Surgery in Space 2007: Where Are We Now?
EDITOR'S NOTE: This article was published in the October 2007 issue of OR Nurse magazine under the title “Where No Surgery Has Gone Before”.
Abstract: This article presents an overview of surgical considerations and advancements in
space up to early 2007; plus contact information for the Space Nursing Society.
By LINDA MARIE HAIGHT PLUSH
MSN, CNS/FNP, FRSH
Past Founding President
Space Nursing Society
On February 26, 2007, National Aeronautics and Space Administration (NASA) announced an undersea mission to include “first flight surgeon”. The mission named NASA Extreme Environment Mission Operations 12, NEEMO 12 for short, will include among many experiments, a hands-on telesurgery demonstrations and robotic telesurgery technology.1 The mission will take place in the ocean depths off the coast of Florida from May 7-18 this year.
The purpose of this phase of the mission is to help surgeons to overcome simulated interplanetary communication lag time issues related to robotic and telesurgery.2 This news release is very exciting since it demonstrates a shift in focus within the United States Space Program. Only in the last few years has the human factors issues of space flight begun to take center stage; brought on in part by the new push within NASA to return to the Moon and go on to Mars as directed by President Bush’s “Vision for Space Exploration”.3
Over the years, human factors issues were not considered mission critical and received less attention than other aspects of space flight. This was due in part to the short duration of most space flight missions, usually less than 14 days (shuttle flights). It was generally felt that if an astronaut developed a health (surgical) problem on a shuttle mission, it was preferred to return to earth rather than deal with the problem aloft. 4 Although no human being has been operated on in space, some information pertaining to surgery is known.
Researchers from Russia conducted several surgical experiments in space and reported minimal arterial and venous bleeding. They found surface tension to be the over riding factor, where blood tended to form fluid domes that adhered to the bleeding tissue. This can make it difficult for the healthcare providers to see a clear surgical field, as blood sticks to instruments and tissues. The Russians were also concerned about evisceration (body organs tend to proceed outward due to the higher pressures inside the body versus the space cabin atmosphere) after a laprotomy, suggesting that laproscopic techniques and equipment might solve some of the containment issues that occur with large incisions.5 Other curious adaptations will be required due to the nature of zero gravity (zero-g) itself and space craft design.
Surgeons and support staff as well as the patient will have to be harnessed or anchored to the walls. Surgical tools will need to be tethered, moored by magnets, or secured to a surface to prevent them from floating away. The surgical field itself will more than likely be encased in some containment field to prevent contamination of the space craft environment by the surgical procedure. The operating “theatre” will by necessity be extremely small in comparison to surgical rooms on earth, requiring miniature surgical tools. Those tools on board will be limited due to space and weight. Tools that can be used for several procedures or serve multiple functions will be preferred. The space craft design will dictate which section of a hallway, corridor, or node will be cordoned off for the surgical procedure. Do not assume that all crew assisting with the surgery will be anchored on the same surface or floor as on earth. Some of the crew could very well be anchored on an opposite wall over your head. No gas anesthetics will be possible6, unless you want the entire crew to go to sleep. Space craft routinely reuse and recirculate the cabin atmosphere (closed-loop) sending it through scrubbers to remove unwanted carbon dioxide6. Escaping anesthetic from around a patient’s mask would be both a serious fire hazard and a danger to the crew. In the event of a leak it would be difficult or impossible to vent the cabin to space to remove any residual gas without losing a considerable amount of your breathable atmosphere. Sterilizing equipment should prove interesting. No chemicals that would compromise the cabin atmosphere by out-gassing are allowed. Energy use is strictly allotted. Considerations would have to be made on how much energy the procedure would require or use off any batteries or solar array (any lighting, robotic or electrical equipment). Suturing might be preferred over cauterization. The position of the spacecraft in space and the associated time delay and available bandwidth for transmission of information for communications with earth are also a concern. As the distance lengthens between earth and the craft so does the time delay for communications. At some point telesurgery and telerobotics become impossible due to this time delay. If a signal is delayed by more than 0.7 seconds, a surgeon will begin to have problems controlling the surgical robot.7 Everything floats in zero-g including all kinds of cabin debris, which makes it difficult to maintain any kind of sterile field . Since there is no up or down in space, there is no guarantee that air, foam and fluids will be in any particular place in an intravenous (IV) line or any other container (IV bag). Infusion pumps will be needed for delivery of any medications or IV fluids with strict attention to any air or foam risks.8,9 Thus far the discussion has focused on the environmental concerns for surgery in space, but space has effects on the human crew that must also be considered.
