrey D. Young, Ph.D.

OverviewOverview

Historical PerspectiveHistorical Perspective

Surgical Needs in Manned SpaceflightSurgical Needs in Manned Spaceflight

Pre-Op and AnesthesiaPre-Op and Anesthesia

The Operative Theater at 0gThe Operative Theater at 0g

Post-Op Post-Op

On the HorizonOn the Horizon

Physicians and ExplorersPhysicians and Explorers

Dr. William Munkhouse accompanied Captain James Cook aboard the Dr. William Munkhouse accompanied Captain James Cook aboard the Endeavor and is credited with reducing the incidence of scurvy and Endeavor and is credited with reducing the incidence of scurvy and containing infectious disease outbreaks during the expedition.containing infectious disease outbreaks during the expedition.

Historical Medical IssuesHistorical Medical Issues

InfectionInfection Lessons from History Lessons from History

TraumaTrauma Exploration is never without riskExploration is never without risk

Space MedicineSpace Medicine

The longer we remain in space and the The longer we remain in space and the further we travel, the more likelihood of a further we travel, the more likelihood of a medical emergency.medical emergency.

The key to surviving that emergency will The key to surviving that emergency will lie solely with how well it was anticipated.lie solely with how well it was anticipated.

Surgical ConcernsSurgical Concerns

AppendicitisAppendicitis EmergentEmergent No good prophylaxisNo good prophylaxis

UrosepsisUrosepsis Kidney Stones result from the calciuresis associated Kidney Stones result from the calciuresis associated

with bone mineral loss and changes in fluid dynamics with bone mineral loss and changes in fluid dynamics and metabolism, in microgravity.and metabolism, in microgravity.

Incidences of documented in-flight urinary calculus Incidences of documented in-flight urinary calculus and a case of urosepsis in the Russian Space Agency and a case of urosepsis in the Russian Space Agency during the Salyut program.during the Salyut program.

Sepsis and pain could compromise the affected Sepsis and pain could compromise the affected crewmember’s functionality, thereby potentially crewmember’s functionality, thereby potentially jeopardizing the entire mission.jeopardizing the entire mission.

Trauma: Physics 101Trauma: Physics 101

F= maF= ma

Mass does not equal weightMass does not equal weight

Objects with large mass and/or extreme Objects with large mass and/or extreme accelerations can place crews at risk for accelerations can place crews at risk for blunt force trauma.blunt force trauma.

Emergency ManagementEmergency Management

ABCs!!!ABCs!!!

AirwayAirway

Restraining DeviceRestraining Device

LaryngoscopyLaryngoscopy

At least one other approach to At least one other approach to laryngoscopy in microgravity is possible: laryngoscopy in microgravity is possible: grasping the head of an unrestrained grasping the head of an unrestrained patient with one’s knees affords a quick, patient with one’s knees affords a quick, stable, though distant, view of the glottic stable, though distant, view of the glottic opening.opening.

LaryngoscopyLaryngoscopy

BreathingBreathing

Need adequate ventilatory support Need adequate ventilatory support including an efficient gas handling including an efficient gas handling apparatus or risk contaminating crew apparatus or risk contaminating crew compartment.compartment.

*Anesthetic gasses require gravity for *Anesthetic gasses require gravity for proper administration.proper administration.

CirculationCirculation

Cardiovascular deconditioning, disruptions Cardiovascular deconditioning, disruptions of central modulation of baroreceptor of central modulation of baroreceptor reflexes, nonresponsiveness of autonomic reflexes, nonresponsiveness of autonomic function to cardiovascular stresses, and function to cardiovascular stresses, and decreases of intravascular volume have decreases of intravascular volume have been frequently observed during and been frequently observed during and immediately after spaceflight.immediately after spaceflight.

Not corrected with fluid resuscitation.Not corrected with fluid resuscitation.

Fluid HandlingFluid Handling

Gas and liquid do not Gas and liquid do not separate in microgravityseparate in microgravity

Need liquid/ air separators Need liquid/ air separators and infusion pumps.and infusion pumps.

Suction dependent on Suction dependent on gravity separation-need for gravity separation-need for microgravity suction microgravity suction technologytechnology

*Cost*Cost

Anesthesia ConcernsAnesthesia Concerns

Bion 11- Primates flown for 14 days in a Bion 11- Primates flown for 14 days in a biosatellite.biosatellite.

Animals given Anesthesia 1 day post-flight Animals given Anesthesia 1 day post-flight either died or had serious complicationseither died or had serious complications

Anesthesia given >7 days post-flight Anesthesia given >7 days post-flight without difficulty.without difficulty.

MusculoskeletalMusculoskeletal

Loss of muscle and bone mass during Loss of muscle and bone mass during spaceflight is well documented.spaceflight is well documented.

Redistribution of ACH receptors has been Redistribution of ACH receptors has been demonstrated in bedridden patients and use of demonstrated in bedridden patients and use of depolarizing muscle relaxants in these patients depolarizing muscle relaxants in these patients has been shown to cause hyperkalemic has been shown to cause hyperkalemic cardiovascular collapse.cardiovascular collapse.

There are currently no good studies on the use There are currently no good studies on the use on non-depolarizing muscle relaxants.on non-depolarizing muscle relaxants.

