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"  One morning in April, I pulled up to a nondescript gray stucco duplex that fronted a canal in Key Largo. From the outside, the structure looked like an ordinary Florida condo, but if you peered over the fence into the covered portico, you could see a dizzying collection of air and mixed-gas tanks and the latest high-tech scuba gear splayed out everywhere. I entered the condo to find two women and three men, all shoeless and in shorts and T-shirts, eating breakfast and talking into a speakerphone. They appeared to be laid-back and relaxed, but they were engaged in serious science. The condo was a command center. The barefoot inhabitants were engineers and scientists, and the speakerphone was connected by radio to astronauts who were, at that moment, 3 miles off the coast and 62 ft. under the sea. These astro/aquanauts had been living in a capsule for two weeks and were carrying out the most elaborate undersea experiments ever attempted. I was at &amp;quot;mission control&amp;quot; as a consultant to NEEMO 9 (NASA Extreme Environment Mission Operations 9). Led by United Space Alliance scientist Bill Todd, with daily operations managed by Marc Reagan, the NEEMO project places astronauts in an undersea environment to simulate living and working conditions that they may face on the International Space Station, and could one day encounter on the moon and Mars. One of the goals of the NEEMO project is to use technology to enable doctors to perform surgery in environments that are too dangerous or remote to reach in person. I was invited because I am a microsurgeon and because of my experience as a doctor who practices &amp;quot;extreme medicine.&amp;quot; Before I could scuba dive without a NASA escort, I had to be certified as a NURC (National Underwater Research Center) diver. The center&amp;#039;s associate director, Otto Rutten, took me out to the Life Support Buoy (LSB) floating above the capsule to get tested. After a few feats of aquatic endurance, as well as a demonstration of some basic scuba knowledge, I was NURC&amp;#039;d and ready to visit the lab. The Aquarius Undersea Laboratory is a cylinder roughly the size and color of a school bus and about as cramped inside as a space station. I dove down to the seafloor with several NEEMO scientists, where we met up with two astronauts, Dave Williams and Ron Garan, outside the capsule. They were doing an EVA (Extra-Vehicular Activity) &amp;quot;moonwalk.&amp;quot; The astronauts were walking upright, thanks to weights added to their belts and boots to simulate the gravitational pull they would feel on Mars--one-third that of the Earth. Accompanying the astronauts was Scuttle, an ROV (remotely operated vehicle) that resembles a go-kart. Scuttle was controlled from within the capsule by astronaut Nicole Stott. Today the astronauts were engaged in a building experiment, constructing a temporary Water Lab, using Scuttle to bring them tools. The undersea environment provides more than just a gravitational stand-in for Mars; it also approximates the isolation and danger involved in a deep-space mission. Unexpected things go wrong here--just as they would in space--and that demands creative thinking from the astronauts and helps mission planners prepare for when the stakes are higher. Although I spent part of my time with the NEEMO crew observing experiments like these, I was primarily here to witness the first successful attempt to operate a remote robotic surgery system in an extreme environment. On my second day, Dr. Tim Broderick, a University of Cincinnati surgeon, and I watched a robot inside Aquarius replicate the movements of a human 1500 miles away. I&amp;#039;ve been present for three generations of NEEMO surgery. In 2004, I was the first person to do actual surgery inside the capsule--done the old-fashioned way, by hand, after an astronaut sliced his hand cutting PVC tubing. Last year, Tim and I performed mock surgery, following the step-by-step instructions of Dr. Mehran Anvari, director of McMaster University&amp;#039;s Centre for Minimal Access Surgery, who telementored us from Hamilton, Ontario. This year, Anvari, still in Ontario, performed the surgery himself, manipulating a new robotics system consisting of an M7 master robot and an identical slave robot inside Aquarius. The system was developed in response to an idea (and funding) from the U.S. Army&amp;#039;s Telemedicine and Advanced Technology Research Center (TATRC) headed by Dr. Gerald Moses, who wanted a robot that could perform surgery in hazardous and remote locations. Designed by SRI International, the M7 surgical robot is the first such machine small enough to fit inside Aquarius. It has two arms that move with seven degrees of freedom: up-down (x-axis), left-right (y-axis), in-out (z-axis), yaw (around x), pitch (around y), roll (around z) and pinch (opening and closing of the pincer tips). The arm position and movement of the master robot was recorded and sent over the Internet to mission control, where the data were transmitted wirelessly to the LSB, which was hard-wired to Aquarius, then to the slave robot. There is, however, a catch: The system has an unavoidable time delay of 0.250 millisecond due to the speed-of-light transmission. This latency posed no problem in our test suture of a plastic tube (standing in for an artery). But when the delay was artificially increased to 3 seconds to mimic transmission to the moon, Anvari lost the ability to tie a knot. The signal delay on a transmission to Mars would be 20 minutes. Clearly, semiautonomous robots will have to be developed to do much of the surgery themselves. The robotic surgery on NEEMO 9 may also prove to have other, nonspace applications. Robotic surgeons could make sophisticated surgery available in dangerous or remote areas--on the battlefield, for instance. Such a system could be used with DARPA&amp;#039;s unmanned Trauma Pod tank-ambulance. My final day with the crew was &amp;quot;splash-up,&amp;quot; when the aquanauts resurface. It&amp;#039;s a journey of around 60 ft., but it takes nearly 17 hours. Any faster could be deadly. The crew has been breathing pressurized air inside Aquarius, and after 18 days their blood is saturated with nitrogen. If the pressure were suddenly released, they could get the bends--when gaseous nitrogen comes rapidly out of solution, forming bubbles that can block blood vessels. The recipe for decompression was nearing completion as we headed out in the morning to greet the aquanauts. As the divers climbed on board our recovery boat, Nicole waved to her husband and son on the spectator boat. Tim took a deep breath and said, &amp;quot;It&amp;#039;s good to feel fresh air.&amp;quot; Ron heard him and said, &amp;quot;So that&amp;#039;s what that smell is.&amp;quot; An aquanaut performs a &amp;quot;moonwalk&amp;quot; outside the Aquarius lab off Key Largo. PHOTOGRAPH BY NASA. "^^<http://www.w3.org/2001/XMLSchema#string>
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