At the University of Toronto, Canada, Professor of Surgery, Dr. Adam Dubrowksi notes that the weightless environment affects a person’s hand-eye coordination, aim and ability to apply a certain amount of force when undertaking tasks.10 He is developing a space-surgery training program that has 3 phases. The first step is adaption to zero-g using an inverted paradigm, where participants are placed upside down on something similar to a bed to simulated weightless orientation. Phase two places the participants in a neutral buoyancy water tank similar to the tank that astronauts train in for missions, to simulate zero-g, in Houston, Texas. After adjusting the person’s weights to simulate weightlessness they are asked to perform some tasks.
The third phase, places the participants in an aircraft flying a parabolic flight plan. This is a series of ascents and descents allowing for temporary “free-fall” for some seconds during the descents. Participants are asked to practice suturing skills while in “free-fall”.11 The longer you stay in space the more likely is the potential for medical problems to occur. Currently, astronauts are given a few hours of medical instruction prior to space flight. There is no guarantee that a physician, nurse, or military corps man will be among the selected crew for any given mission. Dr. Dubrowksi, feels that this is “insufficient for treating serious injuries”12. He goes on to further say that, “no one understands what happens when you’re in zero gravity and need to suture or staple a wounded person”.13
In 2003, during the NeuroLab Space Mission, the first recovery surgical procedure was performed on five, 21 day old rats. They were anesthetized and their soleus and extensor digitornum longus leg muscles were injected with label. The surgical incisions were closed with wound adhesive. All the rats recovered without complications.14. Therefore, some people took exception to the European Space Agency announcement on September 25, 2006, that they would conduct later in that week, the “World’s first zero gravity surgery”.15 A team of three French physicians, using a custom made operating block, backed by two anesthetists , and a team of French army parachutists, removed a fatty tumor from the forearm of a human volunteer over a 3 hour parabolic flight. The surgical tools were miniaturized and held in place with magnets.
The operating area was smaller than a traditional setting and it was designed by a French elevator manufacturer. 16 Surgeon Dominique Martin, from Bordeaux University Hospital in south-western France, stated that, the French team had been rehearsing the operation since February 2006. There were no complications noted for the procedure. However, in NASA literature, it has been noted that some bacteria grow faster in space (BIOSAT missions 1960-70’s)16, 17. Studies are just now beginning to shed light on issues related to drug stability in space. In a real life situation it is doubtful that the crew in space will have either experience in, or practiced the procedure in advance. The outcomes of a real life surgery in space are not so clear.
Nurses can contribute meaningfully in the development of healthcare teams in space using their experience from Earth. For example a group of 64 perioperative and postanesthesia nurses, with an average 10 years experience, were informally asked to prepare a surgical suite in a space station. They had the same concerns found in space literature18 . Although this was informal research, it confirms that nurses can meaningfully contribute to the space program.
Nurses finally may have a significant role in space. Although nurses have applied to participate in the astronaut program, none have been selected, and the reasons are speculative19.
