Case Report
Open Access
Fetal Echography Remotely Controlled Using A Tele-
Operated Motorized Probe and Echograph Unit
Philippe Arbeille1*,Jose Ruiz2,Gabriel Carles3,Victorita Stefanescu4,
Monica Georgescu1
1UMPS-CERCOM,Faculte de Medecine,37032,Tours, France
2Dept Ostetrica i Gynecologia, Hospital de Ceuta, Spain.
3Sce Obstetrique et Gynecologie, Hopital ouest guyanais St Laurent du Maroni, Guyane, France.
4Pediatric Hospital , Galate, Romania.
2Dept Ostetrica i Gynecologia, Hospital de Ceuta, Spain.
3Sce Obstetrique et Gynecologie, Hopital ouest guyanais St Laurent du Maroni, Guyane, France.
4Pediatric Hospital , Galate, Romania.
*Corresponding author: Philippe Arbeille, Professor,Faculty of the Medecine, Blv Tonnelle,37032-
Tours – France.Tel:+33 680 105 488, E-mail:
@
Received: January 03, 2017; Accepted: January 19, 2017; Published: February 01, 2017
Citation: Philippe Arbeille,Jose Ruiz,Gabriel Carles,Victorita Stefanescu,Monica Georgescu (2017)Fetal Echography Remotely Controlled Using A Tele-Operated Motorized Probe and Echograph Unit. SOJ Gynecol Obstet Womens Health 3(1): 1-6 DOI: http://dx.doi.org/10.15226/2381-2915/3/1/00118
AbstractTop
Objective:
to evaluate the performance of a new device for fetal
tele-echographyin isolated medical centers.
Methods: fetal tele-echography and Doppler was performed using, a) a portable echograph which setting and function (Doppler pulsed and color, 3D capture..) can be operated from away via internet, b) equipped with motorized probes (400g, 430cm3) which transducer can be orientated from away by an expert also via internet. The pregnant were in medical center far away from the expert center.
Results: two patient and expert centre were used for testing the feasibility of fetal tele-echography: Hospital of Ceuta (South Spain) with Tours Hospital (France) as expert center (1800km away), and the dispensary of Apatou (40km inside Amazonian forest, French Guyana) with St Laurent du Maroni (Sea border French Guyana) as expert center. At the patient site there was a midwife not trained for practicing echography, whose role was to hold the probe on the pregnant at the location indicated by the expert and to maintain it motionless. Fifteen pregnancies were remotely investigated 10 located in Ceuta (23 to36w GA) and 5 located at Apatou dispensary (10-34w GA). In each case the expert could visualize the fetal head (biparietal) the abdomen (transverse), the femur, the placenta and the umbilical chord and measure de corresponding parameters. The time duration of tele-operated echography was 15 to 20 min. Umbilical Doppler was performed in 6 pregnancy.
Discussion: the light tele-operated echograph and probe allowed to perform easily and in a limited timefetal echography and Doppler on pregnant far away from the expert. The system required only domestic internet between the expert and patient site.
Keywords: Fetal echography;Tele-Medicine;Tele-Echography;Tele- Operated Probe;Tele-Operated Echograph
Abbrevations: f/s:Frame per second;GA:Gestational age;GP:General practitioner;MHZ:Mega hertz;PC:Personal computer; RF:Radiofrequency;USB:Universal serial bus;W: week;Kb/s:Kilo bits per second;Mb/s:Mega bits per second;3D:3 dimensional.
Methods: fetal tele-echography and Doppler was performed using, a) a portable echograph which setting and function (Doppler pulsed and color, 3D capture..) can be operated from away via internet, b) equipped with motorized probes (400g, 430cm3) which transducer can be orientated from away by an expert also via internet. The pregnant were in medical center far away from the expert center.