Aseptic TechniqueAseptic Technique

The cfu count and particulate matter aboard The cfu count and particulate matter aboard space vehicles is approximately 10x higher than space vehicles is approximately 10x higher than that found in a standard OR.that found in a standard OR.

Need for laminar flow, HEPA and UV sterilization Need for laminar flow, HEPA and UV sterilization technologies.technologies.

Need alternatives to scrub, gowning, gloving, Need alternatives to scrub, gowning, gloving, draping, etc.draping, etc.

Expandable ChambersExpandable Chambers

Surgery in MicrogravitySurgery in Microgravity

Surgery in MicrogravitySurgery in Microgravity

Laparoscopic SurgeryLaparoscopic Surgery

Ideal as it contains fluid, blood, etc. and Ideal as it contains fluid, blood, etc. and reduces the risk of airborne contamination.reduces the risk of airborne contamination.

Potential problems with visualizationPotential problems with visualization

1g Trend. 1g Supine 0g Supine

Laparoscopic SurgeryLaparoscopic Surgery

A more round pneumoperitoneum was A more round pneumoperitoneum was created, allowing easier manipulation of created, allowing easier manipulation of the instruments.the instruments.Bowel, tethered to the mesentery, lifted Bowel, tethered to the mesentery, lifted superiorly remaining clear of abdominal superiorly remaining clear of abdominal wall and allowing direct visualization.wall and allowing direct visualization.Debris and blood adhered to the Debris and blood adhered to the abdominal wall due to surface tensions abdominal wall due to surface tensions and thus kept the relatively clear.and thus kept the relatively clear.

HAL SurgeryHAL Surgery

Simulated HALS was Simulated HALS was successfully performed in successfully performed in microgravity.microgravity.The astronaut and surgeon The astronaut and surgeon easily ran the intestines and easily ran the intestines and ligated the appendix during ligated the appendix during periods of microgravity.periods of microgravity.Microgravity MIS experience Microgravity MIS experience parallels terrestrial MIS parallels terrestrial MIS experience in that HALS is experience in that HALS is subjectively easier to subjectively easier to perform than traditional perform than traditional laparoscopic surgery.laparoscopic surgery.

Microsurgery in MicrogravityMicrosurgery in Microgravity

If during a parabolic flight a surgeon If during a parabolic flight a surgeon is able to perform very precise is able to perform very precise surgery, a physician with basic surgery, a physician with basic surgery training will be able to surgery training will be able to perform basic surgical procedures perform basic surgical procedures during spaceflights. during spaceflights. Such a physician on board should be Such a physician on board should be able to manage the usual medical able to manage the usual medical problems and control a prospective problems and control a prospective surgical robot or perform surgery surgical robot or perform surgery himself.himself.

Surgery in SpaceflightSurgery in Spaceflight

Surgery in SpaceflightSurgery in Spaceflight

No decrement in manual dexterity noted in No decrement in manual dexterity noted in spaceflight.spaceflight.

Operative time during spaceflight were Operative time during spaceflight were longer due to the need to restrain surgical longer due to the need to restrain surgical equipment and supplies.equipment and supplies.

Comparable complex surgical procedures Comparable complex surgical procedures should be feasible on humans.should be feasible on humans.

TelemedicineTelemedicine

TelemedicineTelemedicine

TelemedicineTelemedicineThe study demonstrated that downlinked The study demonstrated that downlinked endoscopic surgical and ultrasound images endoscopic surgical and ultrasound images obtained in 0obtained in 0g g are comparable in quality to 1are comparable in quality to 1g g images, and therefore are useful for diagnostic images, and therefore are useful for diagnostic clinical utility via telemedicine transmission.clinical utility via telemedicine transmission.

Must have appropriate equipment onboard. Must have appropriate equipment onboard.

Communication delays become an issue the Communication delays become an issue the greater distance traveled.greater distance traveled.

Post-Op: Wound healingPost-Op: Wound healing

Analysis of full thickness abdominal skin Analysis of full thickness abdominal skin incisions of rats flown on Endeavor, showed incisions of rats flown on Endeavor, showed increased inflammatory responses, increased increased inflammatory responses, increased fibroplasia, abnormal arrangement of collagen fibroplasia, abnormal arrangement of collagen fibers and reduced stress at maximum load. fibers and reduced stress at maximum load. Bone healing during spaceflight is impaired with Bone healing during spaceflight is impaired with reduced callus formation and reduced reduced callus formation and reduced angiogenesis.angiogenesis.Injured muscles showed disruptions in their Injured muscles showed disruptions in their microvasculature, with a paucity of recognizable microvasculature, with a paucity of recognizable capillaries.capillaries.

On the HorizonOn the Horizon

Preparation: Simulators to train crew in surgical Preparation: Simulators to train crew in surgical and medical skillsand medical skills

Pre-Op: Infusion pumps for IV sedation and Pre-Op: Infusion pumps for IV sedation and options for efficient 0g anesthesiaoptions for efficient 0g anesthesia

Minimally invasive surgery: Better visualization, Minimally invasive surgery: Better visualization, and hemodynamics.and hemodynamics.

Telemedicine and remote surgery: implementing Telemedicine and remote surgery: implementing a long distance sub-specialty consult service.a long distance sub-specialty consult service.

Post-Op: Research to foster a better Post-Op: Research to foster a better understanding of healing in microgravity. understanding of healing in microgravity.

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