One reason often cited is the multiple levels of education that dilute and confound nursing’s credibility20. The entry level for most recognized professional careers is a Bachelor’s Degree with engineering now pushing for a Master’s Degree21. With that said, however, the best fit in the proposed healthcare team may be an advanced practice nurse; possibility an advanced practice nurse with perioperative and recovery experience. These nurses would be technically able to perform emergency procedures, understand and use aseptic techniques, be easier to guide through telerobotic or telesurgery than other crew members without healthcare backgrounds, have general nursing skills, familiar with recovery from anesthetics, able to multi-task, thus they are cost effective. These nurses would also need a solid background in infection control due to the closed-loop design of space craft. Infections allowed to contaminate the life support systems could seriously endanger the entire crew22. It is easy to envision these nurses becoming central members of the space crew.
In summary, to date there has been no surgical procedure done on a human being in space. Several simulations in parabolic flight, in neutral buoyancy tanks, and in undersea labs have been and are being conducted to provide information in anticipation of the day when such an event occurs in space. Even with the controversy regarding the educational preparation of nurses, the best and most cost effective person to select for a crew member maybe the advanced practice nurse with perioperative and recovery experience. These nurses would be easier for Earth bound surgeons to guide through surgical robotic and telesurgery procedures than a non-medical crew member. In addition, nurses are able to perform other essential tasks/multi-task. We are at the beginning of surgery in space with much to learn. With NASA looking to the Moon and on to Mars, it is only a matter of time before a surgical procedure will be needed in space.
Supplement : Space Nursing Society
In order to prevent nursing and other allied health professions from forever being Earth-bound disciplines, several nurses and one pharmacist, including the late nursing theorist, Martha Rogers, decided to form the Space Nursing Society (SNS) to promote the nursing profession within the space program. Since then SNS has grown to over 400 members worldwide. For more information on the Space Nursing Society and its activities go to: www.spacenursingsociety.net or online: Wikipedia, key words: space nursing society.
1. NASA Headquarters, NASA Announces Undersea Mission to Include First Surgeon.
February 26, 2007. Doc. NASA Press: Release: 07-53.
3. NASA Headquarters, Statement of NASA Administrator Michael Griffin Before the
House Committee on Science & Technology: FY 2008 Budget Hearing. Doc. NASA Status
Report: Released March 15, 2007.
4. Barbara Czerwinski, Linda Plush, & Barbara Bailes, “Nurses’ Contributions to the US
Space Program” AORN Journal 71, No 3, (May 2000) 1051-1057.
6. Duncan Granham-Rowe, “Scrubbing up for robotic surgery in space” NewScientist.com
News Service (October 11, 2004). Online:
9. Agency France-Presse. “World’s first zero gravity surgery” Cosmos Magazine Monday,
September 25, 2006. Online: http://www.cosmomagazine.com/node/683.
10. Elizabeth Raynor, “Yes, it’s rocket science: Professor explores surgery in space”
University of Toronto: Press Release (February 16, 2006). Online:
14. Jay C. Buckey, Jr., Dafydd R. Williams, & Danny A. Riley, “Surgery and Recovery in
Space” The NeuroLab Spacelab Mission: Neuroscience Research in Space. In:Associated Press
Release: “Setting the record straight on weightless surgery” (October 3, 2006) Online:
16. Dale W. Jenkins. “USSR and US BioScience” BioScience 18, 06 (June 1968) 543-549.
17. NASA “Life into Space” NASA Reference Publication-1372, (1997) for inquires on this
Publication contact: Kenneth Souza, Associate Director for Life Sciences, Mail Stop 200-7,
NASA-Ames Research Center, Moffett Field, CA 94035.
18. Linda M.H. Plush and Barbara Czerwinski “Planning a surgical suite in a space station”
Speech presented at the 46th annual AORN Congress, San Francisco, March 28, 1999.
19. Barbara Czerwinski, Linda Plush, & Barbara Bailes, “Nurses’ Contributions to the US
Space Program” AORN Journal 71, No 3, (May 2000) 1051-1057.
21. Institute of Electrical and Electronics Engineers, Inc. (IEEE) Membership Services Online:
22. Barbara Czerwinski, Linda Plush, & Barbara Bailes, “Nurses’ Contributions to the US
Space Program” AORN Journal 71, No 3, (May 2000) 1051-1057.