Results: two patient and expert centre were used for testing the feasibility of fetal tele-echography: Hospital of Ceuta (South Spain) with Tours Hospital (France) as expert center (1800km away), and the dispensary of Apatou (40km inside Amazonian forest, French Guyana) with St Laurent du Maroni (Sea border French Guyana) as expert center. At the patient site there was a midwife not trained for practicing echography, whose role was to hold the probe on the pregnant at the location indicated by the expert and to maintain it motionless. Fifteen pregnancies were remotely investigated 10 located in Ceuta (23 to36w GA) and 5 located at Apatou dispensary (10-34w GA). In each case the expert could visualize the fetal head (biparietal) the abdomen (transverse), the femur, the placenta and the umbilical chord and measure de corresponding parameters. The time duration of tele-operated echography was 15 to 20 min. Umbilical Doppler was performed in 6 pregnancy.
Discussion: the light tele-operated echograph and probe allowed to perform easily and in a limited timefetal echography and Doppler on pregnant far away from the expert. The system required only domestic internet between the expert and patient site.
Keywords: Fetal echography;Tele-Medicine;Tele-Echography;Tele- Operated Probe;Tele-Operated Echograph
Abbrevations: f/s:Frame per second;GA:Gestational age;GP:General practitioner;MHZ:Mega hertz;PC:Personal computer; RF:Radiofrequency;USB:Universal serial bus;W: week;Kb/s:Kilo bits per second;Mb/s:Mega bits per second;3D:3 dimensional.
Introduction
Echography and Doppler are the first imaging modality
which can be setup without huge and costly installation but the
examination has to be performed by a Medical Doctor specially
trained for Echography and Doppler (A Sonographer). Moreover
the sonographer must be specialized in echography/Doppler in
various domain like abdominal, pelvic, vascular, fetal echography.
Thus it is evident that such multi-disciplinary sonographer
cannot exist in isolated medical center with limited facilities and
served by only some general practitioners (GP) assisted by nurses
and midwife. Thus remote echography and Doppler could be
of great help for the GPto identify very quickly emergency situation
to be transferred immediately and other that can be treated
on place. Access to remote echography will facilitate and make
safer the medical diagnosis, which may result in a quicker decision
making and a better medical assessment.
Several method were designed and validated for providing remote ultrasound examination to isolated subjects and patient. These methods were based on tele-operated systems (Arbeille et al., 2005; 2016, Georgescu et al., 2015; Vieyres et al., 2003), remote analysis of video capture, or remote guidance through videoconferencing (Awadallah et al., 2006; Hamilton et al., 2011; Otta et al., 2012; Randolph et al., 1999) or volume capture with 3D reconstruction (Arbeille et al., 2014; Kratochwil et al., 2000; Masuda et al., 2001).
A new compact system with a tele-operable light echograph (setting and function controlled from away) equipped with motorized probes (transducer orientation controlled from away) was tested for fetal tele-echography and Doppler. It was hypothesized that this compact and simplified system requiring only domestic Internet, and a “non sonographer” operator by the side of the patient, will be sufficient for performing remotely a reliable fetal echography.
Several method were designed and validated for providing remote ultrasound examination to isolated subjects and patient. These methods were based on tele-operated systems (Arbeille et al., 2005; 2016, Georgescu et al., 2015; Vieyres et al., 2003), remote analysis of video capture, or remote guidance through videoconferencing (Awadallah et al., 2006; Hamilton et al., 2011; Otta et al., 2012; Randolph et al., 1999) or volume capture with 3D reconstruction (Arbeille et al., 2014; Kratochwil et al., 2000; Masuda et al., 2001).
A new compact system with a tele-operable light echograph (setting and function controlled from away) equipped with motorized probes (transducer orientation controlled from away) was tested for fetal tele-echography and Doppler. It was hypothesized that this compact and simplified system requiring only domestic Internet, and a “non sonographer” operator by the side of the patient, will be sufficient for performing remotely a reliable fetal echography.
Methods
Portable Echograph and probe Tele-operated
A commercially available echograph (Orcheolite, Sonoscanner,
Paris, France) was modified to allow for tele-operation through
an Internet connection (Teamviewer, Goppingen, Germany)
(Figure 1-3). At the expert site, the trained sonographer adjusted
the settings (gain, depth, etc.) and functions (Doppler, colour,
3D, etc.) of the echograph using a standard PC keyboard. Each
setting or function of the echograph was identified by a letters
on the keyboard, for example and increased and
decreased gain where activated the PW Doppler mode.
The design and weight (6kg) of the echograph was not altered;
however, additional functions were added to the operation
including elastography, 3D reconstruction, Panoramic, and radio
frequency (RF) display and process
Two specialized tele-operated probes were developed (Vermon, Tours, France) for this system which were similar to commercial 3D probes, but slightly larger and heavier (400cm3 and 430g). The first motorized probe (for deep organs abdomen and fetus) contained a convex array transducer (3.5-7MHz) providing a wide image used for the assessment of deep organs (Figure 4-6). This probe was tele-operated using one motor to tilt the transducer (+550 to -550) and a second to rotate the transducer around the central axis (+/-1800). The second probe contained
Two specialized tele-operated probes were developed (Vermon, Tours, France) for this system which were similar to commercial 3D probes, but slightly larger and heavier (400cm3 and 430g). The first motorized probe (for deep organs abdomen and fetus) contained a convex array transducer (3.5-7MHz) providing a wide image used for the assessment of deep organs (Figure 4-6). This probe was tele-operated using one motor to tilt the transducer (+550 to -550) and a second to rotate the transducer around the central axis (+/-1800). The second probe contained
Figure 1: (a) Motorized probe (400cm3 and 430g). The
transducer (3,5MHz curved array) can be remotely tilted and
rotated (arrows) from away by the expert while manipulating
(b) the dummy probe (arrow) (c) the tele-operated portable
Echograph(6kg) and tele-operated probe (arrow).
Figure 2: a) The patient site with the non-sonographer operator
(midwife) holding the motorized probe on the pregnant
and b) the expert site with the expert sonographer manipulating
the dummy probe with his left hand (arrow) and
selecting the ultrasound function on the keyboard with his
right hand (arrow). On his screen the ambient video from
the patient site with the pregnant and the midwife, and the
echographic video.
a linear array transducer (5-15MHz) used for the assessment
of superficial organs. In contrast to the convex probe, the
linear transducer was only tele-operated using one motor for
the tilt movement (+550 to -550) as it was believed that the
non-sonographer operator would be able to identify the long
and shot axes of the superficial organs of interest (blood vessels,
muscles). The probes were connected to the echograph using
the standard probe connector through which the echograph sent
the order sent by the expert to change the orientation of the
transducer. Using custom software (Optimalog, St. Cyr-sur-Loire,
France), movements of a dummy probelocated at the expert site
were mimicked by the transducer of the motorized probe at the
patient site (Arbeille et all 2016).
Two IP camera (IP AXIS camera, Paris, France) allowed the expert sonographer to communicate with the non-sonographer operator at the patient site. A switch was used to control simultaneously the Internet connection for the portable computer, the echograph, and the IP Camera.
At the expert site (Figure 2), a basic portable computer, connected
Two IP camera (IP AXIS camera, Paris, France) allowed the expert sonographer to communicate with the non-sonographer operator at the patient site. A switch was used to control simultaneously the Internet connection for the portable computer, the echograph, and the IP Camera.
At the expert site (Figure 2), a basic portable computer, connected
Figure 3: a) Apatou dispensary (Amazonian forest, French
Guyana) b) Pregnant, midwife, tele-echograph and motorized
probes
Figure 4: a) Biparietal view b)Transverse abdominal view
c)Femur view, and measurements.
to Internet, was used to tele-operate the echograph and motorized
probe and for the videoconference (IP AXIS camera, Paris,
France) between the two sites. The dummy probe was connected
to this computer via a USB plug.
Fetal tele-echography procedure
The patient site Doctor (GP) call the Expert approximately 1h
prior to the Fetal Tele-echography and presents the clinical status
of the pregnant and schedule the examination. When the pregnant
is ready the patient site operator (GP, midwife) open the
Internet connection and check with the expert that he receive the
ambient video (to see and talk to the pregnant or the GP) as well
as the fetal echographic video.
The Expert tells the distant operator to locate the motorized probe close to the Umbilic, and turn around 3600 slowly in order to identify where the acoustic windows for the fetal head, abdomen, femur chord. . . are. Each acoustic window is identify by an hour (3h, 5h, 9h. . . ) like on a clock centered on the Umbilic. Then the expert ask the operator to locate the probe at each desired acoustic window and at each of these location to maintain the probe motionless, vertical to the skin, while the expert tilt and rotate the transducer until he get the expected fetal view (biparietal, transverse abdomen, femur . . . ). The expert adjust the gain, depth. . . on the echographic image and freeze and store the image. When the perfect view is frozen the expert can measure distance, surfaces . . . and store these data. In the case of Umbilical Doppler the operator locate the probe at the level of the placenta acoustic window, and the expert orientate remotely the transducer and activate the color Doppler mode to visualize the umbilical arteries and vein. Then he locate the pulsed Doppler
The Expert tells the distant operator to locate the motorized probe close to the Umbilic, and turn around 3600 slowly in order to identify where the acoustic windows for the fetal head, abdomen, femur chord. . . are. Each acoustic window is identify by an hour (3h, 5h, 9h. . . ) like on a clock centered on the Umbilic. Then the expert ask the operator to locate the probe at each desired acoustic window and at each of these location to maintain the probe motionless, vertical to the skin, while the expert tilt and rotate the transducer until he get the expected fetal view (biparietal, transverse abdomen, femur . . . ). The expert adjust the gain, depth. . . on the echographic image and freeze and store the image. When the perfect view is frozen the expert can measure distance, surfaces . . . and store these data. In the case of Umbilical Doppler the operator locate the probe at the level of the placenta acoustic window, and the expert orientate remotely the transducer and activate the color Doppler mode to visualize the umbilical arteries and vein. Then he locate the pulsed Doppler
Figure 5: a) Placenta, and umbilical flow in color b) Pulsed
Doppler: Umbilical artery and vein velocity spectrum .
Figure 6: Example of fetal tele-echography of an 8 GA pregnancy,
with poor satellite communication. The upper and left
border of the uterus is not clearly display, such image could
be improved by giving the priority to the quality of the image.
sample volume inside the vessel and trigger the pulsed Doppler
mode. Lastly the Expert adjust the Doppler gain, the spectrum
baseline, the frequency scale, the sample volume size... On the
frozen Doppler spectrum the expert can measure systolic, diastolic
velocities, vascular resistance indices.
Results
Population
Two patient and expert centre were used for testing the feasibility
of fetal tele echography: hospital of Ceuta (Spanish city,
south limit of Europ) with Tours Hospital (France) as expert center
(1800km away), and the dispensary of Apatou (40km inside
Amazonian forest, French Guyana) with St Laurent du Maroni
(Sea border french Guyana) as expert center. The link between
Ceuta and Tours was a ground Internet while between Apatou
and St Laurent du Maroni a satellite Internet was used.
At the patient site there was an operator (a midwife) not trained at all for practicing echography.
The tele-echography test was approved by the Ethical committee of the area where the tele -echography took place (Heath Regional Agency = ARS Agence Regionale de Sante). Each patient were informed about the protocol of Tele-echography and signed a formal consent form.
Fifteen pregnancies were remotely investigated, 10 located in Ceuta (23 to 36w GA) and 5 located at Apatou dispensary (10- 34w GA).
The duration of the tele echography was limited to 20min because this examination was followed by a conventional echography by a sonographer.
At the patient site there was an operator (a midwife) not trained at all for practicing echography.
The tele-echography test was approved by the Ethical committee of the area where the tele -echography took place (Heath Regional Agency = ARS Agence Regionale de Sante). Each patient were informed about the protocol of Tele-echography and signed a formal consent form.
Fifteen pregnancies were remotely investigated, 10 located in Ceuta (23 to 36w GA) and 5 located at Apatou dispensary (10- 34w GA).
The duration of the tele echography was limited to 20min because this examination was followed by a conventional echography by a sonographer.
Fetal tele-echography performances
In each case the expert could visualize the fetal head (biparietal)
the abdomen (transverse section), the femur (long axis), the placenta
and in 6 cases the umbilical chord (color Doppler), and
measure the corresponding parameters (Biparietal diameter, Abdomen
diameters, Femur length, umbilical Doppler velocities).
The quality of the image reaching the Expert center was not different than the quality of those stowed directly into the Echograph at the patient site except in the case of satellite Internet but in this case the quality was restored by giving the priority to the quality image while losing partially the realtime display.
The time duration of tele-operated echography was 15 to 20 min for the pregnant in Ceuta while the duration was slightly longer (some minutes) for the patient in Apatou as the satellite Internet introduced a delay up the 3-4 s.
Doppler of the umbilical flow was performed in 6 of the pregnancies, and voluntarily not on every pregnancy as the Teleechography duration was limited to 20min for ethical reason as this examination was followed by a conventional echography.
The quality of the image reaching the Expert center was not different than the quality of those stowed directly into the Echograph at the patient site except in the case of satellite Internet but in this case the quality was restored by giving the priority to the quality image while losing partially the realtime display.
The time duration of tele-operated echography was 15 to 20 min for the pregnant in Ceuta while the duration was slightly longer (some minutes) for the patient in Apatou as the satellite Internet introduced a delay up the 3-4 s.
Doppler of the umbilical flow was performed in 6 of the pregnancies, and voluntarily not on every pregnancy as the Teleechography duration was limited to 20min for ethical reason as this examination was followed by a conventional echography.
Discussion
The new light tele-operated echograph and probe allowed to
perform easily and in a limited time fetal echography and
Doppler on pregnant far away from the expert. The system
required only domestic internet between the expert and patient
site and no competence in echography at the patient site.
Technical consideration
at the patient site (distant or isolated) the tele-operated system
is compact (Commercial portable echograph modified; Figure 1)
and light: 6kg, plus 2 probes of 400g, 430cm3 each. The probe
size and weight make it very easy to manipulate especially for
paramedics who most of the time are women. Moreover the light
weight allow the distant operator to locate it accurately at the
place indicated by the expert and to translate it by 1, 2 cm at the
request of the expert.
Patient comments
The motorized probe aspect is not really different from a
conventional 3D probe and thus do not generate any additional
stress compare to a conventional echography. None of the patient
refused the tele-echography and after the examination they did
not report any discomfort. The video conferencing allowed the
patient and the Expert to talk together and to see each other
all along the tele-echography, which contributed to maintain
the link between the sonographer and the pregnant. With the
tele-echography the pregnant did not have to travel to have the
echography nor to wait for an appointment at the radiological
center, and was informed very rapidly on the fetal growth and
behavior.
Environment required
The tele-operated system requires 220/110 volt electrical supply,
and a domestic Internet, in the present test 256Kb/s to 1Mb/s
were found sufficient. In case of poor Internet the Expert gave
priority to “the refreshment rate” of the image while searching
for the appropriate fetal organ view (Ex: bi-parietal, transverse
abdomen. . . ). Then without moving the probe transducer he
switched to “priority to the image density” (quality) which
allowed him to get an acceptable image for the diagnosis. In the
present test we had most of the time 1Mbit/s bandwidth with a
frame rate of 10f/s and a delay of 2s, which was sufficient for
getting echographic images and Doppler data quite in realtime
and of good quality for diagnosis.
The quality of the image reaching the expert office was very high and close to the quality of the image recorded in the Echograph of the patient site, at least when the Internet flow rate was higher than 512 kb/s and the frame rate around 10 f/s. Thus the compression/decompression and the other processing of the images/ video while traveling on Internet did not affect significantly the brightness, contrast or resolution of the echographic image. In case of poor Internet the delay was higher and the priority was given to the image density, the examination was longer but the quality of the echography remained acceptable.
The quality of the image reaching the expert office was very high and close to the quality of the image recorded in the Echograph of the patient site, at least when the Internet flow rate was higher than 512 kb/s and the frame rate around 10 f/s. Thus the compression/decompression and the other processing of the images/ video while traveling on Internet did not affect significantly the brightness, contrast or resolution of the echographic image. In case of poor Internet the delay was higher and the priority was given to the image density, the examination was longer but the quality of the echography remained acceptable.
Required competency for the distant operator
No specific training nor ultrasound knowledge was required for
the operator by the side of the patient. The Echograph and the
probe orientation being fully controlled (tele-operated) from
away by the expert, the distant operator task was limited to
locate the probe at the acoustic window of the organ to be
investigated. Thus any person with basic knowledge of anatomy
could serve as an operator. Additionally because there is no need
for any training for the distant operator, he can serve any expert
for any kind of echography for abdominal, pelvic, vascular, fetal,
superficial organs. . . Consequently any patient in isolated site
can have access anytime to all type of echography tele-operated
by an expert of the organ and of the pathology investigated.
Other applications
In case there are GP or paramedic more or less trained or with
limited practice (because not too many opportunity to preform
echography in isolated medical center), the system allow a control
of their echographies by an expert to secure the diagnostic.
Lastly the system could be used for training remotely future
sonographers still under training or to confirm the diagnostic
of another distant sonographer in case of difficult diagnostic
(Tele-echography for second opinion between sonographers).
Cost of installation
Presently the equipment for the patient site “Tele echograph and
probes” can be purchased at Sonoscanner Cie (Paris, France)
around 50 K € that is to say 20 K € more than a simple portable
Echograph. The equipment of the Expert site is limited to a
portable PC (approx. 0,5K€) to which the dummy probe (1K€)
is USB connected. The expert center equipment is movable as it
requires only a domestic Internet access, thus it can be activated
from various places: home, vacation places, hotel. . . . which
allow any Expert to perform a tele-echography in emergency
wherever he is.
Integration of the tele-echography modality in the
health care system
An expert center can manage several patient site (5 to 10). Our
estimation concluded that a Health House (General population
in rural areas) schedule 2 to 3 tele-echography per day while
a Senior Living Communities (Patient higher than 80 year)
schedule 1 tele-echography per week. Presently these patient
even the oldest ones have to get an appointment at a radiological
center for the echography and to travel 40–60km (total
3-4h). The estimation concerning isolated dispensary in Guyana
reported approximately 1 general or obstetrical echography per
day. Presently the dispensary are visited by a sonographer (who
carry the echograph in the pirogue. . . ) once a month, thus in
case of suspected emergency the patient has to be transferred
by helicopter with the risk to order the transfer too late or for
nothing. A one year practice in a Health House have shown
that the use of tele echography in routine (for abdomen, pelvis,
vessels, small parts) did not increase the number of echography.
Other methods for tele echography
Fiftheen years ago a robotic arm to which an echographic probe
was fixed and which was tele-operated from away was designed
by our lab (Vieyres et al 2003). This system was successfully
tested for fetal echography in 2005 but the device was heavy
and big and had to be suspended to a mechanical support (Arbeille
et al 2005). The whole device was difficult to move and
rather impressive for the pregnant. The other methods proposed
were based on the processing of echographic video or on the
processing of volumic recordings (3D) or used remote guidance
through video-conferencing (Awadallah et al., 2006; Hamilton et
al., 2011; Otta et al., 2012; Randolph et al., 1999, Arbeille et
al., 2014; Kratochwil et al., 2000; Masuda et al., 2001). Unfortunately
most of these method could not provide a realtime
tele-echography, except the remote guidance but this method was
too much time consuming and in fact works only if the distant
operator had been trained for fetal echography.
Conclusion
Presently, the medical reliability and usefulness of teleechography
for isolated patients has been demonstrated for general
and fetal echography and Doppler. The control of the
echograph setting and functions with the use of the motorized
probe improved both the time required for the examination and
the quality of the echographic and Doppler data. The motorized
probe and tele-operated echograph also provided a method
of tele-echography that can quickly generate reliable diagnoses
while requiring no training of the operator at the patient site.
Acknowledgement
The authors thanks Mme M Porcher and Roselyne Claveau (Assistantsonographer)
and Mr Joel Blouin (engineer) for their active
contribution.
Declararion
Ethical approval
The tele echography study was approved by the Ethical committee
of the area where the tele echography took place (Heath Regional
Agency = ARS Agence Regionale de Sante). Each patient
were informed about the protocol of Tele echography and signed
a formal consent form.
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